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CREATING SUCCESS FOR CHILDREN WITH MULTIPLE ISSUES

GREAT LAKES CONGRESS MARCH 2018

First hour

Celia Hinrichs, O.D., FCOVD

Thanks

• Nancy Torgerson

• Stacey Coulter

• Mehrnaz Green

• Mary Bartuccio

• Allen Cohen

• Neera Kapoor

• Penelope Suter

• Irwin Suchoff

• Ken Ciuffreda

• Rob Fox

• Cathy Stern

Becoming disabled• Roughly one in five Americans lives with a disability. So

where is our pride movement? Asks Rosemarie Garland-Thomson

• http://www.nytimes.com/2016/08/21/opinion/sunday/becoming-disabled.html

• Rosemarie Garland-Thomson is Professor of English at Emory University, where her fields of study are disability studies, American literature and culture, feminist theory, and bioethics.

Why do parents decide they want treatment for their multiply challenged child?

•Eye contact

•Better social skills

•Better education

Parents also want

• Independence • Sports

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• With the increased incidence of executive dysfunction disorders, such as ADHD, Nonverbal Learning Disabilities, and ASD (1 in 88 children), as well as increasing populations of children with severe sensory integration and emotional regulation difficulties, optometrists must learn effective measures to

improve the success inthese populations.

Defining the “problem” or “spirited” child: inflexible, low frustration tolerance, poor problem solving skills

• Recent estimates in the United States show that about one in six, or about 15%, of children aged 3 through 17 years have one or more developmental disabilities.

• An expanding literature base indicates the incidence and prevalence of emotional/behavioral problems in young children is increasing. The U.S. Department of Health and Human Services (DHHS) 1999 report, Mental Health: A Report of the Surgeon General, estimates that at leastone in five (20%) children and adolescents has a mental health disorder at some point in their life from childhood to adolescence.

• The term “serious emotional disturbance” refers to a diagnosed mental health problem that substantially disrupts a child's ability to function socially, academically, and emotionally. It is not a formal DSM-V diagnosis, but rather an administrative term used by state and federal agencies to identify a population of children who have significant emotional and behavioral problems and who have a high need for services.

• Mental Health America | 1.800.969.6642http://www.mentalhealthamerica.net/find-affiliate

• NAMI | National Alliance on Mental Illness | 1.800.950.NAMIhttp://www.nami.org/template.cfm?section=Your_Local_Nami

• National Mental Health Consumers’ Self-Help Clearinghouse 1.800.553.4539 http://www.cdsdirectory.org/

Characteristics of TemperamentThere are at least nine major characteristics that make up temperament and can affect the exam.

• Activity level: the level of physical activity, motion, restlessness or fidgety behavior that a child demonstrates in daily activities

(and which also may affect sleep).

• Rhythmicity or regularity: the presence or absence of a regular pattern for basic physical functions such as appetite, sleep and bowel habits.

• Approach and withdrawal: the way a child initially responds to a new stimulus (rapid and bold or slow and hesitant), whether it be people, situations, places, foods, changes in routines or other transitions.

• Adaptability: the degree of ease or difficulty with which a child adjusts to change or a new situation, and how well the youngster can modify the reaction.

• Intensity: the energy level with which a child responds to a situation, whether positive or negative.

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• Mood: the mood, positive or negative, or degree of pleasantness or unfriendliness in a child's words and behaviors.

• Attention span: the ability to concentrate or stay with a task, with or without distraction.

• Distractibility: the ease with which a child can be distracted from a task by environmental (usually visual or auditory) stimuli.

• Sensory threshold: the amount of stimulation required for a child to respond. Some children respond to the slightest stimulation, and others require intense amounts.

Getting ready for the “problem” child

• Preparing your staff

• Identifying staff’s concerns

• Providing information

• Managing anxiety of patient, parent, and self

• Thinking about scheduling

• Identifying sensory triggers

• Dealing with meltdowns, pica, bolting, disrobing

• Identifying possible strategies and responses

Preparing your staff

• Is there anything that is important or helpful for making the examination successful?

• Social Story• Dr. Coulter link

http://links.lww.com/OPX/A189.

• Think about your website.

• www.youtube.com/watch?v=r6j1dzaKDxI

Surveying the Environment

Surveying the EnvironmentVisualFluorescent lightsReflective surfaces (mirrors, windows)White surfacesCertain colors (yellow, red, orange)Jewelry, metallic-look clothes

Auditory

Busy, highly trafficked rooms

Multiple conversations

Background music

High-pitched toys

Unexpected loud sounds

SmellPerfume, after shave, toothpasteNew construction/paintCleaning Fluids

What to expect

• A lot of variation -nonverbal to very verbal

• Apparent cognition “low” to “high” functioning

• Range of sensory processing issues

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• Many children just want to hear that everything is okay.

Areas to consider outside of testing

• Observation of the Child

• Medical History

• Educational History

• Rehabilitation Therapy

• Ocular History and Symptoms

Gathering the Information• All educational and medical history is reviewed before the patient is seen. Our staff is educated on questions to ask.

• Bob Sanet’s questionnaire is great and adapted for our office

• We now schedule patients once they send in their information. The goal can be that examination is a diagnosis to bring the patient back for further evaluation.

• This allows me to prioritize in the first visit.• Watch the forms

ex. developmental questions and lists well beyond the performance of the child.

Medical history

• Try to get a clear picture of the medical issues• REQUEST RECORDS-

• History of accident/medical problems• Your role can be very different depending on the duration of the

problem- important to know what has been evaluated• TS head turn• Sudden double vision

• Neurological summary/ Developmental Pedi

• Summary of CAT scan and MRI tests-• looking at extent of damage and/or specific information.

20 yo with SIB

• Significant bout of head-directed SIB against a wall or the floor. The report is not clear, but we know it was not poking or another smaller object. Bilateral ecchymosis.

• Long history of non-concomitancy was noted as Brown’s tendon sheath when he could not turn the eye up in 2008 in my first evaluation. There are no scars around the area, and he is not an eye poker. He can now move the eye up, and it is only seen in extreme gaze. He is a difficult patient for all in that he will not allow covering of either eye and will not do the stereopsis testing, but otherwise testing is within normal limits including the DFE, which has to be done with him sitting up and folks to monitor any sudden behaviors.

• The “helical CT of the maxillofacial region performed without intravenous contrast” notes a “3mm hyperdensefocus in the medial anterior, and superior aspect of the right orbit which they note” could be related to the calcification of the trochlear apparatus. However, given the patient’s age and history of trauma, the possibility of a foreign body cannot be excluded. Correlate with clinical exam.”

• Does this fit Brown’s tendon sheath syndrome? Jason Clopton says yes.

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• Strategies for success in the optometric examination

1. Intake

2. Scheduling

3. Control of sensory triggers

4. Use of visual supports/schedule

Basic Optometric Vision Examination

• Approach to patient

• Minimize movements around the patient

• Keep room illumination relatively dim (try to eliminate fluorescent)

• Take frequent breaks in testing. Have the patient close their eyes.

• Work slowly to give the patient processing time.

• Recognize that all senses can overload, vision, sound, smell, tactile and proprioceptive

• https://www.youtube.com/watch?v=d68TZf2y8YM

• https://www.youtube.com/watch?v=OxfLS7mjCKk

• Managing Procedural Anxiety in Children-Baruch S. Krauss, M.D., Benjamin A. Krauss, and Steven M. Green, M.D., N Engl J Med 2016; 374:e19 4/21/16: 10.1056/NEJMvcm1411127

Clinical pearls to address behaviors

The importance of affect

Pacing, pacing, pacing

• DO NOT TREAT AVOIDANCE OR “NO” AS REJECTION!!

• Position yourself in front of the patient

• Insist gently on a response

• Do what the patient tells you to do; take turns being in charge

• It is important to distinguish a difficult temperament from other problems. For instance, recurrent or chronic illnesses, or emotional and physical stresses, can cause behavioral difficulties that are really not a problem with temperament at all.• Cortical Visual Impairment

• Cerebral palsy

• Down syndrome

• ADHD/NLD

• Oppositional Deviant Disorder (ODD), bipolar, intermittent explosive disorder, Tourette’s, reactive attachment, depression, Obsessive Compulsive Disorder

• ASD

• Head trauma

• Oppositional Defiant Disorder ODD is a condition in which a child displays an ongoing pattern of an angry or irritable mood, defiant or argumentative behavior, and vindictiveness toward people in authority. The child's behavior often disrupts the child's normal daily activities, including activities within the family and at school.

• Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers.

• Intermittent explosive disorder (sometimes abbreviated as IED) is a behavioral disorder characterized by explosive outbursts of anger and violence, often to the point of rage, that are disproportionate to the situation at hand (e.g., impulsive screaming triggered by relatively inconsequential events).

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• Obsessive Compulsive Disorder (OCD) is an anxiety disorder that involves unwanted and disturbing thoughts, images, or urges (obsessions) that intrude into a child/teen’s mind and cause a great deal of anxiety or discomfort, which the child/teen then tries to reduce by engaging in repetitive behaviors or mental acts (compulsions).

• Tourette Syndrome is one type of Tic Disorder. Tics are involuntary, repetitive movements and vocalizations. They are the defining feature of a group of childhood-onset, neurodevelopmental conditions known collectively as Tic Disorders and individually as Tourette Syndrome, Chronic Tic Disorder (Motor or Vocal Type), and Provisional Tic Disorder. The three Tic Disorders are distinguished by the types of tics present (motor, vocal/phonic, or both) and by the length of time that the tics have been present.

• Bipolar disorder is a chronic mental illness that causes dramatic shifts in a person’s mood, energy and ability to think clearly. People with bipolar have high and low moods, known as mania and depression, which differ from the typical ups and downs most people experience.

• Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working.

Communication

• Consider expressive and receptive language – yours and patient’s

• Receptive• Provide simple directions

• Use visual supports/gestures to provide context

• Affect

• Expressive• Does patient use words, device,

PECs (Picture Exchange Communication)?

Remember supports for transitioning Thank you, Stacey Coulter

• VISUAL SCHEDULE

• Shows order of tests

• What’s next

• Reminds patient of what to do

• First then $9.99 Visual Schedule Planner $6.99 for smartphone or iPad

What Is Vision?

Elliott Forrest, O.D., viewed vision in the broad sense as an interaction of all major body systems serving perception, cognition and the monitoring of all forms of visually-guided behavior. Vision is no longer simply optical, which sees clearly, comfortably and singly.

Vision is learned and therefore

can be remediated.

• ANNALS OF MEDICINE

• JANUARY 23, 2017 ISSUE

• THE HEROISM OF INCREMENTAL CARE

• We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.

• By Atul Gawande

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• An example of incremental care

Optom Vis Sci. 2009 Oct; 86(10): 1169–1177.Academic Behaviors in Children with Convergence Insufficiency with and without Parent-Reported ADHD

Michael Rouse, OD, MS, FAAO, Eric Borsting, OD, MS, FAAO, G. Lynn Mitchell, MPH, FAAO, Marjean Taylor Kulp, OD, MS, FAAO, Mitchell Scheiman, OD, FAAO, Deborah Amster, OD, FAAO, Rachael Coulter, OD, FAAO, Gregory Fecho, OD, Michael Gallaway, OD, FAAO, and CITT Study Groupa

You can’t depend on your eyes when your imagination is out of focus.

Mark Twain

•Approaches to this population tend to be disease based when our evaluations are developmental.

•Learn the disease impacts, but think developmental.

•This approach will be to look at many of the common diseases, but the information will be inserted in the overall approach.

Basics of my evaluation

•Use the terms to familiarize.

•Don’t get bogged down in the details.

•Learn the flow and the approach.

•Think about the sensory impact and loading.

•watch sensory overloading

Absolutes and Universals

• “It is important for the reader to recognize these absolute directives and take them as a genuine observation of the writer that may, under certain conditions of observation be different and therefore not hold as absolute.” Paul Harris Vision Rehab p. 232

This is a critical observation for children with

with multiple issues. Gather information consistently.

Pediatric Vision Rehabilitation

• Comprehensive term which involves many specialists

• I am a member of a transdisciplinary team

• Evaluation must translate into practical applications

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How do we support with or without OVT?

•Ocular health assessment

•Refraction

•Bifocals or near prescriptions

•Yoked prism lenses

•Tints

•Binasals/patching/MFBF

•Explaining the problem!!

Medications

• Medications- impact on performance and side effects• Ritalin- accommodative problems? Time of day??

• Anticonvulsants- depending on the drug- blurred vision, dilated pupils, photosensitivity

• Benadryl-blurred vision- I have seen this side effect occasionally with other asthma medications

• Valium- blurred vision, double vision

• Don’t know the drug- look it up! Complex children can be on trial periods of non-standard drugs

• Ex: teenager on Belviq, Depakote, Citalopram, Onfi and CBD oil finally less grand mal seizure and functioning

Ocular History and Symptoms

• Previous evaluations-treatment plans

• REQUEST RECORDS

• Many of my patients see several eye doctors for different needs.

• Make sure that we are all working together.

• Is the patient receiving adequate vision care?

Lots of ocular health concerns. Can we help?

• 11 yo Complicated ophthalmological history led to assumptions

• HX-cataract removed at 2 weeks, secondary membrane and anterior vitrectomy at six months, strab surgery at 3 yo and valve implant at 4 yo

• +18.50 CL OS, cannot raise left eye well, LXT now, report 20/70 OS

• Neuropsych- mood disorder, anxiety

• WISC VCI 102,PRI 100, WM 88, PS 73

• Referred for visual spatial, visual deficits

• VA dist OD 20/20, OS 20/400 later able to get 10/50 with Feinbloom and -1.00 over CL on OS

• near VA OD 20/25-, OS 20/150 fluc

• Static fluc astig OS- no change in findings

• NPC OS supp, Vergences OS supp

• Cover test non-concomitant left exotropia, cannot look up beyond midline, no convergence of OS

• Randot E with add OD +0.75, OS +2.00

• DEM 11 yo vert 52, horz, 86

After 16 sessions of OVT, refraction change OD plano /+0.75 add, OS plano-3.00x150 / +2.00 add

• Dist acuity OD 20/20, OS 20/50

• Near acuity with bifocal 20/20 OU,OD 20/20, OS 20/40

• NPC 10” left eye turns out, fluctuates,

• 12 diopter left exotropia distance and near

• DEM vert 51 horz 65

• Wold Sentence Copy 49 letters

• Monroe III 8.5

• RECOMMEND more OVT

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• Full exploration of symptoms- ocular history con’t

• What do the parents and child expect from this evaluation?

• COVD lifestyle questionnaire-standardized

• Head Trauma1. VOMS (Brief Vestibular/Ocular motor screening)

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209316/)

2. CISS (Coping Inventory for Stressful Situations) (https://www.ncbi.nlm.nih.gov/labs/articles/24708080/)

• Dutton CVI questionnaire

• In young children with poor communication skills, this may involve observations from many professionals and the parents. What have the parents, teachers and therapists noted?

• Children are often better at describing problems than expected- ask the child

Ocular History, cont.• Certified legally blind?

• In most states children with 20/70 or less acuity are defined as visually impaired and receive support from the services of a teacher for the visually impaired. Legal blindness is defined as 20/200 or worse acuity best corrected, or less than 20 degree fields.

Remember CVI- now leading cause of visual impairment in USA in children

Educational History

• Educational testing- increased testing

• Neuropsychological battery

• IEP evaluation/ Psycho-educational evaluation

• Physical Therapy Assessment

• Speech and Language Assessment

• Occupational Therapy Assessment

• Behavioral Assessment

• Teacher of the Visually Impaired Assessment

• Technology Assessment

Vision Enhancement

• “The goal is to bring the mind in alignment with the point of attention, and the resulting perception in line with reality. The more accurate perceptions are, the better concentration will be and vice versa.” The person learns how to do more by doing less. Albert Shankman, O.D.

• Therefore, is the child working too hard

to see?

“Just Look” Dr. Glen “Bubba” SteeleWhat are we looking for?

STAMINA AND FLUENCY

Sequence for OVT Controlled then AutomaticThanks Jack Richman

Controlled Processes

• Slow and Less Efficient

• Aware

• Controllable

• Voluntary

• More Effort

• Smaller Central Processing

Automatic Processes

• Fast and Efficient

• Unaware of Process

• Involuntary

• Less Effort

• Greater Central Processing Capacity

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Eye Movement Problem wasRelated to Attention, Impulsiveness, and Distractibility

• The findings found that the measurement of off-task looking time and off-task fixations during a sustained visual attention test (CPT, Ocular Pursuits) is significantly related to the classrooms teachers' observations of personal-social behavior (Classroom Checklist) and the child's decision making style (Matching Familiar Figures).

• This approach to measuring sustained attention has potential use as a clinical tool in identifying and monitoring treatment for children with visually-related learning problems.

Use of a Sustained Visual Attention Task to Determine Children at Risk for Learning Problems, J Am Optom Assoc. 1986 Jan;57(1):20-6. Richman JE.

Key to automaticity:Practice with repetition with feedback

Once a certain level of proficiency has been reached, the task needs to be successfully completed. This is the key to automaticity:

Practice with repetition with feedbackLESS TIME without AWARENESS

We call this loading in our treatment approach.

In this population, increase in automaticity occurs at levels not considered.

i.e. increase in fixation

Must we do this alone?

• In this field you may be working with a team. “Home optometric vision therapy” may in fact be done at school or in early intervention. You may be most effective with that person.

Physical Therapists• Vision therapy can be

done with lenses in physical therapy if appropriate

• With the youngest children, I often work closely with the physical therapist

• Sports-oriented physical therapy best fits our model - it uses movement and loading

Testing or goals in occupational therapy

• The OT looks at visual system through tracking, integration of vision with other sensory systems and some visual perceptual testing

• In a transdisciplinary model with school children, I can work closely with an OT or a teacher of the visually impaired

Speech and Language

• Communication systems

• My functional visual information often translates directly into visual communication boards. Ex. use of letters, spacing, size of details, color issues

• Speech and language works on adapting the environment for executive issues.

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Rehabilitation/Therapy Testing or goals with teacher of the visually impaired (TVI)

Older model low vision Neuro-vision rehabilitation

• The literature and information about these populations is often described in people with vision loss without an understanding of behavioral optometry.• Vision stimulation

• Adapting the environment

• Rehabilitation versus Habilitation

Dutton’s work on CVI has shifted our approach

Dr. Christine Roman Lantzy

Cortical Visual Impairment:

An Approach to Assessment and Intervention

Increasingly I am asking the TVI to be the point

person for complicated visual cases.

What do you notice?

Observation of the Child• Mobility, gait, body posture and head position

• Appearance

• Accompanied by? Interaction with people?

• Visual Curiosity

• Intentional use of vision- DIR concept

Mobility-head and/or body position, gait

• Use this information in your evaluation to show change. Ex. glasses can create changes in head tilt and body posture

• With poor visual responses, in what positions do visual responses occur? Ex. Child is plano on floor and -5.00 sph OU sitting.

• Under what conditions will he look away, look at you?

• First watch, if you simply use vision and no sound, does the head come up. Does it only go down when he talks? When he stands? When he moves?

• If I put you in a tough place, how fast will you give up vision?

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Physical Posture• What posture does the person take when attempting to be visual?

• Under what postural conditions is the person most easily visual?

• What postures indicate stress?

• http://www.marianjoylibrary.org/Residency/Key%20References/documents/Ref32.pdf

• https://visionhelp.wordpress.com/2016/07/20/better-balance-means-better-vision/

Body PostureA Matter of Balance: Motor Control

is Related to Children’s Spatial

and Proportional Reasoning Skills

http://journal.frontiersin.org/article/10.3389/fpsyg.2015.02049/full

• Wheelchairs are set up to contain, but are not necessarily best for movement or vision.

Cerebral Palsy

• Cerebral palsy is a static neurologic condition resulting from brain injury that occurs before cerebral development is complete.

Primary concerns with cerebral palsy in my examination

• Position is critical- What is comfortable for the child? Take the child out of the wheelchair- see how findings change on the floor, etc.

• Fatigue is really an issue- child walking to class

• Speech and language related to eating issues

Visual Awareness

• Send home the questionnaire ahead of time. Ask questions about when and how the patient responds to visual cues.

• Don’t forget to give yourself time to watch the child in your space.

• Be careful to determine when vision can lead.

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Accompanied by? Interactions with people?

Autism Spectrum DisorderWhat do we know?

• 1 out of 42 boys and 1 out of 189 girls in the USA will develop autism and overall is 1 in 68.

• ASDs are biologically based neurodevelopmental disorders that are highly heritable. Despite this fact, the exact cause still is unknown. Finding the cause has been daunting because of genetic complexity and phenotypic variation.

• It has become more and more apparent that the etiology is multifactorial with a variety of genetic and, to a lesser extent, environmental factors playing a role.

• Siblings of a child with ASD have a higher risk of having the disease as well as children born to mothers over 35 years of age.

• Environmental Issues

Regardless of the mechanism, a review of studies published in the past 50 years revealed convincing evidence that most cases of ASDs result from interacting genetic factors. The expression of the autism gene(s) may be influenced by environmental factors.

• Patricia Lemer’s latest book

• Genetics

• Environmental triggers

• Changes in diet and nutrition

Current Concept of Autism

1. Behavioral Disorder Syndrome

2. Multiple etiologies - genetic and environmental

3. Lifelong disorder

a. Different appearance (e.g. peer interactions change throughout life)

b. Importance of early diagnosis

c. Need for sustained support

4. Selective or greater impairment in social interaction

5. Common use of ASD including Autistic disorder and PDD-NOS

Single Spectrum with Individual Variability

• Severity of ASD symptoms

• Pattern of onset and clinical course

• Etiological factors

• Cognitive abilities

• Associated conditions

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Three signs of ASD are now two:

1. Social communication – merger of social and communication domains

1. Deficits in communication are intimately related to social deficits

2. De-emphasizes language skills not involved in communication

3. Created a double-counting problem of DSM IV

2. Fixated interests and repetitive behaviors

GT

• A significant percentage of children with autism spectrum disorders (ASD) have gastrointestinal symptoms including diarrhea, constipation, abdominal pain and reflux.

• Research is supporting the modification of diet

• Deficits in Joint Attention seem to be one of the most distinguishing characteristics of very young children with ASDs. JA is a normal, spontaneously occurring behavior whereby the infant shows enjoyment in sharing an object (or event) with another person by looking back and forth between the two.

Applied Behavioral Analysis (ABA)• Applied: Applied interventions deal with problems of demonstrated

social importance.

• Behavioral: Applied interventions deal with measurable behavior (or reports if they can be validated).

• Analytic: Applied interventions require an objective demonstration that the procedures caused the effect.

• Technological: Applied interventions are described well enough that they can be implemented by anyone with training and resources.

• Conceptual Systems: Applied interventions arise from a specific and identifiable theoretical base rather than being a set of packages or tricks.

• Effective: Applied interventions produce strong, socially important effects.

• Generality: Applied interventions are designed from the outset to operate in new environments and continue after the formal treatments have ended.

DIR/FloortimeDevelopmental Individual Difference Relationship Model

• Developed by Dr. Stanley Greenspan and Serena Wieder, Ph.D.

•D is developmental Milestones Stages 1-6

1. Self regulation and interest in the world

2. Intimacy, engagement and falling in love

3. Two way communication

4. Complex communication

5. Emotional ideas

6. Emotional and logical thinking

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•I for Individual differences

• Difficulty with sensory activities

• Processing difficulties

• Difficulties with motor planning and sequencing

•R for Relationship based

•Floortime is the technique

1. Following the child's lead

2. Joining the child's world and pulling them into a shared world in order to help them master each of their Functional Emotional Developmental Capacities

• “Floortime involves this polarity, or this dialectic, or this tension between following the child’s lead, entering his world and pulling him into your world, finding his pleasures and his joys, and challenging him to master each of the levels that we are talking about. That means paying attention to the child’s individual differences in terms of the way they process sounds and sights and movements and modulate sensations, and also paying attention to the family patterns and therapists to your own personalities so you know how you have to stretch to work with a particular child so you can enter their world and tailor your interactions to their nervous system. That is the heart of Floortime. “

CeliaHinrichsOD@gmail.com

See you at 2:30! • Celia Hinrichs, O.D., FCOVD

• 169 Powers Road

• Sudbury MA 01776

• 978-443-7529

• CAHVISION.COM

EXAMINATION FOR SUCCESS Part 1

GREAT LAKES CONGRESS MARCH 2018

Second hour

Celia Hinrichs, O.D., FCOVD

How does the examination impact the

our treatment approach?

• External Evaluation

• Visual acuity testing

• Eye Coordination

• Refraction testing

• Other testing

• Ocular health assessment

Where can we get results?

• Tests that yield better results- remember to consider stamina, fluency

• EOM- fixation, tracking, saccadic shifts side to side/near to far, DEM or King Devick testing

• Nearpoint of convergence adaptations

• Vergences/Jump Ductions- repeat for stamina

• Stereopsis Local versus Global

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External evaluation• Pupils

• Extraocular Motor function• Nystagmus evaluation

• Comitancy testing-head posture clues

• Fixation

• Pursuits and Saccades• DEM testing, if possible

• Ocular Vestibular• Think about conversation as a

measure of automaticity

• Conversation in walking used as a predictor of falls in the elderly.

Pupils• Size in dim and bright

conditions

• Reactivity (remember hippus)

• Accommodative response

• Relative afferent pupil defect (RAPD)

• Specific pupillary anomalies which can induce photosensitivity include spasm of the near reflex, springing pupil (a benign episodic pupillary mydriasis), anisocoria, traumatic mydriasis and a relative afferent pupillary defect

Photosensitivity, possibly functional photophobia• Causes include cortical changes in light sensitivity,

magnocellular damage, bino vision disorders, PTVS, and ocular damage.

• Patients report a perception of waviness or shimmering of their surround, worse in bright light.

• May also have reduced visual performance in the dark.

• Research indicates association with migraine/HA.

• More common in the dizzy patient.

•Binocular Vision DisordersReduction in symptoms with covering of an eye

•PTVS (Post Trauma Vision Syndrome)

• Padula looks at imbalance of central and peripheral processing.

Magnocellular damage

• Patients tested demonstrated elevated dark adaptation thresholds, which means less light sensitivity in the dark. Research indicates that the rods were most affected, but cones were also mildly affected.

• Ciuffreda and Kappor found 50% of ABI patients who reported light sensitivity exhibited elevated dark adaptation thresholds.

•Cortical Hyperexcitability• Under-inhibition causing glutamate over activity

Medications contributing

• The side effects of these medications may have a relationship to the visual symptoms noted by patients with TBI. Specifically, symptoms of photosensitivity, dry eye, or poor stereopsis were found more frequently in patients taking certain medications, suggesting that the symptoms may be a drug-induced side effect.

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BL issues with medication

• Patient has autism and a left thalamic lesion.

• Meds 8mg of Abilify at 8AM and 7PM by mouth. He takes Gabapentin IC, Neurontin 600mg at 8AM, 2PM and 7PM by mouth.

• An intermittent eye movement disorder considered nystagmoid in which the eyes drift up during the episode-video.

Seizure disorders

• Seizures are classified in two main categories:

• Partial Seizures: involve a part of the brain.

1. Simple partial seizures -- Symptoms may include involuntary twitching of the muscles or arms and legs; changes in vision; vertigo; and experiencing unusual tastes or smells. The person does not lose consciousness.

2. Complex partial seizures -- Symptoms may be similar to those of partial seizures, but the person does lose awareness for a time. The person may engage in repetitive behavior (like walking in a circle or rubbing their hands) or stare.

Generalized Seizures involve much more or all of

the brain.

• Absence seizures (petit mal) -- Symptoms may include staring and brief loss of consciousness.

• Myoclonic seizures -- Symptoms may include jerking or twitching of the limbs on both sides of the body.

• Tonic-clonic seizures (grand mal) -- Symptoms may include loss of consciousness, shaking or jerking of the body, and loss of bladder control. The person may have an aura or an unusual feeling before the seizure starts. These seizures can last from 5 - 20 minutes.

Treatment with Tints

• Consider 30-40% indoors, 80-85% outdoors

• General sensitivity to all light - consider brown and blue gray tints

• Fluorescent sensitivity

• consider FL41, blue or gray tints

• Don’t forget brimmed hats

• Patients will use NoIR for side panels

• Patient with head trauma and exhaustion- 30% blue reduced disequilibrium

Tints • Remember to look at contrast sensitivity as well as other findings.

• Research supports improvement in reading with filters

• Richman noted decreased visual stress in head trauma case

• www.oepf.org/sites/default/files/journals/jbo-volume-18.../18-6%20Richman.pdf

NORA Kit • Green/Blue 20%

• Blue/Green 20%

• E-50 Blue

• E-30 Blue

• E-15 Blue

• Z-1 Blue

• FL-41 27%

• FL-41 50%

• FL-41 75%

• 511

• 527 Chadwick Optical

• Noir 88

)

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Syntonics -Cathy Stern

Rob Fox

Debbie Zelinsky

I still have limited experience, but I can see where patients respond to tint or light treatment rather than plus, bifocals, binasals or yoked prism.

Debbie Zelinsky has worked on an approach to determine which type of lens treatment would be most helpful including plus, yokes and tint.

Seizure RA

• Established research on continuum migraines to seizures.

• Remember migraines more common in younger boys than girls until menarche

• Headache, epilepsy and photosensitivity: how are they connected? Dorothe´e G. A. Kasteleijn-Nolst Trenite´ • Alberto Verrotti • Alessia Di Fonzo • Laura Cantonetti • Raffaella Bruschi • Francesco Chiarelli • Maria Pia Villa • Pasquale Parisi,J Headache Pain (2010) 11:469–476 DOI 10.1007/s10194-010-0229-9

• https://link.springer.com/content/pdf/10.1007/s10194-010-0229-9.pdf

• Understanding the effects of mild traumatic brain injury on the pupillary light reflex, Ken Ciuffreda, Nabin Joshi and James Truong Published Online:4 Aug 2017https://doi.org/10.2217/cnc-2016-0029

Photic SeizuresThanks Cathy Stern

• Occurs in 0.3-3% population

• Patients diagnosed with epilepsy have 2-14%

• Photic or pattern stimulations can provoke seizures, but not known to increase chances of subsequent epilepsy.

• Photic seizure triggers

• Intensities of 0.2-1.5 million candlepower

• Frequencies of 15-25 Hz provocative, but range is 1-65 Hz

• Light-dark borders can induce pattern sens. seizures

• Red color can be a factor

RA with seizures• 17 yo Patient reported by neurologist to “experience daily paroxysmal events that are triggered by visual stimuli when highly focused and absorbed in what she is doing.” Occurs with video games, long reading

• Neuroradiology events assoc with dysfunction in mesial temporal lobes

• Medical hx- 32 week premature birth, LD, ADHD, mood disorder

• 17 year old female taking Focalin, Paxil, Topamax, Detrol, Rosarum

• Wearing deep Zeis cobalt blue filter(Z1F133)

• Tilts head to right shoulder throughout

• OD-1.25-0.50x130 20/25

• OS-1.25-0.50x90 20/25 20/20-OU

• NVA 20/40 likes to remove glasses –unchanged

• Cover test ortho distance, eso at near

• NPC 5”/8”, +2.00 8”/10”, -2.00 4”/10”

• JD 14BO/8BI near

• Randot E- 7 feet, BABO #3

• MEM +1.00 sph OU with 2BD OU 20/20 near

• See Sick saccadic fine, near far bothers eyes

• DEM vert 23, horz uses finger 42+5

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Follow up appointment• -1.50 sph OU cc 2BD and a +1.00 add OU

• 20/20 out of either eye and both eyes d&n

• NPC TTN, JD 16BO,12BI at near

• Randot E at 10 feet and BABO #8

• 9500 card 20/40 at near, +1.50 20/40, -1.00 20/40

• DEM horz 35, not using finger

• Got seizure reading so ordered blue tint clip

Most recent

• MED-Tryleptal, Paxel, Detral LA, Focalin tranzadone for sleep

• -3.00 sph OU cc 2BD and a +2.00 add OU

• 20/20 out of either eye and both eyes d&n

• NPC TTN, JD 18/14BO,12/10BI at near

• Randot E at 10 feet and BABO #8

• 9500 card 20/30 at near +1.50 20/40, -1.00 20/40

• Fix disp ortho distance and eso at near

• videogameseizures.org

Ocular motility

• Fixation - key factor in sustaining visual attention - 4 months expected

• Pursuits - medial temporal mediated

• Saccades - visually controlled motor response

•predicted/remembered/reflex

•generated in frontal lobe unlike fixation/pursuits

Concomitancy testing• Direct observation

• Version Testing

• Ocular from Congenital Torticollis

• Underacting- paresis due to trauma, mechanical issues such as faulty muscle insertions, ligament or tendon abnormalities, innervational deficiencies due to impairment of cranial nerves, III, IV or VI.

• Duction testing-move the mono eye into affected DAF

Head posture

• If it affects head posture in primary gaze think about prism

Why do they close an eye?

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Why do they hold their chin up? DEM, King Devick, Visagraph

• Developmental Eye Movement test

• The DEM test consists of a vertical array of numbers and a horizontal array of numbers and can diagnose oculomotor dysfunction and visual-verbal automatic skills

• King Devick

• The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters, Galetta et al

• www.ncbi.nlm.nih.gov/pmc/articles/PMC3087467/

• Visagraph (Readalyzer) outcomes of duration of fixation and reading rate relate to standardized reading achievement scores; DEM results do not. www.ncbi.nlm.nih.gov/pubmed/21217407

The Vestibular System Provides• A motor center to move around three dimensionally

• An emotional center for self regulation

• A perceptual center so we are not lost in space

• A spatial-temporal center with which to relate to objects, people and events in our world

• Multisensory Awareness… Position in Time, Space and Gravity, Proprioception, Tactile, Speed, Duration, and Differentiation of Movement – Kinesthesia, Vision, Sound

• THIS IS VISION AND WHERE!!

Visual-Vestibular Interactions – the Vestibulo-Ocular Reflex (VOR)• Purpose: to maintain stable retinal images during head

movement • Both SCCs (semicircular canals) and otoliths contribute

• SCCs compensate for rotation (angular VOR)

• Primarily responsible for gaze stabilization -Otoliths compensate for translational movement (linear VOR)

• Comes into play when viewing near targets and head is being moved at high frequencies

• Cerebellum plays a regulatory role

• If retinal image motion is >2 deg/sec, cerebellum will modify action of the vestibular nuclei

Accommodative/Convergence

• Movement of print

• Floating of words

• Words run together or double

• Loss of place

Vestibular/Disequilibrium

• Light sensitivity

• “foggy feeling”

• Floor or walls tilting

• Walking on soft floor

• Disturbed by multisensory information

Visual causes of Disequilibrium

• Vision and Optical

• Anisometropia

• Uncorrected hyperopia

• Uncorrected astigmatism

• Peripheral distortions (PALs)

• Glare flickering lights, and reflections

• Sensorimotor Vision

• EOM anomalies

• Acc Dysfunction

• Vertical phorias

• Distance Esophoria

• Int. Strabismus

• Conv Insufficiency

• Fixation Disparity

• Restricted fus. ranges

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Neuro-Ocular Vestibular Dysfunction (NOVD) or the See-Sick Syndrome (SSS)• Sensory Conflict as a cause of motion sickness

• Visual vestibular interactions

• Conflicts between visual and vestibular information causing motion sickness

• Typical symptoms of conflict

• Dr. Suchoff, Dr. Ciufredda, Dr. Kapoor

• Dr. Roderic Gillilan- optometry approach

• Mary Kawar- occupational therapy approach

Visual acuity with motion standards

• Stable visual acuity (SVA): assess monocular/binocular acuity with the head and visual acuity chart both stable

• Dynamic visual acuity (DVA): assess monocular and binocular acuity at far or near while the head is slowly (1Hz is 60 rotations per minute, if possible, and no neck issues) moving horizontally

• If DVA is more than two lines poorer than SVA, then there is a visual-vestibular problem

Roderic W. Gillilan O.D. Testing Sequence

1. Hold Wolff wands 6 inches apart Harmon’s distance from the patient

2. Have the patient go back and forth 5X as you watch.

3. Ask about symptoms in the stomach, chest or head and watch for jaw movements.

4. Repeat while holding the sticks 6 and 12 inches away.

Since we can’t do the standard examination, we must remember the signs to support our examination

Symptoms of Ocular Motility Dysfunction

• need to reread to obtain meaning, excessive head/body movements with reading, print wiggling, swirling, or running together, skips lines, loses place in reading, difficulty keeping place copying from the board.

• Remember that oculomotor problems may indicate a generalized visual processing problem- DOMD

Developmental Oculomotor Dysfunction

• fixation issues

• tracking problems- often talk about the visual spatial aspects of tracking –reading the letters on the acuity chart

• Nystagmus

• Concomitancy issues

• See sick evaluation

Visual acuity testing

• I use visual acuity testing as a probe, not just a number to write down. Many need isolated lines or individual letters. Watch the difference in performance. Think about it as a visual cognitive task. Thanks Len Press

• Try to test in different formats to probe ability and attention. Do several tests to get a more accurate reading. Look at fluency as well. Remember that near testing is affected by uncorrected myopia.

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Visual acuity tests

• Snellen acuity testing

• many children can do numbers better than letters-Feinbloom

• Lea symbols

• Broken Wheel acuity test

• Teller cards

• Richman Face dot test

• Cardiff

• Visually evoked responses

Lea Cards

Preferential Looking Format

• Teller Cards • Richman Face dot test

Visual Acuity AssessmentCardiff Cards

• Vanishing optotypes.

• The targets disappear at the patient’s resolution limit.

• The cards contain pictures of a house, car, fish, train, dog and duck.

• The pictures are in up/down rather than right/left separations.

• Easier to distinguish in cases of congenital nystagmus.

• Does not use a peephole as in Teller acuity.

• The practitioner does not know the position of the target.

• Credit for a particular acuity level.

Patient must correctly identify two out of three presentations.

Visual Acuity AssessmentOptokinetic Nystagmus (OKN)

• Used to verify if the patient possess a cortical visual response.

• Developmental ages between 18 months and seven years.

• Requires little to no effort by the patient.

• The drum is spun slowly and the examiner observes the patient’s eye movements as they follow the rotating drum.

• The patient should exhibit a nystagmus movement.

Visual Evoked Response/Potential• Electrodiagnostic testing is a very precise way to quantify the patient’s

visual acuity.

• With Visual Evoked Response (VER), a scalp electrode is used to record electrical signals from the visual cortex while the patient views a grating or checkerboard stimulus.

www.usneurologicals.com

Remember any test can be done in a matching format

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Near acuity• Many of the children with multiple issues have poorer near acuity. Be prepared to test both crowded and single letter format. Be prepared to the school about appropriate font size.

Contrast Sensitivity testing

• Detailed contrast sensitivity measurements that include both size (spatial frequency) and contrast are used to plot a person's contrast sensitivity function (CSF).

• Sine-wave grating targets with thicker bars represent low spatial frequencies; targets with thinner bars represent higher spatial frequencies. In this regard, determining a person's CSF is much like evaluating the sensitivity of his or her hearing, which involves using tones of low and high pitch as well as variations in volume.

• Your contrast sensitivity function essentially is a plotting of the curve that defines the lowest contrast level that you can detect for each spatial frequency tested.

Contrast sensitivity testing- impacts our ability to

detect faces and recognize objects

Pelli-Robson Chart

Doing more with CVI patients

Attention IssuesThanks Jack Richman

• Remember on these tests to try to go back to the previous level to see where attention returns.

• Poor attention, distractibility, loss of fixation, extra saccades and fixation in pursuit tasks are signs of OMD and attentional problems.

• Research indicates correlations between visual skills deficits and attentional deficits.

How does neurology and neurobiology support our understanding of vision?

• Neuroplasticity

• Duffy- not disuse but active inhibition while maintaining anatomical connections

• Limbic System-cortical plasticity through arousal, attention, motivation and emotion

• This supports that vision is learned and can be remediated on a neurological level

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The dorsal stream begins with V1, goes through Visual area V2, then to the dorsomedial area and Visual area MT (also known as V5) and to the posterior parietal cortex. The dorsal stream, sometimes called the “Where am I, where is it," is associated with motion, representation of object locations, and control of the eyes and arms, especially when visual information is used to guide saccades or reaching.

•spatial orientation

•binocular fusion/depth perception

•the location, the movement and the movement direction and velocity of objects in space

Think of dual system processing in CVI

The ventral stream begins with V1, goes through visual area V2, then through visual area V4, and to the inferior temporal cortex. The ventral stream, sometimes called the "What Pathway," is associated with form recognition and object representation. It is also associated with storage of long-term memory.

• recognize objects and colors

• read text and learn and remember visual objects (e.g., words and their meanings)

Ventral system –object vision

• IT -Inferior temporal lobe- what is it?

• object recognition with close connections to limbic system, importance of what is seen

Dorsal visual system ““““spatial vision””””

• news.nationalgeographic.com/2016/01/160111-insects-animals-science-

• praying-mantises-3d-vision/

• PPC-posterior parietal cortex- where is it? How to?- spatial coordinates guide us through space through sensorimotor transformation of motion with depth perception and stereopsis serving to interpret and organize space.

• LIP- visual attention saccade

• In PPC integration of visual, proprioceptive and vestibular

Summary of transient and sustained subsystems• Transient

• Fast

• Short latency response

• High sensitivity to contrast

• Peripheral vision dominant

• Flicker, movement, depth, brightness. Localization

• Short wavelengths (blue)

• Global analysis

• Prepares system for input of slower detailed information

• Sustained• Slow

• Longer response-persists

• Low sensitivity to contrast

• Central, fovea dominant

• Stationary/good acuity

• Longer wavelengths (red)

• Identification of shapes and patterns

• Responds and is dependent on transient output

Visual perception versus visual control of skilled action• Goodale and Milner (1992) have criticized the what vs.

where dichotomy by highlighting that both systems process information about object size, orientation, shape, and spatial location.

• They suggest placing a greater emphasis on how that information is transformed and used differently by the two systems, suggesting that the distinction should be between visual perception in the ventral pathway and visual control of skilled action in the dorsal pathway.

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Optic flow

• Through superior colliculus to medial temporal lobe then on to PPC

• These are the questions of what is moving, the person or the object or both and proportional speeds.

• Optic flow is thought to be involved in motion sickness in head trauma

• Influence of Complexity and Coupling of Optic Flow on Visually Induced Motion Sickness

• L. James Smart Jr., Edward W. Otten, Adam J. Strang, Eric M. Littman, and Henry E. Cook Educational Psychology Vol. 26 , Iss. 4, 2014

The complicated truth

• The dichotomy of the dorsal/ventral pathways is still contentious among vision scientists and psychologists. The neuroscience community is still not in agreement regarding the degree to which these streams are segregated (they are, in fact, heavily interconnected) or the functional significance which should be attached to them. The hypothesis is probably an over-simplification of the true state of affairs in the visual cortex.

• An evolving view of duplex vision: separate but interacting cortical ...

• https://www.ncbi.nlm.nih.gov/pubmed/15082326

Cerebral/Cortical Visual Impairment

What is CVI?• Cortical visual impairment (CVI) is bilateral decreased

visual response due to an abnormality affecting the part of the brain responsible for sight. It is one of the most frequent causes of visual impairment in children from developed countries.

Common causes of CVI in infants and young children include:

1. hypoxic ischemic encephalopathy (HIE) (in the term born infant)

2. Periventricular leukomalacia (PVL)(in the preterm infant)

3. traumatic brain injury due to shaken baby syndrome and accidental head injuries

4. neonatal hypoglycemia, infections (e.g. viral meningitis)

5. severe epilespsy

6. metabolic disorders

7. Other causes include: • antenatal drug use by the mother• cardiac arrest

• twin pregnancy

• central nervous system developmental defects

• Advances in neuroimaging and research performed mostly on animals have provided a better understanding of the visual pathways involved in CVI and the molecular mechanisms of the damage.

• Attention now is being directed to the involvement of visual functions other than acuity in CVI, such as the “cognitive” aspects. Neuroanatomical correlation with these other aspects of vision gradually is becoming available.

CVI through TVI diagnosis and treatment

• Phase 1 Getting the child to look

• Phase 2 Integrating vision with function

• Phase 3 Resolving Characteristics

• Assessment and treatment is based on 10 characteristics

• Color, Movement, Latency, Visual Field, Complexity, Light Gazing, Distance, Visual Reflexive Response, Visual Novelty, Visual Motor

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SA

• In my practice the boundaries of a CVI and a visual based learning disability are more and more blurred. It used to be that it required documented changes to be seen on MRI.

SA 3 yo boy

• HX PDD-NOS, hypotonia, suspected metabolic disorder, developmental delays, some reports indicate mild right hemiparesis, left handed, almost non verbal

• Neuropsych thinks left damage and reorganization of brain to right side to compensate

• Seen by several eye doctors and neurologists to evaluate vision, tentative CVI diagnosis, normal MRI, 20/130 or worse in grating acuities

• Recently 20/40 on Cardiff, moderate exotropia, no eye contact, suspect dorsal stream dysfunction

• Lea matching 15 M print, 20/30 Face dot

• EOM avoids fixating left, turns head

• NPC eyes come together range 14-10”

• CT LXT, near intermittent primarily LXT

• With auditory input immed. const XT

• Vergence convergences inter to 10BO

• Randot E at 12 inches - held glasses off face

• Refraction +2.00 sph OU - unable to put on face

• MEM +0.50 ??

• Recommendations:

• Use of pictures in communications - size recommendations

• Start at 10-14” where eyes work best for eye contact

• Simplify environment to encourage visual interactions.

• Recommend quiet spaces to explore vision

• OVT

Diagnostic OVT• In confusing cases, I can recommend an opportunity to explore better

• In 6 sessions, S was able to start matching symbols at 20/80, 20/125 at near

• Parents report finding pictures in book

• Becoming more adventurous in exploring space, tracking marsdenball, jump and balance activities

Returned 7 months later• Parents continue to see changes in near work and playing

chase

• Eye contact better, but inconsistent

• VA 10/16 OD, OU and 10/20 OS Lea,

• 20/250 at near

• NPC 8”

• CT LXT at near int 35 LXT

• Vergences no BO

• No Randot

• Yoked prism assessment 10BL best 18 int LXT, NPC 3” rest of exam unchanged.

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Recently

• Returns with prism glasses 5BL OU, 2 hours semi clear patch on OD - parents report less eye turn, no problems wearing glasses

• All testing done with RX pl 10BL OU

• VA Snellen letters 20/70 each eye, near 20/160

• NPC 6”

• CT int LXT no eye turn to 7 feet, near ortho

• Vergences near 14 BO SILO response

• Findings stable with 5BL OU Rx, recommend semi clear patch OD 2 hours daily

• Looks like DVM II with CVI dorsal dysfunction

• Still recommend OVT- working with TVI and OT

What type of stimulation is helpful for

children with CVI?

• Large, high contrast, lighted, reflective and moving objects; e.g. mobile

• Touch or sound to attract child’s attention

• Visual materials presented in a simple, uncluttered manner with increasing complexity as tolerated

• Presentation of visual material from different directions/angles

• Variable level of light in environment (some children do better with a lighted toy in dim room initially)

• Extra time for responses to visual stimuli

• Avoidance of over stimulation

• Avoidance of visual tasks when child is hungry, tired, frustrated, etc.

• The literature uses a vision loss model without an understanding of behavioral optometry

• Vision stimulation

• Adapting the environment

• Rehabilitation versus Habilitation

“The girl who played with her hand”

Delayed Visual Maturation• Eliminate

• Refraction difficulties

• Nystagmus- neuroimaging needed

• Leber’s amaurosis – ERG extinguished, pupil response poor, usually pendular nystagmus

• VOR- normal then CVI or DVM

• fast movement portion missing-oculomotor apraxia

Blindsight

Three types defined1. Action blindsight - patient can do saccade or point into blind field

2. Attention blindsight - attention factors contribute which prime the attention so here must prime perceptual tasks in intact field without motor response review information

3. Agnosopsia- can guess perceptual tasks such as form or color without conscious awareness of the object

CVI research indicates that children should have treatment for 2 months before assuming no improvement.

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Getting visual attentionVisual Curiosity

can indicate a level of visual function and/or cognitive potential

Eye Coordination

In this population there may not be a second chance. Watch carefully and use different tests to impact your therapy. Think about impact of refraction.

• Near Point of Convergence

• Eye position

• When can the child use both eyes together?

Motor Fusion

• It is the ability to align the eyes in such a manner that sensory fusion can be maintained. The stimulus for these fusional eye movements is retinal disparity outside panum’s area and the eyes moving in opposite direction (vergence). Unlike sensory fusion, motor fusion is the exclusive function of the extrafoveal retinal periphery.

Near Point of Convergence

• Probe using +/-flippers, red lens, yoked prism, small amount of base-in and Bangerter foils

Cover test• Use touch and localization to see impact

• Probe using +/-flippers, yoked prisms, binasals, Bangerter foils

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Vergence testing • Use prism bar to test near and distance if possible.

• Expect 12BO/4BI distance, 20BO/10BI near

• Look for SILO in this population. Seems to equate with fluency.

Vergence Testing-non verbal patient

Sx of Vergence Dysfunction

• Print wiggling, swirling, running together, periodic double vision, skipping or rereading lines while reading, difficulty keeping place when copying from board, headaches

Vergence

• Tonic

• Fusional - disparity driven vergence

• Voluntary - volitional control

• Accommodative vergence

• Proximal vergence

• Different areas of the brain control these different types.

Sensory Fusion• It is the ability to appreciate two similar images, one with each eye, and interpret them as one. Single visual image is the hallmark of retinal correspondence. For sensory fusion to occur, the images not only must be located on corresponding retinal areas, but also must be sufficiently similar in size, brightness and sharpness to permit sensory fusion. Unequal images are a severe obstacle to fusion.

• Fusion, whether sensory or motor, is always a central process (i.e. it takes place in the visual cortex).

Sensory Fusion • Use Randot E, BABO Randot testing, Wirt Circles, Smiley Face

• Worth 4 dot - probe again

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PASS Test “Smiley Face”

• Uses polarized spectacles

• Two card presentation can be given PLT

• Present at a distance of 40 cm

• Disparities are 480, 240, 120 and 60 seconds of arc

Global Stereopsis

• Randot Stereotest and Random-dot E Stereotest use crossed polarized filters. Disparity is also constructed vectographically.

• Lang Stereotest uses a panographictechnique (Fricke and Siderov, 1997) to present disparity, and therefore, no filters are required. Patients are required to identify pictures on the Lang Stereotest.

Local or Contour Stereopsis

• An example of a contour stereotest used in the clinic is the Titmus Fly Stereotest. In the Titmus Fly Stereotest, horizontal disparity is presented via the vectographic technique (Fricke and Siderov, 1997). When tested at 40 cm, the fly has a disparity of 3,600 sec of arc; the disparity of the animals range from 400 – 100 sec of arc, and the disparity of the Wirt rings range from 800 – 40 sec of arc.

Evaluation of Global and Local Stereopsis

Fixation Disparity• Six different kinds of vergence eye movements work together: tonic, proximal, accommodative, disparity, vergence adaptation and voluntary vergence.

• Disparity vergence is the mechanism that fine tunes fixation. The others provide a supporting role for disparity vergence.

• Normally disparity vergence leaves a small residual misalignment. This is known as a fixation disparity

• A normal fixation disparity is beneficial to help stabilize fixation.

Paul Lederer Fixation Disparity Cards

• I use this system whenever possible for prescribing prism, particularly vertical prism.

• Instructional Set

• Is the “E” clear?

• Are the two arrows pointing up and down the same color?

• If they connected in the center, would they connect in position 1,2, or 3 in which I demonstrated eso, ortho and exo.

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EXAMINATION FOR SUCCESS PART 2

GREAT LAKES CONGRESS MARCH 2018

Third hour

Celia Hinrichs, O.D., FCOVD

Refraction Testing• Fixation is often poor - there is no exact answer, and it

can change

• Near retinoscopy often gives more information

• Look for improvements with any glasses in:

• Fixation and eye contact

• Posture - look for reductions in head tilts, differences on performance testing

• *** Consider a partial prescription

• Consider a trial period with the prescription - I compare it to a trial period with a medication

• Visual Function of Moderately Hyperopic 4- and 5-Year-Old Children in the Vision In Preschoolers - Hyperopia In Preschoolers Study

Refractive Error Assessment

Static Retinoscopy• Performed out of the phoropter, using lens racks and plus spectacles

(+1.50D to +2.00D) to fog the patient.

• Getting the patient to fixate in the distance may be a difficult task. The use of musical toys, bubbles and video players with cartoons may alleviate this problem. All children love to count fingers.

Mohindra Near Retinoscopy• Objective, near retinoscopy.

• Used when cycloplegia is contraindicated or unwarranted.

• The patient fixates on the retinoscope light monocularly at 50cm.

• The test is performed in complete darkness.

• The child may be occluded by a patch or the parent’s hand.

• Add -1.25D to the gross sphere power obtained if child is 18 months or older.

• Add -0.75D to the gross sphere power obtained if child is 18 months or younger.

Refractive Error AssessmentAutorefraction

• Used to confirm the results from retinoscopy.

high cylinder or oblique axes.

• Need proper fixation in order to gather measurements.

Keratometry• Used to confirm the amount and axis of the corneal astigmatism.

• Integrity of the cornea - appearance of the mires.

Cycloplegic retinoscopy• Useful in patients with fluctuations in their accommodative system,

complicated refractions to give us further information.

• Avoid over dosage in children with Down’s syndrome, cerebral palsy

and other central nervous system disorders.

C8

Watch impact of lenses on posture• What posture does the

person take when attempting to be visual?

• Under what postural conditions is the person most easily visual?

• What postures indicate stress?

Lenses are a very powerful tool

• Think about partial prescriptions.

• Bifocals - careful, more is not better

Slide 184

C8 Is it Down's or Down Syndrome?Celia, 1/30/2018

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Success of partial prescription

• Diagnosed CVI and optic atrophy, high myopia, surgical correction for XT at 3 yo.- sensory management issues

• When he wanted to be visual, he got very close to the page.

• Static -10.00 sph OU

• MEM at preferred distance -2.50 sph OU

All frames have strengths and weaknesses

Miraflex • Metal Free • No screws • No pads • No hinges • No adjustments or replacement parts required • Hypoallergenic, soft, light material adapts to child's facial structure • Anatomical bridge design • Holds any prescription to correct preemie and infant needs Littlefoureyes.com-parents talk about how glasses work for them.

Solo Bambini• Offers solid, one piece,

flexible, unbreakable glasses for babies through adults.

• These glasses are also non-magnetic and thus can be worn in MRI machines and by those with programmable shunts or VNS devices.

• They also offer other styles and brands of pediatric glasses.

• http://teachinglearnerswithmultipleneeds.blogspot.com

Tomato Glasses • Super Flexible, Ultralight

• Adjustable temple

• Adjustable Non-Slip Nose Pads

• Retain the shape of the wearer

Specs4us- ”Erin’s World” frame line

• Typical frames have the bridge aligned at the top of the frame. Since most individuals with Down Syndrome have a low flat bridge, standard frames will slide down their nose.

• Erin’s World Frames have a lowered bridge and temple placement for balance and support. Infants and toddlers with Down Syndrome usually experience sensory issues and have smaller close set ears; cable temples are usually a bother to them.

• http://www.huffingtonpost.com/entry/single-moms-eyewear-company-helps-kids-with-down-syndrome-get-glasses-they-deserve_us_

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Croakies • These can work well, if fit snuggly but not tight. It will not eliminate taking off the glasses, but makes the child work at it.

• Consider fidget toys

• I tell parents that the glasses can be a fidget toy, if only one around.

R.C. ASD?? CVI case?? 8yo

• This case highlights the issues in diagnostic work

• Originally diagnosed ASD now thought to be CVI and right hemisphere dysfunction

• Referred by OTR/L, communication was difficult and not consistent, using tactile for vision support

• HX-Born prematurely at 32 weeks, anemia of prematurity, undescended testicle, required oxygen for 48 hrs, missing rib, cardiac defects which closed w/o surgery, failure to thrive, developmental delays, hypotonia. Genetics testing was normal.

• Previous - blocked tear ducts

• Sx “side looking,” poor fixation, close to page, eye rubbing, tired left eye goes up when turns head.

• VA Single letter–needs pointing at the target to see 10/20 OD, OS, OU, near 20/200

• EOM - won’t fixate, non concomitant or double hyper

• NPC 6” alt

• CT variable left hyper ET

• Randot E negative

• Static approx +2.00 sph OU w/+0.75 sph OU 20/20 S.L.

• MEM tough ?+2.00 OU Randot 18”, BABO 600 sec of arc, 20/80

• Ocular health assessment poor fixation? OS, blocked tear ducts, no pallor, pupils

• Angels - poor monolateral, Piaget L/R – none, MORO+

Dx V syndrome int primarily LET

Rx +0.75 sph OU with +1.25 add OU

Copy forms only circle Rx +2.00 sph OU –

Rec OVT - as described later

6 months later - Binasals – start OVT

3 months later - RX +2.00 sph OU 20/20- whole line, 20/30 at near

NPC 3”/5”

CT ortho dist and near with binasals

Randot E 2.5 feet

Sx of Accommodative Dysfunction

• Fluctuating vision at near, transient blur, vision blurrier at end of the day, excessive rubbing of the eyes, esp. with near work, eye strain and fatigue associated with near work.

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Accommodation

• Tonic

• Reflex driven to clear a target

• Voluntary - volitional control

• Convergence CA/C versus AC/A

• Proximal vergence

• Again, different areas of the brain control these different types.

Near Retinoscopy

Book Retinoscopy- watching the reflex with different demands

What does touch do to the reflex?

Williams Syndrome patient

• Her teacher had requested the consultation. She noted that K.F. appeared to function as well with and without the glasses for all near tasks, but had difficulties negotiating space while walking without the glasses. (O.D.-20.50, O.S.-19.75).

• Refraction O.D.-17.00

• O.S.-16.00 using Mohindra technique

• Book Retinoscopy technique using puppets for attention-image clearer and brighter with +2.00 over static

• K.F. left this Rx on and looked around the room

• RX OD-15.00, OS -14.00

• Esotropia reduced immediately-approx. 24 diopters or less- unable to do acuity testing. I gave her the old glasses which she took off immediately and pointed to the trial frame!

• Ophthalmoscopy - glanced at moving target, no pallor, myopic disc posterior pole glance WNL no fixation from fovea

• She flipped out when we tried to apply the drops- exam was over

• Impression• 1. high myopia• 2. at least partially

accommodative left esotropia• 3. nystagmus- left jerk,

history indicates congenital• 3. ocular history indicates

concern for degenerative high myopia-patient needs a complete retinal evaluation regularly to assess concerns, but treatment plan the same at this time.

• K.F. returned in two months. She wasn't wearing the glasses consistently, but she no longer lifted her glasses to look at near. Acuity testing was in the range of 20/100-20/60 on the Face test noted above. I could not cover an eye.

• Nystagmus amplitude seemed significantly reduced.

• Cover test Krimsky technique ortho in the distance intermittent left esotropia at near.

• Randot E-no go

• Refraction -14.00 O.U. cycloplegic was the same

• Near retinoscopy using a toy approximately +2.00 add

• Dilated fundus evaluation myopic discs O.U. with scleral and pigment cresc., A/V2/3 no foveal reflex seen, posterior pole WNL, periphery in glances no sign of retinal degenerations

• RX -12.00 sph OU

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• Visual acuity 20/150 on Broken Wheel acuity testing.

• near isolated LH shapes 20/150

• if held at 6 inches she identified 1.6M print

• Nystagmus left jerk with pendular

• Versions full comitant, still using head movements to supplement at times, she often lost fixation and would look away on pursuits

• Saccadic testing using Wolf wand-only attended briefly before looking away

• Randot E-negative at one foot

• Refraction -12.00 O.U. using Mohindra technique

• Near Retinoscopy- MEM technique approx. +.50 fluctuating

• K.F. Returned in six months. Everyone was very excited. She was wearing the glasses all the time. She only removed them to show anger. K.M. was doing better with negotiating space in school. No one saw an eye turn anymore. She was doing much better in school and very well on the computer now.

• Her teacher noted that she no longer needed to highlight her work for her to scan correctly. K.M. was still on Ritalin.

• Impression• 1. High Myopia• 2. binocularity more stable-

question continued monofixation with possible high esophoria

• 3. Concerns about possible left amblyopia

• 4. EOM dysfunction• 5. Accommodative instability

at best

Testing amplitude of accommodation

• Push up method• Hard to discern except

objectively using near retinoscopy

• Minus method with flippers

9500 card

Accommodative Facility using binocular controls

What do you think?• School referred. See tracking issues

• and visual fatigue.

• OT sees midline jump, receded NPC

• PROM 30 weeks/delivery 32 weeks /4 lb 4 oz/repeated kindergarten

• Celiac disease, ASD

• SX blurred vision, int blur, eyes hurt, tired. Paper close to her head when reading or writing. Tilts her head when reading

• 1st OD mild congenital cataracts, mult. nevi on iris, myopic astigmatism OD, Rx +1.00 readers child says helps

• 2nd OD exophoria distance and near, reduced stereopsis, AI, EOM dysfunction Rec OVT What do you think?

•

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Diagnosis and Treatment• Anisometropia OD -0.75,

OS Plano

• Divergence Excess int RXT

• AI (reduced acuity at near)

• EOM Dysfunction-automaticity and tracking on DEM

• Ocular vestibular issues-dizzy crossing midline with jaw support

• Bilateral integration issues

• Visual motor delays

• RX OD-0.75, OS Plano with +1.00 add OU

• Chose bifocal contact lenses

• OVT-12 sessions

• RXT-pulls back/distance vergences 4BO, Randot E 9 feet, 40 sec of arc near, no supp on assoc phoria, still AI, EOM dysfunction

• Inconsistent CL in summer reminded to wear regularly continue OVT

Down Syndrome • Significant refractive error, strabismus and accommodative issues are common.

• Usually occurs when there is an extra copy of chromosome 21. This form of Down syndrome is called Trisomy 21.

• Down syndrome is the single most common cause of human birth defects.

• 5-10% have dual diagnosis with autism.

Systemic Manifestations• Mental retardation

• Moderate to severe with an IQ range of 20-85.

• Seizure disorders• Psychiatric disorders

• Higher risk for autism, attention deficit disorder and other behavioral issues.

• Premature aging• Graying or hair loss, cataracts and hearing loss.• Sleep apnea.• Dementia like Alzheimer’s disease.

• Congenital heart defects• Common cause of death in the first two years of life. 30-50% of DS patients.

• Acute leukemia• 15 times greater in this population.

• Infectious diseases• 12-fold increase.• Pneumonia.

• Hearing loss and chronic otitis media

Use of Topical Medications

• Increased susceptibility to atropine

• Vasovagal actions• Twofold increase has been reported.

• Atropine ophthalmic• Shown to cause a more rapid, sustained pupillary

dilation.

• Glaucoma• Avoid medications with cardiovascular and respiratory

side effects.

Remember how to determine use of yokes

versus simple plus lenses or both

• Stereopsis testing

• Fixation disparity testing using Lederer card distance and near

• Walking, sitting, hitting Marsden ball, Jump vergence testing using prism

• Worth 4 dot with +/-2.00

• Acuity testing - remember it is a visual cognitive demand

Bangerter Foils• Another tool to bring about change in visual processing

• It can be used in a home-based program or as part of office therapy

• It appears to act similarly to monocular training in a binocular field

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Think before bifocal

• Kindergarten child

• Intermittent esotropia in the distance

• 30 diopter RET at near

• Smartphone issues

Use of partial occlusion

Mitochondrial disease

• Think mitochondrial disease when three

or more organ systems are involved

• Many experts refer to Mitochondrial Disease as the "Notorious

Masquerader" because it wears the mask of many different

illnesses

• Less dramatic case S. J.

Leber’s Heredity Optic Neuropathy

• Bilateral, painless, subacute visual failure that develops during young adult life.

• Visual acuity is severely reduced to counting fingers or worse in the majority of cases.

• Visual field testing shows an enlarging dense central or centrocecal scotoma.

• After the acute phase, the optic discs become atrophic.

Severe case

• In the severe case, acuity will drop during the examination. Damage can occur with too much stress.

• Can we build stamina?

Other testing

• Field Testing

• Confrontation field testing

• Amsler grid

• Tangent screen

• Goldmann perimeter

• CVI lower field issues

• Think about attention in these populations.

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Visual Neglect

• Differentiating from field loss

• Extinction: hold both hands up. Finger count using both hands.

• Skip letters on left side of acuity chart.

• Visual spatial midline testing - remember patient can move his eyes, but not head. Present from one side, but do both. Repeat testing.

• Walking down a hall, sitting in a chair.

TS

• Stroke child - visual exam and treatment

• Example of recovery of vertical/field loss difficulties

Ocular health Assessment

Reconfirm the diagnosis

Does the case make sense in light of the behavioral findings?

These patients should have a very thorough ocular health assessment. If you can’t get a look, refer.

• Color vision testing

• Ishihara

• Waggoner

• Color swatches -matching

Anterior Segment EvaluationGross inspection can be performed with:

• A high plus lens (20D lens with a penlight or BIO light)

• A hand-held or stationary slit lamp

• The Bluminator®

an LED-based ophthalmic illuminator.

emits either a white or a blue light.

provides a 7x image.

powered by a nonrechargeable battery with an expected life span of three to five years.

The anterior chamber can be evaluated by using a trans-illuminator

and checking for limbal glow.

• The trans-illuminator should be placed to the temporal side of the patent’s face.

• The practitioner should note the amount of glow that is transmitted throughout the chamber angle and is visible on the nasal side of the globe.

• A shadow may suggest a bowed iris while a uniform glow suggests a flat iris.

Posterior Segment Evaluation

Be creative!

The patient may have to:• Lay on the floor

• Sit in their parent’s lap

• Sit in a wheelchair

The practitioner may have to:• Lay on the floor

• Crawl on the floor

• Make sounds (of their own choosing)

Photosensitivity is very common • Due to medications or pathology (aniridia or rod monochromatism)

• Using low illumination or a red-free filter may promote patient cooperation

Sedation may be required

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Measuring Intraocular Pressure

Goldmann Applanation Tonometry (GAT)• Gold standard

Digital tension estimation• When all else fails!

• Reliable means of obtaining IOP- Ficarra et al

particularly in the range of 6mmHg to 22mmHg.

• To perform this test

The patient should close their eyes and look down.

One index finger should be used to keep the eye in position.

The other index finger should be used to apply pressure above the tarsal plate.

The pressure estimation is obtained by the pressing finger force felt by the stationary index finger.

• Pressures should be recorded as ‘soft to touch,’ ‘medium to touch,’

or ‘hard to touch.’

Measuring Intraocular Pressure

• iCare Tonometer

• Hand held

• Requires no anesthetic

• Patient must be sitting up

Developmental Visual Information -Processing Use of visual cognitive skills for extracting and organizing

visual information from the environment and integrating this information with other sensory modalities and higher cognitive functions.

Think in terms of perception, cognition and conceptualization.

Sensorimotor processing deficits affect VIP.

Visual Information Processing

• The visual information model has elements of the visuomotor model, but attaches primacy to cognitive rather than motor factors. Len Press p. 139

• Major subsystems of perception are sensory, motor and perception. Attempts to isolate perception from cognition don’t work clinically.

• Two optometric Piagetian scholars - Suchoff and Wachs - recommended less foundation on motor skills and great emphasis on cognitive skills.

• Recent research supports for visual spatial WM

Information Gathered in History• What does the neuropsychological battery tell you about the child?

• Most common test seen is the WISC

• O.T. are often doing much of the visual information testing battery that I learned -DEM, Beery, MFVP battery

Executive Function (EF)

• Executive Function is the ability to integrate a present awareness with future anticipation and past experience to develop a reasonable plan (accounting for space, timeand people) for present action.

• Significant variation in the subtests of the WISC- EF disorder is suspect.

• Relationship between motor coordination and executive function in adolescents http://www.marianjoylibrary.org/Residency/Key%20References/documents/Ref32.pdf

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ADHD DSM 5 Diagnostic Criterion • People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity

• that interferes with functioning or development

• Why are we interested?• Granet DB, Gomi CF, Ventura R, Miller-Scholte A. The

Relationship between Convergence Insufficiency and ADHD. Strabismus 2005 Dec; 13(4):163-8.

• Borsting E, Mitchell GL, Kulp MT, Scheiman M, Amster DM, Cotter S, Coulter RA, Fecho G, Gallaway MF, Granet D, et al. Improvement in academic behaviors after successful treatment of convergence insufficiency, Optom Vis Sci. 2012 Jan; 89(1):12-8.

• Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on tasks or play activities.

• Often does not seem to listen when spoken to directly.

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has trouble organizing tasks and activities.

• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted

• Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

• Often fidgets with or taps hands or feet, or squirms in seat.

• Often leaves seat in situations when remaining seated is expected.

• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

• Often unable to play or take part in leisure activities quietly.

• Is often "on the go" acting as if "driven by a motor."

• Often talks excessively.

• Often blurts out an answer before a question has been completed.

• Often has trouble waiting his/her turn.

• Often interrupts or intrudes on others (e.g., butts into conversations or games)

• In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

• Several symptoms are present in two or more setting, (such as at home, school or work; with friends or relatives; in other activities).

• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

• Combined Presentation: if enough symptoms of both inattention and hyperactivity-impulsivity were present for the past 6 months

• Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

• Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

• Because symptoms can change over time, the presentation may change over time as well.

Changes in the DSM-5 from the DSM-4• The fifth edition of the DSM was released in May 2013

and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD:

• Symptoms can now occur by age 12 rather than by age 6;

• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting;

• New descriptions were added to show what symptoms might look like at older ages

• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.

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Wechsler Intelligence Scale for Children WISC IV versus V

This test is helpful to talk about prioritizing for the child. It allows us to compare with other tests of visual processing.Remember this test is meaningless without tests that look at the child’s learning in school. It is a test of cognitive functioning.

WISC IV

• Verbal Comprehension

• Perceptual Reasoning

• Working Memory

• Processing Speed

WISC V

• Verbal Comprehension

• Visual Spatial

• Fluid Reasoning Index

• Working Memory

• Processing Speed

Executive Function Disorder • DSM V eliminates NLD as

a diagnosis

• If not meeting ASD standards, now often called EFD

• Need to separate from ADHD as struggles can be very different.

• New issues with boundary of CVI versus a right hemisphere learning disability.

Simultaneous versus Sequential Processing• Simultaneous processing is the mental process we use to

integrate separate bits of information or stimuli into a whole. Processing a person’s face, maps and graphs, having a good sense of direction, and being able to see how puzzle pieces fit together are examples of simultaneous processing.

• Successive processing is what we use to linearly organize bits of information into a chainlike progression. The order of words in sentences, mathematical procedures, multi-step directions, a series of digits such as a phone number and musical notes in a tune are examples of stimuli that need to be processed successively.

Rey Ostereith Drawing samplevisuospatial abilities, memory, attention, planning, and working memory

Executive Function Therapy

• Medication

• Neurofeedback

• Computer programs like Cog-Med

• Occupational therapists

• Behavioral optometry

• Speech and Language therapists- usually more involved in adapting the environment

• Physical therapy using sports model

Read the Room and Follow the STOP signsThanks to Sarah Ward, M.S., CCC/SLP

Space

Read the

Room

What is

the

space

telling you

about:

What's

going

on?

Time

Get on the

Timeline

What is the

time telling

you about

the:

Pace

Time of

day

What is

happening

at this

Moment in

Time?

Objects

Read the

Object

What does the

object tell you?

People

Read the

Person

What are they

telling

you?

Face

Body

Appearance

Mood

Pace

Saying

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KM

• Concerns about PDD or NVLD - with gifts

• Hx of mild CI, AI

• Ocular vest symptoms

• Stamina issues

Visual Information Processing Testing

• Many of my patients are unable to do standard testing. Skills are considered through observation.

• Bilateral integration-Standing Angels

• Visual spatial skills-directionality

• Visual analysis

• Visual motor

• Auditory visual integration

Behavioral Observations of Visual Processing Difficulties• Gross motor and bilateral integration

• Directionality

• Form perception and discrimination

• Figure ground

• Visual closure

• Visual sequencing

• Visual motor integration

• Auditory-visual integration

Primitive ReflexesThank you Carol Marusich, Caroline Hurst, Svetlana Masgutova

• Successful function relies directly on the emergence, maturation, and integration of related primary motor infant reflexes

• Moro Reflex, Tonic Labyrinthine Reflex [TLR], Asymmetrical Tonic Neck Reflex [ATNR], Symmetrical Tonic Neck Reflex [STNR], Plantar Reflex, Palmer Reflex, Rooting Reflex, and Spinal Galant Reflex

• Permission for Carol Hurst video

• It is my experience that if you load enough under the correct conditions, primitive reflexes can reemerge.

Signs of Gross Motor and Bilateral Integration Difficulties• Lack of coordination and balance between 2 sides of

system

• Tends to fall and bump into objects excessively

• Poor in athletics

• Tends to play with younger children

• Difficulty with rhythmic activities

• Difficulty sitting, standing still

• I do a great deal of lens treatment and optometric prism therapy with OTs and PTs.

Testing• Usually tested with Standing Angels in the Snow - done

on back as needed

• Alternate 3 hop

• WACS test - general motor portion

• Primitive Reflex testing

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Symptoms of Directionality Difficulties

• Difficulty learning right and left

• Reverses letters and words with copying, writing, numbers on the DEM

• Use directionality in testing

• Tested most easily in this population using Piaget L/R/ Gardner if needed

Form Perception and Discrimination

• Confusion of likenesses and differences seen in letter or shape recognition

• Uses other senses to support what should be visual discriminations

• WACs testing

• TVPS

Signs of Figure Ground Issue

• Difficulty determining what is significant from what is insignificant

• Hard time with color vision testing, but knows colors

• Poorer Stereopsis in Randot testing

• Stops work before finished or perseverates on details

• Difficulty completing work

• Difficulty learning to read

Signs of Visual Closure Issues

• Ignores details in visual tasks

• Can do several parts, but not put together

• Work is incomplete

• Slow work

• Possible poor comprehension with reading

• Children with autism and NVLD do poorly on these tasks according to the literature

Signs of Visual Sequencing Issue

• Difficulty organizing himself and materials

• Poor spelling

• Ignores left/right direction

• Difficulty with visual tasks with more than one step

Visual Motor Integration• Difficulty copying from blackboard

• Sloppy drawing and writing

• Poor spacing, excessive erasing

• Can respond orally, but not produce answers in writing

• Testing often done before me, so I use• Wold Sentence Copy with WC Maples

modifications

• Gesell Copy Forms

• WACS

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Auditory Visual Integration Rethinking

• Auditory visual integration most closely correlated reading scores in grades 1-6 Solan

• Signs

• poor spelling

• difficulty reading phonetically

• difficulty relating symbols to sound

• Testing -TAAS, Dyslexia Screener

• Consider auditory integration therapy/Interactive metronome

Visual Perceptual Testing

• Many of these children are difficult to evaluate for everyone.

• Testing usually indicates a minimum level.

• Watch for patterns in different tests for support of your findings.

• I often use the information in my diagnosis, if possible, and incorporate the information in the active vision therapy program.

• “When vision works well, it guides and leads the body; when not, it interferes.” John Streff, O.D

Vision Development Overview Thanks Ron Berger

• Birth to 6 mo: reflex to reflex integration of fixation, E/H coordination, focus

• 6 mo - 2 years: Physical maturation inc eye-hand visually directed movement

• 9 mo - 2 years: object permanence beginnings of memory

• 1-3 years: same-different, match on top, match side by side

• 3-5 years: recall of experienced events, auditory visual match and recall, recall by pictorial imaging

• 5-7 years: manipulation of non-complex forms

• 6-11years: manipulation of moderately complex patterns, visualization of self elsewhere

• 8-14 years: complex visual thinking and problem solving with visual clues

Harry Wachs teaches us

Piaget refers to two major components of intellectual development:

• sensorimotor (action involved)

• operational (object involved) knowledge

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Piaget- Cognitive Development

• 0-2 Sensory motor learning only (touching to learn)

• 2-6 preoperational “the world is the way I see it” “you moved the target on cover test” “tall is the biggest”

• 6-12 Concrete operational - learn ability to “conserve”

• 12- formal operational act upon ideas

WACSWachs Analysis of Cognitive Structure

• 1.Identification of Objects (Visual Discrimination)

• 2. Object Design

• 3. Graphic Design

• 4. General Movement

• Many of my school age patients do not meet the top standards of this test.

Wachs Visual Blocks testThanks to Richard Shank

• Uses parquetry block patterns to explore visual spatial imagery

• The first step is matching

• Then the patient is asked to flip the design vertically and horizontally

• Test is in handouts

• Remember that broader sensorimotor processing deficits affect visual information processing. The child may have a deficit in sensorimotor processing and not a primary visual deficit.

Assessment and Treatment Plan

CONSIDER:

• trial period with prescription

• further assessment with prism, yoked prism, binasals

• optometric vision therapy

• low vision devices

• environmental recommendations

• set priorities/treatment plans

• Further referrals as a member of the team

CeliaHinrichsOD@gmail.com

See you at

10AM tomorrow!

• Celia Hinrichs, O.D., FCOVD

• 169 Powers Road

• Sudbury MA 01776

• 978-443-7529

• CAHVISION.COM

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LENS TREATMENT AND OVT FOR

SUCCESS GREAT LAKES CONGRESS

MARCH 2018

Fourth hour

Celia Hinrichs, O.D., FCOVD

Remember how to determine use of yokes versus simple plus lenses or both

• Stereopsis testing

• Fixation disparity testing using Lederer card distance and near

• Walking, sitting, hitting Marsden ball, Jump vergence testing using prism

• Worth 4 dot with +/-2.00

• Acuity testing - remember it is a visual cognitive demand

Yoked Prisms

• Requires a behavioral optometric approach beyond the analytical evaluation

• Smaller amounts (<5 diopters) are considered directive

• Larger amounts are considered disruptive, but can appear to “calm” the patient

• developmental screening can determine level to evaluate in skills and posture

Kraskin versus Kaplan

• Kraskin uses yoked prisms in the same direction as the difficulty to “push” the patient.

• Kaplan looks to decrease the visual symptoms or findings.

• Seeing Through New Eyes

Post Trauma Vision SyndromeThanks Bill Padula

• Signs

• Exotropia or exophoria

• Convergence Insufficiency

• Accommodative Insufficiency

• Ocular Motor Dysfunction

• Increased myopia

• Symptoms

• Double vision

• Blurred vision

• Stable objects appear to move

• Headaches

• Light sensitivity - not the same as photophobia

Abnormal Egocentric Localization

• Ken Ciuffreda differentiates between neuroperceptually based alteration of straight ahead and mechanically based, noted by Padula as Visual Midline Shift Syndrome.

• Seen in patients with hemianopsia, visual neglect, PTVS

• Also seen in my practice are midline shifts with developmental delays

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Dr. Kaplan explored yoked prisms through different tasks to consider a yoked prescription.

Probe Using Yoked PrismsRemember also Lederer fixation disparity testing.

HC 11 yo girl

• Referred by PS - has had OVT and made “great gains," but still complains of blurred vision dist and near. She has bifocals that she does not wear.

• Long list of diagnostic work and treatment approaches, MRI indicates damage right side, Bacterial meningitis at 3 months, ADHD, Dyslexia, CVI concerns, profound sensorineural hearing loss left ear.

Findings• Obs. Continually shifting head to the left to put OD more central

• VA 20/20 OD, OS, OU, near 20/30 fluent 20/20 isolated letters

• EOM - interm. midline jump, See Sick findings

• NPC TTN faster convergence OS

• CT ortho, eso at near

• Vergences 8BO/1BI dist, 18BO/4BI near

• Static +0.50 sph OU

• MEM +0.75 OU total

• Randot E at 10 feet, BABO 20 seconds of arc

• AO vecto suppressed OS below 20/40

• DEM V54, H70 (at 11 V 37.14+/-5.42, H 42.62 +/-7.61)

• Bilateral integration – continue motor overflow with right arm

• Retained MORO reflex

• Hard to measure egocentric shift, but walked through doors in the center with BR and left side with BL. Was able to handle a number of tasks described later with 3BR OU best.

HC

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• Rx +0.50 sph with 3BR OU - reduces head turn, 20/20 acuity distance and near, better symmetrical convergence on NPC, no midline jump seen in saccadic fixations across midline.

• At PE reports wears them all the time, no blur, eyes less tired, no head turn, no motion sickness symptoms.

• One year later, no need for BR prism, but responded well to +0.50 sph OU 2BD. With this RX, DEM 3 year gain!

• Recommended OVT – She completed the OVT program geared toward visual skills improvement and did well.

Prism therapy treatment using prism glasses with other professionals can work well – see handout

Child with complex seizures in prism therapy-LS

11 yo ASD, Mitochondrial Dysfunction, Anxiety

• VA: 10/10 out of either eye and 10/10 (20/20) with both eyes using Feinbloom letters presented at 10 feet, matching format. At near she could identify 20/60 letters in a row and 20/30 letters if presented singly. Often turned her head to put her eyes in right gaze or turned her head to the left.

• Unable to fixate for greater than 2 seconds. Concomitant but clearly was most comfortable in right gaze.

• Int. RXT, she would move into right gaze or close her right eye when the target was closer than 10 inches. Converges only left eye in testing.

• MEM indicated over focused. With any relaxation of focus, her nearpoint of convergence receded further to 15 inches.

• Testing as noted above supported a midline shift such that 10 diopter BL OU yoked prism improved performance.

• Nearpoint of convergence improved immediately to 6 inches and decreased again to 12 inches, when it was removed. With the prism, her right eye now demonstrated convergence in testing and both eyes stayed open.

• Vergence testing now gave ranges at near of 8BO and 8BI with the prism bar. Without the yoked prism, closed the right eye in convergence testing.

• Stereopsis improved at near to 30 seconds of arc and again decreased to 100 seconds of arc in Randot Stereo without the yoked glasses 10 BL OU. When she walked around with this treatment lens, she appeared to suddenly notice her foot placement and the room around her.

• Depth perception or stereopsis was tested both distance and near (Randot E at 4 feet, 100 seconds of arc at near).

• Ocular health screening was attempted and was difficult as expected. The media was clear. The optic nerve showed no obvious pallor. There is clear foveal reflex in both eyes. The posterior pole was within normal limits. The anterior segment appeared within normal limits with magnification. Digital tonometry was within normal limits. Needs DFE.

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• Convergence Insufficiency with intermittent Right Exotropia at near, Reduced Stereopsis, Accommodative Insufficiency, and Oculomotor Dysfunction with ocular vestibular difficulties.

• Yoked prism therapy is the first step for the reasons noted above. This level of yoked prism treatment (10 Base Left in both eyes) is usually given as an optometric vision therapy treatment rather than prescribed in glasses. There was some evidence in the diagnostics that treatment could shift quickly. Therefore, she was given yoked prism therapy glasses in 10 BL OU and asked to wear them for the next three weeks.

1 month later- get eye contact and no turning of the head

• Acuity unchanged.

• No right gaze preference

• Now can converge her eyes to 6 inches before the left eye drifts out and can converge along the midline with no head turn. With her treatment prism glasses (10BL OU), she would converge to one inch and there was no drift of the left eye. Less prism (5BL OU) now allowed the patient to do all these tasks.

• Vergence testing indicated convergence and divergence ranges at near without any evidence of the intermittent exotropia seen at the first evaluation.

•

• Without the prism treatment, she was under focused for near targets. The new prism treatment also improved her near crowded acuity to 20/80, but this was hard for her for any length of time.

• Depth perception or stereopsis was tested both distance and near (Randot E at 4 feet, 60 seconds of arc at near). Near depth perception has improved and is better when she wears her prism glasses (240 seconds of arc to 60 seconds of arc).

• Working with her iPad, holding it close and might be covering her right eye with her hand. With 5BL OU, she immediately pushed the iPad further out and stopped holding her right hand near her eye.

Three months later

• Her occupational therapist reports that she does better with the prism glasses, but there has been some “stimming” on the right side. Her headaches are significantly reduced. She still closes her right eye frequently with fatigue. Only able to wear the glasses for 30 minutes 2X daily in school and 3X 30 minutes at home.

• Focused more accurately with a mild hyperopic prescription of +0.50 sph OU. With this prescription and prism (+0.50 sph OU 5 BL OU), her acuity is maintained both distance and near, her nearpoint of convergence is still 3 inches and depth perception using Randot E is noted at 6 feet. With less prism, she closes her right eye more frequently again.

• Returns with her lens treatment glasses (OD+0.50 sph 5BI, OS+0.50 sph 5BO). She now approaches with eye contact and smiles on greeting. Her mother reports that she wears the glasses all the time and feels that her eye contact is excellent. She no longer closes the right eye. There is still an occasional headache with eye pain and eye strain. She is rubbing her eyes at times, but it might be allergies.

• Still CI (4BO at near before she closes left eye), NPC 4 inches or better. Her depth perception testing is normal in the distance and better at near (Randot 200 seconds, 60 seconds of arc on Smiley Face test).

Prism Therapy and OVT

• See handout

• PE after 13 sessions of OVT

• Used illuminated Snellen letters in a matching format with her communication device. With her present glasses, she tested 20/20 out of either eye and 20/20 with both eyes open in single line format and read the 20/25 line in crowded letter format. She again understood the organization of the chart left to right and top to bottom. At near, she did 20/25 crowded print.

• NPC TTN, Vergences at near 14BO/10BI, Randot E at 10 feet, BABO 100 sec shapes

• 9500 card 20/40 +2.00 20/50, -2.00 20/80

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• A negative answer is just as important

Yoked Prism Effects

Guidelines only - look for performance changes

• Prism-oriented base down in both eyes

• Effect is upward spatial shift, expansion

• Consider in flexion

• Prism-oriented base up in both eyes

• Effect is downward shift, compression

• Consider with hyperextension

• Prism-oriented base right in both eyes

• Effect is a left shift, floor tilts right

• Consider with right midline shift, left weakness

• Prism-oriented base left in both eyes

• Effect is a right shift, floor tilts left

• Consider with left midline shift, right weakness

Yoked prism hints

• Remember the child afraid of space. He does well here with smaller amounts of yoked prism.

• The mover often won’t respond to small amounts. Think about the red green therapy and larger amounts of yoked prism. I will use 10-15 diopters to obtain a change and increased awareness.

Optometric Vision Therapy

• Optometric vision therapy using a lens prescription only - consider tint

• Any lens combination can be used in conjunction with other therapies

• In-office optometric vision therapy

• “When vision works well, it guides and leads the body; when not, it interferes.” John Streff, O.D

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In-Office Optometric Vision Therapy

• Prism and lenses are used to effect change in the therapy

• Consider position to make the process easier

• Use large simple targets at first

• Remember that even verbal instruction can be overloading

• Movement, balance, auditory input and cognitive demand are used to increase load

Management in Optometric Vision Therapy and the Examination

• Engagement - practice social skills – Chatter - can only engage verbally or by touching objects

• Wants to control the topic

• Need to understand their way

• Avoid the treatment

• Sensitive to any physical touching - patient feels as sharp pain

• Be aware of your energy and grounding - can’t rush, stay focused and clear - helpful but strong

• Speak softer to get softer

• Consider ignoring behavior

• Offer quiet breaks - time outs – no talking or engagement

• Behavior management• How can you do the task differently?

• Child picks order of treatment by sorting cards

• Parent in the room?

Position impact

• Midline development

Auditory Impact

• Impact of environment -too much noise - consider headphones - schedule differently

• Visual signals may be most effective

• Using pitch and volume to increase awareness

• Metronome

• Then add back noises to increase the load

• http://www.oepf.org/product/parallels-between-auditory-visual-processing; http://www.oepf.org/sites/default/files/23_4_PRESS.pdf

• http://www.oepf.org/product/parallels-between-auditory-visual-processing; http://www.oepf.org/sites/default/files/23_4_PRESS.pdf

Astronaut Board for Ocular Vestibular Treatment Mary Kawar, OTR/L https://www.youtube.com/watch?v=gpu5i2ufnaQ

Used in testing and treatment in patient With or without fixation

Mary Kawar, OTR/L“Astronaut training”

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Astronaut Training

https://www.youtube.com/watch?v=gpu5i2ufnaQ

Preparing exercises for the ocular vestibular board

• Twirling

• Rotating with touch

• Rotating and touching toes

• Hands above touching to hands through legs touching Remind me of Curt Baxstrom’s series in ABI

• Think also about yoked prism therapy

Most common shift is level of arousal or alertness

Active Vision Therapy

• Fixation

• Pursuits/Saccades

• Visual motor integration

• Ocular vestibular integration

• Think about CORE strength

• Primitive reflex/motor patterns

• Directionality

• Midline integration

• DO NOT TREAT AVOIDANCE OR “NO” AS REJECTION!! Position yourself in front of the patient

• Insist on a response

• Do what the patient tells you to do; take turns being in charge

• Allow frequent sensory-motor breaks or incorporate them into therapeutic activities such as bouncing, swinging, rolling, spinning, deep pressure, etc.

• Use gestures, tone of voice, and body language that are familiar to the patient to accentuate what you say and do.

• Be flexible in your approach; sometimes there is more than one way to get the job done- joy in trampoline

• Identify and praise appropriate behavior

• Set limits, but make sure they understand the rules

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• I need to work in short bursts in this population so my techniques need to move “up and down” easily to work several areas at once.

• Rely on behavioral changes only in most work

• 12 week progress evaluations to check in-is what I am doing making a difference? I tell patients that this is my test..

Hierarchy

• Fixation/body/ directionality/tracking/ focusing/visual thinking/standard OVT

Incorporate visual perceptual in my work

• Accommodation

• Binocularity

• Fine visual motor work

• Visual form thinking

• Visual logic thinking

MODIFYING OVT FOR SUCCESS

GREAT LAKES CONGRESS MARCH 2018

Fifth hour

Celia Hinrichs, O.D., FCOVD

Traditional Optometric Vision Therapy

• I hope to get to level that we can do the usual treatment approaches for a patient with visual skills deficits or visual learning deficits – thanks Bob Sanet

• Here you need to think about the theory behind the approach to lower the cognitive or physical demand

• Improving Dorsal Stream Function in Dyslexics by Training Figure/Ground Motion Discrimination Improves Attention, Reading Fluency, and Working Memory

• Terri Lawton

• http://journal.frontiersin.org/article/10.3389/fnhum.2016.00397/full

• How do we do this in the vision therapy room?

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What if they hate spinning?

• Optometric prism therapy- see handout

• The technique involves continually changing the orientation every 3-5 minutes to teach the patient of the impact of peripheral visual skills and the integration with the other senses.

Using the SUNY Motor Series

What are we working on in this sequence?Bilateral integration and directionality for starters

• Balance board Theraball

Adaptations are necessary

• beginning theraballwith cp

• falling off ball

• later on ball

• adaptation for walking rail with cp

• ataxia and walking rail

Three techniques varied for the patientGeneralization

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How do we load?• Can the patient do it?

• Can they do more lines?

• Can they verbalize-left/right, middle?

• Add the arms

• pdbq chart

• Do as MFBF or bino

• Do it as a visual memory task as I call out the directions?

Brock String work

This is often frustrating in this population at most levels. Why? What techniques do you use?

Pointer in a straw technique Use these concepts in near tasks with lenses

Use of red green in therapy room See impact in therapy room

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Activities with the Red Green Glasses/Black lightThanks also to Dr. Torgerson and Dr. Rose

Activities with Red Green Glasses/Black lightThanks also to Dr. Torgerson and Dr. Rose

• This technique was used a great many years ago with patients’ vision loss and then with autism. I am now seeing it used with patients with CVI.

• The red green glasses are worn for all activities. Glasses are not necessary for black light activities, but it must take place in a dark room. Both techniques use white objects. Children with visual impairments can also benefit, and it is called vision stimulation in their literature.

Start with red green glasses

1.Some patients need to just start with you helping them move parts of their body while they look at the light. Try white gloves, white socks. Consider theories of motor development in a hierarchy of techniques. Start with the parent or therapist helping with the movement, then imitating the movement, then doing it with verbal commands.

2.Next consider flashlight tag, even a miner’s light. The child can “zap” objects around the room which they choose and then ones which you suggest. Consider adding rhythmic component which helps some children and makes it more difficult for others.

1.Play tag games with two flashlights held or mounted on the child’s head.

2.Walk a beam or white line on the floor while watching the light.

3.Play with a large white balloon. Graduate to play with large white balls to small white balls, consider white bean bag or koosh ball.

4.Young children do interesting visual activities when placed in a “sandbox” of white rice with the red green glasses on and are just allowed to dig and play.

1. Make white play dough or clay. Some children do not like to touch this. Consult with the occupational therapist on tactile issues.

2. Play visual perceptual games with white parquetry blocks and simple patterns to copy.

3. Recognize that all glow in the dark toys are a good white.

4. Light brite with clear, red and green pegs only copying designs. First just concentrate on the activity of placing the pegs in the hole in any design, then give patterns to do or copy or letters to copy. I have also worked with white pegboards.

5. White marker board with a black marker. Some therapists and parents have found that many skills can be placed on a white background to improve visual attention to the task.

Success!• History of brain damage - agenesis of corpus callosum

• Before black light treatment approach, did not respond to visual cues

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Summary

• Monitor sensory environment/minimize noise and other distractions

• Consider using visual instructions only

• Change position to decrease the overall load

• Consider lenses - to decrease the load or “increase the volume” of visual input

• Have many activities doing the same task so spending only a short time on each task.

• Black light or red green activities to increase the volume - often called vision stimulation

Visual Cognitive Therapy

Visual-Cognitive Therapy integrates sensorimotor and cognitive hierarchies to strengthen vision development. As you have seen I often incorporate with my basic visual skills work.

• Presented at an appropriate overall developmental level, not just visual development.

• Presented in a way that is meaningful and interesting to the patient.

• Tailored to meet the child’s unique needs.

Visual Thinking Thanks Carl Hillier

• What do you see?

• Phone call or email

• Sorting

• Rapid Naming

• Often incorporate with prism or other filters

Categories

Visual/Spatial Portals to Thinking, Feeling

and Movement:

• Advancing Competencies and Emotional Development in Children with Learning and Autism Spectrum Disorders

• Thanks to Mehry Green and Nancy Torgerson with education from Bob Sanet

DIR/FloortimeDevelopmental Individual Difference Relationship Model

• Developed by Dr. Stanley Greenspan and Serena Wieder, Ph.D.

•D is developmental Milestones Stages 1-6

1. Self regulation and interest in the world

2. Intimacy, engagement and falling in love

3. Two way communication

4. Complex communication

5. Emotional ideas

6. Emotional and logical thinking

This is a different way of organizing how you evaluate and work in the optometric vision therapy room.

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•I for Individual differences

• Difficulty with sensory activities

• Processing difficulties

• Difficulties with motor planning and sequencing

•R for Relationship based

•Floortime is the technique

1. Following the child's lead

2. Joining the child's world and pulling them into a shared world in order to help them master each of their Functional Emotional Developmental Capacities

Foundation Capacities for Development

• There are three:

• Activate

• Organize

• Integrate

• How well this happens depends on individual differences

• Arousal and regulation

• Vestibular and proprioceptive abilities

• Auditory and Visual Spatial processing

• Relationships

•So how does this work in the exam and therapy room?

VISUAL SPATIAL PROCESSING

Observations:

• Observe and focus on a desired object

• Alternate gaze (initiate joint attention visually)

• Guide vision across space-differentiating visual figure ground

VISUAL SPATIAL PROCESSING

Observations:

• Explore 2+ areas of a room and search for a desired object

• Explore more than two areas with active visual assessment of space, shape and materials.

Body Awareness and Space

• Year 1: Purposeful, coordinated movement, guided by vision and sound

• Year 2: Purposeful movement for interactive play

• SC patient first floortime

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Thanks Dr. CoulterOptometry and Vision Development

Volume 40, No. 3, 2009

• The Role of Optometry in Early

Identification of Autism Spectrum Disorders

• by Leonard J. Press, OD, FAAO, FCOVD; Jack E. Richman, OD, FAAO, FCOVD

• Serving the Needs of the Patient with Autism

• by Rachel A. Coulter, OD, FCOVD, FAAO

• Understanding the Visual Symptoms of Individuals with Autism Spectrum Disorder (ASD)

• by Rachel A Coulter, OD, FCOVD, FAAO

Summary of Care

• Treatment:

• Lens treatment - make it easier to take in visual information.

• Yoked prism therapy - improve the use of peripheral visual system in vision and movement.

• Optometric vision therapy - reduce the load by building fluency and automaticity in the visual skills.

Communications SystemsWe need to integrate our OVT work into these systems.

• Often visual systems will work best, especially with motor planning issues

• The best system will often correlate with our findings - share your information with speech and language specialist or communication specialist

• acuity, contrast sensitivity, focusing, tracking

• visual perceptual screening

• use any system in your testing - probe with our tools to improve performance

Communication Systems

• Facilitated communication

• Cause and effect

Mayer Johnson Symbols

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ipadinsight.com/ipad-in-education-2/10-great-ipad-apps-for-students-on-the-autism-spectrum/

Thanks Lynn Hellerstein!

PC 7 yo male

• ASD recently diagnosed seizure disorder, many years of ABA

• Exotropia appeared at 18 months

• Med: Zoloft, Depakote

• Patient indicates his eyes hurt, light sensitive

• EXAM

• VA 10/20 OD, OS, OU matching isolated Feinbloom #• Near VA 20/120 whole chart, 20/60 isolated #??

• EOM - limited fixation, no tracking

• NPC 10” OS out +/-2.00 LXT, +/-1.00 TTN

• CT 25 LXT, intermittent 12 LXT (90%) pulls in for touch

• Randot E at 4 feet

• Static +0.50 sph OU, MEM +1.00 total reflex brighter

• Yoked prism assessment walking rail, hitting Marsden ball, catching ball - better with BU, BD loses all interest

• No body awareness in testing

• Binasals - possibly less incidence of turn

DX DE pattern, AI, EOM dysfunction

Rec

1. plano 2BU/+1.00 add OU inside; RTO 2 months

2. Classroom support

3. Optometric vision therapy

• Parents report decrease in eye turn and increase in visual awareness with RX

• Now diagnosed Landau-Kleffner Syndrome

• Med -Topamax

• Findings indicate NPC 3”, CT DE pattern, left exotropia 30% and no eye turn at near.

• Randot E at 10 feet, Randot 100 sec of arc

• Looks under and over glasses

• Rec OVT RG therapy work on fixation

• Rx change plano OU /+1.00 add OU

Optometric Vision Therapy• Basic approach,

trampoline, angels, theraball, balance board, walking rail

• Started very basic - only legs, few symbols

• Lots of yoked prism

• Loves RG techniques, very engaged - ball play, Perceptive (one card at a time), What is in a square?

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• Can the child use left/right concepts in a different place?

• Think about loading the patient - verbal, red green lenses, yokes.

Visualization treatment. Thanks John Abbondanza

Very linear/poor Visual memory

Visualization/Visual Memory

• How do we determine visual memory?

• How do we improve it?

• How can we use it to help reading?

Adapting Steve Ingersoll’s approach

Do as a visual memory task. Introduce text slowly Can the child verbalize first?

Work toward sentence structure for reading with comprehension Dynamic Reading programs

• Moving Text Dynamic ReadingThe material to be read remains in the center of the screen and does not move down the page from top to bottom, therefore saccadic eye movements are not required.

• Standard Dynamic Reading

The print moves left to right and top to bottom. This step continues the emphasis on fluency, and reduction of fixations & regressions. It introduces the added complexity of top to bottom reading.

• Whole Line Dynamic ReadingThe material to be read does not move left to right, but is presented an entire line at a time. The patient must self-generate left to right eye movements while processing the information. The reading material moves down the page one line at a time to the end of the passage. The speed is determined by the patient’s reading rate and comprehension level. This is a critical bridge to normal reading.

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• In these populations, you must be familiar with the issues of brain injury.

• I tell parents we need to think about these patients in two clear categories.

• What can we fix? Both habilitation and rehabilitation, which we call vision rehabilitation, with its basis in optometric vision therapy

• How must we adapt the environment? Traditionally, low vision care

• Our examination must answer these questions.

Think about sensory integration and visualization• Recognize that 20% of the retinal fibers go directly to the superior colliculus/brain stem for control of eye movements and integration on that level.

• The other 80% go to the dorsal lateral geniculate nucleus. However, note that only 20% of the information processed by LGN is retinal. Majority of input is from cortex, thalamus mid brain and brainstem, which allows the M/P fibers to be modulated by non-visual input.

Summary

• We have a great deal to offer the pediatric patient

• Success involves setting priorities and working with other members of the patient’s team

• Are the parents’ and child’s goals being met?

• Examination techniques and vision therapy need to be modified

CeliaHinrichsOD@gmail.com

• Celia Hinrichs, O.D., FCOVD

• 169 Powers Road

• Sudbury MA 01776

• 978-443-7529

• CAHVISION.COM