1. Diagnosis and TherapeuticIntervention of Vision Function andFunctional Vision Anomalies in PCV

2. Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular VisionIllinois Eye Institute/Illinois College of OptometryLyons Family Eye CareChicago, Ildmaino@ico.eduICO.eduLyonsFamilyEyeCare.comMainosMemos.com 3. Vision Function and Functional Vision Anomalies in PCVThe American Conference on Pediatric Cortical Visual Impairmentbrings together professionals in optometry, ophthalmology,occupational therapy and visual educational psychology to increasethe understanding of the definition, diagnosis and management ofcortical vision loss in children.(Dr Dominick Maino, PCVI Society Founding Board member, Dr. Joseph Maino, Dr. Kerri Pillen) 4. Vision Function and Functional Vision Anomalies in PCV1. History and Definition of pediatric cortical visualimpairment (PCVI).2. Describe the diagnostic criteria utilized in optometry.3. Discuss the treatment techniques. 5. Pediatric Cerebral Visual Impairment History of CVI Brain injury 19th centurywith Phineas P. Gage 6. Pediatric Cerebral Visual Impairment World War I, woundedveterans with brain injury Displayed perceived motionin the blind, non-seeingvisual field. Ability to sense motion,lights, and colors Conscious or subconscious. 7. Pediatric Cerebral Visual Impairment Statokinetic dissociation (in children) greater reduction in sensitivity to stationary visual stimuli relative tosimilar targets in motion Riddoch phenomenon (adults) Ability to sense movement even though blind See moving objectsbut not stationary ones Blindsight Ability to sense objects in the way 8. Pediatric Cerebral Visual Impairment Statokinetic dissociation (in children) Movement in the peripheral visual field may elicit asmile in the blind child with quadraplegia and profoundintellectual disability. Children who are fed with a spoon may intermittentlyopen their mouths to receive food when the spoon ismoved in an arc from the peripheral visual fields, butnot when it approaches the mouth from straightahead. 9. Pediatric Cerebral Visual Impairment Statokinetic dissociation (in children) For those children who understand language stating whatis being seen as the child reacts to it may enhance bothvisual and language development. Such children may rock to and fro. Whether this generatesan image is difficult to know. Rarely, children with cerebral blindness who are mobilemove slowly around obstacles. This phenomenon has beencalled travel vision (Blindsight). Alesterlund L, Maino D. That the blind may see: A review: Blindsight and its implications foroptometrists. J Optom Vis Dev 1999;30(2):86-93 10. Pediatric Cerebral Visual Impairment 1980s adults with bilateral occipital cortex insult(cortical blindness) Term applied to children. Cortical visual impairment used in the 1980sonward Definition of CVI includes injury lateralgeniculate nucleus/visual cortex 11. Pediatric Cerebral Visual Impairment Reduced visual acuity identifying feature.Many children damage to white mattersurrounding the ventricals (perventricularleukomalacia PVL) Cerebral Visual Impairment now used(especially in Europe) 12. Pediatric Cerebral Visual ImpairmentCerebral vs Cortical Visual Impairment Cerebral visual impairment: inclusive term Reduced visual acuity Oculomotor anomalies Visual field loss Vision information processing problems Cognitive Visual Dysfunction (CVD) Used to identify visual perceptual anomalies Used to identify vision information processingproblems 13. Pediatric Cerebral Visual Impairment Classification of CVI Ocular visual impairment: Refractive state. Optics,Eye health Cerebral visual impairment: Neuro-pathwayproblems, cortical problems, oculomotordysfunction, vision information processing (dorsaland ventral streaming processing mechanisms) 14. Pediatric Cerebral Visual ImpairmentThe ventral stream (also known as the "whatpathway") travels to the temporal lobe and isinvolved with object identification. The dorsal stream(or, "where pathway") terminates in the parietal lobeand process spatial locations. 15. Pediatric Cortical Visual ImpairmentReduced visual acuity due to abrain problem 16. Pediatric Cerebral Visual Impairment Delayed Visual Maturation (DVM) DVM type I Visually impaired infants: improved visualabilities by the age of 6 months, often withouttreatment. DVM type II: attention problems, associated withneurological/learning abnormalities. Improvementtakes longer DVM III: children have nystagmus, albinism. Visionimproves later, can improve to low-normal levels. DVM IV: associated with retinal,optic nerve, macular anomalies 17. Pediatric Cerebral Visual Impairment Defining Other Disorders and PCVI Variability with defining disorders not uncommon Autism rare anomaly Definition altered so that the number of those onthe Spectrum is now considered epidemic Legal, legislative, health care, insurance issues 18. Pediatric Cerebral Visual Impairment Should we be concerned about how PVCI is defined?Absolutely! American Association on Intellectual andDevelopmental Disabilities changed definition ofmental retardation Decreasing IQ cut off point from to 80 to 70 Added adaptive behavior qualifications Result: instantly cured hundreds of thousands of thosewith mental retardation/intellectual disabilityovernight 19. Pediatric Cerebral Visual ImpairmentWhat we call a thing is veryimportantTo name it is to have powerover it 20. Pediatric Cerebral Visual ImpairmentDetermining Vision Function andFunctional Vision in Children withPediatric Cerebral Visual Impairment 21. Vision Function and Functional Vision Anomalies in PCVDiagnostic Approaches & Strategies1.Case History2.Visual Acuity3.Refractive Error4.Vision Function Assessment5.Ocular Health6.Special Tools 22. Vision Function and Functional Vision Anomalies in PCVVision FunctionClarity of vision (visual acuity, contrastsensitivity, refractive error)Oculomotor ability (pursuits andsaccades; convergence and divergence)Accommodation (focusing)Depth perception (3D vision) 23. Vision Function and Functional Vision Anomalies in PCVVision FunctionEye healthBiomicroscopyTonometryDilated Fundus EvaluationSpecial diagnostic toolsEOG (electrooculogram)ERG (electroretinogram)VER/VEP (visually evoked responsevisual evoked potential) 24. Vision Function and Functional Vision Anomalies in PCVFunctional VisionFunctionally induced disability that overlayspathologically induced disabilityUncorrected refractive error : AmblyopiaConstant Strabismus: AmblyopiaOculomotor dysfunction, Binocular visiondysfunction, Accommodative dysfunction:Attention 25. Vision Function and Functional Vision Anomalies in PCVFunctional visionVision information processing (VIP)/Visual perceptual skillslaterality/directionalityvisual motor integrationnon-motor perceptual skillsauditory perceptual/processing 26. Vision Function and Functional Vision Anomalies in PCVVision FunctionClarity of visionWhat is visual acuity?What is contrast sensitivity?What is refractive error? 27. Vision Function and Functional Vision Anomalies in PCVVision FunctionClarity of visionWhat is visual acuity?The ability to see a certain sizeobject at a certain distance. 28. Vision Function and Functional Vision Anomalies in PCVVision FunctionClarity of visionWhat is contrast sensitivity? 29. Vision Function and Functional Vision Anomalies in PCVContrast sensitivity measures the ability tosee details at low contrast levels. Visualinformation at low contrast levels isparticularly important:1. in communication, since the faintshadows on our faces carry the visualinformation related to facialexpressions. 30. Vision Function and Functional Vision Anomalies in PCV2. in orientation and mobility, wherewe need to see such critical low-contrastforms as the curb, faint shadows, andstairs when walking down. In traffic, thedemanding situations are at lowcontrast levels, for example, seeing indusk, rain, fog, snow fall, and at night. 31. Vision Function and Functional Vision Anomalies in PCV3. in every day tasks, where thereare numerous visual tasks at lowcontrast, like cutting an onion on alight colored surface, pouring coffeeinto a dark mug, checking thequality of ironing, etc. 32. Vision Function and Functional Vision Anomalies in PCV4. in near vision tasks like readingand writing, if the information is atlow contrast as in poor quality copiesor in a fancy, barely readableinvitation, etc.from http://www.lea-test.fi/en/vistests/pediatric/cstests/cstests.html 33. Vision Function and Functional Vision Anomalies in PCV 34. Vision Function and Functional Vision Anomalies in PCV 35. Vision Function and Functional Vision Anomalies in PCV 36. Vision Function and Functional Vision Anomalies in PCV 37. Tests ofVisualAcuity andContrastUsed withpermission 38. Vision Function and Functional Vision Anomalies in PCV 39. Pursuits,Saccades,Convergence 40. Vision Function and Functional Vision Anomalies in PCVRetinoscopyBook (Getman)1. At the Free and Easy reading level, the reflex varied from neutral to with motion andwas bright, had sharp edges and had a pinkish color.2. At the instructional reading level (which was defined as maintaining the reading taskwith comprehension in spite of being stressed) the reflex was a varying fast against motionwhile the color was bright, sharp, and very pink.3. At the frustration reading level (which was defined as reading with minimalcomprehension) the reflex showed a slow against motion with a dull brick red color.Bell (Apell)Dynamic (#5 & #6 OEP)MEM (Haynes) 41. Vision Function and Functional Vision Anomalies in PCVRetinoscopyBell (Apell)Target(Wolf Wand) directly in front of the retinoscopePatient fixates the targetMove the ball toward the patient slowly and smoothlyThe distance of the target from the patient is recorded for a change in motion orother changes of interestExpect to see a change from with to against on the way in at 35 - 42cm. (14 - 17inches) and a change from against to with at 37.5 - 45 cm. (15 -18inches).Dynamic (#5 & #6 OEP)MEM (Haynes) 42. Vision Function and Functional Vision Anomalies in PCVRetinoscopyDynamic (#5 & #6 OEP)Distance retinoscopy (#4) in placePatient behind the phoropterExaminers retinoscope at a 20 (twenty) inch distance from the patient.Patient fixates small letters or a picturePatient looks, reads, names, and interact visually with the targetPlus spheres added until against motion is seenThen plus spheres are reduced until the first neutral (no motion) responseLens in the phoropter is recorded as the gross finding.The #5 retinoscopy, like the other 21 point findings, had no specific meaning byitself until it was compared to other findings as part of the total analyticalexamination. The #5, like the 14B gross, will approximate the most plus lensacceptable for near. 43. Vision Function and Functional Vision Anomalies in PCVRetinoscopyMEM Retinoscopy (Monocular Estimation Method)Patient reads grade appropriate material usually affixed to the retinoscopeWorking distance is the patients Harmon distanceQuickly dip lenses in front of the reading materialA +.25 to +.75 lag of accommodation is considered normalA high lag would be +1.00 or greaterAccommodative excess would be any AM notedAlso note variability of reflex, color and other variabilityStress Point RetinoscopyKraskin & HarmonFor more info see: http://www.oepf.org/VTAids/Retinoscopy.pdf 44. Retinoscopy 45. Color vision, copy forms,Matching, Visual Fields 46. Pediatric Cerebral Visual ImpairmentTherapeutic Strategies for theTreatment ofPediatric Cerebral VisualImpairment 47. Pediatric Cerebral Visual Impairment Treatment begins with the basics. Vision function Refractive correction Spectacles therapeutic Eye health 48. Pediatric Cerebral Visual Impairment Treatment with spectacle/lenses multi-focal prescription/bifocal prism occlusion 49. Pediatric Cerebral Visual Impairment 50. Pediatric Cerebral Visual Impairment 51. Pediatric Cerebral Visual Impairment Treatment with spectacle/lenses/computer devices task specific glasses high + adds (magnification) Telescopes Microscopes 52. Pediatric Cerebral Visual Impairment Vision Therapy Oculomotor/hand-eye/accommodation& fusion Biocular Binocular Integration 53. Pediatric Cerebral Visual Impairment Vision Therapy Integration/Stabilization Visual stimulation Vision informationprocessing Vestibular/VisionApps 4 Vision Developmenthttp://www.sovoto.com/group/apps4VisionDevelopment 54. Pediatric Cerebral Visual ImpairmentPerceptual Learning vs Vision Therapy 55. Pediatric Cerebral Visual ImpairmentThinking Outside the LightBox 56. Pediatric Cerebral Visual ImpairmentThink Outcomes! 57. Pediatric Cerebral Visual ImpairmentWhat follows is supplemental informationto the presentation, resources andreferences that are not necessarily a part ofthis presentation, but which I thought youwould like to have for your owninformation. 58. Pediatric Cerebral Visual ImpairmentHow Do Environmental Factors,Medications and Non-Visual HandicapsAffect the Evaluation and Treatment ofPediatric Cerebral Visual Impairment? 59. Pediatric Cerebral Visual ImpairmentFor individuals with disability Medications: Prescribed many more medications Higher affinity for adverse effects due toenvironmental/systemic factors Seldom complain of symptoms related to their disability,systemic anomalies, or medication side effects 60. Pediatric Cerebral Visual Impairment Alternative and complementarymedical therapiesMaino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17Lemer P. Complementary and Alternative Approaches. In Taub M, Bartuccio M, Maino D.Visual Diagnosis and Care of Patients with Special Needs. Lippincott, Williams, Wilkins.2012 Traditional allopathic approaches 61. Pediatric Cerebral Visual Impairment Mental illnesses in children Pediatric Bipolar disorder Pediatric depression 62. Pediatric Cerebral Visual Impairment Major environmental hazard: People do not know how to respond make assumptions true for lay individuals, teacher, health careprofessionals 63. Medication Side EffectsAntidepressantsAbdominal pain/constipation Blurred visionAbnormal dreams/thinking Increased risk ofDisturbancesAnxiety Photophobia 64. Medication Side EffectsAnticonvulsantsMemory problems/amnesia Blurred visionSedation Dimming of visionInsomnia DiplopiaBronchitis Involuntary eye movementsFluid retention Dry eye 65. Medication Side EffectsAnti-ParkisonsAbnormal dreams/insomnia Vision abnormalitiesIncreased muscle tone/weakness Blurred visionInvoluntary movements MydriasisHallucinations Decreasedaccommodation 66. Medication Side EffectsTranquilizersBreast development in men Risk of narrow angle GLCBreathing problems Cycloplegia/MydriasisInsomnia Decreased visionTardive dyskinesia Capsular cataract 67. Medication Side EffectsAnti-anxietyAnemia Decreased accommodationSeizures NystagmusBlood disorders DiplopiaUnusual excitement Mydriasis 68. PCVI: References Dutton GN, Bax M. (eds). Visual impairment in children due to damage tothe brain. Clinics in Developmental Medicine. no 186. MacKieth Press.London;2010. Strategies for dealing with visual problems due to cerebral visualimpairment: Gillian McDaid, Debbie Cockburn, Gordon N Dutton availablefrom http://www.ssc.education.ed.ac.uk/courses/vi&multi/vjan08i.html Alesterlund L, Maino D. That the blind may see: A review: Blindsight andits implications for optometrists. J Optom Vis Dev 1999;30(2):86-93 Kran B. Mayer L. Vision impairment and brain damage. In Taub M,Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient withSpecial Needs. Lippincott Williams & Wilkins , NY, New York; 2012:135-146. 69. PCVI: References Colenbrander A. Whats in a name? Appropriate terminologyfor CVI. J Vis Impair Blind. 2010:583-585 Roman Lantzy CA, Lantzy A. Outcomes and opportunities: Astudy of children with cortical visual impairment. J Vis ImpairBlind. 2010:649-653. http://www.aph.org/cvi/define.html Cerebral Visual Impairment in Periventricular Leukomalacia:MR Correlation: Available fromhttp://www.ajnr.org/content/17/5/979.full.pdf 70. References Luek AH. Cortical or cerebral visual impairment in children: A briefoverview. J Vis Impair Blind. 2010:585-592. Woodhouse JM, Maino DM. Down syndrome: In Taub M, BartuccioM, Maino D. (Eds) Visual Diagnosis and Care of the Patient withSpecial Needs. Lippincott Williams & Wilkins , NY, New York; 2012:31-40. Wesson M, Maino D. Oculo-visual findings in Down syndrome,cerebral palsy, and mental retardation with non-specific etiology. InMaino D (ed). Diagnosis and Management of Special Populations.Mosby-Yearbook, Inc. St. Louis, MO. 1995:17-54. Taub M, Reddell A. Cerebral Palsy. In Taub M, Bartuccio M, Maino D.(Eds) Visual Diagnosis and Care of the Patient with Special Needs.Lippincott Williams & Wilkins , NY, New York; 2012:21-30. 71. References Ciuffreda K, Kapoor N. Acquired brain injury. InTaub M, Bartuccio M, Maino D. (Eds) VisualDiagnosis and Care of the Patient with SpecialNeeds. Lippincott Williams & Wilkins , NY, NewYork; 2012:95-100. Roman-Lantzy, C. Cortical visual impairment: Anapproach to assessment and intervention. AFBPress, NY, New York; 2007. http://www.MainosMemos.com 72. Pediatric Cerebral Visual Impairment Resources Facebook (http://www.facebook.com/Thinkingoutsidethelightbox) Pinterest http://pinterest.com/achampine0302/cortical-visual-impairment-cvi-goodies/ Blogs http://www.MainosMemos.blogspot.com Apps http://www.sovoto.com/group/apps4VisionDevelopment Infant Visual Stimulations https://itunes.apple.com/us/app/infant-visual-stimulation/id427443223 Infant Visual Stimulation Videohttps://www.youtube.com/watch?v=Eyj5PqwUn0w COVD http://www.COVD.org OEPF http://www.OEPF.org Vision Help blog http://visionhelp.wordpress.com/ MainosMemos http://www.MainosMemos.blogspot.com 73. Dominick M. Maino, OD, MEd, FAAO, FCOVD-AProfessor of Pediatrics/Binocular Vision Illinois Eye InstituteIllinois College of Optometry3241 S. Michigan Ave. Chicago, Il 60616Lyons Family Eye Care3250 N. Lincoln Ave. Chicago, Il 60657dmaino@ico.eduICO.eduLyonsFamilyEyeCare.comMainosMemos.com