This is my presentation handout for the American Conference on Pediatric Cerebral Visual Impairment

1. A National Conference on Dominick M. Maino, O.D., M.Ed., F.A.A.O.
The Evaluation and Treatment of
Professor, Pediatrics/Binocular Vision Service
Pediatric Cerebral Visual Impairment Illinois College of Optometry
Illinois Eye Institute
The Children’s Hospital and 3241 S. Michigan Ave. Chicago, Il. 60616
Medical Center of Omaha, NE 312-949-7280 (Voice) 312-949-7358 (fax)
dmaino@ico.edu www.ico.edu
LyonsFamilyEyeCare.com
MainosMemos.blogspot.com
The Patient with Special Needs
The Child with Special Needs
A Brief Overview
Individuals with Special Needs Pediatric Cerebral Visual Impairment
Cerebral Palsy Autism • 1. Defining Pediatric Cerebral Visual Impairment
Down Syndrome Intellectual Disability
Fragile X Syndrome Brain Injury • Definition confusing, misunderstood and imprecise.
• Pediatric Cerebral Visual Impairment (PCVI).
Psychiatric Illness ….and…. • Pediatric Cortical Visual Impairment
• Delayed Visual Development
Pediatric Cerebral Visual Impairment
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2. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• North America • History of CVI
• Brain injury 19th century
•Cortical Visual Impairment with Phineas P. Gage
• Elsewhere
•Cerebral Visual Impairment
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• World War I, wounded
veterans with brain injury • Statokinetic dissociation (in children)
• Displayed perceived • greater reduction in sensitivity to stationary visual
motion in the “blind, non- stimuli relative to similar targets in motion
seeing” visual field. • Riddoch phenomenon (adults)
• Ability to sense movement even though blind
• Ability to sense motion, • “See” moving objects…but not stationary ones
lights, and colors
• Blindsight
• Conscious or • Ability to ‘sense’ objects in the way
subconscious.
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Statokinetic dissociation (in children) • Statokinetic dissociation (in children)
• Movement in the peripheral visual field may elicit a smile • For those children who understand language stating what is
in the blind child with quadraplegia and profound being seen as the child reacts to it may enhance both visual
intellectual disability. and language development.
• Children who are fed with a spoon may intermittently open • Such children may rock to and fro. Whether this generates
their mouths to receive food when the spoon is moved in an an image is difficult to know.
arc from the peripheral visual fields, but not when it • Rarely, children with cerebral blindness who are mobile
approaches the mouth from straight ahead. move slowly around obstacles. This phenomenon has been
called travel vision.
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3. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• 1980’s adults with bilateral occipital cortex •Reduced visual acuity identifying
insult (cortical blindness)
feature.
• Term applied to children.
• Cortical visual impairment used in the •Many children damage to white
1980’s onward matter surrounding the ventricals
• Definition of CVI includes injury lateral (perventricular leukomalacia PVL)
geniculate nucleus/visual cortex •Cerebral Visual Impairment now used
(especially in Europe)
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Cerebral visual impairment: inclusive term • Classification of CVI
• Reduced visual acuity • Ocular visual impairment: Refractive state. Optics, Eye
• Oculomotor anomalies health
• Visual field loss • Cerebral visual impairment: Neuro-pathway problems,
• Vision information processing problems cortical problems, oculomotor dysfunction, vision
• Cognitive Visual Dysfunction (CVD) information processing (dorsal and ventral streaming
• Used to identify visual perceptual anomalies processing mechanisms)
• Used to identify vision information processing
problems
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
The ventral stream (also known as the "what pathway") • Delayed Visual Maturation (DVM)
travels to the temporal lobe and is involved with object • DVM type I Visually impaired infants: improved
visual abilities by the age of 6 months, often
identification. The dorsal stream (or, "where pathway") without treatment.
terminates in the parietal lobe and process spatial locations. • DVM type II: attention problems, associated with
neurological/learning abnormalities. Improvement
takes longer
• DVM III: children have nystagmus, albinism.
Vision improves later, can improve to low-normal
levels.
• DVM IV: associated with retinal,
optic nerve, macular anomalies
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4. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Should we be concerned about how PVCI is defined?
• Defining Other Disorders and PCVI Absolutely!
• Variability with defining disorders not • American Association on Intellectual and
uncommon Developmental Disabilities changed definition of
• Autism rare anomaly mental retardation
• Definition altered so that the number of • Decreasing IQ cut off point from to 80 to 70
those on the Spectrum is now considered • Added adaptive behavior qualifications
epidemic • Result: instantly cured hundreds of thousands of
• Legal, legislative, health care, those with mental retardation/intellectual
disability overnight
insurance issues
Pediatric Cerebral Visual Impairment PCVI: References
• Dutton GN, Bax M. (eds). Visual impairment in children due to damage to the
brain. Clinics in Developmental Medicine. no 186. MacKieth Press.
What we call a thing is very important London;2010.
• Strategies for dealing with visual problems due to cerebral visual impairment:
Gillian McDaid, Debbie Cockburn, Gordon N Dutton available from
http://www.ssc.education.ed.ac.uk/courses/vi&multi/vjan08i.html
To name it is to have power over it • Alesterlund L, Maino D. That the blind may see: A review: Blindsight and its
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 with
Special Needs. Lippincott Williams & Wilkins , NY, New York; 2012:135-
146.
PCVI: References Pediatric Cerebral Visual Impairment
• Colenbrander A. What’s in a name? Appropriate terminology
Determining Vision Function and
for CVI. J Vis Impair Blind. 2010:583-585 Functional Vision in Children with
• Roman Lantzy CA, Lantzy A. Outcomes and opportunities: A
study of children with cortical visual impairment. J Vis Impair Pediatric Cerebral Visual Impairment
Blind. 2010:649-653.
• http://www.aph.org/cvi/define.html
• Cerebral Visual Impairment in Periventricular Leukomalacia:
MR Correlation: Available from
http://www.ajnr.org/content/17/5/979.full.pdf
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5. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
Determining Vision Function and Functional Vision in Children Determining Vision Function and Functional Vision in Children
with Pediatric Cerebral Visual Impairment with Pediatric Cerebral Visual Impairment
• Need to assess vision function and • Oculomotor ability (pursuits and saccades;
functional vision convergence and divergence, strabismus)
• Vision function
•Clarity of vision (visual acuity, •Pursuits/Visual Tracking
contrast sensitivity, refractive error,
Amblyopia)
•Saccades
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
Determining Vision Function and Functional Vision in Children Determining Vision Function and Functional Vision in Children
with Pediatric Cerebral Visual Impairment with Pediatric Cerebral Visual Impairment
• Binocular Vision • Accommodation (focusing)
• Convergence insufficiency/excess • Accommodative insufficiency
• Divergence insufficiency/excess • Accommodative excess
• Strabismus • Ill-sustained accommodation
• Exotropia • Accommodative instability
• Esotropia
• Hypertropia
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
Determining Vision Function and Functional Vision in Determining Vision Function and Functional Vision in Children
Children with Pediatric Cerebral Visual Impairment with Pediatric Cerebral Visual Impairment
• Depth perception (3D vision) • Eye health
• Binocular vision (Stereoscopy) is the ability to align and focus both eyes
• Cornea, lens, pupil,
accurately on an object and then combine the visual images from each eye into • iris, vitreous, optic nerve,
a single, clear, three dimensional perception. Difficulty seeing in 3D can arise
when eye fatigue occurs, forcing the eyes to make adjustments to focus
• retina
•
simultaneously on images that are near and far away.
Symptoms indicating a potential problem viewing images in 3D can vary,
• Visual Cortex
but some common symptoms include headaches, blurred vision, nausea
and dizziness.
• Other areas of the brain (motor,
• executive function)
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6. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
Determining Vision Function and Functional Vision in Children Vision Function of Children with Disability
with Pediatric Cerebral Visual Impairment
Down Syndrome: Visual Acuity, Refractive Error,
Strabismus/Oculomotor, Accommodation, Ocular health, Vision
• Special diagnostic tools Information Processing, Other
• EOG (electrooculogram) Cerebral Palsy: Visual Acuity, Refractive Error,
• ERG (electroretinogram)
Strabismus/Oculomotor, Accommodation, Ocular Health, Vision
• VER/VEP (visually evoked
Information Processing, Other
response visual evoked potential)
Brain Injury: Visual Acuity, Refractive Error,
Strabismus/Oculomotor, Accommodation, Ocular Health, Vision
Information Processing, Other
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
Functional vision • Vision information processing (VIP)/Visual
perceptual skills
Functionally induced disability that
overlays pathologically induced • Laterality/Directionality
disability • Visual motor integration
• Uncorrected refractive error • Non-motor perceptual skills
• Amblyopia • Auditory perceptual/processing
• On top of vision loss due
• to cerebral impairment
• Down Syndrome
• Cerebral Palsy
References References
• Luek AH. Cortical or cerebral visual impairment in children: A brief overview.
J Vis Impair Blind. 2010:585-592.
• Ciuffreda K, Kapoor N. Acquired brain injury. In Taub M,
Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of
• Woodhouse JM, Maino DM. Down syndrome: In Taub M, Bartuccio M, Maino
D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. the Patient with Special Needs. Lippincott Williams &
Lippincott Williams & Wilkins , NY, New York; 2012:31-40. Wilkins , NY, New York; 2012:95-100.
• Wesson M, Maino D. Oculo-visual findings in Down syndrome, cerebral palsy,
• Roman-Lantzy, C. Cortical visual impairment: An
and mental retardation with non-specific etiology. In Maino D (ed). Diagnosis
and Management of Special Populations. Mosby-Yearbook, Inc. St. Louis, MO. approach to assessment and intervention. AFB Press, NY,
1995:17-54. New York; 2007.
• Taub M, Reddell A. Cerebral Palsy. In Taub M, Bartuccio M, Maino D. (Eds)
• http://www.3deyehealth.org/
Visual Diagnosis and Care of the Patient with Special Needs. Lippincott
Williams & Wilkins , NY, New York; 2012:21-30. • http://www.MainosMemos.blogspot.com
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7. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Treatment begins with the basics.
Therapeutic Strategies for the •Vision function
Treatment of •Refractive correction
•Spectacles therapeutic
Pediatric Cerebral Visual Impairment •Eye health
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Treatment with spectacle/lenses • Treatment with spectacle/lenses
• multi-focal prescription/bifocal • task specific glasses
• prism • high “+” adds (magnification)
• occlusion • Telescopes
• Microscopes
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Vision Therapy • Vision Therapy
• Oculomotor/hand- • Integration/Stabilization
eye/accommodation • Visual stimulation
& fusion • Vision information
processing
• Biocular • Vestibular/Vision
• Binocular Apps 4 Vision Development
http://www.sovoto.com/group/apps4VisionDevelopment
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8. Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Resources Thinking Outside the LightBox
• Facebook
(http://www.facebook.com/Thinkingoutsidet
helightbox)
• Pinterest
http://pinterest.com/achampine0302/cortic
al-visual-impairment-cvi-goodies/
• Blogs
http://www.MainosMemos.blogspot.com
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
How Do Environmental Factors, Medications For individuals with disability…
and Non-Visual Handicaps Affect the • Medications: Prescribed many more medications
Evaluation and Treatment of Pediatric • Higher affinity for adverse effects due to environmental/systemic
factors
Cerebral Visual Impairment?
• Seldom complain of symptoms related to their disability, systemic
anomalies, or medication side effects
Pediatric Cerebral Visual Impairment Pediatric Cerebral Visual Impairment
• Alternative and complementary
medical therapies • Mental illnesses in children
Maino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17 • Pediatric Bipolar disorder
Lemer 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
• Pediatric depression
• Traditional allopathic approaches
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9. Pediatric Cerebral Visual Impairment Medication Side Effects
Antidepressants
• Major environmental hazard: People
Abdominal pain/constipation Blurred vision
• do not know how to respond Abnormal dreams/thinking Increased risk of Glaucoma
• make assumptions Abnormal ejaculation/orgasm
Anxiety
Visual Disturbances
Photophobia
• true for lay individuals, teacher, health
care professionals
• Other
Medication Side Effects Medication Side Effects
Anticonvulsants Anti-Parkisons
Memory problems/amnesia Blurred vision Abnormal dreams/insomnia Vision abnormalities
Sedation Dimming of vision Increased muscle tone/weakness Blurred vision
Insomnia Diplopia Involuntary movements Mydriasis
Bronchitis Involuntary eye movements Hallucinations Decreased accommodation
Fluid retention Dry eye
Medication Side Effects Medication Side Effects
Tranquilizers Anti-anxiety
Breast development in men Risk of narrow angle GLC Anemia Decreased accommodation
Breathing problems Cycloplegia/Mydriasis Seizures Nystagmus
Insomnia Decreased vision Blood disorders Diplopia
Tardive dyskinesia Capsular cataract Unusual excitement Mydriasis
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10. Dominick M. Maino, O.D., M.Ed., F.A.A.O.
Professor, Pediatrics/Binocular Vision Service
Illinois College of Optometry
Illinois Eye Institute
3241 S. Michigan Ave. Chicago, Il. 60616
312-949-7280 (Voice) 312-949-7358 (fax)
dmaino@ico.edu www.ico.edu
LyonsFamilyEyeCare.com
MainosMemos.blogspot.com
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