Presentation given at the Vision's Impact on Learning Conference 9-11

1. Dominick M. Maino, O.D., M.Ed., F.A.A.O.,
The Child with F.C.O.V.D-A.
Special Needs Professor,
Pediatrics/Binocular Vision Service
P di i /Bi l Vi i S i
Illinois College of Optometry
Illinois Eye Institute
Part 1 3241 S. Michigan Ave. Chicago, Il. 60616
312-949-7280 (Voice) 312-949-7358 (fax)
dmaino@ico.edu MainosMemos.blogspot.com
www.ico.edu nw.optometry.net
Children with Special Needs Children with Special Needs
•Learning Disability •Autism
•ADHD •Mental Retardation/Intellectual
•C b l Palsy
Cerebral P l Disability
•Down Syndrome •Acquired/Traumatic Brain Injury
•Fragile X Syndrome •Mental Illness/Psychiatric Illness
Learning Disabilities Learning Disabilities
Reading/Dyslexia Reading/Dyslexia
Dyscalculia
Dysgraphia Reading disabilities common
Dyslexia rare
1

2. Learning Disabilities Learning Disabilities
Reading/Dyslexia Dyscalculia (Math Disability)
Language Based
g g 3 and 6% of the population
Vision Based Neurological Dyscalculia
Combination of Language/Vision Deficits in working & short term memory
Congenital/hereditary (Gerstmann syndrome: Dyscalculia + Dysgraphia)
Learning Disabilities Learning Disabilities
ADHD/ADD Etiology
Dysgraphia
Working memory (orthographic coding)
g y( g p g) Brain Functioning
Motor planning Heredity
Attentional issues Exposure to Toxic Substances
Brain Trauma, Tumors, Strokes or Disease
Functional Vision Problems
Learning Disabilities Learning Disabilities
ADHD/ADD Not Caused By: ADHD/ADD Treatment
Diet Medication
Hormones Psychotherapy
Vestibular dysfunction Education or Training
Poor parenting A combination of treatments
Television Oculomotor therapy/Vision Therapy
2

3. Cerebral Palsy
• What is it?
• What is it’s etiology?
• What is it’s prevalence/incidence?
• How is it classified?
• What are it’s visual characteristics?
Cerebral Palsy Cerebral Palsy Etiology
• Cerebral Palsy is a persistent, but not Something goes awry just before, during or
unchanging, disorder of movement and just after birth:
posture appearing in the early years of life
Prenatal
due to traumatic or inflammatory brain
damage. Neonatal
• Affects virtually all motor systems Postnatal
• Can be acquired
Cerebral Palsy Incidence/Prevalence Cerebral Palsy Incidence/Prevalence
• Incidence 2-4/1000 live births • 75% of CP occurs during pregnancy , 5% during childbirth
and/or 15% after birth up to age 3
• Prevalence 1.5-2/1000 live • 80% the etiology is unknown
• births 10% of cases are acquired (trauma) • There are 550,000-764,000 persons in the USA with
• N l lif spans, 40% live to age 40, many
Normal life li t 40 cerebral palsy
living into their senior years • The number of new cases have increased 25% during the
past decade (1990’s)
• > 1/2 million individual with CP living in USA • There are now 10,000 new cases/year.
• Average lifetime cost per person of $921,000 (in 2003
dollars)
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4. Cerebral Palsy Classifications Cerebral Palsy Visual Characteristics
Wesson M, Maino D. Oculovisual findings in children with Down syndrome, Cerebral
Palsy, and mental retardation without specific etiology. In Maino, D. (ed)
Diagnosis and management of special populations. 1995. St. Louis, Mo. , Mosby-
• Spastic - 70-80% Yearbook Inc.:17-54.
• Binocular acuity could be evaluated in
• Dyskinetic/Athetoid - 10-15% 45% of individuals below age 13
• Ataxic - <5% • For CP patients VAs are generally
decreased when compared to those
• Mixed measured for individuals with Down
Syndrome
• Much higher incidence of ocular disease
and neurological dysfunction
Cerebral Palsy Refractive Characteristics Cerebral Palsy Refractive Characteristic
Scheiman MM. Optometric findings in children with cerebral palsy. Am J Optom Physiol
Opt 1984;61:321-333
• 60% significant refractive error • Hyperopia present 3Xs
more than when compared
• Hyperopia (>+1.50) 3X more common among to myopia
CP children than in non-affected individuals
non affected
• Other studies (Black, Breakey et al, Duckman,
• Wesson & Maino note:
• many more hyperopes
LoCasio) support increased refractive error than myopes
being present • average amount of
significant myopia is
greater
Cerebral Palsy Binocular
Cerebral Palsy InteractionTips
Characteristics
• Prevalence of strabismus exceeds that of
general population by a factor of 10! • Positioning
• Slightly more esotropia than exotropia • Right tools (objective)
• D ki ti Strabismus
Dyskinetic St bi • No sudden movement
• slow tonic deviation similar to • No loud, unexpected noises
vergence
• change from ET to XT • Speak smoothly, soothingly, softly….if
• usually associated with athetoid appropriate, sing to the patient!
classification • Smile, smile SMILE!!!
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5. Cerebral Palsy Cerebral Palsy
Barca L, Cappelli FR, Di Giulio P, Staccioli S, Castelli E. Outpatient assessment of
neurovisual functions in children with Cerebral Palsy. Res Dev Disabil. 2010 Mar-
• Saunders KJ, Little JA, McClelland JF, Jackson AJ. Profile of refractive errors in cerebral palsy:
impact of severity of motor impairment (GMFCS) and CP subtype on refractive outcome. Invest
Apr;31(2):488-95. Epub 2009 Dec 5.
Ophthalmol Vis Sci. 2010 Jun;51(6):2885-90. Epub 2010 Jan 27.
….Overall, 73% patients had . … A significantly higher prevalence and magnitude
of refractive error was found in the CP group …..
g p
impairments …..the majority of
the Higher spherical refractive errors were
which presenting difficulties on significantly associated with the nonspastic CP ….
The presence and magnitude of astigmatism were
both visuoperceptual and greater when intellectual impairment was more
visuospatial tasks (79%).. … severe, …. High refractive errors are common in
CP, pointing to impairment of the
emmetropization process. ….
Cerebral Palsy Cerebral Palsy
Ross LM, Heron G, Mackie R, McWilliam R, Dutton GN.
McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ. Reduced accommodative function in dyskinetic cerebral palsy: a novel
management strategy. Dev Med Child Neurol. 2000 Oct;42(10):701-3. Links
Accommodative dysfunction in children with cerebral palsy:
a population-based study. Invest Ophthalmol Vis Sci. 2006 ….The near-vision symptoms were completely
May;47(5):1824-30. removed and reading dramatically improved with
the provision of varifocal spectacles. Varifocal
p p
Brain injury such as that present in CP has a lenses provide an optimal correction for far,
intermediate (i.e. for computer screens), and
significant impact on accommodative near distances (i.e. for reading). Managing this type
function. These findings have implications of patient with varifocal spectacles has not been
for the optometric care of children with CP previously reported. It is clearly very important
and inform our understanding of the impact to prescribe an optimal spectacle correction
to provide clear vision to
of early brain injury on visual development.
optimize learning.
Down Syndrome
From: http://www.ndss.org/aboutds/aboutds.html#Down
Children with Down syndrome have been included in regular academic
classrooms in schools across the country. In some instances they are
integrated into specific courses, while in other situations students are
fully included in the regular classroom for all subjects. The degree of
mainstreaming is based in the abilities of the individual; but the trend is
for full inclusion in the social and educational life of the community.
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6. Down Syndrome Down Syndrome
• What is it? • Langdon Down 1866
• What is it’s etiology?
• What is it s prevalence/incidence?
it’s
• “Mongolism” no longer used
• What are it’s physical/visual characteristics? • Most common genetic anomaly
• Variable levels of ability & disability
Down Syndrome Down Syndrome Prevalence/Incidence
Down syndrome is the most commonly • 1 in 800-1000 live births
occurring genetic condition. One in • 1 in 12 for older mothers (>=49yrs of age)
every 800 to 1,000 live births is a child • Most babies with Down syndrome born to
younger mothers (80% born to moms younger than 35)
with Do n s ndrome representing
ith Down syndrome, • Most frequently encounter “viable” genetic
approximately 5,000+ births per year in anomaly
the United States alone. Today, Down • Most frequently encounter “special” patient
syndrome affects more than 350,000 • Prevalence increasing (improved survival rates)
people in the United States. http://www.nichd.nih.gov/publications/pubs/downsyndrome.cfm
Down Syndrome Etiology Down Syndrome Etiology
• Genetics • Genetics: Trisomy 21
• 95% demonstrate non-disjunction of one
chromosome during meiosis (Trisomy 21)
• 2-4% mosaicism
• 3-4% Robertsonian translocation of the long
3 4%
arm of chromosome 21 to another
chromosome usually #14
• risk of having a second child with Trisomy
21 or mosaic Down syndrome is 1 in 100.
The risk is higher if one parent is a carrier of a translocated cell.
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7. Down Syndrome Refractive Error Down Syndrome Binocular
Characteristics
Many more hyperopes than 23-44% have strabismus
(Wesson & Maino) Down syndrome and
myopes, but those with myopia strabismus shows a constant unilateral
tended to have higher esotropia of less than 20 PD at near.
near
(Greatly reduced number show ET at distance)
magnitudes
It’s suggested that the etiology is a high
Up to 49% may exhibit some ACA ratio rather that of a basic ET
astigmatism
What’s New in Down Syndrome What’s New in Down Syndrome
Al-Bagdady M, Stewart RE, Watts P, Murphy PJ, Woodhouse JM. Bifocals Haugen OH, Hovding G, Eide GE. Biometric measurements of the eyes in teenagers and
young adults with Down syndrome.Acta Ophthalmol Scand. 2001 Dec;79(6):616-25.
and Down's syndrome: correction or treatment? Ophthalmic Physiol
Opt. 2009 Jul;29(4):416-21. Epub 2009 May 11.
CONCLUSIONS: Thinning of the corneal
Accommodation is reduced in approximately 75% of stroma may account for the steeper
children with Down's syndrome (DS). Bifocals have
(DS) cornea and the high frequency of
been shown to be beneficial and they are currently astigmatism in Down syndrome due to
prescribed regularly.. … Bifocals are an effective lower corneal rigidity. It may also be of
correction for the reduced accommodation in children
etiological importance to the increased
with DS and also act to improve accommodation with
a success rate of 65%. …. incidence of keratoconus in Down
syndrome.
Haugen OH, Hovding G, Lundstrom I.Refractive development in children Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. Association
with Down's syndrome: a population based, longitudinal study. Br J Ophthalmol.
2001 Jun;85(6):714-9. between accommodative accuracy, hypermetropia, and strabismus
in children with Down's syndrome Optom Vis Sci. 2007
Feb;84(2):149-55.
….Accommodation weakness may be of
aetiological importance to the high ….This study demonstrates the marked
This st d
frequency of refractive errors association between under-
encountered in patients with Down's accommodation, hypermetropia, and
syndrome. strabismus in children with Down's
syndrome. ….
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8. Haugen OH, Hovding G.Strabismus and binocular function in children with Stewart RE, Margaret Woodhouse J, Trojanowska LD. In
Down syndrome. A population-based, longitudinal study.Acta Ophthalmol focus: the use of bifocal spectacles with children with
Scand. 2001 Apr;79(2):133-9. Down's syndrome.Ophthalmic Physiol Opt. 2005
Nov;25(6):514-22
…The majority of the Down syndrome
children with strabismus have an …….Based on the results of this
acquired esotropia and hence a study, eye examinations of children
potential for binocularity.
binocularity with Down's syndrome should
y
Hypermetropia and accommodation routinely include a measure of
weakness are probably important accommodation at near, and bifocal
factors in esotropia ……. spectacles should be considered for
those who show under-
accommodation.
Fragile X Syndrome
• What is it?
• What is it’s etiology?
• What is it s prevalence/incidence?
it’s
• What are it’s physical/visual characteristics?
Fragile X Syndrome Fragile X Syndrome
Most frequently encountered inherited form of X-linked MR 1:600 in affected males
mental retardation (X-linked MR) 1:400 female carriers
Often misdiagnosed in the past
g p
Prevalence 2.6 cases per 1,000 in the
26 1 000
“New” syndrome that has caught the
imagination of researchers around the world general population, over 10% of all
1st human disease shown to be caused by a cases of mental retardation
repeated nucleotide sequence
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9. Fragile X Syndrome Fragile X Syndrome Characteristics
Fra X
• Large prominent ears
1 in 4000 males with full mutation • Long narrow face
1 in 4000 to 6000 females with full • Macro-orchidism
mutation (80% affected men)
1 in 800 men are carriers
Other: hypotonia, seizures,
1 in 260 women are carriers recurrent otitis
media
Fragile X Syndrome Characteristics Fragile X Syndrome Characteristics
• Large prominent ears • Large prominent ears
• Long narrow face • Long narrow face
• Macro-orchidism (80%
( • Macro-orchidism (80%
(
affected men) affected men)
Other: hypotonia, seizures, Other: hypotonia, seizures,
recurrent otitis media recurrent otitismedia
Fragile X Syndrome Characteristics Fragile X Syndrome Characteristics
• First demonstrated genetic etiology of Gaze Avoidance
learning disability
• Variable mental retardation
• Math, language delay How do you conduct an
• Sensory integration problems examination on an individual
• Attentional deficits that won’t look at you?
• Psychiatric illnesses (shy)
9

10. Fragile X Syndrome Diagnosis
Genetics
• Triplet nucleotide repeated sequence
• cytosine, guanine, guanine (CGG)
• 0-50 CGG repeats normal, 50-200
premutation, > 200 full syndrome
• Fragile site on X chromosome (band
q27.3)
Fragile X Syndrome Ocular Findings What’s New in Fragile X Syndrome
• Hatton DD, Buckley E, Lachiewicz A, Roberts J. Ocular status of boys with fragile X syndrome: a
• Strabismus (33-50%) prospective study. J AAPOS. 1998 Oct;2(5):298-302.
• Nystagmus …observe a higher prevalence of strabismus than
that found in the general population (8% vs 0.5%
• Refractive error to 1
t 1…., 17% of th sample did have significant
f the l h i ifi t
• Accommodative dysfunctions? refractive errors. In addition to evaluating the
• Oculomotor anomalies ocular motility of children with fragile X
syndrome, cycloplegic refraction should also be
• Ocular Health? performed to determine whether refractive
• Perceptual dysfunction problems are present.
What’s New in Fragile X Syndrome What’s New in Fragile X Syndrome
Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM, Treitman TM.Cognitive and visual processing Effect of CX516, an AMPA-modulating compound, on cognition
skills and their relationship to mutation size in full and premutation female fragile X carriers.Optom Vis Sci.
2000 Nov;77(11):592-9. and behavior in fragile X syndrome: a controlled trial. Berry-
Kravis E, Krause SE, Block SS, Guter S, Wuu J, Leurgans S,
….full mutation female carriers performed more
Decle P, Potanos K, Cook E, Salt J, Maino D, Weinberg D, Lara
poorly in visual-motor processing and analysis- R, Jardini T, Cogswell J, Johnson SA, Hagerman R. J Child
synthesis on the Woodcock Johnson Psycho-
Woodcock-Johnson Psycho Adolesc Psychopharmacol. 2006 Oct;16(5):525-40.PMID:
Educational Battery-Revised, The Developmental 17069542
Test of Visual Motor Integration, and on five of the Cognitive and visual processing skills and their relationship to
seven subtests of the Test of Visual-Perceptual mutation size in full and premutation female fragile X carriers.
Skills. Regression analyses revealed significant Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM,
negative correlations between mutation size and Treitman TM. Optom Vis Sci. 2000 Nov;77(11):592-9.PMID:
cognitive ability. … 11138833
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11. What’s New in Fragile X Syndrome Autism
The fragile X female: a case report of the visual, visual perceptual,
and ocular health findings. Amin VR, Maino DM. J Am Optom The incidence of
Assoc. 1995 May;66(5):
Optometric findings in the fragile X syndrome. Maino DM, Wesson autism has increased
M,
M Schlange D, Cibis G, Maino JH. Optom Vis Sci. 1991
Aug;68(8):
D G JH Sci from 1 in 10,000 in
10 000
Mental retardation syndromes with associated ocular defects. Maino the 1970s to 1 in 110
DM, Maino JH, Maino SA.
J Am Optom Assoc. 1990 Sep;61(9):707-16.
today, an increase of
Ocular anomalies in fragile X syndrome. Maino DM, Schlange D, over 6,000%. …
Maino JH, Caden B. J Am Optom Assoc. 1990 Apr;61(4):316-23
Autism Autism Etiology
Yeast infections
Do Parents cause their children to be autistic ? Intolerance to specific food substances
There are autistic children born to parents who do not fit the autistic parent personality pattern. (Gluten intolerance ("Leaky Gut Syndrome"/Casein intolerance causing
Parents who do fit the description of the supposedly pathogenic parent have normal, non-autistic intestinal permeability and allowing improperly digested peptides to enter
children.
Frequently siblings of autistic children are normal.
the bloodstream and cross the blood-brain barrier which may mimic
Autistic children are behaviorally unusual "from the moment of birth " ***
from birth. neurotransmitters and result in the scrambling of sensory input. I've also
g y p
There is a consistent ratio of three or four boys to one girl. heard "Leaky Gut Syndrome" described as lack of the beneficial bacteria
Virtually all cases of twins reported in the literature have been identical, with both twins that aids digestion, and that the resulting matter in the bloodstream invokes
afflicted. *** an unnecessary immune reaction)
Autism can occur or be closely simulated in children with known organic brain damage. ***
The symptomatology is highly unique and specific.
Phenolsulphertransferase (PST) deficiency--theory that some with autism are
There is an absence of gradations of infantile autism which would low on sulphate or an enzyme that uses this, called phenol-
create "blends" from normal to severely afflicted. sulphotransferase-P. This means that they will be unable to get rid of amines
and phenolic compounds once they no longer have any use for them. These
then stay in their body and may cause adverse effects, even in the brain.
Autism Etiology Autism Etiology
Brain injury, Constitutional vulnerability
Developmental aphasia , Deficits in the reticular
activating system, An unfortunate interplay
between ps chogenic
bet een psychogenic and
neurodevelopmental factors, Structural
My Goodness!
cerebellar changes, Genetic causes, Viral Maino DM, Viola, SG, Donati R. The
Etiology of Autism. Optom Vis
causes, Immunological ties, Vaccines, Dev 2009:(40)3:150-156.
Seizures
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12. Autism Etiology Autism
Impairment in social interactions
What the research Impairment in communication
shows… Restricted repertoire of activities
Autism Autism
Asperger
Childhood Syndrome Childhood
g
Disintegrative g
Disintegrative
Disorder Autism
A ti Disorder
Rett Syndrome
Autism US FDA Statement Autism
IOM Report: No Link Between Vaccines and Autism Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen
By Michelle Meadows VL, et al. Early thimerosal exposure and neuropsychological outcomes at 7
to 10 years. N Engl J Med. 2007 Sep 27;357(13):1281-92
There is no link between autism and the
measles-mumps-rubella (MMR) vaccine or the
Childhood Childhood
i
g
Disintegrative
vaccine preservative thi
Disorder ti thimerosal, according to a
l di t Our study does not support
g
Disintegrative
Disorder
report released by the Institute of Medicine's a causal association between early
(IOM) Immunization Safety Review exposure to mercury from thimerosal-containing vaccines and immune
Committee. globulins and deficits in neuropsychological functioning at the age of 7 to
10 years.
http://www.fda.gov/fdac/features/2004/504_iom.html
12

13. Autism Summary
Andrew Wakefield (born 1956) is a British former
surgeon and researcher best known for his discredited
work regarding the MMR vaccine and its claimed connection
Childhood
Disintegrative
ith
g
with autism and i fl
Disorder
d inflammatory bowel disease. Wakefield was the lead author
t b l di W k fi ld th l d th
of a 1998 study, published in The Lancet, which reported bowel symptoms in
twelve children diagnosed with autism spectrum disorders, to which the authors
suggested a possible link with the MMR vaccine. Though stating "We did not
Autism?
prove an association between measles, mumps, and rubella vaccine and the
syndrome described," the paper tabulated parental allegations, and adopted these
allegations as fact for the purpose of calculating a temporal link between receipt
of the vaccine and the first onset of what were described as "behavioural
symptoms“.
Mental Retardation without Specific Etiology Mental Retardation Classification
Most frequently encountered form of Intellectual Classification IQ
Disability Mild/Educable Mentally Handicapped 50-70
Moderate/Trainable Mentally Handicapped 35-55
4000 k O li Mendelian Inheritance
known Online M d li I h i Severe 20-40
in Man Profound below 20
http://www.ncbi.nlm.nih.gov/omim
10 times that are unknown!
Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
Neuroplasticity Neuroplasticity & Rehabilitation
Maino D. Neuroplasticity: Teaching an Old Brain New Tricks. Rev Optom Use it or lose it. If you do not drive specific brain functions, functional
2009. 46(1):62-64,66-70. loss will occur.
(http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106025/) Use it and improve it. Therapy that drives cortical function enhances that
particular function.
ti l f ti
Specificity. The therapy you choose determines the resultant plasticity and
function.
Repetition matters. Plasticity that results in functional change requires
repetition.
Intensity matters. Induction of plasticity requires the appropriate amount
of intensity.
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14. Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
Neuroplasticity & Rehabilitation Post Trauma Vision Syndrome Symptoms/Signs
Time matters. Different forms of plasticity take place at different times
during therapy.
Double vision
Salience matters. It has to be important to the individual. Headaches
Age matters Plasticity is easier in a younger brain, but is also possible in an
matters. brain
adult brain. Blurred vision
Transference. Neuroplasticity, and the change in function that results from Dizziness or nausea
one therapy, can augment the attainment of similar behaviors.
Interference. Plasticity in response to one experience can interfere with the Light sensitivity
acquisition of other behaviors.
Attention or concentration difficulties
Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for
rehabilitation after brain damage. J Speech Lang Hear Res 2008 Feb;51(1):S225-39.
Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
• Staring behavior (low blink rate) • Pulls away from objects when they are
• Spatial disorientation brought close to them
• Losing place when reading • Exotropia or high exophoria
• Can’t find beginning of next line when •AAccommodative i ffi i
d ti insufficiency
reading • Convergence insufficiency
• Comprehension problems when reading • Poor fixations and pursuits
• Visual memory problems • Unstable peripheral vision
Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
• Associated neuromotor Visual Midline Shift Syndrome
difficulties with balance, • Dizziness or nausea
coordination and posture
p • Spatial disorientation
p
• Perceived movement of • Consistently stays to one side of
stationary objects hallway or room
• Bumps into objects when walking
14

15. Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
Visual Midline Shift Syndrome References
• Poor walking or posture: leans back on TBI a Major Cause of Disability
heels, forward, or to one side when by Marc B. Taub, OD, FAAO, FCOVD
walking, standing or seated in a chair
lki t di t di h i Clinical O l
Cli i l Oculomotor Training in Traumatic Brain
t T i i i T ti B i
Injury by Kenneth J. Ciuffreda, OD, PhD, FAAO,
• Perception of the floor being tilted FCOVD-A, Diana P. Ludlam, BS, COVT, Neera
• Associated neuromotor difficulties with Kapoor, OD, MS, FAAO
balance, coordination and posture
Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury
References References
• Myopia and Accommodative Insufficiency • Oculo-Visual Evaluation of the Patient with
Associated with Moderate Head Trauma Traumatic Brain Injury
by Steve Leslie B Optom FACBO FCOVD
Leslie, Optom, FACBO, by Maria Mandese, OD
Mandese
• Neuro-Optometry and the United States Legal • Traumatic Brain Injury and Binasal Occlusion
System by Alissa Proctor, OD
by Theodore S. Kadet, OD, FCOVD, R. E.
http://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx
Bodkin, JD, MBA, Attorney-at-Law
Questions? Contact:
Dominick M. Maino, OD, MEd, FAAO,FCOVD-A
Professor, Pediatric/Binocular Vision Service
Illinois Eye Institute Illinois College of Optometry
3241 S. Michigan Ave. Chicago, Il. 60616
312-949-7280 (phone) 312-949-7660 (f )
312 949 7280 ( h ) 312 949 7660 (fax)
dmaino@ico.edu
www.ico.edu www.nw.optometry.net
MainosMemos.blogspot.com
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