This document provides guidance on visual diagnosis and care of patients with special needs. It emphasizes preparing for the examination by speaking clearly, listening carefully, and treating the patient with dignity. A thorough case history and assessment of visual acuity, refractive error, binocular vision, ocular health, and special tests are recommended. Treatment may include refractive correction, vision therapy, surgery, and referrals. Creative, patient-centered care tailored to the individual is emphasized.

1. Visual Diagnosis and Care of Dominick M. Maino, O.D., M.Ed., F.A.A.O.
Patients with Special Needs Professor,
Pediatrics/Binocular Vision Service
Examination/Treatment 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.com
Diagnosis Diagnosis
• Preparing for the examination
Assessment Techniques for Special • greet patient by name
Populations • position yourself at patient’s eye
level
• be on schedule
Use everything you know, be creative, and • consider patient’s wishes about
family/friends in exam room
trust your objective evaluation skills! • direct initial comments to patient
• treat patient as a person first, then
as an individual with a disability
Diagnosis
• Preparing for the examination
• speak clearly
• listen carefully
• use short command sentences Treat the patient the
• “look here”
• “do this” way you would want
• “watch my light” to be treated!
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2. Remember the 10 Commandments Remember the 10 Commandments
1.) Speak directly to the 4.) If you offer assistance wait 7.) Listen attentively when talking to 10.) Relax. Don’t be
person rather than thru a people who have difficulty embarrassed if you use
until the offer is accepted, speaking and wait for them to
companion or sign language then listen and wait for finish.
common expressions that
interpreter. instructions. seems torelate to a person’s
8.) Place yourself at eye level
disability.
2.)Always offer to shake 5.) Treat adults as adults. when talking to someone in a
hands when introduced. 6.) Do not lean against or hand
wheelchair.
3.)Always identify yourself 9.) Tap a person who is deaf on the The Ten Commandments of
on someone's wheelchair or shoulder or wave your hand to
and others who are with you cart. Communicating with People
get their attention .
when meeting someone who With Disabilities
is blind.
Case History Case History
• Demographic Information
• Medical history including their disability
• typically taking many medications
• Visual history
• Educational history
• Rehabilitation history
• Vocational history
• Recreational history
Visual Acuity Visual Acuity
•Use highest level possible
• Snellen
•binocular before monocular testing
•adaptive positioning
• Broken Wheel
• HOTV
E
•use assistants, friends, family members • Lea Symbols FP
•limited window of opportunity • Teller Acuity Cards
•randomize optotypes, use reinforcers • OKN TOZ
•test=game, be creative
HOVT
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3. Visual Acuity Visual Acuity
• Snellen • Snellen
• Broken Wheel • Broken Wheel
• HOTV • HOTV
• Lea Symbols • Lea Symbols
• Teller Acuity Cards • Teller Acuity Cards
• OKN • OKN
Visual Acuity Visual Acuity
• Snellen • Snellen
• Broken Wheel • Broken Wheel
• HOTV • HOTV
• Lea Symbols • Lea Symbols
• Teller Acuity Cards • Teller Acuity Cards
• OKN • OKN
Visual Acuity Visual Acuity
• Snellen • Snellen
• Broken Wheel • Broken Wheel
• HOTV
• HOTV • Lea Symbols
• Lea Symbols • Teller Acuity Cards
• Teller Acuity Cards • OKN preferential looking
• OKN • Cardiff Cards cards that use form
discrimination with
vanishing optotypes
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4. Visual Acuity Refractive Error
Mohindra Dynamic Retinoscopy
•lens bars, 50 cm working distance
•dark, pt looks at light
•neutralize primary meridians
•write in spherocyindrical form
•add a (-) minus 1.25 to the sphere
Refractive Error Refractive Error
• Cycloplegic/Mydriatic spray • Keratometry
• hand held electronic devices (Nidek)
• Placido’s disk
• Spray on closed lids, • keratoscope
have pt blink, wipe off
excess (.5% Cyclo, .5% Myd,
2.5% Phenyl)
Binocular Vision Assessment Binocular Vision Assessment
Incidence of Strabismus
• Observation
• Observation
• Cover Test CEREBRAL PALSY 15-60%
• Cover Test
• Bruckner MENTAL
• Bruckner
RETARDATION 16-40%
• Angle Kappa
• Angle Kappa
• Hirschberg
DOWN SYNDROME 41-75%
• Hirschberg
• Krimsky DEAFNESS 29%
• Krimsky
NORMAL CHILDREN 2-4%
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5. Binocular Vision Assessment Binocular Vision Assessment
• Observation • Observation
• Cover Test • Cover Test
• Bruckner • Bruckner
• Angle Kappa • Angle Kappa
• Hirschberg • Hirschberg
• Krimsky • Krimsky
Binocular Vision Assessment Binocular Vision Assessment
• Observation • Observation
• Cover Test • Cover Test
• Bruckner • Bruckner
• Angle Kappa • Angle Kappa
• Hirschberg • Hirschberg
• Krimsky • Krimsky
Binocular Vision Assessment Binocular Vision Assessment
• Lang stereotest • Lang stereotest
• Random Dot E • Random Dot E
• Worth 4 Dot • Worth 4 Dot
• MEM Nearpoint • MEM Nearpoint
Retinoscopy Retinoscopy
• NPC • NPC
• Accommodative Facility • Accommodative Facility
• Saccades/Pursuits • Saccades/Pursuits
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6. Binocular Vision Assessment Binocular Vision Assessment
• Lang stereotest • Lang stereotest
• Random Dot E • Random Dot E
• Worth 4 Dot • Worth 4 Dot
• MEM Nearpoint Retinoscopy • MEM Nearpoint
• NPC Retinoscopy
• Accommodative Facility • NPC
• Saccades/Pursuits http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html • Accommodative Facility
• Saccades/Pursuits
Binocular Vision Assessment Binocular Vision Assessment
• Lang stereotest • Lang stereotest
• Random Dot E • Random Dot E
• Worth 4 Dot • Worth 4 Dot
• MEM Nearpoint • MEM Nearpoint
Retinoscopy Retinoscopy
• NPC • NPC
• Accommodative Facility • Accommodative Facility
• Saccades/Pursuits • Saccades/Pursuits
Ocular Health Ocular Health
• Hand held devices
• Hand held devices • Slit lamp
• Slit lamp • Keeler/Tonopen/
• Tonopen/Perkins • Perkins
• BIO/MIO/direct • BIO/MIO/direct
http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html
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7. Tangential Penlight Angle
Ocular Health
Estimation
• Hand held devices • Penlight at temporal aspect of
• Slit lamp •
cornea
Angle between 20-35 degrees to
• Tonopen/Perkins the facial plane
• BIO/MIO/direct •
•
Maximum brightness
Open angle = nasal illumination at
least 75% as bright as temporal
illumination
Special Testing Special Testing
Ultrasound, B-Scan
• VEP, ERG, EOG • VEP, ERG, EOG
• Sweep VEP • Sweep VEP CPT 76512 (contact B-scan);
• Ultrasound (A/B scan) • Ultrasound (A/B scan) Indications
Examination of the posterior
• TOVA • TOVA portion of the eye when direct
• Visagraph • Visagraph view is precluded by media
opacities. Evaluation of
intraocular or orbital masses.
For more info:
http://www.healthgate.co.uk/dp
/dph.0253.shtml
Special Testing The Test of Variables of Attention Special Testing
(T.O.V.A.®),
a 21.6 minute computerized continuous
• VEP, ERG, EOG performance test used by professionals • VEP, ERG, EOG
• Sweep VEP in the diagnosis and monitoring • Sweep VEP
• Ultrasound (A/B scan) of treatment of attention deficit disorder • Ultrasound (A/B scan)
(ADD)/attention deficit hyperactivity
• TOVA disorder (ADHD) in children and adults. • TOVA
• Visagraph The standardized test is well normed and • Visagraph
extremely helpful in predicting
responsiveness to treatment modality.
More info at: http://www.tova.net/
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8. Assessment Treatment
• Refractive
• Working with incomplete or “fuzzy” clinical data
• “Get over it!” •Patient’s cognitive level
• Seek help •Patient’s motor ability
• Dr. Dominick Maino •Patient’s therapy goals
• 312-949-7282 •Patient’s vocational goals
• dmaino@ico.edu •Patient’s self abusive behaviors
•Living conditions
•Past success
Treatment Treatment
• When Do You Correct Refractive Error? • Binocular Vision Dysfunction
• Strabismus
•Myopia > 1.00D • Rx, VT, surgery
• Amblyopia
•Hyperopia > 2.00D • Rx, VT
•WR Astig > 2.00D • Accommodation dysfunction
•AR Astig > 1.00D • Rx, VT
•Oblique Astig > 1.00D • Oculomotor anomalies
•Anisometropia > 1.00D • Rx, VT
Treatment Treatment
Ocular Health
Ocular
Treat as you would any other Health
patient. May even be more anterior
aggressive in your treatment segment:
lids, lashes
conjunctiva,
cornea
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9. Treatment Treatment
• Lens
• refer/treat optically
• GLC
• cataract • Treat/Refer
• lenticonus • Many need
• Fundus/Optic nerve surgical
• diagnose/refer intervention
Referral Resources Summary
Developmental Disabilities Service • All deserve optometric vision care
Neumann Family Services • If all you do is take a detailed case history, it’s probably
of the more than any have even attempted before
• Do not underestimate the power of glasses
Illinois Eye Institute • Be creative, use want you know, invent!
3241 S. Michigan Ave.
• Treat (optically, functionally, medically) because we do
Chicago, Il. 60616 it all!
312-949-7280 (Pediatrics)
Questions? Contact:
Dominick M. Maino, OD, MEd, FAAO, FCOVD-A
Professor, Pediatric/Binocular Vision Service
Distinguished Practitioner, Academies of Practice
Leonardo da Vinci Award of Excellence in Medicine, Recipient
Illinois Eye Institute Illinois College of Optometry
3241 S. Michigan Ave. Chicago, Il. 60616
312-949-7280 (phone) 312-949-7660 (fax)
dmaino@ico.edu www.ico.edu
LyonsFamilyEyeCare.com MainosMemos.com
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