American Conference on Pediatric Cerebral Visual Impairment

A National Conference on
The Evaluation and Treatment of
Pediatric Cerebral Visual Impairment

The Children’s Hospital and
Medical Center of Omaha, NE

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

The Child with Special Needs
A Brief Overview

The Patient with Special Needs

Individuals with Special Needs

Cerebral Palsy Autism
Down Syndrome Intellectual Disability
Fragile X Syndrome Brain Injury
Psychiatric Illness ….and….



• 1. Defining Pediatric Cerebral Visual Impairment

• Definition confusing, misunderstood and imprecise.
• Pediatric Cerebral Visual Impairment (PCVI).
• Pediatric Cortical Visual Impairment
• Delayed Visual Development


• North America
•Cortical Visual Impairment
• Elsewhere
•Cerebral Visual Impairment


• History of CVI
• Brain injury 19th century
with Phineas P. Gage


• World War I, wounded
veterans with brain injury
• Displayed perceived
motion in the “blind, non-
seeing” visual field.
• Ability to sense motion,
lights, and colors
• Conscious or
subconscious.


• Statokinetic dissociation (in children)
• greater reduction in sensitivity to stationary visual
stimuli relative to similar targets in motion
• Riddoch phenomenon (adults)
• Ability to sense movement even though blind
• “See” moving objects…but not stationary ones

• Blindsight
• Ability to ‘sense’ objects in the way


• Movement in the peripheral visual field may elicit a smile
in the blind child with quadraplegia and profound
intellectual disability.
• Children who are fed with a spoon may intermittently open
their mouths to receive food when the spoon is moved in an
arc from the peripheral visual fields, but not when it
approaches the mouth from straight ahead.


• For those children who understand language stating what is
being seen as the child reacts to it may enhance both visual
and language development.
• Such children may rock to and fro. Whether this generates
an image is difficult to know.
• Rarely, children with cerebral blindness who are mobile
move slowly around obstacles. This phenomenon has been
called travel vision.


• 1980’s adults with bilateral occipital cortex
insult (cortical blindness)
• Term applied to children.
• Cortical visual impairment used in the
1980’s onward
• Definition of CVI includes injury lateral
geniculate nucleus/visual cortex


•Reduced visual acuity identifying
feature.
•Many children damage to white
matter surrounding the ventricals
(perventricular leukomalacia PVL)
•Cerebral Visual Impairment now used
(especially in Europe)


• 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 processing
problems


• Classification of CVI
• Ocular visual impairment: Refractive state. Optics, Eye
health
• Cerebral visual impairment: Neuro-pathway problems,
cortical problems, oculomotor dysfunction, vision
information processing (dorsal and ventral streaming
processing mechanisms)


The ventral stream (also known as the "what pathway")
travels to the temporal lobe and is involved with object
identification. The dorsal stream (or, "where pathway")
terminates in the parietal lobe and process spatial locations.


• Delayed Visual Maturation (DVM)
• DVM type I Visually impaired infants: improved
visual abilities by the age of 6 months, often
without treatment.
• 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


• Defining Other Disorders and PCVI
• Variability with defining disorders not
uncommon
• Autism rare anomaly
• Definition altered so that the number of
those on the Spectrum is now considered
epidemic
• Legal, legislative, health care,
insurance issues

• Should we be concerned about how PVCI is defined?
Absolutely!
• American Association on Intellectual and
Developmental Disabilities changed definition of
mental retardation
• Decreasing IQ cut off point from to 80 to 70
• Added adaptive behavior qualifications
• Result: instantly cured hundreds of thousands of
those with mental retardation/intellectual
disability overnight


What we call a thing is very important

To name it is to have power over it

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.
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
• 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

• Colenbrander A. What’s in a name? Appropriate terminology
for CVI. J Vis Impair Blind. 2010:583-585
• Roman Lantzy CA, Lantzy A. Outcomes and opportunities: A
study of children with cortical visual impairment. J Vis Impair
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


Determining Vision Function and
Functional Vision in Children with

Determining Vision Function and Functional Vision in Children
with Pediatric Cerebral Visual Impairment

• Need to assess vision function and
functional vision
• Vision function
•Clarity of vision (visual acuity,
contrast sensitivity, refractive error,
Amblyopia)


• Oculomotor ability (pursuits and saccades;
convergence and divergence, strabismus)

•Pursuits/Visual Tracking
•Saccades


• Binocular Vision
• Convergence insufficiency/excess
• Divergence insufficiency/excess
• Strabismus
• Exotropia
• Esotropia
• Hypertropia


• Accommodation (focusing)
• Accommodative insufficiency
• Accommodative excess
• Ill-sustained accommodation
• Accommodative instability

Determining Vision Function and Functional Vision in
Children with Pediatric Cerebral Visual Impairment
• Depth perception (3D vision)
• Binocular vision (Stereoscopy) is the ability to align and focus both eyes
accurately on an object and then combine the visual images from each eye into
a single, clear, three dimensional perception. Difficulty seeing in 3D can arise
when eye fatigue occurs, forcing the eyes to make adjustments to focus
simultaneously on images that are near and far away.
• Symptoms indicating a potential problem viewing images in 3D can vary,
but some common symptoms include headaches, blurred vision, nausea
and dizziness.

• Eye health
• Cornea, lens, pupil,
• iris, vitreous, optic nerve,
• retina
• Visual Cortex
• Other areas of the brain (motor,
• executive function)


• Special diagnostic tools
• EOG (electrooculogram)
• ERG (electroretinogram)
• VER/VEP (visually evoked
response visual evoked potential)

Vision Function of Children with Disability
Down Syndrome: Visual Acuity, Refractive Error,
Strabismus/Oculomotor, Accommodation, Ocular health, Vision
Information Processing, Other

Cerebral Palsy: Visual Acuity, Refractive Error,
Strabismus/Oculomotor, Accommodation, Ocular Health, Vision

Brain Injury: Visual Acuity, Refractive Error,
Strabismus/Oculomotor, Accommodation, Ocular Health, Vision


Functional vision
Functionally induced disability that
overlays pathologically induced
disability
• Uncorrected refractive error
• Amblyopia
• On top of vision loss due
• to cerebral impairment
• Down Syndrome
• Cerebral Palsy


• Vision information processing (VIP)/Visual
perceptual skills

• Laterality/Directionality
• Visual motor integration
• Non-motor perceptual skills
• Auditory perceptual/processing

References
• Luek AH. Cortical or cerebral visual impairment in children: A brief overview.
J Vis Impair Blind. 2010:585-592.
• Woodhouse JM, Maino DM. Down syndrome: In Taub M, Bartuccio M, Maino
D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs.
Lippincott Williams & Wilkins , NY, New York; 2012:31-40.
• Wesson M, Maino D. Oculo-visual findings in Down syndrome, cerebral palsy,
and mental retardation with non-specific etiology. In Maino 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.

References

• Ciuffreda K, Kapoor N. Acquired brain injury. In Taub M,
Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of
the Patient with Special Needs. Lippincott Williams &
Wilkins , NY, New York; 2012:95-100.
• Roman-Lantzy, C. Cortical visual impairment: An
approach to assessment and intervention. AFB Press, NY,
New York; 2007.
• http://www.3deyehealth.org/
• http://www.MainosMemos.blogspot.com


Therapeutic Strategies for the
Treatment of


• Treatment begins with the basics.
•Vision function
•Refractive correction
•Spectacles therapeutic
•Eye health


• Treatment with spectacle/lenses
• multi-focal prescription/bifocal
• prism
• occlusion


• Treatment with spectacle/lenses
• task specific glasses
• high “+” adds (magnification)
• Telescopes
• Microscopes


• Vision Therapy
• Oculomotor/hand-
eye/accommodation
& fusion
• Biocular
• Binocular


• Vision Therapy
• Integration/Stabilization
• Visual stimulation
• Vision information
processing
• Vestibular/Vision
Apps 4 Vision Development
http://www.sovoto.com/group/apps4VisionDevelopment


• Resources
• Facebook
(http://www.facebook.com/Thinkingoutsidet
helightbox)
• Pinterest
http://pinterest.com/achampine0302/cortic
al-visual-impairment-cvi-goodies/
• Blogs
http://www.MainosMemos.blogspot.com

Thinking Outside the LightBox


How Do Environmental Factors, Medications
and Non-Visual Handicaps Affect the
Evaluation and Treatment of Pediatric
Cerebral Visual Impairment?


For individuals with disability…

• Medications: Prescribed many more medications
• Higher affinity for adverse effects due to environmental/systemic
factors
• Seldom complain of symptoms related to their disability, systemic
anomalies, or medication side effects


• Alternative and complementary
medical therapies
Maino D. Evidence based medicine and CAM: a review. Optom Vis Dev 2012;43(1):13-17

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

• Traditional allopathic approaches


• Mental illnesses in children
• Pediatric Bipolar disorder
• Pediatric depression


• Major environmental hazard: People
• do not know how to respond
• make assumptions
• true for lay individuals, teacher, health
care professionals
• Other

Medication Side Effects

Antidepressants
Abdominal pain/constipation Blurred vision
Abnormal dreams/thinking Increased risk of Glaucoma
Abnormal ejaculation/orgasm Visual Disturbances
Anxiety Photophobia


Anticonvulsants
Memory problems/amnesia Blurred vision
Sedation Dimming of vision
Insomnia Diplopia
Bronchitis Involuntary eye movements
Fluid retention Dry eye


Anti-Parkisons
Abnormal dreams/insomnia Vision abnormalities
Increased muscle tone/weakness Blurred vision
Involuntary movements Mydriasis
Hallucinations Decreased accommodation


Tranquilizers
Breast development in men Risk of narrow angle GLC
Breathing problems Cycloplegia/Mydriasis
Insomnia Decreased vision
Tardive dyskinesia Capsular cataract


Anti-anxiety
Anemia Decreased accommodation
Seizures Nystagmus
Blood disorders Diplopia
Unusual excitement Mydriasis

American Conference on Pediatric Cerebral Visual Impairment

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