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Visual Diagnosis and
Care of the Patient with
    Special Needs
Syndromes/Genetic Anomalies/Brain Injury
Dominick M. Maino, O.D., M.Ed., F.A.A.O.,
             F.C.O.V.D-A.
                    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 MainosMemos.com
        www.ico.edu LyonsFamilyEyeCare.com
Taub M, Bartuccio M, Maino D. (Eds)
Visual Diagnosis and Care of the Patient
with Special Needs. Lippincott, Williams &
Wilkins. New York, NY;2012.
Steel G, Maino D. The Life Cycle Approach to Care for Patients with
Special Needs.

Taub M, Reddell AS. Cerebral Palsy.

Woodhouse M. Maino D. Down Syndrome.

Berrry-Kravis E, Maino D. Fragile X

Coulter RA. Autism

Schnell PH, Maino D, Jespersen R. Psychiatric Illness and Associated
Oculo-visual Anomalies.

Bartuccio M, Browing RT, Howell AC. ADHD

Ciuffreda K, Kapoor N. Acquired Brain Injury.

Maino D, Donati, R, Pang, Viola S, Barry S. Neuroplasticity.

Lran BS, Mayer DL. Vision Impairment and Brain Damage
Children with Special Needs


•Learning Disability
•ADHD
•Cerebral Palsy
•Down Syndrome
•Fragile X Syndrome
Children with Special Needs

•Autism
•Mental Retardation/Intellectual
 Disability
•Acquired/Traumatic Brain Injury
•Mental Illness/Psychiatric Illness
Learning Disabilities


Reading/Dyslexia
  Dyscalculia
  Dysgraphia
Learning Disabilities


Reading/Dyslexia
Reading disabilities common

       Dyslexia rare
Learning Disabilities


Reading/Dyslexia
      Language Based
        Vision Based
Combination of Language/Vision
Learning Disabilities


     Dyscalculia (Math Disability)
               3 and 6% of the population
            Neurological Dyscalculia
   Deficits in working & short term memory
Congenital/hereditary (Gerstmann syndrome: Dyscalculia + Dysgraphia)
Learning Disabilities


         Dysgraphia
Working memory (orthographic coding)
         Motor planning
        Attentional issues
Learning Disabilities

   ADHD/ADD Etiology
           Brain Functioning
               Heredity
      Exposure to Toxic Substances
Brain Trauma, Tumors, Strokes or Disease
       Functional Vision Problems
Learning Disabilities

ADHD/ADD Not Caused By:
              Diet
           Hormones
     Vestibular dysfunction
        Poor parenting
           Television
Learning Disabilities

ADHD/ADD Treatment
           Medication
         Psychotherapy
      Education or Training
   A combination of treatments
Oculomotor therapy/Vision Therapy
Visual Diagnosis and Care of Patients with Special Needs: Syndromes
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 is a persistent, but not
  unchanging, disorder of movement and
  posture appearing in the early years of life
  due to traumatic or inflammatory brain
  damage.
• Affects virtually all motor systems
• Can be acquired
Cerebral Palsy   Etiology


Something goes awry just before, during or
 just after birth:
                   Prenatal
                   Neonatal
                   Postnatal
Cerebral Palsy     Incidence/Prevalence

• 764,000+ children and adults
• 500,000 children under age of 18
• 2-3 children out of 1,000 (as low as 2.3 per 1,000 to 3.6
  per 1,000)

• 10,000 babies born each year
• 8,000 - 10,000 babies and infants are
  diagnosed per year
Cerebral Palsy   Incidence/Prevalence

• Around 1,200 to 1,500 preschool-aged
 children are diagnosed per year
• births 10% of cases are acquired
  (trauma)
• Normal life spans, 40% live to age 40,
  many living into their senior years
Cerebral Palsy     Incidence/Prevalence

•   75% of CP occurs during pregnancy , 5% during childbirth
    and/or 15% after birth up to age 3
•   80% the etiology is unknown
•   The number of new cases have increased 25% during the
    past decade (1990’s)
•   Average lifetime cost per person of $921,000 (in 2003
    dollars)
Cerebral Palsy   Classifications



• Spastic - 61% to 76.9%
• Dyskinetic/Athetoid - 10-15%
• Ataxic - <5%
• Mixed
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-
   Yearbook Inc.:17-54.

• Binocular acuity could be evaluated in
    45% of individuals below age 13
•   For CP patients VAs are generally
    decreased when compared to those
    measured for individuals with Down
    Syndrome
•   Much higher incidence of ocular disease
    and neurological dysfunction
Cerebral Palsy                  Refractive Characteristics

Scheiman MM. Optometric findings in children with cerebral palsy. Am J Optom Physiol
   Opt 1984;61:321-333

• 60% significant refractive error
• Hyperopia (>+1.50) 3X more common among
    CP children than in non-affected individuals
•   Other studies (Black, Breakey et al, Duckman,
    LoCasio) support increased refractive error
    being present
Cerebral Palsy   Refractive Characteristic


• Hyperopia present 3Xs
  more than when compared
  to myopia
• Wesson & Maino note:
  • many more hyperopes
    than myopes
  • average amount of
    significant myopia is
    greater
Cerebral Palsy     Binocular
                 Characteristics

• Prevalence of strabismus exceeds that of
  general population by a factor of 10!
• Slightly more esotropia than exotropia
• Dyskinetic Strabismus
  • slow tonic deviation similar to
    vergence
  • change from ET to XT
  • usually associated with athetoid
    classification
Cerebral Palsy InteractionTips


• Positioning
• Right tools (objective)
• No sudden movement
• No loud, unexpected noises
• Speak smoothly, soothingly, softly….if
  appropriate, sing to the patient!
• Smile, smile SMILE!!!
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-
   Apr;31(2):488-95. Epub 2009 Dec 5.



    ….Overall, 73% patients had
     impairments …..the majority of
     which presenting difficulties on
     both visuoperceptual and
     visuospatial tasks (79%).. …
Cerebral Palsy
•   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
    Ophthalmol Vis Sci. 2010 Jun;51(6):2885-90. Epub 2010 Jan 27.


     . … A significantly higher prevalence and magnitude
       of refractive error was found in the CP group …..
       Higher spherical refractive errors were
       significantly associated with the nonspastic CP ….
       The presence and magnitude of astigmatism were
       greater when intellectual impairment was more
       severe, …. High refractive errors are common in
       CP, pointing to impairment of the
       emmetropization process. ….
Cerebral Palsy

McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ.
Accommodative dysfunction in children with cerebral palsy:
  a population-based study. Invest Ophthalmol Vis Sci. 2006
  May;47(5):1824-30.


Brain injury such as that present in CP has a
 significant impact on accommodative
 function. These findings have implications
 for the optometric care of children with CP
 and inform our understanding of the impact
 of early brain injury on visual development.
Cerebral Palsy
Ross LM, Heron G, Mackie R, McWilliam R, Dutton GN.
Reduced accommodative function in dyskinetic cerebral palsy: a novel
  management strategy. Dev Med Child Neurol. 2000 Oct;42(10):701-3. Links


….The near-vision symptoms were completely
 removed and reading dramatically improved with
 the provision of varifocal spectacles. Varifocal
 lenses provide an optimal correction for far,
 intermediate (i.e. for computer screens), and
 near distances (i.e. for reading). Managing this type
 of patient with varifocal spectacles has not been
 previously reported. It is clearly very important
 to prescribe an optimal spectacle correction
 to provide clear vision to
optimize learning.
Visual Diagnosis and Care of Patients with Special Needs: Syndromes
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.
Down Syndrome


• What is it?
• What is it’s etiology?
• What is it’s prevalence/incidence?
• What are it’s physical/visual characteristics?
Down Syndrome


• Langdon Down 1866
• “Mongolism” no longer used
• Most common genetic anomaly
• Variable levels of ability & disability
Down Syndrome

From 1979 to 2003 the prevalence of
 Down syndrome increased by 31.1%,
 from 9.0 to 11.8 per 10,000 live births.
 In 2002 prevalence among children and
 adolescents aged 0 to 19 was 1 in 971, or
 approximately 83,400 children and
 adolescents living with Down syndrome
 in the Unites States.
Down Syndrome            Prevalence/Incidence

• 1 in 12 for older mothers (>=49yrs of age)
• Most babies with Down syndrome born to
    younger mothers (80% born to moms younger than 35)
•   Most frequently encounter “viable” genetic
    anomaly
•   Most frequently encounter “special” patient
•   Prevalence increasing (improved survival rates)
http://www.nichd.nih.gov/publications/pubs/downsyndrome.cfm
You will see individual with Down
    Syndrome in Your Office
Down Syndrome Etiology
• Genetics
  • 95% demonstrate non-disjunction of one
    chromosome during meiosis (Trisomy 21)
  • 2-4% mosaicism
  • 3-4% Robertsonian translocation of the long
    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.
Down Syndrome Etiology

•   Genetics: Trisomy 21
Down Syndrome   Refractive Error

Many more hyperopes than
 myopes, but those with myopia
 tended to have higher
 magnitudes
Up to 49% may exhibit some
 astigmatism
Down Syndrome              Binocular
                   Characteristics

23-44% have strabismus
(Wesson & Maino) Down syndrome and
  strabismus shows a constant unilateral
  esotropia of less than 20 PD at near.
 (Greatly reduced number show ET at distance)
 It’s suggested that the etiology is a high
 ACA ratio rather that of a basic ET
What’s New in Down Syndrome
Al-Bagdady M, Stewart RE, Watts P, Murphy PJ, Woodhouse JM. Bifocals
and Down's syndrome: correction or treatment? Ophthalmic Physiol
Opt. 2009 Jul;29(4):416-21. Epub 2009 May 11.

   Accommodation is reduced in approximately 75% of
   children with Down's syndrome (DS). Bifocals have
   been shown to be beneficial and they are currently
   prescribed regularly.. … Bifocals are an effective
   correction for the reduced accommodation in children
   with DS and also act to improve accommodation with
   a success rate of 65%. ….
What’s New in Down Syndrome
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.



Thinning of the corneal stroma may
account for the steeper cornea and the
high frequency of astigmatism in Down
syndrome due to lower corneal rigidity.
It may also be of etiological importance
to the increased incidence of
keratoconus in Down syndrome.
Haugen OH, Hovding G, Lundstrom I.Refractive development in children
with Down's syndrome: a population based, longitudinal study. Br J Ophthalmol.
2001 Jun;85(6):714-9.


….Accommodation weakness may be of
aetiological importance to the high
frequency of refractive errors
encountered in patients with Down's
syndrome.
Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. Association
between accommodative accuracy, hypermetropia, and strabismus
in children with Down's syndrome Optom Vis Sci. 2007
Feb;84(2):149-55.


….This study demonstrates the marked
association between under-
accommodation, hypermetropia, and
strabismus in children with Down's
syndrome. ….
Haugen OH, Hovding G.Strabismus and binocular function in children with
Down syndrome. A population-based, longitudinal study.Acta Ophthalmol
Scand. 2001 Apr;79(2):133-9.


…The majority of the Down syndrome
children with strabismus have an
acquired esotropia and hence a
potential for binocularity.
Hypermetropia and accommodation
weakness are probably important
factors in esotropia …….
Stewart RE, Woodhouse MJ, Trojanowska LD. In focus:
the use of bifocal spectacles with children with Down's
syndrome.Ophthalmic Physiol Opt. 2005 Nov;25(6):514-22

   …….Based on the results of this
   study, eye examinations of children
   with Down's syndrome should
   routinely include a measure of
   accommodation at near, and bifocal
   spectacles should be considered for
   those who show under-
   accommodation.
Visual Diagnosis and Care of Patients with Special Needs: Syndromes
Fragile X Syndrome


• What is it?
• What is it’s etiology?
• What is it’s prevalence/incidence?
• What are it’s physical/visual characteristics?
Fragile X Syndrome


Most frequently encountered inherited form of
  mental retardation (X-linked MR)
Often misdiagnosed in the past
“New” syndrome that has caught the
  imagination of researchers around the world
1st human disease shown to be caused by a
  repeated nucleotide sequence
Fragile X Syndrome

X-linked MR 1:600 in affected males
1/2500-4000 males 1/7000-8000 females
     female carriers 1/130-250 population
            male carrier 1/250-800
       10% of undiagnosed ID in males
  3% of previously undiagnosed ID in females
Fragile X Syndrome    Characteristics




• Large prominent ears
• Long narrow face
• Macro-orchidism
  (80% affected men)

Other: hypotonia, seizures,
 recurrent otitis
     media
Fragile X Syndrome    Characteristics




• Large prominent ears
• Long narrow face
• Macro-orchidism (80%
  affected men)

Other: hypotonia, seizures,
 recurrent otitis media
Fragile X Syndrome    Characteristics




• Large prominent ears
• Long narrow face
• Macro-orchidism (80%
  affected men)

Other: hypotonia, seizures,
 recurrent otitismedia
Fragile X Syndrome     Characteristics




• First demonstrated genetic etiology of
  learning disability
• Variable mental retardation
• Math, language delay
• Sensory integration problems
• Attentional deficits
• Psychiatric illnesses (shy)
Fragile X Syndrome   Characteristics




          Gaze Avoidance

How do you conduct an
 examination on an individual
 that won’t look at you?
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)
Visual Diagnosis and Care of Patients with Special Needs: Syndromes
Fragile X Syndrome   Ocular Findings


• Strabismus (33-50%)
• Nystagmus
• Refractive error
• Accommodative dysfunctions?
• Oculomotor anomalies
• Ocular Health?
• Perceptual dysfunction
What’s New in Fragile X Syndrome
•   Hatton DD, Buckley E, Lachiewicz A, Roberts J. Ocular status of boys with fragile X syndrome: a
    prospective study. J AAPOS. 1998 Oct;2(5):298-302.



…observe a higher prevalence of strabismus than
 that found in the general population (8% vs 0.5%
 to 1…., 17% of the sample did have significant
 refractive errors. In addition to evaluating the
 ocular motility of children with fragile X
 syndrome, cycloplegic refraction should also be
 performed to determine whether refractive
 problems are present.
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
    skills and their relationship to mutation size in full and premutation female fragile X carriers.Optom Vis Sci.
    2000 Nov;77(11):592-9.


    ….full mutation female carriers performed more
    poorly in visual-motor processing and analysis-
    synthesis on the Woodcock-Johnson Psycho-
    Educational Battery-Revised, The Developmental
    Test of Visual Motor Integration, and on five of the
    seven subtests of the Test of Visual-Perceptual
    Skills. Regression analyses revealed significant
    negative correlations between mutation size and
    cognitive ability. …
What’s New in Fragile X Syndrome
Effect of CX516, an AMPA-modulating compound, on cognition
  and behavior in fragile X syndrome: a controlled trial. Berry-
  Kravis E, Krause SE, Block SS, Guter S, Wuu J, Leurgans S,
  Decle P, Potanos K, Cook E, Salt J, Maino D, Weinberg D, Lara
  R, Jardini T, Cogswell J, Johnson SA, Hagerman R. J Child
  Adolesc Psychopharmacol. 2006 Oct;16(5):525-40.PMID:
  17069542
Cognitive and visual processing skills and their relationship to
  mutation size in full and premutation female fragile X carriers.
  Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM,
  Treitman TM. Optom Vis Sci. 2000 Nov;77(11):592-9.PMID:
  11138833
What’s New in Fragile X Syndrome

The fragile X female: a case report of the visual, visual perceptual,
  and ocular health findings. Amin VR, Maino DM. J Am Optom
  Assoc. 1995 May;66(5):
Optometric findings in the fragile X syndrome. Maino DM, Wesson
  M, Schlange D, Cibis G, Maino JH. Optom Vis Sci. 1991
  Aug;68(8):
Mental retardation syndromes with associated ocular defects. Maino
  DM, Maino JH, Maino SA.
J Am Optom Assoc. 1990 Sep;61(9):707-16.
Ocular anomalies in fragile X syndrome. Maino DM, Schlange D,
  Maino JH, Caden B. J Am Optom Assoc. 1990 Apr;61(4):316-23
Fragile X-associated tremor/ataxia syndrome
                       (FXTAS)

reported in 33-40% of men older than 50 years and, less
frequently (4-8%), in older women with premutations in the
fragile X mental retardation (FMR1) gene.
Clinical features (FXTAS): incontinence, impotence, cerebellar
ataxia, peripheral neuropathy, autonomic dysfunction/orthostatic
hypotension, severe intention tremor, and other signs of
neurodegeneration (brain atrophy, memory loss and dementia,
anxiety, depression, and irritability). Premature ovarian failure
in 25% of women with premutations; this represents a 30-fold
increase compared with the general population.
Autism




Factors such as younger age of diagnosis, broadening of diagnostic criteria, improvements in the availability
of services, and better awareness of the disorder have all been attributed to the change in autism
prevalence. However, recent epidemiological studies indicated that, while these factors do account for a
portion of the change, they cannot account for all of the increase alone
Autism

                     Do Parents cause their children to be autistic ?
There are autistic children born to parents who do not fit the autistic parent personality pattern.
Parents who do fit the description of the supposedly pathogenic parent have normal, non-autistic
    children.
Frequently siblings of autistic children are normal.
Autistic children are behaviorally unusual "from the moment of birth." ***
There is a consistent ratio of three or four boys to one girl.
Virtually all cases of twins reported in the literature have been identical, with both twins
    afflicted. ***
Autism can occur or be closely simulated in children with known organic brain damage. ***
The symptomatology is highly unique and specific.
There is an absence of gradations of infantile autism which would
create "blends" from normal to severely afflicted.
Autism Etiology
Yeast infections
Intolerance to specific food substances
(Gluten intolerance ("Leaky Gut Syndrome"/Casein intolerance causing
    intestinal permeability and allowing improperly digested peptides to enter
    the bloodstream and cross the blood-brain barrier which may mimic
    neurotransmitters and result in the scrambling of sensory input. I've also
    heard "Leaky Gut Syndrome" described as lack of the beneficial bacteria
    that aids digestion, and that the resulting matter in the bloodstream invokes
    an unnecessary immune reaction)
Phenolsulphertransferase (PST) deficiency--theory that some with autism are
    low on sulphate or an enzyme that uses this, called phenol-
    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

  Brain injury, Constitutional vulnerability
Developmental aphasia , Deficits in the reticular
   activating system, An unfortunate interplay
            between psychogenic and
     neurodevelopmental factors, Structural
    cerebellar changes, Genetic causes, Viral
      causes, Immunological ties, Vaccines,
                    Seizures
Autism Etiology




 My Goodness!
Maino DM, Viola, SG, Donati R. The
Etiology of Autism. Optom Vis
Dev 2009:(40)3:150-156.
Autism Etiology




What the research
    shows…
Autism



Impairment in social interactions
 Impairment in communication
Restricted repertoire of activities
Autism


                            Asperger
Childhood                   Syndrome
Disintegrative
Disorder         Autism

                            Rett Syndrome
Autism



Childhood
Disintegrative
Disorder
Autism US FDA Statement
IOM Report: No Link Between Vaccines and Autism
By Michelle Meadows
There is no link between autism and the
measles-mumps-rubella (MMR) vaccine or the
   Childhood
   Disintegrative
vaccine preservative thimerosal, according to a
   Disorder
report released by the Institute of Medicine's
(IOM) Immunization Safety Review
Committee.
http://www.fda.gov/fdac/features/2004/504_iom.html
Autism
Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen
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

  Childhood
Our study does not support
  Disintegrative
  Disorder

a causal association                                    between early
exposure to mercury from thimerosal-containing vaccines and immune
globulins and deficits in neuropsychological functioning at the age of 7 to
10 years.
Autism

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
with autism and inflammatory bowel disease. Wakefield was the lead author
  Disorder
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
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“.
Summary




Autism?
Mental Retardation without Specific Etiology



Most frequently encountered form of Intellectual
 Disability

4000 known Online Mendelian Inheritance
 in Man
    http://www.ncbi.nlm.nih.gov/omim
25% of the etiologies are unknown!
Mental Retardation    Classification


  Classification                               IQ
Mild/Educable Mentally Handicapped             50-70
Moderate/Trainable Mentally Handicapped        35-55
Severe                                         20-40
Profound                                       below 20
Acquired/Traumatic Brain Injury

Neuroplasticity
Maino D. Neuroplasticity: Teaching an Old Brain New Tricks. Rev Optom
  2009. 46(1):62-64,66-70.
  (http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106025/)
Acquired/Traumatic Brain Injury

Neuroplasticity & Rehabilitation
Use it or lose it. If you do not drive specific brain functions, functional
  loss will occur.
Use it and improve it. Therapy that drives cortical function enhances that
  particular function.
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.
Acquired/Traumatic Brain Injury

Neuroplasticity & Rehabilitation
Time matters. Different forms of plasticity take place at different times
   during therapy.
Salience matters. It has to be important to the individual.
Age matters. Plasticity is easier in a younger brain, but is also possible in an
   adult brain.
Transference. Neuroplasticity, and the change in function that results from
   one therapy, can augment the attainment of similar behaviors.
Interference. Plasticity in response to one experience can interfere with the
   acquisition of other behaviors.
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

Post Trauma Vision Syndrome Symptoms/Signs
                 Double vision
                   Headaches
                 Blurred vision
              Dizziness or nausea
                Light sensitivity
     Attention or concentration difficulties
Acquired/Traumatic Brain Injury

• Staring behavior (low blink rate)
• Spatial disorientation
• Losing place when reading
• Can’t find beginning of next line when
  reading
• Comprehension problems when reading
• Visual memory problems
Acquired/Traumatic Brain Injury

• Pulls away from objects when they are
  brought close to them
• Exotropia or high exophoria
• Accommodative insufficiency
• Convergence insufficiency
• Poor fixations and pursuits
• Unstable peripheral vision
Acquired/Traumatic Brain Injury

• Associated neuromotor
  difficulties with balance,
  coordination and posture
• Perceived movement of
  stationary objects
Acquired/Traumatic Brain Injury

     Visual Midline Shift Syndrome
• Dizziness or nausea
• Spatial disorientation
• Consistently stays to one side of
  hallway or room
• Bumps into objects when walking
Acquired/Traumatic Brain Injury

     Visual Midline Shift Syndrome
• Poor walking or posture: leans back on
  heels, forward, or to one side when
  walking, standing or seated in a chair
• Perception of the floor being tilted
• Associated neuromotor difficulties with
  balance, coordination and posture
Acquired/Traumatic Brain Injury

                   References
TBI a Major Cause of Disability
 by Marc B. Taub, OD, FAAO, FCOVD
Clinical Oculomotor Training in Traumatic Brain
 Injury by Kenneth J. Ciuffreda, OD, PhD, FAAO,
 FCOVD-A, Diana P. Ludlam, BS, COVT, Neera
 Kapoor, OD, MS, FAAO
Acquired/Traumatic Brain Injury

                    References
• Myopia and Accommodative Insufficiency
  Associated with Moderate Head Trauma
  by Steve Leslie, B Optom, FACBO, FCOVD
• Neuro-Optometry and the United States Legal
  System
  by Theodore S. Kadet, OD, FCOVD, R. E.
  Bodkin, JD, MBA, Attorney-at-Law
Acquired/Traumatic Brain Injury

                     References
• Oculo-Visual Evaluation of the Patient with
  Traumatic Brain Injury
  by Maria Mandese, OD
• Traumatic Brain Injury and Binasal Occlusion
  by Alissa Proctor, OD
http://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx
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 (fax)

                 dmaino@ico.edu
     www.ico.edu    LyonsFamilyEyeCare.com
               MainosMemos.com

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Visual Diagnosis and Care of Patients with Special Needs: Syndromes

  • 1. Visual Diagnosis and Care of the Patient with Special Needs Syndromes/Genetic Anomalies/Brain Injury
  • 2. Dominick M. Maino, O.D., M.Ed., F.A.A.O., F.C.O.V.D-A. 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 MainosMemos.com www.ico.edu LyonsFamilyEyeCare.com
  • 3. Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient with Special Needs. Lippincott, Williams & Wilkins. New York, NY;2012. Steel G, Maino D. The Life Cycle Approach to Care for Patients with Special Needs. Taub M, Reddell AS. Cerebral Palsy. Woodhouse M. Maino D. Down Syndrome. Berrry-Kravis E, Maino D. Fragile X Coulter RA. Autism Schnell PH, Maino D, Jespersen R. Psychiatric Illness and Associated Oculo-visual Anomalies. Bartuccio M, Browing RT, Howell AC. ADHD Ciuffreda K, Kapoor N. Acquired Brain Injury. Maino D, Donati, R, Pang, Viola S, Barry S. Neuroplasticity. Lran BS, Mayer DL. Vision Impairment and Brain Damage
  • 4. Children with Special Needs •Learning Disability •ADHD •Cerebral Palsy •Down Syndrome •Fragile X Syndrome
  • 5. Children with Special Needs •Autism •Mental Retardation/Intellectual Disability •Acquired/Traumatic Brain Injury •Mental Illness/Psychiatric Illness
  • 6. Learning Disabilities Reading/Dyslexia Dyscalculia Dysgraphia
  • 8. Learning Disabilities Reading/Dyslexia Language Based Vision Based Combination of Language/Vision
  • 9. Learning Disabilities Dyscalculia (Math Disability) 3 and 6% of the population Neurological Dyscalculia Deficits in working & short term memory Congenital/hereditary (Gerstmann syndrome: Dyscalculia + Dysgraphia)
  • 10. Learning Disabilities Dysgraphia Working memory (orthographic coding) Motor planning Attentional issues
  • 11. Learning Disabilities ADHD/ADD Etiology Brain Functioning Heredity Exposure to Toxic Substances Brain Trauma, Tumors, Strokes or Disease Functional Vision Problems
  • 12. Learning Disabilities ADHD/ADD Not Caused By: Diet Hormones Vestibular dysfunction Poor parenting Television
  • 13. Learning Disabilities ADHD/ADD Treatment Medication Psychotherapy Education or Training A combination of treatments Oculomotor therapy/Vision Therapy
  • 15. 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?
  • 16. Cerebral Palsy • Cerebral Palsy is a persistent, but not unchanging, disorder of movement and posture appearing in the early years of life due to traumatic or inflammatory brain damage. • Affects virtually all motor systems • Can be acquired
  • 17. Cerebral Palsy Etiology Something goes awry just before, during or just after birth: Prenatal Neonatal Postnatal
  • 18. Cerebral Palsy Incidence/Prevalence • 764,000+ children and adults • 500,000 children under age of 18 • 2-3 children out of 1,000 (as low as 2.3 per 1,000 to 3.6 per 1,000) • 10,000 babies born each year • 8,000 - 10,000 babies and infants are diagnosed per year
  • 19. Cerebral Palsy Incidence/Prevalence • Around 1,200 to 1,500 preschool-aged children are diagnosed per year • births 10% of cases are acquired (trauma) • Normal life spans, 40% live to age 40, many living into their senior years
  • 20. Cerebral Palsy Incidence/Prevalence • 75% of CP occurs during pregnancy , 5% during childbirth and/or 15% after birth up to age 3 • 80% the etiology is unknown • The number of new cases have increased 25% during the past decade (1990’s) • Average lifetime cost per person of $921,000 (in 2003 dollars)
  • 21. Cerebral Palsy Classifications • Spastic - 61% to 76.9% • Dyskinetic/Athetoid - 10-15% • Ataxic - <5% • Mixed
  • 22. 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- Yearbook Inc.:17-54. • Binocular acuity could be evaluated in 45% of individuals below age 13 • For CP patients VAs are generally decreased when compared to those measured for individuals with Down Syndrome • Much higher incidence of ocular disease and neurological dysfunction
  • 23. Cerebral Palsy Refractive Characteristics Scheiman MM. Optometric findings in children with cerebral palsy. Am J Optom Physiol Opt 1984;61:321-333 • 60% significant refractive error • Hyperopia (>+1.50) 3X more common among CP children than in non-affected individuals • Other studies (Black, Breakey et al, Duckman, LoCasio) support increased refractive error being present
  • 24. Cerebral Palsy Refractive Characteristic • Hyperopia present 3Xs more than when compared to myopia • Wesson & Maino note: • many more hyperopes than myopes • average amount of significant myopia is greater
  • 25. Cerebral Palsy Binocular Characteristics • Prevalence of strabismus exceeds that of general population by a factor of 10! • Slightly more esotropia than exotropia • Dyskinetic Strabismus • slow tonic deviation similar to vergence • change from ET to XT • usually associated with athetoid classification
  • 26. Cerebral Palsy InteractionTips • Positioning • Right tools (objective) • No sudden movement • No loud, unexpected noises • Speak smoothly, soothingly, softly….if appropriate, sing to the patient! • Smile, smile SMILE!!!
  • 27. 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- Apr;31(2):488-95. Epub 2009 Dec 5. ….Overall, 73% patients had impairments …..the majority of which presenting difficulties on both visuoperceptual and visuospatial tasks (79%).. …
  • 28. Cerebral Palsy • 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 Ophthalmol Vis Sci. 2010 Jun;51(6):2885-90. Epub 2010 Jan 27. . … A significantly higher prevalence and magnitude of refractive error was found in the CP group ….. Higher spherical refractive errors were significantly associated with the nonspastic CP …. The presence and magnitude of astigmatism were greater when intellectual impairment was more severe, …. High refractive errors are common in CP, pointing to impairment of the emmetropization process. ….
  • 29. Cerebral Palsy McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ. Accommodative dysfunction in children with cerebral palsy: a population-based study. Invest Ophthalmol Vis Sci. 2006 May;47(5):1824-30. Brain injury such as that present in CP has a significant impact on accommodative function. These findings have implications for the optometric care of children with CP and inform our understanding of the impact of early brain injury on visual development.
  • 30. Cerebral Palsy Ross LM, Heron G, Mackie R, McWilliam R, Dutton GN. Reduced accommodative function in dyskinetic cerebral palsy: a novel management strategy. Dev Med Child Neurol. 2000 Oct;42(10):701-3. Links ….The near-vision symptoms were completely removed and reading dramatically improved with the provision of varifocal spectacles. Varifocal lenses provide an optimal correction for far, intermediate (i.e. for computer screens), and near distances (i.e. for reading). Managing this type of patient with varifocal spectacles has not been previously reported. It is clearly very important to prescribe an optimal spectacle correction to provide clear vision to optimize learning.
  • 32. 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.
  • 33. Down Syndrome • What is it? • What is it’s etiology? • What is it’s prevalence/incidence? • What are it’s physical/visual characteristics?
  • 34. Down Syndrome • Langdon Down 1866 • “Mongolism” no longer used • Most common genetic anomaly • Variable levels of ability & disability
  • 35. Down Syndrome From 1979 to 2003 the prevalence of Down syndrome increased by 31.1%, from 9.0 to 11.8 per 10,000 live births. In 2002 prevalence among children and adolescents aged 0 to 19 was 1 in 971, or approximately 83,400 children and adolescents living with Down syndrome in the Unites States.
  • 36. Down Syndrome Prevalence/Incidence • 1 in 12 for older mothers (>=49yrs of age) • Most babies with Down syndrome born to younger mothers (80% born to moms younger than 35) • Most frequently encounter “viable” genetic anomaly • Most frequently encounter “special” patient • Prevalence increasing (improved survival rates) http://www.nichd.nih.gov/publications/pubs/downsyndrome.cfm
  • 37. You will see individual with Down Syndrome in Your Office
  • 38. Down Syndrome Etiology • Genetics • 95% demonstrate non-disjunction of one chromosome during meiosis (Trisomy 21) • 2-4% mosaicism • 3-4% Robertsonian translocation of the long 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.
  • 39. Down Syndrome Etiology • Genetics: Trisomy 21
  • 40. Down Syndrome Refractive Error Many more hyperopes than myopes, but those with myopia tended to have higher magnitudes Up to 49% may exhibit some astigmatism
  • 41. Down Syndrome Binocular Characteristics 23-44% have strabismus (Wesson & Maino) Down syndrome and strabismus shows a constant unilateral esotropia of less than 20 PD at near. (Greatly reduced number show ET at distance) It’s suggested that the etiology is a high ACA ratio rather that of a basic ET
  • 42. What’s New in Down Syndrome Al-Bagdady M, Stewart RE, Watts P, Murphy PJ, Woodhouse JM. Bifocals and Down's syndrome: correction or treatment? Ophthalmic Physiol Opt. 2009 Jul;29(4):416-21. Epub 2009 May 11. Accommodation is reduced in approximately 75% of children with Down's syndrome (DS). Bifocals have been shown to be beneficial and they are currently prescribed regularly.. … Bifocals are an effective correction for the reduced accommodation in children with DS and also act to improve accommodation with a success rate of 65%. ….
  • 43. What’s New in Down Syndrome 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. Thinning of the corneal stroma may account for the steeper cornea and the high frequency of astigmatism in Down syndrome due to lower corneal rigidity. It may also be of etiological importance to the increased incidence of keratoconus in Down syndrome.
  • 44. Haugen OH, Hovding G, Lundstrom I.Refractive development in children with Down's syndrome: a population based, longitudinal study. Br J Ophthalmol. 2001 Jun;85(6):714-9. ….Accommodation weakness may be of aetiological importance to the high frequency of refractive errors encountered in patients with Down's syndrome.
  • 45. Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. Association between accommodative accuracy, hypermetropia, and strabismus in children with Down's syndrome Optom Vis Sci. 2007 Feb;84(2):149-55. ….This study demonstrates the marked association between under- accommodation, hypermetropia, and strabismus in children with Down's syndrome. ….
  • 46. Haugen OH, Hovding G.Strabismus and binocular function in children with Down syndrome. A population-based, longitudinal study.Acta Ophthalmol Scand. 2001 Apr;79(2):133-9. …The majority of the Down syndrome children with strabismus have an acquired esotropia and hence a potential for binocularity. Hypermetropia and accommodation weakness are probably important factors in esotropia …….
  • 47. Stewart RE, Woodhouse MJ, Trojanowska LD. In focus: the use of bifocal spectacles with children with Down's syndrome.Ophthalmic Physiol Opt. 2005 Nov;25(6):514-22 …….Based on the results of this study, eye examinations of children with Down's syndrome should routinely include a measure of accommodation at near, and bifocal spectacles should be considered for those who show under- accommodation.
  • 49. Fragile X Syndrome • What is it? • What is it’s etiology? • What is it’s prevalence/incidence? • What are it’s physical/visual characteristics?
  • 50. Fragile X Syndrome Most frequently encountered inherited form of mental retardation (X-linked MR) Often misdiagnosed in the past “New” syndrome that has caught the imagination of researchers around the world 1st human disease shown to be caused by a repeated nucleotide sequence
  • 51. Fragile X Syndrome X-linked MR 1:600 in affected males 1/2500-4000 males 1/7000-8000 females female carriers 1/130-250 population male carrier 1/250-800 10% of undiagnosed ID in males 3% of previously undiagnosed ID in females
  • 52. Fragile X Syndrome Characteristics • Large prominent ears • Long narrow face • Macro-orchidism (80% affected men) Other: hypotonia, seizures, recurrent otitis media
  • 53. Fragile X Syndrome Characteristics • Large prominent ears • Long narrow face • Macro-orchidism (80% affected men) Other: hypotonia, seizures, recurrent otitis media
  • 54. Fragile X Syndrome Characteristics • Large prominent ears • Long narrow face • Macro-orchidism (80% affected men) Other: hypotonia, seizures, recurrent otitismedia
  • 55. Fragile X Syndrome Characteristics • First demonstrated genetic etiology of learning disability • Variable mental retardation • Math, language delay • Sensory integration problems • Attentional deficits • Psychiatric illnesses (shy)
  • 56. Fragile X Syndrome Characteristics Gaze Avoidance How do you conduct an examination on an individual that won’t look at you?
  • 57. 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)
  • 59. Fragile X Syndrome Ocular Findings • Strabismus (33-50%) • Nystagmus • Refractive error • Accommodative dysfunctions? • Oculomotor anomalies • Ocular Health? • Perceptual dysfunction
  • 60. What’s New in Fragile X Syndrome • Hatton DD, Buckley E, Lachiewicz A, Roberts J. Ocular status of boys with fragile X syndrome: a prospective study. J AAPOS. 1998 Oct;2(5):298-302. …observe a higher prevalence of strabismus than that found in the general population (8% vs 0.5% to 1…., 17% of the sample did have significant refractive errors. In addition to evaluating the ocular motility of children with fragile X syndrome, cycloplegic refraction should also be performed to determine whether refractive problems are present.
  • 61. 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 skills and their relationship to mutation size in full and premutation female fragile X carriers.Optom Vis Sci. 2000 Nov;77(11):592-9. ….full mutation female carriers performed more poorly in visual-motor processing and analysis- synthesis on the Woodcock-Johnson Psycho- Educational Battery-Revised, The Developmental Test of Visual Motor Integration, and on five of the seven subtests of the Test of Visual-Perceptual Skills. Regression analyses revealed significant negative correlations between mutation size and cognitive ability. …
  • 62. What’s New in Fragile X Syndrome Effect of CX516, an AMPA-modulating compound, on cognition and behavior in fragile X syndrome: a controlled trial. Berry- Kravis E, Krause SE, Block SS, Guter S, Wuu J, Leurgans S, Decle P, Potanos K, Cook E, Salt J, Maino D, Weinberg D, Lara R, Jardini T, Cogswell J, Johnson SA, Hagerman R. J Child Adolesc Psychopharmacol. 2006 Oct;16(5):525-40.PMID: 17069542 Cognitive and visual processing skills and their relationship to mutation size in full and premutation female fragile X carriers. Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM, Treitman TM. Optom Vis Sci. 2000 Nov;77(11):592-9.PMID: 11138833
  • 63. What’s New in Fragile X Syndrome The fragile X female: a case report of the visual, visual perceptual, and ocular health findings. Amin VR, Maino DM. J Am Optom Assoc. 1995 May;66(5): Optometric findings in the fragile X syndrome. Maino DM, Wesson M, Schlange D, Cibis G, Maino JH. Optom Vis Sci. 1991 Aug;68(8): Mental retardation syndromes with associated ocular defects. Maino DM, Maino JH, Maino SA. J Am Optom Assoc. 1990 Sep;61(9):707-16. Ocular anomalies in fragile X syndrome. Maino DM, Schlange D, Maino JH, Caden B. J Am Optom Assoc. 1990 Apr;61(4):316-23
  • 64. Fragile X-associated tremor/ataxia syndrome (FXTAS) reported in 33-40% of men older than 50 years and, less frequently (4-8%), in older women with premutations in the fragile X mental retardation (FMR1) gene. Clinical features (FXTAS): incontinence, impotence, cerebellar ataxia, peripheral neuropathy, autonomic dysfunction/orthostatic hypotension, severe intention tremor, and other signs of neurodegeneration (brain atrophy, memory loss and dementia, anxiety, depression, and irritability). Premature ovarian failure in 25% of women with premutations; this represents a 30-fold increase compared with the general population.
  • 65. Autism Factors such as younger age of diagnosis, broadening of diagnostic criteria, improvements in the availability of services, and better awareness of the disorder have all been attributed to the change in autism prevalence. However, recent epidemiological studies indicated that, while these factors do account for a portion of the change, they cannot account for all of the increase alone
  • 66. Autism Do Parents cause their children to be autistic ? There are autistic children born to parents who do not fit the autistic parent personality pattern. Parents who do fit the description of the supposedly pathogenic parent have normal, non-autistic children. Frequently siblings of autistic children are normal. Autistic children are behaviorally unusual "from the moment of birth." *** There is a consistent ratio of three or four boys to one girl. Virtually all cases of twins reported in the literature have been identical, with both twins afflicted. *** Autism can occur or be closely simulated in children with known organic brain damage. *** The symptomatology is highly unique and specific. There is an absence of gradations of infantile autism which would create "blends" from normal to severely afflicted.
  • 67. Autism Etiology Yeast infections Intolerance to specific food substances (Gluten intolerance ("Leaky Gut Syndrome"/Casein intolerance causing intestinal permeability and allowing improperly digested peptides to enter the bloodstream and cross the blood-brain barrier which may mimic neurotransmitters and result in the scrambling of sensory input. I've also heard "Leaky Gut Syndrome" described as lack of the beneficial bacteria that aids digestion, and that the resulting matter in the bloodstream invokes an unnecessary immune reaction) Phenolsulphertransferase (PST) deficiency--theory that some with autism are low on sulphate or an enzyme that uses this, called phenol- 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.
  • 68. Autism Etiology Brain injury, Constitutional vulnerability Developmental aphasia , Deficits in the reticular activating system, An unfortunate interplay between psychogenic and neurodevelopmental factors, Structural cerebellar changes, Genetic causes, Viral causes, Immunological ties, Vaccines, Seizures
  • 69. Autism Etiology My Goodness! Maino DM, Viola, SG, Donati R. The Etiology of Autism. Optom Vis Dev 2009:(40)3:150-156.
  • 70. Autism Etiology What the research shows…
  • 71. Autism Impairment in social interactions Impairment in communication Restricted repertoire of activities
  • 72. Autism Asperger Childhood Syndrome Disintegrative Disorder Autism Rett Syndrome
  • 74. Autism US FDA Statement IOM Report: No Link Between Vaccines and Autism By Michelle Meadows There is no link between autism and the measles-mumps-rubella (MMR) vaccine or the Childhood Disintegrative vaccine preservative thimerosal, according to a Disorder report released by the Institute of Medicine's (IOM) Immunization Safety Review Committee. http://www.fda.gov/fdac/features/2004/504_iom.html
  • 75. Autism Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen 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 Childhood Our study does not support Disintegrative Disorder a causal association between early exposure to mercury from thimerosal-containing vaccines and immune globulins and deficits in neuropsychological functioning at the age of 7 to 10 years.
  • 76. Autism 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 with autism and inflammatory bowel disease. Wakefield was the lead author Disorder 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 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“.
  • 78. Mental Retardation without Specific Etiology Most frequently encountered form of Intellectual Disability 4000 known Online Mendelian Inheritance in Man http://www.ncbi.nlm.nih.gov/omim 25% of the etiologies are unknown!
  • 79. Mental Retardation Classification Classification IQ Mild/Educable Mentally Handicapped 50-70 Moderate/Trainable Mentally Handicapped 35-55 Severe 20-40 Profound below 20
  • 80. Acquired/Traumatic Brain Injury Neuroplasticity Maino D. Neuroplasticity: Teaching an Old Brain New Tricks. Rev Optom 2009. 46(1):62-64,66-70. (http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106025/)
  • 81. Acquired/Traumatic Brain Injury Neuroplasticity & Rehabilitation Use it or lose it. If you do not drive specific brain functions, functional loss will occur. Use it and improve it. Therapy that drives cortical function enhances that particular function. 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.
  • 82. Acquired/Traumatic Brain Injury Neuroplasticity & Rehabilitation Time matters. Different forms of plasticity take place at different times during therapy. Salience matters. It has to be important to the individual. Age matters. Plasticity is easier in a younger brain, but is also possible in an adult brain. Transference. Neuroplasticity, and the change in function that results from one therapy, can augment the attainment of similar behaviors. Interference. Plasticity in response to one experience can interfere with the acquisition of other behaviors. 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.
  • 83. Acquired/Traumatic Brain Injury Post Trauma Vision Syndrome Symptoms/Signs Double vision Headaches Blurred vision Dizziness or nausea Light sensitivity Attention or concentration difficulties
  • 84. Acquired/Traumatic Brain Injury • Staring behavior (low blink rate) • Spatial disorientation • Losing place when reading • Can’t find beginning of next line when reading • Comprehension problems when reading • Visual memory problems
  • 85. Acquired/Traumatic Brain Injury • Pulls away from objects when they are brought close to them • Exotropia or high exophoria • Accommodative insufficiency • Convergence insufficiency • Poor fixations and pursuits • Unstable peripheral vision
  • 86. Acquired/Traumatic Brain Injury • Associated neuromotor difficulties with balance, coordination and posture • Perceived movement of stationary objects
  • 87. Acquired/Traumatic Brain Injury Visual Midline Shift Syndrome • Dizziness or nausea • Spatial disorientation • Consistently stays to one side of hallway or room • Bumps into objects when walking
  • 88. Acquired/Traumatic Brain Injury Visual Midline Shift Syndrome • Poor walking or posture: leans back on heels, forward, or to one side when walking, standing or seated in a chair • Perception of the floor being tilted • Associated neuromotor difficulties with balance, coordination and posture
  • 89. Acquired/Traumatic Brain Injury References TBI a Major Cause of Disability by Marc B. Taub, OD, FAAO, FCOVD Clinical Oculomotor Training in Traumatic Brain Injury by Kenneth J. Ciuffreda, OD, PhD, FAAO, FCOVD-A, Diana P. Ludlam, BS, COVT, Neera Kapoor, OD, MS, FAAO
  • 90. Acquired/Traumatic Brain Injury References • Myopia and Accommodative Insufficiency Associated with Moderate Head Trauma by Steve Leslie, B Optom, FACBO, FCOVD • Neuro-Optometry and the United States Legal System by Theodore S. Kadet, OD, FCOVD, R. E. Bodkin, JD, MBA, Attorney-at-Law
  • 91. Acquired/Traumatic Brain Injury References • Oculo-Visual Evaluation of the Patient with Traumatic Brain Injury by Maria Mandese, OD • Traumatic Brain Injury and Binasal Occlusion by Alissa Proctor, OD http://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx
  • 92. 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 (fax) dmaino@ico.edu www.ico.edu LyonsFamilyEyeCare.com MainosMemos.com