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
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
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)
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.
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)
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.
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