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Barry S. Kran, OD, FAAO Darick W. Wright, MA, COMS, CLVT D. Luisa Mayer, PhD. MEd

Cortical/Cerebral Visual Impairment Is it one or several or entities? Can it co-exist with ocular impairments? SESSION ONE. Barry S. Kran, OD, FAAO Darick W. Wright, MA, COMS, CLVT D. Luisa Mayer, PhD. MEd. Webinar Objectives.

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Barry S. Kran, OD, FAAO Darick W. Wright, MA, COMS, CLVT D. Luisa Mayer, PhD. MEd

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  1. Cortical/Cerebral Visual ImpairmentIs it one or several or entities?Can it co-exist with ocular impairments?SESSION ONE Barry S. Kran, OD, FAAO Darick W. Wright, MA, COMS, CLVT D. Luisa Mayer, PhD. MEd

  2. Webinar Objectives • Increase understanding of the diversity of signs and symptoms of vision impairment secondary to pediatric brain damage/maldevelopment • Understand the difference between brain-related or non-brain related classifications of vision loss

  3. What is What? “What about a premie with some ROP, but not blinding, and maybe a little brain injury but not a devastated brain?” “Some TVI’s say it is really important for them to know if a child’s poor vision is due to the brain or the eye (retina) because they would teach them differently” Comment by Pediatric Ophthalmologist

  4. http://library.thinkquest.org/C001501/brain/braindevelopment.htmhttp://library.thinkquest.org/C001501/brain/braindevelopment.htm Accessed 07/09/2010 Brain Development From 24 wks to term, each cortical neuron establishes ~1000 synaptic connections • In the last trimester,several hundred million synapses are created every minute! Wyatt JS. Mechanisms of brain injury in the newborn. Eye (2007)12, 1261-63

  5. Preterm brain injury Focal & generalized white matter abnormalities (PVL) Impaired cortical folding, reduced grey and white matter volumes Reduced growth and development of posterior corpus callosum and its connections http://neonatology.ucsf.edu/specialized-care/cerebral-palsy.aspx Accessed 9 July 2010 Pediatric Brain Damage and Visual Impairment

  6. Pediatric Brain Damage and Visual Impairment • Cerebral palsy • Poor gross & fine motor skills • Poor adaptive functioning • Lower intelligence quotient • Behavioral & emotional problems • Asthma • Visual pathway abnormalities (e.g.; ROP, myopia, strabismus) • Cortical/Cerebral VI Preterm infants are at risk for: http://www.nytimes.com/imagepages/2007/08/01/health/adam/ 18117Grayandwhitematterofthebrain.html Accessed 11 July 2010 O’Connor AR, Wilson CM, Fielder AR. Ophthalmological Problems associated with premature birth. Eye (2007)21, 1245-60

  7. http://neonatology.ucsf.edu/specialized-care/cerebral-palsy.aspxhttp://neonatology.ucsf.edu/specialized-care/cerebral-palsy.aspx Accessed 9 July 2010 Pediatric Brain Damage and Visual Impairment Hypoxic ischemic encephalopathy (HIE) • Diffuse brain damage • cerebral cortex, thalamus and brainstem • Problems with motor control, cognition, emotions, learning • Cortical/Cerebral VI Brain injury at Full term is different than injury at Preterm

  8. Primary Visual Pathway Ocular structures Optic tracts to the LGN and on to the primary visual cortex http://www.nature.com/nrn/journal/v6/n3/images/nrn1630-f4.jpg Accessed 11 July 2010

  9. Ocular Eye structures, to chiasm Ocular motor Brain stem, basal ganglia, thalamus, cerebellum Cortical Primary pathway (post-chiasm to occipital) Cerebral Post-occipital, complex brain processing areas Classification of Vision Loss

  10. Ocular Motor Brain stem, cerebellum Cerebral post-V1 (parietal, temporal lobes, motor cortices & frontal lobes) Cortical post-chiasm to V1 (striate or occipital) CLASSIFICATION OF VISUAL IMPAIRMENT BY CAUSE Ocular Ocular media, retina, optic nerve, to chiasm DL Mayer 2.28.10

  11. Pre-chiasmal visual pathway Eyes, retina, optic nerves Significant uncorrected refractive error Media opacities (ie. cataracts) Retinal lesions Retinal degeneration/dystrophy Optic nerve damage Ocular Vision Impairment Chiasm

  12. Ocular Vision Impairment Diagnostic examples: Retinopathy of prematurity* (retinal +) Achromatopsia (retinal) Leber congenital amaurosis (retinal) Albinism (macular hypoplasia and reduced ON fibers crossing at chiasm) Optic nerve hypoplasia* *Brain related visual difficulties may co-occur

  13. Ocular Ocular media, retina, optic nerve, to chiasm Cerebral post-V1 (parietal, temporal lobes, motor cortices & frontal lobes) Cortical post-chiasm to V1 (striate or occipital) CLASSIFICATION OF VISUAL IMPAIRMENT BY CAUSE Ocular Motor Brain stem, cerebellum DL Mayer 2.28.10

  14. May need to be differentiated from visual field loss, or CVI Nystagmus “Nulling” head-eye positions Convergence null Ocular Motor Apraxia (OMA) Lack of horizontal saccades Head thrusts to move eyes to target, overshoot and correction to fixate Ocular Motor Vision Impairment

  15. Ocular Motor Brain stem, cerebellum Ocular Ocular media, retina, optic nerve, to chiasm Cerebral post-V1 (parietal, temporal lobes, motor cortices & frontal lobes) Cortical post-chiasm to V1 (striate or occipital) CLASSIFICATION OF VISUAL IMPAIRMENT BY CAUSE DL Mayer 2.28.10

  16. Cerebrum http://www.hermes-press.com/altstates.htm Accessed 07/13/2010

  17. Cerebrum http://www.hermes-press.com/altstates.htm Accessed 07/13/2010

  18. Characteristics Post chiasmal to occipital lobe damage Light gazing or withdrawal Better visual attention for: Moving vs. static objects Familiar vs. novel objects Simple vs. complex environments Difficulty integrating gaze with reach Difficulty integrating looking with listening Poor social gaze Delayed visual (& other) responses Dr. Christine Roman-Lantzy Cortical Visual Impairment

  19. Ocular Motor Brain stem, cerebellum Ocular Ocular media, retina, optic nerve, to chiasm Cerebral post-V1 (parietal, temporal lobes, motor cortices & frontal lobes) Cortical post-chiasm to V1 (striate or occipital) CLASSIFICATION OF VISUAL IMPAIRMENT BY CAUSE DL Mayer 2.28.10

  20. Cerebrum http://www.hermes-press.com/altstates.htm Accessed 07/13/2010

  21. Characteristics Post occipital lobe brain damage Complex brain processing difficulties Dorsal/ventral stream dysfunctions Prof. Gordon Dutton Dr. August Colenbrander calls “Cognitive dysfunction” Cerebral Visual Impairment

  22. Dorsal & Ventral “pathways”

  23. Ventral Stream Occipital Lobe Temporal Lobe

  24. Apple!

  25. Recognitionof objects Occipital lobes Receive visual input (primary visual pathway) Temporal lobes – input from occipital lobes Visual “library” Words, numbers, shapes, landmarks Faces Color Ventral Stream–“What is it?”

  26. Dorsal Stream Motor Cortex Posterior Parietal Frontal Cortex Occipital Lobe

  27. Vision for action - visual attention, visually guided movement Occipital - posterior parietal lobes Integration of sensory input with attention and during motor output, management of visual complexity Feedback from frontal cortices Motor planning, head/eye movement, visual guidance of movement Dorsal stream-“Where is it?”

  28. ????

  29. Reach Attend, Attend Fixate with Eyes I want it

  30. Reach with right hand It’s in front of me I want it Apple!

  31. How do I move? Too Much Information! !!!!!!!! Where do I look??? ?????

  32. G N Dutton 2012

  33. Brain damage that occurs pre-term is different than damage that occurs with full-term babies. Vision Loss can be classified based on location within the brain and visual pathway as: Ocular Ocular Motor Cortical Cerebral Summary

  34. Visual Sequelae of Pediatric Brain Damage A complex combination of abnormal visual behaviors due to brain damage, with probable subcategories that CAN co-exist with ocular & ocular-motor categories. Summary

  35. Historically, many have defined Cortical Vision Impairment as being associated only with the visual pathway and occipital lobe. Cerebral Vision Impairment involves other portions of the brain that are required for visual function. Dr. Gordon Dutton’s - impact of damage to the Dorsal and Ventral Streams on visual function. Summary

  36. About Brain Injury www.waiting.com/brainanatomy.html#anchor2884157 Brain Injury Association - http://www.biasd.com/en_brain_map.html Wikipedia - http://en.wikipedia.org/wiki/Brain Dennison E, Hall Lueck A eds. Proceedings Summit on Cerebral/Cortical Visual Impairment April 30, 2005 2006 AFB Press NY, NY Dutton GN, Bax M, editors. Clinics in developmental medicine no. 186: visual impairment in children due to damage to the brain. London: Mac Keith Press; 2010 Hoyt CS. Visual function in the brain-damaged child. Eye. 2003;17:369–84. Kran BS, Mayer DL. Chapter 14 Vision impairment and brain damage in Taub, Bartuccio, Maino eds Visual diagnosis and care of the patient with special needs. Lippincott 2012 Lueck, A (2010) Cortical or Cerebral Visual Impairment in Children: A Brief Overview. JVIB, AFB press. Roman-Lantzy C. Cortical Visual Impairment: An approach to assessment and intervention 2007 AFB Press NY, NY Images & Resources

  37. KranB@neco.edu Darick.Wright@Perkins.org MayerL@neco.edu Cortical/Cerebral Visual ImpairmentIs it one or several entities?Can it co-exist with ocular impairments?

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