Ophthalmologic Examination Integrated With The Functional Aspects of CVI

1. Ophthalmologic Examination Integrated With The Functional Aspects of CVI Sharon S Lehman, MD FAAP Chief Ophthalmology Nemours Children’s Clinic Clinical Professor of Ophthalmology and Pediatrics Robison D Harley MD Endowed Chair of Pediatric Ophthalmology

2. 12 month ex 23-week premature infant with tracheostomy, h/o retinopathy of prematurity who has been recently diagnosed with cerebral palsy. Child’s mother is concerned that child looks past her, stares at lights and looks away when reaching for an object.

3. OPHTHALMOLOGIST REPORT:IMPRESSION: ROP RESOLVED; NORMAL EYE EXAMRECOMMENDATIONS: F/U 1 YEAR

4. What my exam should include… • Obtain history focused on child’s visual behavior/characteristics • Validate parent’s observations • Learn patient’s expectations for their child • Perform complete ophthalmologic examination • Provide medical diagnosis and medical necessity • Refer for services for visually impaired • Make specific recommendations tailored to individual patient • Provide information to patient’s team • Provide educational materials/support group information • Provide opportunity for parent’s to ask questions

5. Classic Ophthalmologic Exam – Exam #1Focus: History and Structure • History with CVI modified questionnaire • Physical-Classic Ophthalmologic Exam • Visual acuity • Pupillary reaction • External • Anterior and posterior segment • Alignment and motility • Cycloplegic refraction

6. CVI Ophthalmologic Exam #2Focus: Function • Classic Ophthalmologic Exam #1 • History with CVI modified questionnaire • Structural Physical exam + • Physical • Accommodative amplitude/dynamic retinoscopy • Convergence amplitude/NPC • Visual attention/fixation/visually guided behavior • Latency • Saccades/pursuits • Directionality of line • Contrast Sensitivity

7. CVI Ophthalmologic Exam #3Focus: Higher Level Function • Classic Ophthalmologic Exam #1 + • CVI Ophthalmologic Exam #2 + • Physical • Executive functions • Figure ground skills • Comparison of size and shape • Visual center

8. CVI Type 3 Exam (Higher Level Function) CVI Type 2 Exam (Function) Low function High function Phase 1 Phase 2 Phase 3

9. What my exam is not… • It is NOT a substitute for evaluation by Teacher of Visually Impaired • It is NOT a substitute for evaluation by Occupational Therapist • It is NOT a substitute for evaluation by Physical Therapist • It is NOT a substitute for evaluation by Learning/Reading Specialist

10. HISTORY • “Please tell me about your child’s vision”. • There is no better expert than a child’s parent. • They will often tell you most of you need to know.

11. CVI Modified Questionnaire Preference for specific colors: Improved visual response with movement: Latency (delay in response to visual stimuli Abnormal field of vision (eg: hemianopsia or island of visual response) Difficulty with visual complexity: Preference for looking at lights and non purposeful gaze Difficulty with distance viewing Atypical visual behavior (eg: frequently looking up or away while tracking, eccentric viewing) Difficulty with visual novelty Absent or clumsy visually guided motor responses Adapted from: Roman-Lantzy, Christine; Cortical Visual Impairment: an approach to assessment and intervention; American Foundation for the Blind; New York, New York; 2007 M

12. Multidisciplinary team approach Parents/family Primary care physician Pediatric ophthalmologist Pediatric neurologist Educational specialist Teacher of visually impaired Teacher of the hearing impaired Occupational therapist Physical therapist Speech therapist Feeding specialist

13. EXAM #1 • History with CVI modified questionnaire and basic ophthalmologic exam • r/o structural eye abnormalities/confounding factors • Determine any necessary optical correction • Determine any necessary medical or surgical ophthalmologic treatment • Child with limited visual response who is learning to use vision

14. EXAM #2 • History and Modified CVI Questionnaire and Exam #1 • Additional aspects of exam • Accommodative amplitude/dynamic retinoscopy • Convergence amplitude/NPC • Visual attention/fixation/visually guided behavior • Latency • Saccades/pursuits • Directionality of line • Contrast Sensitivity • Child with higher visual function learning to use vision more effectively along with other functions of daily life

15. EXAM #3 • History and Modified CVI Questionnaire and Exam #1 + Exam #2 + Physical • Executive functions • Figure ground skills • Comparison of size and shape • Visual center • CVI characteristics improved or resolving with higher level visual function deficits (Cerebral?)

16. CVI Type 3 Exam (Higher Level Function) CVI Type 2 Exam (Function) Low function High function Phase 1 Phase 2 Phase 3

17. What my exam should include… • Obtain history focused on child’s visual behavior/characteristics • Validate parent’s observations • Learn patient’s expectations for their child • Perform complete ophthalmologic examination • Provide medical diagnosis and medical necessity • Refer for services for visually impaired • Make specific recommendations tailored to individual patient • Provide information to patient’s team • Provide educational materials/support group information • Provide opportunity for parent’s to ask questions

18. 12 month ex 23-week premature infant with tracheostomy, h/o retinopathy of prematurity who has been recently diagnosed with cerebral palsy. Child’s mother is concerned that child looks past her, stares at lights and looks away when reaching for an object.

19. OPHTHALMOLOGIST REPORT:IMPRESSION: ROP RESOLVED; NORMAL EYE EXAMRECOMMENDATIONS: F/U 1 YEAR

20. Ophthalmologist’s ReportImpression/Diagnosis IMPRESSION: • Cortical visual impairment • Severe visual impairment both eyes • Retinopathy of prematurity Stage 2 Zone II both eyes – resolved • Cerebral palsy • Premature infant • Hypermetropia both eyes not requiring correction

21. Ophthalmologist’s ReportRecommendations • Treat underlying medical conditions. • No glasses are necessary • Recommendations: • Use high contrast and brightly colored visual materials. • Use additional cues (lights, sound, vibration and movement) to attract visual attention. • Avoid overstimulation. • Provide support for child’s body when performing visual tasks. • Avoid verbal distractions when child is performing visual tasks. • Perform visual tasks in non-distracting environment. • Refer for evaluation for services for vision.

22. Ophthalmologist’s ReportRecommendations • Copy of diagnosis, medical necessity and recommendations sent to patient’s team • Educational material and support group information given to family • Family’s questions answered, they expressed understanding and agree with plan • Include contact information so other members of child’s team can share information.

23. PEDIATRIC OPHTHALMOLOGISTS: Would you like to learn more about CVI?GOOD NEWS!Reference: Lehman SS, Attitudes Concerning Cortical Visual Impairment Among Pediatric Ophthalmologists and Teachers of the Visually Impaired¿ presented at 2016 American Conference on Pediatric Cortical Visual Impairment, Omaha, Nebraska, July 8-9, 2016

24. Modalities to Assist Pediatric Ophthalmologists with CVI • Providing education and templates for: • History • Physical examination • Providing diagnosis • Referral for services • Making recommendations/interventions

25. TEMPLATES FOR RECOMMENDATIONS/INTERVENTIONS • Should not be cookie cutter. • Need to be specific to each child’s circumstances • Need to be incorporated into child’s activities of daily living • Need to include environmental modifications • Need to include developmentally appropriate recreation (play) for older children

26. TEMPLATES FOR CVI INTERVENTIONS/RECOMMENDATIONSFOR PEDIATRIC OPHTHALMOLOGISTS

27. TEMPLATES FOR CVI INTERVENTIONS/RECOMMENDATIONSFOR PEDIATRIC OPHTHALMOLOGISTS

28. I need your feedback about improving the pediatric ophthalmologist’s care of children with CVI Please email me at: slehman@nemours.org