Visual Health in Learning Disability NHFN Birmingham

1. Visual Health in Learning DisabilityNHFN Birmingham Gordon Ilett Optometrist gordonilett@gmail.com

2. Disclosure • Partner Linklater Warren Optometrists • Trustee SeeAbility • Co-Director Special Olympics Opening Eyes GB • Councillor Association of Optometrists

3. Sight • Up to 90% of our sensory information will come from the sense of sight • Most daily tasks are more difficult when vision is impaired • We all tend to assume others perception of their environment is the same as ours

4. Vision • People with learning disabilities are 10x more likely to have serious sight problems • 60% will need spectacles and may need support to get used to them • 9.3% meet the criteria for sight impaired or serious sight impairment (partial sight or blind) registration • Those with severe and profound learning disabilities are most likely to have sight problems Emerson & Robertson 2011

5. Questions • Do you know the visual status of all of your service users? • How does undetected visual impairment affect • Safety, health and wellbeing? • Effective allocation of resources? • Will detecting and treating an individuals sight problem reduce the amount of support required? • Can you empower the individual?

6. Drivers for Change • Valuing People & Valuing People Now • Death by Indifference (Mencap 2007) • ‘Healthcare for All’ (2008) • Must offer ‘equality of care’ Human Rights Act, DDA / EA, ECHR, Mental Capacity Act • Support for GP DES for people with severe and profound LD and maintenance of registers of people with LD on practice lists • Doing the right thing!

7. The Eye and Vision

8. Embryology • Human eye starts to develop at 3 weeks gestation • Blood supply from approx 4 months • Retinal blood vessels reach nasal ora at 36 weeks, temporal vessels 40 weeks • Development of eye and visual pathway continues throughout pregnancy and early life. • The eye is an extension of the brain

9. The Human Eye • Vision – Optic Nerve CN2 • Motor – Oculormotor CN3, Trochlear ON 4, Abducens ON 6 • Sensation Trigeminal • ON 5 http://www.99main.com/~charlief/theeyebg.gif

10. Development of Acuity

11. Visual Pathway Retinocalcerine and tectal pathway Lea Hyvärinen

12. LGN d Parvo Magno Interlaminar Primary Visual Cortex Higher Visual Areas in Cortex Superior Colliculus Pulvinar Retinogeniculate Geniculostrate ‘Traditional’ Pathway’ LGN v Pretectum ‘Primative’ pathways to mid brain and other neuclei Neuclei of Accessory optic tract From Milner & Goodale 2006 Suprachiasmatic nucleus

13. Cortical Visual Processing • From primary cortex links to visual association areas • Dorsal (Where?) pathway • Ventral (What?) Pathway

14. The Reading Process • Location of word on page • Accurate accommodation and gaze directed so image on fovea – mid brain and CN 2, 3,4,6 • Image to Brodman’s Area (BA) 17 & 18 (via CN2) • Temp Occipital Cortex BA39 – Structure and form • To BA 21 & 42 Wernicke’s area – phonetic representation • BA 44&45 Broca’s area - speech MRC Cognition and Brain Sciences Unit

15. Process in reading a word • To read ‘FOX’ • Recognise letters and order – F(1)O(2)X(3) • To lexicon or brains dictionary –recognition of familiar order of letters • Semantic system then associates features with word • Speech output converts word into phonetic sound • Speech generated using motor control of jaw, tongue, voice-box and breathing

16. Learning Disability and Vision • Neuro-developmental disorder causes LD so all parts of eye and visual development may be affected • Structural defects may be caused by developmental abnormalities • Developmental defects may lead to further structural damage • Behavioural changes may lead to injuries to the eye

17. Periventricular Leucomalacia • Damage to white matter adjacent to ventricles • Present in up to 25% of pre term infants • Affects visual and acoustic tracts as well as descending cortico-spinal tracts • Up to 60% may develop cerebral palsy • Visual impairment and perceptual abnormalities www.pedsradiology.com

19. Actions Needed • Functional Assessment of all clients • Document visual abilities • Commission Pathways to allow extended eye exams • Ensure regular 2 yearly eye examinations • Work with Secondary Care Providers to ensure equal access • Document outcomes and advice given

20. Functional Vision Assessment • Designed for use by Carers • SeeAbility Functional Vision Assessment Tool • www.lookupinfo.org • Checklist 1 - Appearance of the eyes • the appearance of a persons eyes may raise concerns about their eye health • Checklist 2 - Behaviour • a persons behaviour may be related to poor vision or other eye care needs • Checklist 3 - Poor central vision • this is when a person cannot see straight ahead very well • Checklist 4 - Poor peripheral vision • sometimes a person has difficulties seeing to the sides and up and down • Checklist 5 - Sensitivity to light • some people experience difficulties because their eyes are very sensitive to light • Checklist 6 - Poor colour vision (or contrast sensitivity) • some people do not see colours very well and can find it difficult to see objects clearly against different backgrounds • Checklist 7 - Poor vision in one eye • some people have poor vision in one eye only

21. Eye Examination Pathways • KAB – Bexley • RNIB Bridge to Vision • SeeAbility Eye 2 Eye • LOCSU Sight test pathway • WOPEC - Accreditation for practitioners

22. LOCSU Pathway

23. Can Eye Examinations be done? • Yes

24. Pathway Support • Pre examination reporting – Telling the Optometrist about me form – SeeAbility • Appropriate facilities and equipment – desensitisation visits • Funding of extended eye examinations and repeat visits • Includes domiciliary services • Feedback forms and reporting – SeeAbility forms or PHP/Health Passports completed • Information leaflets on Eye health and Spectacles - SeeAbility

25. Secondary Care • Royal College of Ophthalmologists Guidelines • GMC Guidelines • Good Practice eg Sheffield • Advocacy and support

26. Remember • Assess Visual Function • Record Functional Ability • Organise Eye Examinations • Create Pathways • Record Results • Modify Care Plans • Empower Individuals

27. SeeAbilitywww.lookupinfo.orgwww.seeAbility.org Paula Spinks-Chamberlain LOCSU www.locsu.co.uk Katrina Venerus Information & Help