1
Q
Loss of vision can cause global delays in what 5 areas?
A
- cognition
- Speech
- Motor
- Psychological
- Self-Care
2
Q
describe how a child with vision loss may not have cognitive object permanence
A
the fairy phenomenon: something goes out of vision and think it disappears like magic. The visual child immediately looks because they have cognitive feedback.
3
Q
How is speech learned? How does this affect a low vision child?
A
children learn speech by watching others speak and move their mouths.
4
Q
How may a child with vision loss have motor problems?
A
moving in environment is scary so they don’t move around as much. Driven by sign to go towards parents, or sees a toys across room and they go to get it.
5
Q
How may a child with vision loss have psychological problems?
A
bonding: requires eye contact, smiling, etc. Babies see their parents smiling and by reflex they learn to smile but these children don’t do that they have never learn that social cue
LV kids may stay in egocenricax level of bonding much longer
6
Q
How may a child with vision loss lack self care?
A
miss social cues. Example: its important to learn that you go the bathroom in the bathroom. Example: not making a huge mess when you eat
7
Q
What is the purpose of the pediatric low vision evaluation? (10)
A
- to establish a baseline visual acuity measurement and visual functioning level.
- To help parents and teachers better understand their child’s visual condition and visual functioning, ie. how he/she sees
- To determine if there is refractive error and whether refractive error is significant enough to warrant lenses
- To provide info and assistance as needed in process of determining the most appropriate learning and literacy media
- To determine if low vision devices, technology equipment, or other adaptations and accommodations will likely enhance the student’s functioning level in school and/or community
- To assess visual skills in terms of whether or not vision loss is likely to be a major factor when there are concerns about other developmental areas
- To assist the education team members with patient management as well as trial and/or acquisition of recommended devices or equipment
- To assess if other related services are indicated (e.g O and M)
- To assess vision in terms of acquiring an instructional permit or driver’s license when appropriate
- To provide timely reevaluation to determine if visual functioning is improving, remaining stable, or otherwise changing
8
Q
When taking case history on a peds low vision, it is important to establish ____
A
goals
- what doe student need to do?
- what does student want to do?
**Individualized education plan/IFSP
9
Q
For a peds low vision exam, should we measure formal VAs first?
A
probably not, the child is probably anxiety filled so open them up to the exam first with talking to them and asking questions making them feel more comfortable doing stuff like EOMs, NPC first before formal VAs
10
Q
Use teller acuity cards for _____ ages
A
birth to 2 years
11
Q
Use Keeler cards for _______ ages
A
birth to 2 years
12
Q
Use Cardiff cards for ______ ages
A
3-5 years old (preschool)
13
Q
Use Lea symbols for ____ages
A
5-7 years
14
Q
Use feinbloom for _____ ages
A
7 and above
15
Q
For a peds low vision exam, should you take monocular or binocular VAs first ?
A
do binocular first, show same presentation monocularly
16
Q
Tell Acuity Cards
- utilizes ____preferential looking
- (over/under) estimates VA
- 1-6mo test at: ___cm
- 6+mo test at: ___cn
- Acuity is the highest level where ___ of 4 is correct
- Can present in preferred gaze
- Alternate between horizontal and vertical presentation
A
forced choice
overestimates
1-6mo: 38cm
6+mo: 55cm
3 of 4 correct
17
Q
Keeler cards
- Test distance: ___cm
- Blank side of the card has open circle than can distract patient
A
38cm
18
Q
Cardiff acuity
- targets are ____optotypes
- test at ______ distance
- ___ cards available at each acuity level
- record acuity as highest level at which at least ___ of 3 correct
A
vanishing
1m or 50cm
3 cards
2 of 3 correct
19
Q
Gold stand of vision testing in peds
A
Lea Symbols
20
Q
Lea Symbols
- chart calibrated for ___foot test distance
- identify or match symbols on each line
- acuity level is __ of 5 symbols
A
10 foot test distance
3 of 5
21
Q
True or false for peds low vision:
- may need to measure gaze other than primary
- no VA test used in isolation can accurately and completely assess visual functioning
A
true
22
Q
Resolution tests (over/under)estimate VA
A
overestimate
23
Q
Peds Low vision: consider prescribing significant refractive error regardless of ____ or _____
A
VA
cognitive level
24
Q
Peds low vision: cover test for motor alignment can often be difficult due to ___
A
nystagmus
25
Peds low vision: adequate but increased head turning with horizontal tracking may indicate _____ or ____
homonymous VF loss
neurological midline abnormalities
26
Peds low vision: best objective method for measuring accommodation
MEM
27
Color naming requires a cognitive level of _____ years
3-4
28
Peds low vision: accommodative response study conclusions
accommodative response in children with visual impairment showed can't accommodate well and don't respond in the way we would predict
29
Most common adaptation in peds low vision
hold material closer to the eye
30
management options for peds low vision
1. angular magnification (low vision devices)
2. electronic magnifications (CCTV, computer software)
3. Relative size magnification (enlarged print)
4. sensory substitution (braille, audio devices)
5. Relative distance magnification ( hold material closer to the eye)
31
When prescribing a low vision device for peds, what should you consider?
1. aids with a need/goal in mind
2. cognitive and/or motor ability
3. visual ergonomics (slant board, classroom setting)
32
Management for pre-school/early elementary low vision peds patient with mild to moderate impairment
1. SRx, reading add
2. "paperweight" stand mag
3. filters
4. classroom modifications
33
Management for pre-school/early elementary low vision peds patient with moderate to severe impairment
1. SRx
2. CCTV/video mag
3. Filters
4. Classroom modifications
34
Management for older elementary peds patient with mild to moderate impairment
1. SRx
2. CCTV/video mag
3. Filters
4. Classroom modifications
5. handheld telescope (prerequisite to bioptic)
35
Management for older elementary peds patient with moderate to severe impairment
1. SRx
2. CCTV/video mag
3. Filters
4. Classroom modifications
5. portable video magnification
36
Management middle school and high school aged low vision with mild to moderate impairment
1. SRx
2. CCTV/video mag
3. Filters
4. Classroom modifications
5. Bioptic
6. Laptop
37
Management middle school and high school aged low vision with moderate to severe impairment
1. SRx
2. CCTV/video mag
3. Filters
4. Classroom modifications
5. portable video magnification
6. laptop with video magnification
38
Peds low vision report should include what?
1. VA
2. Refractive status
3. Sensory status
4. Ocular health
5. Recommendations (classroom accommodations: slant board, large print, seating, null point considerations)
39
Role of optometrist in peds low vision rehab team
1. manage primary vision concerns
2. co-manage ocular health concerns
3. help the parents navigate the unfamiliar territory of special needs
4. collaborative consultation with team members
40
Role of pediatric opthalmologist in peds low vision rehab team
1. manage pathology
2. prognosis
3. collaborative consultation with team members
41
Responsible for teaching low vision child tactile communication, calendar scheduling/helping with daily organization
total communication specialist
42
Provides services on evaluation, direct therapy, and consultation. Identifies factors contributing to delays and sets up goals and treatment plan. Does in home, clinic based, and/or individual therapy such as sensory integration, ADL skills, and helps patients who need EV training. Requires a master's degree.
occupational therapist
43
Rehab pediatric low vision team member that does more braces, walkers and help with sitting up/trunk control and muscle engagement. More designed around skeletal motor refinement
PT
44
Rehab pediatric low vision team member that teaches picture exchange communication, co-signing, using switches, etc. Treats speech issues and teaches motor oral exercises, language concerns.
speech and language therapist
45
Rehab pediatric low vision team member that determines if hearing normal and treats any loss
audiologist
46
Rehab pediatric low vision team member that helps with developing confidence moving within environment, sound sourcing/echolocation, developing body awareness, moving in community, pre-cane/cane training, traveling routes
orientation and mobility specialist
47
Rehab pediatric low vision team member that works closely with optometrist, adapts educational materials as needed, trains students on use of low vision aids rx'ed by OD, provides braille and pre-braille activities
teacher of the visually impaired
48
Braille grade 1
no contractions
49
braille grade 2
over 200 contractions
50
braille grade 3
no punctuations
51
Nemeth code
braille math code
52
Rehab pediatric low vision team member that treats emotional issues, grief counseling, helps child learn to socialize with other kids and create bonds to play.
psychologist
53
Rehab pediatric low vision team member that evaluates individual technology needs, recommends devices to OD, outside agencies, and patient
technology specialist
54
State agency that supports individuals with disabilities, assigns each patient to a counselor. Patient must have a goal of becoming productive member of society. Provides funding and support for education, low vision services.
Department of rehabilitation
55
4 main categories of low vision patients
1. reduced acuity
2. central field defect
3. peripheral field defect
4. reduced CS, glare sensitivity
56
Application and prescription of low vision devices is always done after _____
refraction
57
4 common causes of low vision reduced acuity
1. albinism
2. cataract
3. cortical visual impairment
4. congenital nystagmus
58
Use _____ to dampen nystagmus
CLs
59
4 common causes of central field loss
1. ARMD
2. diabetic ret (from CSME)
3. cone dystrophy
4. stargardt's
60
3 best management strategies for patient with central field loss
1. best correction
2. determine best EV location, train to make efficient
3. Respond well to magnification
61
5 common causes of peripheral field loss
1. glaucoma
2. TBI
3. retinitis pigmentosa
4. stroke
5. diabetic retinopathy (from PRP laser treatments)
62
3 best management strategies for patient with peripheral field loss
1. best correction
2. O and M referral to train visual skills: scanning, locating, searching
3. reverse TS, mirror, minus lenses
* limited response to magnification
63
3 common causes of reduced contrast sensitivity and glare sensitivity
1. optic atrophy
2. corneal dystrophy/degnerations
3. cataracts
64
best management strategies for patient with reduced contrast/glare sensitivity
1. best correction
2. evaluate filters: NoIR, tints, coatings, acetate sheets, lighting, typoscope, bold-lined paper, felt tip pens
3. Provide magnification as needed - consider CCTV for contract enhancing magnifiers
65
Congenital condition characterized by lack of pigment (body's inability to produce pigment) or reduced pigment. AR or AD. 1 in 20,000. Fundus will show normal optic nerve with peripheral pallor. VAs 20/40-20/100. Color vision normal. Full visual fields. Lack of stereo from optic nerve fibers not crossing at optic chiasm.
Albinism
66
What condition characterized by white eyebrows and eyelashes, irides light blue with transillumination causing photophobia, lack of foveal pigment with macular hypoplasia, nystagmus, high hyperopia or WTR astigmatism, strabismus (ET)
albinism
67
condition prone to easily bruising, nose bleeds/bleeding easily, and susceptibility to infection
albinism
68
Management for Albinism
1. correct refractive error with glasses or contacts
2. control illumination with tints, aperture control contacts, UV, visors, hats, etc
3. magnification at distance and near (respond well)
4. TS: monocular and bioptic (driving)
5. prism if null point causes head turn/tilt
6. support groups
7. genetic counseling
69
Management of macular degeneration low vision
1. refraction - esp near
2. determine best EV location and train to make efficient EV
3. determine magnification needs and appropriate devices = responds well to magnification
4. lighting and non-optical evaluation
70
Most likely diagnosis in a child with low vision but retina looks completely normal fundoscopically. Pt complains of near blur.
stargardt's
71
Autosomal recessive, aka fundss flavimaculatus characterized by beaten bronze appearance to the fovea with parafoveal flecks (fish shaped)
stargardts
72
Stargardt low vision management
1. vocational rehab and counseling for younger patients
2. refractive error correction
3. EV techniques
4. magnification at distance and near
5. direct illumination
6. support groups
73
management for low vision loss from diabetic retinopathy
1. medication administration education
2. monitor blood glucose levels
3. dietary management
4. exercise: O&M concerns
5. visual examination of the extremities
6. opt for flexible easy modified or adaptable systems and avoid expensive custom made systems that are fix-focused and unadaptable = because fluctuating acuity common
74
Low vision management of myopic degeneration
1. best Rx, note vertex; polycarb, 1.66 double concave aspheric, 1.74 index, myodisc, roll and polish, AR coat
2. SCL or RGPs*
3. D and N mag devices - clip on TS may not work due to edge thickness, use HHT with SRx
4. Can remove Rx to provide built in microscope
5. O&M if extensive RPR, cry or scleral buckle
75
Group of retinal hereditary dystrophies characterized by progressive visual field loss, night blindness, and abnormal ERG. AR and AD are most common forms. X-linked I most severe and earliest onset. More common in males.
RP
76
Bone spicule pigment formation, loss of pigment, moth-eaten prominent choroidal vasculature, attenuated retinal arterioles, waxy pallor, smaller C/D ratio, ONH druse. CME, PSC, night blindness. Delayed dark and light adaptation speed. Decreased color sensitivity, photophobia
RP
77
Visual field symptoms of RP
1. prolonged light/dark adaptation
| 2. normal light levels may appear dim.
78
Management of RP low vision
1 . limited response to magnification = do a reverse TS, mirror, minus lenses
2. train visual skills: scanning, locating, searching
79
low vision management for glaucoma
1. magnification with respect to field: may start with SM to maximize patient's VF, bar magnifier
2. CCTV (contrast feature) and computer adaptations
3. directed illumination with reduction of glare
4. tints/filters/lighting: NOIR yellow inside
5. O and M
6. flashlight for night travel
7. support groups
8. ADL training
9. talking books
10. HHT for magnification and magnification (~2.5x)
80
most likely diagnosis if normal looking fundus but missing cones on OCT
achromatopsia
81
hereditary condition in which cones didn't develop properly, leading to a loss of color discrimination and acuity. Its can have extreme photophobia and nystagmus. Decreased color perceptions. Blond fungi and fine disturbances of RPE in the macula
achromatopsia
82
low vision management for achromatopsia
1. reduce illumination with filters, tints, sideshields
2. red tinted or dark tinted CLs (including pupil) and sunglasses to allow rods to function and decrease photophobia
3. magnification devices for distance and near
4. genetic counseling
5. support groups
83
Approx ___million people in the US have TBI annually
1.7 million
84
2 types of TBIs
1. blast related TBIs
| 2. Non-blast related TBIs (falls, motor vehicle accidents, struck by/against events, assaults)
85
leading cause of TBI
falls (40%)
86
Falls disproportionately affect what two age groups?
youngest and oldest
55%: 0 to 14yo
81%: 65+
87
2nd leading cause of TBI
blunt trauma (15%)
88
3rd leading cause of TBI
motor vehicle accidents (14%)
89
about ___% of all TBIs due to assaults
10%
90
greatest estimated number of TBI related ER visits due to what activities?
```
bicycling
football
playground activities
basketball
soccer
```
91
TBI accounted for >10% of injury Er visits for what types of activities?
1. horseback riding
2. ice skating
3. golfing
4. all terrain vehicle riding
5. tobogganing/sledding
92
Signs of a concussion
1. dazed
2. confused
3. amnesia
4. loss of consciousness
93
symptoms of a concussion
1. headache
2. nausea, vomiting
3. drowsiness, feeling sluggish
4. dizziness
94
occurs when sustained second concussion before 1st has healing. Increased IOP. Could be fatal.
Second impact syndrome
95
TBI in military and veteran population are typically blast related and make up ____%
13%
96
Loss of consciousness time for TBI:
- mild:
- mod:
- severe:
- mild: 0-30min
- mod: >30min to <24 hours
- severe: >24 hours
97
Alteration of consciousness time for TBI:
- mild:
- mod:
- severe:
- mild:up to 24 hours
| - mod and sever: >24 hours, severity based on other criteria
98
Post traumatic amnesia time for TBI:
- mild:
- mod:
- severe:
- mild: 0-1 day
- mod: >1 - <7 day
- severe: > 7days
99
Glasgow coma score for TBI:
- mild:
- mod:
- severe:
- mild: 13-15
- mod: 9-12
- severe: <9
100
What effects on vision does a TBI have?
1. increased subjective vision complaints
2. light sensitivity
3. diplopia
4. reading complaints/deficits
5. strabismus
6. accommodation defect
7. convergence defect
8. pursuit, saccade, fixation defects
9. VF defects
101
Do visual complaints vary if TBI is blast vs. non-blast related?
no, study showed that whether cause in non-blast or blast related the patients have the same complaints
102
comorbidities common with TBIs?
1. migraines/headaches
2. sleep disorders
3. anxiety
4. benign paroxysmal positional vertigo
5. substance abuse
103
Urgent TBI symptoms
1. flashes of light
2. floaters
3. missing part of VF/restricted field of vision
4. pain
104
reading symptoms with glasses for TBI patient
1. double vision
2. HA/browache/fatigue/eyestrian
3. unable to sustain near work/reading
4. skip or lose place
5. have difficulty finding next line
6. blur in distance after reading
7. poor reading comprehension
8. easily distracted/decreased attention span/poor concentration
105
1 minute observation of posture/balance. Repeat with eyes closed. Positive if the patient sways (or falls) with eyes closed
Roberg's test
106
3 balance contributors in the body
1. vestibular (SC canals)
2. vision
3. proprioception
107
false sense of motion (spinning)
vertigo
108
Vestibular rehabilitation therapy: 3 exercises
1. habituation
2. gaze stabilization
3. balance training
109
machine that assesses patient's ability to effectively use appropriate visual, vestibular, and proprioceptive information (or suppress inappropriate information)
computerized dynamic posturography
110
For displaced otoliths (from utricle) from the semicircular canals for benign paroxysmal positional vertigo
canalith repositioning procedures
| "epley maneuver"
111
egocentric localization. pt's vision is shifted very slightly from center of body. high history of TBI
visual midline shift syndrome (VMSS)
112
Visual midline shift syndrome: ___ and ___ types are the 2 most common but we don't know why
right
| anterior
113
Anterior midline shift, rx ___ yolked prism
BD
114
posterior midline shift, rx ___ yolked prism
BU
115
right midline shift, rx ___ yolked prism
BL
116
left midline shift, rx ___ yolked prism
BR
117
visual motion sensitivity treatment
binasal occlusion
118
4 common differential diagnoses for diplopia
1. CN palsy
2. MG
3. decompensated phoria
4. convergence or divergence insufficiency
119
Strabismus after TBI: more common in blast or non-blast related TBI? Which type of strab?
non-blast: 46%
blast: 29%
exotropia more common than esotropia
120
CN4 palsies most commonly due to what?
head trauma and vascular infarcts
121
```
Isolated CN4 palsies in adults:
___% traumatic
___% Idiopathic
____% vascular
____% tumor or aneurysm
```
40
30
20
10
122
CN4 palsy: common complaint of _____ diplopia, and diplopia worse when looking _____ with affected eye
vertical
medially
123
CN4 palsy: head tilt present ___% of patients
70%
124
3 good clinical tests for CN4 palsy
1. parks 3 step
2. positive bielschowsky's test
3. double Maddox rod test
125
What is a positive bielschowsky's test?
hyper deviation increases on head tilt toward affected side
126
double Maddox rod tests for what kind of tropia
cyclo
127
a syndrome characterized by the acute onset of a neurologic deficit that persists for at least 24 hours, reflects focal involvement of the CNS, and is the result of a disturbance of the cerebral circulation
stroke
| *aka: CVA or acquired brain injury
128
2 types of strokes
ischemic
| hemorrhagic
129
stroke is the #____ leading cause of death in high and low income countries
stroke
130
Which type of stroke is less predictable in pattern of involvement?
hemorrhagic stroke
131
___% of patients with stroke suffer from visual disorders
20-40%
*VF defects, diplopia, hemisensory deficit
132
What pathway
ventral: occipital cortex --> temporal cortex
133
where pathway
dorsal: occipital cortex --> parietal cortex
134
object agnosia
inability to recognize objects by sight
bilateral occipitotemporal (ventral pathway) dysfunction
135
prosopagnosia
inability to recognize familiar faces
usually occurs with bilateral occipital lobe damage
S homonymous VF defects are common
136
not acknowledging seeing objects in an area of vision known to be intact. Usually due to damage in the right hemisphere (posterior parietal cortex, frontal eye fields, cingulate gyrus) that mediates attention in both hemifields
hemispatial neglect
137
VA qualifications for medicare billing for occupational therapist in-home training
20/70 or worse
138
Patients with poor ADL skills or those who need EV training can benefit from what rehab team member?
occupational therapist
139
How to take dynamic VA to test for VOR problem in a TBI exam
can quickly assess VOR with having pt shake head from side to side and ask them if they can read the line easily. Difference of 2 or more lines before they can start to see you suspect a VOR problem
140
Why is binasal occlusion prescribed for people with visual motion sensitivity?
where visual overlap happens from both eyes so you can get rid of excessive visual stimulation with binasal occlusion
Low vision
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