Cortical/Cerebral Visual · PDF fileCortical/Cerebral Visual Impairment Is it one or several...
Transcript of Cortical/Cerebral Visual · PDF fileCortical/Cerebral Visual Impairment Is it one or several...
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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
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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
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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
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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
http://library.thinkquest.org/C001501/brain/braindevelopment.htm
Accessed 07/09/2010
Brain Development
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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
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– 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
O’Connor AR, Wilson CM, Fielder AR. Ophthalmological Problems associated with premature birth. Eye (2007)21, 1245-60
http://www.nytimes.com/imagepages/2007/08/01/health/adam/
18117Grayandwhitematterofthebrain.html Accessed 11 July 2010
Preterm infants are at risk for:
Pediatric Brain Damage and
Visual Impairment
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http://neonatology.ucsf.edu/specialized-care/cerebral-palsy.aspx
Accessed 9 July 2010
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
Pediatric Brain Damage and
Visual Impairment
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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
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Classification of Vision Loss
• 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
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DL Mayer
2.28.10
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)
Ocular Motor Brain stem,
cerebellum
CLASSIFICATION OF
VISUAL IMPAIRMENT
BY CAUSE
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Ocular Vision Impairment
Pre-chiasmal visual pathway
Eyes, retina, optic nerves
– Significant uncorrected refractive
error
– Media opacities (ie. cataracts)
– Retinal lesions
– Retinal degeneration/dystrophy
– Optic nerve damage
Chiasm
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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
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DL Mayer
2.28.10
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)
Ocular Motor Brain stem,
cerebellum
CLASSIFICATION OF
VISUAL IMPAIRMENT
BY CAUSE
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Ocular Motor Vision Impairment
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
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Cortical post-chiasm to V1
(striate or occipital)
DL Mayer
2.28.10
Cerebral post-V1
(parietal, temporal lobes,
motor cortices & frontal lobes)
Ocular
Ocular media, retina,
optic nerve, to chiasm
Ocular Motor Brain stem,
cerebellum
CLASSIFICATION OF
VISUAL IMPAIRMENT
BY CAUSE
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Cerebrum
http://www.hermes-press.com/altstates.htm Accessed 07/13/2010
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Cerebrum
http://www.hermes-press.com/altstates.htm Accessed 07/13/2010
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Cortical Visual Impairment
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
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DL Mayer
2.28.10
Cerebral post-V1
(parietal, temporal lobes,
motor cortices & frontal lobes)
Cortical post-chiasm to V1
(striate or occipital)
Ocular Ocular media, retina,
optic nerve, to chiasm
Ocular Motor Brain stem,
cerebellum
CLASSIFICATION OF
VISUAL IMPAIRMENT
BY CAUSE
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Cerebrum
http://www.hermes-press.com/altstates.htm Accessed 07/13/2010
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Cerebral Visual Impairment
Characteristics
• Post occipital lobe brain damage
– Complex brain processing difficulties
– Dorsal/ventral stream dysfunctions
• Prof. Gordon Dutton
• Dr. August Colenbrander calls “Cognitive
dysfunction”
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Dorsal & Ventral “pathways”
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Ventral Stream – “What is it?”
Recognition of objects
Occipital lobes – Receive visual input (primary visual pathway)
Temporal lobes – input from occipital lobes
– Visual “library”
– Words, numbers, shapes, landmarks
– Faces
– Color
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Ventral Stream
Occipital Lobe
Temporal Lobe
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Apple!
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????
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Dorsal Stream
Occipital Lobe
Posterior Parietal
Motor Cortex
Frontal Cortex
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Dorsal stream -“Where is it?”
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
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I want it
Attend, Attend
Fixate with
Eyes
Reach
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Apple!
I want it
It’s in front of me Reach with
right hand
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?????
Too Much
Information!
!!!!!!!! Where do I
look???
How do I move?
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G N Dutton 2012
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Summary
• 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
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Summary
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.
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Summary
• 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.
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Images & Resources
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
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Cortical/Cerebral Visual Impairment
Is it one or several entities?
Can it co-exist with ocular impairments?
Barry S. Kran, OD, FAAO
Darick W. Wright, MA, COMS, CLVT
D. Luisa Mayer, PhD. MEd