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Visual Diagnosis and Care of

Patients with Special Needs Examination/Treatment

Dominick M. Maino, O.D., M.Ed., F.A.A.O.

Professor,

Pediatrics/Binocular Vision Service

Illinois College of Optometry

Illinois Eye Institute 3241 S. Michigan Ave.

Chicago, Il. 60616

312-949-7280 (Voice) 312-949-7358 (fax)

dmaino@ico.edu

www.ico.edu LyonsFamilyEyeCare.com

MainosMemos.com

Diagnosis

Assessment Techniques for Special

Populations

Use everything you know, be creative, and

trust your objective evaluation skills!

Diagnosis

• Preparing for the examination

• greet patient by name • position yourself at patient’s eye

level • be on schedule • consider patient’s wishes about

family/friends in exam room • direct initial comments to patient • treat patient as a person first, then

as an individual with a disability

Diagnosis

• Preparing for the examination • speak clearly • listen carefully • use short command sentences

• “look here”

• “do this”

• “watch my light”

Treat the patient the

way you would want

to be treated!

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Remember the 10 Commandments

1.) Speak directly to the

person rather than thru a

companion or sign language

interpreter.

2.)Always offer to shake

hands when introduced.

3.)Always identify yourself

and others who are with you

when meeting someone who

is blind.

4.) If you offer assistance wait

until the offer is accepted,

then listen and wait for

instructions.

5.) Treat adults as adults.

6.) Do not lean against or hand

on someone's wheelchair or

cart.

Remember the 10 Commandments

7.) Listen attentively when talking to

people who have difficulty

speaking and wait for them to

finish.

8.) Place yourself at eye level

when talking to someone in a

wheelchair.

9.) Tap a person who is deaf on the

shoulder or wave your hand to

get their attention.

10.) Relax. Don’t be

embarrassed if you use

common expressions that

seems torelate to a person’s

disability.

The Ten Commandments of

Communicating with People

With Disabilities

Case History Case History

• Demographic Information

• Medical history including their disability • typically taking many medications

• Visual history

• Educational history

• Rehabilitation history

• Vocational history

• Recreational history

Visual Acuity

•Use highest level possible

•binocular before monocular testing

•adaptive positioning

•use assistants, friends, family members

•limited window of opportunity

•randomize optotypes, use reinforcers

•test=game, be creative

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

E F P

T O Z

H O V T

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Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

Visual Acuity

• Snellen

• Broken Wheel

• HOTV

• Lea Symbols

• Teller Acuity Cards

• OKN

• Cardiff Cards preferential looking

cards that use form

discrimination with

vanishing optotypes

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Visual Acuity Refractive Error

Mohindra Dynamic Retinoscopy

•lens bars, 50 cm working distance

•dark, pt looks at light

•neutralize primary meridians

•write in spherocyindrical form

•add a (-) minus 1.25 to the sphere

Refractive Error

• Cycloplegic/Mydriatic spray

• Spray on closed lids, have pt blink, wipe off excess (.5% Cyclo, .5% Myd, 2.5% Phenyl)

Refractive Error

• Keratometry • hand held electronic devices (Nidek) • Placido’s disk • keratoscope

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

Incidence of Strabismus

CEREBRAL PALSY 15-60%

MENTAL

RETARDATION 16-40%

DOWN SYNDROME 41-75%

DEAFNESS 29%

NORMAL CHILDREN 2-4%

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

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Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Observation

• Cover Test

• Bruckner

• Angle Kappa

• Hirschberg

• Krimsky

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

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Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Binocular Vision Assessment

• Lang stereotest

• Random Dot E

• Worth 4 Dot

• MEM Nearpoint

Retinoscopy

• NPC

• Accommodative Facility

• Saccades/Pursuits

Ocular Health

•Hand held devices

•Slit lamp •Tonopen/Perkins •BIO/MIO/direct

http://opt.pacificu.edu/ce/catalog/14041-GO/14041-GO.html

Ocular Health

•Hand held devices

•Slit lamp •Keeler/Tonopen/ •Perkins •BIO/MIO/direct

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Ocular Health

•Hand held devices

•Slit lamp •Tonopen/Perkins •BIO/MIO/direct

Tangential Penlight Angle

Estimation

• Penlight at temporal aspect of

cornea

• Angle between 20-35 degrees to

the facial plane

• Maximum brightness

• Open angle = nasal illumination at

least 75% as bright as temporal

illumination

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

• Visagraph

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

• Visagraph

Ultrasound, B-Scan

CPT 76512 (contact B-scan);

Indications

Examination of the posterior

portion of the eye when direct

view is precluded by media

opacities. Evaluation of

intraocular or orbital masses.

For more info:

http://www.healthgate.co.uk/dp

/dph.0253.shtml

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

• Visagraph

The Test of Variables of Attention

(T.O.V.A.®),

a 21.6 minute computerized continuous

performance test used by professionals

in the diagnosis and monitoring

of treatment of attention deficit disorder

(ADD)/attention deficit hyperactivity

disorder (ADHD) in children and adults.

The standardized test is well normed and

extremely helpful in predicting

responsiveness to treatment modality.

More info at: http://www.tova.net/

Special Testing

• VEP, ERG, EOG

• Sweep VEP

• Ultrasound (A/B scan)

• TOVA

• Visagraph

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Assessment

• Working with incomplete or “fuzzy” clinical data

• “Get over it!”

• Seek help • Dr. Dominick Maino • 312-949-7282 • dmaino@ico.edu

Treatment

• Refractive

•Patient’s cognitive level

•Patient’s motor ability

•Patient’s therapy goals

•Patient’s vocational goals

•Patient’s self abusive behaviors

•Living conditions

•Past success

Treatment

• When Do You Correct Refractive Error?

•Myopia > 1.00D

•Hyperopia > 2.00D

•WR Astig > 2.00D

•AR Astig > 1.00D

•Oblique Astig > 1.00D

•Anisometropia > 1.00D

Treatment

• Binocular Vision Dysfunction • Strabismus

• Rx, VT, surgery • Amblyopia

• Rx, VT • Accommodation dysfunction

• Rx, VT • Oculomotor anomalies

• Rx, VT

Treatment

Ocular Health

Treat as you would any other

patient. May even be more

aggressive in your treatment

Treatment

Ocular

Health

anterior segment:

lids, lashes

conjunctiva, cornea

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Treatment

• Lens • refer/treat optically • cataract • lenticonus

• Fundus/Optic nerve • diagnose/refer

Treatment

• GLC •Treat/Refer •Many need surgical intervention

Referral Resources

Developmental Disabilities Service

Neumann Family Services of the

Illinois Eye Institute 3241 S. Michigan Ave.

Chicago, Il. 60616

312-949-7280 (Pediatrics)

Summary

• All deserve optometric vision care

• If all you do is take a detailed case history, it’s probably

more than any have even attempted before

• Do not underestimate the power of glasses

• Be creative, use want you know, invent!

• Treat (optically, functionally, medically) because we do

it all!

Questions? Contact:

Dominick M. Maino, OD, MEd, FAAO, FCOVD-A

Professor, Pediatric/Binocular Vision Service Distinguished Practitioner, Academies of Practice

Leonardo da Vinci Award of Excellence in Medicine, Recipient

Illinois Eye Institute Illinois College of Optometry

3241 S. Michigan Ave. Chicago, Il. 60616

312-949-7280 (phone) 312-949-7660 (fax)

dmaino@ico.edu www.ico.edu

LyonsFamilyEyeCare.com MainosMemos.com