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Visual Diagnosis and Care of the Patient with Special Needs: Syndromes

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Visual Diagnosis and Care of the Patient with Special Needs: Syndromes

  1. 1. Visual Diagnosis and Dominick M. Maino, O.D., M.Ed., F.A.A.O., F.C.O.V.D-A. Care of the Patient with Professor, Pediatrics/Binocular Vision Service Special Needs Illinois College of Optometry Illinois Eye Institute 3241 S. Michigan Ave. Chicago, Il. 60616 Syndromes/Genetic Anomalies/Brain Injury 312-949-7280 (Voice) 312-949-7358 (fax) dmaino@ico.edu MainosMemos.com www.ico.edu LyonsFamilyEyeCare.com Taub M, Bartuccio M, Maino D. (Eds) Visual Diagnosis and Care of the Patient Children with Special Needs with Special Needs. Lippincott, Williams & Wilkins. New York, NY;2012. Steel G, Maino D. The Life Cycle Approach to Care for Patients with Special Needs. Taub M, Reddell AS. Cerebral Palsy. •Learning Disability Woodhouse M. Maino D. Down Syndrome. Berrry-Kravis E, Maino D. Fragile X •ADHD Coulter RA. Autism Schnell PH, Maino D, Jespersen R. Psychiatric Illness and Associated Oculo-visual Anomalies. •Cerebral Palsy Bartuccio M, Browing RT, Howell AC. ADHD Ciuffreda K, Kapoor N. Acquired Brain Injury. •Down Syndrome Maino D, Donati, R, Pang, Viola S, Barry S. Neuroplasticity. Lran BS, Mayer DL. Vision Impairment and Brain Damage •Fragile X Syndrome Children with Special Needs Learning Disabilities•Autism•Mental Retardation/Intellectual Reading/Dyslexia Disability Dyscalculia•Acquired/Traumatic Brain Injury Dysgraphia•Mental Illness/Psychiatric Illness 1
  2. 2. Learning Disabilities Learning Disabilities Reading/Dyslexia Reading/Dyslexia Language Based Vision Based Reading disabilities common Combination of Language/Vision Dyslexia rare Learning Disabilities Learning Disabilities Dyscalculia (Math Disability) Dysgraphia 3 and 6% of the population Working memory (orthographic coding) Neurological Dyscalculia Motor planning Deficits in working & short term memory Attentional issuesCongenital/hereditary (Gerstmann syndrome: Dyscalculia + Dysgraphia) Learning Disabilities Learning Disabilities ADHD/ADD Etiology ADHD/ADD Not Caused By: Brain Functioning Diet Heredity Hormones Exposure to Toxic Substances Vestibular dysfunction Brain Trauma, Tumors, Strokes or Disease Poor parenting Functional Vision Problems Television 2
  3. 3. Learning Disabilities ADHD/ADD Treatment Medication Psychotherapy Education or Training A combination of treatments Oculomotor therapy/Vision Therapy Cerebral Palsy Cerebral Palsy• What is it? • Cerebral Palsy is a persistent, but not• What is it’s etiology? unchanging, disorder of movement and• What is it’s prevalence/incidence? posture appearing in the early years of life• How is it classified? due to traumatic or inflammatory brain• What are it’s visual characteristics? damage. • Affects virtually all motor systems • Can be acquired Cerebral Palsy Etiology Cerebral Palsy Incidence/PrevalenceSomething goes awry just before, during or • 764,000+ children and adults just after birth: • 500,000 children under age of 18 • 2-3 children out of 1,000 (as low as 2.3 per 1,000 to 3.6 Prenatal per 1,000) Neonatal • 10,000 babies born each year Postnatal • 8,000 - 10,000 babies and infants are diagnosed per year 3
  4. 4. Cerebral Palsy Incidence/Prevalence Cerebral Palsy Incidence/Prevalence• Around 1,200 to 1,500 preschool-aged • 75% of CP occurs during pregnancy , 5% during childbirth and/or 15% after birth up to age 3 children are diagnosed per year • 80% the etiology is unknown• births 10% of cases are acquired • The number of new cases have increased 25% during the past decade (1990’s) (trauma) • Average lifetime cost per person of $921,000 (in 2003• Normal life spans, 40% live to age 40, dollars) many living into their senior years Cerebral Palsy Classifications Cerebral Palsy Visual Characteristics Wesson M, Maino D. Oculovisual findings in children with Down syndrome, Cerebral Palsy, and mental retardation without specific etiology. In Maino, D. (ed) Diagnosis and management of special populations. 1995. St. Louis, Mo. , Mosby- • Spastic - 61% to 76.9% Yearbook Inc.:17-54. • Binocular acuity could be evaluated in • Dyskinetic/Athetoid - 10-15% 45% of individuals below age 13 • Ataxic - <5% • For CP patients VAs are generally decreased when compared to those • Mixed measured for individuals with Down Syndrome • Much higher incidence of ocular disease and neurological dysfunction Cerebral Palsy Refractive Characteristics Cerebral Palsy Refractive CharacteristicScheiman MM. Optometric findings in children with cerebral palsy. Am J Optom Physiol Opt 1984;61:321-333• 60% significant refractive error • Hyperopia present 3Xs more than when compared• Hyperopia (>+1.50) 3X more common among to myopia CP children than in non-affected individuals• Other studies (Black, Breakey et al, Duckman, • Wesson & Maino note: • many more hyperopes LoCasio) support increased refractive error than myopes being present • average amount of significant myopia is greater 4
  5. 5. Cerebral Palsy Binocular Cerebral Palsy InteractionTips Characteristics• Prevalence of strabismus exceeds that of general population by a factor of 10! • Positioning• Slightly more esotropia than exotropia • Right tools (objective)• Dyskinetic Strabismus • No sudden movement • slow tonic deviation similar to • No loud, unexpected noises vergence • change from ET to XT • Speak smoothly, soothingly, softly….if • usually associated with athetoid appropriate, sing to the patient! classification • Smile, smile SMILE!!! Cerebral Palsy Cerebral PalsyBarca L, Cappelli FR, Di Giulio P, Staccioli S, Castelli E. Outpatient assessment of neurovisual functions in children with Cerebral Palsy. Res Dev Disabil. 2010 Mar- • Saunders KJ, Little JA, McClelland JF, Jackson AJ. Profile of refractive errors in cerebral palsy: impact of severity of motor impairment (GMFCS) and CP subtype on refractive outcome. Invest Apr;31(2):488-95. Epub 2009 Dec 5. Ophthalmol Vis Sci. 2010 Jun;51(6):2885-90. Epub 2010 Jan 27. ….Overall, 73% patients had . … A significantly higher prevalence and magnitude of refractive error was found in the CP group ….. impairments …..the majority of Higher spherical refractive errors were which presenting difficulties on significantly associated with the nonspastic CP …. The presence and magnitude of astigmatism were both visuoperceptual and greater when intellectual impairment was more visuospatial tasks (79%).. … severe, …. High refractive errors are common in CP, pointing to impairment of the emmetropization process. …. Cerebral Palsy Cerebral Palsy Ross LM, Heron G, Mackie R, McWilliam R, Dutton GN.McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ. Reduced accommodative function in dyskinetic cerebral palsy: a novel management strategy. Dev Med Child Neurol. 2000 Oct;42(10):701-3. LinksAccommodative dysfunction in children with cerebral palsy: a population-based study. Invest Ophthalmol Vis Sci. 2006 ….The near-vision symptoms were completely May;47(5):1824-30. removed and reading dramatically improved with the provision of varifocal spectacles. VarifocalBrain injury such as that present in CP has a lenses provide an optimal correction for far, intermediate (i.e. for computer screens), and significant impact on accommodative near distances (i.e. for reading). Managing this type function. These findings have implications of patient with varifocal spectacles has not been for the optometric care of children with CP previously reported. It is clearly very important and inform our understanding of the impact to prescribe an optimal spectacle correction to provide clear vision to of early brain injury on visual development. optimize learning. 5
  6. 6. Down Syndrome From: http://www.ndss.org/aboutds/aboutds.html#Down Children with Down syndrome have been included in regular academic classrooms in schools across the country. In some instances they are integrated into specific courses, while in other situations students are fully included in the regular classroom for all subjects. The degree of mainstreaming is based in the abilities of the individual; but the trend is for full inclusion in the social and educational life of the community. Down Syndrome Down Syndrome• What is it? • Langdon Down 1866• What is it’s etiology?• What is it’s prevalence/incidence? • “Mongolism” no longer used• What are it’s physical/visual characteristics? • Most common genetic anomaly • Variable levels of ability & disability Down Syndrome Down Syndrome Prevalence/IncidenceFrom 1979 to 2003 the prevalence of • 1 in 12 for older mothers (>=49yrs of age) Down syndrome increased by 31.1%, • Most babies with Down syndrome born to younger mothers (80% born to moms younger than 35) from 9.0 to 11.8 per 10,000 live births. • Most frequently encounter “viable” genetic In 2002 prevalence among children and anomaly adolescents aged 0 to 19 was 1 in 971, or • Most frequently encounter “special” patient approximately 83,400 children and • Prevalence increasing (improved survival rates) adolescents living with Down syndrome http://www.nichd.nih.gov/publications/pubs/downsyndrome.cfm in the Unites States. 6
  7. 7. You will see individual with Down Down Syndrome Etiology Syndrome in Your Office • Genetics • 95% demonstrate non-disjunction of one chromosome during meiosis (Trisomy 21) • 2-4% mosaicism • 3-4% Robertsonian translocation of the long arm of chromosome 21 to another chromosome usually #14 • risk of having a second child with Trisomy 21 or mosaic Down syndrome is 1 in 100. The risk is higher if one parent is a carrier of a translocated cell. Down Syndrome Etiology Down Syndrome Refractive Error• Genetics: Trisomy 21 Many more hyperopes than myopes, but those with myopia tended to have higher magnitudes Up to 49% may exhibit some astigmatism Down Syndrome Binocular What’s New in Down Syndrome Characteristics23-44% have strabismus Al-Bagdady M, Stewart RE, Watts P, Murphy PJ, Woodhouse JM. Bifocals and Downs syndrome: correction or treatment? Ophthalmic Physiol(Wesson & Maino) Down syndrome and Opt. 2009 Jul;29(4):416-21. Epub 2009 May 11. strabismus shows a constant unilateral Accommodation is reduced in approximately 75% of esotropia of less than 20 PD at near. children with Downs syndrome (DS). Bifocals have (Greatly reduced number show ET at distance) been shown to be beneficial and they are currently prescribed regularly.. … Bifocals are an effective It’s suggested that the etiology is a high correction for the reduced accommodation in children ACA ratio rather that of a basic ET with DS and also act to improve accommodation with a success rate of 65%. …. 7
  8. 8. What’s New in Down SyndromeHaugen OH, Hovding G, Eide GE. Biometric measurements of the eyes in teenagers and Haugen OH, Hovding G, Lundstrom I.Refractive development in childrenyoung adults with Down syndrome.Acta Ophthalmol Scand. 2001 Dec;79(6):616-25. with Downs syndrome: a population based, longitudinal study. Br J Ophthalmol. 2001 Jun;85(6):714-9.Thinning of the corneal stroma mayaccount for the steeper cornea and the ….Accommodation weakness may be ofhigh frequency of astigmatism in Down aetiological importance to the highsyndrome due to lower corneal rigidity. frequency of refractive errorsIt may also be of etiological importance encountered in patients with Downsto the increased incidence of syndrome.keratoconus in Down syndrome. Haugen OH, Hovding G.Strabismus and binocular function in children with Down syndrome. A population-based, longitudinal study.Acta Ophthalmol Scand. 2001 Apr;79(2):133-9.Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. Associationbetween accommodative accuracy, hypermetropia, and strabismus …The majority of the Down syndromein children with Downs syndrome Optom Vis Sci. 2007 children with strabismus have anFeb;84(2):149-55. acquired esotropia and hence a….This study demonstrates the marked potential for binocularity.association between under- Hypermetropia and accommodation weakness are probably importantaccommodation, hypermetropia, and factors in esotropia …….strabismus in children with Downssyndrome. …. Stewart RE, Woodhouse MJ, Trojanowska LD. In focus: the use of bifocal spectacles with children with Downs syndrome.Ophthalmic Physiol Opt. 2005 Nov;25(6):514-22 …….Based on the results of this study, eye examinations of children with Downs syndrome should routinely include a measure of accommodation at near, and bifocal spectacles should be considered for those who show under- accommodation. 8
  9. 9. Fragile X Syndrome Fragile X Syndrome• What is it? Most frequently encountered inherited form of• What is it’s etiology? mental retardation (X-linked MR)• What is it’s prevalence/incidence? Often misdiagnosed in the past• What are it’s physical/visual characteristics? “New” syndrome that has caught the imagination of researchers around the world 1st human disease shown to be caused by a repeated nucleotide sequence Fragile X Syndrome Fragile X Syndrome CharacteristicsX-linked MR 1:600 in affected males • Large prominent ears1/2500-4000 males 1/7000-8000 females • Long narrow face female carriers 1/130-250 population • Macro-orchidism male carrier 1/250-800 (80% affected men) 10% of undiagnosed ID in males Other: hypotonia, seizures, 3% of previously undiagnosed ID in females recurrent otitis media Fragile X Syndrome Characteristics Fragile X Syndrome Characteristics• Large prominent ears • Large prominent ears• Long narrow face • Long narrow face• Macro-orchidism (80% • Macro-orchidism (80% affected men) affected men)Other: hypotonia, seizures, Other: hypotonia, seizures, recurrent otitis media recurrent otitis media 9
  10. 10. Fragile X Syndrome Characteristics Fragile X Syndrome Characteristics• First demonstrated genetic etiology of Gaze Avoidance learning disability• Variable mental retardation• Math, language delay How do you conduct an• Sensory integration problems examination on an individual• Attentional deficits that won’t look at you?• Psychiatric illnesses (shy) Fragile X Syndrome DiagnosisGenetics• Triplet nucleotide repeated sequence • cytosine, guanine, guanine (CGG) • 0-50 CGG repeats normal, 50-200 premutation, > 200 full syndrome• Fragile site on X chromosome (band q27.3) Fragile X Syndrome Ocular Findings What’s New in Fragile X Syndrome • Hatton DD, Buckley E, Lachiewicz A, Roberts J. Ocular status of boys with fragile X syndrome: a• Strabismus (33-50%) prospective study. J AAPOS. 1998 Oct;2(5):298-302.• Nystagmus …observe a higher prevalence of strabismus than that found in the general population (8% vs 0.5%• Refractive error to 1…., 17% of the sample did have significant• Accommodative dysfunctions? refractive errors. In addition to evaluating the• Oculomotor anomalies ocular motility of children with fragile X syndrome, cycloplegic refraction should also be• Ocular Health? performed to determine whether refractive• Perceptual dysfunction problems are present. 10
  11. 11. What’s New in Fragile X Syndrome What’s New in Fragile X Syndrome Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM, Treitman TM.Cognitive and visual processing Effect of CX516, an AMPA-modulating compound, on cognition skills and their relationship to mutation size in full and premutation female fragile X carriers.Optom Vis Sci. 2000 Nov;77(11):592-9. and behavior in fragile X syndrome: a controlled trial. Berry- Kravis E, Krause SE, Block SS, Guter S, Wuu J, Leurgans S, ….full mutation female carriers performed more Decle P, Potanos K, Cook E, Salt J, Maino D, Weinberg D, Lara poorly in visual-motor processing and analysis- R, Jardini T, Cogswell J, Johnson SA, Hagerman R. J Child synthesis on the Woodcock-Johnson Psycho- Adolesc Psychopharmacol. 2006 Oct;16(5):525-40.PMID: Educational Battery-Revised, The Developmental 17069542 Test of Visual Motor Integration, and on five of the Cognitive and visual processing skills and their relationship to seven subtests of the Test of Visual-Perceptual mutation size in full and premutation female fragile X carriers. Skills. Regression analyses revealed significant Block SS, Brusca-Vega R, Pizzi WJ, Berry-Kravis E, Maino DM, negative correlations between mutation size and Treitman TM. Optom Vis Sci. 2000 Nov;77(11):592-9.PMID: cognitive ability. … 11138833 What’s New in Fragile X Syndrome Fragile X-associated tremor/ataxia syndrome (FXTAS) The fragile X female: a case report of the visual, visual perceptual, reported in 33-40% of men older than 50 years and, less and ocular health findings. Amin VR, Maino DM. J Am Optom frequently (4-8%), in older women with premutations in the Assoc. 1995 May;66(5): fragile X mental retardation (FMR1) gene. Optometric findings in the fragile X syndrome. Maino DM, Wesson Clinical features (FXTAS): incontinence, impotence, cerebellar M, Schlange D, Cibis G, Maino JH. Optom Vis Sci. 1991 ataxia, peripheral neuropathy, autonomic dysfunction/orthostatic Aug;68(8): hypotension, severe intention tremor, and other signs of Mental retardation syndromes with associated ocular defects. Maino neurodegeneration (brain atrophy, memory loss and dementia, DM, Maino JH, Maino SA. anxiety, depression, and irritability). Premature ovarian failure J Am Optom Assoc. 1990 Sep;61(9):707-16. in 25% of women with premutations; this represents a 30-fold Ocular anomalies in fragile X syndrome. Maino DM, Schlange D, increase compared with the general population. Maino JH, Caden B. J Am Optom Assoc. 1990 Apr;61(4):316-23 Autism Autism Do Parents cause their children to be autistic ? There are autistic children born to parents who do not fit the autistic parent personality pattern. Parents who do fit the description of the supposedly pathogenic parent have normal, non-autistic children. Frequently siblings of autistic children are normal. Autistic children are behaviorally unusual "from the moment of birth." *** There is a consistent ratio of three or four boys to one girl. Virtually all cases of twins reported in the literature have been identical, with both twins afflicted. *** Autism can occur or be closely simulated in children with known organic brain damage. *** The symptomatology is highly unique and specific.Factors such as younger age of diagnosis, broadening of diagnostic criteria, improvements in the availability There is an absence of gradations of infantile autism which wouldof services, and better awareness of the disorder have all been attributed to the change in autism create "blends" from normal to severely afflicted.prevalence. However, recent epidemiological studies indicated that, while these factors do account for aportion of the change, they cannot account for all of the increase alone 11
  12. 12. Autism Etiology Autism EtiologyYeast infectionsIntolerance to specific food substances Brain injury, Constitutional vulnerability(Gluten intolerance ("Leaky Gut Syndrome"/Casein intolerance causing intestinal permeability and allowing improperly digested peptides to enter Developmental aphasia , Deficits in the reticular the bloodstream and cross the blood-brain barrier which may mimic activating system, An unfortunate interplay neurotransmitters and result in the scrambling of sensory input. Ive also heard "Leaky Gut Syndrome" described as lack of the beneficial bacteria between psychogenic and that aids digestion, and that the resulting matter in the bloodstream invokes an unnecessary immune reaction) neurodevelopmental factors, StructuralPhenolsulphertransferase (PST) deficiency--theory that some with autism are cerebellar changes, Genetic causes, Viral low on sulphate or an enzyme that uses this, called phenol- sulphotransferase-P. This means that they will be unable to get rid of amines causes, Immunological ties, Vaccines, and phenolic compounds once they no longer have any use for them. These then stay in their body and may cause adverse effects, even in the brain. Seizures Autism Etiology Autism Etiology My Goodness! What the research shows… Maino DM, Viola, SG, Donati R. The Etiology of Autism. Optom Vis Dev 2009:(40)3:150-156. Autism Autism Asperger Impairment in social interactions Childhood Syndrome Impairment in communication Disintegrative Disorder Autism Restricted repertoire of activities Rett Syndrome 12
  13. 13. Autism Autism US FDA Statement IOM Report: No Link Between Vaccines and Autism By Michelle Meadows There is no link between autism and the Childhood measles-mumps-rubella (MMR) vaccine or the Childhood Disintegrative Disintegrative Disorder vaccine preservative thimerosal, according to a Disorder report released by the Institute of Medicines (IOM) Immunization Safety Review Committee. http://www.fda.gov/fdac/features/2004/504_iom.html Autism AutismThompson WW, Price C, Goodson B, Shay DK, Benson P, HinrichsenVL, et al. Early thimerosal exposure and neuropsychological outcomes at 7 Andrew Wakefield (born 1956) is a British formerto 10 years. N Engl J Med. 2007 Sep 27;357(13):1281-92 surgeon and researcher best known for his discredited Childhood work regarding the MMR vaccine and its claimed connection ChildhoodOur study does not support Disintegrative Disorder Disintegrative with autism and inflammatory bowel disease. Wakefield was the lead author Disorder of a 1998 study, published in The Lancet, which reported bowel symptoms ina causal association between early twelve children diagnosed with autism spectrum disorders, to which the authors suggested a possible link with the MMR vaccine. Though stating "We did notexposure to mercury from thimerosal-containing vaccines and immune prove an association between measles, mumps, and rubella vaccine and theglobulins and deficits in neuropsychological functioning at the age of 7 to syndrome described," the paper tabulated parental allegations, and adopted these10 years. allegations as fact for the purpose of calculating a temporal link between receipt of the vaccine and the first onset of what were described as "behavioural symptoms“. Summary Mental Retardation without Specific Etiology Most frequently encountered form of Intellectual Autism? Disability 4000 known Online Mendelian Inheritance in Man http://www.ncbi.nlm.nih.gov/omim 25% of the etiologies are unknown! 13
  14. 14. Mental Retardation Classification Acquired/Traumatic Brain Injury Neuroplasticity Classification IQ Maino D. Neuroplasticity: Teaching an Old Brain New Tricks. Rev OptomMild/Educable Mentally Handicapped 50-70 2009. 46(1):62-64,66-70. (http://www.revoptom.com/continuing_education/tabviewtest/lessonid/106025/)Moderate/Trainable Mentally Handicapped 35-55Severe 20-40Profound below 20 Acquired/Traumatic Brain Injury Acquired/Traumatic Brain InjuryNeuroplasticity & Rehabilitation Neuroplasticity & RehabilitationUse it or lose it. If you do not drive specific brain functions, functional Time matters. Different forms of plasticity take place at different times loss will occur. during therapy.Use it and improve it. Therapy that drives cortical function enhances that Salience matters. It has to be important to the individual. particular function. Age matters. Plasticity is easier in a younger brain, but is also possible in an adult brain.Specificity. The therapy you choose determines the resultant plasticity and function. Transference. Neuroplasticity, and the change in function that results from one therapy, can augment the attainment of similar behaviors.Repetition matters. Plasticity that results in functional change requires Interference. Plasticity in response to one experience can interfere with the repetition. acquisition of other behaviors.Intensity matters. Induction of plasticity requires the appropriate amount Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for of intensity. rehabilitation after brain damage. J Speech Lang Hear Res 2008 Feb;51(1):S225-39. Acquired/Traumatic Brain Injury Acquired/Traumatic Brain InjuryPost Trauma Vision Syndrome Symptoms/Signs • Staring behavior (low blink rate) Double vision • Spatial disorientation Headaches • Losing place when reading Blurred vision • Can’t find beginning of next line when Dizziness or nausea reading Light sensitivity • Comprehension problems when reading Attention or concentration difficulties • Visual memory problems 14
  15. 15. Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury • Pulls away from objects when they are brought close to them • Associated neuromotor difficulties with balance, • Exotropia or high exophoria • Accommodative insufficiency coordination and posture • Convergence insufficiency • Perceived movement of • Poor fixations and pursuits stationary objects • Unstable peripheral vision Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury Visual Midline Shift Syndrome Visual Midline Shift Syndrome • Dizziness or nausea • Poor walking or posture: leans back on heels, forward, or to one side when • Spatial disorientation walking, standing or seated in a chair • Consistently stays to one side of • Perception of the floor being tilted hallway or room • Associated neuromotor difficulties with • Bumps into objects when walking balance, coordination and posture Acquired/Traumatic Brain Injury Acquired/Traumatic Brain Injury References ReferencesTBI a Major Cause of Disability • Myopia and Accommodative Insufficiency by Marc B. Taub, OD, FAAO, FCOVD Associated with Moderate Head TraumaClinical Oculomotor Training in Traumatic Brain by Steve Leslie, B Optom, FACBO, FCOVD Injury by Kenneth J. Ciuffreda, OD, PhD, FAAO, • Neuro-Optometry and the United States Legal FCOVD-A, Diana P. Ludlam, BS, COVT, Neera System Kapoor, OD, MS, FAAO by Theodore S. Kadet, OD, FCOVD, R. E. Bodkin, JD, MBA, Attorney-at-Law 15
  16. 16. Acquired/Traumatic Brain Injury Questions? Contact: References Dominick M. Maino, OD, MEd, FAAO,FCOVD-A• Oculo-Visual Evaluation of the Patient with Professor, Pediatric/Binocular Vision Service Illinois Eye Institute Illinois College of Optometry Traumatic Brain Injury 3241 S. Michigan Ave. Chicago, Il. 60616 by Maria Mandese, OD 312-949-7280 (phone) 312-949-7660 (fax)• Traumatic Brain Injury and Binasal Occlusion dmaino@ico.edu by Alissa Proctor, OD www.ico.edu LyonsFamilyEyeCare.com MainosMemos.comhttp://www.covd.org/Home/OVDJournal/OVD401/tabid/263/Default.aspx 16