Texas School for the Blind and Visually Impaired

Outreach Programs
www.tsbvi.edu !"#$%!%$&'(" "")) *. %!th St. +ustin, Texas -&-!'

#)"#$"( Texas .ocus /ystagmus in 0hildren1 0auses, 2ffects and Strategies

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Presented by 4r. +na Pere5, O4, .++O 6ow Vision 7ehabilitation 3ichael 2. 4eBa8ey V+30

4eveloped for Texas School for the Blind 9 Visually Impaired

Outreach Programs

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

Nystagmus in Children: Causes, Effects, and Strategies

+na 3. Pere5, O4, .++O 6ow Vision 7ehabilitation, 3ichael 2. 4eBa8ey V+30, ;niversity of <ouston 0ollege of Optometry Objectives
". Participants will discover the causes and treatments for nystagmus. #. Participants will review how nystagmus affects visual performance in both near and distance visual activities, as well as ways to improve visual performance.

Nystagmus
0ondition in which the eyes ma8e repetitive, uncontrolled movements, often resulting in reduced vision Types of movement Side to side1 hori5ontal nystagmus ;p and down1 vertical nystagmus 7otary1 torsional nystagmus

Nystagmus is a sign of a problem

Ocular structure Pathways that connect the eye to the parts of the brain that deal with eye movement It is not really a condition in its own right=

Two main types of nystagmus

0ongenital nystagmus or early onset nystagmus It appears in the first months of life

+c>uired nystagmus 4evelops later in life

/ystagmus affects one in "!)) people

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

Causes of Nystagmus
Physiological nystagmus : normal part of how our eyes wor8 If you watch someone?s eyes as they are watching a train passing, their eyes follow the train then flic8 bac8 to a starting point@ this is repeated over and over OA/ drum

Pathological nystagmus : If the eye or the visual pathway Bwhere visual information is processedC are damaged

Idiopathic nystagmus : condition starts early in life and the cause is un8nown

Congenital Nystagmus
Occurs in the first couple of years of life 0aused by two things1 ". + problem with the eye structure #. + problem with the visual pathway from the eye to the brain

New born babies

+ll children are born with a visual system that is not fully developed Vision continues to develop in the first few years of life as a result of the eye and brain being stimulated

Eye conditions affecting vision

0ongenital cataracts : lac8 of good stimulation to the retina 0ongenital glaucoma : damaged optic nerve Optic nerve hypoplasia : under developed optic nerve +lbinism : under developed macula

Visual system will not develop normally

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

Severity of the congenital nystagmus

4epends on the severity of the sight loss caused by the underlying condition Vision tends to worsen when1 o The eye movements of the nystagmus increases /ot being at the null point

o Patient is stress andDor fatigue o There is occlusion of an eye

Congenital Nystagmus
It is not painful It does not lead to progressive vision loss .or the most part, patient do not see the world Eumping Typically, vision tend to improve until it stabili5es at age five or six.

Fiving children plenty of visual stimulation in the early years leads to best use of visual function

c!uired Nystagmus
Typically, develops in adulthood 0auses 3ultiple sclerosis Brain tumorD brain inEury 2ffects of a drug1 4ilantin Banti$sei5ure medC Thiamine or Vit B"# deficiency

Patients are aware of the movement1 Oscillopsia. Typically, very disabling

"rug #nduced Nystagmus

4ilantin BphenytoinC : an anti$sei5ure medication 2xcessive alcohol Sedating medications

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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Classifying Nystagmus
4escribing eye movements Ger8 nystagmus1 movement is >uic8 in one direction and slow in another Pendular1 the speed of movement is e>ual in both directions

4irection of the nystagmus Vertical <ori5ontal 0ircularDtortional

$er% and &endular Nystagmus

Video 0lip

Null &oint
+ particular head position that results in the slowest eye movement 7eductions in the movement BamplitudeC of the nystagmus usually means the vision is at its best Visual acuity is variable #)D() to #)D#))

Null point
Video clip

Nystagmus Treatment
/ystagmus cannot be cured 3uscle surgery o 7educes the amount of head turn needed to reach the null point o 0osmeticDPostural 3edication1 Botox BbaclofenC o Temporary effect Biofeedbac8 training o 3a8ing patients aware of the movement thru visual and audio signals

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

&harmacologic, Optical, and Surgical Treatments

0hoice of treatment depends on the characteristics of the nystagmus and the severity of the associated visual symptoms 2lectro$optical devices are currently being developed Boptical stabili5erC

"ifferent meds for different types of nystagmus

4ownbeat nystagmus o %$aminopyridine, (,%$diaminopyridine or clona5epam ;pbeat nystagmus o 3emantine, %$aminopyridine or baclofen Torsional nystagmus o gabapentin +c>uired pendular nystagmus o In multiple sclerosis1 partially suppressed by gabapentin or mematine o In oculopalatal tremor1 gabapentin, memantine or trihexyphenidyl Infantile nystagmus nystagmus o Fabapentin, memanine, aceta5olamide, contact lenses, prisms, or surgery.

'a(imi)ing *isual +unction with Nystagmus

2arly intervention Visual stimulation with engagement of the environment

Because of the variability in patients with congenital nystagmus Bwith or without pathologyC it is difficult to predict best V+

#ntervention:

ctive loo%ing, searching, , selecting

Visual curiosity o Visual o Tactile

2xplore environment o 3obility

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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"#ST NCE
Video 0lip

E(tending *isual -each

<aving a desireDneed to loo8 at a distance o Typically, distance is of little conse>uence to a young child with visual impairments 0reating curiosity for exploration 0reating s8ills for safety 0reating independence

.ow do we ma%e it interesting/

Incorporating navigational s8ills o The child should learn landmar8s and give directions o This is to be done without the use of optical devices which provide detail information li8e telescopes ;se a Hbig wheelI and place cones to navigate a path

#mplications for "istance

The use of telescopes BTSC in cases of congenital nystagmus is not contraindicated Patients with nystagmus generally perform very well with the use of TS

Telescopes for distance

Provide magnification by creating a larger image and placing it on the retina If the magnification is %x, then the image movement through the TS is %x faster If the patient has congenital nystagmus, they will /OT see the image Eumping

-ecommendations for "istance

3odified seating placement o Specific distance in meters or feet Introduction to the use of <<TS o 6ocali5ationD0opying s8ills o TS power for in$ classroom activities
/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

o TS power for outside activities Bmay be differentC

NE -0-E "#N1
Video 0lip

-eading with Congenital Nystagmus

Visual acuity is typically reduced It is not possible to predict with any amount of certainty the visual acuity by the amplitudeDfre>uency of the nystagmus The null point is the position of least eye movement and best resolution The words on a page are /OT Eumping when reading

+oveation &eriods
Intervals in the 0/ waveform when the eye velocity is relatively slow and the target is imaged on or near the fovea. Initially, it was thought that patients with 0/ HsampleI their environment only during foveation and suppressed visual input thru out the rest of the 0/ waveform@ and in this way they do not have the perception of oscillopsia. 2vidence has been found against this hypothesis. Gin K<, Foldstein <P, 7einec8e 74. +bsence of visual sampling in infantile nystagmus. Aorean G Ophthalmology "J&J

#mplications for -eading -esearch2based information

Patients with 0/ have e>ual maximum reading speeds when comparing rapid serial visual presentation B7SVPC and continuous text B0TC o %%J and %%& wordsDminute Patients with 0/ can read at rates faster than the fre>uency of nystagmus o This suggest that they are able to read during non$foveation periods. *oo S, Bedell <. Beating the Beat1 7eading can be faster than the fre>uency of the eye movements in persons with congenital nystagmus. Optometry and Vision Science. +ug #))&

3hat does this mean for our visually impaired students4/

Patients with congenital nystagmus need to have a reading reserveL They should not be reading at their threshold=
/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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3a8e sure that this has been address for each student

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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&roviding -eading -eserve

6ow Vision Optometrist can provide Print si5e recommendation 7eading glassesDbifocals Incorporation of magnifiers ;se of 00TV1 with an enlargement recommendation

5* -ehab Optometrist need to %now4

*hat is the patientMs reading levelN o 4oes it correlate with their grade levelN *hat is the reading demandN o Si5e of textboo8 print1 scienceDsocial studies o Si5e of math print o Is patient reading paperbac8 boo8s o Is patient reading off the computer screen

#mplications for School

Best correction in place +llow patient?s prefer head position, so as to reach their null point which in turn provides best visual resolution There is no way of predicting visual acuity in patients with nystagmus 0ongenital nystagmus is not a progressive condition Patients with congenital nystagmus do not see the world moving Patients with nystagmus respond very well to the implementation of optical devices

/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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Te(as School for the 6lind , *isually #mpaired Outreach &rograms

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OThis proEect is supported by the ;.S. 4epartment of 2ducation, Office of Special 2ducation Programs BOS2PC. Opinions expressed herein are those of the authors and do not necessarily represent the position of the ;.S. 4epartment of 2ducation.
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/ystagmus in 0hildren1 0auses, 2ffects and Strategies : Pere5, #)"# : #)"# Texas .ocus 0onference

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