Trican Lawsuits: There are a number of ways to assess visual functioning in the newborn. Optico-kinetic nystagmus is a reflex that is normally present in newborns, and can help the pediatrician assess the pathways leading to the visual part of the brain. A drum with alternating black and white lines is rotated in front of die baby, with both of the bab/s eyes opened or one eye patched. A positive reflex is seen when there are horizontal jerks in the eye as the eye tries to follow and then pulls back, with die fast component being in the direction opposite to die rotation. This reflex can be seen in premature babies as early as 30 weeks’ gestation (bom after 30 weeks in die womb).
Other aspects of visual function can be measured by a baby’s blink response to light, which develops at approximately 25 weeks’ gestation. The pupils constrict in response to light at 29 to 31 weeks’ gestation. Some discriminatory visual function appears by 31 to 32 weeks’ gestational age. Tests using preferential looking (where the baby chooses to focus on a more interesting or more appealing picture) can estimate the actual visual acuity of a newborn.
Visual-evoked potential (VEP) or visual evoked response (VER) have also been used to assess the integrity of the entire system up to die cortex, but dieir usefulness is limited because the exact site in die brain where die abnormal response occurs cannot be determined. A visual-evoked potential is an electroencephalogram used in combination with a computer to assess the brain’s response to visual stimuli such as a flashing light, or a checkerboard pattern. To test vision, the baby’s responses are compared with those of children known to have normal vision.
There are two basic lands of vision tests, those that require minimal cooperation and diose that require active participation by the child. In young children, Allen cards and the illiterate E game are the vision tests most commonly used. Allen cards are cards printed with objects familiar to children (such as a teddy bear, a telephone, or a birthday cake), and designed for use at 20 feet or less. The child is asked to identify the pictures on the cards. In the E game, die letter E is presented in different directions and the child is instructed to mimic the direction by pointing his or her hand or arm. In children who are a bit older and know die alphabet, the Snellen letters remain die standard test, using a chart with nine lines of letters measuring acuity from 20/10 to 20/200.
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A child with cerebral palsy, just like any other child, should have his or her eyes examined when there is any deviation from normal. Deviations include crossed eyes, roving eyes, or an abnormal appearance of die eyes. The examination is initially done by the primary care physician; if an abnormality is confirmed, the child is usually referred to an eye specialist—the ophthalmologist.
For children with significant physical risks, such as infants widi a very low birthweight who were exposed to oxygen, the initial eye exam is usually done in the nursery by an ophthalmologist. Except for these children, who continue to see an ophthalmologist, children with cerebral palsy can be evaluated routinely by their primary care physicians at each visit and can be referred to an ophdialmologist if an abnormality is noted.
The exam should include an evaluation of the way die eyes move (specifically looking for crossing of the eyes) and a sense of visual acuity, diat is, how well the child is seeing and following with his or her eyes. If the child is referred to an ophthalmologist, die ophthalmologist will dilate die pupil with eye drops in order to examine for refractive errors (farsightedness, nearsightedness, or astigmatism) and to evaluate die retina and internal structures of die eye. The dilated pupil evaluation will also help in evaluation of amblyopia (“lazy eye”).
There are three goals for any child with cross-eye. These goals are the same regardless of whether the child has cerebral palsy or not. They are: (1) good and equal visual acuity in each eye, (2) ocular alignment (meaning getting the eyes straight, both for cosmetic reasons and for functional reasons), and (3) being able to use bodi eyes togedier. Strabismus is normally treated by correcting the visual acuity in each eye, either widi glasses or by patching. If a significant strabismus remains even after these therapies, then surgery is indicated.
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Operations for strabismus are done under general anesthesia in an operating room. The eye muscles are either tightened or loosened. The main risk to a child from this operation is die anesdietic one. The complications of the operation itself are exceedingly rare and primarily involve infection. The most common complication is either incomplete or overcorrection of the crossed eyes. Approximately 70 to 75 percent of children respond to the initial surgical intervention with good alignment of their eyes, but one out of every four or five children requires more dian one surgical procedure. For this reason, if diere is any possibility that nonsurgical treatment such as glasses or patching will work, dien tiiese are tried first.
For a person to be able to see, several things must occur. First, the person must have a clear optical structure, meaning that there are no cataracts or opacities (conditions that block light) that obstruct vision of the eye itself. Second, the person must be able to focus on an object, which sometimes requires wearing corrective glasses. Third, the person’s eye must be able to pick up the light and transfer it into energy to send the image to the brain. The retina picks up the light and transfers this light stimulus to the optic nerve, which then conducts the nerve impulse to the back of the brain. Finally, the back of the brain, specifically die occipital lobe, must translate these electrical impulses into visual stimuli, which are then interpreted by the brain.
In optic nerve atrophy, the third process described above is impaired. That is, the optic nerve itself is injured and the light image cannot get from die eye to die brain. In cortical blindness, die ocular apparatus (the eye, retina, and nerve) is normal but the part of the brain which should pick up the visual stimuli is not working properly and cannot convert the electrical energy into a visual image. In children with cerebral palsy, blindness can be a result of damage to die retina, die optic nerve, or the occipital lobe of the brain. Premature infants who were exposed to oxygen may suffer a severe form of retinopathy resulting in retinal detachment, which interferes with the reception of light by the retina due to damage to the photoreceptor cells, and obstructs transmission of light to the optic nerve. Other children with cerebral palsy may have suffered lack of oxygen or blood supply at birth or in die months diereafter, resulting in damage either to the optic nerve or to the occipital area of the brain—or both.
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