Visual Health in Learning Disability NHFN Birmingham Gordon Ilett Optometrist gordonilett@gmail.com

Disclosure Partner Linklater Warren Optometrists Trustee SeeAbility Co-Director Special Olympics Opening Eyes GB Councillor Association of Optometrists

Sight Up to 90% of our sensory information will come from the sense of sight Most daily tasks are more difficult when vision is impaired We all tend to assume others perception of their environment is the same as ours

Vision People with learning disabilities are 10x more likely to have serious sight problems 60% will need spectacles and may need support to get used to them 9.3% meet the criteria for sight impaired or serious sight impairment (partial sight or blind) registration Those with severe and profound learning disabilities are most likely to have sight problems Emerson & Robertson 2011

Questions Do you know the visual status of all of your service users? How does undetected visual impairment affect Safety, health and wellbeing? Effective allocation of resources? Will detecting and treating an individuals sight problem reduce the amount of support required? Can you empower the individual?

Drivers for Change Valuing People & Valuing People Now Death by Indifference (Mencap 2007) ‘Healthcare for All’ (2008) Must offer ‘equality of care’ Human Rights Act, DDA / EA, ECHR, Mental Capacity Act Support for GP DES for people with severe and profound LD and maintenance of registers of people with LD on practice lists Doing the right thing!

The Eye and Vision

Embryology Human eye starts to develop at 3 weeks gestation Blood supply from approx 4 months Retinal blood vessels reach nasal ora at 36 weeks, temporal vessels 40 weeks Development of eye and visual pathway continues throughout pregnancy and early life. The eye is an extension of the brain

The Human Eye Vision – Optic Nerve CN2 Motor – Oculormotor CN3, Trochlear ON 4, Abducens ON 6 Sensation Trigeminal ON 5 http://www.99main.com/~charlief/theeyebg.gif

Development of Acuity Age (months) OKN FPL VEP 1 20/300 20/400 6 20/60 20/150 20/20 12 20/40 20/100 36

Visual Pathway Retinocalcerine and tectal pathway Lea Hyvärinen From the occipital lobe, the visual information is sent to other visual centers in the brain through two major pathways: the dorsal and the ventral stream. The dorsal stream starts in the occipital lobe and travels on the superior portion of the brain to the parietal lobes for interpretation in space, positioning, orientation and motor coordination. The ventral stream starts in the occipital lobe and travels through the inferior and lateral portions of the brain on both sides to the temporal lobe and other sub cortical areas for interpretation and recognition of images. In the next two slides, you will have the chance to experience the roles of the dorsal and ventral stream in daily life situations. Lea Hyvärinen

Higher Visual Areas in Cortex LGN d Parvo Magno Interlaminar Primary Visual Cortex Higher Visual Areas in Cortex Superior Colliculus Pulvinar Retinogeniculate Geniculostrate ‘Traditional’ Pathway’ LGN v Pretectum ‘Primative’ pathways to mid brain and other neuclei Neuclei of Accessory optic tract From Milner & Goodale 2006 Suprachiasmatic nucleus

Cortical Visual Processing From primary cortex links to visual association areas Dorsal (Where?) pathway Ventral (What?) Pathway The dorsal stream controls visually guided movements, spatial planning and mapping, rapid eye movements and motor planning. It is closely related and coordinated with the motor planning and execution portion of the frontal lobe. The dorsal stream is “vision for movement”. The ventral stream helps us in recognizing, analyzing and storing visual information. The ventral stream is responsible for recognizing faces, objects, words, maps, shapes, patterns and the significance of the images we see. Of course, both the ventral and dorsal stream are interconnected, coordinated and acting as a team in all visual activities we perform daily, each one of them in its own specific role. When there is damage to any of these areas in the brain, visual processing and understanding can be impaired in a variety of degrees depending on the severity of the lesion. This type of visual impairment is neurologically based or also called cerebral vision impairment or neurologically based vision loss.

The Reading Process Location of word on page Accurate accommodation and gaze directed so image on fovea – mid brain and CN 2, 3,4,6 Image to Brodman’s Area (BA) 17 & 18 (via CN2) Temp Occipital Cortex BA39 – Structure and form To BA 21 & 42 Wernicke’s area – phonetic representation BA 44&45 Broca’s area - speech MRC Cognition and Brain Sciences Unit

Process in reading a word To read ‘FOX’ Recognise letters and order – F(1)O(2)X(3) To lexicon or brains dictionary –recognition of familiar order of letters Semantic system then associates features with word Speech output converts word into phonetic sound Speech generated using motor control of jaw, tongue, voice-box and breathing

Learning Disability and Vision Neuro-developmental disorder causes LD so all parts of eye and visual development may be affected Structural defects may be caused by developmental abnormalities Developmental defects may lead to further structural damage Behavioural changes may lead to injuries to the eye

Periventricular Leucomalacia Damage to white matter adjacent to ventricles Present in up to 25% of pre term infants Affects visual and acoustic tracts as well as descending cortico-spinal tracts Up to 60% may develop cerebral palsy Visual impairment and perceptual abnormalities www.pedsradiology.com

Actions Needed Functional Assessment of all clients Document visual abilities Commission Pathways to allow extended eye exams Ensure regular 2 yearly eye examinations Work with Secondary Care Providers to ensure equal access Document outcomes and advice given

Functional Vision Assessment Designed for use by Carers SeeAbility Functional Vision Assessment Tool www.lookupinfo.org Checklist 1 - Appearance of the eyes the appearance of a persons eyes may raise concerns about their eye health Checklist 2 - Behaviour a persons behaviour may be related to poor vision or other eye care needs Checklist 3 - Poor central vision this is when a person cannot see straight ahead very well Checklist 4 - Poor peripheral vision sometimes a person has difficulties seeing to the sides and up and down Checklist 5 - Sensitivity to light some people experience difficulties because their eyes are very sensitive to light Checklist 6 - Poor colour vision (or contrast sensitivity) some people do not see colours very well and can find it difficult to see objects clearly against different backgrounds Checklist 7 - Poor vision in one eye some people have poor vision in one eye only

Eye Examination Pathways KAB – Bexley RNIB Bridge to Vision SeeAbility Eye 2 Eye LOCSU Sight test pathway WOPEC - Accreditation for practitioners

LOCSU Pathway

Can Eye Examinations be done? Yes

Pathway Support Pre examination reporting – Telling the Optometrist about me form – SeeAbility Appropriate facilities and equipment – desensitisation visits Funding of extended eye examinations and repeat visits Includes domiciliary services Feedback forms and reporting – SeeAbility forms or PHP/Health Passports completed Information leaflets on Eye health and Spectacles - SeeAbility

Secondary Care Royal College of Ophthalmologists Guidelines GMC Guidelines Good Practice eg Sheffield Advocacy and support

Remember Assess Visual Function Record Functional Ability Organise Eye Examinations Create Pathways Record Results Modify Care Plans Empower Individuals

Information & Help SeeAbility www.lookupinfo.org www.seeAbility.org Paula Spinks-Chamberlain LOCSU www.locsu.co.uk Katrina Venerus