1. Visual Health in Learning Disability NHFN Birmingham
Gordon Ilett
Optometrist

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

3. 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

4. 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

5. 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?

6. 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!

7. The Eye and Vision

8. 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

9. The Human Eye Vision – Optic Nerve CN2
Motor – Oculormotor CN3, Trochlear ON 4, Abducens ON 6
Sensation Trigeminal
ON 5

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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

17. 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

19. 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

20. Functional Vision Assessment
Designed for use by Carers
SeeAbility Functional Vision Assessment Tool
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

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

22. LOCSU Pathway

23. Can Eye Examinations be done?
Yes

24. 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

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

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

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