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Child's Nerv Syst (1985) 1:115-122 mGN$

© Springer-Verlag 1985

Ocular motility, visual acuity and dysfunction of neuropsychological
impairment in children with shunted uncomplicated hydrocephalus*
Harriet K. Zeiner 1 . . , George P. Prigatano 2, Michael Pollay 2, Charles B. Biscoe 2 and Richard V. Smith 2
1 Section of Neuropsychology, Department of Neurosurgery, Presbyterian Hospital, N.E. 13th at Lincoln Boulevard, Oklahoma City,
OK 73104, USA
2 Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma, USA

Abstract. Children with shunted, uncomplicated, com- (performance IQ) scores in hydrocephalic children com-
municating hydrocephalus were tested to determine (1) pared to normal controls [1, 6, 14, 21]. Performance IQ is
the persistence of neuropsychological impairment and (2) heavily weighted with visuospatial and psychomotor tasks.
the relationship between neuropsychological functioning, Dennis et al. [5] have attempted to explain the pres-
ocular motility, and acuity abnormalities. Eighteen hydro- ence of visuospatial and visuomotor deficits in these
cephalic and 18 individually age- and sex-matched con- children on the basis of ocular abnormalities of acuity and
trols were given a neuropsychological battery, repeated motility. The incidence of abnormalities of ocular motility
after an interval of 1 year. Hydrocephalic children were and acuity is known to be high in hydrocephalus [20].
also tested at the beginning of the second year for Dennis etal. [5] have correlated a history of ocular
strabismus, amblyopia and visual acuity. Their medical motility and acuity abnormalities in medical histories with
records were reviewed for history of ocular motility and/or IQ in hydrocephalic children. They found that ocular
acuity abnormalities. Hydrocephalic children with normal abnormalities in medical histories were associated with a
range IQ were found to have lower verbal IQ, memory, lower absolute level of nonverbal intelligence, i.e., perfor-
and fine motor skills compared to controls. A history of mance IQ. However, verbal IQ was not related to oculo-
ocular motility and acuity abnormalities was associated motor disturbances in a heterogeneous group of hydro-
with impaired visuospatial and verbal problem-solving cephalic children. These authors suggested that ocular
skills. acuity and motility disturbances possibly result in im-
paired development of the visual cortex and, consequently,
Key words: Hydrocephalus - Neuropsychological func- influence nonverbal intelligence in hydrocephalus because
tioning - Visual acuity - Ocular motility - Cognitive im- of impaired visuospatial and visuomotor performance.
pairment. While it is an interesting hypothesis that ocular acuity and
motility abnormalities may underlie visuospatial and
visuomotor impairments in hydrocephalic children, the
evidence is limited to a correlation between performance
Reports in the literature of psychometric and neuro- IQ and a medical history of ocular acuity abnormalities.
psychological assessment of hydrocephalic children have No data have been reported concerning broader neuro-
primarily been cross-sectional in nature [6, 12-15, 21]. Yet psychological status, nor have concomitant, or a history
it is clear from the literature on learning-disabled children of ocular motility and acuity abnormalities been reported
that patterns of neuropsychological difficulties may inter- in these children.
act with age and change over time as the child proceeds We conducted a longitudinal neuropsychological study
through various neurodevelopmental stages [4]. These of a homogeneous group of children with shunted, un-
cross-sectional psychometric and neuropsychological complicated, communicating hydrocephalus. A previous
studies emphasize that hydrocephalic children show a report of first-year findings disclosed visuospatial, visuo-
predominance of failures on visuospatial and visuomotor motor, verbal intelligence, and memory deficits in hydro-
tests [12, 13, 15]. Several studies have reported, for exam- cephalic children with (estimated) normal range IQ [10].
ple, significantly lower performance Intelligence Quotient The hypothesis that ocular acuity and motility abnor-
malities underlay poor visuospatial and visuomotor per-
formance was reported between the first and second year
* This research was supported by the National March of Dimes
Birth Defects Foundation, Social and Behavioral Sciences Re- of our neuropsychological data collection [5]. This report
search Grant No. 12-57, and a grant from the Oklahoma Crip- resulted in the addition of concurrent ocular motility and
pled Children's Society acuity testing to the neuropsychological examination
** To whom offprint requests should be addressed during the second year of our research. Since detailed

upward right. Cover-uncover testfor heterophorias. covered eye movement ceased. and academic reading perfor- of the second year of testing and therefore these tests took place mance. were tested with and without glasses [16].. Sixteen were right-handed. 7 female. consistency of recall over five trials to be assessed independently. the The Vocabulary subtest of the WISC-R (age 6. test detects deviations that are kept under control by fusion Ventricular size was essentially normal. occurs if a heterophoria is present. The child was asked to fixate the children to assess cognitive impairment associated with hydro. The first section of the test gives a baseline measure of visual scanning and motor speed. The apex of the prism was held towards the direction of deviation (esotropia or esophoria is an inward Control subjects were 18 elementary school children. This was a group of 18 children with shunted. The amount of strabismus was Eleven were male. 2 were then noted. to each subject. 7 female. If the eyes are straight (ortho- description of the subjects follows. Direction of gaze. . a scale score of 7 deviated and performed a fusional movement upon removal of or above).3 years (a range of 5 to 11 years). and Design or Vocabulary subtest scale scores of the WISC-R or the examiner noted whether or not the eye under the cover WPPSI in the normal or near normal range (i. The Block children could be checked since the same clinical group o f Design subtest of the WISC-R or WPPSI was given to estimate children was serially tested. correlated with n e u r o p s y c h o l o g i c a l status. but the occluder was quickly removed.e. The tests were jects. sex-matched with the hydrocephalic children. Ocular assessment Concomitant strabismus testing: For the second series. for each eye. right. up testing a n d (2) to investigate the relationship b e t w e e n Two Benton Visual Retention tests were administered. by the same experimenter. Three tests of memory were given. The prism-cover test ambidextrous. The monocular cover-uncover communicating hydrocephalus. per- cover-uncover test. downward right All subjects received a 2-h battery of both verbal and visuospatial 1/m without moving their heads. age. the fol- lowing tests were used to assess presence or absence of concomi- Su~ec~ tant strabismus. The following tests were chosen. The alternate cover test was then repeated with a near Hydrocephalic group target (33 cm). only on the second occasion. standard deviation 1. acuity test in the hydrocephalic group. in prism diopters. Prism-cover test. as long as both eyes are open.2 years.and deviation. Materials and methods The Child's Trails Making Test. movement and/or accommodation abnormalities were also reviewed for analysis. and 2 were ambidextrous. standard deviation was 1. Finally. Each eye was then alternately cephalus per se have been described elsewhere [10]. and the range was 4 to is disrupted by covering one eye.5 and above) or stability o f r e p o r t e d n e u r o p s y c h o l o g i c a l deficits in these WPPSI was given to estimate verbal intelligence [17]. the prism test for strabismus. Eleven were male. each eye 5 left-handed.and sex-matched formation processing. nonverbal reasoning skills [17. This was considered to be The p u r p o s e o f the work p r e s e n t e d in this report was representative of performance IQ. All had either a WISC-R or WPPSI Block Design was repeated with a near (33 era) and far (6 m) target. downward center. A brief covered with a visual occluder. eyes on a distant target (6 m). Both an extensive description of the subject population and the rationale for using homogeneous subgroups of hydrocephalic The cover test for heterotropias. Medical histories of gaze. a deviation of the covered eye 11 years. uncomplicated. These were administered in the same then noted in each of these nine positions. at both near and far fixation.116 m e d i c a l records were available o n all h y d r o c e p h a l i c sub. when fusion 6. The cover-uncover test was performed on both eyes. upward center. phoria). The Lafayette Grooved Pegboard Test was used as a measure for both fine motor coordination and speed [9]. the uncovered eye will not move. downward left. Comparison of Eighteen hydrocephalic children with shunted. nonverbal reasoning skills. order. The mean age was mechanisms. Children or Vocabulary subtest scale score in the normal range.3 years. The amount of strabismus present was measured Controls with graduated prisms. with and without corrected vision. The mul- ocular motility a n d acuity d i s t u r b a n c e s a n d n e u r o p s y . Hydrocephalic children were asked to follow a Neuropsychological assessment target and to look left. Parts A and B (intermediate form). memory. the sampled verbal reasoning skills. The Fuld Object-Memory therefore twofold: (1) to test the stability of previously Test [7] is a verbal recall task and allows initial recall and reported n e u r o p s y c h o l o g i c a l findings b y a 1-year follow. uncomplicated. All rows were used. was given to assess more complex forms of visual-spatial Overview problem solving [11]. If strabismus is present (heterotropia). This was at the beginning speed of information processing. historical d a t a o n ocular f u n c t i o n i n g could also be administered twice. exotropia or exophoria is an outward deviation). Forms A and B [19]. free motor speed and coordination. the cover. a condition in which there is a deviation of the eyes. The tests selected functions were also measured via the alternate cover test. and a visual ceptual motor skills. However. upward left. the diagnosis being made by CT. Ocular motility and acuity Reading Mastery Test. chological i m p a i r m e n t . the uncovered eye will move and will assume fixation. As in the cover test.5 years. normal children were given a series of neuropsychological tests Academic reading skill was assessed with the Woodcock twice. 18]. The mean age was Successively increasing diopter prisms were applied until the un- 6. Eleven were right-handed. with 1 year between the tests. The presence of strabismus was neuropsychologieal tests. Parts A and B were used to measure the individual's speed of in- communicating hydrocephalus and 18 age. tiple choice form of the test assesses recognition memory for visual-spatial material [2]. All had either Block was covered in turn. center. separated by a period of 1 year.

On a task requiring scanning and motor speed one eye is functionally impaired or suppressed. no fixation alone (Trails. the image from one eye is suppressed by the brain to reduce diplopia). within normal limits.. P=0. observed.97. Institutional Review Board of the University of Oklahoma Health revealed no significant difference between hydrocephalic Sciences Center.43. in a "within-group" comparison of plained. were subjects. and Intellectual assessment. there was evidence of impaired defects of gaze. If visual acuity in complex.03). accommodation. df= 33. Table 1 summarizes the neuro- gaze were noted. When a complex cognitive element was added mus. Memory function. and visuospatial non. and corrective lenses or surgery for strabismus. but showed no discrepancy between first-year findings will be presented to compare to second.0005) by surgical treatment.03). df= 28. Accuracy Memory functions. Thus.26.0.02). Excluded from the analyses were references to psychological test performance of hydrocephalic children the "setting-sun sign. to the same task (Trails. year results and to relate to ocular motility and acuity functioning. They Fine motorpeJformance. Hydrocephalic children continued did not differ from controls on the Block Design subtest to demonstrate significantly slower left-hand time on the but did show a trend for poorer performance.97.46) [22].03) central in origin. a brief review of the (t=2. Hydro- ment of conjugate upward gaze. and is not associated with long-standing than did controls. df= 14. P = 0 . visual acuity discrepancies between eyes. 1 9 ) [22].51.37. nor was dominant hand minus nondominant tween hands (dominant hand minus nondominant hand) hand time significantly different between groups (t = 1. The significantly different from that between dominant and absolute difference in time between hands was not sig- nondominant hand times in the controls ( t = 1. or acuity. read for a history of ambylopia. df= 15. P = 0. groups. paired. ." This appearance of the eyes. there were no significant dif- verbal recall were impaired relative to normal controls. no difference between groups was deviations will occur during the cover-uncover testing for strabis. Laterality of abnormalities in acuity. is believed to be due to in- creasing pressure on the midbrain or tectum. and matched controls for the second assessment. disappears when intracranial pressure is relieved and the Block Design subtest (t = 3. Lafayette Grooved Pegboard than did controls.paired t-tests in a "within-group" comparison not Medical records (available on all the hydrocephalic children) were reported in the previous study [10]. 117 Acuity testing was not significantly different for hydrocephalic children compared to controls (t = 0. P = 0. P=0. hydrocephalic children were slower and less accurate than controls. P = 0. ferences in the n u m b e r of left-hand pegs dropped between Nonverbal visuospatial recognition m e m o r y was not im. verbal and performance skills in hydrocephalic children in tained from all parents or legal guardians of the children who the 5 to 11 years of age range. Informed consent. The difference in pegs dropped (errors) be. Paired t-tests.14). Hydrocephalic children showed a tendency to be Hydrocephalic children suffered impaired speed of fine slower with the right hand than did controls.27. but this was motor performance in both right and left hands compared not significant ( t = 1. with the left hand improved. Hydrocephalic performance on the Fuld (verbal memory) and the Benton Our previous paper documents the initial findings of Visual Retention Test (multiple choice form) improved to neuropsychological test performances in these children. Three of the children had been referred to Second-year neuropsychological results ophthalmologists. children for the first assessments (t = 1.e. The nature of the procedure had been fully ex. prior to surgical cephalic children demonstrated significantly lower scale shunting for hydrocephalus in infants. This phenomenon is scores on the Vocabulary subtest (t = 2. P=0. tests on the second occasion (t = 0. was ob. a measure of nonverbal memory) First-year neuropsychological results (summary) than did controls (t = 2. verbal recall. prior to participation in the study. esotropia or exotropia.25. The basic findings were that hydrocephalic children had lower Vocabulary scale scores compared to controls.60. P = 0. This difference in time between dominant and between right-hand time and left-hand time was not sig- nondominant hands in the hydrocephalic group was not nificant between groups (t=0.525. Part A). Part B). Matched controls demonstrated significantly higher Since the first-year neuropsychological results have been Vocabulary than Block Design scale scores at the first tests described in detail elsewhere [10].33). The difference to controls. P=0. Hydrocephafic children made sig- nificantly more errors on the Benton Visual Retention Test (graphomotor form. A Speed of information processing in hydrocephalic chil- visual acuity discrepancy of two or more lines between the eyes is dren was impaired only when cognitive elements became the diagnostic test for ambylopia (i.07). but sig- nificantly higher Vocabulary than Block Design scale Results scores for the second assessment (t=2. with impair. nificantly different between groups (t=1. P=0. df=23. procedures and consent forms were approved by the Vocabulary subtests and Block Design subtest scale scores. accommodation. df= 21. df= 28. who provided medical records for these chil- dren.56). Past history of ocular abnormality Academic reading performance was in the normal range . P = 0.61).51.747. dr= 18. P = 0. Visual acuity was checked with a standard Snellen Eye Chart.

0 23. d f = 2 7 .2 5.006 Pegs dropped 15 0.0 16. 0 0 6 ) . The hydrocephalic childrens' m e a n was the 50th rotation errors and left side of design errors did not percentile.2 . total num- percentile on the Woodcock Reading Test.4 0.2 0.7 13.4 0.00 Sum of words recalled over 5 trials 15 38. distortion errors. d f = 2 8 . over 5 trials and consistency o f recall on trial 1 and over 5 o f information processing.3 15 89.5 0. considerably below average.7 0.03 Block Design subtest scale score 15 7.8 15 79.3 11.7 .6 -7.7 2. The n u m b e r o f errors m a d e between Hydrocephalic scores on all o f the reading subtests hands (right h a n d minus left hand) was also not sig.6 1. proved on the following tests in the second year: F u l d P = 0 . The hydrocephalic m e a n for the analogies was P = 0 . fine m o t o r co.3 0.8 13.1.7 --4.4 15 0. 0 2 ) .3 1.0.9 0.62 Total time (both hands) 15 264.2 15 11. Hydrocephalic children One-year.8 3. df= 24. F o r m B ber of errors. F o r the Benton due to the above-average reading percentile o f the control Visual Retention Test.7 . trials).1 21.1 3.1 2.12 Benton Visual Retention Test Multiple choice form: number correct 15 7.3 0. children.6 0.8 15 0.1 -0. 3 1 .1.2 59.1 8. multiple choice form ( n u m b e r correct increased. two-year comparisons were significantly slower than controls on Part A o f the Trails Test (t=2.7 50.03 Lafayette Grooved Pegboard Right hand Time (in seconds) 15 133.7 0.0 145. df= 16.1.3 0.04.4 0. p e r i p h e r a l errors and m a j o r Academic reading performance.3 2.and Probability second-year second-year of between N X SD differences N X SD differences groups t-test WISC-R or WPPSI Vocabulary subtest scale score 15 9.9 15 59.19 Part B: Time (in seconds) 13 100.0.006 d f = 2 7 . Benton Visual Retention Test.6 36.9 3.6 15 10. They were also sig.1 15 40. P = 0 .18 Woodcock Reading Mastery Test. significantly improve in the second year.8 12.118 Table 1.2 1. Hydrocephalie children distortion errors decreased). They did not m a k e more errors than controls. This appears to represent an i m p r o v e m e n t in the accuracy M e m o r y Test (sum o f words recalled on trial 1.4 1.4 -1.0 53. ommission errors.9 15 9.6 15 7.7 .66 number errors 15 13. Speed of information processing. Trial 1 15 7.6 0. with the exception of reading nificantly different between groups ( t = l .5 0.52. P = 0 . trial 5. 2 0 ) . Form B Total reading percentile 12 50.6 0. However.1 12.9 15 8.7 16. but not speed.1 3.7 1.5 0.1 15 4. representing average reading skill.1 0. .1 29.6 20.49 Graphomotor form (D): number correct 15 5. g r a p h o m o t o r form.3 1. Benton Visual Retention Test.1.04 Errors 13 2.7 14 80.0 2.1 0.1 0. significantly differed from controls in total reading g r a p h o m o t o r form ( n u m b e r correct increased.8 70.2 3.2 20. this difference was right side o f design errors decreased). analogies.2 15 0. ordination continued to be i m p a i r e d during the second year.5 4.1 -8.0 .6 15 0.6 -0. 0 4 ) . Neuropsychological assessment of second-year data Test Hydrocephalic children First.15 Left hand Time (in seconds) 15 131.07 Pegs dropped 15 1. for hydro- cephalic children. P = 0 .8 .9 6. F o r hydrocephalic children.and Controls First.7 -1.2 -0. perseveration errors and ( t = 3.9 0.9 1.4 37. 2 5 ) . A two-way analysis o f variance with r e p e a t e d measures (group x years x test scores) revealed that both groups im- nificantly slower than controls on Part B ( t = 2.02 Errors 15 0.9 15 169.0005 Fuld Object-Memory Evaluation Sum of words recalled.8 0.1 0.1 105.7 0.0 -14.8 27.8 percentile.7 15 26.3 1.0.5 0.4 . were at the 50th percentile.1 22.4 0.1 2.27.02 Child's Trails Making Test (Intermediate form) Part A: Time (in seconds) 15 41. 32.

Hydrocephalic neuropsychological impairment Impairment Since the groups differed on Vocabulary subtest scale scores the first year and both Vocabulary and Block Year 1 Year 2 Design scale scores the second year. was not paired in both years of the study. the first year and only in the left hand the second year (of Benton Visual Retention Test.05). 119 Neuropsychological status and intelligence Table 2. the hydro- Table 2 demonstrates that hydrocephalic children per. Verbal performance was equally im. Normal IQ does not equal normal neuropsychological status. .05) Right hand Yes No between groups in either the first or second year. or (3) processing in hydrocephalic children was impaired only mixed i. per se.13. and no other brain anomaly. P=0. Hydrocephalic Verbal and performance IQ scores the second year.e. to verbal IQ obtained for populations of hydrocephalic formation processing on a visuospatial task were slower in children with multiple brain problems. Benton Visual Retention: graphomotor Yes No Benton Visual Retention: multiple choice No No With Vocabulary as the covariate. that is. Their impairments were not limited to visuospatially in accuracy from controls. Hydrocephalic children were significantly Stability of deficits: Hydrocephalic children with normal slower in left-hand time on the Lafayette Grooved Peg. The evidence of a material-specific dysfunction. visuospatially) oriented (Block Design subtest.02) and on the Trails Test. the presence of normal range (estimated) IQ.. the following significant Mixed tests differences between groups were obtained: Trails.75. Vocabulary scale scores Fuld Yes No were then used separately as the covariate (groupsx test Visuospatially oriented tests scores). P=0. graphomotor Trails. Nonverbal To determine if hydrocephalic children demonstrated any (visuospatial) recognition memory was not impaired. Lafayette Grooved Pegboard chological test revealed significant differences (P--0. had board (F=5. second year nonverbal memory deficits did recur. com- children tended to make more errors on Part B of the pared to age and sex-matched controls. With Left hand Yes Yes Block Design as the covariate. The Benton Visual Retention Test. was in the normal range. a multivariant analysis ofcovariance was applied to partial-out the effects Verbally oriented tests of IQ. Fuld Object Memory Test. the neuro.. P=0. P=0. Memory functions.07).61. Nonverbal recall memory and speed of fine-motor coordination in a visual-spatial task were poorer for hydrocephalics than could be accounted for by their lower intellectual abilities or compared to controls. Academic reading performance oriented material.87.03) compared to controls. both verbal and nonverbal (visuospatial) recall. cephalic children were slower in motor function than con- formed equally poorly in all three categories of tests both trols in speed of information processing. (2) heavily performance impaired speed of fine motor performance in both hands (i.e. Conclusions drawn from neuropsychological data Second .67. associated with a reading disability in either year. Hydrocephalic children had Test. Part A Speed No Yes Accuracy No No Firstyear. In the second year. but did not differ years. Part B) elements (Trails Making Test. hydrocephalic children than could be accounted for by Several subtle neuropsychological deficits occurred in their lower intellectual abilities compared to controls. Part B form number of errors (F=3. PartB lower (estimated) Verbal IQ scores the first year and lower (F=5. This is in contrast to Trails Test. speed of information choice forms. the Lafayette Speed Yes Yes Grooved Pegboard combined times (both hands) (F---7. This psychological tests were categorized as (1) heavily verbally could be accounted for by the lower IQ of the hydrocephalic oriented (Vocabulary subtest.01) and left-hand time (F=4. range (estimated) IQ. Hydrocephalus. but this failed to reach statistical significance reports in the literature of lowered performance IQ relative (F=3. Fine motor speed and speed of in. P=0. compared to controls.year. and then Block Design scale scores were used as Block Design No Yes the covariate (groups × test scores).03) were sig- nificantly greater in hydrocephalic children. Neuropsychological analysis by content were impaired in these hydrocephalic children when com- pared with normal controls for the first year. no neuropsy. Woodcock Reading Mastery children compared to controls.47. the Lafayette Grooved Pegboard). graphomotor and multiple testing). Accuracy Yes No P=0. At the first assessment. Parts A and B). combining both verbal and performance when cognitive elements became complex (Trails. to determine if differences in (estimated) IQ Vocabulary Yes Yes could account for the differences in neuropsychological Woodcock No No test performance between groups.

Thus. P=0. On the Benton Current acuity testing. This is not surprising.5. for these groups on the first year's neuropsychological test which they underwent alternate occlusion therapy. N = 8) than did children with a normal visual history (mean= Direction of gaze. All ocular-motility abnormalities were right eye related to the earliest neuropsychological test scores (first esophorias. children with a history (upward) when the eyes were tested jointly (versions). When tested for visual N = 12. SD=4. graphomotor form. The third demonstrated an dent t-tests on mean test scores for the second year neuro- intermittent esophoria which could not be consistently psychological tests were then run between strabismus- measured.2. On the Fuld test.3. 2 of the children also had a history of ambylopia.01). fight-hand .001). children with a discrepancy of two or more lines on the Snellen Chart history of strabismus and/or ambylopia made more right- between right and left eyes.0. No significant differences were corrective glasses. N = 8. (2) impairments which improve the second year.71. Type of strabismus (N= 15) in hydrocephalic children is examined over a 2-year period. SD = 3. recalled fewer correct words (mean= 27. None of the 15 children showed a Visual Retention Test. neither ambylopia nor side-of-design errors (mean = 9. N = 8) than did functional blindness in one eye could be diagnosed. t=4. Three underwent corrective surgery. Two of scores.05).09. P=0. Six of children with a normal visual history (mean = 6. abnormalities. Only 3 of the 18 hydrocephalic psychological test scores (second year). Eight of the 15 children had a history of only 3 of the 18 children had strabismus at the time of strabismus: 53% of the sample.7. Indepen- one child. history of strabismus and/or ambylopia (mean=l.7. two sets of analyses were conducted: (1) current evidence of strabismus was related to concomitant neuro- Current strabismus testing. Table 3 and those with no history of ocular motility or acuity summarizes the strabismus findings. three patterns appear: (1) impairments which Number remain unchanged. The hydrocephalic group was divided into two when not tested. Hence. SD= 1. Left eye 1 Impaired functions which remained stable for the year Both eyes 1 included Verbal (estimated) IQ. SD = 1. Of these 8. Three tests were found to be significantly different the children with strabismus also had gaze impairment between groups.3. dr= 12.26. Independent t-tests were then run between mus. a demonstrated current impaired movement of conjugate history of strabismus and/or ambylopia was associated gaze (versions or ductions) in any direction. than did children with no (ductions). motility and acuity abnormalities appears to be associated with poor neuropsychological performance and is not restricted solely to visuospatial and/or visuomotor tasks. None had a record of third or children with a history of strabismus and/or ambylopia fourth nerve dysfunction or sixth nerve palsy. obtained between evidence of current strabismus and neuropsychological test scores. and (2) past evi- children (16%) had strabismus during the second year of dence of ocular motility and acuity abnormalities were the study. SD=2.6. the children's eyes appeared straight year). t=2. chil- acuity (with corrected vision). 1 had exotropia neuropsychological testing. all children demonstrated dren with a history of strabismus and/or ambylopia normal visual acuity. P=0. and decreased speed of com- Right eye 0 plex information processing. df= 18.6. SD =4. N = 12. since Past history. The 3 cases of with both increased errors of accuracy in visuospatial tasks current strabismus occurred in the central plane of fixation and poorer verbal recall memory.3. In addition to strabis. that is. nonverbal recall memory. None of the hydrocephalic children 35. Exotropia left-hand fine motor speed. and (3) nonimpaired first-year functions Estropia Right eye 5 which become impaired the second year. Evidence of ocular only.120 Ocular results acuity. Four The hydrocephalic group was then divided into those received corrective glasses. Neuropsychological functioning and ocular assessment To determine the interaction between neuropsychological Discussion functioning and abnormalities of ocular motility and When the stability of the neuropsychological impairments Table 3. N--6). but of strabismus or ambylopia made significantly more errors no restriction of gaze when the eyes were tested separately (mean=6. and 7 esotropia. 6 ° in the second).9. Fifteen hydrocephalic children showed no present and strabismus-absent groups. the children had corrected vision. Left eye 1 Impairments which improved during the year to within Both eyes 0 normal limits include verbal recall memory. On Trails Part B. Bartletts' correction strabismus with either near or far fixation. dr= 18. t=2.4. but the alternate cover-uncover test groups on the basis of the presence or absence of strabis- revealed a latent inward deviation of the fight eye (12 ° in mus at the time of neuropsychological testing. with or without was used when applicable.

is further who present with strabismus show a poorer clinical course reflected in the continued poor performance of the left neurosurgically than do hydrocephalic children without hand in fine motor speed for the second year. Improvement oc. The discrepancy between higher Vocabulary ferences may help shed light on the nature of cognitive scores compared to Block Design. concerning the relationship showed an absolute magnitude of changes of 53-s im. tion.7 s. Although hydrocephalic children showed improvement in This mild relationship between a history of ocular their speed of simple information processing. when Block Design was paralled out. one was verbal memory (Fuld). e. In the second year tests. (3) up- deficits in hydrocephalic children showed impairment of a ward gaze paresis (Parinaud's sign) with ventriculomegaly number of generalized neuropsychological functions: and pressure on the midbrain tectum (eliminated in the vocabulary. children and controls. alternative forms of nonverbal memory tests were used The CNS level of dysfunction underlying poor visuo- (and nonverbal recall memory remained impaired both motor and visuospatial performance in hydrocephalics is years). for nonverbal recognition (Benton Visual test which is visuomotor or visuospatial in nature (and Retention. while Block poorer performance on Block Design compared to con. which became more impaired the year. The small ventricles). function subsuming the documented abnormalities of curred in verbal recall memory-. 8]. second-year testing revealed the stability of the vocabulary. Multiple Choice) and verbal recall (Fuld). the trend became statistically solving skill levels. Further investigation into these dif- significant. in agreement with the clinical impressions of the neuro- This pattern of improvement in hydrocephalic chil. the hydro. This im. Hydrocephalic children actually reduced motility and/or acuity abnormalities appears to be related their time as a group from a mean of 50. acuity functioning. (concomitant strabismus). (2) cranial nerve dysfunction The previous report on first-year neuropsychological (oculomotor. and (5) speed of information processing. discrepancy in hydrocephalics [4. The decrease in motor neuropsychological tests.8). 9]. 8. resulted in disrupted development of visual cortex and im- trols still was not enough to reach normal levels of func.3 s (SD 24.4 s) by 33 s. Hydro. and memory (verbal and nonverbal). did not occur the A history of strabismus and/or ambylopia was asso- first year. the same tests were administered. graphomotor form) and compared to controls (on Trails Test. 121 fine motor speed and accuracy. That is. strabismus. paired nonverbal intelligence in hydrocephalic children. present population which had functioning shunts and ordination. both first and also not known.7 s (see verbal and visuospatial material. an improvement of 12. Poor perfor- . However. A history of ocular- esting anomaly. statistically paralled out of the data analysis for the second First-year functions. so that showing greater improvement than con. However. they fail to keep up with the concurrently in. between neuropsychological and ocular motility and provement from the first year to the second. a frequently reported disturbances in this group ofhydrocephalic children. trochlear or abducens nerve palsy). hand-eye coordination.8 s (SD 27. and accuracy of complex information processing. beyond the support provided by the data. The which purports to measure lateralized cortical dysfunction) Fuld test has since been shown to be sensitive to practice is due primarily to cortical dysfunction is a leap-of-logic effects. hydrocephalic children showed a trend for reflection of long-term learning capacity.1 s (SD 12. In the first.g.6 s (SD20. This was primarily due to ciated with impaired performance on three (out of eight) the decreasing Block Design score. no significant neuropsychological deficits were ob- second year compared to controls. but did the second. not restricted to visuospatial and visuomotor tests. surgical authors. Vocabulary scores may be more a year tests. A general pattern can be abstracted from the results: Abnormalities of ocular motility and acuity in hydro- although hydrocephalic children improve in their actual cephalic children may be due to impairment of any of the scores. speed of information processing.. a history of Table 1). cephalic left-hand performance on the Lafayette Pegboard A caveat must be made. Design (and performance IQ) may reflect current problem- trols. their improvement did not keep up ocular motility and acuity abnormalities appears related to with controls whose first year mean of 38. not enough to catch up with controls. measure of performance IQ) and speed of both motor significant deficits still remained between hydrocephalic scanning and simple information processing. Dennis et al. hand-eye co. While not known. pontine lateral gaze center and vestibular system). Part A) is an inter. [5] have suggested that a provement was greater than the absolute magnitude of relationship between a history of ocular abnormalities and change of controls (20. an improvement of 8.1). However. they still did abnormality and poorer neuropsychological functioning is not catch up with normal controls. The CNS level of dys- and nonverbal memory impairment. This improvement of ocular motility and acuity function in hydrocephalics is verbal memory may be more apparent than real. frontal or occipital eye fields [3. left-hand fine motor It is interesting to note that when vocabulary was accuracy.9) to a to impaired neuropsychological functioning for both mean of 41. To assume that poor performance on a second years. Two were visuospatial (Trails speed of simple information processing in hydrocephalics and Benton Visual Retention Test. following mechanisms: (1) ocular muscle dysfunction creasing performance of controls. They note that hydrocephalic children dren.0) a broad range of neuropsychological functioning and is decreased to 26. that the effects of visual disturbances controls. (4) lesions of the brainstem (MLF. intellectual functioning revealed information about cortical cephalic children were at a level notably lower than dysfunction. include Block Design (a tained.

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