What IS Optic Nerve Hypoplasia? - Everything I Know Part 2 -

Okay, we're back.  I hope from my last post you were able to come away with a general overview of what optic nerve hypoplasia is.  If you didn't catch that post, or if you've stumbled upon my blog because your child was just diagnosed with optic nerve hypoplasia, I'd recommend beginning here for information, or here for the beginning of our own story with ONH : )

In January I attended a conference put on by the Texas School for the Blind and Visually Impaired (TBSVI) specifically for parents of children with ONH.  At this particular meeting, we were able to hear information from an ophthalmologist who had become something of a specialist regarding ONH.  I loved what she said at the very beginning - ONH is a brain problem.  It's not an eye problem.  That's why vision isn't (always) the only thing affected by ONH.

The optic nerves exist in a part of the brain called the 'midline'.  Because kids with ONH obviously have malformations in this part of the brain, one of the first things that happens (or SHOULD, MUST, MAKE IT HAPPEN) after an ONH diagnosis is a referral to an endocrinologist and an order for an MRI of the brain.

Below are two pictures of different views of the brain and its regions/parts/whatever you call brain stuff.

The first is a side view - the midbrain that is usually checked for additional abnormalities after the diagnosis of ONH includes the corpus callosum, the hypothalamus, and the pituitary gland.  (Image courtesy of a Google search, which yielded this picture in a foreign language.  Good luck with the link.)

This picture (below) shows a view of the brain from above.  You can see how the optic nerves cross just in front of the pituitary gland in the middle of the brain.  (Image courtesy of some lecture notes from a community college.  Knock yourself out.)

Okay, so what does this all mean?  Why are these parts of the brain important?

First and foremost, let's discuss the pituitary gland, aka the reason you'll be referred to an endocrinologist (doctor specializing in glands/hormones).  The pituitary gland is responsible for secreting the hormones that keep the body functioning normally.  Because hormone abnormalities can have drastic consequences (loss of consciousness, mental retardation, even death), it is imperative that a child with an ONH diagnosis be monitored for pituitary function.  And because the hormone levels can fluctuate at any time or stage in life, people with ONH should continue to be monitored with regularity even if everything is functioning normally.  Sources vary, but it is reported that 75-80% of people with ONH have some degree of pituitary dysfunction.

The hormones secreted from the pituitary gland are responsible for the following things:

• growth, temperature regulation, sex organs, thyroid gland function, metabolism, water balance/regulation in the body (related to kidney function as well), blood pressure, and pain relief 

Your endocrinologist will regularly monitor your child's hormone levels by ordering blood tests and, at each appointment, check to make sure she is growing normally.  This specialist will also review the results of your MRI.

Hayes' hormone tests have come back in the normal range after each screen.  He has always 'thrived', which is to say, grown and eaten normally.  He is tested every six months and will be until he is 2 (or 3, can't remember).  At that point, if he is still maintaining 'regularity' as far as his hormone levels, he will only be checked once a year.  Of course, if there are any changes in behavior or activity, we will contact his endocrinologist to run tests to make sure something hasn't gone awry, because hormone problems can manifest themselves at any time.  (For more information about the pituitary gland, talk to your endocrinologist and click here.)  And, for the record, I love our endocrinologist.  He is hilarious and looks like Dennis Hoffman, and he thinks I look like Brittany Murphy.  I was not as thrilled and am still confused about that.)

This is Hayes and me at his endocrinology appointment on my birthday in 2013.  As you can see, he's chunky thriving, and I look nothing like Ms. Murphy.  No offense to her, and may she rest in peace.)

Let's talk about the MRI.  An MRI is an image done by magnetic resonance imaging.  I have basically no idea how this works.  Okay, I have some idea, but I feel more comfortable explaining why a person with ONH is ordered an MRI than how exactly the MRI is done.  (For much, much more re: the MRI, please talk to your endocrinologist/neurologist/ophthalmologist and click here.)  The MRI for ONH will be focused on the brain, and will be specifically taken for review of the midline.  

We had a few issues as we went to have the MRI done in the spring of 2013.  Hayes was getting over RSV and had recurring colds, which led to us postponing the scan once before we finally got to do it.  I was a nervous wreck.  Because Hayes was only six months old when he had his MRI done, he had to be put under anesthesia in order to ensure his absolute stillness.  He also had to fast (which, at that time, meant no bottles) for a period of time before the MRI was done.  The whole thing took a whole morning - arriving at the hospital at its earliest opening (some tortuous time like 6 or 7 am, and my mom and I drove in from Jacksboro for the appointment), and after he went in around 8 or 9 I didn't see him until after lunch.  I tweeted a lot about it.  Here's a link to a tweet/picture of Hayes in his hospital gown, 10 hours since last bottle and pre-anesthesia.  You can find me on Twitter by my handle @christieandrews .)

What else is the MRI looking at?  We already talked about the pituitary gland.  So next, the corpus callosum.  The corpus callosum is a group of fibers that connect the left and right sides of the brain.  These fibers allow the sides to 'talk' to each other.  Here's something completely mind-baffling about the corpus callosum: it can be completely missing and you might never know.  Some people with absent corpus callosums go on to college: some with partial loss of the same section of the brain have significant cognitive and motor impairments.  When the corpus callosum is thin, malformed, partially or completely missing, it is called agenesis of the corpus callosum.  (For more information about the corpus callosum, talk to your neurologist and visit this site.  A wonderful organization exists called the National Organization for Disorders of the Corpus Callosum, but unfortunately its website is temporarily down.)

Attached to the corpus callosum is the septum pellucidum, which is a thin membrane that runs to another part of the brain.  A condition often associated with ONH, called SOD (Septo-optic Dysplasia) involves diminished optic nerves, pituitary gland dysfunction (hormone problems), and a missing septum pellucidum.  For more information about SOD, talk to your ophthalmologist, endocrinologist, and/or neurologist and click here. 

I took the call regarding Hayes' MRI results on April 24, 2013.  As I'm writing this, that's only 11 days less than a year ago.  Hayes HAS a corpus callosum, but because he was six months old at the time of his MRI, his brain was six-months-old-tiny, as was his corpus callosum.  It's hard to tell, at that size, if a corpus callosum is malformed.  Hayes has not been diagnosed with SOD, as he doesn't seem to be 'missing' any brain parts and he has yet to have any endocrine issues.  Since his MRI, I've been wondering if his corpus callosum could be linked to some of the motor problems/delays he has, which you'll learn about later.  If your child has been diagnosed with SOD (or ONH), I would highly, highly recommend joining the Facebook group called 'Parents of Children with Optic Nerve Hypoplasia (ONH) / and Septo-Optic Dysplasia (SOD)'.)

Alright.  So.  We know that an ophthalmologist will refer a patient with ONH to an endocrinologist, and hopefully order an MRI (and it's not just to spend money; we understand why.).  Who do we discuss the MRI results with (aside from the endocrinologist... and the ophthalmologist.... and your family doctor/general practitioner/pediatrician...)?  We go to the neurologist.  A neurologist is doctor specializing in disorders of the nervous system, aka the brain.  And, obviously, ONH is a disorder of the brain.  The neurologist will (should) review the MRI results with you in detail.  She should show parents the MRI itself, discuss the findings in each targeted area, and explain what those findings mean.  A neurologist will be the doctor contacted in case of seizure activity, since that can be and is associated with ONH.  If the MRI results are inconclusive for any reason, the neurologist will refer you to other specialists.  (We'll discuss that later.)

I like our neurologist as a human and as a professional.  I really just haven't learned anything from our appointments with him.  He showed us Hayes' MRI results (pretty cool) and is willing to answer my ridiculous please-predict-the-future questions, but because Hayes has some other things going on that aren't explained by his MRI, he's referred us to other doctors.  We check in with our neurologist every six months to discuss any changes in behavior, monitor for signs of seizure activity, and keep track of his development.  The neurologist was the one who FINALLY said 'hypotonia' out loud for me, and is the one who is most concerned about his global developmental delays (which means delays in cognitive, speech, and gross/fine motor skills).

And from this point?  Rinse, lather, repeat.  And adjust as your preferred brand of shampoo is renamed, discontinued, or new and improved.  Because this is the medical community.

So, a recapitulation of post-ONH diagnosis and the 'D-team' assembly. (D is for Doctor, not performance.*  Hopefully.)

ONH diagnois (most likely via the ophthalmologist) then

• Endocrinologist
• hormone tests
• Neurologist
• MRI

Everything I Know Series

What IS Optic Nerve Hypoplasia - Part 1

What IS Optic Nerve Hypoplasia - Part 2 (you are here)

• LEGEND
• Medical information / New Terms
• Personal Andrews information
• Medical specialists
• Therapy / Government Programs
• Really important information
• and links I think you should visit always look like this

If all this helps just one person, I will feel incredibly accomplished.  It's a lot of typing if it doesn't.  :-)  I'm going to condition you to expect a really cute Hayes picture at the end of each installment, so here:

What?  Stop it, I know.  Hayes and Koby catching a snooze after a long weekend.  Hayes is smiling in his sleep.

* Remember, you can fire anybody who isn't up to snuff.  You can always question, challenge, and ask for clarification.  Above all, if you aren't satisfied, you can find another doctor (therapist/case manager/etc.)

What IS Optic Nerve Hypoplasia? - Everything I Know Part 1 -

It's come to my attention that everyone who reads the blog knows something's up with Hayes.  A little over half know that he has a neurological condition (a congenital birth defect) called optic nerve hypoplasia (ONH).  Less know, however, what that really means and entails.  And a few know there's some other stuff going on too; things that no one can really describe well or explain.

I think that sometimes even really, really close loved ones can feel uncomfortable when asking parents whose children have atypical development to explain, in detail, what's going on and why.  And so, they don't*.

I also know that I have read ... a lot... of information (printed and online) about optic nerve hypoplasia; I still Google it sometimes to see if anything new comes up.  I know how it feels to be a frightened mother looking to educate myself on something I'd never heard of until it affected my baby.

SO I want to do an exhaustive post (series) that covers everything that we know about ONH because of Hayes.  Please keep in mind that I am neither a doctor nor a pediatric therapist, and I am describing our family's experiences and decisions regarding this condition.  I'll post medical information, signs, and links I consider to be useful resources.

Optic nerve hypoplasia is a congenital (before birth) neurological (brain) condition resulting in varying degrees of vision loss and can be associated with other disorders and conditions.  Hypoplasia means 'under-developed', and so the name of the condition itself basically describes the fact that the optic nerves were malformed as the baby's brain developed during pregnancy.  The optic nerves are the nerves that connect the eyes to the brain.  There are no known causes of ONH, but studies have linked the usage of drugs, young maternal age, primaparity (first pregnancy), and low maternal weight gain to the condition.  It is not known to be a hereditary condition and is not currently linked specifically to any chromosomal malformations.

When a person has optic nerve hypoplasia, it can affect one (unilateral) or both (bilateral) eyes, and the development can be moderately to severely under-developed.  For example, one person with ONH may have optic nerves that are only slightly smaller than the typically developed person's, while another may have optic nerves that are almost completely diminished.  Obviously, this means that even with the same medical condition, vision loss can range from near to normal acuity (what we call "20/20") to no light perception, meaning that the brain does not perceive the image of light through the eyes.

Every ophthalmology appointment/MRI result has indicated to us that Hayes's optic nerves, while smaller than average, are not markedly underdeveloped.  Unfortunately, as he is still unable to talk, we are not sure of just how much/well he is able to see.

It is important to remember that even with a bilateral ONH diagnosis that the brain will adapt to the under-developed optic nerves.  And so while the optic nerves will not themselves repair or grow stronger, the brain can learn to read their signals better over time, often until the ages of three to five.

This is also why it is important to monitor the health and function of the eyes.  ONH is sometimes associated with strabismus (eye crossing) and nystagmus (eye shaking).  In the case of strabismus, if the eyes are crossed for a long period of time, the brain will eventually 'shut off' the signals it receives from one of the eyes to cancel the 'double vision' effect.  (This is called amblyopia.  Read more about it here.)  Treatment can be consulted with your ophthalmologist and generally consists of patching either eye or undergoing strabismus corrective surgery. (For more information on strabismus, talk to your child's ophthalmologist and click here.)

It was because of strabismus that we were initially referred to a pediatric ophthalmologist by our family physician after Hayes's four month check up, and in turn it was the ophthalmologist who first diagnosed Hayes with optic nerve hypoplasia.  Hayes had the strabismus corrective surgery in July.  His eyes have healed nicely and do not cross as frequently.  Because both of his eyes have always seemed to cross equally, rather than one or the other, our doctor has never recommended patching, and for this reason I am less comfortable giving extensive information on patching.  (For more information on patching as an aid for eye alignment and acuity, talk to your child's ophthalmologist and click here.)

Nystagmus often occurs in people with ONH, and it means that the eyes move quickly, or 'bounce' in different motions, like up and down or side to side.  Interestingly, people with ONH can find their 'null point, which is an angle at which they can look at things without having their eyes move constantly.  (For more information on nystagmus, talk to your child's ophthalmologist and click here.)

We have been on the watch to see if Hayes seems to prefer looking at objects or people from certain angles, which may indicate that he has found a 'null point'.  There is actually a surgical procedure that can 'move' a person's null point.  For example, it would be much more convenient if the null point could be found when the eyes were looking straight forward, instead of looking at things obliquely from a wide angle.  So far, we have not noticed Hayes preferring any such positioning.  

We have noticed him 'nodding' quite a bit, and at this last appointment, the ophthalmologist referenced a condition called spasmus nutans that is associated with nystagmus, although not necessarily with ONH.  Spasmus nutans is characterized by nystagmus and head movements, such as nodding.  It generally manifests during infancy and early childhood, but generally resolves itself by ages 3-4.  Because the signs can also be misread as spasmus nutans when they can actually be signs of problems such as brain tumors, doctors will often order MRI scans to be done.  Since Hayes has already had this done with no concerns coming up, our doctor felt comfortable ruling that out.  (For more information about spasmus nutans, talk to your child's ophthalmologist and click here.)


Because no one likes to scroll forever, this wraps up the first part of what I hope will be an informative, frequently updated series about optic nerve hypoplasia and hypotonia (in broad scope) and our journey with Hayes (in specific detail).  Stay tuned for: associated conditions, posts on early childhood intervention and how to get it, hypotonia, global developmental delay, genetics, and most likely more.

Everything I Know Series

What IS Optic Nerve Hypoplasia - Part 1 (you are here)

What IS Optic Nerve Hypoplasia - Part 2 

• LEGEND
• Medical information / New Terms
• Personal Andrews information
• Medical specialists
• Therapy / Government Programs
• Really important information
• and links I think you should visit always look like this

But here's your reward for making it this far.  Hayes says, "I bet you thought she'd never stop talking!"

*It's okay to ask.  : )

Prophecies, Progress, and One Identity-Stealing Transformer

I'd love to take you back to this moment, as I wrote this when Hayes was just ten days old:

A second child is a heart-breaking miracle, a treasure mindful of time.  He is precious because his parents have learned the meaning of cherish.

Okay, so maybe the postpartum hormones were a-swirlin' that day; I know it's a tad on the dramatic side. But I've been revisiting that thought over and over again.  It's almost like my own personal memory verse that became something of a self-fulfilling prophecy for Hayes and me.

I would lie if I told you it isn't hard when Koby and I attend Hayes's pediatric check-ups; we sit there and say "No" for about five minutes straight as the nurse keeps asking all the questions she's bound to ask about his development.  "Is he walking?" "Is he crawling?" "Is he pulling up on furniture?" "Is he babbling?" "Does he play hide and seek?" "Will he look for missing objects?" .... Please, please stop, we think.

I would lie if I told you it isn't hard when we see kids Hayes' age running and laughing and talking.  Because it is.  It's not a resentful, pitiful feeling.  But it's a hard one.

BUT.  Our little treasure mindful of time keeps reminding us that HE progresses on his own time, and it transforms the ordinarily mundane into the explosively joyful.

Yesterday, Hayes grabbed my face and looked into my eyes.  He just ran his slobbery, pudgy hand all over my face, looking at me and studying me in a completely new way.  

For any other mother, if her 16 month old did that, it would probably be answered with - Look little man, here are your 10,000 toys.  Could you please pinch and play with them instead of Mommy's cheeks and hair?  I know and say this because that is exactly what I would have felt when Knox was ALWAYS UP IN MY GRILL about a year or so ago.

But when Hayes did it - purposefully reached for and held my face - it made my heart race and flutter.  CHERISHED moment.

Here's a video of Hayes in his Little Room.  The Little Room is an Active Learning therapy tool we've been able to use thanks to our wonderful VI teacher.  He's laying on a Resonance Board; the Little Room is the torture-chamber apparatus that appears to be encasing him.  This was his first time in the Little Room, and not coincidentally, this is the most he'd ever interacted visually-physically with ANYTHING.  (I've since moved some of the objects around - I didn't like how close those spiky dish scrubbers were to his face/eyes, and I let some of the higher-hanging objects down a bit.  It is recommended to establish places for the objects -and then not move them- for memory encouragement.  And obviously, children should be monitored the entire time while they're in the LR.  Don't mind the other, non-monitored child destroying the living room in the background.)  For more information on Little Rooms, Resonance Boards, and Active Learning, check out these links:

This Link
or This Pinterest Board
or This Link


Heartfelt outpouring over - I have to go attend to Knox, who is refusing to believe me that the toy he is holding is. in. fact. a Transformer, and not a Yellow Batman.  

** Update: I later apologized and said, "Okay, you're right.  It is Batman.  How silly of me."  To which Knox replied, "Good job, Mommy."  These guys teach me lessons all the time.**