TRANSCRIPT - Successes in Early Vision Screening Ð 10/17/22 >>Kate: Good afternoon, everyone. We'll get started in just a minute. I have shared in the chat the link to the handout, so if you want to grab that so you've got it for the presentation. Also, as we're waiting to get started, if you want to let us know where you're joining from, I always love to see that. From Boerne and from Dallas. Hello. Oh and Tracy. Hi. Hi, Lanette in Kilgore. Hey, we've got good Texas representation today. Oh, North Carolina. I didn't know there was a Norfolk, Nebraska. Cool. Welcome, Julie. Also, if you want to take this minute and change in your chat box there's a little dropdown menu and if you want to change that to say "everyone." That way everyone will be able to see your questions and comments. We're going to get started in just a few seconds. Hi, Valerie. Where in Virginia are you? And Linda, that is not a problem. Oh, I love Williamsburg. I taught in Prince William County for several years. Annie from salt lake, my other home. We're really excited about this session. I'm seeing a lot of new names, so this is great. What a great topic for you to join us today. So just a few announcements that I want to make sure that you all have. If you have a question or a comment during the presentation, please post that in the chat box. Make sure that your chat, the little dropdown menu says "everyone" so everyone can see what your comment or question is. Your microphones and cameras with automatically muted so you don't need to worry about those. The handout for today's session has been shared in the chat and we'll share it a few more times throughout the presentation so that you have that for immediate viewing. They will also be available for later viewing along with the recording of this and past Coffee Hour sessions. You can find those in the Coffee Hour archives, which are located on our new website, so tsbvi.edu. Go to "statewide resources" and then "professional development" and you'll see a link on that page. Click the link that says Coffee Hour and that will take you to all the recordings, handouts, transcripts, and chat information. To obtain your CEUs or professional development credit, respond to the evaluation e-mailed to you from our registration website, escWorks. And you'll enter the code that I will give you at the end of today's session. So no opening code, just the code at the end of the session. And then that CEU certificate will automatically generate when you finish that evaluation. Well, I am excited to introduce today's presenters. We have Dr. Cathy Smyth and Tamara Miller joining us from the Anchor Center in Colorado. I'm going to let them introduce themselves a little bit more. >>Cathy: Hi, everybody. Welcome to Success in Early Vision Screening and thank you for inviting us to talk about this project. We're really excited about it. So I'm Dr. Cathy Smyth. I've been a TSVI for about 36 years, mostly in early intervention. Went back to school to do my PhD and am back at Anchor Center for Blind Children in Denver, Colorado and have the privilege of being the director of research there. Tammy, do you want to take it away for your introduction? >>Tamara: Sure. Hello, Tammy Miller. I have been a TSVI for not too long. This is my seventh year, and I was introduced to this field because I have a daughter who has a visual impairment. And Cathy Smyth happened to be our home visit provider for early intervention vision services. This daughter is a senior this year. Cathy and I have known each other for a long time and now we get to work together at Anchor Center. I recently stepped into the position of the director of children's programs and services and I am so thankful that I still have the opportunity to work with Cathy on the research team and specifically on this project because it is near and dear to my heart. There's a little bit of about us. >>Cathy: She's one of our most -- she's been doing it the longest so we're happy to have her. So she can answer all your questions if we have time. So let's get started. Early visual skills in preterm and full-term infants are the first sensory system to develop, to support the infant's learning potential. Validated screenings are available to evaluate early visual function and have even been correlated in research to the child's neurological status and possible presence of brain-based visual impairment. Identifying these potential risks means that medical and early intervention personnel can create targeted early interventions to support families. Providing quality early interventions can lead to improvements in functional vision and in educational outcomes for identified children. We hope. That's what we're looking at. So this presentation is about the NAVEG test administration for cerebral vision impairment in premature infants. This is the official name of the study that we've been doing over the past three years, so we have IRB approval from 2019 through this year. The primary investigator was our pediatric ophthalmologist that works with us at Anchor Center for Blind Children, Robert King, and he has privileges in the NICU at the Rocky Mountain hospital for children in Colorado. The other two co-investigators are neonatologies in the NICU and the research assistants were Callie Robinson and Tammy, of course. Next slide . All right. So the NAVEG, why do we use the NAVEG? Let's talk about the history. So the test that we use for this assessment, for this thing is the NAVEG, which is the Neonatal Assessment Visual European Grid, which is very awkward to say, and we call it the NAVEG. So you'll be hearing that. The history of this is they did a study in Brescia, Italy in 2011 to 2014 in the department of neonatology and it included 80 infants at or below 34 weeks and 80 infants born at 40 weeks. So full term. They did find the instrument was sufficiently sensitive to identify neurological risk. So not brain-based visual impairment or CVI in particular, but neurological risk. So you can see the jump that we hope to make with this. Our goal in our study is to identify infants who need early intervention services in the NICU. As you know, often all they are looking at in the NICU is retinopathy of prematurity. So we feel like there needs to be some kind of visual assessment that is broader. I want to share personally, as a TSVI, probably if you would have told me five to three years ago that we could test for visual function in babies younger than six months, I would have said, no, you can't. And every teacher, every mentor I ever said, pediatric ophthalmologists I talked to always said, no, you can't. And I think Tammy will agree with me that one of the things that we have learned in this study is that, yes, you can. They totally can. They can completely do these tasks and it's just amazing. But we also recognize that we have to convince people and that there's still many ophthalmologists and practitioners who believe that vision screenings cannot be done until six months. Next slide. So why use the NAVEG? Some of the reasons is why should we do this specifically is it has been validated in Italy to identify infants at risk for neurological issues. So we've already got a valid test for some feature that we're looking for. It's allowed us to develop standardized components of the visual screening. So I know this summer at AER there was a lot of discussion about standardizing FEAs, and I think we feel pretty confident that the pieces of the FVA that are included in the NAVEG are easily standardized. We use the same materials. We do it the same way. We have a code dictionary, how do we score this. And it is very easy to standardize. Not only that, it's easy to train. It's not invasive so we can tell parents in the NICU this is not the ROP check. We are not doing a medical procedure. This is totally a functional vision procedure and it can help us make referrals, early referrals to TVI and EI services. Next slide. And I think that's you, Tammy. >>Tamara: It is. So we're just going to talk a little bit about brain-based visual impairments. We know from prior research that the brain-based visual impairments are the leading cause of visual impairments in children under 3. And we also know that the causes of a brain-based visual impairment are prematurity and oxygen loss. And we'll go over those on the next slide. We also know that functional vision can improve. You know, this is one of the few, if any visual impairments that exist that with early intervention can improve. And that is an incredible fact. Some of the causes of brain-based visual impairments are prematurity. Just prematurity on its own. Those brains are sometimes not fully developed by the time a baby is born. And that can cause brain-based visual impairment. Ventricular hemorrhage, any brain bleeds are common, especially among premature babies but can also happen with full-term babies. Any types of chromosomal or genetic disorders can cause damage to the brain. Focal damage to the brain. So any type of injury or tumor or dysplasia, you know, actual damage physically to the brain can cause a brain-based visual impairment. HIE, hypoxic ischemic encephalopathy -- I got it right. I never say that right. That is lack of oxygen to the brain. We know that that can damage brain tissue. Any type of infantile spasms or epilepsy, seizures. We know that those can cause damage to the brain. Periventricular leukomalacia or PVL, that's that white matter, either lack of or softening or damage to the white matter in the brain. Different types of metabolic disorders can be involved. Any type of meningitis or encephalitis, any type of infections can cause damage to the brain. And also neonatal hypoglycemia. I think that in my experience in doing the first phase of this study at Rocky Mountain hospital for children, I probably encountered almost all of these on babies that we have done this screening on. I don't know that I've seen that last one, the hypoglycemia, that one's a little new to me. But all of these others I think have been represented in our study, so they're all definite possibilities of reasons for that damage to the brain. The NAVEG screening itself is very simple. And we're not going to go through, you know, all of the components but we'll give you just an overview today of what we use and what we're looking for. So there are three sections of the NAVEG screening and we are looking at ocular visual components, motor visual components, and perceptual visual components. And the ocular visual components are looking at things that we often look at when we do an FVA. We're looking at the pupillary light reflects score, any type of abnormalities we might see when we're looking at the eye from the outside. And then the motor visual components, we're looking for other familiar things to us as TSVIs. We're looking for strabismus. We're looking at how are these babies tracking and looking at objects. And this picture you can see some of those objects that we use. And they're not anything, you know, too strange. You see lacrosse balls with an X on it. That might be new to you. That was included in the original NAVEG screening in Italy that we continued and we now use those in our FVAs. We find that babies and young children like to look at a lacrosse ball with a black Sharpie X on it. That's been a fun addition for us at Anchor Center. Finally with the perceptual visual components. We're looking at the contrast sensitivity and we're looking at their visual fields, are all of their visual fields intact. Again, very familiar things but we're just doing it in a way that is standardized and, you know, very simplistic ways to do this. So the screening itself is really pretty basic and the information that it gives us is pretty incredible. Cathy, we're back to you. Tell me when you're ready. >>Cathy: Hang on for a second. So I mentioned Dr. Robert King earlier. He's the primary investigator of the study at Rocky Mountain Hospital for Children with us. And he works in -- so at Anchor Center we are lucky to have an assessment center and it includes two lanes of an ophthalmology clinic and Dr. King provides services for our family, follow-up services . So this is super important to him and he is the one who found the NAVEG. He is the one who is so excited about it. And I just want you to hear some of his own words about this because he is our very best advocate for moving this forward. So now you can play the video. Dr. Robert king is a pediatric ophthalmologist that provides eye care for Anchor Center for Blind Children in Denver, Colorado at our on-site eye clinic. He's been a pediatric ophthalmologist for 35 years and is currently the primary investigator at Rocky Mountain hospital for children's neonatal intensive care unit for our collaborative NAVEG project as we explore early vision screening. So welcome, Dr. King. >>Thank you. >>Cathy: So can you tell us a little bit about how you learned about the Neonatal Assessment Visual European Grid, or NAVEG, and why you think it's important to use in the NICU? >>Yes, I can. Thank you for the opportunity. I want to call everyone's attention to a book that you're probably familiar with, Vision and the Brain by Amanda LUek and Gordon Dutton. The copyright, I believe, was 2015. I became aware of this from one of our teachers of students with vision impairments, TSVIs, Kelley Robinson in our office in our Anchor Center. And she asked me if I had ever seen this book. I said no. This was about in 2016, I'm going to say. So based on her referral and immediately referred, like I'm hanging on your shoulder here. Give me the book. We looked at this book and we decided -- she and I decided that we would start a journal club. And so we had a book club of reviewing with all of the TSVIs and a couple of other people on staff at Anchor Center, reading this book together and discussing it. And we did two chapters at a time. And it was -- first of all, it was really a great idea and fun to do and we all should be doing that regularly. >>Cathy: Yeah. What a great opportunity for us as TSVIs to interact with you this way too. >>And vice versa. So in chapter 4, chapter 4 of the book, we're going along reading chapter 1 and 2 in the first week and the second week we read chapter 3 and 4. Chapter 4, which I just showed you on page two of chapter 4 was -- I'm going to read this to you because it absolutely floored me. It was like a total mind-blowing experience. Two of the authors, those are the doctors from Italy, I believe, recently assessed visual function in full-term and pre-term newborns through an easily-administered clinical instrument called NAVEG. Neonatal Assessment Visual European Grid which provided a detailed analysis of visual functioning using a grid made up of three main sections: Ocular, motor, and perceptual visual components. And so within this book of Vision and the Brain, they did not discuss how they went about this. And, in fact, the only reference in the book was to -- a journal article that had yet to be published. And so by the time we went through all this, the journal article had been published and so we got our hands on this. And it was a very detailed article about how they administered the test and how the test was performed and, you know, all the methods and materials that they used. And but I must say that just reading that one section that I read to you was very eye opening to me because I had no idea and it really gave me a pathway into sort of discovering for myself what brain-based vision impairment is. Not that the book, the entire book isn't excellent, it's just excellent, but that was really the catch for me. And so we started down this road of trying to do this testing in our children's hospital, Rocky Mountain Hospital for Children and to do that required an IRB and an investigational protocol and all these things that Cathy has been so involved with. And so we started doing this test. My first question for myself was is this even possible? Can we possibly do these things on these little -- not just newborns but premature infants? >>Cathy: I have to say, that's true for me too. So 35 years in the field for me as well, and if you would have told me that we could do the screening on premature infants, I would have said, no. We can't do that before six months. We can't do that. >>Yeah. I like you picked up six months because that was sort of the going deal for us -- for me in being in pediatric ophthalmology. We didn't really make too many vision assessments, if you will, before the kids were six months old. And we would put off families and parents with those statements that, oh, we can't really do too much until they're six months old. Okay. So going into the nursery the first time, I was pretty nervous about am I going to be able to do this? Am I going to fall flat on my face? But the first baby that, you know, like first one out of the box did the test. Like, the whole thing. They did the cards, they did the Heidi figures, both central fix as well as with contrast sensitivity. I mean, it was amazing. Amazing. And so we realized at that point in time that we really could administer this test. And so we went down the road to have a protocol, which we've administered now for three years, I think. >>Cathy: Yeah, almost three years. Yeah. >>And we were put off by COVID, et cetera. But the administration of the test is successful. >>Cathy: Yes. >>And it has shown a rate of problems in this cohort of babies that may be as high as 25%. When we started, Dr. Fossi and Mollanaro said it was 15%. We probably found it is higher but there are lots of problems in putting a study together such as follow up and whether babies are discharged before you see them and this and that. But nevertheless, all that stuff aside, it has been a very successful endeavor. >>Cathy: Well, I this I we need to remember too that their original study included babies that were full term as well. >>Yes. >>Cathy: So they looked at full term and premature and then they got their 15%. We're only looking at that prematurity piece and so we've definitely run, you know, so the data, I don't have all the data yet but it's definitely 20% to 25% consistently of not passing. So that's pretty exciting, we think. All right. So here's the next question. Do you feel it is necessary for medical personnel to administer the NAVEG in the NICU? >>I would say the answer is no. The qualification I would give you is that part of the NAVEG is ocular. So, in other words, the health of the eyeball. And so the pediatric ophthalmologist is going to have to look at the eyeball, including the dilated fundoscopic examination, including optic nerve and retina to make the statement the baby does not have optic nerve hypoplasia. All of these babies do get fundoscopic evaluations. I have done thousands of these and that is an adequate exam to rule out most other pathology. So now we're talking about can non-physician personnel administer the NAVEG test. Once again, I would say there's a little qualification in there. We're using our teachers of students with visual impairments who have really special training in observing visual-perceptual things as well as motor things, just all the stuff we're looking for here. And people who are trained to be able to do this can certainly administer the test. I would say that it can be administered -- so there's a really important examination tool and that is force preferential looking. When you do a Teller card, as all of you know, you are looking for the force preference that a child has to look at the Teller grading. And we use that force preference also for visual field tests. Did they force, did they force themselves to look at the object in their periphery that you were trying to show? And it goes on and on in that way of looking. So force preferential looking is a standard examination technique for teachers of students with visual impairments. It's something that we use day in and day out. And given that reality that you can train someone to observe in that way, yes. Many other people can do it. >>Cathy: Yeah. And I -- as a TSVI myself and having that history and working with our screeners, I think what's so exciting about the NAVEG for us is it really is standardized. So we're not just waving something in front of the baby and seeing what's happening. We have equipment that we use. We do and as you get better at it, you do it in a very, you know, you have your way of doing it and sometimes you can get, like you said, you can get the same information from one piece of equipment. You don't have to use all of it all the time. And it's the closest thing I've ever used in a functional vision eval to doing a standardized test. It's exciting. It's things we do as TSVIs all the time. We look at tracking. We look at contrast. We look at all these things but we've never had to do it in such a standardized way. And that's why I think it's to see the results be so consistent is really exciting. So, yeah. >>The test can be done by a trained person. >>Cathy: Yes. >>We've headed back and forth about this, Cathy and I have. We expect that there will be -- let's just use an example that one of the NICU nurses in a particular NICU -- or five of them -- have a particular interest in being able to do this. And have a skill set that includes observation. Of course, they're all observing all the time for different things for babies, so that observational mode is nothing new to them. Can they be trained for what we want them to do for this test? The answer is yes. It won't be universal but it will be pretty good. >>Cathy: At this point we're just using TSVIs, which is a good thing because we do already have some of these skills already. >>That's ideal but it's not -- if it's going to be a universally-applied principle, it won't always be TSVIs. >>Cathy: That is true. That is true. Okay. Last question. This is the big one though, I think. So after almost three years of administering the NAVEG, what have you learned about the information that we've gained from it? Do you believe it benefits families and children who are identified at risk? >>Yes. Absolutely. And the primary reason from a scientific standpoint is neuroplasticity. Neuroplasticity is the concept that the brain can rewire itself, if you will, to overcome its deficiencies. And we know that early on -- for example, there's more plasticity in a six-month-old than there is in a six-year-old. You can imagine the embarrassment is the wrong word but I'll use it. Embarrassment for someone like me who is used to seeing little babies and realize that over the years I have not even thought about brain-based vision impairment until the kid was quite a bit older, like maybe a year old. Think of all of the time we lost in trying to help those children during that time. And it really is astonishing that that's the way it is. But the concept of neuroplasticity -- it's funny to me that I deal with children with amblyopia. Amblyopia is when you have to patch one eye to make the other eye see better, that concept. And we know that if we patch a six-month-old baby, their vision will be equal in a week or two. It usually is very fast. If you don't get that same kid until he's two years old, it will be six months of patching or more. If you don't get them until they're kindergarten age, you probably will never be able to equalize their vision. And that is all plasticity of the vision system for patching. And we're taking this concept and blowing it up for all other aspects of visual behavior or visual functioning, I should say, not behavior. And realizing that plasticity plays a role in all of that. So the earlier you get started, the better off you are. And I think parents and families are so open to this, it is just amazing. Usually they're a step ahead of us as far as realizing something might be wrong but sometimes not and they all appreciate the, you know, the work that we try to get them to start doing. They're the most important parties in this. They're the ones who are going to work with the child and they need to get started early, the earlier the better. If we don't have a diagnosis early, then we can't get them started early. So the NAVEG has given us the wherewithal to give a diagnosis or at least even suggest a diagnosis earlier than later. >>Cathy: Yeah. And have follow up and make referrals to early interventions so we can be helping those families right away. Because that's what it's all about. It's super exciting for us on our end as well because we know that the later -- again, the later we see these children the less help we can give them. So if we can help families right away, it's unbelievable. So thank you very much for talking to us about the NAVEG. >>Thank you. >>Cathy: We're just going to keep doing what we're doing. Thank you so much for your support. >>And thank everyone for their collaborative support. We really need to be involved together in taking care of these kids. >>Cathy: Absolutely. [ End of video ] >>Cathy: So we wish we could clone him for all of you but he is a powerful force. I'll tell you, you can ask many of our board members how often they've seen Dr. King carrying vision in the brain around underneath his arm. Have you seen this? Have you seen this? It's wonderful for us. So the current NAVEG study at Rocky Mountain Hospital for Children is almost complete. We're just doing follow-up calls to find out if babies are being diagnosed with brain-based visual impairment or other diagnoses. The original cohort were identified through retinopathy of prematurity lists, so those babies on the list to be checked for ROP, and they had to be born at 31 and 6 weeks or earlier. So earlier than 32 weeks. So they had to be born. The actual screenings, the NAVEG screenings, occurred between 35 and 40 weeks and before discharge. So if a baby went home before 40 weeks, if we didn't catch them then it's not like we could follow them and do the screening at home. It had to be in the hospital. So we're not going to give you details but please remember that the NAVEG is a screening tool. It is not a diagnostic tool. The aim is to determine whether children need a referral or not for follow-up ophthalmology care and intervention . Each item on the NAVEG has a score. So the way we explain it, because this helps most people, is that you want a golf score. So you want the least amount. A healthy child response. So what we would expect to be would be a 0. 1 is an incomplete response. For some items, that just means you see it in one eye. For some items you don't get. So for instance -- Tammy, correct me if I'm wrong on this -- so in visual fields you have to have all four visual fields to get a healthy child response. And if you just miss one you might get a 1 or an atypical. If you miss all of them. So a total score of 6 and over indicates significant neurological risk of visual impairment and that would indicate a referral. There are -- I want to say 16, 17 items on the NAVEG so if you get a 6 or more, we do a referral. And in general we have a few babies that get a 5 or a 6 but for the most part they're either getting 0 or 1 or they're getting 13, 14, 15. So it's either -- it's usually pretty clear when they're at risk. One of the reasons -- I'm sorry if you can't see me. I'm on my phone today and I can't see myself so I don't know if I'm not holding things the right way. But I'm at a conference today about newborn screening and it's really interesting to me. One of the women this morning said we've abandoned the term "abnormal." So we don't say that a baby has had an abnormal screening anymore. It's all about levels of risk. And I think that really spoke to me and I think that's really relevant for the NAVEG itself. All right. Next slide. So here's some of the results of the study, the demographics. We're able to do -- we were cleared to do 130 but with COVID and babies going home early, we ended up with 81 complete screenings. Of those we had 26 referrals. That's a 32% referral rate. 49 males, 32 females. Average age of successful screening was 37.8 weeks. Right smack there in the middle. Those babies did the best -- were easiest to screen. At this point -- so this is a caveat, right? I only have 81 screenings. I need thousands of screenings to know if this is really accurate. Right now there's no relationship between a high score and interventricular hemorrhage, which is a little bit different than some of the other research in the field in this. Tammy, up to you for the next one. >>Tamara: All right. So, what have we learned so far in this study? So we do have some things that give us a little bit concern and have made it a little bit tricky. The timing is first of all. Babies are often discharged prior to being able to be screened. So sometimes we will have them consented and they will go home, which is a wonderful thing and we celebrate that. If a baby gets to go home before they're 40 weeks, that is a wonderful thing. That means that baby is doing well and is healthy and can go home. But that sometimes means we didn't have a chance to screen them and they miss out on that opportunity. Babies are often not available for screening. Many of these babies are sick and they have other things going on and sometimes our limited window of being able to be there in the hospital was not an ideal time or day for those babies. But also because we need to make sure that babies are from good behavioral state. We need them to be in a quiet, alert state in order to really assess what their vision is doing. If they're asleep, we can't do it. If they're upset and crying, we can't do it so we need them to be calm and awake. And that is really tricky for a preemie because preemies are still supposed to be in the womb and they sleep most of their day. And so that made it a little bit tricky. And then also because this is a human research study, the consenting process is very strict, of course. And we had to have written consent from parents and sometimes parents weren't available for consent. Sometimes families live out of state or far away or not able to be there at the hospital often or sometimes even when they are at the hospital they were unable to, you know, sign the consent form and, you know, all sorts of problems there. And also there are some trickiness with the follow-up part of our study. We need to do a follow-up and we do phone calls at six months and one year and we ask questions likes has your child received a visual diagnosis? And we need those to eliminate false positives. We want to know did we refer any of these babies. Did any of these babies not pass the screening but then not end up getting a CVI diagnosis. And one of the issues is that parents don't always respond to e-mails or calls from us at Anchor Center. We are not hospital personnel so we cannot say that we're calling from Rocky Mountain NICU and sometimes they don't realize the importance of our call and they don't get back to us. And then also parents have a choice, right? Early intervention services are optional. We cannot force any of these things on these families and so many of these families having a preemie in the hospital is overwhelming and they have a whole bunch of other health things going on and they might not be able to make these types of things a priority. And so these are all, you know, reasons that make it a little bit difficult. And part of the reason that our numbers were a little bit lower than we expected them to be. And add COVID on to that. Made it very tricky. We know that early intervention does make a difference. Since 2017, the staff at Anchor Center for Blind Children have conducted a total of 120 CVI range assessments with 87 students. This is outside of our study in the hospital. This is our own study at the Anchor Center. Out of those 37, 34 of them were assessed more than once. Of these 34 students, 85% demonstrated an improved CVI range score which measures the changes in functional vision. And this is after receiving Anchor Center's specialized early interventions and education. So we find that very promising and we look forward to adding to those numbers as time goes on. What do we know? We know that babies are capable. And Cathy and Dr. King have both already brought this up today. Even at 37 weeks. In fact, we actually even had one, 36 weeks gestation baby pass this NAVEG screening with flying colors. This little girl, teeny. Her head was the size of my fist. She did all of these things and we could tell this baby had great vision at 36 weeks. It was incredible. We also know that this could be the beginning of changing the standard of care. This was brought up a little bit too. We know that there are other screenings being done at birth, including a quick hearing screening but there is nothing in place as of now for vision. And so we're hoping that this can be the beginning of others realizing that babies are capable of showing us what they can do vision-wise at birth. We also know that early brain plasticity can rewire brain pathways. The key word there is early. We need to be catching these babies earlier than we are currently able to. We also know that we can help parents improve brain based visual impairments and that's the model of early intervention in our country. It's a family and parent early intervention program where we are in the homes and we are working with families and with caregivers and parents to intervene. To show them some tips and tricks that they can do to help their babies be able to see better and rewire those visual pathways and improve their functional vision. And then Cathy already mentioned this a little bit. But parents find information empowering. We know this. When we have families that learn about this when their babies are so young, they do find it very empowering and we can work with them and show them that they can take part in helping their baby. And that is just a really exciting part of this screening, of this whole project. >>Cathy: Okay. So we want to wrap this up for you. This last piece -- and here's a great picture of Tammy doing training. So I just want to share that at the request of early intervention programs we have developed a set of trainings to address these standardized components to use the NAVEG for data collection and functional vision improvement. So one of the things that we've noticed at Anchor Center is that as we've started to use the NAVEG, part of our FVAs for little ones, our results are more consistent and precise. So we feel like we're getting better at doing these kind of standardized tasks on the functional vision assessment. And then of course every baby is different and you need to add on different things and do it in different ways. But these basic standardized parts of a functional vision assessment, it has made us better. So next slide. So I want to share one example. So, yes, it's great that we're in the hospital so we're finishing up Rocky Mountain Hospital for Children sometime in the next couple of months. We've got the same study using the same parameters in our children's hospital in Denver, Colorado. And Tammy and another screener will be doing that study. But it's hard to get into the hospital. So I want to share that Kate's mom, Karen Borg in Utah was one of our very first early intervention organizations and Karen called me and said I don't want to wait for the NICU anymore. I want my babies in Utah to have this. So she requested a training. This was during COVID, and so we put our heads together and put a training together and she is amazing. So she has arranged that every infant that comes out of the NICU that receives early intervention in the State of Utah gets a NAVEG screening from her people. We train them and her early intervention people statewide do that, those screenings on those babies. The numbers I have right now, and I'm sure they're different because they're doing more every day. They began in August of 2021 and their current numbers, they've completed 196 NAVEG screenings and they have a very consistent referral rate of 15% to 20%, which is right there where ours are. And so I'm so excited to share that news. The NAVEG doesn't have to just be done in the hospitals. TSVIs can absolutely do this through their early intervention processes and every state is doing it a little bit differently but the important thing is that we're doing it, right? So last slide here. We want to say thank you. Here's Tammy and my contact information. Feel free to e-mail me if you are interested in the NAVEG training or you just want to know more about the project, please let me know and I will get back to you as soon as I can. Tammy's available as well. If you want more information about brain-based visual impairment and neuroplasticity, I highly recommend that you visit the laboratory for visual neuroplasticity. It's out of Harvard and has some great research study. So, I think that wraps us up for us. So let us know if there's any questions we can answer. >>Kate: Steven asked a question in the chat. This is Kate. He said 15% to 20% referral rate to MD for diagnosis. What percent are then diagnosed with a brain-based visual impairment or other visual impairment? >>Cathy: So I don't think we have that information yet. We're still collecting that data. So we are absolutely, through the hospital studies we are officially collecting that data. I cannot say if the early intervention programs in Utah or anywhere else are collecting that data because I'm not in charge of that. But, yes, that's a very important question and we need to follow up with that. But I can tell you that we have probably -- so in our referral rate of the babies that I have followed up with for our study, we've had probably five that have ended up through follow-up getting a diagnosis of detailed visual maturation but still, still they are being diagnosed with other issues such as nastagmus or strabismus. If they hadn't been followed from the NICU because they got that referral, would we have picked up on that strabismus or nastagmus as quickly? I don't know the answer to that. That's a hypothetical but we feel that it's a win-win for everybody that babies are getting referrals so early, whether they end up with brain-based visual impairment or not. Did that answer the question? >>Kate: I'm going to say yes. >>Cathy: Okay.