 We'll just have to wing it and sorry will improvise and my name is Leonard Isakowitz. I am a retired consultant ophthalmologist and a member of council. Nicholas Nicholas, and it's my good fortune to welcome you here tonight and to chair the meeting. And I have a housekeeping type things which the regulars will be used to but could you please turn mobiles and pages off unless you desperately need it because you're on call. The fire exits, which I just discovered are on this side and this side, and I believe you can get out of the back. Quicker here. When we've changed the running order very slightly we used to have a five minutes break between the, the talk and questions Q&A, but we're trying to reduce that a little so there'll just be enough time for the council members to collect the microphones to wander around and ask your questions. And there are also questions from people, there are a few people on Zoom by special request. And so, Geraint, who will be here somewhere there he is back and will be feeding those questions to me. There will be no practice fire alarms. So if you hear one scoot. It's my pleasure to introduce a friend and colleague, both of us retired now, Professor Gordon Dutton, who until recently was a consultant ophthalmologist in the greater Glasgow and applied health board. And going back a bit, he trained, he just told me now, he's from Chester. And he went to school in Chester at a school that was inaugurated, I think by Henry VIII that right. So, he knows exactly what to do. If he gets any difficult issues. He studied medicine at the University of Bristol. We also started training in ophthalmology. Which was longer road than it is nowadays. It was over seven years just to become an ophthalmologist. It's a little less now, and people often do a year of subspecialty because ophthalmology like many fields are becoming a field of subspecialists. He then trained in Glasgow, he was the senior lecturer in the Tenant Institute of Ophthalmology, and eventually became a consultant. He worked at York Hill for many years. And during that time, he specialized in children whose vision was disturbed by their neurological problems. And we realized at that time that this was becoming a far more common problem because of the success of the neonatologists and keeping little babies alive, premature babies. Besides his expertise in this, which he says has actually been as much of a hobby as his other interests. I would describe him, he might describe this as a polymath. So I'm only going to give you a brief description of his interests, that he is a very keen gardener. He does, he describes it as carpentry, but I think it's more cabinet making because he's meticulous in what he does, and his family. So with that brief introduction, Gordon Dutton. Thank you so much for inviting me to give this talk. I've had the privilege of working with many hundred people who have had their own individual unique visual difficulties as a result of brain injury. And assembling all this information over the years has been a particular hobby. This talk, as you can see, is entitled the impact of brain injury upon vision. What can this teach us about how our minds see, and a few examples. What I'm going to do is to show you a few videos made by friends through this talk, which show that this is really very much a team effort. This is the beauty of a sunset or a famous landmark. We can with our vision appreciate and understand, and also guide our movement through the world. These are two distinct separate visual tasks. Yet, how do our minds achieve this remarkable phenomenon. We want to focus on how we can use it, how vision can be understood in part by the impact of some examples of focal, I mean specific and local brain injury affecting elements of the brain's visual system. Only everybody in this audience will be fully aware that the eye is a camera, a little room, a space in which the picture is cast upon the back of the eye through the optics of the front of the eye, the clear watch glass of the cornea, all smarty shaped and sized lens behind upon the surface of the retina, which acts as the amazing film in our camera. As an ophthalmologist when we look into the eye, we see the nerve at the back, the optic nerve, the blood vessels, the darker ones being Venus blood, the thinner bright ones, lighter ones being arts more arterials. The area in the center, which is in this area, which is where we have our central vision, and then all the way around in the dome of the eye, to the extent that I can see my finger here, just behind myself, because the light is coming in to my peripheral retina. And therefore, we have a big field of vision. If you look at this picture, I wonder how many people see a bird? Would you hand up if you see a bird? Well actually it's a rabbit. Look again. Now, the reason I show that is that this gives us a little insight into how our minds are seeing. We find see by comparison with a vast library of visual information inside, and it is through this means that we, you hypothesized, everything we see is a hypothesis of mind, you hypothesized that it might have been a bird. But as you can now see, it is truly a rabbit. If you look at this, take your finger and cite those two dark lines. They look as if they're different in length, but go like that, cite it, and then move to the other side, and you will see that they are exactly the same length. This shows us that what is reality is not what we see. What is our reality is what we perceive and construct from our prior knowledge, here the prior knowledge of what constitutes depth. In this picture, it looks quite reasonable, doesn't it? Because the mouth is the right way up. The eyes are the right way up, but the face is upside down. So what happens when we invert it? And this relates to the fact that when people are looking at a picture of a face and their eye movements are being recorded, those eye movements move from eye to eye, briefly to mouth, and a quick gaze around the perimeter. So with our central vision, our analytical central vision, we are predestined to spend time looking at eyes, just as the newborn infant does to its mother. More of that later. This film is going to show you a story, and here we go. My name is Nicola McDowell. As a teenager, I found school work easy. I had loads of friends and was really good at sports, particularly netball and swimming. I won age group national swimming titles and was aiming to represent New Zealand at the 2000 Sydney Olympics. I was living the dream. Then one day, when I was 16, something happened. I have no memory of their events, but friends have filled in the gaps. Apparently, I was training in the pool and started complaining of not feeling well. Firstly, of a headache, then spots in front of my eyes, followed by jizziness and numbness in my fingers and toes, then an extreme sense of coldness in my whole body. When my dad came to pick me up from the training, he found me unconscious by the poolside, receiving emergency medical attention. My lips were blue and I had stopped breathing. At the back of my brain and my left occipital lobe, an artery had started bleeding. My friends were witnessing what happens when a part of the brain is suddenly starved of oxygen. Due to a number of extraordinary strokes of luck, I survived. It seemed the only effect was that I could no longer see on my right side. So if this is what someone with typical vision sees, this is what I see. Apart from all I see, so not on the left, but in the middle. And yes, I have gone out only brushing one side of my hair. But for something I have been assured by many really should have killed me, to have left me just with the loss of vision on one side, seems like I got away pretty lightly. I hadn't. An invisible enemy had infected my brain. School work was more difficult. I couldn't concentrate. Things didn't make sense and I didn't know why. I couldn't follow the teacher and my grades started falling. I managed to offend just about everyone without knowing why and what I was doing wrong. I went from social butterfly to social outcast. Increasingly I hid away from the world. As expected, I became very low, unaware of my invisible enemy. I just accepted it was all me. Somehow I made it through college, deciding on teaching as a career. I was naturally drawn to working with children with visual impairments, initially specializing in orientation mobility and then as a specialist teacher or TVI. One day at a conference for work, I was listening to Professor Gordon Dutton explaining a visual impairment from the brain. Incredibly, I realized he was explaining me. But how could this stranger describe my whole world without ever having met me? At the end of the talk, I went up to Professor Dutton and nervously said, I think I have what you just described. He was describing cerebral visual impairment. As I learned more, everything started to make sense. Knowing CVI was the cause when I was able to start working on life changing, life affirming, life empowering solutions. CVI stopped being my invisible enemy and became a part of me, a part of who I am. Non-infestation, just something that needs thought, planning, care and attention. I was still working with children with visual impairments and like everyone in vision, seeing more and more children with CVI added to our caseloads. Talking to their parents, I recognized myself and many of their children who were often confused, struggling with school and friendships as I did and blaming themselves like there must be something wrong with them. So as you're probably guessed, I've missed the 2000 Olympics in Sydney, but I have a new dream, a bigger dream, a better dream. My dream is to help the CVI community. I'm so proud to be a part of. I've met and worked with the most amazing people, particularly others affected by CVI. So that's me. I never thought I would say this again, but I'm still living the dream with CVI. So what happened to her was she had a bleed from an arterial venous malformation into her left back of the brain called the occipital lobes. If you were to take your hands, I'm going to do it and place my hands over my ears. My palms are over my temporal lobes. My fingers are over my posterior parietal lobes. And my thumbs over lie my occipital lobes. And it is the occipital lobes that receive the visual information. And we know this from the work of Gordon Holmes in 1918, who plotted the nature of the parts of the brain, which parts of the brain saw what? Because of the design of British helmets, which allowed shrapnel to go into the visual brain, but not the German helmets. So the work was all British. And sadly, and the bits, the shrapnel's positions and shapes enabled Gordon Holmes to produce this remarkably accurate diagram, in which, as you can see, at the back of the brain here, the image is served for the center. And I've seen a young man in Taiwan who had a motorbike accident where he suddenly stopped and his brain inside his head went back forwards and backwards and bruised the very tip at the back. And so he lost his central vision, because that was what was injured. So as you can see, the brain maps vision perfectly identically for each eye, so that a target up there will be seen in the same part of both eyes, but it goes to the same brain cell in the occipital lobes. Remarkable. And Gordon Holmes was the first. Well, the very first there was a mantle also did it in the Sino Japanese War, but Holmes did it more in more detail to show how the brain is perfectly representing external visual space. So how much brain is responsible for seeing. Well, Gordon Holmes argued that it was just the blue bit at the back. The signal from the eyes comes into a relay station, known as the lateral geniculate or knee shaped body. And then it comes to the back of the brain to the occipital lobes, but actually it's much more than that. The vision related brain comprises around 40% of cerebral tissue at a conservative estimate 40% of your whole brain being devoted to the creation of the imagery around us, integrating with all the other senses. This is about the case of a 50 year old newspaper editor, who suddenly collapsed and when he woke up about 10 minutes later, he was unable to see in the top left area of his vision. Gosh, if everything can go wrong, everything go wrong. The next slide is now not playing as I'm, I'm, sorry, that one, that one. In the next slide, you would see, I don't know if you need help now. In the next slide, you would see. Thank you. I shall project a bit more as well. In the next slide, you will see that, or would see if you could see it, that the imagery in the top left hand quarter comes down and enters the brain and creates a shape in the bottom left hand corner of your brain. And it's true for every one of the four quadrants is represented. So in essence, on the back of the brain, when I look. How do I use the microphone and turn around. I should project further at the back of the brain. When one is looking down here, the top right hand quarter sees in both eyes. It's exactly in this representation. Now, moving on to the next slide, which I do not show you, can I show you at the moment. It's a picture of this gentleman's brain. The problem is that he has developed a stroke of his right temporal lobe. And the visual pathway has gone through in a loop through the right temporal lobe. And so we know that if you can't see up here from Gordon Holmes's work and other work. We know that you cannot see in the top left hand quarter from the temporal lobe. But the other thing that this man had was an inability to recognize faces. The other post is Greek for face a is not to know and Gnosis is knowledge. And so it's not to have knowledge of faces is prosopagnosia. He had developed prosopagnosia as a consequence of this stroke. He then also found that he couldn't find his way about. He had arrived in the clinic with his wife, and his wife. So I asked the question, do you have any difficulty finding a way about he said, no, I don't have any difficulty. And his wife said, Oh, you do. You have great difficulty. I took you into work the other day and you walked straight into the sweetie shop. So that is called toposive shape or knowledge of space. And so he had topographic agnosia as well. Have you ever recognized that you yourselves do not know when when you see somebody up. Thank you. I don't know what you did there. When you see somebody's face. You don't recognize them if they're in the wrong place. And that is because places and faces are filed in your right temporal mode in nearly everybody's right temporal but sometimes the left together. So, now I can show you the pictures. Let's see who it was. Thank you, Leonard. So scans, the right is on the left, the left is on the right. So the right brain has had a stroke in the temporal lobe. And this is how we could not recognize faces because this is the part of the brain that recognize his faces. And he also lost his way. But now I'm hoping. But there is no sound. The last thing I remember is lying here in my own bed. And I vaguely remember being taken to the hospital. And then after that I don't remember anything. When I woke up it was completely black. Absolutely black. When Malina Channing was 29 years old she was left blind by a stroke. My eyes are perfect but it's the damage that the stroke did to my brain. It had completely decimated her primary visual cortex. That area at the back of the brain that processes all the information from your eyes. But then a little while later. I was giving Stephanie a bath and running the tap, running the water. I see the water moving. But then they went and told all the doctors. They said it's her imagination. And then I started seeing the rain coming down from the sky. The windscreen wipers on. The steam coming from my coffee cup. And though she couldn't see her daughter. I would see her ponytail moving left to right. It seemed to be things that were moving but nobody believed me. She visited neurologists in Canada who showed her this weird shifting grid. And I actually started crying because I could see it. It turns out there are these modules in the brain that are specialized for processing higher order aspects of vision like recognizing faces or letters or motion. And it seemed that in Malina's brain the information coming through the eyes had found a way to bypass that broken primary visual cortex and still get out to that motion module. A part of her brain that was apparently still intact. It was just amazing what I can see. I can avoid obstacles and fill the kettle. I'm seeing colours better but I can't see people. I don't see your face. I mean you're there but I just see this shadow. That compartmental nature of vision that may have been her blessing is also proving to be a quiet curse. Just now and again it hits me, you know, why can't I see my daughter's face and who does she look like and it's so frustrating and then I think about it for a while and then I think, oh well, at least I'm here. So as a sequel, so in essence I saw her and then read this wonderful book which I commend to you. You have to read it about three times to understand it but it's a really good book about sight unseen which is an exploration of conscious and unconscious vision in which their patient DF could not consciously see form yet could move accurately and freely through space. And so I referred her to a team in London, Ontario who'd written this book and when she viewed that moving map what happened was these little orange parts of her brain lit up. The bit which had been discovered that when destroyed by strokes on both sides leads to selective disturbance of motion vision and Zill, von Cramer and my were the first people to describe this in 1983 as a specific entity and they coined the term a kind of top seer an inability to see anything that moves. I've now seen many people with this kind of top seer difficulty seeing fast movement but being not being able to but a being able to see slower movement. And now here she is accurately reaching for moving balls. Now, I would love to show you the video and so let's see what happens it should start in a moment. And if it does, we'll be able to see as I was told it was reconfigured to start seeing the movement. So here with what is remarkable is that she is able to move and reach for moving balls accurately and in the script. She said. She gets a, she's viewing big, she's catching bigger balls and little balls and in the script, she actually says, oh, that's the real one. Oh, here we are. There we had a big one and when this next ball comes, watch this. That's a big ball. And now the next one's a little one. And she says, oh, that's the real one. But I didn't know that until I caught it. So here with what is remarkable, showing that she can move freely without even knowing how it happens. When I first met Malina, she gave the story you've just heard. And I said to her, I'd like you to walk around these three chairs and figure of eight fashion. And she said, I don't think I can do that. And I said, I think you can have a go. And she did. She walked perfectly around those chairs at this sort of pace, perfectly able to go around them in figure of eight fashion. And she said, I didn't know I can do that. Because I was aware from this literature that despite having no visual brain whatsoever, according to Gordon Holmes, she was able to move through the world she could not see, accurately. So the obvious thing to prescribe for her was a rocking chair. And that's what I did. So that she could start to learn to see as she moved within her lounge. And so as she rocked, she could see. As she stopped rocking, everything disappeared. Gradually, however, she aimed the ability to be able to see without having to rock. And then Miracle of Miracles. I've read in the book, Sight Unseen, that it's possible to move your finger around the letters you can't see, like an E or an L. And so she later learned to read by outlining each letter that she could not see using her forefinger. And then she learned to imagine doing this or imagine pantomime is also described in the book, Sight Unseen. She became able to read headlines, despite not having what was considered by Gordon Holmes to have a visual brain at all. So how do we understand how do we explain this. We explain it by the fact that the way our brains work is when I got you to put your hands like this. I was explaining that we have visual cortex at the back which does the primary processing of the incoming signal. And then the signal is split into two dimensions. One goes into the temporal lobes. And which is where the library of everything we have ever seen is filed. And we have a complete wonderful library. But it also goes up to the top to the parietal lobes, which is where we create a map in relation to our bodies that enables us to freely move through the world. The lower stream, when a body is lying on the anatomical table. This is on the back. And so the green stream or the vision for action pathway is known as the dorsal stream, and the blue stream which is the vision for perception and recognition pathway is the ventral stream. But she'd lost her visual cortex. She'd lost her ventral stream. The parietal lobe was okay. And so was the movement detection center. And so what this shows us brilliantly and has been published in 2019 in great detail after about 17 years of research on this one lady. And what this shows is that the our brains are dichotomized into two separate distinct entities, one for recognition, and the other that enables you to run up a flight of stairs. I didn't actually judge it. My parietal lobes did it for me without even thinking about it. Does it be you two. The antithesis when vision for action is not working so well. During the first world war, Gordon Holmes is a busy man he also described six further soldiers whose posterior parietal lobe pathways and both sides have been severely injured by shrapnel. So this is the other way around, but their temporal lobes are intact. They could see, see clearly and recognize what they're looking at. But what they although they retained good clarity of vision and good 3D vision, they lost much of their lower vision. They could only give attention to one or two things at once, and they could not use their vision to guide their movements. And so, and they also had lower visual field impairment, as you could see in this image, which is the lack of vision down below is that black area in the upper diagrams. And that is where, so where the shrapnel had gone through the brain. And so that you can see if you look at the lower field, it's going through the positive price load with that looping up of the visual pathway into the positive price or most of us. Oh gosh, let me do that. So now, in fact, this condition had also been discovered in 1909 by Balint, who first described how strokes at the back of the brain in a patient led to the same set of visual difficulties. He could describe Balint syndrome comprising inaccurate visual guidance of movement, inability to see more than one or two things at once, and inability to move both eyes to look at a nominated target. When three year old Chris developed a heart valve infection. This led to bleeding into his brain because the infection I got into the arteries of the brain. And as I told him with visual difficulties, 10 years later, people hadn't realized what his problems were for seven years. But brain imaging showed severe damage to both posterior parietal nodes. And his visual behaviors match those of Balint syndrome. He was the first child with this condition to be described to my knowledge. And as a young child, he was hesitant on stairs. He would lie on the ground with his foot. He would lie on the ground, watching TV upside down to use his upper visual field to watch TV upside down. He would go down the sides on his stomach to use his upper visual field to do that. He would move a plate away to be able to eat, and he would hold up books high up to use his upper visual field. He would play with toys on the kitchen cabinets because again they were up high. All these behaviors were his natural adaptation as not to being able to see down below. He would not jump off a bench. He would not jump into a swimming pool. He became angry when a low table was moved and had difficulty walking on uneven ground, often refusing to cross floor boundaries and refusing to play games with low balls like hockey. These are all natural reactions to not seeing down below. Also, nothing that was dropped was ever picked up. His food is left on the near side of the plate, while his shoes on the floor were missed and constantly getting scuffed. He could reach out accurately above eye level but was clumsy when reaching down below eye level for obvious reasons. And these behaviors are also the natural outcomes of lack or low quality efficient down below. He would look close to screens despite good vision and normal optics in order to singular focus on single elements. He would sometimes listen, I can't see it, you can see the script either, listen by sitting on the floor behind people like this, while also looking away during conversations because he couldn't encompass somebody's face and listen at the same time. There was much mental processing for him. Do you know people that look away from your face when they're listening to you? He disliked patterns and preferred plain ones instead. He also sometimes liked to line up his toys. Why, not because he was autistic, but because he could find them again. He could not find a friend in a group, nor find a toy in a toy box, nor find an item of clothes in a pile of clothes. He was waiting to spread them out instead, while crowded text was very difficult to read. These behaviors are the adaptive reactions and natural outcomes of impaired visual search due to the posterior parietal lobes not having that map. Many of these were the behaviors that Nicola in the first film heard about and recognized for the very first time as being hers too, and that they were all down to her having the same problem. With time, using his strengths and abilities, he learned to scan the ground ahead to declutter his bedroom to master text above what he was reading, so that he would have less to read. Better use his hearing and touch and systematically scan his surroundings. And a year later he showed much greater independence and self esteem whilst behavioral outbursts from frustration were much fewer. A recent research project carried out in Bristol on school children of studying 1480 children has shown that 3.4% of children in mainstream school have got this problem. 3.4%. And there are being diagnosed with behavioral diagnoses, but in fact, they've actually got a specific brain one. And obviously, if one can recognize this problem and take appropriate action, then that makes an enormous difference because it did for this young man and many, many others. He explained that he could couldn't locate where sound was coming from. He liked his new phone because friends called him and he couldn't find them. He has white matter problems around where those red arrows are pointing to. Around the water spaces in the brain or peri ventricular white matter disorder, due to being born prematurely, and he couldn't hear what people said while he was looking at them because there was too much to process. He also didn't know where sound was coming from. But when asked what a kicked ball look like he said, well, it disappears for a few feet but comes back when it's slow down, of course, he actually use those words. He told me he had dyskinetopsia. It's easier in gold because everything is going towards me, he said, he also cannot count fingers on a fast moving hand, but he can only count them when they move that slowly. So he's, this is a common description for being unable to see fast movement. If one looks at this, how do I make the videos work? Can you just do that again? Because it's too much to try and it's like dropping a hat and telling me at the same time. So, if you watch these brains, because you found the recipe, there we are, thank you. What you'll see is the whole brain white matter connections are taken away and now look at them stripped down to the visual system. In a control normal person, the pathway which I called the dorsal stream at the top. That pathway has now been imaged by clever magnetic resonance imaging scanning called tractography, whereas the ventral stream is not so bad. And this is what these people have. They have fewer fibers there. Fewer fibers means less. So this remarkable video of MRI tractography, which was made by lots the Meribet and his team in Boston, really shows us that the ability to handle a lot of data is constrained. Why? Whoops, move on. Everyone thinks about airport security channels. The more security channels that are the shorter the queue, because we, the people, the more channels that are the more quickly people get into the airport, because they are being parallel processed into the airport. Exactly the same provision that data is being parallel processed through to consciousness from the occipital parietal area to the front to gain consciousness of what we see. If there's fewer channels, you can see fewer data, less information, and it everything becomes limited until you have a visual constriction of only being able to see maybe only one thing at once. What would this picture look like? Maybe this only the head of this man can be seen clearly. So one item can be seen clearly like the face of the man on the right. Many affected have a wide gap between their fingers and thumb when reaching or place their hand on top to collect something or even beyond it to grasp it and gather it up as natural adaptations and compensations. If you do it for yourself, if I reach for the glass over to there, I can't reach it with a right gap. I have to gather it up to pick it up. There's my adaptation, because in a more peripheral field, the vision is more blurred. This impaired visual guidance of movement relates to the impaired 3D mental mapping of the scene. Asked us the impairment of visual search. I shouldn't have written brown boxes, but this area creates for us in real time, non-conscious 3D mental emulation of our surroundings that guide our movements, giving the detailed visual motor framework for the 3D emulation of the visual scene in the temporal lobes to be mapped on to. Unlike the occipital lobe scene that relates to the head and eyes, the mapped parietal lobe scene relates to the body. So if somebody has a parietal lesion just there, I've seen them sit in a room and if you ask them to look around, they'll say you're there but you're not. But if you ask them to move their body but they'll say, oh, I can see both half the audience now, but they don't know they can't see that because that's called anosognosia, not to know that you do not know. If you've lost a part of the brain, you cannot know that you've lost what you can't see. So in that game Minecraft, the blocks making up the picture are 3D pixels called voxels. This in a sense is true for the posterior parietal virtual mental map which matches our surroundings and so guides the movement of our hands and feet and bodies. Conceptually if the voxels are big going to fewer nerve cells and movement guided by vision becomes inaccurate. This is called Optic Ataxia. We believe that Optic Ataxia may also have a flip side because a number of little children who are markedly affected fear and cow-off bomb and lash out at approaching people and objects. We of course are all self-referenced. We all think that they see as we see but of course they do not. And so that fear that comes from not being able to map what is coming towards them leads the lashing out. They're not. They're not being naughty. They're doing what comes naturally to protecting themselves. We believe that this likely reflects the impaired 3D mental mapping and have referred to this concept as looming. If I could return to Nicola's video well, I did explain to you that when we're in the audience and she stood on the stage, I said, would you just look out at the audience? She said yes. How many people can you see? She said two. Look away. Look back. How many people do you see now? Two? Are they the same two? Oh certainly not. Could you find the first two? No, that would be impossible. So her damage has led to her having an inability to see more than one or two things at once called simultane agnosia. She had lived with this for a period of 17 years without understanding it. And once she came to understand it, believe it or not, she came to be able to improve her vision. She came to learn to use this little island of vision because she had previously had amnosagnosia for condition. She did not know that she could not see more than one thing at once. That might sound absurd, but that was the truth. And that is the truth for those people with this condition. Once you introduce them to this concept, it all starts to make sense and they can start to learn and find their ways around. So, I'd like them to just say vision is also underpinned with layers of other vision. And remarkably, somebody, people who've had strokes like Malina but not Malina in this case, many of them are able, despite being totally blind, to recognize the emotion of facial expression and the person they're looking at. In fact, in an effective blind site, they can actually detect the affect or emotion of the person they're looking at, even though they can't see them because they're not looking at them. It's sort of paradox. So how does that come about? We blink before we see that fly, don't we? We blink before it, way ahead of seeing it. That's because we've got a protective visual system as well. We've got two crocodiles and not so big in us. And a newborn baby, as I mentioned, will look at the mother. How can they possibly know to do that? How do they know to find the eyes? That is because it is mediated in the brainstem, in the upper midbrain. This non-conscious automatic reflex vision provided by direct pathways from our eyes directly to the upper midbrain which get there faster. The signals from our eyes take a tenth of a second to get to the visual brain, and a tenth of a second to us recognizing it, and therefore we are living a fifth of a second in the past. That's why linesmen are always wrong. And so, in that context, this bit of visual brain is working all hard, all the time for us, and actually it's totally non-conscious and protecting us. So we've got layers of different aspects of vision. So to summarize the conscious vision, this was an advert I found in the BMJ years ago, but it's very accurate because you've got the little man at the front looking through the telescope, passing the information back to the guy at the back in the front of the telescope, who is then categorizing it, and then sending it down to the little man at the back, and he's got his three tubs to actually work out what it is he's looking at in the temporal lobes, and up to the top to map the scene to be able to move through it. Now here, I wanted to show you a video of Daniel, oh it worked this time, and Daniel without a script is rather difficult, but Daniel has two glass eyes. He can find his way about very, very accurately. And he's a friend of mine. So what he's saying here is that blindness for him is trivial. He lost his eyes because he had had tumors in them called retinoblastomas removed at the age of 18 months. He's not seen from the age of 18 months but his parents allowed him to play to explore to find his way about, and he discovered that if he went, you could work out where things were. He was a human bat. I may have actually listened to the program about Daniel on the radio for just recently because it came out recently, and I'll tell you about it shortly, called Batman and Ethan. To actually learn about this Batman and Ethan is really worth watching. And also, some of you may have seen Ethan, because Ethan was the young man who won the, sorry, the national BBC National Competition Young Persons Music Award. I've got nominal aphasia, which is not surprising at the moment. But he is just on the television recently brilliant piano by Chopin. You see it one or two people. So he's been teaching this blind boy called Ethan and was teaching him how to move around. Now watch this that you've seen Daniel. Now watch the video that you're about to see. So there he is. There is Daniel cycling. Now, wait a minute. He's in the blue areas. He's in the light blue areas. All of those people are totally blind. Now here is another boy that's totally blind. And he's going. And so that's what the vision is like for him. But there's Daniel teaching this young man who's blind from eye blindness due to damage to his front of the eyes. Oh, there's me talking about it when I'm a bit younger. And explaining that the vision is in the brain in that area there to his audience. And that was a scanner that that he went through and I'm going to explain what happened because I referred him to the same team in Canada who did some amazing experimental work on Daniel. He's in light blue. There is cycling. He's got two glass eyes. How does he do that? He got he's got placards on his bike. Anyway, for the program that was called Batman and Ethan, I was invited with my watch this watch this he's totally blind. Wow. And they said again. Yeah, there goes. So, so he says, I hear with my ears. He echolocates. He's like a bat or dolphin many other species, we can all potentially do it if we learn it. And even people who've learned it. He's taught people the age of 12 to echolocate and recycle freely. So, in essence, that was that video as scripted. And he just about to show you a little bit. What he does is he holds held held holds up that perspective holding and he goes, and you can hear it change as he moves the perspective to and forward and backwards. Here we are. He's about to bring it towards himself. And it got the pitch changes it goes. It's the sound that you would hear if you're listening to this video. So I'll move on. And I referred him to the same team as I said in London, Ontario, where the they placed him in an anechoic chamber in which there was a solid rod like that, and they asked him to locate it. And then they take him out and move it and then he's located again. And that's the scatter ground of the position as he located it. And remarkably, the upper scatter ground, which is the ability to see with active echolocation is not as good as having a conversation. When he's having a conversation, the echoes around him create imagery and pictures in his mind. And when the Batman and Ethan was being filmed. My son and I, my son's the same age as Ethan and we were, it was his birthday, and we were climbing a hill. And in the distance, there was a cliff and Ethan went, Wow. And, and I was walking with them Batman with Daniel, and he said to me, Oh, beautiful cliffs over there. I said, you can see the cliffs. Yeah. That's what they look like. Well, they stretch from there to there. There's a smooth upper bit and then there's a bit that there's a shelf and then just closer. And he strangled it a bit exact description. I said, How do you see it? I don't really know I see it at the picture in my mind. So they put him that they got Daniel to, and again, you can see the film, this film material through Batman and Ethan on the, by searching for it, you'll pick it up straight away online. So. And what happened to Daniel was he suggested an experiment and that was that he would go around with microphones on his ears, and he would go, as he walked about, he walked really about without bumping into anything. And they recorded his sounds and echoes. They played him in a very expensive functional magnetic resonance imaging scanner that measures blood flow in the active parts of the brain, the visual brain being very active. Hey presto, when they, when they played him his recordings of what they did was they played the recordings of his sounds and echoes. They then played the recordings of his sounds. They subtracted picture two from picture one, which was the recording of the brains blood flow to the echoes only. And you can see that the in Daniel's brain in the top right hand picture on the left hand side, and it's that's the dominant side of the brain that sees more than the left side. He's lighting up with no lighter whatsoever in a control. Daniel uses occipital lobes to see Daniel can see very well thank you very much with no eyes. So what is vision. Vision is a construct of mind, a miraculous construct of mind integrated with all the other senses, and using a vast quantities of processing within the mind. In a sensitive reflection, in a sense, what we are doing is we are creating the image, and we are super imposing it upon what we deem to be reality. Thank you. Thank you very much Gordon on behalf of the society. I apologize for the AV problems that we've had, but knowing Gordon as I do, and being such a good communicator. I don't know anybody else who could cope with the situation so well done Gordon. We have our two roving microphones here. So, from the ether. So does anybody have a question that they'd like to ask just before just before you do. Can I ask a question just to set the ball rolling. What about blind musicians, because of Stevie Wonder. How do they, is it just for you or how do they learn where to put their fingers on the keyboard. Isn't that amazing. I mean, watching Ethan play in the young people's BBC competition. It's amazing. And the answer is that they reference themselves perfectly. Ethan is a good echo locator he'll know precisely where the piano is and where he is precisely. So I think we grossly, we must never be self referencing. Daniel described his schooling as well intentioned structure disempowerment. Thanks very much. Is that working. Very good. Thank you. Two closely related questions. The 3.4% of the Bristol children mentioned 1800 roughly. Did they all have balance syndrome. The point is that none of them had balance syndrome practically. They had subtle mild variants of it. They had difficulty processing a lot of information at once. So it was a form first. We did a fascinating study in Glasgow, where we were recruited to study 100 people, people in various parts of Scotland, who had sought adult literacy tuition. And part of our evaluation was to evaluate why they couldn't see so why they couldn't read. And so we did in depth assessment of their vision, including the capacity to handle complex visual scenes. 97% of those people seeking adult literacy tuition had a mild version of balance. The related question about the 3.4% was, what was the major apparent reason for their problem. Was it prematurity or what. There's a range of causes we teach in medicine. I teach thin maiden traumatic hematologic infective neoplastic metabolic after genetic degenerative not acquired whole range of possibilities. So, for example, the, the, the prematurity is an association or cause, low blood sugar at an early stage of development. It's a difficult pregnancy, or a difficult delivery, where the baby goes blue and has to be resuscitated. All of these are typical stories, but in a round about in my experience around about three to four out of 10, you never find the cause. So the question is one of, one of the back from Garrett. And so, so, could you just give the, because he can't speak. Are many child psychologist aware of this problem. So, could you repeat that are many child psychologists aware of this problem with children, and are looking to see whether it's a problem with the eyesight rather attention deficit disorders and such like. No, despite enormous efforts on our part. It's not well recognized, but we're working hard on it. If you're interested in understanding this in children. We've made a website with about 1000 pages called CVI Scotland, and if you just type in CVI Scotland, you can read lots about it. This is curriculum vitae information or cerebral visual impairment. Yeah, cerebral visual cerebral visual impairment Charlie Victor Indigo Charlie Victor Indigo. A question from Pat's online. She's asking about the echo location. Daniel and Ethan relying primarily on sounds that they're making themselves, or is it the passive sounds are getting from environments that are guiding the most. If you speak to Daniel who is the person who's been the principal world exponent of this, and whose scan has proven that it exists. He'll tell you that both are equally important as is long cane training, and many, many other attributes. It's just as we all have experience of our world through all our senses. The echo location is just one component of a panoply of approaches, which he and the people he's trained employee. T shirt. If the wind is the eyes of the windows of the soul. And we look at a saint called Saint Cuthbert on the, when he was coming to the end of his life. He would live in an environment similar to this your pictures, but he didn't want to see the beauty of the environment, and he built walls around him to kind of see above see into into into kind of ascendance ascendancy and I'm just wondering what your actual experience was this kind of hermit going through at the end of his life. It was a, like you saying in a scientific way, was it an occipital lobe experience, or was he actually touching on some kind of light beyond that. And so, you alluded to the fascinating phenomenon. Those people who have been to Antarctica, where there is nothing but white to see rapidly find that their minds are big, progressively becoming enhanced into their prior memories. And it's, if one considers that 40% of brain activity is visual, but one then eliminates the visual input, then the rich nature of prior knowledge of linguistic knowledge bubbles to the four, because, again, all brains are parallel to remove all that vision. You have a mind which can be replete with the whole elements of soul, body, history, knowledge with the exclusion of vision. I'm going to ask a few questions about the brain before we get to the next one. Going back to what's the nature of your life. Yes. You're asking for a level of knowledge that's not available to me, but part of this, of course, is that bird's eyes are very variable in nature. And the type of bird that I'm conscious of is the Falcon that has a telescope within its eye and can see very, very fine tiny detail in the far distance, but with a peripheral wide peripheral vision, and having eyes on both sides of your head, and they are able to interact means that in the center, there is binocular vision, but for the whole surroundings through 360 degrees and all the way down, they have vision. Yeah. Yeah. Well, one of the very interesting things. Yeah. And it's true for us too. We see our feet when you're walking. I can see my foot now as I look at you. And so I do know where I'm putting my feet, but that is happening automatically. It's that automaticity, which is the miracle. Yes, they are different. I don't know the details of the hour. What is the individual defect specifically associated with dyslexia? Specifically, yes, dyslexia is defined by psychologists as a disability that is a specific disability in reading, despite having good function in all the other elements that will otherwise enable you to read like, like IQ, etc. It has to be a focal deficit. And the dyslexia has would be, and I could give it at least another hour's lecture, because the disability reading has many, many forms. It's been made for a long time and there still is the idea that it is a disability in creating phonemes in the mind that is phonetic and not visual. But people are now recognizing that there is a wide range of visual difficulties, which preclude or interfere with reading, and including the whole the many of the things that I've been talking about. Those are missed, because people are not looking. You can only see what you are cognate for. Otherwise, you miss it. You see driver. He's dyslexic. He doesn't need to read. Absolutely, along with many famous people, including Einstein. What I was referring to is the effect that this has upon, if one eliminates vast amounts of incoming information, it releases the capacity for thought. My last question, please, is society of skill, we're looking at it, but, you know, in America, there's this change of legislation removing the woman's automatic rights to abortion. Yeah. Just to see where I'm going. Do you think that America could be faced with an epidemic of children with visual perception? I don't mean that the majority, but if there are more children born prematurely, you know, children that are, let's say, the result of who are attempted, you know, therapeutic abortion at home, could we be faced with an even larger, maybe faced with an even larger problem. Let me, let me, let me, let me phrase that side with me, it's political, which it wasn't meant to be, but when you get children, we do have more and more children rescued from premature, and that's why, as I understand it, in the past, they would have passed away, they would not have survived. There are a lot of children like us who are wonderful survivors, talented, gifted people. Absolutely. But they do have perceptual problems. But they know it to be their norm. They do, but what my question is, how, what is your strategy to help children with these subtle and complex defects? As a question, because every individual child with cerebral visual impairment has their own specific unique pattern of difficulties that nobody else has, my strategy is to do in depth profiling by in depth detailed analysis of the history examination and careful assessment to find out what each individual child's difficulties are, and then to do our best to construct a sufficient knowledge and information to enhance parenting of the young child, but also at a later time to give in depth feedback to the nature of vision, because what's fascinating is that, as Daniel has taught me a lot, because he regards people with blind, who are blind, are accused of having blindisms of having behaviors which are not quite typical, because they're not like mine, you know. And so Daniel has coined the time, sightism, the sighted people have got all these terrible behaviors that don't really help people that cannot see. So I think what one actually needs is to stop self referencing, stop thinking that you are the way that everybody else perceives the world and think that everybody perceives the world differently. And if somebody drives through that narrow gap, well they've got a visual difficulty, and they're not stupid, but they see the world in their own normal. One memory that I have for them when I was guided by you is you impressed me very much by saying that you are more interested in what these kids can do, rather than what they can't do. Absolutely. So I think playing to this change that was very, as you can see, stages of me to this day. And any, any more questions, there's a. At the back of the back. At the far back, back, back, Phil behind you. And the very wide range of the difference symptoms that you're seeing from the different problems people having. Is there any way of standardizing testing to find which people might need treatments or diagnosis individually or, you know, it's anything that could be done mass screening to try and find people who may need assistance potentially and the, the key appears to be the approach that we've adopted actually and that is we identified a set of 52 questions, which will profile a child's visual difficulty. Since then, we also found that there were five questions of families that would identify with a high level of specificity and sensitivity, children at risk of cerebral visual impairment, who could then be ascertained. Actually structured history taking is emerging. And most recently this literature has suggested a set of just eight questions that will specifically identify very accurately, the children who need to be investigated further. It's by going online and typing in Arvin Chandner to read his paper. The paper I'm talking about was written by a gentleman who's currently in San Francisco by the name of Parvind. I'll ask me at the end. There's another question. Yeah, Phil's there. Not so much a question as a comment. We had the good fortune to be referred to you some time ago. I remember very well. And you did two things which I still recall one was to visit Kelvin Dale Primary School to explain to the teachers, indeed, but the problem which was transformative in terms of their attitude to an intangible set of problems. And you also gave us a 12 page report listing a whole lot of visual disabilities saying this will be useful to you throughout life, which it has been so thank you very much. That's welcome. Thank you. And I was just going to come back to the children you're saying about the percentage of kids down in Bristol and etc. And it seems to be that that's going to end up being quite a large number of children. It's great to identify it but what, where do they go? Where do they get the help? How does that happen? Big question. Society. It's great finding out but what do we then do? Absolutely. And that's why I spent the last 12, the last 10 years of retirement actually creating a website, but mainly with the help of with the, with the drive of a wonderful mom called Helen, whose son has profound visual difficulties. And what was interesting about Helen's story was that she too had been told her child would never speak. Don't forget that the brain processes in time, place and person. Your child can clearly only see one thing at once and therefore any words that refer to anything your child cannot see will have no meaning and therefore be an accessible to him. Your child obviously processes very slowly because the electrical signals go through his brain take a long time to get there and back and therefore you need to start teaching him by using one word for a single experience at a time. And she started by holding his hand and said, and he now I've got a lovely little video of him about three years ago after three years of hard work of him saying, He's never spoken to the age of six, but so what I'm getting at is it we need a sea change in understanding. And what she has done has created online. If you want to have a look at CVI Scotland, you can actually see me giving 61 lectures, each four minutes long five minutes long. We are on the topic for the lay person. So we're doing our best to disseminate it worldwide. And we know that this information is has been accessed in 183 countries and there are only 196 isn't. It's working, but there's a long, long way to go. A long way to go for professions to understand the impact of vision and to learn vision. The big problem is that in, in occupational therapy, physiotherapy, the time devoted to vision is only about two hours. It doesn't come at any of this. It's not there within the undergraduate course until it is there. There's not going to be a service anybody's going to be satisfied with. I think we're going to have to, we're out of time now. I'm afraid. I'm afraid we're out of time. So, and, but, but drinks will be served afterwards should you wish to come around and have a chat. And if you have any specific questions and want to take notes or Professor Dutton's email address. I'm email this address. But I'll just, I'll just wind up by, first of all, thanking you very much. And this is a lifetime's interest that we've heard and explained to us tonight as you can tell it's a complex issue. Not everybody, especially not ophthalmologists like myself to think of ourselves as eye mechanics, sort of simplistically speaking, not many people would have the understanding and insight to go into these matters in depth. And, you know, when we are working near to somebody who's doing something pioneering, we don't realize how special it is until it gets recognized by other people and Gordon has been invited to speak around the world is influenced people. And they have started special clinics training people, often with his help in how to deal with these problematic children, who can be helped. And so this was a quiet revolution, just in my neighborhood, and we only realized it's just about when you were starting to retire and all right, what are we going to do without Gordon. And it was wonderful because there's a whole new branch of the medical profession in ophthalmology, and it is taking off its own way to go. So Gordon, thank you very much. You've given us a wonderful evening. You've coped, and I apologize again for the technical problems. And you've answered the questions with thought and kindness so little token from the Society for you. Thank you very much. Please thank you.