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Working with Children with Cortical Visual Impairment

From a PT/OT Perspective
Karen Barrows, PT, DPT, MHS, PCS
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Objectives

 Name the ten characteristics associated with CVI

 Understand the three phases of CVI progression

 Learn
treatment techniques and therapy modifications to
support and facilitate the vision of a person with CVI

 Generate treatment modifications and techniques to

support persons with visual loss from cortical visual
impairments (CVI)

 Understand the visual differences in those with CVI

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CORTICAL VISUAL IMPAIRMENT…A
WHOLE NEW PARADIGM
“Visual impairment due to damage or disorder of the visual pathways and
visual centers in the brain, including the pathways servicing visual
perception, cognition, and visual guidance of movement.” Can coexist with
ocular motor disorders and can be the result of perinatal brain dysfunction
or trauma. CVI affects nearly 2/1000 live births and accounts for 20-25% of
visually impaired children in developed countries. (Dutton, Lueck 2015)

A child with CVI meets the following criteria:

1. an eye exam that can’t fully explain the child’s use of vision
2. history or presence of neurological issues
3. presence of behavior or visual responses collectively associated with CVI
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Two main streams of neural visual information:

Dorsal: visual pathway between the occipital and posterior parietal lobes, the
“where” and “how” pathway. It is used to localize and visually search, switch
attention, and visual guidance of movement, mostly subconsciously.

Ventral: visual path between occipital and temporal lobes. Determines “what is
it” to understand what we see, conscious vision. The right temporal lobe
provides the main library of all the faces we recognize, the left lobe is the main
library of shapes and objects
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Characteristics associated with CVI:
(Roman-Lantzy 2018)

Color Complexity-sensory
Movement Complexity of faces
Latency Light
Fields Distance
Complexity of object Reflexes
Complexity of array Novelty
Absence of visually
guided reach
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Three phases associated with the development of CVI, 6
based on Dr. Roman Lantzy CVI range testing

 Phase I: score of 0-3 on the range and refers to the least visually aware
level. The focus of this phase is in building visual behavior throughout
the child’s day, emphasizes environmental modifications to allow the
child to use his vision more consistently in preferred environment and
with preferred objects.

 Phase II: score of 3-7 on the range and refers to integrating function and
vision. The focus of this phase is to build functional use of vision

 Phase III: score of 7+, the focus is on more challenging visual skills such
as negotiating the environment, reading, and use of vision throughout
the day.
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Basic Modifications for all phases:

 have a plain background available/reduce clutter

 have the ability to reduce the light intensity of a room and cover
strong light sources
 eliminate artificial aromas
 reduce/eliminate unnecessary sounds
 wear plain clothing or cover busy patterns when working face to
face
 have CVI appropriate toys/objects/technology available
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Basic Modifications for all phases:

 have options for positioning the child and the objects being
seen

 have child wear corrective lenses if available

 be mindful of the need for rest breaks

 work as a team to provide visual reinforcement during a child’s

day

 obtain visually specific information such as acuity, visual fields,

and CVI range when expecting physically demanding skill,
expect visual needs to be simplified
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“3 Ds” of intervention program

 Development: provide stimulation and activities at the

child’s current developmental levels and increase
complexity over time

 Diversity of visual
stimulation: initiate with regard of
preferred objects, advance to generalized objects then
novel

 Duration: increase the length of time of visual use over

the day
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Phase I (Roman-Lantzy 2018)

 buildingvisual behavior throughout the child’s day,

emphasizes environmental modifications to allow the
child to use his vision more consistently in preferred
environment and with preferred objects.
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COLOR: (Roman-Lantzy 2018)

 Determine ifthere is a preferred color, highly saturated

primary colors often best

 Keep objects limited to one color

 Have objects stand out against a neutral background

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Movement: (Roman-Lantzy 2018)

 Gently move object (gentle shake) within child’s visual

field

 Use
objects that have reflective properties (perceived as
movement)

 Limit distraction of
unintended outside movement i.e..
people walking close by, other objects moving
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Video: Josian with red balloon video

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Latency (Roman-Lantzy 2018)
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 Determine thelength of time an object needs to be

presented before a response is given. Keep in mind that this
can change throughout the day due to fatigue, interest, well
being

 Notethe length of time required to respond to a variety of

objects and activities to determine those most preferred

 Usepreferred objects/activities to increase visual use and

slowly add more novel objects to determine progression and
challenge the child’s visual use (discuss with TVI how to
progress to novel)

Video: Leonie with yellow light video

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Fields (Roman-Lantzy 2018)
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 Determine preferred fields of visual use, remember that lower visual

fields are often impaired therefore present objects in a higher field
with the use of slant boards or other supportive surface

 Most often a child prefers a peripheral field for visual regard, one is
often preferred over another

 Present an object/activity in the preferred field and over time work

toward accessing the other lateral field, superior, midline, and
inferior
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Complexity of object (Roman-Lantzy 2018)

 Keep object to one color without designs to break the

outline of the object
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Complexity of Array (Roman-Lantzy 2018)

 Keep background as neutral as possible by reducing light in room and

using a neutral screen/wall (black, white, cream etc.)

 Assess the environment and cover visually complex areas that the
child may be working in, such as sheets to cover a bookcase, use of
an invisiboard to block a busy view, or use a purposefully blank wall
as a backdrop for focused activities
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Complexity-Sensory (Roman-Lantzy 2018)

 Assess the sensory levels of the treatment area

 Keepsound, intense light sources that are distracting,

smell, and temperature at reduced/modulated levels or
reduce distractions if possible
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Complexity-Faces (Roman-Lantzy 2018)

 Do not assume that the child should look at your face. At

this phase the face is too complex to process. Looking
away and listening to your voice will likely be your best
response (face video)

Josian face regard

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Light (Roman-Lantzy 2018)

 Reduce the ambient lighting in the room to reduce distraction of the

environment and reduce overall complexity

 Provide direct light sources on the object to gain increased visual

attention, trial different color lights such as red and yellow

 Utilize objects that are lit from within or behind. A light box is a good
tool or an ipad with a very simple application i.e.. Fluidity, Electra

Video: Savannah activating

CVI friendly toy video
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Distance (Roman-Lantzy 2018)

 Determine the distance that the child uses his vision best.
Start by holding a simple object within a foot of the child
and slowly progress outward. Assess the child’s ability to
stay focused on the object. As each session occurs, you
may find that the distance of best visual use varies due to
fatigue, illness, and complexity of object. Generally the
closer the object, the easier to use vision.
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Video: Cyrus walking with ipad video

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Novelty (Roman-Lantzy 2018)
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 What are the child’s favorite/preferred toys

 toy may appear to be too visually complex, but the child may be
focusing on the sound and its familiarity

 Slowly increase the novelty of object by presenting new objects with

visual similarities

to

 Present familiar and slightly novel objects within a session as tolerated

 Novel objects presented repeatedly become familiar and preferred

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Phase II (Roman-Lantzy 2018)

 integratingfunction and vision. The focus of this

phase is to build functional use of vision
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Color
 Child can
now attend to more colors although highly
saturated are still preferred

 Color highlighting of an object’s salient, 3-D or 2-D

features is needed
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Video: Abigail standing with ipad video

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Video: Emmett pouring video

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Movement

 Movement may still be needed to elicit attention but not

always to sustain attention

 Still easily distracted with movement in close

environment (approximately 8 feet)
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Latency

 Latency is
steadily reducing especially with familiar
objects and when well rested and feeling well

 Latency can increase when the child has tired of the

object/activity or is fatigued or ill
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Fields

 Thechild is able to localize objects in an additional

peripheral field although may still prefer one

 Continue to present objects in other fields to determine

the child’s ability to localize and fixate, don’t always work
in the preferred field, but encourage using another
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Complexity of object

 Thechild can localize or fixate on objects that have two

or more colored surfaces

 Two dimensional objects may be introduced on backlit

surfaces, i.e.. ipad
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Complexity of array
 General lighting of room may increase

 Backgrounds may need to stay neutral but may start to

become patterned with two colors

 Simple two-dimensional objects may be detected especially

familiar

 Backlighting or focused light may not be required though may

improve focus on novel objects
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Complexity-sensory

 Now able to visually localize and fixate even with low

intensity, familiar sounds and when other single sensory
inputs are present

 As
the child progresses, more complex sensory
backgrounds may be tolerated
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Complexity-faces

 Brief fixation on familiar faces may be possible, especially

parents

 Brief eye contact with image in mirror may be possible

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Light
 Changing of room lighting usually not required

 Child may be
distracted by direct light sources (windows)
but can be more easily re-directed to task

 Visualfixation may occur with 2 dimensional materials on

a lighted surface
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Distance

 Ability to locate and

fixate on a target that is farther
away, 6-10 feet, possible or more, familiar objects are
often located more easily
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Novelty

 Able to fixateon objects that are similar to familiar

objects or on novel objects after several exposures. Able
to view 2 and 3 dimensional material although may not
be able to interpret what the object is. Some visual
curiosity seen
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Visually Guided Reach

 Oftenin this phase a child will quickly glance at the

object, look away and then reach

Video: Savannah reaching for switch

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Phase III (Roman-Lantzy 2018)

 focus on more
challenging visual skills such as negotiating
the environment, reading, and use of vision throughout
the day
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Color 41

 Color highlighting of materials or environment may be

needed

Video: Striped ball rolling

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Movement
 May be occasionally needed to get attention but not to
sustain

 May be distracted with objects farther away, 8+ feet

 Movement will continue to alert to object

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Latency

 Reduced periods of latency and reduced length of latency

noted

 Occurs primarily when tired, ill, hungry, postictal

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Fields
 Able to visually
fixate in three fields though may still
prefer one or two

 Lower visual field may still be atypical (often likely)

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Complexity of Object
 Objects canbe fixated upon and recognized with 3+colors
or patterns on surface

 Two dimensional images may not require backlighting

 Use salient features to identify objects/images

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Complexity of Array
 Able to visually fixate on objects against more complex
backgrounds

 2 dimensional images detected against a

background
with 3+ additional elements (more complex pictures)
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Complexity - Sensory

 Able to visually
fixate with increasing levels of competing
sensory information

 Novel
environments may require a reduction in sensory
complexity
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Complexity- Faces

 Eye contact with familiar and unfamiliar people increases

 May be less attentive to a new or unfamiliar person

 More typical response to mirror image

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Light

 Light gazing no longer an issue

 May attend to strong light sources when tired, ill, or

stressed

 Backlighting continues to assist in regard and

identification of 2 dimensional objects
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Distance

 Able to locate and fixate on targets farther away, as great

at 10+ feet

 Able to see and attend to objects in familiar and novel

settings

 May attend to large moving objects at great distances,

15+ feet
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Novelty
 Utilizes salient features to recognize and identify new
objects or images

 Visual curiosity in new environments is seen

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Visually guided reach

 Visually guided reach and grasp is seen at all times

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Reminders
 A child’sability to use vision under any characteristic can fluctuate
greatly due to internal and external issues such as illness, fatigue,
novelty and complexity of environment
 Do not assume an expected level of visual use at the start of each
activity, assess the child’s function at the time and modify as
needed
 If the child is not appropriately supported or is purposefully being
challenged to hold positions with physical effort, expect visual
skills to be further challenged
 Do these characteristics resemble behaviors seen in ASD?
 Evenif person is in Phase III, some characteristics such as
complexity and fields may never fully resolve
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Questions/Discussion
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References
 Fulton, A. (2017, April). Ophthalmology and Cortical Visual Impairment
in Third Annual CVI Symposium. Perkins School for the Blind,
Watertown, MA.
 Lueck, AH, Dutton, G. N. (Eds.). (2015). Vision and the brain,
understanding cerebral visual impairment in children. NY: AFB Press.
 Holbrook, C., Koenig, A. J. (Eds.). (2000). Foundations of education, 2nd
edition: Vol. 1. NY: AFB Press.
 Roman-Lantzy, C. (2018). Cortical visual impairment, an approach to
assessment and intervention, 2nd edition: NY: AFB Press.
 Presenter, Mazel, E. (2016, July). Cortical visual impairment. presented
at Perkins School for the Blind, Watertown, MA.
 Presenter, Roman-Lantzy, C. (2016). Perkins CVI training initiative.
Presented at Perkins School for the Blind, Watertown, MA
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References
 Third annual CVI symposium: best practices and current
research, Dr. Anne Fulton, 4/7/2017
 Foundations of education seconds edition Vol 1. M. Cay
Holbrook, Alan J. Koenig Eds, AFB Press NY 2000
 Vision and the Brain, understanding cerebral visual impairment
in children, Amanda Hall Lueck, Gordon N. Dutton Eds, AFB
Press 2015 NY
 Cortical Visual Impairment-an approach to assessment and
intervention, 2nd ed, Christine Roman-Lantzy AFB Press NY
2018