Working with Children with Cortical Visual Impairment From a ...

Working with Children with Cortical Visual Impairment From a ...

1 Working with Children with Cortical Visual Impairment From a PT/OT Perspective Karen Barrows, PT, DPT, MHS, PCS 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 2 2

CORTICAL VISUAL IMPAIRMENTA 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 cant fully explain the childs use of vision 2. history or presence of neurological issues 3. presence of behavior or visual responses collectively associated with CVI 3 3 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 4 4 Characteristics associated with CVI: (Roman-Lantzy 2018) Color Movement Latency Fields

Complexity of object Complexity of array Complexity-sensory Complexity of faces Light Distance Reflexes Novelty Absence of visually guided reach 5 5 Three phases associated with the development of

CVI, 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 childs 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. 6 6 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 wear unnecessary sounds plain clothing or cover busy patterns when working face to face have

CVI appropriate toys/objects/technology available 7 7 8 8 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 childs day obtain visually specific information such as acuity, visual fields, and CVI range when expecting physically demanding skill,

expect visual needs to be simplified 9 9 3 Ds of intervention program Development: provide stimulation and activities at the childs 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: the day increase the length of time of visual use over Phase I (Roman-Lantzy 2018) building visual behavior throughout the childs day, emphasizes environmental modifications to allow the

child to use his vision more consistently in preferred environment and with preferred objects. 10 10 COLOR: 11 11 (Roman-Lantzy 2018) Determine if there is a preferred color, highly saturated primary colors often best

Keep objects limited to one color Have objects stand out against a neutral background Movement: Gently 12 12 (Roman-Lantzy 2018)

move object (gentle shake) within childs 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 13 13

Video: Josian with red balloon video Latency (Roman-Lantzy 2018) Determine the length 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 Note the length of time required to respond to a variety of

objects and activities to determine those most preferred Use preferred objects/activities to increase visual use and slowly add more novel objects to determine progression and challenge the childs visual use (discuss with TVI how to progress to novel) Video: Leonie with yellow light video 14 14 Fields

(Roman-Lantzy 2018) 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 15 15 Complexity of object Keep 16 16 (Roman-Lantzy 2018) object to one color without designs to break the outline of the object

Complexity of Array 17 17 (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 Complexity-Sensory Assess the Keep 18 18 (Roman-Lantzy 2018) sensory levels of the treatment area sound, intense light sources that are distracting, smell, and temperature at reduced/modulated levels or reduce distractions if possible

Complexity-Faces 19 19 (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 Light

20 20 (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 Distance Determine 21 21 (Roman-Lantzy 2018) 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 childs 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. 22 22 Video: Cyrus walking with ipad video Novelty (Roman-Lantzy 2018)

What are the childs 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 23 23 Phase II integrating 24 24 (Roman-Lantzy 2018)

function and vision. The focus of this phase is to build functional use of vision Color Child can now attend to more colors although highly saturated are still preferred Color highlighting of an objects salient, 3-D or 2-D features is needed 25

25 26 26 Video: Abigail standing with ipad video 27 27 Video: Emmett pouring video 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) 28 28 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 29 29 Fields The child 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 childs ability to localize and fixate, dont always work in the preferred field, but encourage using another 30 30 Complexity of object The child 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 31 31 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 32 32 33 33 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 34 34 Complexity-faces Brief fixation

on familiar faces may be possible, especially parents Brief eye contact with image in mirror may be possible 35 35 36 36 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 Visual fixation may occur with 2 dimensional materials on a lighted surface 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 37 37 Novelty Able to fixate on 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

38 38 Visually Guided Reach Often in this phase a child will quickly glance at the object, look away and then reach Video: Savannah reaching for switch 39 39 Phase III focus

40 40 (Roman-Lantzy 2018) on more challenging visual skills such as negotiating the environment, reading, and use of vision throughout the day Color Color highlighting of materials or environment may be needed Video: Striped ball rolling

41 41 42 42 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 43 43 Latency Reduced periods of latency and reduced length of latency noted Occurs

primarily when tired, ill, hungry, postictal 44 44 Fields Able to visually fixate in three fields though may still prefer one or two Lower visual field may still be atypical (often likely)

45 45 Complexity of Object Objects can be fixated upon and recognized with 3+colors or patterns on surface Two dimensional Use images may not require backlighting salient features to identify objects/images

46 46 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) 47 47

Complexity - Sensory Able to visually fixate with increasing levels of competing sensory information Novel environments may require a reduction in sensory complexity 48 48 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 49 49 50

50 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 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 51 51 52 52 53 53 54 54 Novelty Utilizes salient features

to recognize and identify new objects or images Visual curiosity in new environments is seen Visually guided reach Visually guided reach and grasp is seen at all times 55 55

Reminders 56 56 A childs ability 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 childs 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? Even if person is in Phase III, some characteristics such as complexity and fields may never fully resolve 57

57 Questions/Discussion References 58 58 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 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 59 59

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