cortical vision impairment sharon steed, ms, ccc-slp anmed health [email protected]

Cortical VisionCortical VisionImpairmentImpairmentSharon Steed, MS, CCC-SLPSharon Steed, MS, CCC-SLPAnMED HealthAnMED [email protected]@anmedhealth.org

Training ObjectivesTraining Objectives

Define Cortical Vision Impairment. Define Cortical Vision Impairment. List three potential causes of Cortical Vision List three potential causes of Cortical Vision

Impairments.Impairments. Provide three diagnostic signs of Cortical Provide three diagnostic signs of Cortical

Vision Impairments. Vision Impairments. Describe two treatment strategies to support Describe two treatment strategies to support

progress of an individual with Cortical Vision progress of an individual with Cortical Vision Impairments.Impairments.

Participants will:Participants will:

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Cortical Vision ImpairmentCortical Vision Impairment

Definition:Definition:

A temporary or permanent visual A temporary or permanent visual dysfunction resulting from damage or dysfunction resulting from damage or injury to the visual systems of the injury to the visual systems of the brain. The level of severity can range brain. The level of severity can range from mild to severe depending on the from mild to severe depending on the age of individual at time of insult age of individual at time of insult along with the location and intensity along with the location and intensity of the damage.of the damage.

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Cortical Vision ImpairmentCortical Vision Impairment

Definition continued…Definition continued…

The inability of the brain’s visual The inability of the brain’s visual systems to consistently process and systems to consistently process and interpret visual information.interpret visual information.

- Not a disease or a condition of the - Not a disease or a condition of the eye itself.eye itself.

- Not an indicator of cognitive skills.- Not an indicator of cognitive skills.

Diagnosed by a trained ophthalmologist.Diagnosed by a trained ophthalmologist.

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Cortical Visual Impairment (CVI)Cortical Visual Impairment (CVI)

Also known as neurological visual Also known as neurological visual impairment, cerebral visual impairment, cerebral visual impairment, delayed visual maturation, impairment, delayed visual maturation, or cortical blindness. or cortical blindness.

In North America the condition is In North America the condition is described as “cortical visual described as “cortical visual impairment.” impairment.”

In Europe, the term “cerebral visual In Europe, the term “cerebral visual impairment" is used.impairment" is used.

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Causes of CVICauses of CVI Hypoxic (reduced oxygen to tissue) brain Hypoxic (reduced oxygen to tissue) brain

damage found in:damage found in:- babies who experience Sudden Infant - babies who experience Sudden Infant Death Death Syndrome, but liveSyndrome, but live- individuals who experience a cardiac arrest- individuals who experience a cardiac arrest- individuals resuscitated from drowning - individuals resuscitated from drowning - individuals who have experienced - individuals who have experienced extended extended episodes of epileptic seizuresepisodes of epileptic seizures

Structural brain developmental disorders Structural brain developmental disorders (such as hydrocephalus, spina bifida, (such as hydrocephalus, spina bifida, agenesis of the corpus callosum, and agenesis of the corpus callosum, and microcephaly)microcephaly) 6

Causes of CVICauses of CVI Anoxic brain damage (results from the absence Anoxic brain damage (results from the absence

of oxygen to the tissues---asphyxia occurring of oxygen to the tissues---asphyxia occurring during birth or later in life)during birth or later in life)

Intraventricular hemorrhage (brain bleed often Intraventricular hemorrhage (brain bleed often

occurring in premature infants)occurring in premature infants) Periventricular leukomalacia (reduced blood flow Periventricular leukomalacia (reduced blood flow

to brain’s white matter in premature infants)to brain’s white matter in premature infants)

Stroke in utero (may occur in full-term or Stroke in utero (may occur in full-term or premature infants--in general, cause of stroke premature infants--in general, cause of stroke unknown but can be the result of an episode of unknown but can be the result of an episode of asphyxia)asphyxia)

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Causes of CVICauses of CVI Traumatic Brain InjuryTraumatic Brain Injury

Infections to the brain/central nervous Infections to the brain/central nervous system such as meningitis and encephalitissystem such as meningitis and encephalitis

Progressive disorders (such as Tay Sachs, Progressive disorders (such as Tay Sachs, Batten’s Disease)Batten’s Disease)

Intrauterine infections (STORCH- a medical Intrauterine infections (STORCH- a medical acronym that stands for intrauterine acronym that stands for intrauterine infections transferred to the baby through the infections transferred to the baby through the placenta which includes S-syphilis, T- placenta which includes S-syphilis, T- toxoplasmosis, O-others such as hepatitis, toxoplasmosis, O-others such as hepatitis, HIV, West Nile virus, malaria, tuberculosis, R-HIV, West Nile virus, malaria, tuberculosis, R-rubella, C- cytomegalovirus, and H- Herpes rubella, C- cytomegalovirus, and H- Herpes Simplex virus)Simplex virus)

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General Characteristics of General Characteristics of Individuals with CVIIndividuals with CVI

May also have visual impairments such as May also have visual impairments such as optic nerve atrophy, optic nerve dysplasia, optic nerve atrophy, optic nerve dysplasia, strabismus.strabismus.

Often have no or a poor visual response even Often have no or a poor visual response even in the presence of a normal vision exam and in the presence of a normal vision exam and normally functioning pupils.normally functioning pupils.

May have multiple disabilities to include motor May have multiple disabilities to include motor and/or cognitive delays, problems and/or cognitive delays, problems communicating and learning language as the communicating and learning language as the result of cerebral palsy, seizures, severe to result of cerebral palsy, seizures, severe to mild learning disabilities and other neurological mild learning disabilities and other neurological problems.problems.

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General Characteristics of General Characteristics of Individuals with CVIIndividuals with CVI

Approximately 80% of Approximately 80% of children with cerebral children with cerebral palsy also have CVIpalsy also have CVI

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Diagnostic Signs of CVIDiagnostic Signs of CVI The lack of blinking (atypical visual reflexes).The lack of blinking (atypical visual reflexes).

Staring at lights for an extended period. (light Staring at lights for an extended period. (light gazing preference).gazing preference).

Tends to turn his or her head to the side when Tends to turn his or her head to the side when reaching for an object (unable to demonstrate an reaching for an object (unable to demonstrate an intact visual guided reach).intact visual guided reach).

A short visual attention span, but may improve if A short visual attention span, but may improve if object is moving.object is moving.

Items in parenthesis are key visual behaviors to Items in parenthesis are key visual behaviors to assess and target in treatment. assess and target in treatment.

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Diagnostic Signs of CVIDiagnostic Signs of CVI Problems with looking at an object presented at Problems with looking at an object presented at

a distance (distance viewing is difficult and a distance (distance viewing is difficult and varies at different phases). varies at different phases).

Fluctuations in visual functioning throughout the Fluctuations in visual functioning throughout the day.day.

Perceives color—has color preference of usually Perceives color—has color preference of usually red or yellow. red or yellow.

Problems with objects presented in some visual Problems with objects presented in some visual fields (visual field preferences may use one fields (visual field preferences may use one peripheral field better or may use central vision). peripheral field better or may use central vision).

Fatigues quickly when engaged in visual Fatigues quickly when engaged in visual activities.activities.

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Diagnostic Signs of CVIDiagnostic Signs of CVI Prefers to look at familiar rather than new Prefers to look at familiar rather than new

objects (problems with visual novelty). objects (problems with visual novelty). Needs extended response time when looking Needs extended response time when looking

at objects.at objects. Problems looking at objects that are visually Problems looking at objects that are visually

complex (difficulties with visual complexity).complex (difficulties with visual complexity).

The severity level of an individual’s CVI often The severity level of an individual’s CVI often correlates to the number of characteristics he correlates to the number of characteristics he or she demonstrates. Remember : An or she demonstrates. Remember : An individual with CVI may improve.individual with CVI may improve.

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Scoring Range for CVIScoring Range for CVI

Phase I: CVI Range Level 0 to 3 (inconsistent visual attention on Phase I: CVI Range Level 0 to 3 (inconsistent visual attention on objects)objects)

- Need single color or personally preferred color - Need single color or personally preferred color

objects.objects.

- Shiny objects.- Shiny objects.

- Objects with movement .- Objects with movement .

- Familiar objects.- Familiar objects.

- Objects presented in a simple background.- Objects presented in a simple background.

Roman-Lantzy, Cortical Visual Impairment: Roman-Lantzy, Cortical Visual Impairment:

An Approach to Assessment and Intervention, 2007An Approach to Assessment and Intervention, 2007

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Phase I: CVI Range Level 0 to 3 Phase I: CVI Range Level 0 to 3 ( inconsistent visual attention on objects)( inconsistent visual attention on objects)

- Identify 3-5 objects to use with an individual - Identify 3-5 objects to use with an individual based on observation and assessment. based on observation and assessment.

- Suggested objects: slinky, reflective pinwheel, - Suggested objects: slinky, reflective pinwheel, windsock, Elmo doll, mobile made out of windsock, Elmo doll, mobile made out of

silverware.silverware.

-- Design activities focusing on Design activities focusing on

the use of these objects for the use of these objects for

repeated practice in a repeated practice in a

supportive environment.supportive environment.15


Phase I: CVI Range Level 0 to 3 ( inconsistent Phase I: CVI Range Level 0 to 3 ( inconsistent visual attention on objects)visual attention on objects)

If individual demonstrates signs of fatigue (such If individual demonstrates signs of fatigue (such as yawning, avoiding looking, sleeping, closing as yawning, avoiding looking, sleeping, closing eyes, grimacing, yawning, etc.) try: eyes, grimacing, yawning, etc.) try:

- Reducing stimuli.- Reducing stimuli.

- Providing longer periods of visual - Providing longer periods of visual gazing.gazing.

- Reducing stimuli in setting.- Reducing stimuli in setting.

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Phase II: CVI Range Level 4 to 7 ( some functional Phase II: CVI Range Level 4 to 7 ( some functional use of vision )use of vision )

Use individual’s favorite color and add one Use individual’s favorite color and add one or two more colors.or two more colors.

- Individual should begin to tolerate - Individual should begin to tolerate more complex visual patterns. more complex visual patterns.

Put reflective strips on objects. Put reflective strips on objects.

- Reduction in light gazing by - Reduction in light gazing by individualindividual

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Phase II: CVI Range Level 4 to 7 ( some functional use of Phase II: CVI Range Level 4 to 7 ( some functional use of vision vision )

Use objects from daily routines and activities Use objects from daily routines and activities that are the individual’s preferred colorthat are the individual’s preferred color

- May also wrap in reflective material. - May also wrap in reflective material.

- Includes toothbrush, cup, fork, switches, - Includes toothbrush, cup, fork, switches, lightbox, etc. lightbox, etc.

- Use new objects that are the individual’s - Use new objects that are the individual’s preferred color during activities. preferred color during activities.

- Place objects on black or plain - Place objects on black or plain backgrounds to support the visually backgrounds to support the visually

guided reach skill. guided reach skill.

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Phase III: CVI Range Level 7 ½ to 10 ( using vision Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )to perform most activities )

- - Beginning to demonstrate a visually Beginning to demonstrate a visually guided guided reach. reach.

- Problems continue with complex visual - Problems continue with complex visual setting. setting.

- Difficulty with images/words on paper. - Difficulty with images/words on paper.

- Problems with objects over 10-15 feet - Problems with objects over 10-15 feet from from the individual. the individual.

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Suggested objects: highlighters, simple picture Suggested objects: highlighters, simple picture books with outline only, theme based books books with outline only, theme based books “my favorite toys”, “foods I like to eat” and “my favorite toys”, “foods I like to eat” and others, use photos only of faces initially, can others, use photos only of faces initially, can begin to use mirrors, communication symbols of begin to use mirrors, communication symbols of individual’s favorite color, and favorite items individual’s favorite color, and favorite items with simple backgrounds.with simple backgrounds.

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Phase III: CVI Range Level 7 ½ to 10 ( using vision to Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )perform most activities )

Focus on two major skills in this phase: Focus on two major skills in this phase: 1) Activities should be designed to support the 1) Activities should be designed to support the individual in improving skill in determining how individual in improving skill in determining how

objects are the same or different using visual objects are the same or different using visual features.features.- For example, taking old information or familiar - For example, taking old information or familiar

object and relate it to something new but object and relate it to something new but similar similar as the actual interaction takes as the actual interaction takes place with the place with the new object. (i.e. new object. (i.e. compare a bus to the family compare a bus to the family car) car)

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Focus on two major skills in this phase Focus on two major skills in this phase (continued): (continued):

2) Support the individual to use his or her vision 2) Support the individual to use his or her vision to to discern visual details from the discern visual details from the background, background, visually visually discriminate discriminate within the setting and deal with visually within the setting and deal with visually complex objects successfully.complex objects successfully.

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For example:For example:

Begin with a simple book that uses the Begin with a simple book that uses the individuals favorite color for the main individuals favorite color for the main character or object in the story, such as character or object in the story, such as Clifford, the red dog. The activities range Clifford, the red dog. The activities range from from finding a stuffed Clifford, to using a finding a stuffed Clifford, to using a pop-up pop-up book about Clifford to visually locating a Clifford book about Clifford to visually locating a Clifford

dog with movement to finding smaller dog with movement to finding smaller Cliffords Cliffords in a “hidden picture” type activity.in a “hidden picture” type activity.

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Remember to watch for signs of the Remember to watch for signs of the individual fatiguing, dealing with too individual fatiguing, dealing with too much new information, being much new information, being

stressed stressed or over stimulated during or over stimulated during activities in activities in each of these phases.each of these phases.

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Treatment IdeasTreatment Ideas

Using the individual’s favorite color items may Using the individual’s favorite color items may stimulate visual attention on an objects being stimulate visual attention on an objects being used in activities.used in activities.

When presenting the object to the individual, When presenting the object to the individual, say the name of the item, place item on left or say the name of the item, place item on left or right side (not in the center) and wait for an right side (not in the center) and wait for an extended period.extended period.

Use simple designs.Use simple designs.

Use objects with movement and/or reflective Use objects with movement and/or reflective material.material.

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Attach deflated mylar balloons on objects to Attach deflated mylar balloons on objects to give the illusion of movement.give the illusion of movement.

Reduce the complexity in environment, on the Reduce the complexity in environment, on the pages of a book pages of a book

Minimize input to all senses. Do not reward Minimize input to all senses. Do not reward individual with praise, food, touch until he or individual with praise, food, touch until he or she has ended his or her visual attention to she has ended his or her visual attention to an object.an object.

Presenting items close to the individual—Presenting items close to the individual—maximum distance is 18”-24”.maximum distance is 18”-24”.

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Watch the individual during the session for Watch the individual during the session for signs of tiring.signs of tiring.

Make sure the individual is positioned with as Make sure the individual is positioned with as much physical support as needed.much physical support as needed.

Place light source behind or beside individual.Place light source behind or beside individual.

Provide an extended wait time before Provide an extended wait time before

expecting the individual to visually respond.expecting the individual to visually respond.

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Wait…Wait…Wait…Wait…Wait…Wait…and…and…

WaitWait

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AT and Treatment IdeasAT and Treatment Ideas Work in a room where noise and lighting Work in a room where noise and lighting

can be controlled.can be controlled.

Consider switch colors, size contrast colorsConsider switch colors, size contrast colors

—think about how you can adapt the switch —think about how you can adapt the switch with materials and colors based on the with materials and colors based on the individual’s preferences and CVI needs.individual’s preferences and CVI needs.

Consider placement of switches based onConsider placement of switches based on

the individual’s motoric skills and CVI the individual’s motoric skills and CVI needs.needs.

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AT and Treatment IdeasAT and Treatment Ideas

Initially, individuals with CVI demonstrate a Initially, individuals with CVI demonstrate a preference towards movement only. Use toys preference towards movement only. Use toys with sound later if appropriate.with sound later if appropriate.

Start with simple puzzles with each piece Start with simple puzzles with each piece outlined in black.outlined in black.

Select symbols based on individual’s color Select symbols based on individual’s color preferences, need for lack of background preferences, need for lack of background clutter, personal interests and contrasting clutter, personal interests and contrasting colors. colors.

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AT and Treatment IdeasAT and Treatment Ideas

Select books with a single picture per page Select books with a single picture per page and simple backgrounds.and simple backgrounds.

Books should have one theme and contain Books should have one theme and contain familiar items.familiar items.

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AT and Treatment IdeasAT and Treatment Ideas If augmentative communication devices are needed, If augmentative communication devices are needed,

consider the following techniques and features:consider the following techniques and features:- partner assisted scanning.- partner assisted scanning.

- a communication system with or without - a communication system with or without speech output that includes tactile speech output that includes tactile

input.input.

- a speech device with a zoom text feature.- a speech device with a zoom text feature.

- two-switch auditory - two-switch auditory scanning to access scanning to access a speech output a speech output communication communication device. device.

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Notes from a presentation at ATIA 2008 on CVI by Debbie Notes from a presentation at ATIA 2008 on CVI by Debbie Budash and Kathy Quesenberry, West Virginia Dept of Budash and Kathy Quesenberry, West Virginia Dept of Education.Education. Roman-Lantzy, Christine (2007). Cortical Visual Impairment Roman-Lantzy, Christine (2007). Cortical Visual Impairment An Approach to Assessment and Intervention, ISBN 978-0-An Approach to Assessment and Intervention, ISBN 978-0-89128-829-0 Can be ordered from American Foundation for 89128-829-0 Can be ordered from American Foundation for the Blind at www.afb.org/storethe Blind at www.afb.org/store www.blindbabiestypepad.comwww.blindbabiestypepad.comScroll down to area on Fact Sheets to include Cortical Visual Scroll down to area on Fact Sheets to include Cortical Visual ImpairmentImpairment. . www.idahocdhd.org/DNN/Default.aspx?www.idahocdhd.org/DNN/Default.aspx?alias=www.idahocdhd.org/dnn/cydb Idaho alias=www.idahocdhd.org/dnn/cydb Idaho Project for Children and Youth with Deaf-Blindness- click on Project for Children and Youth with Deaf-Blindness- click on fact sheets on side bar to locate information on Cortical fact sheets on side bar to locate information on Cortical Visual ImpairmentVisual Impairment. .

Helpful References/WebsitesHelpful References/Websites

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www.lburkhart.com/handcvi.htm www.lburkhart.com/handcvi.htm Developing Visual Skills for Children who Face Cortical Visual Developing Visual Skills for Children who Face Cortical Visual Impairments by Linda J. BurkhartImpairments by Linda J. Burkhart..

www.tsbvi.edu/Outrach/seehear/fall98/cortical.htm www.tsbvi.edu/Outrach/seehear/fall98/cortical.htm Cortical Visual Impairment Pediatric Visual Diagnosis Fact Cortical Visual Impairment Pediatric Visual Diagnosis Fact Sheet Reprinted from Blind Babies Foundation.Sheet Reprinted from Blind Babies Foundation.

www.sesa.org/newsltr/ref_CVI/cvi5.html www.sesa.org/newsltr/ref_CVI/cvi5.html Special Education Service Agency ( SESA) Intervention Special Education Service Agency ( SESA) Intervention strategies for a Student with Cortical Visual Impairment by strategies for a Student with Cortical Visual Impairment by Alan Weinstein, Anchorage School District.Alan Weinstein, Anchorage School District.

www.sfsu.edu www.sfsu.edu California Deaf –Blind Services –Cortical Visual Impairment California Deaf –Blind Services –Cortical Visual Impairment Fact Sheet.Fact Sheet.

www.unr.edu/educ/ndsip www.unr.edu/educ/ndsip Nevada Dual Sensory Impairment Project Tips for Home or Nevada Dual Sensory Impairment Project Tips for Home or School on Cortical Visual Impairment.School on Cortical Visual Impairment.

Helpful WebsitesHelpful Websites

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Thank you!Thank you!

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cortical vision impairment sharon steed, ms, ccc-slp anmed health [email protected]

Documents

cortical visual impairment

neurological visual

visual maturation

visual information

cortical blindness

brains visual systems

permanent visual dysfunction

premature infants stroke