Cortical Visual Impairment: What’s the Scoop?Susan Brennan, PhD, susan.brennan@iaedb.orgRegional Director/Deafblind Project DirectorCynthia White-Botello, MS Ed, cindy.whitebotello@iaedb.orgConsultant for Children with Multiple Disabilities & Deafblindness

� Overview of Cortical Visual Impairment (CVI)� Ten Characteristics of CVI� Three Phases of CVI� The CVI FVA

� CVI, Communication & AAC� Closing

1

Cortical Visual Impairment (CVI)� This condition refers to the inability of the brain to

process visual information provided by the ocular system causing the child to have difficulty using the visual input received.

� Has potential for improvement � CVI can be paired with an ocular impairment, or found

alone.� CVI is not an indication of the child’s cognitive ability� It frequently occurs with other disabilities as a result of

the brain injury� Relatively new etiology

2

A child with CVI may perceive the world as a kaleidoscope of meaningless

visual patterns

Roman-Lantzy. “Cortical Visual Impairment” Perkins School for the Blind & Visually Impaired, Fitchburg State University online, Fall 2018.

What causes CVI?�Premature birth�Brain injury�Central nervous system infections�Brain defects or malformation�Any situation that causes oxygen deprivation to the brain

4

Determining if the Child has CVI

Three Gates:1. Medical History – file review, neurological assessment is best.

2. A normal eye exam which does not explain why the child is not able to use their vision

3. The unique CVI characteristics are present

5

6

10 Characteristics of CVI1. Color preference2. Need for movement3. Visual latency4. Visual field preferences5. Difficulties with visual complexity6. Need for light7. Difficulty with distance viewing8. Atypical visual reflexes9. Difficulty with visual novelty10. Absence of visually guided reach

1. Color Preference or attraction�Highly saturated or vibrant colors

may alert and help to maintain visual attention �Red and yellow are frequently

preferred�Use of color can serve as a visual

anchor

7

8

2. Need for Movement�Movement of the object�Shiny or reflective

objects�Child is moving

(independently or being moved)�Child moves head

Roman-Lantzy. “Cortical Visual Impairment” Perkins School for the Blind & Visually Impaired, Fitchburg State University online, Fall 2018.

3. Visual Latency� It may take the child extended

periods of time to demonstrate a visual response.�Child may demonstrate a delay in

using vision to “look at” a target when a new item is presented or a new activity starts.

9

Roman-Lantzy. “Cortical Visual Impairment” Perkins School for the Blind & Visually Impaired, Fitchburg State University online, Fall 2018.

4. Visual Field: Preferences or Difficulties

�Child typically shows a field dependency or preference. They have a place where their “best use of vision” is noted.�Child will typically use peripheral vision. �Commonly dysfunction of lower field is present �Rare that central field is preferred,

�Child often appears to be “looking through” people or objects.

10

5. Complexity

Graphic from "Literacy Adaptations for Students Who are Deafblind" webinar, www.perkinselearning.org

11

• Surface of the object• Visual array• Sensory environment: internal &

external • Human face

12

6. Need for light� Staring at lights or light

sources is often observed in early phases�May be difficult to redirect

child’s attention away from a light source.� Sources of light should be

positioned behind child IF they are being asked t look at a competing visual target� Can be used as a visual

anchor (iPad, light boxes)

13

7. Difficulty with Distance Viewing�Students may try to bring

visual target close �May be related to

complexity of array, child brings the target in to crowd out other competing visual targets. �Often never resolves

8. Atypical Visual Reflex response

�Blink to touch between eye brows�Blink to threat�Reflexes often absent, latent, or inconsistent* Observe response time from when an object is presented until the student turns to look at the object

14

9. Visual Novelty

�Children prefer familiar items over novel items.�May “ignore” something novel.�Different from ocular impairments, typically novelty attracts attention.

15

10. Absence of visually directed reach�Typically presents as impaired visually guided reach�reflects difficulty with the integration of dorsal & ventral stream processing

16

Complexity of object17

Complexity of array

18

Complexity of sensory environment

19

Human faces and facial expressions

20

Turn to the person on your right…�Which characteristics have you seen the most?�Are there characteristics that you find difficult to identify?

21

CVI Phases

�Phase 1 : building visual behavior

�Phase 2: integrating vision with function

�Phase 3: refinement of CVI characteristics*

22

Dorsal vs ventral stream processing

https://aeolipera.wordpress.com/2017/11/14/rostral-caudal-streams-a-speculative-thing-i-done-did/

Phase I – students in this phase require environments without visual or auditory distractions. Goal is building consistent visual behavior for children who barely use their vision at all, except in the most controlled situations.

24

Characteristics of Phase I:

1. Dominant color preference

2. Require significant wait time, even with familiar objects

3. Need a clean, simple background

4. Working to become consistent in looking at a small

repertoire of objects

Phase II: Student can maintain visual attention in environments with some visual and auditory competition.

Goal is integrating vision with function. Characteristics of Phase II:

1. More consistent eye-to-object contact with favorite colored objects

2. Looking at the object cannot consistently be equated with interpreting (moving from dorsal to ventral stream processing)

3. Salient features and comparative thought now become a need

25

Considerations in Phase II:

�Complexity needs to be controlled but they can interpret more patterns on 3-D objects�By the end on Phase ll simple 2-D forms (pictures) can be used�The use of light or a preferred color can be used as an anchor to draw in visual attention

26

Phase III “refinement” of the CVI characteristics

Goal is to facilitate “resolution” of the CVI

characteristics that remain active and that affect the

student.

� Student is able to function visually, may not appear as a

recognizably as a student with CVI

� Difficulty with visual complexity, novelty, distance viewing and field

may persist

Currently, it is believed that CVI never truly resolves.

27

Phase III: Students can locate objects in typical or non-adapted settings.

In Phase III the goal is to facilitate “resolution” of the CVI characteristics that remain active and that affect the student.

Characteristics of Phase III:

1. Difficulties with complexity in two-dimensional materials

2. Difficulty with visual complexity

3. Difficulty with distance viewing, especially in unfamiliar indoor and in outdoor areas, most commonly in the lower fields.

4. Difficulty with visually guided reach when the object is very small or against a complex background.

28

Turn to the person on your left side…�Which phase are most of your students/clients in?�Which phase do you find most difficult to develop interventions?�What is one question you have about the phases?

29

30

Sensory Access• CVI Phase and

Characteristics• Preferred learning

channels

Communication LevelAccess

• Presymbolic/Symbolic• Prelinguistic/Linguistic

A Balanced Communication Plan

• Multi-sensory access• Universal Design

• Model TOTALCOMMUNICATION• Provide a robust AAC program

receptively

Sensory Access for CVI: Design and Implementation

MaterialConsiderationsWhat does the AAC system look/feel

like?

Environmental Considerations How can the setting be modified?

Presentation of AACHow can the learner best access theAAC

system/mode?

Des

ign

Impl

emen

tatio

n

Chris Russell, 2019

Phase I Intervention: Most Characteristics

��NO visual processing of 2-‐D

��Maximize visual access to modalities but don’t expect visual fixation

��Tactile components are critical

Goal: Stabilize visual functioning

Looking is a goal in itself

High level of environmental control

Chris Russell, 2019

Color Complexity Light

Tactile &/or auditory access with visual adaptations

Chris Russell, 2019

Phase II Intervention

Goal: Integrate Vision and Function

What needs to be adapted visually in order to elicitand sustain visual

attention at targeted points in a routine?

• Able to use vision in activities, with adaptations and opportunities

• Early ÆÆLate Phase II• Level of visual

adaptation needed

• 2D emergingCVI Schedule & PlanningTools

Chris Russell, 2019

Color Complexity Light

Visual Novelty Visual Fields

Iconicity – 3D,2DObjects, partial objects Photos, line drawings

Phase III Intervention

Salient feature -‐what specific part of the symbol gives it unique meaning?

“Critical component” (Bent & Buckley, 2013)

Goal: Vision for learning

• Demonstrate visual curiosity

• Can process 2-‐D• Need

adaptations to support learning and visual vocabulary

Chris Russell, 2019

Colored Keyguard http://www.laseredpics.biz

Beware of glare!

Don’t limit the number of cells on a device; Limit the number of cells used in the array

Chris Russell, 2019

Visual & Tactile Modifications to Sign

All Phases:Consider background complexity (clothing, backdrop)

Phase I:• Tactile Sign / Hand-‐Under-‐Hand Modeling

Phase II (Early ÆÆLate):• Visual sign at near, tactile supports still needed• Consider visual field preferences -‐tracking• Reduced complexity of backdropis critical• Allow for “looking away” in visually guided reach

Phase III:• Visual sign may be accessible at increased

distance• Tactile modifications still may be needed in

complex or novel environments

Accessible Back-‐channeling: VisualTactile

Auditory Combination/TOTALCOMM.

Chris Russell, 2019

Environmental Considerations & Presentation

Complexity

Light Color

Visual Fields

Distance

Movement Visual Novelty

Closing: My CVI Journey

Questions, Comments,

Closing

44

Where to go for more information..� Cortical Visual Impairment (CVI)� “Cortical Visual Impairment: An Approach to Assessment &

Intervention” by Christine Roman-Lantzy � Cortical Visual Impairment by APH http://tech.aph.org/cvi/� Strategies to See https://strategytosee.com/

� Visual Impairments General� Perkins School for the Blind

http://www.perkinselearning.org/videos/about-watch-learn� Paths to Literacy http://www.pathstoliteracy.org/

45

Bibliography� Russell, Christopher. Cortical Visual Impairment: Focus on

Alternative and Augmentative Communication. Deafblind Summer Symposium, June 6, 2019.

� Roman-Lantzy, C. (2018). Cortical Visual Impairment: An Approach to Assessment and Intervention. New York: AFB Press.� Roman-Lantzy, C. (2018). Cortical Visual Impairment. Course

through Perkins School for the

46

This%tool%was%developed%using%content%from:%Roman,%C.%(2007)%Cortical%visual%impairment:%An%approach%to%assessment%and%intervention.%%New$York,$NY:$AFB$Press.$Presymbolic%and%emerging%symbolic%communication%development%can%be%assessed%using%The$Communication$Matrix:%Rowland,%C.%(1996).%Communication%matrix.%Portland,$OR:$Design$to$Learn.$

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Tactile%tangible%symbols%for%anticipation2%

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Use%highNtech%devices%(iPad,%tablet)%for%visual%experiences%with%looking%at%preferred%apps%that%include%color%and%movement,%with%minimal%complexity.%

Use%whole%or%partial%objects%that%are%concrete%representations%of%preferred%and%frequent%activities,%events,%objects%

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Considerations%for%receptive%and%modeled%sign%language:%In%Phase%I,%the%learner%may%need%to%receive%sign%language%tactilely%or%with%handNunderNhand%support.%In%all%Phases%consider%background%complexity%when%presenting%signs%(clothing,%backdrop).%

Design

(

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Outline%visual%AAC%targets%with%(colored)%tactile%components%(keyguards,%tactile%grids)%

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Light:%Illuminate%visual%targets%with%a%flashlight,%from%behind;%Present%items%on%a%lightNbox(

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Visual%Field%Preference:%Present%all%AAC%materials%in%the%learner’s%preferred%visual%field(s).(

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Present%AAC%against%a%black%trifold%board%to%reduce%visual%complexity,%present%visual%targets%one%at%a%time.(

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CVI%Phase%I:%Designing%and%Implementing%Appropriate%AAC%Goal%of%Phase%I%intervention:%Stabilize%Visual%Functioning%

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DRAFT - NOT FOR DUPLICATION OR DISSEMINATION - New York Deaf-Blind Collaborative, 2016

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Material(Considerations(–(What(does(the(AAC(system(look/feel(like?%

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Novelty:%Develop%AAC%vocabulary%with%familiar%items%and%words,%pair%with%familiar%objects%and%highly%adapted%2LD%images%such%as%photos%of%real%objects.%%

Light:%Support%use%of%visually%difficult%targets%with%backLlighting,%either%on%the%display/target%itself,%or%on%a%light%box%

If%the%learner%is%able%to%access%2LD%targets,%minimize%complexity%of%array%and%target%(for%any%form%of%AAC).%

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CVI%Phase%II:%Designing%and%Implementing%Appropriate%AAC%Goal%of%Phase%II%intervention:%Integrate%Vision%&%Function%

%

In%Phase%II,%the%learner%is%able%to%use%vision%to%access%information%(to%varying%degrees)%within%activities%throughout%the%day.%%The%learner%in%Phase%II%requires%

thoughtful%adaptations%to%support%visual%attention%in%all%activities/routines%based%on%how%the%CVI%Characteristics%specifically%affect%his/her%functional%vision.1%

%

1%Complete%The(CVI(Range((Roman,(2007)%before%using%this%tool.%In%Phase%II%in%particular%it%will%be%useful%for%the%collaborative%team%to%complete%a%CVI%Schedule%(Roman,%2007)%to%plan%specific%adaptations%to%materials%and%presentation%based%on%which%Characteristics%are%most%impacted%in%each%activity,%throughout%the%day.%%2%Do%not%limit%the%number%of%cells%in%a%display;%use%occluders%to%block%unused%cells.%

DRAFT - NOT FOR DUPLICATION OR DISSEMINATION - New York Deaf-Blind Collaborative, 2016

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Voice%output%devices%and%dynamic%displays:%%Displays%may%have%increasingly%complex%arrays;%May%require%increased%adaptation%to%highlight%salient%features%of%target%for%each%symbol%used%

Visually%concrete%tangible%symbols%for%anticipation:%Increase%complexity%of%target%(items%with%6L8%colors%and%patterns);%provide%receptive%exposure%to%2LD%images%but%do%not%use%as%primary%expressive%mode%%

Teach%visual%discrimination,%recognition%and%identification%of%familiar%and%novel%items%using%tangible%symbols%as%categories%for%sorting%and%referring%to%these%items%

iPads%and%tablets:%May%use%in%conjunction%with%multiple%modes%of%communication%with%increased%complexity%of%array%and%target;%May%use%as%dynamic%communication%device,%and%also%for%literacy,%games%and%activities%

Consistently%highlight%salient%features%on%%partial%or%whole%objects%that%concretely%represent%preferred%%activities,%events,%people%

Introduce%learner%to%a%wider%range%of%partial%and%whole%objects%while%emphasizing%the%salient%visual%features%connecting%them%conceptually%

Assess%specific%need%for%presenting%2LD%images%with%color%highlights,%frames,%and%occluders;%May%benefit%from%outlining%large%print%words%with%color%(bubbling)%

Considerations%for%receptive%and%modeled%sign%language:%Visual%sign%at%increased%distance,%with%reduced%complexity%of%backdrop%including%clothing%and%background.%%

Desig

n(

Material(Considerations(–(What(does(the(AAC(system(look/feel(like?%

Color:%Increased%number%of%colors%on%a%display%or%target%(6L8);%Use%color%to%outline%(bubble)%words%and%highlight%salient%features%of%complex%%2LD%visual%information%on%symbols,%images,%books.%

Complexity:%Increased%complexity%of%array%and%target%on%2LD%materials%and%on%background%patterns;%Support%with%adaptations%to%salient%features%of%targets%%

Novelty:%Use%AAC%symbols%that%closely%represent%familiar%visual%vocabulary.%Increase%novelty%by%showing%different%images/symbols%of%these%core%vocabulary%while%highlighting%and%teaching%salient%features%

Light:%Use%backLlighting%to%support%access%to%2LD%and%complex%targets%(iPad/tablet,%dynamic%display)%as%needed%

Complexity:%Increased%number%of%cells%visible%on%displays%and%number%of%symbols%used%on%communication%boards%

Increased%simultaneous%use%of%multimodal%(total)%communication,%for%example%using%speech/sign%and%visual%AAC%modes%at%the%same%time%%

Note:%Depending%on%the%level%of%visual%functioning%in%Phase%III,%the%learner%may%not%require%extensive%design%modifications;%determine%specific%use%of%color,%light%etc.%based%on%CVI%Range%Assessment.1%See%below:%emphasis%in%Phase%III%is%often%on%implementation/learning.%%Environmental(Considerations(–(How(can(the(setting(be(modified?%

Implem

entatio

n(

Learners%in%Phase%III%do%not%require%extensive%modifications%to%the%environment,%but%may%experience%difficulty%in%novel%or%complex%environments%or%when%overstimulated%or%fatigued.%%Determine%additional%environmental%modifications%with%CVI%Range%Assessment,%Rating%2.%%Presentation(of(AAC(–(How(can(the(learner(best(access(the(AAC(system?%

Emphasize%implementation%of%AAC%through%conceptually%appropriate%strategies%to%teach%salient%features:%What$is$the$unique,$defining$feature$of$a$visual$target$(in$AAC,$often$a$symbol$or$image)?%%%%%Complexity:%Consider%the%positioning%of%the%child%with%regard%to%background%complexity;%assess%complexity%of%patterns%on%clothing%(

Use%partnerLassisted%strategies%to%point%out,%highlight,%label%and%describe%AAC%targets%and%visual%references%

Distance:%Learner%may%be%able%to%access%AAC/communication%up%to%10’L20’%away;%may%require%visual%adaptations%to%complexity%at%distance(

Visual%Field%Preference:%Learners%in%Phase%III%often%still%have%difficulty%in%lower%field%–%present%AAC%accordingly;%Use%a%slant%board%for%books/2LD%%

Visual%latency:%Allow%for%increased%latency%in%complex%environments%or%when%the%learner%is%fatigued(

Visually%guided%reach:%Allow%the%learner%to%lookLlook%awayLtouch%for%the%most%complex%targets;%allow%wait%time%and%add%visual/auditory%prompts%

Used%increased%verbal%or%signed%description%and%labeling%of%what%the%learner%is%looking%at,%for%total%communication.%

Address%AAC%presentation%differences%in%seated%vs%moving%(Orientation%and%Mobility)%routines(

Support%attention%to%faces%by%considering%additional%sensory/visual%complexity%(while%partner%is%speaking%vs%silent,%moving%vs%still)%

CVI%Phase%III:%Designing%and%Implementing%Appropriate%AAC%Goal%of%Phase%III%intervention:%Vision%for%Learning%

%

In%Phase%III,%the%learner%demonstrates%visual%curiosity,%functional%use%of%vision%in%a%range%of%environments%and%activities,%and%ability%to%attend%to%2LD%targets.%Learners%in%Phase%III%continue%to%benefit%from%visual%adaptations%in%particular%to%support%complexity,%and%

require%extensive%scaffolding%to%learn%salient%features%of%visual%vocabulary.1%%

1%Complete%The(CVI(Range((Roman,(2007)%before%using%this%tool%and%use%results%to%plan%intervention.%%2%Use%the%CVI%Phase%III%Extension%Chart%(Roman,%2007)%to%determine%the%learner’s%ability%to%visually%discriminate,%recognize%and%identify%targets%on%AAC.%For%presymbolic%or%emerging%symbolic%learners,%see%above%recommendations%for%scaffolding%concept%development%prerequisite%to%these%visual%skills.%

DRAFT - NOT FOR DUPLICATION OR DISSEMINATION - New York Deaf-Blind Collaborative, 2016