1. The Student with CVI Determining Functional Vision
Ellen Mazel M.ED, CTVI
CVI Project Manager
Perkins School for the Blind

2. Definitions of CVI
Vision impairment due to damage or disorder of the visual pathways and visual centers in the brain, including the pathways serving visual perception, cognition, and visual guidance of movement.” and may coexist with anterior visual pathway anomalies.
Dutton GN, Lueck AH. Editors.  Impairment of vision due to damage to the brain in Vision and the Brain: 2015 AFB Press Page 4
Not the eye!

3. Gathering Information
Medical: Eye health and Visual function: Low Vision Clinics/Ophthalmology and Neurology reports
Student files
Parents
Educational team members
Distractibility, behaviors, problem areas, history

4. Functional Vision VS. Visual Function
Visual function: Collection of Data: Things that can be measured in a clinical ophthalmic setting.
Functional vision: Collection of observations across multiple settings: The way in which an student uses their vision. 
Who does which

5. Acuity not a measure of functional vision
Twins: History of prematurity and brain damage. Very different acuities and very different functional vision

6. Acuity is not the measure of CVI: Twin: Student L
Neurological History: Bilateral IVH Grade 1-2
Acuity measure 20/160.
Takes 30 minutes to obtain acuity
Ellen:
CVI Range: L scores 5

7. Acuity is not the measure of CVI: Twin student A
Neurological History: Bilateral IVH Grade 4
Acuity measure 20/63.
Takes 5 minutes to get acuity
Ellen:
CVI Range: A scores 3.5 to 4

8. Compare Neurological History: Bilateral IVH Grade 1-2
Acuity measure 20/160.
Takes 30 minutes to obtain acuity
Looks at people and objects
Ellen:
CVI Range: L scores 5
Neurological History: Bilateral IVH Grade 4
Acuity measure 20/63.
Takes 5 minutes to get acuity
Limited visual attention to people and objects
Ellen:
CVI Range: A scores 3.5 to 4

9. Brain Based visual issues not ocular criteria
Roman-Lantzy
Color preference, reliance on color
Reaction to environmental movement, impact of environmental movement
Attention to light, support of backlighting
Reduced visual reflexes to touch and threat

10. Brain Based visual issues not ocular criteria
Difficulties with complexity of object
Difficulties with of array
Difficulties with sensory complexity
Difficulties with facial complexity

11. Brain Based visual issues not ocular criteria
Reduced distance attention and understanding. Where is visual curiosity?
Increased latency for looking or understanding what is seen
Reduced visual motor skills
Difficulties with visual novelty
Visual field preferences.

12. Brain Based visual issues not ocular criteria
Dutton and Ortibus
Visual field differences
Difficulty with visual attention
Impaired perception of movement

13. Brain Based visual issues not ocular criteria
Difficulty handling a complex scene
Difficulty with visually guided movement
Behaviors in crowded environments
Understanding what is being looked at
Ortibus considers lightgazing in Screening

14. Components Parent Interview
Observations in various familiar and unfamiliar settings
Direct assessment setting with highest environmental supports
Parent: history of improvement,

15. Assessment Based on Student Profile
Helps drive instruction programming
Helps drive material creation/adaptation
Helps document changes in vision
Helps readjust environmental supports and material adaptation
Ocular and cortical: applying to the child in front of you

16. Peter’s Ophthalmologist
“Eyes are healthy.”
“Maybe delayed visual maturation.”
“Optic nerves might be a bit pale.”
“See the neurologist.”
“See a strabismus specialist.”
Medical understanding was always a foundation to understand my child's visual impairment

17. Peter: Ocular Functional Vision Assessment
Typical looking eyes
Holds eyes to the left
Alternating exotropia
No eye contact
No fixation
No tracking
No scanning
No response to visual field testing
No blink reflex
No light sensitivity
No information. Treat as a blind child: use only compensatory skills.
Mom is looking to me for how to help her child.
Suggestions are for blind child: narrate environment, explore tactilely, give touch cues.
MAKE sense world compensatory skills.

18. Ocular FVA Leads me to focus on compensatory skills
Leads me to believe the visual skills are fixed and limited

19. Peter: CVI Functional Vision Assessment
Visual Behaviors:
Preference for red materials.
Movement of materials draws and keeps his visual attention. He falls asleep in busy places.
Limited visual attention. Needs extra time to locate and turn to materials.
Locates materials faster in his left visual field at eye level.

20. Peter: CVI Functional Vision Assessment
Visually locates best with simple environments that are quiet, with non-complex backgrounds and if he is solidly positioned.
Stares at light sources and can be visually inattentive.
Looks only at items in near space 12”-18”.
Does not reach out.

21. Peter: CVI Functional Vision Assessment
Recognizes one or two familiar items. Looks faster and sustains visual attention longer.
Locates materials with peripheral vision.
Shows a delayed blink to touch and no blink to threat.
Concrete visual skills that can further be assessed: exact recommendations for the team. I have functional vision.
I have rich information to support current visual skills and to target areas for improvements.

22. Cortical/Cerebral FVA
Leads me to identify real functional vision
Leads me to focus on those functional vision skills
Leads me to focus on compensatory skills to support that vision
Leads me to expect improvement in visual recognition skills.

23. Improvement: Peter 2016 Moved from Phase I to early high Phase II
Visual recognition improved.
Visual attention improved.
Using a TOBII eye gaze system to communicate.
Still needs visual considerations:
-reduced complexity
-exact distance for access
-backlighting
-size of icons
-number in the array
-latency
"Need break", "like it", toys: guitar, frozen toy and piano. "bad", Awesome,
2 times "oh oh" seizure, lunch choices.

24. John: Ophthalmologist
Slight astigmatism
Strabismus
Prescribed glasses

25. John: Ocular Functional Vision Assessment
Typical looking eyes
Esotropia
Looks at faces
Good fixation
Good tracking if moving slowly

26. John: Ocular Functional Vision Assessment
Good scanning using full head movement
Responses to visual field testing with light
Shows blink reflex
No light sensitivity
Visual fields full in confrontation testing with light

27. Ocular FVA Leads one to believe glasses are the supports needed.
Leads one to believe vision is effective for learning

28. John: CVI Functional Vision Assessment
Visual Behaviors:
Preference for red materials. Uses color to to find people in crowded, items at distance, items against complexity
Movement of materials draws visual attention against complexity and at distance. Movement distracts him.
Difficulty with recognition if items are too close together.
Red is liked and used as support: red clothes, red bike, red games pieces, brother in red car, mom wear read.
He has a red bike. board game he automatically picks red color side of the game or symbol.

29. John: CVI Functional Vision Assessment
Needs extra time to locate items against complexity and at distance
Needs extra time to understand new things he sees.
Difficulty in new places
Low visual field is impacted functionally

30. John: CVI Functional Vision Assessment
Visual understanding is optimal in simple environments that are quiet, with non-complex backgrounds and if he is solidly positioned.
Backlighting supports visual discrimination and reduces visual fatigue.
Optimal distance for learning is 4 feet but may need support to understand new materials or events at near.
Beyond 4 is inaccessible and needs support: anxious..

31. John: CVI Functional Vision Assessment
Due to simultanagnosia, he struggles to understand crowded scenes
Understand familiar items and events faster. He can tap into visual prediction.
Shows blink to touch and weaker blink to threat.
Cutting nails. Dog has a face.
I have rich information to support current visual skills and to target areas for improvements.

32. John: CVI Functional Vision Assessment
Difficulty with facial recognition and facial expressions
Difficulty understanding pictures
In new places, he gets quiet, puts his head down and uses vision less.
Impacted by visual fatigue
Helen Keller: pump and old clothes

33. Cortical/Cerebral FVA
Leads me to identify real functional vision, what is and is not accessible.
Leads me to focus on those brain based functional vision skills
Leads me to focus on compensatory skills to support that vision
Leads me to expect visual recognition improvement.
All school meeting, Nonsense words. Off task conversations, low self esteem, social issues, laughing at yelling

34. Correct FVA for students with CVI
Leads me to:
the correct functional vision areas of need.
goals and objectives based on the correct areas of need.
create environmental adaptation that meets student accessibility needs.
create materials matched to the areas of need.
provide teaching methods for accessibility and visual improvement.

35. Cortical/Cerebral FVA
I can explain behaviors through a CVI lens.
I can caution about how vision masks cognitive skills.
I can caution against the diagnosis of autism, ADHD, distractibility and cognitive impairments.
I can instill the belief in changing functional vision.

36. Cortical/Cerebral and Ocular Issues
Assess both:
Tools to use for CVI:
CVI Range
Dutton Survey
Ortibus Teach CVI materials
Matt Tietjen’s “What’s the Complexity?”
Tools to use for ocular:
Outlined by Tammy
Optic nerve palor, low contrast sensitivity, strabismus. Collaboration is essential

37. The Student with CVI Determining Functional Vision
Ellen Mazel M.ED, CTVI
CVI Project Manager
Perkins School for the Blind