1. Cortical Vision Impairment
Sharon Steed, MS, CCC-SLP
AnMED Health

2. Training Objectives Participants will:
Define Cortical Vision Impairment.
List three potential causes of Cortical Vision Impairments.
Provide three diagnostic signs of Cortical Vision Impairments.
Describe two treatment strategies to support progress of an individual with Cortical Vision Impairments.

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

4. Cortical Vision Impairment
Definition continued…
The inability of the brain’s visual systems to consistently process and interpret visual information.
- Not a disease or a condition of the eye itself.
- Not an indicator of cognitive skills.
Diagnosed by a trained ophthalmologist.

5. Cortical Visual Impairment (CVI)
Also known as neurological visual impairment, cerebral visual impairment, delayed visual maturation,
or cortical blindness.
In North America the condition is described as “cortical visual impairment.”
In Europe, the term “cerebral visual impairment" is used.

6. Causes of CVI
Hypoxic (reduced oxygen to tissue) brain damage found in:
- babies who experience Sudden Infant Death Syndrome, but live
- individuals who experience a cardiac arrest
- individuals resuscitated from drowning
- individuals who have experienced extended episodes of epileptic seizures
Structural brain developmental disorders (such as hydrocephalus, spina bifida, agenesis of the corpus callosum, and microcephaly)

7. Causes of CVI
Anoxic brain damage (results from the absence of oxygen to the tissues---asphyxia occurring during birth or later in life)
Intraventricular hemorrhage (brain bleed often occurring in premature infants)
Periventricular leukomalacia (reduced blood flow to brain’s white matter in premature infants)
Stroke in utero (may occur in full-term or premature infants--in general, cause of stroke unknown but can be the result of an episode of asphyxia)

8. Causes of CVI Traumatic Brain Injury
Infections to the brain/central nervous system such as meningitis and encephalitis
Progressive disorders (such as Tay Sachs, Batten’s Disease)
Intrauterine infections (STORCH- a medical acronym that stands for intrauterine infections transferred to the baby through the placenta which includes S-syphilis, T- toxoplasmosis, O-others such as hepatitis, HIV, West Nile virus, malaria, tuberculosis, R-rubella, C- cytomegalovirus, and H- Herpes Simplex virus)

9. General Characteristics of Individuals with CVI
May also have visual impairments such as optic nerve atrophy, optic nerve dysplasia, strabismus.
Often have no or a poor visual response even in the presence of a normal vision exam and normally functioning pupils.
May have multiple disabilities to include motor and/or cognitive delays, problems communicating and learning language as the result of cerebral palsy, seizures, severe to mild learning disabilities and other neurological problems.

10. General Characteristics of Individuals with CVI
Approximately 80% of children with cerebral palsy also have CVI

11. Diagnostic Signs of CVI
The lack of blinking (atypical visual reflexes).
Staring at lights for an extended period. (light gazing preference).
Tends to turn his or her head to the side when reaching for an object (unable to demonstrate an intact visual guided reach).
A short visual attention span, but may improve if object is moving.
Items in parenthesis are key visual behaviors to assess and target in treatment.

12. Diagnostic Signs of CVI
Problems with looking at an object presented at a distance (distance viewing is difficult and varies at different phases). 
Fluctuations in visual functioning throughout the day.
Perceives color—has color preference of usually red or yellow.
Problems with objects presented in some visual fields (visual field preferences may use one peripheral field better or may use central vision).
Fatigues quickly when engaged in visual activities.

13. Diagnostic Signs of CVI
Prefers to look at familiar rather than new objects (problems with visual novelty).
Needs extended response time when looking at objects.
Problems looking at objects that are visually complex (difficulties with visual complexity).
The severity level of an individual’s CVI often correlates to the number of characteristics he or she demonstrates. Remember : An individual with CVI may improve.

14. Scoring Range for CVI
Phase I: CVI Range Level 0 to 3 (inconsistent visual attention on objects)
- Need single color or personally preferred color
objects.
- Shiny objects.
- Objects with movement .
- Familiar objects.
- Objects presented in a simple background.
Roman-Lantzy, Cortical Visual Impairment:
An Approach to Assessment and Intervention, 2007

15. Scoring Range for CVI
Phase I: CVI Range Level 0 to 3 ( inconsistent visual attention on objects)
- Identify 3-5 objects to use with an individual based on observation and assessment.
- Suggested objects: slinky, reflective pinwheel, windsock, Elmo doll, mobile made out of silverware.
- Design activities focusing on
the use of these objects for
repeated practice in a
supportive environment.

16. Scoring Range for CVI
Phase I: CVI Range Level 0 to 3 ( inconsistent visual attention on objects)
If individual demonstrates signs of fatigue (such as yawning, avoiding looking, sleeping, closing eyes, grimacing, yawning, etc.) try:
- Reducing stimuli.
- Providing longer periods of visual gazing.
- Reducing stimuli in setting.

17. Scoring Range for CVI
Phase II: CVI Range Level 4 to 7 ( some functional use of vision )
Use individual’s favorite color and add one or two more colors.
- Individual should begin to tolerate more complex visual patterns.
Put reflective strips on objects.
- Reduction in light gazing by individual

18. Scoring Range for CVI
Phase II: CVI Range Level 4 to 7 ( some functional use of vision )
Use objects from daily routines and activities that are the individual’s preferred color
- May also wrap in reflective material.
- Includes toothbrush, cup, fork, switches, lightbox, etc.
- Use new objects that are the individual’s preferred color during activities.
- Place objects on black or plain backgrounds to support the visually guided reach skill.

19. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
  - Beginning to demonstrate a visually guided reach.
  - Problems continue with complex visual setting.
  - Difficulty with images/words on paper.
  - Problems with objects over feet from the individual.

20. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
Suggested objects: highlighters, simple picture books with outline only, theme based books “my favorite toys”, “foods I like to eat” and others, use photos only of faces initially, can begin to use mirrors, communication symbols of individual’s favorite color, and favorite items with simple backgrounds.

21. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
Focus on two major skills in this phase:
1) Activities should be designed to support the individual in improving skill in determining how objects are the same or different using visual features.
- For example, taking old information or familiar object and relate it to something new but similar as the actual interaction takes place with the new object. (i.e. compare a bus to the family car)

22. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
Focus on two major skills in this phase (continued):
2) Support the individual to use his or her vision to discern visual details from the background, visually discriminate within the setting and deal with visually complex objects successfully.

23. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
For example:
Begin with a simple book that uses the individuals favorite color for the main character or object in the story, such as Clifford, the red dog. The activities range from finding a stuffed Clifford, to using a pop-up book about Clifford to visually locating a Clifford dog with movement to finding smaller Cliffords in a “hidden picture” type activity.

24. Scoring Range for CVI
Phase III: CVI Range Level 7 ½ to 10 ( using vision to perform most activities )
Remember to watch for signs of the individual fatiguing, dealing with too much new information, being stressed or over stimulated during activities in each of these phases.

25. Treatment Ideas
Using the individual’s favorite color items may stimulate visual attention on an objects being used in activities.
When presenting the object to the individual, say the name of the item, place item on left or right side (not in the center) and wait for an extended period.
Use simple designs.
Use objects with movement and/or reflective material.

26. Treatment Ideas
Attach deflated mylar balloons on objects to give the illusion of movement.
Reduce the complexity in environment, on the pages of a book
Minimize input to all senses. Do not reward individual with praise, food, touch until he or she has ended his or her visual attention to an object.
Presenting items close to the individual—maximum distance is 18”-24”.

27. Treatment Ideas
Watch the individual during the session for signs of tiring.
Make sure the individual is positioned with as much physical support as needed.
Place light source behind or beside individual.
Provide an extended wait time before expecting the individual to visually respond.

28. Treatment Ideas
Wait…Wait…Wait…and…
Wait

29. AT and Treatment Ideas
Work in a room where noise and lighting can be controlled.
Consider switch colors, size contrast colors—think about how you can adapt the switch with materials and colors based on the individual’s preferences and CVI needs.
Consider placement of switches based on
the individual’s motoric skills and CVI needs.

30. AT and Treatment Ideas
Initially, individuals with CVI demonstrate a preference towards movement only. Use toys with sound later if appropriate.
Start with simple puzzles with each piece outlined in black.
Select symbols based on individual’s color preferences, need for lack of background clutter, personal interests and contrasting colors.

31. AT and Treatment Ideas
Select books with a single picture per page and simple backgrounds.
Books should have one theme and contain familiar items.

32. AT and Treatment Ideas
If augmentative communication devices are needed, consider the following techniques and features:
- partner assisted scanning.
- a communication system with or without speech output that includes tactile input.
- a speech device with a zoom text feature.
- two-switch auditory
scanning to access
a speech output
communication
device.

33. Helpful References/Websites
Notes from a presentation at ATIA 2008 on CVI by Debbie Budash and Kathy Quesenberry, West Virginia Dept of Education.
Roman-Lantzy, Christine (2007). Cortical Visual Impairment An Approach to Assessment and Intervention, ISBN Can be ordered from American Foundation for the Blind at
Scroll down to area on Fact Sheets to include Cortical Visual Impairment.
Idaho
Project for Children and Youth with Deaf-Blindness- click on fact sheets on side bar to locate information on Cortical Visual Impairment.

34. Helpful Websites www.lburkhart.com/handcvi.htm
Developing Visual Skills for Children who Face Cortical Visual Impairments by Linda J. Burkhart.
Cortical Visual Impairment Pediatric Visual Diagnosis Fact Sheet Reprinted from Blind Babies Foundation.
Special Education Service Agency ( SESA) Intervention strategies for a Student with Cortical Visual Impairment by Alan Weinstein, Anchorage School District.
California Deaf –Blind Services –Cortical Visual Impairment Fact Sheet.
Nevada Dual Sensory Impairment Project Tips for Home or School on Cortical Visual Impairment.

35. Thank you!