Cortical Visual

Impairment

Karen Harpster, PhD, OTR/LKaren.Harpster@cchmc.org

Tricia Gribben, OTR/Lpatricia.Gribben@cchmc.org

Occupational Therapy and Physical TherapyTherapeutic Recreation

AACPDM 2016

Occupational Therapy and Physical Therapy

Disclosure InformationAACPDM 70th Annual Meeting | September 20-24, 2016

Speaker Names:

Karen Harpster and Tricia Gribben

We have no financial relationships to disclose.

We will not discuss off label use and/or investigational use in my presentation

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ObjectivesAt the end of this presentation, the learner will be able to:

• Describe the current body of evidence on therapeutic interventions for children with cortical visual impairment (CVI)

• Describe the behavioral characteristics common in children with CVI and use of the CVI Range

• Explain environmental adaptations, task adaptations, and treatment planning for children with CVI

• Discuss treatment planning for children with CVI and caregiver engagement

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Why is it important?

• Currently, CVI is one of the leading causes of visual impairment, affecting a large number of patients seen by occupational therapists

• Visual skills have a significant impact on development of gross and fine motor skills

• Therapists can make simple modifications to task and environment to enhance functional visual skills

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There are 2 types of visual disorders:

1. Ocular disorders where the pathology of the eye(s) is directly impacted.

1. Neurological disorders where there is impaired or reduced vision due to an impairment or injury to the brain.

CVI is a neurological visual disorder, and it is the fastest growing visual impairment diagnosis today.

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What is CVI?

• Cortical Visual Impairment is when the eye works fine but part of the brain that interprets signals from the eye does not.

• The brain does not consistently understand or interpret what the eyes see.

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Medical Conditions Typically Associated with CVI

• Periventricular Leukomalacia (PVL)

• Asphyxia/Hypoxic Ischemic Encephalopathy

• CVA (stroke)

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Medical Conditions Typically Associated with CVI, -cont.-

• Intraventricular Hemorrhage

• Structural Abnormalities

• Trauma (i.e. head injury)

• Metabolic

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CVI Range

• Developed by Christine Roman-Lantzy

• 10 characteristics that define CVI

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Characteristics associated with CVI:

1. Color preference

• Preference for bright colors/high contrast

2. Need for movement

– Shiny/reflecting or moving

3. Visual latency

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Characteristics associated with CVI:

4. Visual field preferences

– Lower and midline are hardest

5. Difficulties with visual complexity

– Object – progress from single color to multiple

colors

– Environment - Visual and auditory

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Characteristics associated with CVI, -cont.-

6. Light gazing and non purposeful gaze

7. Difficulty with distance viewing

8. Atypical visual reflexes

– Touch bridge of nose

– Quick object towards face

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Characteristics associated with CVI, -cont.-

9. Difficulty with visual novelty

– Can see familiar object better than novel

10. Absence of visually guided reach

– Look then reach

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CVI Phases for intervention

1. Phase I: (CVI Range scores 1-3) The major goal of this phase is to build consistent visual behaviors

2. Phase 2: (CVI Range scores 4-7) The major goal is to integrate vision into all functional routines

3. Phase 3: (CVI Range scores 8-10) The major goal is to demonstrate visual curiosity and to consistently and spontaneously use vision in all tasks

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Common Phase 1 Behaviors:

1. Have strong color preference

2. Strong interest in objects with movement properties

3. Ignore objects with either multiple colors/patterned surface or presented against patterned backgrounds

4. Delay in visual response to objects even when familiar objects are presented

5. Have certain objects they recognized before all others, especially before new objects

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Phase 1Environmental Modifications:

• Large focus on environmental modifications

• Need to focus on one sense at a time (vision)

• The lights should be dimmed if possible

• Eliminating clutter that will distract the child

• Use black background

• Quiet treatment area

• Visual target should be shiny

and a single color

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Phase 1

Visual Attention:

• Children in this phase spend little time looking or visually attending to an object or environment

• Objects need to be held close to the patients face (within 12 inches)

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Phase 1 Intervention

• Focus on increasing the number and duration of glances at an object

• Objects used should be:

• Preferred, single color

• Moving

• Shiny/reflective properties

• The same 3-5 objects should be used consistently in the beginning to increase glances

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Phase 1 Intervention

• Once the child increases the number of glances toward an object, you can work on increasing the duration of looking at the object

• Some common objects that are usually preferred by children in phase 1 are slinky, reflective pinwheel, shiny pom poms, different color flashlights, light up toys, etc.

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Common toys for phase 1

http://www.goodnewsweekly.ca/2010/11/most-popular-toys-from-1940s.html

http://www.worldtwirling.com/html/ch

eerleading_supplies__pom_pom.htm

l

http://sell.lulusoso.com/selling-

leads/733415/33-quot-7-mm-Assorted-

Mardi-Gras-Beads-necklace.html

http://www.starlight.com/confettimylar.html

http://pinside.com/pinball/forum/topic/avengers-mods

http://www.lulusoso.com/products/Flashing-Multi-Colors-

Puffer-Ball.html

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Common Phase 2 Behaviors:

• Exhibit more consistent eye to object contact with objects of preferred color

• Begin to look at objects with one or two additional colors and simple patterns

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Phase 2 Intervention

Goal: Integrate vision with function

• All activities should encourage the child to use their vision to make something happen

• Swatting at objects, switch toys, cause and effect, vibrating toys, etc.

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Phase 2 Intervention

• Activities should combine vision with touch, swat, reach, grasp, or eye-gaze in order to accomplish the task

• ADL tasks (reaching for comb wrapped in mylar)

• Fine motor (reaching for sparkly pom poms)

• Improvements are typically seen in abilities to maintain visual contact with people and objects in controlled settings

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Phase 2 Environmental Modifications for Therapy

• Toys should have no more than 2-3 colors

• Consider the complexity of the environment; There may be difficulty visually attending in a busy therapy gym with a lot of clutter or loud noise

• Visual target should be placed no farther 18 inches from face (depending on activity)

• As the motor demand of the task increases, decrease the visual demand of the task

• Fewer toys out at one time better. For example, with block stacking, hand them 1-2 at a time

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Environmental adaptations using technology :

• Take pictures of three dimensional items on a tablet

• Show the picture of the item on the tablet

• This will allow for moving from viewing three dimensional items into viewing two dimensional items

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Environmental adaptations using technology ( cont.)

• Take pictures of two dimensional materials such as books and allow child to look at each page, swiping to turn the page if able

• The back lighting of the tablet assists with viewing two dimensional materials

• When individuals look at books on tablet then move

to real books.

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Environmental adaptations using technology (cont.)

• If distance viewing is difficult and getting close to and item is not an option ( ie: zoo trip)

• The tablet can be used to bring items at a distance closer

• Take a picture of items at a distance and show them on the tablet

• Discuss the features of the item while in the environment to help with learning

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Common toys for phase 2

Objects with 2-3 colors

http://cutcaster.com/photo/100733867-Colored-soccer-football-balls/

http://www.antistresstoys.com.au/html/stress_nature.htmlhttp://www.zymetrical.com/bulk-assorted-color-duckies-p-1495.html

http://www.shutterstock.com/pic-45111304/stock-photo-an-

orange-toy-plastic-carrot.html

http://www.film.queensu.ca/Cj3b/ToysMedium.html

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Common toys for phase 2

Cause and Effect Toys

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Common Phase 3 Behaviors

• Difficulty with complexity in 2 dimensional materials

• Difficulty with visual complexity and distance viewing in unfamiliar indoor and outdoor areas

• Difficulty with specific visual fields (most commonly lower fields)

• Difficulty with visually guided reach with small objects or on a complex background

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Phase 3 Intervention

Goal: Facilitate the resolution of the CVI characteristics that remain active and affecting function

• Background complexity should be increased over time as the child is able to identify the salient features or details of the object

• Boat against black background

• Boat against wave background

• Boat against waves and cloud background

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Phase 3 Intervention, -cont.-

• Complexity of the environment should be increased over time

– The child should eventually be able to find objects in unfamiliar indoor and outdoor environments

• Difficulty with noticing transitions in the environment including descending steps, drop offs at curbs or surface changes.

– These children often work with orientation and mobility services.

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Phase 3 Intervention (cont)

• Difficulties with handwriting are common

• Begin with three dimensional materials building letters using straight lines and curves

• Use the light box to build visual attention

• Templates of the letters can be shown on the lightbox

• After three dimensional materials are mastered begin forming with markers

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Phase 3 Environmental Modification for Intervention

• Intervention focus on ADL or school task with modifications for characteristic that is still present• Example: latency, color to point out salient features of object,

complexity of task or environment.

• New environments are difficult to process and/or to figure out what to focus visual attention to

• Consider additional practice in new environments to build familiarity and skills in the new environment

• Use narration regarding what the child should be focusing on

• Ask the child to explain what they are seeing

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Common toys/activities for phase 3

• Hidden Picture Activities

• Find all of the “e”

• Object discrimination – very different

pictures, similar pictures, etc.

• Letter discrimination

• Locating part of a complex picture

• Locating signs in the environment

• Highlighting salient features of letters,

sight words, etc.

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Common toys/activities for phase 3, -cont.-

http://bluemoondevotionals.blogspot.com/2010/06/stop-signs.html

http://www.freefoto.com/preview/41-11-4/One-Way-

USA-Road-Sign

http://www.mydeliciousambiguity.com/2012/01/learnin

g-activities-with-legos.html

http://www.123rf.com/photo_7290840_ball-of-

brightly-multi-colored-network-cables-isolated-

on-white-background-ball-of-of-coloured-

wires.html

Increase the complexity of toys (by increasing the number of colors within the toy)

Increase the complexity of sign/object location tasks (by increasing the amount of background included)

https://itunes.apple.com/us/app/color-

drops-childrens-

animated/id484422403?mt=8

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Clinical Scenario

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Take Home Message

• Patients with CVI have the potential to significantly improve functional vision

• Simple environmental and task modifications at home and during a therapy session can make a huge impact on the performance of a patient with CVI

• Caregiver engagement in therapy is essential

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