WITRAND HOSPITAL REHAB IST

CORTICAL
DEPARTMENT OF OCCUPATIONAL THERAPY

VISUAL
IMPAIRMEN
T PREPARED BY ASHLEIGH MARSHALL
COMMUNITY SERVICE OT
 “Not all forms of vision impairment come
with a guide dog and a white stick”

(23 Truths Blind and Visually Impaired People With Others Understood, 2023)
 TERMINOLOGY
1 Cortical Visual Impairment
1 2

2 Aquired Cortical Visual Impairment

4
3
3 Cerebral Visual Impairment

4 Neurological Visual Impairment

 WHAT IS CVI?
2 types of visual
disorders

Ocular Disorders Neurological Disorders

Impairment of the Damage to the brain

pathology of the eyes resulting in impaired or
reduced vision

Congenital

CVI
Acquired
The part of the brain responsible for
interpreting and understanding
signals sent from the eyes does not
(Harpster & Gribben, 2016) work optimally
 WHAT IS CVI?
Most common in childhood (CVI)
BUT can continue into or occur in
adulthood (acquired)

The impairments for congenital and

acquired are the same.

Most prevalent cause of visual loss

(Harpster & Gribben, 2016)

 CRITERIA

1 2 3

An eye examination does The patient has a history The patient shows a
not better explain the of a neurological unique set of specified
visual loss condition (congenital / visual and behavioural
acquired) characteristics

(PCVIS, 2019)
 VISUAL PATHWAY
• Estimated that 40% of our brain is
dedicated to visual processing
• Our “visual brain” consists of the
visual cortex and associative areas
• This includes the visual pathways
• In CVI’s, it is not only the visual
cortex that may be damaged
• Damage to any portion of the
pathway posterior to the lateral
geniculate nucleus

(Afshari & Fulton, 2001)

 VISUAL PATHWAY
Dorsal and Ventral Streams by Gordan Dutton (based on neuropsychologists Milner and Goodale)
“Where” system
Dorsal Stream to
Understanding of where
Parietal Lobe
Works with the frontal lobe

Primary Visual
Stream

Ventral Stream to
“What” system Temporal Lobe
Identifies objects, people &
surrounding
 FOR OTS?
Associated Medical Conditions

• Cerebral Palsy
• Hypoxia
• Asphyxia
• Cerebrovascular Accident (CVA)
• Trauma (e.g. TBI)
• Hydrocephalus

Primary cause of visual impairment

Affects a great number of patients treated by OTs

 FOR OTS?
• Has an impact on one’s engagement in occupations
• The visual sensory system is classified as a client factor thus
under the OTs scope
• In paediatrics, visual skills impact on development of gross
& fine motor skills
• Knowledgably on making task & environmental
modifications to enhance functional visual skills
• To advocate for more appropriate treatment for our Pts as
they are being misunderstood
- Many are misdiagnosed with ASD, developmental
delays, cognitive fallout or learning disabilities when it is in
fact a processing problem

(AOTA, 2020)
 FOR OTS?
Three Basic Rights for People with CVI
(based on United Nations Human
Rights)

• The right to learn

Within OTs
Scope
• The right to independence
• The right to effective social interaction

(UDHR, 1948)
ASSESMEN
T
CVI manifests differently per patient. It is
vital to consider the patient’s individuality
and adapt assessments if necessary
 ASSESSMENT
There are not set or agreed upon clinical guidelines for assessing and diagnosing CVI.
However, there are a few approaches to assessment currently followed.

• First asses and rule out ocular visual impairment

-Basic vision OT assessment looking at oculomotor control, visual
acuity and visual fields
-Refer to an optometrist or ophthalmologist
• Observations / collateral regarding behaviours
• Sentence reading test
• Standardised / non-standardised visual perception assessments
-Observe how they hold their head, do they skip any sections / words /
numbers, how do they go from one line to the next (do they move
their whole body / head or just their eyes, do they shift their body?
• CVI range
• MDT assessment

(E. McConnell et al., 2021)

BEHAVIOURS TO OBSERVE INCLUDE …
• Difficulty looking at & reaching for objects at the same time (look, look-
away-reach pattern)
• Difficulty with fine motor & visual motor skills
• Greatly attracted to lights
• Reacts quicker to auditory than visual stimuli
• Frequently turns head towards one visual field
• Delayed / absent reaction (blink) to touch & threat
• Gets lost easily
• Lacks visual curiosity
• Needs light or movement added to an object to elicit a visual response
• Overgeneralizing concepts based on visual details
• Clumsy
• Not doing things how they’ve been shown
• Not recognising people (prosopagnosia)
• Trouble walking on uneven surfaces
• Unable to identify objects within a crowded area
• Visual neglect
• Visual inattention to parts of a visual field
• Auditory processing dysfunction
DR. CHRISTINE ROMAN-LANTZY’S CVI RANGE
Evaluates the patient’s functional vision in relation to 10 visual & behavioural characteristics.

• Colour preference
• Visual latency
• Need for movement
• Difficulty with novelty
• Visual field preferences
• Complexity
• Difficulty with distance viewing
• Difficulty with visually guided reach
• Atypical visual reflexes
• Need for light
Uses a scale of 0-10 to measure functional vision
0 indicates no visual response
10 indicates almost typical vision
Patients fall into 1 of 3 phases, which guides treatment, dependent on the score
 DR. CHRISTINE ROMAN-LANTZY’S CVI RANGE

1 2 3

Colour Preference Visual Latency Need for Movement

Attracted to visuals of a Visual responses are slow /
specific colour/s. Vibrant delayed. After a “wait
colours alert and maintain period” the patient may
visual attention. eventually turn toward and
focus on the object.
Attracted to objects with
movement properties or
reflective objects creating
the illusion of movement.

(PCVIS, 2019)
 DR. CHRISTINE ROMAN-LANTZY’S CVI RANGE
4 5
Difficulty with Novelty
Attracted to objects that they
have viewed repetitively
while ignoring unknown
objects.
(PCVIS, 2019)
Visual Field Preferences
Information presented in
certain areas of the patients
visual field may either be
ignored or they will turn to
use a specific portion of the
visual field.
6
Need for light
Unusual attraction to light.
Spend unusual time gazing
at sources of light.
 DR. CHRISTINE ROMAN-LANTZY’S CVI RANGE

7 8 9

Difficulty with Distance Difficulty with Visually Atypical Visual Reflexes

Viewing Guided Reach
Atypical visual blink reflex
Patient positions face Patients are unable to look and visual threat response.
closely to the object and has and reach simultaneously.
difficulty recognizing
familiar / large targets
within close vicinity.

(PCVIS, 2019)
 DR. CHRISTINE ROMAN-LANTZY’S CVI RANGE
10

Complexity
Complexity of Patterns Complexity of Sensory
Environment
Patients show the most
consistent visual responses Difficulties with visual
to simple patterns on their attention when there is other
surfaces. sensory stimuli.

Complexity of Visual Array Complexity of Visual

Elements of Faces
Patients receive visual
information due to in tact Unusual regard of faces with
ocular abilities yet absent eye contact and
information is not sorted, minimal discrimination
interpreted or understood.

(PCVIS, 2019)
 GENERAL
TREATMENT
 GUIDELINES
Who: patients who score within the 0-3 range
Goal: to build visual behaviour

• Environment needs to be controlled, calm, quiet & familiar

• Use objects of a single & preferred colour
• Use objects that can move, light up or cause reflection
• Hold objects within the preferred visual field or against a dark plain,
background
• Use objects at near distances
• Allow the patient time to respond to the stimulus

*Patients are usually unable to recognize faces in this phase

(Seeing Sadie, 2023)

 GUIDELINES
Who: patients who score within the 4-7 range
Goal: to integrate vision with function

• Facilitate vision with reaching (function)

-Vision and reaching are completed separately
• Patients are able to see slightly further (approximately 120.00-
180.00cm away)
• Visual latency decreases & patients can tolerate a low level of
background noise
• Movement should be used to promote visual attention yet it is not
needed to keep this attention
• Use objects with 2-3 colours

(Seeing Sadie, 2023)

 GUIDELINES
Who: patients who score within the 7-10 range
Goal: to resolve CVI characteristics

• Patients start to use vision for participation in most activities

• Still exhibits difficulties with complexity
• Patients are able to see further (approximately 305.00-460.00cm
away)
• Patients start to visually examine their environment spontaneously
• Use of vision in nearly all visual fields
• Visually guided reach resolves by the end of the phase
• Patients can visually attend to books / posters with simple pictures,
symbols and colours

(Seeing Sadie, 2023)

 CVI CHART TO GUIDE TREATMENT
ENVRIONMENT & GOALS

(Physio-Pedia, 2022)
 THE OT’S
ROLE WITH
CVI
 Use our knowledge on Simple modifications to Use the principles of
senses to create a the task, materials & neuroplasticity to
multisensory approach environment enhancing encourage learning of lost
with specific feedback and functional visual skills skills in acquired CVI’s
various techniques
(dependent on the
individual) to teach
patients to recognize and
interpret objects
10 PRINCIPLES OF NEUROPLASTICITY

• Use it or lose it • Interference

• Use it and improve it • Time

• Specificity • Age

• Salience • Repetition

• Transference • Intensity
 CVI SCHEDULE
Used to Apply CVI Guidelines / Principles Throughout a Patient’s Day by Integrating
Adaptations within a Daily Routine

• Created by all members involved in treatment, the caregivers / family & the patient

• Includes:

-Time of the day

-CVI characteristics targeted within a task

-CVI accommodations necessary to provide visual access to a task

• Type of home programme

(Roman-Lantzy, 2007, 2018)

 CVI SCHEDULE TIPS

• Start with portions of the day with grading working towards including the whole day

• Primary caregivers by-in is vital. Ensure they are involved in the development to ensure it is
realistic and attainable

• The CVI schedule is aimed at assisting the primary caregivers

• Include photos if needed to minimise the language barrier

• Continuously adapt the schedule as routines change or the CVI range changes

• Place the schedule within an accessible area(s)

(Roman-Lantzy, 2007, 2018)

(Roman-Lantzy, 2007, 2018)
HELPFUL RESOURCES
• https://cviresources.com/about/
• https://cviscotland.org/about.php
• https://pcvis.vision/what-is-cvi/