TITLE Slide: CVI--Strategies and Accommodations for Support in Adult Services
MCB CVI Symposium May 2015 Michelle J. Antinarelli, COMS
Slide one: CVI—Definitions
 Neurologically-based visual impairment
 perinatal insult or injury to brain (trauma, ischemia, anoxia, noxious substance, etc.)
 functional vision loss not comensurate with ocular diagnosis
 genetically-based brain damage resulting in decreased visual function
 visual impairment due to damage or malformation of retinal structures or structures within the posterior pathway
Slide two: Acquired CVI/Traumatic Brain Injury
Soldiers in WWI
Accidental Injury
Childhood or adult stroke (as opposed to perinatal stroke)
Slide three: CVI Experience
Two images on slide
1.
Image of plastic cylinder of iced tea packages in a basket of several items
2.
Image of one tinfoil packet of iced tea on a table
What am I looking at (schema)?
Slide four: CVI Experience
Image on slide
Gray, white and black photograph of unknown image
What am I looking at (experience/schema)?
Slide five: CVI Experience
Image on slide
Gray, white and black photograph with green outline of cow
Putting it into context
Slide six: CVI Experience
Image on slide
Image of sheet of paper imprinted with full cells
What is important to notice (filtering visual information)?
Slide seven: CVI Experience
Image on slide
Image of VCR with multiple electrical connective cords
What is important to attend to (filtering multiple input)?
Slide eight: CVI Experience
Image on slide
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Image of two boxes that appear to be different colors
Am I seeing what everyone else is seeing (common schema)?
Slide nine: Congenital CVI—From a Theoretical Perspective
1.
Roman—Intervention + Time = Improvement
2.
Dutton—Damage in the brain or at the retinal level specifically correlated to visual impact = It is what it is.
3.
Delayed Visual Maturation—50% improve over time
Slide ten: Roman Range—Interventions Based Upon Phase and characteristics
Phase I—learning to look, directing gaze
Phase II—learning to look for a specific purpose
Phase III—learning to generalize visual skills, visual experience, visual undertanding
Slide eleven: Roman—Characteristics of CVI
Light, Movement, Color, Field, Complexity, Novelty, Distance, Latency, Reflexes,
Visually Guided Reach
Slide twelve: Roman Range Phase I Interventions
Use
* light to draw the eye to objects or locations of interest (spotlights)
* motion or mylar to orient to new locations.
* favored color to introduce new objects and landmark locations.
* preferred fields. (Sighted guide w/preferred field on outside)
* large targets to reduce complexity.
* familiar objects/colors to gain attention to location/landmarks.
* position to support visual attention to object/landmark in near space.
* wait time for gaze to be established.
Slide thirteen: Phase I Interventions-Light
Two images on slide
Image of Lighted fishtank , Image of window
Use light to draw attention, cue location.
Slide fourteen: Phase I Intervention-Movement
Two images on slide
Image of mylar balloon, Image of mirror
Use motion or the perception of motion to draw attention.
Slide fifteen: Phase I Intervention-Color
Two images on slide
Image of coat corner, Image of place setting
Use a preferred color (and possibly high contrast) to label personal spaces.
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Slide sixteen: Phase I Intervention-Fields, Large Targets, Near Space
Two images on slide
Image of sighted guide with traveler nearest large red bow
Position individual with preferred field to visual target.
Slide seventeen: Phase I Intervention-Novelty (Familiar)
Two images on slide
Image of yellow soccer ball, image of yellow soccer ball on chair.
Use preferred objects to provide landmarks, draw attention.
Slide eighteen: Phase I Intervention-Latency
Image on slide—clock
Give the student (quiet) time to respond.
Slide nineteen: Phase I Intervention-Complexity
Image on slide-checkerboard pattern
Remember complexity is visual and auditory. SHUSH!
Slide twenty: Phase II Intervention-Light
Two images on slide
Image of task light near lunch tray, Image of lighted toothbrush
Use light to focus attention on tasks. (Block distracting light from windows, overhead lights.)
Slide twenty one: Phase II Intervention-Movement
Two images on slide
Image of shiny backpack, Image of Shiny Mobile
Use motion to draw gaze to targeted areas.
Slide twenty two: Phase II Intervention-Color
Two Images on slide
Image of green toothbrush, Image of toiletries box with green label
Use color to label belongings, locations, and cue independent skills.
Slide twenty three: Phase II Intervention-Fields, Complexity
Two Images on slide
Image of spoon in rice mixture, image of spoon with rice on it separated on plate
Consider visual complexity of the task. Build visual experiences. Prompt use of less preferred fields.
Slide twenty four: Phase III Accommodations
 Building vision in conjunction with functional tasks
 Determining consistency/reliability of vision for tasks
 Gradually decreasing accommodations to the functional/visual threshold
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 ALWAYS recognizing limitations imposed by CVI (motion, light, auditory complexity)
Slide twenty-five: Dutton—Predicting Visual Function
Based on location of damage
Linked to visual behaviors
Co-morbid diagnoses
Slide twenty-six: Occipital Lobe Damage
Image of brain
Right goes left
Left goes right
Top goes down
Bottom goes up
Slide twenty-seven: Dorsal Stream-Where is it?
Image of foot, Image of hand
Occipital lobe connects to posterior parietal (complexity)
Occipital lobe connects to motor cortex (movement—top of cortex moves foot, side moves hand, head and eye control for scanning)
Occipital lobe connects to frontal cortex (choice)
Slide twenty-eight: Dorsal Stream Dysfunction
Impairment of:
*perception of speed of fast moving objects
*ability to split attention
*performance in cluttered settings
*auditory search and localization
*inaccurate reach or movement of lower limbs
*depth perception (true or perceived/even with stereopsis)
-
Slide twenty-nine: Associated Field Defects
Image of compass
* The part of the brain that controls vision on the left side of the body is also close to the area for orientation, route finding, recognition of faces.
* The part of the brain associated with lower limb movement is near the area associated with lower field vision, and is particularly vulnerable to damage in
CP/see often with diagnosis of PVL.
Slide thirty: Ventral Stream-What is it?
Image of library
Occipital to temporal lobe—the library for object recognition (shape and form), facial recognition, route finding
Slide thirty-one: It is what it is. Plan for it.
Two images of walker at curb.
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Anticipate lower field defects, and peripheral (left) field defects.
Slide thirty-two: Case study—The Professor
Age 17, 20/40 acuity, mild hyperopia, some slight strabismus, stereopsis intact,
CP, impairment of both legs & left arm, used rolling walker, no known field losses or other visual impairment, full academic student
Chief complaint---needs mobility because he falls down at high school
Slide thirty-three: The Professor
Assessment: Confrontational fields (loss to 54 inches in front of his feet at surface level), functionally impaired depths & crashing into walls, people who are walking directly in front of him, very distracted by the sounds of others, the movement of others, could not open doors, could not plan step down from curbs, trips over low profile and high profile low contrasting objects
Slide thirty-four: The Professor
O&M Instruction over 1.5 years, Opens doors, Systematically scans walking surfaces when cued, doesn’t bump into people or walls, still distracted by people and movement, can utilize mnemonic to plan step down from curbs, makes all quiet street crossings with good alignment
Slide thirty-five: Strategies for O&M
Image of stairs with yellow bow on railing.
 Use talk aloud.
 Memorize routes, routines orally. (Mnemonics, songs)
 Use compensatory strategies. (tactile cues, audio cues)
 Use compass directions, laterality, directionality.
 Develop problem–solving skills. (questions to ask)
 Drill and kill. (You can improve unconscious vision/movement tasks.)
 Provide visual cues within functional fields. (railing height rather than just on stair lip)
 Use monocular or toilet paper tube to reduce complexity at distance.
Slide thirty-six: Delayed Visual Maturation
What happens without interventions?
Where do we see these individuals?
Why are we concerned about these individuals?
How does this individual present?
Slide thirty-seven: Be concrete.
 Link space to visual cues.
Walk along the side of the street so you can take on step onto the grass.
Cut between the red and the green line (instead of along the black line).
Use a table runner to define the middle of the table.
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Use a placemat to define area for table settings.
Use trays to define working areas.
Separate work spaces.
 Provide organizing rules.
Teach numbering systems for public buildings, community settings.
Teach color coding or alphabetic systems for filing.
Slide thirty-eight: Reduce complexity.
 Keep workspaces and table tops clear of all but necessary materials.
 Eliminate music, audio distractions while teaching new tasks.
 Set up workspaces facing walls, away from doors or busy areas.
 Minimize decorations, moving items, lights, windows in task areas.
 Use real photos rather than icons. (Don’t change items already in use.)
Slide thirty-nine: Accommodate.
 Anticipate distractions due to movement, sounds, light/windows.
 Plan ahead. Preteach in quiet setting.
 Wait until distraction(s) is resolved/removed.
 One input at a time. Describe, wait, then demonstrate.
 Introduce new tasks or materials systematically.
Slide forty: Accommodations
Ocular- high contrast markings on projecting obstacles, cue depth change at surface, task lighting without shadows, use blinds for glare reduction, use anticipators for drop off & obstacles detection
CVI- preferred colors markings on projecting obstacles, cue depth change in known visual fields, targeted lighting without shadows, use blinds for reducing lightgazing/distractions, use anticipators and build visual skills for drop off & obstacle detection
Slide forty-one: Case Study—Cindy
Grade 5, CP, hemiplegia in power chair, diagnosed with CVI, acuity 20/50, mainstreamed with full support, inconsistent use of glasses, chief complaint lack of independence with travel in hallways, bumps into students, runs over students’ feet, bumps into doorframes, academically struggling
Slide forty-two: Cindy
Assessment: Confrontational fields loss in lower left and right quadrants, moreso on the left, visual fatigue led to nonpurposeful gaze every hour or so, unable to demonstrate rights and lefts, transitioned well outside the regular school day parameters
Slide forty-three: Cindy
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Intervention: Drilled and killed weaving obstacles cones gradually adding complexity, taught use of visual shorelines such as lockers, tiles on floor, practices adjusting speeds to pedestrian in front of her, increased print sizes to ½ inch for one year---still in math support but independent in classes otherwise, travels in busy middle school halls during full transition periods, uses whistle minimally to signal right of way, could not learn rights and lefts—uses numbering systems and verbalizing routes for wayfinding
Slide forty-four: Supporting Transition into Adult Services
1.
Know Roman Range/Phase
2.
Know preferred color(s)
3.
Know sensitivity to busy settings (loud, congested, cluttered)
4.
Know co-morbid visual conditions
5.
Know origin of CVI (congenital, acquired) and length of time with condition
6.
Know history of interventions (if any)
Slide forty-five: CVI
Is Visual Impairment.
While the hope is improvement in visual performance, the goal is consistent function across all settings.
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