The CVI Range A Functional Vision Assessment for Individuals with - - PowerPoint PPT Presentation

The CVI Range

A Functional Vision Assessment for Individuals with CVI & Intervention Strategies

Christine Roman Lantzy, Ph.D.

Goals for this session

• to describe the

principles of The CVI Range

• to describe the

rationale for use of The CVI Range

• to describe the

reliability & validity of The CVI Range

• to describe the

procedures for conducting and scoring The CVI Range

• to describe

interventions that are based on CVI Range scores

Cortical Visual Impairment (CVI)

• the leading cause of visual impairment

in children in the United States & “first- world” nations (Good, Jan, Burden, 2001)

• caused by damage or atypical structures

in the visual pathways and/or visual processing centers of the brain

Traditional diagnostics

• MRI-does not reliably confirm or deny

the presence of CVI

• VEP does not reliably describe whether

the child has functional vision

• Teller Acuity Cards do not correlate with

CVI-child’s functional vision

Diagnosis

• I. Eye exam that does not explain the

child’s profound lack of visual attention

• the eye exam is important
• II. History of neurological condition

associated with CVI

• III. The presence of unique CVI visual

and behavioral characteristics

• I. The eye exam
• CVI can exist as a single vision condition
• CVI is also associated with:
• strabismus
• ocular nerve disorders
• coloboma
• refractive errors

• II. Medical conditions

associated with CVI

• asphyxia
• intraventricular

hemorrhage

• white matter

damage/PVL

• metabolic
• stroke
• trauma
• congenital brain

malformations

• infection, congenital

and acquired

• chromosomal disorders

• III. CVI Characteristics

Roman-Lantzy, Cortical Visual Impairment: An Approach to Assessment and Intervention AFB, 2007

book contains detailed descriptions, examples, and scoring guides

The key to understanding how children with CVI see is found in the characteristic CVI behaviors

• attraction to color
• light gazing & non-

purposeful gaze

• movement (dorsal

stream)

• visual complexity

(ventral stream)

• visual latency
• visual field differences
• difficulties with distance

viewing

• visual reflex differences
• difficulties with visual

novelty

• lack of visual motor

match

The CVI Range (Roman Lantzy, 2007) is used to investigate the extent

• f the affect of the 10

characteristic behaviors associated with CVI

The CVI Range measures visual function

• The CVI Range can be used to

describe how children with CVI see

• The CVI Range helps compare visual

function across a diverse population of children 6 months-21 years

• The CVI Range provides common

language to describe levels of function

Purposes of The CVI

Range

• A need to describe a

continuum of visual function

• A need to find a

common language to standardize severity of CVI (think, APGAR)

• A method to monitor

progress and improvements in functional vision

• A method used to

determine appropriate interventions

• Provides a common

language

The CVI Range

• Used as a measure of degree of affect of

CVI

• Developed by Roman
• Based on the constructs developed by

Jan, Hoyt, Groenveld

• Considers CVI in terms of visual

impairment, not used as a definition that includes all forms of visual processing disorders (not sensitive to autism, dyslexia, etc)

The CVI Range

• Differentiates CVI from ocular forms of

visual impairment (WPSBC, 2013)

• 3 highly trained, CVI Range reliable

evaluators tested 45 students with either

• cular or cortical VI
• Diagnosis unknown to data collectors
• Pattern for ocular (all zeros or all 1s); not

consistent with CVI student CVIRange scores

Newcomb data

(Journal of Visual Impairment & Blindness, October, 2010)

• The CVI Range is a reliable and valid

instrument

• highly significant in: internal

consistency, test-retest reliability, inner rater reliability, consistency in Ratings I & II

The CVI Range

• Used with all ability levels & with infants-

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• Scores the degree of CVI on a 0-10

scale

• Describes three broad phases
• I=building visual behavior (score 0-3)
• II=vision+function (score above 3-7)
• III=resolving (score above 7-10)

The CVI Range

• Uses two methods of scoring to obtain a

range or score (across CVI characteristics & within CVI characteristics)

• Considers 10 CVI visual/behavioral

characteristics (color, movement, latency, visual reflexes, novelty, complexity, distance viewing, visual motor, light gazing, visual fields)

Scoring The CVI Range

• Data is collected through:
• observation-living and learning settings
• interview-CRITICAL and provides

much of the key information

• 25 questions that are used to

investigate the potential presence of the characteristics

• direct assessment-the “knee to knee”

elements

Scoring

• occurs after the

information is gathered

all 3 elements of observation, interview and direct assessment must be used and integrated into the scores

Scoring

• Rating I
• R=resolved behavior...the statement

represents a behavior that may have

• nce been true but the individual is now

well above that level of function

Scoring

• +=the statement describes a current

behavior

• these statements become the

present levels of function

Scoring

• +/-= the statement is

partly true or true part of the time

• the statement is neither

true or completely false

scoring

• = the statement represents a

behavior that is above or too difficult for the individual’s present level of visual function

Scoring rating II

• options of 0... .25... .50... .75... 1.0
• circle a value that represents the

DEGREE of affect of the individual characteristic

• 0 represents “full affect of this

characteristic”

• 1.0 represents “the characteristic

behavior is resolved...just like other individuals of the same age

• Rating I= ceiling

affect...where do the +’s end?

• Rating II= add all circled

values for each characteristic

• do not average the 2

scores

• record both...they become

THE RANGE

• assess with another partner until you are

confident with your scoring

• do not over think your observations
• do not eliminate one of the portions of

The CVI Range

• Rating I & Rating II should be in

agreement...no greater than1.5 points is the standard

Educational Applications

• Results from Rating I=descriptions of present levels of

visual functioning

• “the child visually attends for brief periods with
• bjects that are red and blue, against a plain

background, right of midline, and paired with light and movement”

• Results from Rating II=accommodations and

adaptations necessary for access to materials and environments

• allow up to 15 seconds for latency
• present targets in right or left peripheral fields
• instruction within 3 feet of the child
• targets should have no more than 3 colors on

surface

Remember

• In Ratings I & II: you cannot mark a

behavior as resolved (Rating I) or 1.0 (Rating II) UNLESS it is equivalent to the behavior of a typically developing child of the same age

Video Exercises

video sample+identification of Phase and CVI characteristics

video sample #1

16 year old boy history of birth asphyxia educated at a school for the blind not exposed to CVI-specific assessment or interventions

Video #1summary

• Phase I (scores 2-3)
• CVI Characteristics:
• color-red?
• movement-helps

attract and hold attention

• light-helps attract and

hold attention

• latency-frequent
• visual field preference-

looked left & lower

• complexity
• sensory-quiet only
• array-dark

background

• object-single color
• faces-no regard

38

Phase I

Some principles

• “pay it forward”...select materials that

you can apply to Phase II; what is the purpose?

• objects for viewing should ideally extend

from eye to hand

• a lightbox is NOT a stand alone item
• frequency of opportunity is important
• create a schedule of opportunities

Phase I environment

• no visual distractions
• no auditory distractions
• color+light+movement critical
• brief, fleeting visual localizations
• preferred objects most useful
• latency occurs frequently

Phase I Interventions

• single color

(preferred) familiar object

• include

movement/reflect ive

• present in

dominant field

• allow wait time
• one sense at a

time

• pair with light
• black or plain

background

video sample #2

4-year old boy history of bilateral grade IV IVH educated at a school for the blind, exposed to CVI Range assessment and interventions

Video #2 summary

• Early Phase II (score3-4)
• CVI Characteristics
• light gazing-iPad,

backlighting

• color-yellow
• latency
• movement-iPad image
• fields
• complexity
• object-target is

single color

• array-controlled
• sensory-difficulty

integrating touch & sound

Phase II

Vision + function

• Phase I elements of color, low

complexity, movement are applied to

• bjects that the individual can touch,

swat at, reach for, activate, grasp, or make eye contact to create some

• utcome or response
• vision leads/precedes touch
• child perceives their power to impact the

environment

Phase II environment

• reduction of visual and auditory

distractions

• light+movement+color remain important

but with some flexibility in use

• some simultaneous sensory information

tolerated while viewing

• latency decreasing
• new objects selected based on visual

traits of preferred objects

WPSBC photos

Video #3

Early Phase II

2 1/2 year old girl, twin history of premature birth and white matter injury/PVL mom’s interview information about CVI

Summer’s family

Interview Information

25-question CVI Range interview

• mom reports:
• 1. Tell me what you do with a toy to get your child

interested in it? use the sound on the toy. tap it to bring her attention to it & help her identify where it is. lift it up just lower then eye height & off to the left so she can look through her preferred visual window where both eyes look left. don't have a lot of other sounds around. either show her when she's lying down without distracting light around us. in our bed that has solid color sheets is a good place to get her visual attention. in her wheelchair i'll try to help hold her head so that she doesn't have to focus on holding her head up…but this doesn't usually work as well. If she can touch it & bring it to her mouth this helps her interest in the item also.

• 3. does your child have a favorite side or

a favorite head position? if she's looking at something or trying to then she'll let her head fall to the right shoulder & look to the left with both eyes.

• 4. does your child usually find objects by

looking or by feeling for them? feels for

• them. she's clued into her sense of

sound & touch the most.

• 5. do you have concerns about the way

your child sees? yes.

• 6. where do you usually hold objects for your child to

look at? approx 1 foot or less away from her face & off to the left if i am hoping she'll see it. maybe a few inches down from the height of her eyes…closer to the height of her nose or lips.

• 7. what are your child's favorite things in your

house? she loves people: Mom, sister Jade, Dad, grandparents, etc. when we have the fan going in the kitchen or that light on, she's interested in that. i don't think there's many things that she's visually interested in, it's more people & singing.

• 8. what, if anything, have doctors told you about your child's eyes?

strabismus, early on ROP stage 1. recently CVI. to go ahead & play movies in the car for Jade & maybe switch the girls car seats b/c maybe Summer can see some of it out of her eye gaze to the left if she's sitting in the seat on the right side of the car. I haven't switched them yet though, b/c i don't think she'll be able to see that tiny screen b/c it's too far away & too high & too movies are too quick with too much going on. she just prefers to listen. i would like to find something that she can be visually attuned to during our car rides however.

• 12. describe how your child behaves around lamps or

ceiling fans? she looks at them.

• 13. are you usually able to identify (be certain of) what

your child is looking at? there's a big part of a day where i may not know what she's seeing if she's even sensing her eyes & processing the info. There are times when i can really tell that she's looking at me or the fan or light

• r someone else. i'm eager to get an iPad & see if she

attends visually to the vision games if there's no volume. I feel pretty certain that she will!

• 14. does your child usually first notice things that move
• r things that don't move? when people move but i think

it's the dorsal vision that you spoke about. if i'm showing her something, i need to hold it still for a long time (probably at least 7 seconds until she sees it & then longer to interpret it) so that she has time to see it & make sense of it.

• 25. tell me what your child's favorite objects or toys

look like. this ? is a trigger for me b/c as many toys as we have in the house & as many of them that Jade loves, I don't know how to answer this question for

• Summer. I have this deep yearning to find toys that she

will really enjoy & have fun engaging with on her own in addition to with me or others. her favorite toys are often the people she enjoys & all singing songs & talking

• together. she's a happy little girl, not deprived & deeply

loved but she doesn't yet have toys that I at least know she really loves. I'd love help in this area.

Summer’s video

Video #3 summary

• Summer scores in early Phase II, ~3-

4/10

• CVI characteristics include:
• color=.25 gold + red, +/- green
• movement=.25, movement almost

always necessary

• latency=.25

Summer

• visual field preferences=.25; +left and

superior; +/- right, decreased lower

• complexity=.25
• object, 1-2 colors
• array, controlled but not darkened
• sensory, very interfering
• faces, glances toward familiar

Summer

• light gazing=.25, light supports visual

attention and is also a distraction

• distance=.25, attention to a specific

target within approximately 1-2 feet, may notice movement of people, pets...at greater distances

Summer

• reflexes= .25? hard to see in video,

Summer did blink to dad touching forehead

• visual novelty=.25, new objects that are

visually similar to familiar objects

• visually guided reach=.25, occasional

sustained visual attention while

• rganizing or actually reaching

Summer’s interventions

• will be developed to match, not exceed
• r be lower than her CVI Range score

Phase III intervention considerations

two big themes

• increasing amounts of background

information

• identifying salient features

Phase III environment

• little or no adaptation of familiar

environments required

• novel sounds or unexpected movement

in environment may be a factor in visual attention

Video #4

Griffen 24 weeks gestation, grade III & IV IVH CVI, seizures, language difficulties

Griffen

• Initially scored 2 on The CVI Range
• Currently scores 8
• Attends both special needs and

Montesorri preschool

Griffen’s Phase III sample

salient features supporting literacy

• CVI Range score in high Phase II, early

Phase III

• begin with images of familiar objects
• add number of elements & complexity

vary size, placement & number

begin with one object, build to 2 then add small amounts of background

salient features remain stable even when the image varies…”Elmo-ness”

Internal detail, salient features-building ventral stream vision

some salient features are obvious

some salient features are subtle

“things that can live in your house”

“things that can live

• n a farm”

Some thoughts about reading & communication systems

Consider

• the use of color (the return of preferred

color)

• low complexity images
• distance between symbols
• placement off midline

Words

• sight words are easier for students with

CVI

• phonemic awareness is also critical
• begin with high variability (go & done)
• use color highlighting to tightly outline

the word

• fade outlining as words are memorized

So…in review

• identify

individuals with CVI in a timely manner

• conduct The CVI

Range to determine the degree of affect

• f CVI
• design

interventions to match The CVI Range score

• create
• pportunities

that are part of the individual’s routine

Expect Improvements

• Phase III is the goal
• Improvements in functional vision “feeds”

all other areas of human development

• Increased independence & competence

Thank you

Christine Roman Lantzy croman@cviresources.com