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This handout is the basis of a training exercise intended to start a discussion on CVI and assessment among peers, specifically, teachers of students with visual impairments who work with children who may be experiencing visual impairment related to neurological causes. The handout is intended to accompany the videos that are linked within it, and should not be used for any other purpose. The assessment process and assessment forms created by Dr. Christine Roman-Lantzy in Cortical Visual Impairment: An Approach to Assessment and Intervention (New York: AFB Press, © 2007, American Foundation for the Blind, used with permission of the publisher; all rights reserved) have been used in this exercise to help us structure our thinking and organize information. The forms and an explanation of how they are to be used are included in Cortical Visual Impairment: An Approach to Assessment and Intervention available from AFB Press at www.afb.org/store.

Some of the forms have been modified to enhance accessibility. Dr. Roman-Lantzy has not reviewed or approved the way in which they have been displayed, modified, or scored for the purposes of this exercise, which is intended to be the basis of an exploratory interchange among peers. Please feel free to question, comment, and/or correct the material here in the discussion box provided. A comment form is available on each individual video.

  • Profile video | Profile transcript
  • 17 years old
  • Traumatic Brain Injury at age 11.
  • Orthopedic ally Impaired–CP
  • Eye Exam indicates that there is no ocular visual impairment; CVI is the main cause.

CVI Parent Interview Questions: (teacher and mother filled in answers together)
(p. 34, Roman-Lantzy, 2007)

Parent Interview video | Interview transcript

  1. Tell me what you do with a toy to get your child interested in it?  Definitely interested in any kind of basketball, balls of any size (size doesn’t matter).  Doesn’t take much to get him interested in something. Before it may have needed movement or be a red color but they are past that. 
  2. When you show your child something, how do you know he or she sees it? I ask him to tell me about it.  That is where we have gotten to pictures.  Describe it for me and he does.  Especially objects in space.  In pictures we question and wonder if he is guessing. 
  3. Does your child have a favorite side or a favorite head position? He tilts to the right.  When we have worked on visual things especially with picture cards/ etc.  We always do them up or eye level.  (Such as on a white erase board more on the right then on the left).   He has a harder time attending to things that are down in front of him. 
  4. Does your child usually find objects by look or by feeling for them? Most of the time by looking.  Sometimes when things are on the table I catch him feeling for items.  They had a big keys keyboard and he could tell you all the letters that were yellow.  Using his hands and using his eyes at the same time was difficult.  
  5. Do you have concerns about the way your child sees? Yes, it is not something that is constant and you can have days that are different.  We will start understanding what he is seeing more and more.  The other part is that I am concerned about his vision in the way of reading and him being completely independent.  Three or four years ago they worked on sensitivity in his fingers for Braille.
  6. Where do you usually hold objects for your child to look at?  At eye level (best).  Ian can see objects pretty much on any plane.  It is the 2D that is trickier.
  7. What are your child’s favorite things in your house?  Basketball, mixer, monkey (named Dexter), anything with the Lakers, Air Hockey table and his Wii.  His CD’s– he learned through repetition. 
  8. What, if anything, have doctors told you about your child’s eyes?  That they are 20/20.  There is nothing wrong with his eyes– it is all in the brain. 
  9. When does your child usually like to look at things?  When he is awake and alert.  When he gets really tired it is hard to see.  It takes a lot of conscious effort to see things– low contrast.
  10. What color are the things your child likes to look at most?  If we are on the highway, he always points out yellow cars.  Also things that are red.  Bright colors.  He is not dependent on color to see like he used to be.  Contrast definitely helps him see better/ he misses a lot of detail.
  11. What does your child do when he or she is near very shiny or mirrored objects?  This is not as applicable now– but early on it would get his attention.
  12. Describe how your child behaves around lamps or ceiling fans.  Doesn’t stammer on them.  He is normal around them. 
  13. Are you usually able to identify what your child is looking at?  Sometimes it is difficult.  Mom has been told that his peripheral vision in his brain is stronger than his straight on focus. 
  14. Does your child usually first notice things that move or things that don’t move? When he first started getting into objects it required movement.  He probably attends to things better if they move.  He does not require it anymore.
  15. How does your child position his or her head when you think he or she is looking at something?  I don’t know.  (Maybe down towards the left, teacher thinks.)
  16. Do you think your child has a “favorite” color?  Purple/Gold (Lakers).  As far as visually yellow or red.
  17. Does your child seem to notice things more at home or more in new places?  If it is objects or when driving to San Antonio he can point out where they are.  In some unfamiliar situations it may be harder. 
  18. Describe how your child positions his or her head when swatting or reaching toward something.  He reaches with his left and guessing that his head is cocked to the right (guessing to the right/teacher sees to the Left).
  19. How does your child react when you give him or her new things to look at?  Both the language retrieval and vision are when he has a difficult time with new things.  He knows what they are.  If you give him multiple choice he can retrieve it. 
  20. Do you position your child in a certain way to help him or her see things?  When they would do cards they did it at eye level.  He was not as successful when things were on the table.  There cannot be a lot of stuff competing with what he is trying to see.  He can point to the details of an object on a picture card and then he would be able to put those cards together and label the object.
  21. Have you ever been concerned about the way your child’s eyes move? No
  22. What does your child do when there are many objects in front of him or her to look at?  That is overload.  He may try but then it is just too much.
  23. Tell me about the faces your child prefers to look at.  Pretty girl faces.  Calendar of pretty girls he would rather look at that! That is one of the suggestions one center had made about retraining Ian’s brain that there should be pictures of pretty girls and have Ian describe what they are doing differently in the pictures.
  24. If your child had his or her own object to look at and a new object, which object would he or she prefer?  Depends on what the other object is. 
  25. Tell me what your child’s favorite objects or toys look like.  Pictures of girls, basketball, etc.  Can be anything and any size. Flat and does not have the dimension that is the problem– it is not going to help just making it bigger. 

Answer Key for Ian's CVI Resolution Chart (Cheat Sheet)

INTERVIEW: (* on chart) (+ positive for CVI, – negative for CVI, ? inconclusive)

  1. + Targets movement (2) and fields (4).  Positive for CVI because it used to require movement, but don’t mark on chart for current functioning.  Actually addresses color: Mark on chart in row 1, range 9–10.
  2. + Targets visual attention/non–purposeful gaze (6).  Answer refers to complexity (5), and places him in the 8–9 range.  He looks at pictures but may be guessing as to their meaning, and sees 3–d better (“objects in space”).  Mark on chart in row 5 on line between range 7–8 and 8–9.  Positive for CVI but not for what question asks.
  3. + Asks about field preference (4) and additional disabilities.  Answer seems to be positive for fields– “more on the right” & “harder to attend to things down in front”.  Mark this on resolution chart in row 4, range 3–4.
  4. + Asks about visually guided reach (10) or visual complexity (5).  Answer positive for visually guided reach because of “using hands and eyes together at the same time was difficult”.  Mark this on row 10, in range 5–6.  Make note on chart that highlighting with yellow is helpful.
  5. + Is asking about appearance of the eye/eye exam.  Positive for CVI because of comments on how visual function changes.  Not necessary to mark anywhere on chart.
  6. + Asks about visual field preferences (4) and visual complexity (5).  Answers give positive answers for fields “can see objects pretty much on any plane”  (4) and complexity “”2D is trickier” (5).  Record range 9–10 in row 4.   Answer is inconclusive as far as range for complexity so no markings necessary.
  7. ? This question targets light–gazing/non–purposeful gaze (6), movement (2), and visual novelty (9).  The answer does not give clear information to mark on chart–just that he’s a teen! 
  8. + Asks about eye exam.  Positive for CVI.  20/20 vision in eyes, but vision is still impaired.  Make note under distance, row 7, that eyes are 20/20, FYI.
  9. + Asks about visual novelty (9) and complexity (5).  Answer is positive for latency (3).  Mark on chart in row 3, range 5–6.
  10. +Asks about color preference (1) and novelty (9).  Answer is positive for color preference, but not specific enough to mark on chart (1).   Make note that yellow and red highlighting help draw visual attention under row 1.
  11. + Asks about light gazing (6), movement (2), and color preference (1).  Answer is positive for CVI in that he used to light–gaze, but it is now resolved.  Mark in row 6 under range 5–6.
  12. + Asks about non–purposeful gaze/light–gazing (6).  Answer is same as 11.  Mark in row 6 under range 5–6.
  13. ? Asks about non–purposeful gaze (6).  Answer addresses fields but is inconclusive.
  14. + Asks about movement (2) and fields (4).  Answer is positive CVI for movement because it used to be needed but is no longer needed but still helps with attention.  Record on chart in row 2 range 7–8.
  15. ? Targets fields (4).  Answer is inconclusive.
  16. +Asks about color preference(1).  Answer is positive for CVI.  Mark on row 1, range 7–8, continues to prefer red and yellow.
  17. + Targets complexity of array (5) and non–purposeful gaze (6) and novelty (9).  Answer addresses complexity but answer is not on chart–he is able to look in a very complex situation–while driving in car looking out window.  Answer also addresses novelty because he can point out objects on familiar drive.  Mark in row 9 under range 7–8.
  18. ? Targets visual motor (10) and field preferences (4).  Answer is inconclusive because some of the way he moves/turns his body has to do with motor impairment.
  19. + Targets novelty (9) and complexity (5).  Answer is positive for novelty–in that giving multiple choice may serve as warm–up time.  Mark in row 9 under range 7–8.
  20. + Asks about fields (4) and complexity (5).  Answer addresses complexity in that “there cannot be a lot of stuff competing with what he’s trying to see”.  This refers to visual clutter, not auditory.  It may be marked in row 5, range 7–8 by process of elimination.  (5–6 too low, 9–10 too high for this).
  21. ? Asks about eyes.  Targets those kids who do not already have CVI diagnosis.  Answer is inconclusive.
  22. + Targets complexity (5) and novelty (9).  Answer is positive for complexity (5).  “That is overload–he may try but then it is just too much.”  Mark in row 5, range 7–8, same reason as question 20.
  23. ? Targets novelty (9) and complexity(5).  Inconclusive–it does not say what Ian does in response to the pictures of pretty girls.
  24. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive.
  25. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive

         17 positives, 0 negatives, 8 inconclusives.

OBSERVATION: (• on chart)

Observation video | Observation transcript

  1. Accurate reach while looking at van door to close it.  Visually guided reach–mark row 10 under range 9–10.
  2. Recognized “fruit” from 5 ft.  Mark row 5 (complexity), range 9–10 and row 7 (distance), range 5–6.
  3. Color–first looked at red, Lisa asked to identify, touched to gain more information. (pepper)  Supports continued attraction to things that are red and that Ian continues to need tactual information to check/verify visual information.  Also, has trouble differentiating red and orange: identified red apple as an orange.  Good information, but not for chart.
  4. When asked if it’s a lemon or a lime, he leaned in to narrow field and decrease complexity. Mark on chart, row 5 (complexity), range 9–10.
  5. Hard to tell the color of the lime when it was over complex, multi–colored background.  Easier when over black and white background.  Mark under complexity, row 5, range 9–10.
  6. Identifies orange correctly, quickly while touching and holding over plain background. Mark under complexity, row 5, range 9–10.
  7. When asked to pick something from a complex array that did not include red, Ian picked a yellow squash.  Make note, yellow still draws visual attention.
  8. Is able to visually function with background noise. (Music, Lisa talking, etc.)  Use milk/eggs as example.  Mark on chart under complexity, row 5, range 7–8.
  9. Gum shelf shows fatigue–looking away and not looking close, like when really looking for visual information.  This began after about 10 minutes of looking in new environment.  Mark in latency, row 3, range 5–6.
  10. Doesn’t look at cashier at all, even though he’s pretty social–fatigue. Mark in latency, row 3, range 5–6.
  11. Finds van from 20 feet (or more) in unfamiliar environment!  Distance–mark in row 7 under range 9–10.

DIRECT ASSESSMENT (^ on chart):

Session 1:

Direct Assessment #1 video | Assessment #1 transcript

  1. When asked to pick up skittles off table, picks up red first, then yellow, then other colors.  Finds in many fields. Mark in row 4 (field preferences), range 9–10.
  2. Notices object in left, right, and upper peripheral fields quickly, minutely faster response when object moving. Mark in row 4 (field preferences), range 9–10.
  3. Pictures: After viewing pictures section, mark in row 5 (complexity) range 7–8.
    • Color outline or white not necessary to help Ian look at picture.
    • Single colored items are most easily identified in pictures, such as the van (identified as a car–large expanse of white) and the pool (large expanse of blue).  This might be a helpful strategy.
    • Outlining pictures in a particular may be used for categorization, such as person, place, object, (provides a hint–visual categorizing is something CR recommends for students at this phase, too), but don’t use red and orange.  Ian can’t tell them apart well enough.
    • Ian uses strategy of moving close, moving and turning picture but it does not seem to help. 
  4. Cluttered background with with 4 previously recognized pics, gets close but can’t find pool (picks van instead–blotch of white when blue pool probably blended into background.)  Mark in complexity, row 5, under range 7–8.
  5. Blocks–picked an orange block when asked for red.  When asked to pick any block and say the color picked yellow. Harder to find green, but accurately picked it.  Has trouble with red and orange, but better if they’re next to each other for comparison(?).  Also–obviously getting tired.  Ian has been intensely using his vision for about 10 minutes (mark in row 3 (latency) range 5–6.

Session 2:

Direct Assessment #2 video | Assessment #2 transcript

  1. Faces: recognized familiar people in context.  When they were out of context he had more trouble.  Mark in complexity, row 5, range 7–8.
  2. Moving and handling is a strategy Ian uses–it seems to work better with objects than pictures.  He gets information from tactile and auditory senses over and above vision–might be interfering with vision. Mark in complexity, row 5, range 7–8. 
  3. Visually guided reach together or in rapid sequence.  Mark in row 10, box 7–8.
  4. Blink to threat, blink to touch–Mark in Row 8, range 9–10.

CVI Resolution Chart

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Date:                                       Student’s Name:      Ian                                 Evaluator: Lynne & Sara
Use the following chart to help develop areas of needs for development of IEP goals and objectives.

There are three phase categories which group the ranges as follows: Phase I (Range 1–2 to the midpoint of Range 3–4) Building Visual Behavior, Level I Environmental Considerations; Phase II (midpoint of Range 3–4 to midpoint of Range 7–8) Integrating Vision with Function, Level II Environmental Considerations; and Phase III (midpoint of Range 7–8 to Range 9–10) Resolution of CVI characteristics, Level III Environmental Considerations.

CVI Characteristics Range 1–2
(0)
Range 3–4
(.25)
Range 5–6
(.50)
Range 7–8
(.75)
Range 9–10
(1)
Color Preferences
1
*4 yellow draws attn. *10 , ^1 - yellow & red, •3 red, •7 yellow,
Objects viewed are generally a single color Has “favorite” color Objects may have two to three favored colors More colors, familiar patterns regarded
*16
No color or pattern preferences
*1
Need for movement
2
Objects viewed generally have movement or reflective properties More Consistent localization, brief fixations on movement and reflective materials Movement continues to be an important factor to initiate visual attention Movement not required for attention at near
*14
Typical responses to moving targets
Visual latency
3
Prolonged Periods of visual latency Latency slightly decreases after periods of consistent viewing Latency present only when student is tired, stressed or over–stimulated
*9, •9, •10, ^5
Latency rarely present Latency resolved
Visual field preferences
4
Distinct field dependency Shows visual field preferences
*3
Field preferences decreasing with familiar inputs May alternate use of right and left fields Visual fields unrestricted
*6, ^1, ^2
Difficulties with visual complexity
5
Responds only in strictly controlled environments
Generally no regard of the human face
Visually fixates when environment is controlled Student tolerates low levels of familiar background noise
Regards familiar faces when voice does not compete
Competing auditory stimuli tolerated during periods of viewing; student may now maintain visual attention on musical toys
Views simple books or symbols    
*2––––
*20, *22, •8, ^3, ^4
Smiles at re/regards familiar and new faces
^6, ^7
Only the most complex visual environments affect visual response
Views books or other two-dimensional materials|
––––*2,
•2, •4, •5, •6 Typical visual/social responses
Light–gazing and nonpurposeful gaze
6
May localize briefly, but no prolonged fixations on objects or faces
Overly attentive to lights or perhaps ceiling fans
Less attracted to lights; can be redirected to other targets Light is no longer a distracter 
*11, *12
   
Difficulty with distance viewing
7
*8 doctor says 20/20
Visually attends in near space only Occasional visual attention to familiar, moving, or large targets at 2 to 3 feet Visual attention extends beyond near space, up to 4 to 6 feet
•2
Visual attention extends to 10 feet with targets that produce movement Visual attention extends beyond 20 feet
Demonstrates memory of visual events
•11
Atypical visual reflexes
8
No blink in response to touch and/or visual threat Blinks in response to touch, but response may be latent Blink response to touch consistently present
Visual threat response intermittently present
Visual threat response consistently present (both reflexes near 90 present resolved) Visual reflexes always present; resolved
^9
Difficulty with visual novelty
9
Only favorite or known objects elicit visual attention May tolerate novel objects if the novel objects share characteristics of familiar objects Use of “known” objects to initiate looking sequence Selection of objects less restricted, one to two sessions of “warm up” time required 
*17, *19
Selection of objects not restricted
Absence of visually guided reach
10
Look and touch occur as separate functions
Look and touch occur with large and/or moving objects
Look and touch occur with smaller objects that are familiar, lighted, or reflective
Look and touch are still separate
Visually guided reach used with familiar objects or “favorite” color
*4
Look and touch occur in rapid sequence, but not always together
^8
Look and touch occur together consistently
•1

Key:

  • Draw an X though boxes that represent resolved visual behaviors
  • Use highlighter to outline boxes describing current visual functioning
  • Draw an O in boxes describing visual skills that may never resolve because of coexisting ocular conditions

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Essential Forms
The CVI Range

Recording the CVI Range video | Recording the CVI Range transcript

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Student/child’s name:  Ian                                      Age:  17
Evaluator(s):  Lynne and Sara                                          Evaluation Date:  ___00/00___
This assessment protocol is intended for multiple evaluations over a period of time.  Suggested scoring (no less than three times per school year):

  • Initial assessment (red)
  • Second assessment (blue)
  • Third assessment (green) Further assessments will require a new form.
Totals: Evaluation #1 (red) Evaluation #2 (blue) Evaluation #3 (green)
Total for Rating I 9    
Total for Rating II 7.75    
Combine both ratings to get overall CVI Range 7.75–9    

First evaluation on 00/00 shows range of CVI to be 7.75 to 9.

No functional vision 0    1      2      3      4      5      6      7      8      9      10 
                                                              ^00/00^  
Typical or near-typical visual functioning


Figure1: Line graph from 1 to 10, 1 representing no functional vision and 10 representing typical or near–typical visual functioning.

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

The CVI Range:  Across – CVI Characteristics Assessment Method

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Rating I

Rate the following statements as related to the student/child’s visual behaviors by marking the appropriate column to indicate the methods used to support the scores:

  • O = information obtained through observation of the child/student
  • I   = information obtained through interview regarding the child/student
  • D  = information obtained through direct contact with the child/student

In the remaining columns, indicate the assessed degree of the CVI characteristic:

  • R    = The statement represents a revised visual behavior
  • +    = Describes current functioning of student/child
  • +/–  = Partially describes student/child
  • –    = Does not apply to student/child
CVI Range 1–2:  Student functions with minimal visual response
O I D R + +/–  
x x x x             May localize, but no appropriate fixations on objects or faces
x x x x             Consistently attentive to lights or perhaps ceiling fans
x     x x             Prolonged periods of latency in visual tasks
x x x x             Responds only in strictly controlled environments
x x x x             Objects viewed are a single color
x x x x             Objects viewed have movement and/or shiny or reflective properties
x x x x             Visually attends in near space only
        x x             No blink in response to touch or visual threat
x x x x             No regard of the human face
CVI Range 3–4:  Student functions with more consistent visual response
O I D R + +/–  
x         x             Visually fixates when the environment is controlled
x x     x             Less attracted to lights; can be redirected
        x x             Latency slightly decreases after periods of consistent viewing
x     x x             May look at novel objects if they share characteristics of familiar objects
        x x             Blinks in response to touch and/or visual threat, but the responses may be latent and/or inconsistent
x x x x             Has a “favorite” color
        x x             Shows strong visual field preferences
x x x x             May notice moving objects at 2 to 3 feet
x x x x             Look and touch completed as separate events
CVI Range 5–6:  Student uses vision for functional tasks
O I D R + +/–  
        x x             Objects viewed may have two to three colors
x x     x             Light is no longer a distractor
        x     +         Latency present only when the students is tired, stressed, or overstimulated
x x x x             Movement continues to be an important factor for visual attention
x     x x             Student tolerates low levels of background noise
        x x             Blink response to touch is consistently present
        x x             Blink response to visual threat is intermittently present
x     x x             Visual attention now extends beyond near space, up to 4 to 6 feet
x     x x             May regard familiar faces when voice does not compete
CVI Range 7–8:  Student demonstrates visual curiosity
O I D R + +/–  
x x x x             Selection of toys or objects is less restricted; requires one to two sessions of “warm up”
x x     x             Competing auditory stimuli tolerated during periods of viewing; the student may now maintain visual attention on objects that produce music
        x x             Blink response to visual threat consistently present
x             +         Latency rarely present
x     x x             Visual attention extends to 10 feet with targets that produce movement
x     x x             Movement not required for attention at near distance
x     x x             Smiles at/regards familiar and new faces
            ?             May enjoy regarding self in mirror
        x x             Most high–contrast colors and/or familiar patterns regarded
        x     +         May regard familiar faces when voice does not compete
CVI Range 9–10:  Student spontaneously uses vision for most functional activities
O I D R + +/–  
x         x             Selection of toys or objects not restricted
x             +     Only the most complex environments affect visual response
x     x             Latency resolved
x     x     +         No color or pattern preferences
x             +         Visual attention extends beyond 20 feet
        x         +/–     Views books or other two–dimensional materials, simple images
x                 +/–     Uses vision to imitate actions
    x x     +         Demonstrates memory of visual events
x                 +/–     Displays typical visual–social responses
        x x             Visual fields unrestricted
        x     +         Look and reach completed as a single action
        x         +/–     Attends to two–dimensional images against complex backgrounds

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

The CVI Range:  Within – CVI Characteristics Assessment Method

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Rating II

Determine the level of CVI present or resolved in the 10 categories below and add to obtain total score. Rate the following CVI categories as related to the student/child’s visual behaviors by circling (marked with parenthesis on the chart below) the appropriate number (the CVI Resolution Chart may be useful as a scoring guide):

  • 0    Not resolved; usually or always a factor affecting visual functioning
  • .25    Resolving
  • .5    Resolving; sometimes a factor affecting visual functioning
  • .75    Resolving
  • 1     Resolved; not a factor affecting visual functioning
1.  Color preference 0 .25 .5 (.75) 1
Comments:
2.  Need for movement 0 .25 .5 (.75) 1
Comments:
3.  Visual latency 0 .25 (.5) .75 1
Comments:
4.  Visual field preferences 0 .25 .5 .75 (1)
Comments:
5.  Difficulties with visual complexity 0 .25 .5 (.75) 1
Comments:
6.  Light–gazing and nonpurposeful gaze 0 .25 (.5) .75 1
Comments:
7.  Difficulty with distance viewing 0 .25 .5 .75 (1)
Comments:
8.  Atypical visual reflexes 0 .25 .5 .75 (1)
Comments:
9.  Difficulty with visual novelty 0 .25 .5 (.75) 1
Comments:
10. Absence of visually guided reach 0 .25 .5 (.75) 1
Comments:

Total of CVI characteristics present (numbers in parenthesis) = 7.75

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Cortical Visual Impairment (CVI) Assessment

Recommendations video | Recommendations transcript

Student: Ian
Assessors: Lynne McAlister, TVI; Sara Kitchen, TVI
Date: 00–00– 00

Ian was assessed using the Roman–Lantzy (2007) CVI resolution assessment tool. At today’s evaluation date, he is 17 years old. The primary goal of this assessment is to determine functional vision abilities and to identify potential characteristics of CVI that may be interfering with Ian’s functional performance.

Ian’s medical history is consistent with the neurological disorders often associated with CVI. His primary handicapping condition is traumatic brain injury. Ian does not wear corrective lenses and his eye exam indicates CVI as the reason for his visual impairment. The evaluation consisted of analyzing videotapes of Ian in several environments as well as information from his parents and the staff members who work with him. Ian demonstrated characteristics of CVI. This report will be organized according to these characteristics.

Color preference:

Some people with CVI seem to respond more quickly to objects of a particular color. Ian hovers between total resolution of color vision and still preferring certain colors. While he looks at objects of any color, he seems to gravitate toward shades of red and yellow. Ian’s mother states that in the past he may have needed an object to be red or yellow but he is beyond that now. However, he usually picks out red and yellow cars when asked to point them out on the highway. When presented with an array of multicolored skittles, he picked up a red one first, then a yellow. Red shades seem to be the most easily seen color, but when asked to pick up a red block from a colored array he chose an orange block and told me it was red. When asked in the same situation to pick up any block and tell me it’s color, he chose and accurately named the yellow. After picking up a red block, he studied it for some time before correctly identifying it. At a grocery store, he was asked to pick one fruit/vegetable from the array on the shelf. Ian chose a red pepper and named the color orange. He identified a red onion and red apple as orange. When asked to pick another fruit from an array that did not have any red objects in it, he chose a yellow squash. He correctly identified a drawing of a red stop sign saying, “Red, it’s a stop sign.” He identified a drawing of a yield sign as, “a yellow sign.” When asked to identify several multicolored objects, he would invariably pick them up first and then look at them. When asked to identify the object only visually, he looked at it and picked it up. After handling the objects, he correctly identified most of them. He did not identify a brown action figure, but did say that it was orange. While not recognizing a picture of the outside of the campus natatorium (he identifies it as a “building”), when shown a picture of the inside he said, “blue…it’s the pool. I can see it better because it’s blue”. He could not identify a photo of a familiar campus location that was black and white, only identifying the pavilion as being outside. These reactions seem to indicate that color acts as a visual magnet for Ian. He seems to see objects that are in the red/orange spectrum as well as yellow more easily than others. This visual behavior in students with CVI has been corroborated in the literature. 

Need for Movement:

Many people with CVI respond best visually to targets that move in space or have reflective properties. Ian’s mother says while he probably attends to things better if they move, he does not require it anymore. When presented with shiny, moving objects in his peripheral fields, Ian seemed to see the objects a second before he saw them when they were not moving, but it was not a noticeable difference. Ian looks at objects that are neither moving, shiny, nor reflective. This CVI characteristic seems to have been resolved.

Visual Latency:

 This characteristic manifests itself with a delayed response between the time a target is presented and the time when an individual sees it. Ian showed little or no delay in directing his vision to a target. However, he did show delays in correctly identifying a target, such as photos and objects. He took some time to study these items, sometimes moving the item around as an aid in recognizing it. Physically handling objects seemed to directly affect his ability to identify them. Ian displays a visually guided reach, meaning he is able to look at an object and use that information to touch it.

Visual Field Preferences:

Many students with CVI have strong visual field preferences. These field differences are typically not due to damage to the retina or other structures of the eye, they are caused by damage to the visual pathways of the brain. Ian was able to pick up skittles placed in all of his visual fields. He recognized objects coming from behind him without restriction in his right, left, upper, and lower fields. He used his central visual fields to look at objects. These behaviors indicate that this characteristic has been resolved. However, Ian’s mother reports that he tilts his head to the right when viewing objects, and he seems to have a harder time attending to things that are in his lower visual fields. This may be from a difficulty controlling the movements of his head and eyelids, or may indicate a continuing visual difficulty with visual fields.

Visual Complexity:

Difficulties with visual complexity can mean difficulty with the complexity of the surface of the object, of the viewing array, or of the sensory environment. Along with color, this seemed to be the most challenging aspect of Ian’s vision. His mother states that his vision is compromised when there are a lot of things competing with what he is trying to see. When there are too many objects in his visual field it is overload. He may try but then he gives up. Ian was able to identify salient features in two and three–dimensional materials with backgrounds of low complexity. To look at these materials, he often would either bring the object 8 to 12 inches from his eyes, or lower his head the same distance. This succeeds in blocking out background clutter, and is not necessarily an indicator of impaired acuity. However, it is important to refer to an eye specialist when there is a question of visual acuity impairment. Ian’s eye doctor has given him acuity of 20/20. Ian’s mother was also unsure of his ability to interpret two–dimensional pictures, stating that he may be guessing.  Ian was able to identify photos of a van, a person (“it’s a girl”), and the school cafeteria full of people. When presented with a Meyer–Johnson picture of a round smiling face, he asked if it told time. After four pictures he had correctly identified were placed on a very colorful patterned background and asked to find the pool picture, he bent his head four inches from the array and studied it for approximately 45 seconds. He then chose the picture of the white van. After being given a lime at the grocery store, Ian could not name identify it or state it’s color while holding it over the array of the other fruit and vegetables. When asked to turn so that he was holding over the brown floor, he stated it was “greenish”. He was also able to identify an orange when he held it over the uncluttered floor. When asked to identify unspeaking people sitting next to him, Ian accurately named his teacher and TA. When asked to identify a job coach, Ian initially identified him as his RI, and then correctly named him. Faces present a very complex visual array, and the inability to recognize them is very common among people with CVI. This characteristic seems to be resolving in Ian.

Light Gazing and Non Purposeful Gaze:

Some people with CVI have abnormal responses to light, either staring at light, or photophobia. Ian displays none of these behaviors.

Difficulty with Distance Viewing:

Ian recognized a van at a distance of 20 feet. However, distance vision is greatly affected by difficulties with visual complexity, as the further you look the more things that are in the visual field.

Atypical Visual Reflexes:

Ian blinked when a hand approached his face. This is a typical response of the eye to a visual threat.

Difficulty with Visual Novelty:

Many individuals with CVI tend to visually attend to objects or targets seen previously, but may ignore visually novel or new things. Ian’s mother states that in unfamiliar situations it may be more difficult for him to process visual input. She reports that he learns through repetition. When he gets tired it is harder for him to see. Ian seemed to be able to see all the objects I presented, but it took him several seconds of study before he could name an unfamiliar object or picture. This delay was most pronounced in very complex visual environments. Ian told his teacher that if he studied flash cards with sight words on them he would be able to read them better. When Ian’s job coach sat down next to Ian silently within the context of a routine that did not normally include the job coach, it took Ian at least a minute to name him correctly, first labeling him a RI. Ian’s mother states that he has a difficult time with language retrieval paired with visually novel objects

Absence of Visually Guided Reach:

This characteristic may be thought of as hand–eye coordination. Ian’s mother reports that using his hands and eyes together is difficult for him. Ian is able to look at something and pick it up simultaneously. However, once he is holding an object he may not look at it as he tactually manipulates it to aid in recognizing it. In one session with us, Ian insisted on picking up the novel objects we showed him, even though we asked him to just look at them. Tactual input seems to assist him with object recognition.

Lynne McAlister, CTVI, and Sara Kitchen, CTVI

Recommendations

  • Color should be used to anchor Ian’s vision to the objects he needs to look at. The colors red, orange, and yellow should have dominance, then the other colors in the spectrum. This may be done by using color photos of people and places to organize his calendar or some other familiar sequence, the current event highlighted with a red or yellow cardboard frame that can be moved from picture to picture.  Highlight visual targets with red/orange spectrum colors to draw Ian’s visual attention.  Use labeled color photographs (of items, places, etc., that contain color) as symbolic representations in Ian’s daily schedule/activities. Drawn pictures may also be useful as an organizational tool within lessons, especially if he is involved in the drawing and labeling process. These labeled pictures may take the place of written notes. Perhaps experiment with bold print on a red or yellow background to see if this aids in his sight word recognition. The goal is to allow Ian access to a learning media that does not depend on another person to deliver it. Ian may not be able to recognize either the picture or the word at first, but through consistent exposure he may be able to more easily process the information to the point of the picture no longer being necessary.
  • Present visual targets on a plain background.  Allow Ian to bring items close to his face in visually cluttered environments. Always be aware of the visual environment behind the object he is looking at. Simplifying the background of an object or person may allow him to recognize it.
  • Allow Ian tactual access to objects to assist in recognition.  Also, encourage exploration of objects to increase Ian’s knowledge of the tactual properties of objects as they relate to the visual aspects. Encourage Ian to look and manipulate objects at the same time.
  • Use some sort of occluder to block out excess detail on a page of images or symbols. For example, block out all but the individual word that is being read.
  • Experiment with spacing between letters in words to see if it is easier for Ian to recognize the letters when they are farther apart.
  • Highlight environmental landmarks as necessary.
  • Consider the use of a cane, which may help Ian remain anchored to the environment in the presence of a high degree of environmental complexity.
  • Allow Ian time to study a novel object/word before requiring a response. Perhaps he could be given the opportunity to examine materials for an upcoming lesson without adult intervention so that he has some degree of visual recognition of the task.
  • Be aware that Ian experiences visual fatigue after approximately 10 minutes of consistent uninterrupted viewing. This is especially apparent with novel items. Upon reaching this point, Ian stops looking. Build in frequent breaks when asking Ian to use his vision, allowing him to also respond auditorially.
  • While movement may aid Ian’s use of vision, when he is upright and walking he is also concentrating very hard on those motor skills. This divided attention may detract from his ability to process visual input. It will be easier for Ian to perform complex visual tasks when his body is stable and seated.
  • Christine Roman states that instruction for a student with a high resolution of CVI characteristics, such as Ian, has two main themes: teaching sorting skills with reference to the concepts of alike and different, and disembedding salient features from a background. Learning how to compare and contrast the visual properties of objects supports the ability to analyze novel information and visual complexity. Learning to differentiate a feature or object from a background supports the development of the ability to differentiate details and make fine visual discriminations.
  • As with any student with CVI, Ian’s functional vision may be affected by factors such as stress, over–stimulation, fatigue, or too much visual novelty.

 

This handout is the basis of a training exercise intended to start a discussion on CVI and assessment among peers, specifically, teachers of students with visual impairments who work with children who may be experiencing visual impairment related to neurological causes. The handout is intended to accompany the videos that are linked within it, and should not be used for any other purpose. The assessment process and assessment forms created by Dr. Christine Roman-Lantzy in Cortical Visual Impairment: An Approach to Assessment and Intervention (New York: AFB Press, © 2007, American Foundation for the Blind, used with permission of the publisher; all rights reserved) have been used in this exercise to help us structure our thinking and organize information. The forms and an explanation of how they are to be used are included in Cortical Visual Impairment: An Approach to Assessment and Intervention available from AFB Press at www.afb.org/store.

Some of the forms have been modified to enhance accessibility. Dr. Roman-Lantzy has not reviewed or approved the way in which they have been displayed, modified, or scored for the purposes of this exercise, which is intended to be the basis of an exploratory interchange among peers. Please feel free to question, comment, and/or correct the material here in the discussion box provided. A comment form is available on each individual video.

  • Profile video | Profile transcript
  • 9 years old
  • CVI secondary to anoxia from surgery during infancy
  • Auditory processing disorder-Deafblind
  • Developmental delays
  • Speech Impaired
  • Extremely social
  • Uses object calendar-transitioning to pictures (emerging)
  • Intermittent nystagmus while tracking
  • 20/200 Snellen equivalent distance acuity from low vision evaluation-determined using Teller cards.
  • Slight hyperopia-no glasses prescribed.

CVI Interview questions for parents/caregivers:
(p. 34, Roman-Lantzy, 2007)

Parent Interview video | Interview transcript

  1. Tell me what you do with a toy to get your child interested in it?  Parent: If it plays music or lights up I push the button to make it do it.  If it is a toy without music or lights I hold it in front of her face to get her interested in it.  School: Make noise with it.  Mostly she finds things on her own.  Put it in her field.
  2. When you show your child something, how do you know he or she sees it?  Parent: Cassie will grab it or reach for it.  School: She brings it to her face or moves it.  Looks out window of van when moving for the whole trip.
  3. Does your child have a favorite side or a favorite head position?  Parent: Haven’t really seen a true preference but sometimes she’ll tilt her head up.  School: Holds head back, like when looking at faces.  Forward gait-eyelids partially closed.  Blocking field?
  4. Does your child usually find objects by look or by feeling for them?  Parent:  ½ by look and ½ by feel.  School:  Looking then touching.
  5. Do you have concerns about the way your child sees? Parent:  Worry about lack of depth perception causing falls.  School: Nope, only curious.
  6. Where do you usually hold objects for your child to look at?  Parent:  I hold it about a foot to a foot and a half away from face directly in front of her eyes.  Sometimes I wiggle it.  School:  Right in front-central.
  7. What are your child’s favorite things in your house?  Parent:  Her guitar, vacuum cleaner, closets.  School:  Accordion, rolling chair, pots and pans, keyboard, toy car (for crashing), swing, trampoline, slide.
  8. What, if anything, have doctors told you about your child’s eyes?  Parent: physically they are fine except for a little astigmatism in one eye.  School: No problem.
  9. When does your child usually like to look at things?  Parent:  When they light up or glow if they vibrate or wiggle.  School:  Varies.
  10. What color are the things your child likes to look at most?  Parent:  Haven’t really seen a preference.  School:  No major color preference.
  11. What does your child do when he or she is near very shiny or mirrored objects?  Parent:  If it’s very shiny she will squint her eyes.  She will be curious about them.  School:  No large attraction to shiny stuff unless it’s reflecting a lot of light.
  12. Describe how your child behaves around lamps or ceiling fans. Parent:  Likes to see them turned on and off.  School:  Lights, especially to turn off/on.
  13. Are you usually able to identify what your child is looking at?  Parent: Majority of the time.  School:  Yes, because she’ll reach for it.
  14. Does your child usually first notice things that move or things that don’t move?  Parent:  Notices things that move first.  School:  Both-she moves.  Can label when swinging.
  15. How does your child position his or her head when you think he or she is looking at something?  Parent:  Might slightly raise her head up.  School:  Varies.
  16. Do you think your child has a “favorite” color?  Parent:  Have not seen her make a preference for a specific color.  School:  No.
  17. Does your child seem to notice things more at home or more in new places?  Parent:  I would say more in new places.  School:  Doesn’t search things out in new places.  Runs through.  Moves all the time in new environment with no attention to detail.
  18. Describe how your child positions his or her head when swatting or reaching toward something.  Parent:  Holds her head straight towards it for the most part but sometimes will turn head away.  School: Varies.
  19. How does your child react when you give him or her new things to look at?  Parent:  She will shake it and turn it over and around in her hands and then will look at it.  School:  Varies.
  20. Do you position your child in a certain way to help him or her see things?  Parent:  No.  School:  NA
  21. Have you ever been concerned about the way your child’s eyes move?  Parent:  No.  School:  NA
  22. What does your child do when there are many objects in front of him or her to look at?  Parent:  She’ll just take each one at a time and check them out.  School:  Looks less.
  23. Tell me about the faces your child prefers to look at.  Parent:  Her Mom’s Dad’s, and babysitter’s because they are faces of the people she knows, trusts, and loves.  School:  All.  She likes faces but doesn’t seem to differentiate.
  24. If your child had his or her own object to look at and a new object, which object would he or she prefer?  Parent:  For the most part she’ll check out the new object but sometimes she’ll choose the familiar object.  School:  Depends.
  25. Tell me what your child’s favorite objects or toys look like.  Parent: Likes toys or objects that are musical or light up or have soft texture. School: Varies.

Answer Key for Cassie's CVI Resolution Chart (Cheat Sheet)

INTERVIEW: (* on chart) (+ positive for CVI, - negative for CVI, ? inconclusive)

  1. + Asks about movement (2) and fields (4).  Positive for CVI because of fields (4)-  Mark on row 4, range 3-4.
  2. + Asks about visual attention/non-purposeful gaze (6).  Answer refers to the need for movement (2) but not attention.  Positive for movement.  Mark row 2, range 3-4.
  3. + Asks about field preference (4) and additional disabilities.  Mark on row 4, range 3-4.
  4. + Asks about visually guided reach (10) or visual complexity (5).  Answer positive for visually guided reach because of “look then touch”.  Mark row 10, range 3-4.
  5. ? Is asking about appearance of the eye/eye exam.  Reference to child who doesn’t already have CVI diagnosis.  Not applicable because this child has the diagnoses already.
  6. + Asks about visual field preferences (4) and visual complexity (5).  Answers give positive answers for fields (4), distance (7) and movement (2).  Mark row 4, range 3-4, row 7, range 1-2, and row 2, range 5-6.
  7. - This question targets light-gazing/non-purposeful gaze (6), movement (2), and visual novelty (9).  The answer does not refer to any of these. 
  8. + Asks about eye exam.  Answer refers to astigmatism, which doesn’t explain this child’s degree of visual impairment.
  9. + Asks about visual novelty (9) and complexity (5).  Answer is positive for movement (2).  Mark in row 2, range 5-6.
  10. - Asks about color preference (1) and novelty (9).  Answer pertains to color preference.  Mark in row 1, range 9-10.
  11. + Asks about light gazing (6), movement (2), and color preference (1).  Answer is positive for light (2), but not as in gazing.  More as in abnormal reaction.  Mark in row 6, range 3-4.
  12. ? Asks about non-purposeful gaze/light-gazing (6).  Answer is inconclusive.
  13. - Asks about non-purposeful gaze (6).  Answer is negative for this.
  14. + Asks about movement (2) and fields (4).  Answer is positive for movement.  Mark on row 2, range 3-4.
  15. + Targets fields (4).  Answer is positive.  Mark row 4, range 3-4.
  16. - Asks about color preference(1).  Answer could be negative or this could be resolved.  Mark on chart, row 1, range 9-10.
  17. + Targets complexity of array (5) and non-purposeful gaze (6) and novelty (9).  Mark in row 5, range 3-4.
  18. + Targets visual motor (10) and field preferences (4).  Answer is positive for visual motor.  Mark on row 10, range 5-6.
  19. - Targets novelty (9) and complexity (5).  Answer is negative for CVI.
  20. - Asks about fields (4) and complexity (5).  Answer is negative.
  21. ? Asks about eyes.  Again, targets those who do not have diagnosis.  NA.
  22. + Targets complexity (5) and novelty (9).  Answer is positive for complexity.  Mark on row 5, range 3-4.
  23. - Asks about novelty (9) and complexity(5).  Answer is negative.
  24. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive.
  25. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive

         13 positives, 7 negatives, 5 inconclusives.

OBSERVATION VIDEO: (• on chart)

Observation 1: Classroom

Observation 1 - Classroom video | Classroom transcript

  1. Interacts with keyboard tactually NOT visually. Complexity of environment. mark row 5, range 1-2.
  2. Looks closely at calendar picture but not nearsighted.  Probably blocking out background-Complexity.  Mark row 5, range 3-4.  Fields-front/central – mark on chart, row 4, range 3-4.
  3. Reaction to light at window-drawn to it but also photophobic.  Reaction to light-mark row 6, range 3-4.  Shakes toothpaste while looking.  Mark in movement, row 2, range 5-6.  Also, looks at the toothpaste container, which has stripes on it.  Mark in row 1, range 7-8.
  4. Interest in stripes created by shadow of blinds.  Mark in row 1, range 7-8.  Also, odd response to light again.  Mark in light-gazing in row 6, range 3-4.
  5. Is able to look at a complex array of items in bucket and retrieves one item.  Complexity-mark in row 5, range 7-8.  Picks up and visually regards item that is a single color-mark in row 1, range 1-2.
  6. Again, retrieves item from complex array. Complexity-mark in row 5, range 7-8. Picks up and visually regards item that is a single color-but this time the item contains stripes.  Mark in row 1, range 7-8.
  7. Looks and then stops looking when exploring comb (and then brush) tactually.  Complexity of environment – mark row 5, range 3-4.  Visual interest in metal, shiny “finished” container (look then squint x2)- light gazing – mark on chart, row 6, range 3-4.
  8. Looks and then touches in rapid succession when picking up brush.  Visually guided reach  – mark on chart, row 10, range 7-8.  Looks at brush then touches, and stops looking.  Complexity of environment – mark row 5, range 3-4.
  9. Looks at teacher, the music has been turned off and the teacher is not talking.  (This is the first time she looks at her teacher.)  Complexity of environment – mark on chart, row 5, range 5-6.
  10. Interesting looking at Lynne’s arm-might be related to attraction to stripes?  Make note.  Also, Lynne’s arm is moving.  Mark on chart under movement, row 2, range 5-6.
  11. Finds Sara’s hand, which is moving from around 10 feet.  Distance viewing – mark on chart, row 7, range 7-8.  Movement, mark on chart in row 2, range 5-6.
  12. Stripes on paper: holds to face just like picture at calendar.  Blocking out background – complexity, mark row 5, range 3-4. Color preference/interest in stripes – mark row 1, range 7-8.  Fields (lower central)- mark on chart row 4, range 3-4.

Observation 2: Cafeteria

Observation 2 - Cafeteria video | Cafeteria transcript

  1.  Note response to stairs-the presence of shadows creates complexity.  Mark in row 5, range 3-4.  Also, unable to coordinate the use of feet with visual information-this is like visually guided reach, except with the feet.  Mark in row 10, range 3-4.
  2. Gets milk with cluttered background- mark in complexity, row 5, range 3-4.  Looks away when grabbing (in quick succession) – Visually guided reach-mark on chart, row 10, range 7-8.
  3. Looks away from teacher’s face when teacher makes noise.  Mark in complexity, row 5, range 5-6.

DIRECT ASSESSMENT: (^ on chart)

Direct Assessment video | Assessment transcript

  1. Under reaches when going for accordion.  Not on chart but FYI!  No correlation between this and visual condition noted by eye report.
  2. Light gazing/squinting while standing in front of table (probably taking a visual break).  Mark in row 6, range 3-4.
  3. BIG CLIP with lots of possible characteristics!
    • Note accuracy of reach and use of visual/tactual search when there is an array of objects.  Accuracy better with fewer objects (as Cassie clears the area of visual clutter). Complexity of array – mark in row 5, box 3-4.
    • Note number of colors in objects examined-looks longest at item with two or three colors (black cow). Mark in color, row 1, range 5-6.  Also, all these items are new except the accordion.  Mark in visual novelty, row 9, range 7-8.
    • Note increased accuracy of reach toward white cow on black background--maybe due to high contrast (low vision eval. recommends high contrast). 
    • Accurate reach toward moving item (koosh ball).  Mark on chart, row 2, range 5-6. 
    • Visually guided reach-looks and reaches at the same time toward familiar object (accordion): mark in row 10, range 5-6.
  4. During testing of fields with shiny object, note strong response. Mark on chart for movement, row 2, range 5-6.
  5. Finds familiar object on complex background.  Mark in Complexity, row 5, range 5-6.
  6. Loses sight of familiar object when moved out of central field.  Mark in Field Preference, row 4, range 3-4.
  7. Note response to striped glove.  Glances at it- mark in color preference, row 1, range 5-6, or unfamiliar object.  Mark in visual novelty, row 9, range 5-6.  Also, notice how she stops looking when distracted by sound (sneeze).  Mark in complexity, row 5, range 5-6.
  8. Note response to mirror-multiple factors.  Reflection of light draws her and makes her squint, mark on chart in light gazing – row 6, range 3-4.   Movement draws her visual attention - mark on chart in movement, row 2, range 5-6. Views mirror like she does pictures.  Mark in complexity, row 5, range 3-4.
  9. Note response to fan/interest in movement.  Mark on chart - row 2, range 5-6.  Also, visual behaviors seem to be decreasing at this time as Cassie tires.  Mark in latency, row 3, range 5-6. 
  10. Blink to threat intermittent and delayed.  Mark in row 8, range 5-6.

CVI Resolution Chart

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Date:                                       Student’s Name:      Cassie                                                                        Evaluator: Lynne & Sara
Use the following chart to help develop areas of needs for development of IEP goals and objectives.

There are three phase categories which group the ranges as follows: Phase I (Range 1-2 to the midpoint of Range 3-4) Building Visual Behavior, Level I Environmental Considerations; Phase II (midpoint of Range 3-4 to midpoint of Range 7-8) Integrating Vision with Function, Level II Environmental Considerations; and Phase III (midpoint of Range 7-8 to Range 9-10) Resolution of CVI characteristics, Level III Environmental Considerations.

CVI Characteristics Range 1-2
(0)
Range 3-4
(.25)
Range 5-6
(.50)
Range 7-8
(.75)
Range 9-10
(1)
Color Preferences
1
Objects viewed are generally a single color.
•5
Has “favorite” color Objects may have two to three favored colors 
^3, ^7
More colors, familiar patterns regarded
•3, •4, •6, •12
No color or pattern preferences
*10, *16
Need for movement
2
Objects viewed generally have movement or reflective properties More Consistent localization, brief fixations on movement and reflective materials
*2, *14
Movement continues to be an important factor to initiate visual attention
*6, *9, •3, •10, •11, ^3, ^4, ^8, ^9
Movement not required for attention at near Typical responses to moving targets
Visual latency
3
Prolonged Periods of visual latency Latency slightly decreases after periods of consistent viewing Latency present only when student is tired, stressed or over-stimulated
^9
Latency rarely present Latency resolved
Visual field preferences
4
Distinct field dependency Shows visual field preferences
*1, *3, *6, *15, •2, •12, ^6
Field preferences decreasing with familiar inputs May alternate use of right and left fields Visual fields unrestricted
Difficulties with visual complexity
5
Responds only in strictly controlled environments
•1
Generally no regard of the human face
Visually fixates when environment is controlled
*17, *22, •2. •7, •8, •12, •13, •14,
^3, ^8
Student tolerates low levels of familiar background noise
Regards familiar faces when voice does not compete
•9, •15, ^5, ^7
Competing auditory stimuli tolerated during periods of viewing; student may now maintain visual attention on musical toys
Views simple books or symbols     
Smiles at re/regards familiar and new faces
•5, •6
Only the most complex visual environments affect visual response
Views books or other two-dimensional materials                 Typical visual/social responses
Light-gazing and nonpurposeful gaze
6
May localize briefly, but no prolonged fixations on objects or faces
Overly attentive to lights or perhaps ceiling fans
•3
Less attracted to lights; can be redirected to other targets
*11, •3, •4, •7, ^2, ^8
Light is no longer a distracter     
Difficulty with distance viewing
7
Visually attends in near space only
*6
Occasional visual attention to familiar, moving, or large targets at 2 to 3 feet Visual attention extends beyond near space, up to 4 to 6 feet Visual attention extends to 10 feet with targets that produce movement
•11
Visual attention extends beyond 20 feet
Demonstrates memory of visual events
Atypical visual reflexes
8
No blink in response to touch and/or visual threat Blinks in response to touch, but response may be latent Blink response to touch consistently present
^10
Visual threat response intermittently present
Visual threat response consistently present (both reflexes near 90 present resolved) Visual reflexes always present; resolved
Difficulty with visual novelty
9
Only favorite or known objects elicit visual attention May tolerate novel objects if the novel objects share characteristics of familiar objects Use of “known” objects to initiate looking sequence
^7
Selection of objects less restricted, one to two sessions of “warm up” time required 
^3
Selection of objects not restricted
Absence of visually guided reach
10
Look and touch occur as separate functions
Look and touch occur with large and/or moving objects
Look and touch occur with smaller objects that are familiar, lighted, or reflective
Look and touch are still separate
*4, •13
Visually guided reach used with familiar objects or “favorite” color
*18, ^3
Look and touch occur in rapid sequence, but not always together
•8, •14
Look and touch occur together consistently

Key:

  • Draw an X though boxes that represent resolved visual behaviors
  • Use highlighter to outline boxes describing current visual functioning
  • Draw an O in boxes describing visual skills that may never resolve because of coexisting ocular conditions

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Essential Forms
The CVI Range

Recording the CVI Range video | Recording the CVI Range transcript

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Student/child’s name:  Cassie                                           Age: 
Evaluator(s):  Lynne and Sara                                          Evaluation Date:  ___00/00___
This assessment protocol is intended for multiple evaluations over a period of time.  Suggested scoring (no less than three times per school year):
Initial assessment (red)
Second assessment (blue)
Third assessment (green)
Further assessments will require a new form.

Totals: Evaluation #1 (red) Evaluation #2 (blue) Evaluation #3 (green)
Total for Rating I 6    
Total for Rating II 4.5    
Combine both ratings to get overall CVI Range 4.5 - 6    

First evaluation on 00/00 shows range of CVI to be 4.5 to 6.

No functional vision 0    1      2      3      4      5      6      7      8      9      10 
                                    ^00/00^  
Typical or near-typical visual functioning

Figure1: Line graph from 1 to 10, 1 representing no functional vision and 10 representing typical or near-typical visual functioning.

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

The CVI Range:  Across - CVI Characteristics Assessment Method

From Cortical Visual Impairment:  An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York.  All rights reserved.  This page may be reproduced for educational use only.

Rating I

Rate the following statements as related to the student/child’s visual behaviors by marking the appropriate column to indicate the methods used to support the scores:

  • O = information obtained through observation of the child/student
  • I   = information obtained through interview regarding the child/student
  • D  = information obtained through direct contact with the child/student

In the remaining columns, indicate the assessed degree of the CVI characteristic:

  • R    = The statement represents a revised visual behavior
  • +    = Describes current functioning of student/child
  • +/-  = Partially describes student/child
  • –     = Does not apply to student/child
CVI Range 1-2:  Student functions with minimal visual response
O I D R + +/- -  
x x     x             May localize, but no appropriate fixations on objects or faces
x x x x             Consistently attentive to lights or perhaps ceiling fans
        x x             Prolonged periods of latency in visual tasks
x x     x             Responds only in strictly controlled environments
x x     x             Objects viewed are a single color
x x     x             Objects viewed have movement and/or shiny or reflective properties
x x     x             Visually attends in near space only
        x x       No blink in response to touch or visual threat
x x     x       No regard of the human face
CVI Range 3-4:  Student functions with more consistent visual response CVI Range 5-6:  Student uses vision for functional tasks
O I D R + +/- -  
x x         +         Visually fixates when the environment is controlled
x x         +         Less attracted to lights; can be redirected
    x         +         Latency slightly decreases after periods of consistent viewing
x x         +         May look at novel objects if they share characteristics of familiar objects
        x     +         Blinks in response to touch and/or visual threat, but the responses may be latent and/or inconsistent
x x         +         Has a “favorite” color
x x x     +         Shows strong visual field preferences
x x         +         May notice moving objects at 2 to 3 feet
x x x     +         Look and touch completed as separate events
CVI Range 5-6:  Student uses vision for functional tasks
O I D R + +/-  
x x x     +         Objects viewed may have two to three colors
x x x         +/-     Light is no longer a distractor
x     x     +         Latency present only when the students is tired, stressed, or overstimulated
x x x         +/-     Movement continues to be an important factor for visual attention
x     x     +         Student tolerates low levels of background noise
        x x             Blink response to touch is consistently present
        x     +         Blink response to visual threat is intermittently present
x x     x             Visual attention now extends beyond near space, up to 4 to 6 feet
x x         +         May regard familiar faces when voice does not compete
CVI Range 7-8:  Student demonstrates visual curiosity
O I D R + +/-  
x x x         +/-     Selection of toys or objects is less restricted; requires one to two sessions of “warm up”
x x x         +/-     Competing auditory stimuli tolerated during periods of viewing; the student may now maintain visual attention on objects that produce music
x     x         +/-     Blink response to visual threat consistently present
x x x             Latency rarely present
x     x     +         Visual attention extends to 10 feet with targets that produce movement
x x x         +/-     Movement not required for attention at near distance
        x         +/-     Smiles at/regards familiar and new faces
        x         +/-     May enjoy regarding self in mirror
x x             +/-     Most high-contrast colors and/or familiar patterns regarded
x x             +/-     May regard familiar faces when voice does not compete
CVI Range 9-10:  Student spontaneously uses vision for most functional activities
O I D R + +/-  
x     x             Selection of toys or objects not restricted
x x x             Only the most complex environments affect visual response
x     x             Latency resolved
x x x             No color or pattern preferences
    x                 Visual attention extends beyond 20 feet
x x             +/-     Views books or other two-dimensional materials, simple images
x x                 Uses vision to imitate actions
x                 +/-     Demonstrates memory of visual events
x                     Displays typical visual-social responses
x x x             Visual fields unrestricted
x x                 Look and reach completed as a single action
x                     Attends to two-dimensional images against complex backgrounds

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

The CVI Range:  Within - CVI Characteristics Assessment Method

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Rating II

Determine the level of CVI present or resolved in the 10 categories below and add to obtain total score. Rate the following CVI categories as related to the student/child’s visual behaviors by circling the appropriate number (the CVI Resolution Chart may be useful as a scoring guide):

  • 0    Not resolved; usually or always a factor affecting visual functioning
  • .25    Resolving
  • .5    Resolving; sometimes a factor affecting visual functioning
  • .75    Resolving
  • 1     Resolved; not a factor affecting visual functioning
1.  Color preference 0 .25 (.5) .75 1
Comments:
2.  Need for movement 0 .25 (.5) .75 1
Comments:
3.  Visual latency 0 .25 (.5) .75 1
Comments:
4.  Visual field preferences 0 (.25) .5 .75 1
Comments:
5.  Difficulties with visual complexity 0 (.25) .5 .75 1
Comments:
6.  Light-gazing and nonpurposeful gaze 0 (.25) .5 .75 1
Comments:
7.  Difficulty with distance viewing 0 .25 .5 (.75) 1
Comments:
8.  Atypical visual reflexes 0 .25 (.5) .75 1
Comments:
9.  Difficulty with visual novelty 0 .25 (.5) .75 1
Comments:
10. Absence of visually guided reach 0 .25 (.5) .75 1
Comments:

Total of CVI characteristics present (numbers in parenthesis) = 4.5

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Cortical Visual Impairment (CVI) Assessment

Recommendations video | Recommendations transcript

Student Name: Cassie
Assessor(s): Lynne McAlister & Sara Kitchen, CTVIs
Date: 00/00/00

Cassie was observed in her classroom at TSBVI on __________, 0000, and then pulled out of her classroom for direct assessment on ____________ as well.  The environment used for the direct assessment was unfamiliar to Cassie.

Information from interviews with her parents as well as her instructional staff was gathered before the observation.  Information was also gleaned from a low vision evaluation dated 00/00/00.  This assessment was done to determine potential characteristics of CVI that might be interfering with Cassie’s visual performance. 

Cassie carries the diagnoses of CVI as well as nystagmus.  This was caused when Cassie was three months old from anoxia during neurosurgery.  She also has microcephaly, right side weakness, mental retardation, and speech impairment.

During this evaluation, Cassie demonstrated many of the behaviors that are typically associated with the characteristics of CVI.  This report addresses those characteristics as demonstrated by Cassie’s behavior.

Color Preference: 

A color preference was noted neither during the observation period nor during direct assessment; however, Cassie was reported to have a preference for items that are fuchsia at one time.  During observation and assessment, Cassie saw and picked up objects that where white, green, yellow, fuchsia, purple, pink, brown, red, and gray.  She appeared to examine objects of any single color.  Using a specific color may not be necessary to draw Cassie’s visual attention.  It was noticed that Cassie was drawn toward striped patterns including the folded part of an accordion toy, stripes caused by sunlight shining through a blind, a striped overlay for the light box, and a pattern of stripes drawn in black on a white piece of paper.

Materials may be adapted by adding stripes to draw visual attention, however, attention may not be immediate:  Cassie was not able to look at a multicolored striped glove being worn by assessors for the duration of the direct assessment, and actually appeared to be blocking it out at times by placing her hands over the stripes.

Need for Movement: 

Many children with CVI respond best visually to targets that move or have reflective surfaces.  Reflective or shiny materials are likely to be interpreted in the brain as movement.  Cassie was able to respond by looking at shiny objects that were brought into her visual field.  She was also able to visually track these objects by moving her head.  Cassie was also interested in looking at a small fan when it was turned on.  Cassie can be easily redirected from looking at objects that have movement or movement properties, and movement is not required for attention at near.  Movement does, however, attract Cassie’s visual attention and helps to maintain it.   Materials can be adapted by adding reflective surfaces to draw attention.  She is more interested in looking at toys that move or games that require movement of objects. Games with objects that involve movement should continue to be expanded. 

Visual Latency: 

This characteristic is one in which there is a delayed response between the time a target is presented and the time it is noticed.  Cassie would notice a visual target immediately that was unfamiliar but not examine it, especially items that contained multiple colors.  She glanced at these unfamiliar objects and found them with a combination of visual and tactual searching.  She responded immediately by at least glancing when familiar or favored objects were presented. She exhibited a period of latency regarding maintaining visual attention when looking at unfamiliar or visually complex objects.

Cassie should continue to be exposed to a variety of familiar and unfamiliar objects.  Objects that have similar qualities as her favorite familiar objects should be introduced to increase the variety of objects that Cassie will examine.  Continue to provide single color familiar and unfamiliar objects for her exploration.

Visual Field Preferences:

During direct assessment, Cassie did not notice the accordion, her favorite toy, when it was held in her lower peripheral left field until she turned her head, and then was surprised to find it.  She did not notice a red ball in her lower right peripheral field while being assessed as well, but noticed all objects that were in the range of her central field. In Cassie’s low vision evaluation it was noted that Cassie’s visual fields were restricted to 40 degrees in all quadrants.  This means that Cassie will notice objects within her central field.  Objects should be presented directly in front of Cassie.

Difficulties with Visual Complexity:

This area addresses the problems viewing items with complex, patterned surfaces, items within an array  (items presented together instead of singularly), items on a visually complex background, and simultaneously attaining or maintaining visual attention while there is input from other sensory modalities.

Cassie was able to visually notice objects that had complex patterned surfaces, but did not examine them unless they were familiar and moving.  She was more likely to visually examine objects of a single color and move them by turning them over or shaking them.  She was able to visually locate and pick up familiar objects out of an array of other objects.  She was able to locate her accordion on a multicolored piece of cloth, but did not look at her cup on the same piece of cloth.  She seemed to have trouble using her vision while coordinating her own movement.  For example: She played with her accordion and held her head to the side, not looking at it, but looked directly at the accordion while someone else played it.  She very occasionally looked at the accordion while she was manipulating it, causing tactual and auditory input.  Activities such as this should be encouraged.  She was observed playing the keyboard without looking at it but tactually finding a variety of sounds to make.  She also found several items during her hygiene routine visually, reached for them and looked at them, then began to tactually explore them.  While she was receiving tactual information, Cassie stopped looking at the items she was exploring.  Cassie was able to focus on eating in the noisy cafeteria.  She first used her visual sense to locate food and then used only her tactual sense while scooping food from her plate.

While looking at unfamiliar items in a complex environment, Cassie tended to reach toward the area in front of the item and then locate the item tactually.  This is called under-reaching.  When presenting items to Cassie for her to make a choice, items should be arranged horizontally in relation to Cassie as opposed to vertically so that her choice will not be misinterpreted due to an incorrect reach.

Cassie is able to handle a complex visual environment.  When other senses are involved, Cassie generally stops looking or looks only when necessary, for example; she would look at the face of her caregiver but immediately squint or look away when that person spoke to her.  Care should be taken when there is an expectation that Cassie use her vision, such as at Cassie’s calendar, to reduce other sensory input.  This could be done by pointing to or tapping an object and only verbally labeling it after Cassie has looked.  Cassie might not be able to process the simultaneous verbal and sign labels.  It might be helpful to stagger this information.  Cassie was interested in drawings and photos but mostly did not seem to understand what they were.  She labeled one photo of a single color item similarly to how she labeled the actual object.  Photos of items that are a single color can be paired with the object initially.  Staff might experiment with drawing objects that are a single color as well.  Experimentation could also occur with Cassie’s response to photos/drawings that are laminated vs. those that are not. 

Light-gazing and Non-purposeful Gaze: 

Cassie is attracted to looking at lights.  This was seen multiple times during observation and direct assessment.  This behavior is not interruptive.  She can be easily redirected towards other items/activities.  Cassie was also noticed squinting after looking at lights.  She had trouble adjusting her vision after coming indoors from outside, and performed tasks mostly tactually until her eyes adjusted to the change.  She demonstrated both attraction to light and difficulty with light, also known as photophobia.  Light should not be used to draw Cassie’s attention to objects due to her photophobia.

Difficulty with Distance Viewing: 

Cassie was able to find a person to help her and again visually locate the swing in the classroom from approximately 10 feet.  The background was visually cluttered, but familiar.  While outside, Cassie was able to visually locate a ramp at 12 feet during a familiar route and turn toward it.  Cassie has not been observed locating high contrast items, such as a white van, at 20 feet or less.  Cassie will need to be within 10-15 feet to see large familiar objects.  Staff should continue to encourage her to look for large objects within her daily routine, such as the van, particularly on cloudy days if she has time to adapt to the outdoor light.  On days where the sun is bright or the glare is high, expectations should be lowered.

Atypical Visual Reflexes: 

Lack of responses in the blink reflexes when the face near the eyes is touched or when an object is brought toward the face are associated with CVI.  Cassie blinked when an object was brought toward her face, but her response was a bit delayed as well as intermittent. There is no direct programming that can teach a visual reflex.  This is expected to resolve as other characteristics of CVI resolve.

Difficulty with Visual Novelty: 

Cassie is able to attend for short amounts of time to complex, unfamiliar objects, and for longer amounts of time to single-color unfamiliar and familiar objects.  Cassie should not be expected to examine objects that contain more than one color.  Items that are presented to Cassie that hold meaning, such as calendar symbols, should be consistent and single-colored, when possible.

Absence of Visually Guided Reach: 

Cassie can locate items visually and reach for them.  She occasionally looks at an object and then looks away before reaching it.  Motor planning seems to take a great deal of concentration.  Cassie seemed to be able to more accurately reach toward objects presented on a black background that contrasted with it.  She was able to visually notice the approximate location of a 3” black toy with white spots on a black background and then used her tactual search to find it.  She visually located a similar white toy with black spots and reached accurately for it.  Contrast should be accentuated when Cassie is expected to pick up objects, such as while indicating a choice, to help her reach more accurately.

Visual Functioning:

Based on the CVI Range Assessment done on December 2nd and 4th, 0000, Cassie scored in the range of 4.75-6 out of possible 10 (10 represents typical or near typical visual functioning, with little or no effect of CVI).  This puts her in phase II, in which the goal is integrating vision with function.  In this phase, activities should be designed to encourage using vision to make things happen.  Turning things off and on is something Cassie is already greatly interested in.  Combining vision with touch, such as reaching toward an object to make a choice, could be another objective for someone at phase II.  Cassie will most likely begin to maintain visual contact with people and objects when increasing amounts of sensory input is involved.  Activities such as playing the accordion should be continued, as well as other turn-taking opportunities with toys that move and make noise.  Cassie experiments with looking at her accordion while playing it just for a short time.  This is exactly the kind of thing she needs to be doing!

Cassie is a lovely young lady and a joy to spend time with.  It was a pleasure to have the opportunity to assess her vision.

Sara Kitchen, CTVI and Lynne McAlister, CTVI

CVI Adaptations for Cassie

  • Experiment with Cassie’s response to stripes since she was attracted to several striped patterns, including a shadow of window blinds on the wall.
  • Cassie probably can’t see a mirror reflection very well.  Looking in the mirror and saying “Cassie” may be a trained response.  Looking in a mirror may not be a good thing to target within routines currently.
  • Encourage games with objects that involve movement that Cassie does with others or by herself (like playing the accordion).  Expand these types of games.
  • Experiment with adding reflective qualities to draw attention to visual targets.
  • Introduce objects that are visually similar to Cassie’s favorite objects.
  • Provide unfamiliar, single-color objects for Cassie’s exploration.
  • Present objects directly in front of Cassie.
  • Reduce visual clutter in environments where Cassie is required to use vision (when possible), such as at the calendar, at areas where routines are performed, etc.
  • Arrange items horizontally in relation to Cassie when giving a choice.
  • Reduce sensory input when Cassie is expected to look: encourage Cassie to look at your face longer by keeping quiet while she is looking. 
  • Delay verbal labels when signing so that Cassie can attend to visual information instead of providing simultaneous input.
  • Experiment with photos that are of familiar, single color objects.  Experiment with drawing as well, using only one color.  Check for comprehension of picture.
  • Do not use light to draw Cassie’s attention to objects.
  • Encourage Cassie to wear a visor when traveling outside.
  • Do not expect Cassie to be able to identify objects at a distance due to visual clutter.
  • Use consistent, familiar objects to represent activities.
  • Accentuate contrast when Cassie is expected to use visual motor skills to help her reach more accurately.

This handout is the basis of a training exercise intended to start a discussion on CVI and assessment among peers, specifically, teachers of students with visual impairments who work with children who may be experiencing visual impairment related to neurological causes. The handout is intended to accompany the videos that are linked within it, and should not be used for any other purpose. The assessment process and assessment forms created by Dr. Christine Roman-Lantzy in Cortical Visual Impairment: An Approach to Assessment and Intervention (New York: AFB Press, © 2007, American Foundation for the Blind, used with permission of the publisher; all rights reserved) have been used in this exercise to help us structure our thinking and organize information. The forms and an explanation of how they are to be used are included in Cortical Visual Impairment: An Approach to Assessment and Intervention available from AFB Press at www.afb.org/store.

Some of the forms have been modified to enhance accessibility. Dr. Roman-Lantzy has not reviewed or approved the way in which they have been displayed, modified, or scored for the purposes of this exercise, which is intended to be the basis of an exploratory interchange among peers. Please feel free to question, comment, and/or correct the material here in the discussion box provided. A comment form is available on each individual video.

  • Profile Video | Profile Transcript
  • 16 years old
  • ROP, hemorrhaging of retina in right eye (sometime between 00/00(last FVE) and 01/01, complete retinal detachment in right eye), closed head injury, right esotropia, optic atrophy. Field preferences will not resolve.
  • Low vision evaluation from 01/01 stated NLP in right eye, possible form perception at distance in left eye, along with field restriction of 40 degrees.
  • Speech Impaired-uses object calendar receptively.
  • Orthopedically Impaired-CP (spastic quadriplegia)
  • Other Health Impaired-Seizure disorder
  • Very Social, attends to and initiates verbal interactions
  • Very attentive to sounds

CVI Parent Interview questions:
(p. 34, Roman-Lantzy, 2007)

Parent Interview Video | Interview Transcript

  1. Tell me what you do with a toy to get your child interested in it?  Parent: Put toy in hand to hold.  School: Shake it, tap it, make noise, introduce it on his lap, put it on light board and move.
  2. When you show your child something, how do you know he or she sees it?  Parent: Not! Brandon is blind.  School: Head orientation towards object, slow reach out towards it.  (usually with light board or art)
  3. Does your child have a favorite side or a favorite head position?  Parent: Right side.  Also head position. School:  Left side for viewing, right side for most activity, usually head slumped.
  4. Does your child usually find objects by look or by feeling for them?  Parent: He is blind. School: Not usually motivated to look for items, but primarily touch when he does.
  5. Do you have concerns about the way your child sees?  Parent: No, he is blind. School: No answer.
  6. Where do you usually hold objects for your child to look at?  Parent: Put in his hand to hold only he is blind.  School: Center, to left side within 1 foot range.
  7. What are your child’s favorite things in your house?  Parent: Piano, radio.  School: Radio, shakers, rain sticks, drums, instruments, keyboards.
  8. What, if anything, have doctors told you about your child’s eyes?  Parent: Total blind, but I don't think so. School: No answer.
  9. When does your child usually like to look at things?  Parent: Not! He is blind.  School: In front of light board, he will look at sounds.
  10. What color are the things your child likes to look at most?  Parent: None he is blind.  School: Maybe little more attention with red.
  11. What does your child do when he or she is near very shiny or mirrored objects?  Parent: Nothing he is blind.  School: No noticeable change in affect.  We do use tin foil on some symbols, but also couples with noise.
  12. Describe how your child behaves around lamps or ceiling fans. Parent: He looks upward to fans and up to light. School: No change in behavior.
  13. Are you usually able to identify what your child is looking at?  Parent: Yes.  School: If he is trying to use vision he will put his face on object to see it.
  14. Does your child usually first notice things that move or things that don’t move?  Parent: Things that move.  School: Team is undecided.
  15. How does your child position his or her head when you think he or she is looking at something?  Parent: He leans to turn right to listen to things.  School: No answer.
  16. Do you think your child has a “favorite” color?  Parent: No.  School: Maybe red
  17. Does your child seem to notice things more at home or more in new places?  Parent: No.  School: No answer.
  18. Describe how your child positions his or her head when swatting or reaching toward something.  Parent: Straight. School: No regular correlation.
  19. How does your child react when you give him or her new things to look at?  Parent: Does not he is blind.  School: He will reach out and touch it.
  20. Do you position your child in a certain way to help him or her see things?  Parent: No.  School: Items on left side, light underneath.
  21. Have you ever been concerned about the way your child’s eyes move?  Parent: No. School: No Answer.
  22. What does your child do when there are many objects in front of him or her to look at?  Parent: He is blind. School: No Answer.
  23. Tell me about the faces your child prefers to look at.  Parent: None he is blind. School: No Answer.
  24. If your child had his or her own object to look at and a new object, which object would he or she prefer?  Parent: Remember he is blind. School: No Answer.
  25. Tell me what your child’s favorite objects or toys look like.  Parent: He has no favorite objects or toy. School: No Answer.

Answer Key for Brandon's CVI Resolution Chart (Cheat Sheet)

INTERVIEW: (*number on Resolution chart below) (+ = positive for CVI, - =negative for CVI, ? inconclusive)

  1. + Targets movement (2) and fields (4).  Positive for CVI for movement.  Mark row 2, range 1-2.
  2. + Targets visual attention/non-purposeful gaze (6). Answer positive for light-gazing (light box).  Mark in row 6, range 1-2.
  3. + Asks about field preference (4) and additional disabilities.  Answer is positive for fields.  Mark in row 4, range 1-2.
  4. ? Asks about visually guided reach (10) or visual complexity (5).  Answer is inconclusive.
  5. ? Is asking about appearance of the eye/eye exam.  Answer is inconclusive.
  6. + Asks about visual field preferences (4) and visual complexity (5).  Answers positive for field (center-left) and for distance (within 1 foot).  Mark in row 4 (fields) range 1-2, and in row 7 (distance) range 1-2.
  7. ? This question targets light-gazing/non-purposeful gaze (6), movement (2), and visual novelty (9).  Answer inconclusive. 
  8. + Asks about eye exam.  Positive for CVI-“Total blind, but I don’t think so.”
  9. + Asks about visual novelty (9) and complexity (5).  Answer is positive for light gazing.  Mark on chart in row 6, range 1-2. 
  10. + Asks about color preference (1) and novelty (9).  Answer is positive for color preference.  Mark in row 1, range 1-2.
  11. ? Asks about light gazing (6), movement (2), and color preference (1).  Answer is inconclusive.
  12. + Asks about non-purposeful gaze/light-gazing (6).  Answer is positive, mark in row 6, range 1-2.
  13. + Asks about non-purposeful gaze (6).  Answer is positive for distance.  Mark in row 7, range 1-2.
  14. + Asks about movement (2) and fields (4).  Answer is positive CVI for movement.  Mark in row 2, range 1-2.
  15. ? Targets fields (4).  Answer is inconclusive because addresses listening.
  16. + Asks about color preference(1).  Answer is positive.  Mark on row 1, range 3-4.
  17. ? Targets complexity of array (5) and non-purposeful gaze (6) and novelty (9).  Answer is inconclusive.
  18. ? Targets visual motor (10) and field preferences (4).  Answer is inconclusive.
  19. + Targets novelty (9) and complexity (5).  Answer is positive for novelty-because he reaches for new things.  Mark in row 9 under range 3-4.
  20. + Asks about fields (4) and complexity (5).  Answer is positive for fields.  Mark in row 4, range 1-2.
  21. ? Asks about eyes.  Targets those kids who do not already have CVI diagnosis.  Answer is inconclusive.
  22. ? Targets complexity (5) and novelty (9).  Answer is inconclusive.
  23. ? Targets novelty (9) and complexity(5).  Inconclusive.
  24. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive.
  25. ? Asks about novelty (9) and complexity(5).  Answer is inconclusive

13 positives, 0 negatives, 12 inconclusives.

Observation: (•numbers on Resolution chart below )

Observation video | Observation transcript

  1. Light gazing.  Mark Row 6, range 1-2
  2. Does not see yellow whoopee cushion even though it’s familiar- Mark in row 5, Complexity, range 1-2.   Yellow is probably not a “favored” color-make note by color (not on chart, though).   
  3. When teacher is saying, “Left, left, left right left.”  Brandon raises head and looks once.  Later, without the auditory input, holds head up and looks at Eric about every 3 steps. Mark in row 5 (complexity), range 1-2 and in row 7 (distance), range 3-4.
  4. Brandon looks directly at blue button on plain background, single color target, familiar, motivating. Mark in row 1 (color preference) range 1-2, row 5 (complexity), range 3-4, and row 9 (novelty), range 1-2.
  5. Looks at blue button and reaches for it at the same time, mark in row 10 (visually guided reach) range 5-6.  Brandon is doing this while teacher is talking.  Mark in row 5 (complexity) range 3-4.

Direct Assessment: (^number on Resolution chart below)

Assessment 1 - Dark Room

Dark Room Video | Dark Room Transcript

  1. Noticed red plate with light shining on it, leaned in toward plate and reached directly toward it without looking away. Mark on row 1 (color) range 1-2, row 7 (distance), range 1-2, and row 10 (visually guided reach), range 5-6.
  2. Reached toward blue item with light shining on it, looked away (visual motor).  Look at item near end of trial-leaned forward and stopped moving. Mark on row 1 (color) range 1-2, row 7 (distance), range 1-2, and row 10 (visually guided reach), range 3-4.
  3. Leaned in to look at reflective gold thing. Mark in row 2 (movement) range 1-2. Mark in row 7 (distance) range 1-2.  Looked at flashlight. Reached for item and did not look away.  Mark in row 6 (light gazing) range 3-4, and row 10 (visually guided reach), range 3-4.
  4. Looked at the moving silver and blue pinwheel.  Mark in row 1, range 5-6, and row 2 (movement) range 3-4.  Searched in correct direction after looking, but looked away.  Mark in row 10, range 3-4.
  5. Interesting reaction to aluminum pan: sustained gaze-brings head closer to examine, then squints but maintains gaze when bell rings.  Mark in row 7, range 1-2, row 6 (light-gazing), range 1-2 and row 5 (complexity), range 3-4.  Reached for item and looked away before touching. Mark in row 10, range 3-4.
  6. Reached toward moving black, white and pink item after light shined on it.  Brandon glances at dog (pink, white, and black) after light is shined on it, then reaches towards it. Looked away while reaching.  Mark in row 1, range 5-6, row 10 (visually guided reach), range 3-4.  All visual behavior stopped when toy was activated.  Mark in row 5 (complexity), range 1-2.

Assessment 2 - Low Light

Low Light video | Low Light transcript

  1. Red filter on flashlight- noticed in left peripheral and lower central.  Not in upper and right.  Lots of noise.  Mark in row 1 (color) range 3-4, row 4 (fields), range 3-4, and row 5 (complexity), range 3-4.
  2. Noticed moving pink toy against invisiboard with light shining on it. Took about 1.5 minutes (beginning not shown) before glancing briefly.  Mark in row 1 (color) range 1-2, row 2(movement), range 1-2, row 3 (latency), range 1-2, and row 5 (complexity), range 1-2.
  3. Noticed multicolored toy with light shining on it against invisiboard after about 1.5 minutes.  Mark in row 1 (color) range 5-6, row 2(movement), range 1-2, row 3 (latency), range 1-2, and row 5 (complexity), range 1-2.
  4. Sustained gaze (10 seconds) at moving silver reflective pan with invisiboard behind it and light shining on it.  Mark in row 2 (movement), range 1-2, row 5 (complexity), range 1-2, and row 6 (light gazing), range 1-2.
  5. Looked briefly at moving gold beads against black background. Mark in row 2 (movement), range 3-4, and row 5 (complexity), range 1-2.

Assessment 3-Light Box

Light Box video | Light Box transcript

  1. Drawn visually to red light box and then looked away as soon as there was a noise.  Mark in row 1 (color), range 3-4 and row 5 (complexity) range 1-2.
  2. Movement-hypnodisc on red filter-looked almost immediately.  Seemed to be the most immediate visual response during testing. Looked away when hypnodisc was moved again-probably changed the pattern.  Mark in row 1 (color), range 5-6 and row 2 (movement) range 1-2.
  3. Less responsive to small dot pattern, though it did draw visual attention.  Looked briefly. 
  4. When hypnodisc was placed on green filter, responded like when red filter was on but less intense.  Mark row 1 (color), range 3-4.
  5. Sustained gaze black on white pattern hypnodisc (14 seconds), squints.  May be looking at pattern, may be light gazing. 
  6. Shows interest in large dots on white light by looking for about 3 seconds.  Can’t be drawn to zigzag even with red filter.  Again, could be light gazing with dots, and with zigzag, may not be interested in horizontal pattern. 
  7. Squinting when light got bright – may be indicator that this is too bright, or that the lightbox without a filter is too much.  Mark in light gazing, row 6, range 1-2.
  8. Brief, repeated localizations on multi-colored vertical stripes that contains red and blue, even with some noise in the environment.  Wow!  Mark in row 1 (color) range 5-6 and in row 5 (complexity), range 3-4.
  9. Checkerboard- took about 15 seconds before looking, then looked at a couple of times with white/black (3 seconds), looked at much longer with red, (8 seconds with the red filter, then 6 seconds), then shorter fixations with green filter.  Mark in row 1 (color), range 3-4.  Mark in row 3 (latency), range 3-4.

CVI Resolution Chart

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Date:                                       Student’s Name:      Brandon                                                        Evaluator: Eric & Sara

Use the following chart to help develop areas of needs for development of IEP goals and objectives.

There are three phase categories which group the ranges as follows:
Phase I (Range 1-2 to the midpoint of Range 3-4) Building Visual Behavior, Level I Environmental Considerations;
Phase II (midpoint of Range 3-4 to midpoint of Range 7-8) Integrating Vision with Function, Level II Environmental Considerations; and
Phase III (midpoint of Range 7-8 to Range 9-10) Resolution of CVI characteristics, Level III Environmental Considerations.
(Note: the colored symbols and numbers refer to the same colored items above. *purple numbers=interview questions, green numbers=observation clips, ^red numbers=direct assessment video clips).

CVI CharacteristicsRange 1-2
(0)
Range 3-4
(.25)
Range 5-6
(.50)
Range 7-8
(.75)
Range 9-10 
(1)
Color Preferences
1
•2-yellow is not favored.
Objects viewed are generally a single color
*10, •4, ^1, ^2, ^8
Has “favorite” color
*16  ^7, ^12, ^15, ^20
Objects may have two to three favored colors
^4, ^6, ^9, ^13, ^19
More colors, familiar patterns regarded No color or pattern preferences
Need for movement
2
Objects viewed generally have movement or reflective properties
*1, *14, ^3, ^8, ^9, ^10, ^13
More Consistent localization, brief fixations on movement and reflective materials
^11, ^4
Movement continues to be an important factor to initiate visual attention Movement not required for attention at near Typical responses to moving targets
Visual latency
3
Prolonged Periods of visual latency
^8, ^9
Latency slightly decreases after periods of consistent viewing
^20
Latency present only when student is tired, stressed or over-stimulated Latency rarely present Latency resolved
Visual field preferences
4
Distinct field dependency
*3, *6, *20
Shows visual field preferences
^7
Field preferences decreasing with familiar inputs May alternate use of right and left fields Visual fields unrestricted
Difficulties with visual complexity
5
Responds only in strictly controlled environments
•2, •3
Generally no regard of the human face
^6, ^8, ^9, ^10, ^11, ^12
Visually fixates when environment is controlled •4, •5,
^5, ^7, ^19
Student tolerates low levels of familiar background noise
Regards familiar faces when voice does not compete
Competing auditory stimuli tolerated during periods of viewing; student may now maintain visual attention on musical toys
Views simple books or symbols     
Smiles at re/regards familiar and new faces
Only the most complex visual environments affect visual response
Views books or other two-dimensional materials  Typical visual/social responses
Light-gazing and non-purposeful gaze
6
May localize briefly, but no prolonged fixations on objects or faces
Overly attentive to lights or perhaps ceiling fans
*2, *9, *12, •1, ^5, ^10, ^18
Less attracted to lights; can be redirected to other targets
^3
Light is no longer a distracter     
Difficulty with distance viewing
7
Visually attends in near space only
*6, *13,  ^1, ^2, ^3, ^5
Occasional visual attention to familiar, moving, or large targets at 2 to 3 feet  •3 Visual attention extends beyond near space, up to 4 to 6 feet Visual attention extends to 10 feet with targets that produce movement Visual attention extends beyond 20 feet
Demonstrates memory of visual events
Atypical visual reflexes
8
No blink in response to touch and/or visual threat Blinks in response to touch, but response may be latent Blink response to touch consistently present
Visual threat response intermittently present
Visual threat response consistently present (both reflexes near 90 present resolved) Visual reflexes always present; resolved
Difficulty with visual novelty
9
Only favorite or known objects elicit visual attention
•4
May tolerate novel objects if the novel objects share characteristics of familiar objects *19 Use of “known” objects to initiate looking sequence Selection of objects less restricted, one to two sessions of “warm up” time required  Selection of objects not restricted
Absence of visually guided reach
10
Look and touch occur as separate functions
Look and touch occur with large and/or moving objects
Look and touch occur with smaller objects that are familiar, lighted, or reflective
^4, ^5, ^6
Look and touch are still separate
^2, ^3
Visually guided reach used with familiar objects or “favorite” color
•5, ^1
Look and touch occur in rapid sequence, but not always together Look and touch occur together consistently

Key:

  • Draw an X though boxes that represent resolved visual behaviors
  • Use highlighter to outline boxes describing current visual functioning
  • Draw an O in boxes describing visual skills that may never resolve because of coexisting ocular conditions

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Essential Forms
The CVI Range

Recording the CVI Range video | Recording the CVI Range transcript

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Student/child’s name:  Brandon                                        Age: 16
Evaluator(s):  Eric and Sara                                               Evaluation Date:  __00/00____
This assessment protocol is intended for multiple evaluations over a period of time.  Suggested scoring (no less than three times per school year):
Initial assessment (red)
Second assessment (blue)
Third assessment (green)
Further assessments will require a new form.

Totals:Evaluation #1 (red)Evaluation #2 (blue)Evaluation #3 (green)
Total for Rating I 3    
Total for Rating II 1.75    
Combine both ratings to get overall CVI Range 1.75 –3    

First evaluation on 00/00 shows range of CVI to be 1.75 to 3.

No functional vision 0    1      2      3      4      5      6      7      8      9      10 
           ^00/00^  
Typical or near-typical visual functioning

Figure1 Line graph from 1 to 10, 1 representing no functional vision and 10 representing typical or near-typical visual functioning.

From Cortical Visual Impairment:  An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York.  All rights reserved.  This page may be reproduced for educational use only.

The CVI Range:  Across - CVI Characteristics Assessment Method

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Rating I

Rate the following statements as related to the student/child’s visual behaviors by marking the appropriate column to indicate the methods used to support the scores:

  • O = information obtained through observation of the child/student
  • I   = information obtained through interview regarding the child/student
  • D  = information obtained through direct contact with the child/student

In the remaining columns, indicate the assessed degree of the CVI characteristic:

  • R    = The statement represents a revised visual behavior
  • +    = Describes current functioning of student/child
  • +/ –  = Partially describes student/child
  • –    = Does not apply to student/child
CVI Range 1-2:  Student functions with minimal visual response
OIDR++/– 
x   x     +/–   May localize, but no appropriate fixations on objects or faces
  x     +     Consistently attentive to lights or perhaps ceiling fans
    x   +     Prolonged periods of latency in visual tasks
x   x     +/–   Responds only in strictly controlled environments
x x x     +/–   Objects viewed are a single color
  x x     +/–   Objects viewed have movement and/or shiny or reflective properties
x   x     +/–   Visually attends in near space only
  x         No blink in response to touch or visual threat
x   x   +     No regard of the human face
CVI Range 3-4:  Student functions with more consistent visual response
OIDR++/– 
x   x     +/–   Visually fixates when the environment is controlled
x   x   +     Less attracted to lights; can be redirected
    x   +     Latency slightly decreases after periods of consistent viewing
x x x   +     May look at novel objects if they share characteristics of familiar objects
              Blinks in response to touch and/or visual threat, but the responses may be latent and/or inconsistent
  x x   +     Has a “favorite” color
  x x   +     Shows strong visual field preferences
x         +/–   May notice moving objects at 2 to 3 feet
x   x     +/–   Look and touch completed as separate events
CVI Range 5-6:  Student uses vision for functional tasks
OIDR++/– 
  x x     +/–   Objects viewed may have two to three colors
  x x       Light is no longer a distractor
    x       Latency present only when the students is tired, stressed, or overstimulated
x   x     +/–   Movement continues to be an important factor for visual attention
x   x     +/–   Student tolerates low levels of background noise
              Blink response to touch is consistently present
              Blink response to visual threat is intermittently present
x           Visual attention now extends beyond near space, up to 4 to 6 feet
x   x       May regard familiar faces when voice does not compete
CVI Range 7-8:  Student demonstrates visual curiosity
OIDR++/– 
x x x       Selection of toys or objects is less restricted; requires one to two sessions of “warm up”
x   x       Competing auditory stimuli tolerated during periods of viewing; the student may now maintain visual attention on objects that produce music
              Blink response to visual threat consistently present
x   x       Latency rarely present
x           Visual attention extends to 10 feet with targets that produce movement
x   x       Movement not required for attention at near distance
x   x       Smiles at/regards familiar and new faces
  x           May enjoy regarding self in mirror
x x         Most high-contrast colors and/or familiar patterns regarded
x x         May regard familiar faces when voice does not compete
CVI Range 9-10:  Student spontaneously uses vision for most functional activities
OIDR++/– 
            Selection of toys or objects not restricted
            Only the most complex environments affect visual response
            Latency resolved
            No color or pattern preferences
            Visual attention extends beyond 20 feet
            Views books or other two-dimensional materials, simple images
            Uses vision to imitate actions
            Demonstrates memory of visual events
            Displays typical visual-social responses
            Visual fields unrestricted
            Look and reach completed as a single action
            Attends to two-dimensional images against complex backgrounds

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

The CVI Range:  Within - CVI Characteristics Assessment Method

From Cortical Visual Impairment:  An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York.  All rights reserved.  This page may be reproduced for educational use only.

Rating II

Determine the level of CVI present or resolved in the 10 categories below and add to obtain total score. Rate the following CVI categories as related to the student/child’s visual behaviors by circling the appropriate number (the CVI Resolution Chart may be useful as a scoring guide):

  • 0 - Not resolved; usually or always a factor affecting visual functioning
  • .25 - Resolving
  • .5 - Resolving; sometimes a factor affecting visual functioning
  • .75 - Resolving
  • 1 - Resolved; not a factor affecting visual functioning
1.  Color preference 0 (.25) .5 .75 1
Comments:
2.  Need for movement (0) .25 .5 .75 1
Comments:
3.  Visual latency 0 (.25) .5 .75 1
Comments:
4.  Visual field preferences 0 (.25) .5 .75 1
Comments:
5.  Difficulties with visual complexity (0) .25 .5 .75 1
Comments:
6.  Light-gazing and nonpurposeful gaze (0) .25 .5 .75 1
Comments:
7.  Difficulty with distance viewing 0 (.25) .5 .75 1
Comments:
8.  Atypical visual reflexes 0 (.25) .5 .75 1
Comments:
9.  Difficulty with visual novelty 0 (.25) .5 .75 1
Comments:
10. Absence of visually guided reach 0 (.25) .5 .75 1
Comments:

Total of CVI characteristics present (numbers in parenthesis) = 1.75

From Cortical Visual Impairment: An Approach to Assessment and Intervention, by Christine Roman-Lantzy, copyright © 2007, AFB Press, New York. All rights reserved. These forms have been modified to enhance accessibility.

Cortical Visual Impairment (CVI) Assessment

Recommendations video | Recommendations transcript

Name: Brandon
Assessor(s): Eric Grimmett, CTVI, Sara Kitchen, CTVI
Date: 00/00/00

Brandon was born prematurely and has a history of closed head injury and seizure disorders, with subsequent developmental delays in both communication and motor skills.  He is currently a day student at the Texas School for the Blind and Visually Impaired in Austin.  He receives services from a physical therapist, an occupational therapist, a teacher of the visually impaired, a speech therapist, and an orientation and mobility specialist.  Brandon has cerebral palsy, and the muscles in all four limbs are permanently contracted.  Movement is difficult for Brandon, and he cannot walk unaided.  He uses a walker to travel short distances in and around familiar areas, but needs a wheelchair for most travel.  Brandon has the most physical use of his right arm, and he is able to reach out and touch items with this arm.

Brandon is visually impaired due to a combination of coexisting visual conditions.  Brandon had early vision loss due to retinopathy of prematurity (vision loss resulting from abnormal blood vessel growth in the retina in the first few weeks of life), and also has been diagnosed with optic atrophy (damage to the optic nerve) and left eye esotropia (left eye turns inward).  A history of retinal hemorrhaging has led to a recent complete retinal detachment and resulting total blindness in the right eye.  Due to his closed head injuries Brandon has also suffered some damage to his visual cortex, a condition known as cortical visual impairment.  As a result, he may be able to see some images correctly but his brain is not able to interpret the visual information accurately. 

Because Brandon has cortical visual impairment, conventional functional vision evaluation techniques are not effective or appropriate.  Brandon was assessed using the Roman-Lantzy (2007) CVI resolution assessment tool, an evaluation method that determines functional vision and identifies potential characteristics of CVI that may interfere with Brandon’s functional performance.  This report is organized into these specific characteristics.

Color preference:

Brandon was shown several items of single color, including red, blue, green, black and white, yellow, pink and orange.  He was most consistently drawn to the color red, but blue and green also elicited some visual response.  Other colors typically were not noticed for an extended latency period, and when noticed only drew minimal visual attention.  The strongest visual response came when the object was in a single preferred color, but also had reflective qualities when light was directed at it.  A shiny red plate and a silver reflective pie pan held the most interested during the initial assessment.  When working with the lightbox, Brandon had an immediate visual response to the black and white sound spinner disc against both a lighted plain white background and a lighted red background.  Big bold patterns such as a checkerboard or large circles also drew Brandon’s visual interest for sustained periods.  Brandon would reach out for objects when prompted (and sometimes spontaneously), but was overall hesitant to touch unfamiliar items, instead choosing to touch the evaluator’s hand.

Need for movement:

Brandon’s visual attention is initially drawn by movement, either by reflection or by physical means.  Some of the reflective items also emitted soft levels of sound, a strong motivator for Brandon.  Brandon did seem to track moving objects if they held his visual interest, but this was inconclusive.  When working with the lightbox, Brandon was visually drawn to the moving spinning disc, but would only look at it for extended periods once it had stopped moving.  Once the item of interest was removed, Brandon would quickly return his head to his usual position of chin to chest.

Visual latency:

Brandon exhibited extended visual latency (time between presentation of stimulus and looking at the object) when presented with objects that were multi-colored or in non-preferred single colors.  Latency period was much less when he was presented with objects that were in a single preferred color, most notably red.  Latency period was decreased even further when the object also had reflective characteristics.  Latency decreased slightly after a period of consistent viewing.

Visual field preferences:

Brandon does exhibit visual field preferences, but this is partly due to the fact that he cannot see at all out of his right eye.  Brandon favors the central field of his left eye, but also uses his peripheral vision to pick up visual stimuli on his right side.  Brandon responds to light in his upper fields as well, to a lesser degree.  Lower field use is inconclusive at this time, but he did seem to spontaneously reach out to an object in his lower field at one point without any prompting.

Visual complexity:

Brandon did not look at multi-colored objects that did not have motion or sound, and generally would not look at these items unless a light was shone directly onto the item.  The exception to this was a brief spontaneous visual localization on a multi-colored vertical stripe lightbox display.  As mentioned, Brandon was visually drawn to some bold black and white patterns when they were illuminated by the lightbox.  It should be noted that the sensory complexity of the immediate environment had a definite impact on Brandon’s use of vision.  Brandon would typically only use his vision in a very quiet controlled environment; any auditory input would cause him to stop using his vision to focus on the sound.

Light-gazing and non-purposeful gaze:

Light can be used to attract Brandon’s visual attention, and this technique was used throughout the assessment to evaluate his visual response.  He did display some spontaneous light-gazing during the assessment, but in general was not overly attentive to light sources.  Brandon may visually localize on an item briefly, particularly when prompted, but he does not fixate on light, objects or faces.

Distance viewing:

Brandon typically visually attends in near space only.  However, when he was observed traveling down the school hallway, he did display visual attention toward the person walking in front of him at a distance of around three feet.

Atypical visual reflexes:

Brandon does blink in response to touch, but showed little blink reflex in response to a visual threat.  Some squinting at light sources was also observed.

Visual novelty:

Brandon can definitely handle visual novelty when the object shares some characteristic that is motivating to him, such as sound, movement, reflection, and/or a preferred single color.  All of the items used during the assessment were unfamiliar to Brandon, and he showed more visual interest to these than he did for many of his more familiar daily items.  It should be noted however that Brandon did display some tactual defensiveness when presented with these new objects and was generally hesitant to touch them.

Visually guided reach:

Look and reach did occur with the unfamiliar assessment items, even if Brandon was hesitant to actually touch them.  Brandon would typically look first at the item, and then look away when reaching out; look and reach were still separate.  Brandon did display some latency time before reaching towards unfamiliar items, but this latency was substantially less when the object shared some characteristic that was visually attractive to him.  Brandon was much less tactually defensive with familiar items.  In one instance, Brandon did display a visually guided reach.  Brandon was observed when traveling with his walker down the school hallway towards a highly motivating activity, pushing a button to open an exterior school door.  This marked Brandon’s clearest spontaneous, unprompted use of functional vision.  The button was large, dark blue, and familiar, on a light colored, visually simple wall.  Brandon was able to visually fixate on the button for an extended period, and displayed a visually guided reach to activate the button.

Brandon is highly social, and motivated by verbal interactions with familiar and/or preferred communication partners.  This then should always be a key component of his daily activities.  However, improving his visual functioning will exponentially increase his access to information about the world around him, allowing for further levels of independence and exploration.  At this point, Brandon will require significant control of sensory input in his environment in order to use his vision.  To this end it is recommended that some time be set aside each day to introduce activities in quiet environments, activities that are designed to increase visual attention and to thus build stable and sustained looking.  Brandon should have interventions to increase his visual functioning infused throughout his daily routines, and time should be set aside when he can practice his vision in functional activities without other demands being made of him. 

Brandon should be assessed using the CVI Range Assessment on a regular basis to determine if his visual functioning has improved.  Brandon should also have a yearly eye exam due to the instability of his visual functioning, and a regular low vision evaluation is also recommended.

Eric S. Grimmett, CTVI

Accommodations for CVI

Based on the teacher and parent interviews, the observations, and the direct assessments using the CVI Resolution Chart, Brandon prefers and will learn best with the following sensory stimuli and accommodations:

  • Brandon responds best to objects that are red, his favorite color.  He will respond to blue or green objects to a lesser degree.
  • Brandon responds to objects that reflective or shiny.
  • Light can be used to draw his visual attention to an item or a task.
  • Brandon likes objects that make noise.  Keep in mind that he generally will not use his vision when interacting with sound emitting objects.
  • Brandon should participate in functional activities in which he is given opportunities to explore and handle real objects.
  • Brandon enjoys music and playing an electric keyboard is a highly motivating leisure activity.
  • Objects presented against a simple background will best attract his visual attention.
  • Brandon is more likely to tactually explore familiar items.
  • A lightbox can be used to draw his attention to simple patterns.
  • Simple words and phrases should be used when identifying objects or activities.
  • Use consistent simple language with Brandon.
  • Encourage and model appropriate communication.
  • Incorporate both visual and tactual activities into Brandon’s daily routines as much as is feasible.
  • Provide opportunity for repeated exposure and practice in visual functioning and tactual exploration.
  • Integrate consistent materials throughout daily routines.
  • Brandon’s visual functioning may fluctuate and his response to visual stimuli may appear inconsistent due to changes in his immediate environment.
  • New items should be single color, preferable red, and/or high contrast.
  • Use hand under hand techniques to guide Brandon’s reach.
  • Use movement, light, or reflection to draw Brandon’s visual attention.
  • Use simple language and allow processing time when giving Brandon any type of cue or prompt.
  • Allow processing time of up to two minutes for Brandon to respond to unfamiliar visual stimuli.
  • Avoid using flashlights or a lightbox as a stand-alone intervention; these items should be used to highlight items or steps in functional activities.
  • Brandon may be tactually defensive when presented with unfamiliar objects.
  • All competing sensory input must be controlled in order for Brandon to use his vision.  Auditory stimuli are both very motivating and very distracting to Brandon, but will take all of his sensory attention when present.
  • Present objects to be explored visually on Brandon’s left side, in his preferred central field of vision at near distance.
  • Control visual clutter in Brandon’s immediate environment.
  • Allow Brandon several minutes to explore his environment when beginning a new activity.
  • Be sure Brandon has multiple opportunities to use his vision throughout the day.
  • Talk about what he is about to do before doing it, using simple language combined with object symbols.
  • Let Brandon know you are about to touch him.
  • Brandon should receive direct instruction in all areas in which learning occurs through vision or observation, such as social skills and daily living skills.

with Lynne McAlister and Sara Kitchen, certified teachers of the Visually Impaired.

Sara: So, this is the process we're going to use with our students, our three students, in our three case studies.  We're going to go over the interview questions.  We're going to record the information we get from the interview onto the CVI resolution chart, also known as rating two chart.  And then, we're going to take the information we get from the observation which we videotaped.  And we're gonna show you snippets of what we videotaped in the observation, record those on the CVI resolution chart, and then, we're gonna do the same thing with the direct assessment.  And we're gonna gather that information together on the CVI resolution chart.  See kinda how that plays out, where that's guided us.  And then, we will look at the rating one and we'll kind of go through that.  We may not go through it in as much detail because it will take a really long time.

Lynne: Uh-hmm.

Sara: But will go through, especially the areas where the student is scoring, and where we think the student is functioning.  We'll really look at those in detail.  And then, we'll talk about the kinds of interventions that would be helpful for a student who's functioning at this range.  And those are also mentioned in the book.

Lynne: Uh-hmm.

Sara: I don't think there's an intervention chart or anything like that, but there's a lot of, um...

Lynne: There's intervention by phase.

Sara: Right. There's an intervention, just paragraphs written about that, so...  So, that information is in here.  And sometimes we'll be using other information to, you know...or creative things, things that have to do with other things that are going on with the student.

Lynne: Uh-hmm.

Sara: So, that's what we will do, and so tune in for case study 1, 2 or 3.  And, um, those studies will also be...  Those case studies will be at phase 1, 2 and 3.  There are examples of each phase.  Of course, no student is going to be...

Lynne: The same.

Sara: ...the same.

Lynne: Just because you have a phase 1 student, it's not gonna be this...  Your student will may not need the same interventions that our case study students needed.

Sara: Most likely they won't. It'll be different.  Every kid is different.

But we just wanted to give you a feel for the process for student at any phase, and, you know, of course, you're welcome to go skip to phase 3 if you want to, you know.  It's not... Doesn't have to be in order.  And what I discovered is, um, through looking at these three, and that amount of depth and the amount of, you know, really focusing you have to do is that, you know, you think...  You know, I'm a linear person.  So, I think phase 1 is easier and phase 2.  And then phase 3 is the hardest 'cause it's the highest number.  I don't think that's true in this case.  I think that it's really hard to determine with the students looking at very little.

Lynne: Uh-hmm.

Sara: It's harder to determine what's going on and how to, you know...

Lynne: Right.

Sara: ...how to modify for that state and, so...that's just my experience.

Of course, everybody's different, so...  Anyway, so you'll have an opportunity to look at kids at these three different phases.  And hopefully, that'll help guide you in assessing your own students.


Handout (Microsoft Word)

Introduction to Cortical Visual Impairment Handout (Microsoft Word)

Videos


CVI 101

Lynne McAlister and Sara Kitchen introduce concepts related to Cortical Visual Impairment. They discuss the definition, prevalence, possible causes, and diagnosis of CVI. They also explore the notion that the brain is plastic, which allows for rewiring of how sensory information is processed. As you watch the video, keep in mind the students you currently serve (or your own child if you are a parent) and note if any of this information seems applicable.

Introduction to CVI Characteristics

Lynne McAlister and Sara Kitchen introduce the concept that there are 10 characteristics associated with CVI as outlined by Christine Roman-Lantzy. It may be helpful to study chapter 2 of Cortical Visual Impairment: An Approach to Assessment and Intervention, by Dr. Roman-Lantzy, as a companion to this material, especially if you have less experience with CVI.

Color Preference

Lynne and Sara examine the characteristic of color preference for those with CVI. Have you noticed your child or student gazing at a particular color but not at others, or did they used to?

Visual Attention to Movement

Lynne and Sara talk about how movement is integral to the brain's development of visual perception. Have you noticed your child or student visually attending to things that move, such as ceiling fans or mirrors?

Visual Latency

Lynne and Sara explore the characteristic of visual latency, which is a delay in directing vision to a visual target. Different factors such as familiarity of the target or fatigue can affect latency positively or negatively. Can you think of a time when you have experienced latency in your own visual processing? Have you noticed that your student or child responds more quickly to familiar visual input?

Visual Field Preferences

Lynne and Sara discuss visual field preferences. Not only damage to the retina, but also neurological damage or differences can contribute to field deficits. Mixed field preference may also be present. Have you noticed unusual head positioning in your student or child who has CVI?

Visual Complexity

Lynne and Sara discuss the CVI characteristic known as complexity. Complexity is broken up into a variety of sub-categories that show various ways the ability to pick out discrete visual information is impacted by CVI. Challenges can come in the form of too much information, whether it is to the visual system or another sensory system. Have you noticed certain objects are easier for your student or child to look at, or that he looks away as soon as someone talks to or touches him? What visual behaviors do you see in the cafeteria or grocery store?

Abnormal Response to Light

Lynne and Sara discuss the characteristic known as light-gazing. Light is one of the easiest things for the visual system to detect.

Distance Viewing

Lynne and Sara talk about distance viewing being closely related to the characteristic of complexity. Have you noticed that your child or student only looks at items that are very close to her face? Or that she can't recognize familiar landmarks in the environment beyond a certain distance that does not correlate with her distance visual acuity?

Visual Blink Reflex

In this video, the blink reflexes to touch at the bridge of the nose and visual threat are discussed.

Visual Novelty

The characteristic of visual novelty is introduced by Lynne. Do you notice your student or child prefers to look at familiar items or does not notice those that are unfamiliar? Do you notice more looking behavior in a familiar environment?

Visually Guided Reach

Lynne and Sara discuss the CVI characteristic known as visually guided reach.  The integration of vision of movement depends on various parts of the brain working together. Do you notice your student or child looking away before or as they act upon an object?

Resolution of Characteristics

Lynne and Sara provide an overview of how intervention impacts the development of vision for individuals with CVI. There are distinct phases of visual functioning, and within each phase, the teaching goals are different. Doing an assessment provides intervention ideas that address where the student is functioning currently. If you have a student or child with CVI, what phase would you guess they are in based on their visual behaviors?

Introduction to Christine Roman-Lantzy’s Assessment

Lynne and Sara provide an overview of the assessment process that will be used in this web exercise in the section containing three case studies. The assessment is called The CVI Range and was developed by Christine Roman-Lantzy. A tip that we learned recently in addition to the information given in the video is that the score for Rating 2 should be equal to or less than the score for Rating 1.


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