The Student with CVI Determining Functional Vision

1. The Student with CVI Determining Functional Vision Ellen Mazel M.ED, CTVI CVI Project Manager Perkins School for the Blind

2. Definitions of CVI Vision impairment due to damage or disorder of the visual pathways and visual centers in the brain, including the pathways serving visual perception, cognition, and visual guidance of movement.” and may coexist with anterior visual pathway anomalies. Dutton GN, Lueck AH. Editors.  Impairment of vision due to damage to the brain in Vision and the Brain: 2015 AFB Press Page 4

3. Gathering Information • Medical: Eye health and Visual function: Low Vision Clinics/Ophthalmology and Neurology reports • Student files • Parents • Educational team members

4. Functional Vision VS. Visual Function Visual function: Collection of Data: Things that can be measured in a clinical ophthalmic setting. Functional vision: Collection of observations across multiple settings: The way in which an student uses their vision.

5. Acuity not a measure of functional vision

6. Acuity is not the measure of CVI: Twin: Student L Neurological History: Bilateral IVH Grade 1-2 • Acuity measure 20/160. • Takes 30 minutes to obtain acuity Ellen: • CVI Range: L scores 5

7. Acuity is not the measure of CVI: Twin student A Neurological History: Bilateral IVH Grade 4 • Acuity measure 20/63. • Takes 5 minutes to get acuity Ellen: • CVI Range: A scores 3.5 to 4

8. Compare Neurological History: Bilateral IVH Grade 1-2 • Acuity measure 20/160. • Takes 30 minutes to obtain acuity Looks at people and objects Ellen: • CVI Range: L scores 5 Neurological History: Bilateral IVH Grade 4 • Acuity measure 20/63. • Takes 5 minutes to get acuity Limited visual attention to people and objects Ellen: • CVI Range: A scores 3.5 to 4

9. Brain Based visual issues not ocular criteria Roman-Lantzy • Color preference, reliance on color • Reaction to environmental movement, impact of environmental movement • Attention to light, support of backlighting • Reduced visual reflexes to touch and threat

10. Brain Based visual issues not ocular criteria • Difficulties with complexity of object • Difficulties with of array • Difficulties with sensory complexity • Difficulties with facial complexity

11. Brain Based visual issues not ocular criteria • Reduced distance attention and understanding. Where is visual curiosity? • Increased latency for looking or understanding what is seen • Reduced visual motor skills • Difficulties with visual novelty • Visual field preferences.

12. Brain Based visual issues not ocular criteria Dutton and Ortibus • Visual field differences • Difficulty with visual attention • Impaired perception of movement

13. Brain Based visual issues not ocular criteria • Difficulty handling a complex scene • Difficulty with visually guided movement • Behaviors in crowded environments • Understanding what is being looked at

14. Components • Parent Interview • Observations in various familiar and unfamiliar settings • Direct assessment setting with highest environmental supports

15. Assessment Based on Student Profile • Helps drive instruction programming • Helps drive material creation/adaptation • Helps document changes in vision • Helps readjust environmental supports and material adaptation

16. Peter’s Ophthalmologist • “Eyes are healthy.” • “Maybe delayed visual maturation.” • “Optic nerves might be a bit pale.” • “See the neurologist.” • “See a strabismus specialist.”

17. Peter: Ocular Functional Vision Assessment • Typical looking eyes • Holds eyes to the left • Alternating exotropia • No eye contact • No fixation • No tracking • No scanning • No response to visual field testing • No blink reflex • No light sensitivity

18. Ocular FVA • Leads me to focus on compensatory skills • Leads me to believe the visual skills are fixed and limited

19. Peter: CVI Functional Vision Assessment Visual Behaviors: • Preference for red materials. • Movement of materials draws and keeps his visual attention. He falls asleep in busy places. • Limited visual attention. Needs extra time to locate and turn to materials. • Locates materials faster in his left visual field at eye level.

20. Peter: CVI Functional Vision Assessment • Visually locates best with simple environments that are quiet, with non-complex backgrounds and if he is solidly positioned. • Stares at light sources and can be visually inattentive. • Looks only at items in near space 12”-18”. • Does not reach out.

21. Peter: CVI Functional Vision Assessment • Recognizes one or two familiar items. Looks faster and sustains visual attention longer. • Locates materials with peripheral vision. • Shows a delayed blink to touch and no blink to threat.

22. Cortical/Cerebral FVA • Leads me to identify real functional vision • Leads me to focus on those functional vision skills • Leads me to focus on compensatory skills to support that vision • Leads me to expect improvement in visual recognition skills.

23. Improvement: Peter 2016 • Moved from Phase I to early high Phase II • Visual recognition improved. • Visual attention improved. • Using a TOBII eye gaze system to communicate.

24. John: Ophthalmologist • Slight astigmatism • Strabismus • Prescribed glasses

25. John: Ocular Functional Vision Assessment • Typical looking eyes • Esotropia • Looks at faces • Good fixation • Good tracking if moving slowly

26. John: Ocular Functional Vision Assessment • Good scanning using full head movement • Responses to visual field testing with light • Shows blink reflex • No light sensitivity • Visual fields full in confrontation testing with light

27. Ocular FVA • Leads one to believe glasses are the supports needed. • Leads one to believe vision is effective for learning

28. John: CVI Functional Vision Assessment Visual Behaviors: • Preference for red materials. Uses color to to find people in crowded, items at distance, items against complexity • Movement of materials draws visual attention against complexity and at distance. Movement distracts him. • Difficulty with recognition if items are too close together.

29. John: CVI Functional Vision Assessment • Needs extra time to locate items against complexity and at distance • Needs extra time to understand new things he sees. • Difficulty in new places • Low visual field is impacted functionally

30. John: CVI Functional Vision Assessment • Visual understanding is optimal in simple environments that are quiet, with non-complex backgrounds and if he is solidly positioned. • Backlighting supports visual discrimination and reduces visual fatigue. • Optimal distance for learning is 4 feet but may need support to understand new materials or events at near.

31. John: CVI Functional Vision Assessment • Due to simultanagnosia, he struggles to understand crowded scenes • Understand familiar items and events faster. He can tap into visual prediction. • Shows blink to touch and weaker blink to threat.

32. John: CVI Functional Vision Assessment • Difficulty with facial recognition and facial expressions • Difficulty understanding pictures • In new places, he gets quiet, puts his head down and uses vision less. • Impacted by visual fatigue

33. Cortical/Cerebral FVA • Leads me to identify real functional vision, what is and is not accessible. • Leads me to focus on those brain based functional vision skills • Leads me to focus on compensatory skills to support that vision • Leads me to expect visual recognition improvement.

34. Correct FVA for students with CVI Leads me to: • the correct functional vision areas of need. • goals and objectives based on the correct areas of need. • create environmental adaptation that meets student accessibility needs. • create materials matched to the areas of need. • provide teaching methods for accessibility and visual improvement.

35. Cortical/Cerebral FVA • I can explain behaviors through a CVI lens. • I can caution about how vision masks cognitive skills. • I can caution against the diagnosis of autism, ADHD, distractibility and cognitive impairments. • I can instill the belief in changing functional vision.

36. Cortical/Cerebral and Ocular Issues Assess both: Tools to use for CVI: • CVI Range • Dutton Survey • Ortibus Teach CVI materials • Matt Tietjen’s “What’s the Complexity?” Tools to use for ocular: • Outlined by Tammy

37. The Student with CVI Determining Functional Vision Ellen Mazel M.ED, CTVI CVI Project Manager Perkins School for the Blind