Cortical visual impairment (CVI) is visual impairment that occurs due to brain injury rather than an ocular or physical eye condition. CVI is caused by damage to the visual centers of the brain, which disrupts communication to and/or from the eyes. In other words, the eyes can technically see, but the brain does not process the incoming visual stimuli. Vision Stimulation Therapy seeks to reconnect the pathways between the eyes and the brain.
Stimulation of Residual Vision Is Imperative for Cognitive Growth
Visual and cognitive development are largely correlative. Young patients with CVI will need “special learning environments that promote maximum stimulation of residual vision” (Good, Jan, Skoczenski, & Candy, Developmental Medicine & Child Neurology, 2001). Traditional educational settings may not be best for meeting the developmental needs of a child with CVI because there is so much sensory stimulation; instead, a simplified visual environment may be more beneficial, as it requires the child to focus attention on a single visual stimulus. Children with CVI have responded positively to many types of visual stimulation, such as large, high-contrast, lighted, reflective, and moving objects, such as mobiles, the addition of sound or touch to attract the child’s attention, presentation of visual material from different vantages, variations in lighting, and avoidance of over-stimulation, to name a few. Further, when visual tasks are demonstrated in a repetitive fashion, at relatively the same time every day, a child with CVI may learn to associate other non-impaired functions (like time and a consistent location) with linked visual stimuli.
Vision Therapy Models: Light Reflex/Light-Dark Perception
In the article Rehabilitation of Cortical Visual Impairment In Children (Malkowicz, Myers, and Leisman, 2006), researchers explain the vision stimulation therapy they studied. Parents were instructed on the necessary stimulation procedures so that the programs could be performed in the participants’ homes. The child’s visual function level dictated the visual stimulation program, “with specific stimuli and intensity, frequency, and duration assigned.” Initial therapy consists of reinforcing the light reflex and light-dark perception, which is comprised of a flashlight shined briefly into each eye, in a completely dark, quiet room, with a five second pause between eyes. This light stimulation is performed over the course of one minute and is repeated 30 times a day, alternating between eyes each session.
The next phase, designed to stimulate outline perception, involves placing a child near a poster board (or other similar display) containing black and white squares. Initially, the child remains in or near the checkerboard setting during the day, to create contrast around him/her. Later, black and white or bold, bright colorful outline images are added to the checkerboard to add further visual stimulation as the child progresses. Another outline perception program utilizes a penlight shined on a target in a blackened room, for one minute, 10 times a day. The child is required to detect the light, which in this exercise, is shone away from his or her eyes.
In this portion of Malkowicz’s study, single words were written on large pieces of 22x6 inch cardboard in black ink. A session involved “three different words, such [as] ‘shoe,’ ‘hat,’ and ‘Mommy’ and would be presented 10 times daily,” with each session lasting five seconds or less. The presentations were individualized to the child.
The methods applied by Malkowicz and associates showed improved visual functionality in all 20 patients in the CVI study. In fact, “50% of the patients were reading at the conclusion of the program, 37% were able to recognize letters and symbols, and 18% were able to differentiate simple visual objects such as photos.” One child in the study, whose cortical vision impairment was originally noticed at the age of six months, and through CT scans was confirmed to have brain damage, was at vision level one at the onset of the study, but advanced to level seven after just more than a year on the program. The 3-year-old went from having only functional light reflex to being able to read at a kindergarten level.
Dr. Christine Roman is an authority on Cortical Vision Impairment. She is the Director of The Pediatric VIEW Program at The Western Pennsylvania Hospital in Pittsburgh, PA, and a former Project Leader of the CVI Project at The American Printing House for the Blind in Louisville, KY. Dr. Roman asserts that no child is too brain injured to see. She has spent much of her life teaching visually impaired students and is a certified orientation and mobility specialist, and infant developmentalist. Her research and career work offers a wealth of information, videos, and webcasts regarding CVI diagnosis, assessment, early intervention, and therapeutic treatment.
In addition to traditional therapies, technology has brought new and innovative vision stimulation opportunities. Wayfinder Family Services offers an early-intervention iPad video curriculum for families and teachers of the visually impaired. Each section of the curriculum demonstrates how “early-intervention specialists use iPad tablets and applications during in-home services for infants with vision loss or multiple disabilities.” One invaluable program of Wayfinder Family Services is the Blind Babies Foundation, based in California, established to help young children who are blind or visually impaired, and who may also have other disabilities, with critical early intervention and education services. The Blind Babies Foundation collaborates with family members, medical professionals, care providers, and educators to become “successful advocates” for the visually impaired child.
Many visual stimulation therapies exist to help children with Cortical Vision Impairment tap into their residual vision following a congenital or perinatal brain injury. Most of the exercises can be performed in the home with little or no cost to the family and with no risks or side-effects for the child. Children who learn to use their residual vision display cognitive growth over time. Hopefully the resources contained herein will provide guidance for families affected by CVI.