1 Supporting CVI During OM By Jennifer Siff

1 Supporting CVI During O&M By Jennifer Siff, M. Ed. , COMS

Supporting CVI during O&M instruction ■ Very basic introduction to CVI ■ Functional implications- what it means for O&M instruction ■ General instructional strategies for supporting CVI during O&M instruction 2 2

“Vision is so much more than just a picture. . . I think of vision more like an incredible orchestra with each visual process being a musician; all perfectly synchronized… Not every instrument used all of the time, but all there when needed; but it only takes one or two instruments to be slightly out to have an effect on the overall performance of the whole group. If each performer is a visual process, what happens when: One might be absent or missing? Or sometimes too slow? Or maybe inconsistent, so sometimes they perform well and at times they don’t? Or unreliable, so sometimes it’s as if they're not there at all, and other times it is? But that’s very much how vision with CVI is. ” - Helen St. Clair Tracey, CVI Scotland co-founder 3 3

CVI: The Basics ■ CVI = Cortical/Cerebral Visual Impairment; brain-based visual impairment ■ Visual impairment exists in visual systems/ neural pathways of the brain ■ Can occur at any time in life ■ Can occur due to physiology; illness/injury; chemical/metabolic functions in brain ■ Varies from person to person ■ Visual functioning can fluctuate for the individual, depending on many factors 4 4

CVI: The Basics ■ Can be present with or without ocular visual impairment Leading cause of blindness in developed countries: - Affects nearly 2 out of every 1000 live births - Accounts for 20 -25% of VI children in developed countries - as of 2012, listed as most common cause of vision loss in schools for the blind in the US ■ ■ Can go undiagnosed and unaddressed for years (or ever!) ■ CVI behaviors can be mistaken for autism and other disorders 5 5

CVI Characteristics “Hallmarks” of CVI 1. Color 2. Movement 3. Latency 4. Visual Field 6. Lightgazing/Non-purposeful gaze 7. Distance Viewing 8. Visual Reflexes 9. Visual Novelty 5. Complexity (of array; sensory) 10. Visual Motor Source: Roman-Lantzy C. Cortical Visual Impairment: an Approach to Assessment and Intervention. New York: AFB Press; 2018. 6 6

Measuring CVI 1. Christine Roman-Lantzy CVI Range - A tool which assesses the level of impact of a student’s CVI - Three Phases - Scale or Rating of 1 -10 within the three phases - CVI “Score” will have two numbers, indicating functional vision student was able to demonstrate during the assessment 2. Gordon Dutton’s Visual Skills Inventory - a comprehensive list of visual behaviors based on observation & interview of familiar caregiver 3. Els Ortibus “Teach CVI” - screening list of visual behaviors 7 7

“CVI is a spectrum of spectra. ” - Helen St. Clair Tracy, CVI Scotland As an instructor, knowledge of your individual students and their manifestation of CVI is the most important. Even students in the same phase on the CVI range can manifest VERY DIFFERENTLY. “With CVI, there are “No ‘All’s or ‘Always’. ” - Ellen Mazel. 8 8

CVI Adaptations for yourself as instructor ■ Dress Patterns ■ Introductions and descriptors ■ Verbal input - how much is too much? Time yourself to see how long you’re actually waiting ■ Be flexible! Expectations may need to change from day to day or even throughout the day. ■ Plan for extra time and lots of visits 9 9

Implications Phase I ■ May look briefly at lighted/shiny, single-colored and/or moving objects, but can’t sustain gaze ■ 2 -Dimensional Images and multi-colored objects are not accessible to people in Phase I ■ Will likely not be able to use vision during travel time ■ Strategies: LOTS of time & repetition; previewing of objects with aided language input 10 10

Implications Phase II ■ People in Phase II need movement and brightly saturated colors to draw visual attention ■ MAY be able to recognize some 2 D images, depending on where they lie in Phase II; consult with TVI and SLP ■ Complexity and visual fatigue still an issue ■ May be able to use tap cues/auditory cues 11 11

Implications Phase III ■ People in Phase III are working to resolve visual characteristics of CVI ■ Some struggles with unfamiliarity and complexity ■ Can use central vision and can see in all visual fields ■ Strategies: familiarization visits; increased route repetitions; high-tech devices; monoculars; 12 12

Implications Color/Contrast Sensitivity ■ The ability to tell apart different shades of grey ■ Students with CVI may have poor contrast sensitivity ■ ■ ■ Contrast sensitivity is affected by the level of lighting in the environment: low lighting = poorer contrast sensitivity Strategies: high-contrast materials; strategic color highlighting; use of non-visual orientation techniques Use of https: //www. sight-sim. scot. nhs. uk/ 13 13

Implications Simultanagnosia ■ Inability to see more than one thing at a time ■ Inability to see many things at once ■ Inability to see whole picture ■ ■ Will affect ability to visually scan an area to locate landmarks/destinations/people Strategies: practice visual scanning techniques; use of monocular; use of color highlighting; use of tactile or auditory cues/clues/landmarks 14 14

Implications Optic Ataxia ■ Inability to reach visual targets/goals ■ Affects eye-hand coordination ■ ■ DIfficulty grasping doorknobs, pushing elevator buttons, putting their name stamp on a deposit slip, etc. Possible strategies: color highlighting; use of signature guide; use of upper and lower protective 15 15

Delivering Instruction Make sure you- Think holistically ■ Holistic = all systems working together, interconnected ■ Ocular condition + CVI characteristics ■ Environment, emotions, energy levels can all affect vision ■ Work with team to provide best supports ■ Find out demands throughout the day ■ “CVI schedule” 16 16

Delivering Instruction Make sure you- Plan Ahead ■ Be mindful of scheduling times in the community if use of vision is expected ■ Do your own solo trip ahead of service time if necessary ■ Use vision simulators to notice areas of poor contrast sensitivity; use of Sight-sim. website ■ Student dress patterns: sunglasses/hats/visors to block light gazing 17 17

Delivering Instruction Make sure you- Observe ■ Notice what they notice: Landmarks? Colors? Lighting? Sounds? ■ What kind of questions do they ask? ■ What sort of routes give them trouble? Which ones appear easier? ■ Are you always cueing them in the same place along the route? What is different about the environmental features in that place? ■ Different results at different times of day? 18 18

Delivering Instruction Make sure you- Be patient ■ Be prepared for slow processing time ■ Less talking; longer pauses between directions ■ Plan for much repetition of the same route or activity before witnessing progress or familiarity 19 19

Supporting CVI in the Community Lightgazing: Sunglasses, hats with brims Color: Use color highlighting (sparingly) ; duct tape, hockey tape, washi tape Complexity, Movement: simplify background; occluders Latency: give extended wait time; minimal verbal cues; make repeat visits; preview items ahead of time Visual field: use of long cane; present items in preferred visual field; make aware of lower visual field Complexity (sensory): schedule lessons early in the day (lower chance of visual fatigue); visit stores at off-peak hours; be mindful of tap cues! 20 20

Supporting CVI in the Community Distance Viewing: present items at best viewing distance; use of monocular Visual Novelty: familiarization visits; numerous repetitions along same route/to same destinations; practice routes from different directions to recognize landmarks/destinations from different perspectives; discuss salient features prior to viewing or scanning for them Visual Motor: cane skills can help locate obstacles, protect lower visual field; use of adapted upper and lower protective to ensure they are protecting the midline of the body 21 21

CVI in the COVID-19 Era ● INTRODUCE YOURSELF! ● Describe yourself ● Be mindful of even further visual field loss, glare from PPE ● Fatigue! ● Remote learning/virtual school considerations & accommodations 22 22

Conclusion ● If your student has a diagnosis of CVI, use their CVI evaluation for vital information on how to deliver services ● If your student does not have a diagnosis of CVI, but you suspect it due to their visual behaviors, advocate for evaluation ● CVI is a spectrum of spectra; there are no one-size-fits-all interventions, and be ready to adjust your expectations ● Think holistically, plan ahead, observe, and be patient. ● Get creative! 23 23

24 24 Thank you!

Sources 1. Helen St. Clair Tracey “Supporting People with CVI” webinar, via the International Online O&M Symposium, 2020 2. Roman-Lantzy C. Cortical Visual Impairment: an Approach to Assessment and Intervention. New York: AFB Press; 2018. 3. Merabet, L. , 2015. "Looking Inside The Adaptive Brain Of The Blind". 4. CVI Scotland. STEP 1: Understanding CVI. https: //cviscotland. org/documents. php? did=1. Published November 3, 2017. Accessed November 10, 2020. 5. CVI Scotland. STEP 2: Assessing CVI. https: //cviscotland. org/documents. php? did=3. Published November 3, 2017. Accessed November 10, 2020. 6. Andersen, R. , Andersen, K. , Hwang, E. and Hauschild, M. , 2020. Optic Ataxia: From Balint’S Syndrome To The Parietal Reach Region. 25 25