Treatment of Cortical Visual Impairment (CVI) in Children
Children with CVI require immediate referral for specialized functional vision assessment and enrollment in early-intervention programs, combined with family support and educational accommodations tailored to their unique brain-based visual processing deficits. 1
Immediate Actions at Diagnosis
Prompt referral for low-vision rehabilitation services is essential at the time of initial diagnosis, regardless of the child's age. 1 The ophthalmologist must provide:
- Written documentation detailing the level and nature of visual impairment, the cause of reduced vision, and whether the condition is likely to progress 1
- Connections to support organizations and family support services immediately upon diagnosis 1
- Referral for early-vision intervention services with sufficient detail for service providers to understand the complete picture of the child's visual impairment 1
Specialized Assessment for CVI
Children with CVI require a specialized functional vision assessment because their visual characteristics differ fundamentally from children with ocular causes of visual impairment. 1 This is critical because:
- CVI involves damage to the brain's visual processing pathways (posterior to the lateral geniculate nucleus), not the ocular structures 2, 3
- Behavioral responses unique to CVI include color preference, need for movement, visual latency, visual field preference, and difficulty with visual complexity 2
- Standard vision screening may not accurately identify brain-based visual impairment in children with CVI 3
Age-Specific Interventions
Preschool Children (Ages 0-5)
Enrollment in an early-intervention program (Part B under IDEA) should be pursued immediately for preschool-age children diagnosed with bilateral visual impairment. 1 These programs:
- Are available through local school coops, nonprofits, or schools for the blind and provide essential family support and child stimulation 1
- Involve a Teacher of Students with Visual Impairment (TSVI) and a Certified Orientation and Mobility specialist 1
- Facilitate development of an Individualized Education Program (IEP) when the child transitions to elementary school 1
Specific accommodations for preschoolers include:
- Preferential seating close to instruction 1
- Introduction to simple optical magnification (low-power monocular telescopes and dome magnifiers) 1
- Providing a second copy of books that the teacher reads to the class for visual access 1
- Orientation and mobility instruction for safe travel in school and outdoors 1
School-Aged Children
The vision rehabilitation clinical team and the TSVI must collaborate to provide assessment of visual performance and recommendations for devices, training, and accommodations. 1 Key interventions include:
Distance viewing accommodations:
- Video magnifiers for classroom viewing 1
- Interactive electronic smartboards combined with tablet or laptop computers at the child's desk 1
- Monocular telescopes for distance spotting, preferably small enough to use inconspicuously 1
- Technology-based solutions (iPads) that are less stigmatizing than traditional low-vision devices 1
Near vision and writing accommodations:
- Video magnification to view handwriting in real time 1
- Dark felt-tip pens and paper with bold, high-contrast lines 1
- Slant boards to raise books and papers for improved posture 1
- Early keyboarding instruction to optimize computer accessibility options 1
- Print access through magnification or optical character recognition programs that read text aloud 1
Management of Comorbidities
Children with CVI often have other comorbidities (such as cerebral palsy) and require other specialized services beyond vision rehabilitation. 1 This necessitates:
- Multidisciplinary team involvement including occupational therapists, orientation and mobility instructors, and teachers of the visually impaired 1, 3
- Coordination of care for neurological problems that may coexist with CVI 4, 3
- Assessment and management of refractive errors, as cycloplegic retinoscopy is necessary to reveal significant refractive errors that may improve visual acuity 1
Emerging Evidence for Cognitive Rehabilitation
Recent research suggests that Cognitive Rehabilitation Therapy (CRT) may improve functional vision in children with CVI by targeting underlying cognitive deficits. 5 This approach:
- Showed statistically significant improvements in light sensitivity, distant visual field, focusing, maintaining focus, and obstacle avoidance 5
- Enhanced cognitive domains including visual-motor organization, thinking operations, and spatial perception 5
- Is therapist-led, feasible, adaptable, and holds promise for widespread application in pediatric rehabilitation 5
Nonvisual Skills Training
Traditional nonvisual skills training effective for ocular blindness—including braille, orientation and mobility training, and assistive technology—proves indispensable for children with CVI, even when received later in life after delayed diagnosis. 6 These skills:
- Enable access to all aspects of independent life, educational goals, and career pursuits 6
- Should be considered as part of evidence-based multidisciplinary interventions for CVI 6
Educational Documentation Requirements
A Learning Media Assessment should be requested through the school to determine whether print, braille, or a combination of print, audio, and braille is the best approach for literacy. 1 The IEP should specify:
- Tests given in a separate room with additional time as needed 1
- Texts available in e-textbook format with text-enlarging and optical character recognition capability or in audio format 1
- Modifications for sports and physical education to ensure safety and participation 1
Critical Pitfalls to Avoid
Do not delay referral for vision services while waiting for vision to "improve," as early diagnosis and early visual habilitation significantly increase quality of life. 2 Common errors include:
- Failing to recognize that ocular structures in CVI are generally normal or insufficient to explain the visual impairment 2, 4
- Using standard vision screening methods that miss brain-based visual impairment 3
- Not providing protective eyeglasses with correction of significant refractive errors and photochromic or tinted lenses as needed 1
- Overlooking bright children with moderate visual disability who may not be recognized as having special needs 1
Prognosis Considerations
Clinicians should remain optimistic about the child's potential for some vision recovery, as the prognosis in CVI remains uncertain and many children show improvement over time. 4 However: