Physician Prescribing and Referral Patterns in Children with Cerebral Visual Impairment

SIGNIFICANCE

Cerebral visual impairment (CVI) is the leading cause of visual impairment in the developed world. Providing children with CVI with the appropriate treatment ensures the best possible visual outcome and potentially improves quality of life.

PURPOSE

The purpose of this study was to determine physician prescribing and visual rehabilitation referral patterns in children with CVI.

METHODS

A retrospective chart review was completed on children with CVI examined at Cincinnati Children's Hospital Medical Center from January 1, 2008, to March 1, 2018. Significant refractive error warranting correction was determined using the American Academy of Ophthalmology Preferred Guidelines and the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee Guidelines. The CVI Range was used as a surrogate to categorize CVI severity.

RESULTS

A total of 194 children were included. Sixty-eight (35%) had refractive error warranting correction and were prescribed glasses (group RC), 99 (51%) did not have refractive error warranting correction and were not prescribed glasses (group NRNC), 20 (10%) had refractive error warranting correction but were not prescribed glasses (group RNC), and 7 (4%) did not have refractive error warranting correction but were prescribed glasses (group NRC). There was greater than one-line Snellen equivalent difference between group RC (20/156) and group RNC (20/221). There was greater than six-line Snellen equivalent difference between group NRNC (20/149) and group NRC (20/35). Mean CVI Range score 2 values for each group were 5.9, 4.6, 4.8, and 7.1.

CONCLUSIONS

Children with less severe CVI were less likely to have significant refractive error but given glasses. Despite significant refractive error, children with more severe CVI were not prescribed glasses. Children with very low visual function were not prescribed glasses as frequently, possibly limiting their visual rehabilitation. Providers should ensure that all children with CVI are correctly prescribed glasses to provide the best possible visual outcome.

Creating a Path for Systematic Investigation of Children With Cortical Visual Impairment Who Use Augmentative and Alternative Communication

Purpose There is limited information about how to support children with cortical visual impairment (CVI) who require augmentative and alternative communication (AAC). An initial review designed to explore the available evidence was used to outline critical needs in moving research and intervention forward for children who use AAC and have CVI. Method Previous systematic reviews, six databases, and theses and dissertations were systematically searched, along with reviews of the resulting works cited. An initial yield of 575 articles was narrowed to 10, which discussed AAC interventions that included children with CVI. Results Three interventions were technology based, and seven were instructional based. The use of textured microswitches was the most frequent form of technology intervention, with the frequency of switch activations being the most frequently coded outcome. Overall, the studies represent explorations in the area rather than systematic lines of inquiry. Conclusions While evidence shows at least some children with CVI have been included in AAC research to date, the inclusion is more incidental than deliberate. Issues such as clear descriptions of the vision capabilities and needs of participants may have impacted study results.

Increasing a Functional Skill for an Adolescent with Cortical Visual Impairment

The effectiveness of two treatment strategies—verbal prompts and a physical prompt—on the the independent drinking skills of a 17-year-old girl with cortical visual impairment was investigated using a single-subject alternating treatments design in two settings. Ten natural drinking opportunities were observed in 43 sessions in the student's school and home. It was found that the physical prompt was highly effective in promoting the target behavior, whereas verbal prompts were less effective. Independent drinking behaviors appeared to have been maintained in both settings.

Visual Behaviors and Adaptations Associated with Cortical and Ocular Impairment in Children

Visual loss leads to visual behaviors and adaptations that tend to reflect the onset, severity, and types of visual impairment. In this article, the characteristic behaviors associated with different degrees of visual loss and their importance in the diagnosis of cortical versus ocular visual impairment are discussed.

Vision and Orientation and Mobility Consultation for Children with Severe Multiple Disabilities

Vision consultants who work with professionals and parents of children with severe multiple impairments perform a professional role that is changing and challenging. Educational planning is unique, since many children with different levels of disabilities must be served in a variety of individual settings. This article discusses the role of orientation and mobility specialists and teacher-consultants for children who have visual impairments and severe multiple disabilities. Examples of programming contributions of both types of vision consultant are given.

A Model for the Efficient Interdisciplinary Assessment of Young Visually Impaired Children

This article presents a model for an efficient assessment of young visually impaired children and children with multiple handicaps using a team that simultaneously observes various aspects of the child's functioning to gain an understanding of the child as a whole.

Intelligence Profiles of Low Vision and Blind Children

This article reports on an analysis of the WISC-R and WPPSI profiles of 118 visually impaired children without additional neurological problems. A consistent response pattern on the Wechsler batteries emerged, suggesting that the verbal as well as the performance tests can provide useful assessment information.

Visual Therapy: A Theoretically Based Intervention Program

This article offers a model of visual functioning aimed at furthering understanding of the visual process. At each stage practical implications are discussed and intervention strategies for use with visually unresponsive or inattentive infants and children are offered.

Neuroplasticity in cerebral visual impairment (CVI): Assessing functional vision and the neurophysiological correlates of dorsal stream dysfunction

Cerebral visual impairment (CVI) results from perinatal injury to visual processing structures and pathways and is the most common individual cause of pediatric visual impairment and blindness in developed countries. While there is mounting evidence demonstrating extensive neuroplastic reorganization in early onset, profound ocular blindness, how the brain reorganizes in the setting of congenital damage to cerebral (i.e. retro-geniculate) visual pathways remains comparatively poorly understood. Individuals with CVI exhibit a wide range of visual deficits and, in particular, present with impairments of higher order visual spatial processing (referred to as "dorsal stream dysfunction") as well as object recognition (associated with processing along the ventral stream). In this review, we discuss the need for ongoing work to develop novel, neuroscience-inspired approaches to investigate functional visual deficits in this population. We also outline the role played by advanced structural and functional neuroimaging in helping to elucidate the underlying neurophysiology of CVI, and highlight key differences with regard to patterns of neural reorganization previously described in ocular blindness.

A Questionnaire Assessing What Teachers of the Visually Impaired Know About Cortical/Cerebral Vision Impairment

Cortical/cerebral visual impairment (CVI) is now the main cause of visual impairment in developed countries, yet it remains poorly understood. Four hundred and ninteen teachers of the visually impaired (TVIs) from across the United States responded to a questionnaire targeted at evaluating the preparedness of TVIs to serve their students with CVI. The TVIs were asked about their background knowledge, their abilities to assess a student with CVI, and their abilities to apply what they know to best help their students. The primary finding was that there is a perceived unmet need for TVIs to receive formal training in CVI during their certification. The results of this survey provide a foundation for future research on CVI knowledge and education among TVIs.

The Effects of Training on a Young Child with Cortical Visual Impairment: An Exploratory Study

This exploratory study investigated the effects of the components of visual environmental management, visual skills training, and visually dependent task training on the performance of visual behaviors of a young child with cortical visual impairment. These components were implemented by the mother during daily routines.

Cerebral versus Ocular Visual Impairment: The Impact on Developmental Neuroplasticity

Cortical/cerebral visual impairment (CVI) is clinically defined as significant visual dysfunction caused by injury to visual pathways and structures occurring during early perinatal development. Depending on the location and extent of damage, children with CVI often present with a myriad of visual deficits including decreased visual acuity and impaired visual field function. Most striking, however, are impairments in visual processing and attention which have a significant impact on learning, development, and independence. Within the educational arena, current evidence suggests that strategies designed for individuals with ocular visual impairment are not effective in the case of CVI. We propose that this variance may be related to differences in compensatory neuroplasticity related to the type of visual impairment, as well as underlying alterations in brain structural connectivity. We discuss the etiology and nature of visual impairments related to CVI, and how advanced neuroimaging techniques (i.e., diffusion-based imaging) may help uncover differences between ocular and cerebral causes of visual dysfunction. Revealing these differences may help in developing future strategies for the education and rehabilitation of individuals living with visual impairment.

Boy with cortical visual impairment and unilateral hemiparesis in Jeff Huntington's "Slip" (2011)

Face recognition is strongly associated with the human face and face perception is an important part in identifying health qualities of a person and is an integral part of so called spot diagnosis in clinical neurology. Neurology depends in part on observation, description and interpretation of visual information. Similar skills are required in visual art. Here we report a case of eye cortical visual impairment (CVI) and unilateral facial weakness in a boy depicted by the painter Jeff Huntington (2011). The corollary of this is that art serves medical clinical exercise. Art interpretation helps neurology students to apply the same skills they will use in clinical experience and to develop their observational and interpretive skills in non-clinical settings. Furthermore, the development of an increased awareness of emotional and character expression in the human face may facilitate successful doctor-patient relationships.

CVI?! How to define and what terminology to use: Cerebral, cortical or cognitive visual impairment

This article reports on the exchange of ideas at an international conference in San Francisco in April 2005 on the definition, diagnosis and terminology of a condition which is at present variously described as cerebral, cortical or cognitive visual impairment (CVI). Some symptoms are listed, and the condition is compared with, and distinguished from, other visual impairments.

Sleep hygiene for children with neurodevelopmental disabilities

Sleep disturbances in children with neurodevelopmental disabilities are common and have a profound effect on the quality of life of the child, as well as the entire family. Although interventions for sleep problems in these children often involve a combination of behavioral and pharmacologic strategies, the first line of treatment is the promotion of improved sleep habits or "hygiene." Despite the importance of sleep-hygiene principles, defined as basic optimal environmental, scheduling, sleep-practice, and physiologic sleep-promoting factors, clinicians often lack appropriate knowledge and skills to implement them. In addition, sleep-hygiene practices may need to be modified and adapted for this population of children and are often more challenging to implement compared with their healthy counterparts. This first comprehensive, multidisciplinary review of sleep hygiene for children with disabilities presents the rationale for incorporating these measures in their treatment, outlines both general and specific sleep-promotion practices, and discusses problem-solving strategies for implementing them in a variety of clinical practice settings.

Cortical visual impairment in children

Cortical visual impairment (CVI) in children is most commonly caused by peri- or post-natal hypoxia-ischemia, but may also occur following other insults, e.g., trauma, epilepsy, infections, drugs or poisons, and certain neurologic diseases. The disorder differs considerably in etiology, physical findings, and, perhaps, prognosis, from the cortical blindness seen in adults. The same event that causes CVI by damaging the geniculate and/or extrageniculate visual pathways may also damage other areas of the brain, or the retina, optic nerves, or chiasm. Thus, children with CVI often have other neurological problems. Diagnosis may require the participation of a multidisciplinary team and the use of special visual testing techniques. Due to the uncertainty concerning the prognosis in CVI, clinicians should remain optimistic about the child's potential for some vision recovery.