1. Ophthalmologic Examination Integrated With The Functional Aspects of CVI
Sharon S Lehman, MD FAAP
Chief Ophthalmology Nemours Children’s Clinic
Clinical Professor of Ophthalmology and Pediatrics
Robison D Harley MD Endowed Chair of Pediatric Ophthalmology

2. 12 month ex 23-week premature infant with tracheostomy, h/o retinopathy of prematurity who has been recently diagnosed with cerebral palsy.
Child’s mother is concerned that child looks past her, stares at lights and looks away when reaching for an object.

3. OPHTHALMOLOGIST REPORT: IMPRESSION: ROP RESOLVED; NORMAL EYE EXAM RECOMMENDATIONS: F/U 1 YEAR

4. What my exam should include…
Obtain history focused on child’s visual behavior/characteristics
Validate parent’s observations
Learn patient’s expectations for their child
Perform complete ophthalmologic examination
Provide medical diagnosis and medical necessity
Refer for services for visually impaired
Make specific recommendations tailored to individual patient
Provide information to patient’s team
Provide educational materials/support group information
Provide opportunity for parent’s to ask questions

5. Classic Ophthalmologic Exam – Exam #1 Focus: History and Structure
History with CVI modified questionnaire
Physical-Classic Ophthalmologic Exam
Visual acuity
Pupillary reaction
External
Anterior and posterior segment
Alignment and motility
Cycloplegic refraction

6. CVI Ophthalmologic Exam #2 Focus: Function
Classic Ophthalmologic Exam #1
History with CVI modified questionnaire
Structural Physical exam +
Physical
Accommodative amplitude/dynamic retinoscopy
Convergence amplitude/NPC
Visual attention/fixation/visually guided behavior
Latency
Saccades/pursuits
Directionality of line
Contrast Sensitivity

7. CVI Ophthalmologic Exam #3 Focus: Higher Level Function
Classic Ophthalmologic Exam #1 +
CVI Ophthalmologic Exam #2
Physical
Executive functions
Figure ground skills
Comparison of size and shape
Visual center

8. (History and Structure)
CVI Type 1
Exam
(History and Structure)
CVI Type 3 Exam
(Higher Level
Function)
CVI Type 2 Exam
(Function)
Low function High function
Phase Phase Phase 3

9. What my exam is not…
It is NOT a substitute for evaluation by Teacher of Visually Impaired
It is NOT a substitute for evaluation by Occupational Therapist
It is NOT a substitute for evaluation by Physical Therapist
It is NOT a substitute for evaluation by Learning/Reading Specialist

10. “Please tell me about your child’s vision”.
HISTORY
“Please tell me about your child’s vision”.
There is no better expert than a child’s parent.
They will often tell you most of you need to know.

11. CVI Modified Questionnaire
Preference for specific colors: 
Improved visual response with movement:
Latency (delay in response to visual stimuli
Abnormal field of vision (eg: hemianopsia or island of visual response)
Difficulty with visual complexity:
Preference for looking at lights and non purposeful gaze
Difficulty with distance viewing
Atypical visual behavior (eg: frequently looking up or away while tracking, eccentric viewing)
Difficulty with visual novelty
Absent or clumsy visually guided motor responses
Adapted from: Roman-Lantzy, Christine; Cortical Visual Impairment: an approach to assessment and intervention; American Foundation for the Blind; New York, New York; 2007 M

12. Multidisciplinary team approach
Parents/family
Primary care physician
Occupational therapist
Pediatric ophthalmologist
Pediatric neurologist
Physical therapist
Speech therapist
Educational specialist
Feeding specialist
Teacher of visually impaired
Teacher of the hearing impaired

13. EXAM #1
History with CVI modified questionnaire and basic ophthalmologic exam
r/o structural eye abnormalities/confounding factors
Determine any necessary optical correction
Determine any necessary medical or surgical ophthalmologic treatment
Child with limited visual response who is learning to use vision

14. EXAM #2
History and Modified CVI Questionnaire and Exam #1
Additional aspects of exam
Accommodative amplitude/dynamic retinoscopy
Convergence amplitude/NPC
Visual attention/fixation/visually guided behavior
Latency
Saccades/pursuits
Directionality of line
Contrast Sensitivity
Child with higher visual function learning to use vision more effectively along with other functions of daily life

15. EXAM #3 History and Modified CVI Questionnaire and Exam #1 + Exam #2
Physical
Executive functions
Figure ground skills
Comparison of size and shape
Visual center
CVI characteristics improved or resolving with higher level visual function deficits (Cerebral?)

16. (History and Structure)
CVI Type 1
Exam
(History and Structure)
CVI Type 3 Exam
(Higher Level
Function)
CVI Type 2 Exam
(Function)
Low function High function
Phase Phase Phase 3

17. What my exam should include…
Obtain history focused on child’s visual behavior/characteristics
Validate parent’s observations
Learn patient’s expectations for their child
Perform complete ophthalmologic examination
Provide medical diagnosis and medical necessity
Refer for services for visually impaired
Make specific recommendations tailored to individual patient
Provide information to patient’s team
Provide educational materials/support group information
Provide opportunity for parent’s to ask questions

18. 12 month ex 23-week premature infant with tracheostomy, h/o retinopathy of prematurity who has been recently diagnosed with cerebral palsy.
Child’s mother is concerned that child looks past her, stares at lights and looks away when reaching for an object.

19. OPHTHALMOLOGIST REPORT: IMPRESSION: ROP RESOLVED; NORMAL EYE EXAM RECOMMENDATIONS: F/U 1 YEAR

20. Ophthalmologist’s Report Impression/Diagnosis
Cortical visual impairment
Severe visual impairment both eyes
Retinopathy of prematurity Stage 2 Zone II both eyes – resolved
Cerebral palsy
Premature infant
Hypermetropia both eyes not requiring correction

21. Ophthalmologist’s Report Recommendations
Treat underlying medical conditions.
No glasses are necessary
Recommendations:
Use high contrast and brightly colored visual materials.
Use additional cues (lights, sound, vibration and movement) to attract visual attention.
Avoid overstimulation.
Provide support for child’s body when performing visual tasks.
Avoid verbal distractions when child is performing visual tasks.
Perform visual tasks in non-distracting environment.
Refer for evaluation for services for vision.

22. Ophthalmologist’s Report Recommendations
Copy of diagnosis, medical necessity and recommendations sent to patient’s team
Educational material and support group information given to family
Family’s questions answered, they expressed understanding and agree with plan
Include contact information so other members of child’s team can share information.

23. PEDIATRIC OPHTHALMOLOGISTS: Would you like to learn more about CVI
PEDIATRIC OPHTHALMOLOGISTS: Would you like to learn more about CVI? GOOD NEWS! Reference: Lehman SS, Attitudes Concerning Cortical Visual Impairment Among Pediatric Ophthalmologists and Teachers of the Visually Impaired¿ presented at 2016 American Conference on Pediatric Cortical Visual Impairment, Omaha, Nebraska, July 8-9, 2016

24. Modalities to Assist Pediatric Ophthalmologists with CVI
Providing education and templates for:
History
Physical examination
Providing diagnosis
Referral for services
Making recommendations/interventions

25. TEMPLATES FOR RECOMMENDATIONS/INTERVENTIONS
Should not be cookie cutter.
Need to be specific to each child’s circumstances
Need to be incorporated into child’s activities of daily living
Need to include environmental modifications
Need to include developmentally appropriate recreation (play) for older children

26. TEMPLATES FOR CVI INTERVENTIONS/RECOMMENDATIONS FOR PEDIATRIC OPHTHALMOLOGISTS
Characteristic
Interventions for child with limited function (lower phase)
Interventions for child with better function (higher phase)
Preference for specific color
Exploit color preference in choice of visual objects of regard.
Use objects of preferred color for ADL.
Have teacher, instructor, or therapist wear preferred color in order to maintain interest and localization for following (e.g.: learning to drive motorized chair).

27. TEMPLATES FOR CVI INTERVENTIONS/RECOMMENDATIONS FOR PEDIATRIC OPHTHALMOLOGISTS
Characteristic
Interventions for child with limited function (lower phase)
Interventions for child with better function (higher phase)
Latency
Provide extra time for localization and following of visual stimuli.
Gradually work toward decreasing time needed for localization and following.
Provide extra time for completion for educational tasks.

28. Please email me at: slehman@nemours.org
I need your feedback about improving the pediatric ophthalmologist’s care of children with CVI
Please me at: