CVI for Occupational Therapists (OTs)

Written by: Nikoletta Livingston, OT, OTD, OTR, CCVI

What is CVI?

Cerebral/cortical visual impairment (CVI) is a brain-based visual impairment caused by damage or interruption to the visual processing areas of the brain. With CVI, the brain has difficulty recognizing and making sense of the visual world. CVI impacts every aspect of life. The CVI visual behaviors are a framework for understanding the impact of CVI on access and is rooted in current CVI research.

CVI is the leading cause of childhood blindness and low vision, but it is alarmingly underdiagnosed. Less than 20% of kids in the US have a CVI diagnosis. CVI often co-occurs with neurological, neurodevelopmental, or genetic conditions. Those with healthy eyes and without other conditions can still have CVI.

How might CVI impact occupational therapy evaluation & intervention?

CVI can significantly impact students across all domains in the occupational therapy (OT) scope of practice, from effectively evaluating visual function and perception on occupational performance to implementing specific strategies, skill development, and modifications. Given that assessment of visual perception and processing is such a significant part of occupational therapy evaluation, particularly in a school-based setting, it is critical that occupational therapy practitioners (OTPs) screen for and recognize when CVI may be present (see below). Specifically in students, this may include:

Activities of Daily Living: bathing, showering, toileting, personal hygiene, feeding, and functional mobility
Instrumental Activities of Daily Living: home and personal management skills, community access, and maintaining safety
Health Management: managing medication, nutrition, and assistive devices, maintaining healthy sleep patterns, managing pain effectively, and emotional wellbeing
Education: managing printed work, manipulatives, assistive technology, classrooms environments and school hallways, handwriting/typing, social dynamics, self regulation and behavior management, as well as vocational skill development
Play, Leisure, and Social Participation: exploring opportunities, community engagement, meaningful relationships, and maintaining sensory regulation

When might you suspect a student has CVI within your work as an occupational therapy practitioner?

While numerous factors addressed by occupational therapy may also be present with CVI, it is important to note specific key indicators. These may include:

History of hypoxic or anoxic events, very low birth weight, neurological visits, or diagnoses that are common causes of CVI (HIE, PVL, CP, seizure or genetic disorders)

Challenges with visual attention and recognition
Varying visual preferences and inconsistent visual responses
Challenges with visual tracking, vergence, and saccades
Challenges with visual spatial function, visual motor integration, and figure ground differentiation
Heavy reliance on compensatory strategies (color coding, predictability, using tactile or auditory cues first)

Learn more about when to suspect CVI.

What strategies might be helpful to use in the OT setting with students with CVI?

Students with CVI are highly unique, and what works for one person may be extremely challenging for another person. Intervention, as always, should be driven by individual evaluation. Since the function of OT is to consider all the demands for access, and generalization across settings, it is critically important that OTPs evaluate any strategies used in various contexts, to determine how fatigue, lighting, sensory regulation, visual access, and other variables impact the individual’s ability to effectively implement the tool or strategy. Be prepared to adapt; what works in one context may not work in another.

Instructional adaptations

Simplify. For example, present one item at time against a clutter free background; determine what two dimensional access the individual has and modify materials appropriately.
Explore color and contrast. For example, dark text on a light background or light text on dark background; certain colored 3D items against a dark background
Pace and proactive breaks. Organize challenges based on fatigue, tolerance, and environment; pace appropriately, offer breaks, and sensory supports, and provide multi-sensory instruction
Use routines, familiarity, and predictability.
Supportive and accessible positioning. Consider seating and positioning, postural stability and head control, and height and angle of materials (i.e. slant boards).

Environmental adaptations

Simplify. Calm, quiet environments with little visual clutter, predictable and organized
Controllable lighting. Dim or increase brightness as needed, remove overhead lights and use indirect lighting, use task lighting, or draw shades.
Incorporate assistive technology and adaptive equipment. For example, noise canceling tools, auditory and tactile materials, braille (if appropriate)

Remember: this is not the time to work on habituation or desensitization to stimuli. Individuals with CVI CANNOT effectively learn when their visual system is being overpowered.

Zeke, a tall teenager who wears glasses, stands at a table to assemble a pizza on a bagel.

Collaboration ideas

Collaboration is key to the success of occupational therapy intervention!

Share videos of the student being successful and a comparison of them attempting the task without appropriate support.
Push in support and open communication; share tools and resources, tips and tricks.
Collaborative, arena style assessment to minimize stress on student and maximize outcomes.
Co-treat with other disciplines (OT and TVI are an incredible pair).
Keep the student at the center and follow their lead.-The student (and their family) know what works best for them.

Explore more resources on CVI and OT

Note to readers: This article is meant as an overview and brief introduction to CVI, a deep and complex condition with diverse manifestions. It is important to remember that all children with CVI have different needs. The recommendations and suggestions are ideas for a starting point. There is not one size fits all approach for CVI, and interventions and strategies must be match to the student’s individualized needs and comprehensive assessment results.

Explore CVI overviews for various disciplines in our CVI Educator Toolbox.

Nikoletta Livingston, OT, OTD, OTR, CCVI

Nikoletta is a supervising practitioner at Perkins School for the Blind, in the Secondary program, supporting staff working with students ages 14-22 with visual impairments and multiple disabilities. Nikoletta completed her occupational therapy program at Boston University, where she focused her doctoral work on CVI, as well as completed the University of Massachusetts Boston CVI Certificate program. She hopes to contribute towards the development of collaborative practices and understanding between the clinical and educational worlds, working to effectively and comprehensively support individuals with CVI.