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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 525-527

An integrated early intervention approach for children with cerebral visual impairment - A case report

1 Graduate Research Scholar, Elite School of Optometry Affiliated to SASTRA Deemed to be University, Thanjavur and Sankara Nethralaya, Unit of Medical Research Foundation, Chennai, Tamil Nadu, India
2 Head of the Department-Vision Enhancement Clinic (VEC), Sankara Nethralaya, Unit of Medical Research Foundation, Chennai, Tamil Nadu, India
3 Head of the Department- Binocular vision and Vision Therapy Clinic, Sankara Nethralaya, Unit of Medical Research Foundation, Chennai, Tamil Nadu, India
4 Senior pediatric ophthalmologist- Sankara Nethralaya, Unit of Medical Research Foundation, Chennai, Tamil Nadu, India

Date of Submission14-Jul-2021
Date of Acceptance28-Dec-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Jannet Philip
Special Children Vision Clinic, Sankara Nethralaya, Unit of Medical Research Foundation, 18, College Road, Nungambakkam, Chennai - 600006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1860_21

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A 2-year-old child with cerebral visual impairment (CVI) was brought by the mother to the pediatric ophthalmology clinic. She underwent a detailed functional vision and developmental assessment that revealed impairments in visual developmental skills, sensory, motor, and social skills. She was admitted into an integrated, parent-centered, structured early intervention program specifically designed for her for 3-months after which there were improvements noticed in visual developmental skills such as visual fixation, attention, and tracking; sensory skills such as tactile, olfactory, and gustatory; motor skills, including neck control and fine motor grasping; and age-appropriate social and communication skills. Through this case report, we aim to bring out the benefits of an evidence-based systematic early intervention approach in a child with CVI.

Keywords: Cerebral visual impairment, early intervention, functional vision assessment, parent-centered practice

How to cite this article:
Philip J, Sethuraman SR, Hussaindeen JR, Swaminathan M. An integrated early intervention approach for children with cerebral visual impairment - A case report. Indian J Ophthalmol Case Rep 2022;2:525-7

How to cite this URL:
Philip J, Sethuraman SR, Hussaindeen JR, Swaminathan M. An integrated early intervention approach for children with cerebral visual impairment - A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 May 27];2:525-7. Available from: https://www.ijoreports.in/text.asp?2022/2/2/525/342905

Cerebral visual impairment (CVI) is increasing in prevalence in developing countries,[1] necessitating early diagnosis and habilitation in an integrated approach to promote the wellbeing of the child and the family. In India, the gap in the current evidence includes a lack of standardized evidence-based early intervention approaches. This case report of a child with CVI who was provided early intervention in a customized manner depicts the planning, execution, and its benefits.

  Case Report Top

Patient information

A 2-year-old female was brought to the pediatric ophthalmology clinic by the mother with visual concerns noticed since birth. The child was born full-term by vacuum delivery with a birth weight of 2.8 kg. After 10 days from birth, the absence of body movements and cry were observed by the parents. She was admitted to the neonatal intensive care unit for the same and was diagnosed to have seizure disorder for which she was under medication for a few months after birth. She was diagnosed to have neonatal encephalopathy and microcephaly leading to global developmental delay by the neurologist. Her magnetic resonance imaging report showed extensive laminar cortical necrosis in the bilateral cerebral hemispheres and brainstem, and cephalohematoma in the left parietal convexity.

Baseline visual function and functional vision assessment

Comprehensive eye examination revealed insignificant refractive error, normal ocular alignment, and anterior and posterior segment evaluation. The functional vision assessment (FVA) carried out by a pediatric optometrist was based on the literature established by Hyvärinen et al.[2] and Swaminathan et al.[3] [Table 1]. FVA explains the use of visual functions in performing daily activities.
Table 1: Overview of the functional vision assessments of the child

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Early intervention

The study was approved by the Institutional Review Board of Medical Research Foundation, Chennai, and adhered to the declaration of Helsinki. An informed consent form was obtained from the mother before the intervention phase. The goals of early intervention were to help the child to learn to use her vision and achieve a holistic improvement.

Individualized program planning (IPP)

After assessing the other developmental areas of the child, the vision rehabilitation and early intervention specialist conducted 3 months (34 sessions, 1 hour each) of in-office habilitation followed by daily home-based habilitation, which was managed by the mother trained by the rehabilitation professional. The child underwent neuro-developmental and occupational therapy twice a week. She was also referred to a pediatric neurologist. The habilitation was based on the concepts proposed by Pletcher and Younggren.[4],[5] The sequence of the therapy is illustrated in [Figure 1].
Figure 1: The step-wise sequence of the early intervention approach

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Program implementation

Along with the existing protocol in place, the early intervention approaches [Figure 2] were adapted and modified from the early support developmental journal by Dale et al.;[6] they were (i) visual developmental therapy, which included training visual: tracking, attention, robustness, and fixation; (ii) sensory integration therapy, including stimulation and integration of all senses; (iii) movement and mobility, including gross and fine motor training; (iv) development of age-appropriate social, communication, and language skills; and (v) independent self-care. After the completion of each session, the (i) skills trained (ii) activities performed, and (iii) specific observations were documented. The rooms that were used were kept clutter-free and noise-free.
Figure 2: The early-intervention framework adapted in the case

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Outcomes and follow-up

After the habilitation period, improvements were noticed in the overall development of the child [Table 2].
Table 2: Changes in the developmental areas of the child after 3 months of early intervention

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Due to the COVID-19 pandemic regulations and for safety precautions, an in-person follow-up was restricted; instead, a telephonic interview was opted to understand the child's progress. Currently, the child is continuing home-based habilitation and will be starting the next phase of visual skills training. She is in constant care of the neurologist, shows resolved seizures, and is on telephonic follow-up with the rehabilitation specialists and the team. The next step in intervention would be visual skills training, which would include visuomotor integration, visual perceptual skills, and concept development for preschool preparation.

  Discussion Top

The visual cortex is highly plastic to the experiences during post-natal development, and it is important to utilize this sensitive time to intervene in CVI,[7] which has been done in this case. The early intervention approach adopted in this case was based on two well-established studies: (1) the five foundational concepts proposed by Pletcher and Younggren which includes family-centered practice, natural environment, child and adult learning, and quality team practice;[4],[5] and (2) the structured, five-themed developmental framework described by Dale et al.[6] in their paper. We strongly believe that basing our approach on prior evidence by following a systematic, parent-centered protocol involving integrated team practice customized to the needs of the family was the contributing factor to the improvements noticed in the child, and we recommend experts to follow such an approach while intervening children with CVI.

Though we noticed functional improvements in the child, there is a possibility of natural development to have contributed to this, and with a lesser follow-up duration and absence of control, these outcomes cannot be based entirely on the intervention provided. To combat this limitation, we recommend a longitudinal study with a control group and a large sample size. Despite the availability of literature involving early intervention globally,[6],[8],[9],[10] there is paucity in evidence-based approaches to early intervention in India.

  Conclusion Top

Considering the importance of habilitation in CVI, this case report serves as a good starting point, depicting the planning and execution of early intervention thereby creating awareness among CVI experts in India to explore this area for more promising studies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pehere NK, Narasaiah A, Dutton G. Cerebral visual impairment is a major cause of profound visual impairment in children aged less than 3 years. Indian J Ophthalmol 2019;67:1544-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
Hyvärinen L, Jacob N. What and How Does this Child See: Assessment of Visual Functioning for Development and Learning. Finland: Vistest Ltd.; 2011.  Back to cited text no. 2
Swaminathan M, Jayaraman D, Jacob N. Visual function assessment, ocular examination, and intervention in children with developmental delay A systematic approach. Part 1. Indian J Ophthalmol 2019;67:196-203.  Back to cited text no. 3
[PUBMED]  [Full text]  
Pletcher LC, Younggren NO. The Early Intervention: Essential Practices For Quality Services. Baltimore, MD: Brookes; 2013.  Back to cited text no. 4
Ely MS, Ostrosky MM. Applying the foundational concepts from early intervention to services provided to young children with visual impairments: A literature review. J Vis Impair Blind 2018;112:225-38.  Back to cited text no. 5
Dale N, Salt A. Early support developmental journal for children with visual impairment: The case for a new developmental framework for early intervention. Child Care Health Dev 2007;33:684-90.  Back to cited text no. 6
Fazzi E, Signorini SG, Bova SM, Ondei P, Bianchi PE. Early intervention in visually impaired children. Int Cong Ser 2005;1282:117-21.  Back to cited text no. 7
Parents and Their Infants with Visual Impairments (PAIVI). 2nd ed. Kit. Available from: https://www.aph.org/product/parents-and-their-infants-with-visual-impairments-paivi-2nd-edition-kit/. [Last accessed on 2021 Jun 10].  Back to cited text no. 8
Petersen B, Nielsen J. Vision Program: Vision Skills in the Natural Environment: An Intervention Guide for use with Children Birth to Three with Blindness or Vision Impairment. Ogden, UT: Utah Schools for the Deaf and the Blind; 2006.  Back to cited text no. 9
Dale NJ, Sakkalou E, O'Reilly MA, Springall C, Sakki H, Glew S, et al. Home-based early intervention in infants and young children with visual impairment using the Developmental Journal: Longitudinal cohort study. Dev Med Child Neurol 2019;61:697-709.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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