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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 952-954

An interdisciplinary approach to the management of cerebral visual impairment: A case report


1 Institute for Vision Rehabilitation, Child Sight Institute, L V Prasad Eye Institute, Banjara Hills, Hyderabad, Telangana, India
2 Jasti V Ramanamma Children's Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, Banjara Hills, Hyderabad, Telangana, India
3 Biotechnology Industry Research Assistance Council, New Delhi, India

Date of Submission10-Mar-2022
Date of Acceptance05-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Navaneetha Ampolu
Jasti V Ramanamma Children's Eye Care Centre, Child Sight Institute, L V Prasad Eye Institute, Road No. 2, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_636_22

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  Abstract 


We herein present a case of a 14-month-old child presented in the pediatric ophthalmology clinic, who sustained a head injury and had unconsciousness and status epilepticus. The child was diagnosed to have cerebral visual impairment (CVI), hemiplegic cerebral palsy (CP), and global delay in developmental areas. After 167 center-based sessions and 120 home-based sessions of therapeutic intervention, a significant development in the child's functioning was noted and quantified using standard assessment tools like CVI range assessment and Developmental journal for babies and young children with visual Impairment (DJVI). At the age of 2.5 years, the CVI range assessment showed that the child from phase II has moved to phase III of visual development. On the DJVI scale, the child improved from performing 33% age-appropriate activities to 81% activities. This case is a clear example to show the importance of early intervention, an interdisciplinary team approach, and parental motivation and involvement in successful management.

Keywords: Cerebral visual impairment, CVI range assessment, development journal for babies and young children with visual impairment, interdisciplinary approach, rehabilitation-intervention


How to cite this article:
Mojjada M, Ampolu N, Potharaju P, Christy B. An interdisciplinary approach to the management of cerebral visual impairment: A case report. Indian J Ophthalmol Case Rep 2022;2:952-4

How to cite this URL:
Mojjada M, Ampolu N, Potharaju P, Christy B. An interdisciplinary approach to the management of cerebral visual impairment: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:952-4. Available from: https://www.ijoreports.in/text.asp?2022/2/4/952/358179



“Cerebral Visual Impairment (CVI) is a term that describes deficiency in the functions of vision due to damage or malfunction of visual pathways and visual centers of the brain, specifically behind the lateral geniculate body, including optic radiations, occipital cortex, and the visual associative areas.”[1] With the advancement of neonatal care and the rise in the survival rates of preterm and low birth weight infants, the incidence of CVI is increasing and is becoming the common cause of pediatric visual impairment even in developing countries. A study done in South India shows that CVI contributes to nearly 44% of pediatric visual impairment.[2] To date, the management of CVI through ocular or surgical correction is not yet very successful; however, owing to the plasticity of the brain there is a high scope for improving functioning in the critical period; through rehabilitation, if intervened in the early years of life.[3] This case report demonstrates the impact of such intervention provided through an interdisciplinary approach, and with parental involvement.


  Case Report Top


A 14-month-old child was presented to the pediatric ophthalmology clinic, by parents with a chief complaint of lack of eye contact following a head injury due to a fall from a 3 feet height cradle. The child had a history of normal development until the age of 11 months, before the fall. Following the fall, there was a history of loss of consciousness and status epilepticus, and the child was treated under incubation and ventilation for 10 days.

On examination, there was no dazzle or menace reflex present, no significant refractive error was noted, and the anterior segment was within normal limits. Fundus examination revealed partial optic atrophy in both eyes. Magnetic resonance imaging (MRI) brain was suggestive of cortical laminar necrosis. Based on the history and clinical findings, the child was diagnosed to have a CVI and hemiplegic cerebral palsy (CP) and was referred for rehabilitation care.

In an informal assessment by the interdisciplinary team, the child was observed to have a delay in developmental domains. In the follow-up visit, a detailed assessment was conducted to measure the impact of CVI on the development and functioning of the child. The CVI range assessment was conducted to measure the effect of the CVI on functioning and DJVI (Developmental journal for babies and young children with visual impairment) was used to assess the overall development of the child. Briefly, the CVI range is the validated assessment tool by Roman Lantzy that measures the range through Rating I and Rating II.[4] Based on this assessment, the child was categorized to be in phase II of visual functioning, which means that the child had only developed dorsal stream functions and was at the beginning of developing ventral stream functions [Table 1].
Table 1: CVI range assessment pre- and post-intervention showing that the child was in phase II pre-intervention and phase III post-intervention

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DJVI is a systematic framework for tracking the progress of a child from birth to 3 years of age in terms of vision and overall development.[5],[6] The child was found to have a severe developmental delay in the areas of communication, social and emotional development, and play and learning [Figure 1], performing only 33% of expected age-appropriate activities overall, including all the developmental areas.
Figure 1: Percentage of expected age-appropriate activities performed in each area of development pre-intervention (represented in dark grey) and post-intervention (represented in light grey)

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Based on this detailed assessment, an individualized intervention program with long-term and short-term goals was planned with the involvement of the mother, therapists, and other eye health professionals.

The child was trained on visual skills (fixating, scanning, tracking, shifting attention between objects, eye-hand coordination, motion perception), motor skills (alignment of body segments, strengthening lower trunk and limbs, coordination and balance exercises, fine motor skills), speech and language skills (oro-motor issues, babbling sounds and monosyllabic sounds, identification and expression of body parts, common objects, and few fruits), cognitive skills (understanding, memory, problem-solving and perceptual skills, concept development), and self-help skills (activities of daily living). During the therapy sessions, the child was noted to have a chin-down head posture, for which yoked prisms were prescribed. A total of 167 center-based sessions and 120 home-based sessions were provided in 18 months.

Post-intervention, at the age of 2 years 8 months, the CVI range assessment indicated progress; the child from phase II has now moved to phase III of visual development [Table 1] with resolving characteristics such as color preference, need for movement, field preference, absence of visually guided reach, light gazing behavior, and atypical visual reflexes. The characteristics such as difficulty with visual novelty, distance viewing, and visual complexity have slightly improved but require further training. A significant improvement was noted even on the DJVI scale in areas of social, emotional, and communication skills, mobility, and playing, and mild improvement in independent self-care [Figure 1]. Overall, the child has improved to performing 81% of expected age-appropriate activities in all the developmental areas.


  Discussion Top


CVI is a major cause of pediatric visual impairment.[2] It is almost always associated with additional disabilities and affects different areas of development (vision, speech and language, motor, cognition) which are interdependent.[7] Hence, alongside the pediatric ophthalmology examination, the involvement of an interdisciplinary team and parents, in assessment and intervention planning, becomes crucial. Tools like CVI range assessment and DJVI aid in both program planning and outcome measurement.

Hence, it is important to practice an interdisciplinary team approach in case management involving eye health professionals, rehabilitation, and most importantly parents.[8]

Fortunately, holistic care was possible for this child, which made all the difference, however, not all children get such opportunities. The challenges include lack of early identification and referral, lack of trained professionals and training centers, ignorance and poor compliance of the parents to the intervention, socio-economic factors such as illiteracy, financial constraints, etc.

With medical advancement, the survival of high-risk newborn is increasing. Therefore, promoting awareness of the importance of early intervention among parents, and practitioners is crucial to reducing their lifetime disability-related burden.


  Conclusion Top


The improvement in developmental areas of a child with CVI is clear evidence of the importance of early intervention. Early identification and intervention are the keys to the interdisciplinary team approach based on the interpretations of results from standard assessments and timely intervention becomes crucial for addressing CVI.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lueck AH, Dutton G. Vision and the Brain: Understanding Cerebral Visual Impairment in Children. American Foundation for the Blind Arlington, VA, AFB Press; 2015.  Back to cited text no. 1
    
2.
Pehere NK, Narasaiah A, Dutton GN. Cerebral visual impairment is a major cause of profound visual impairment in children aged less than 3 years: A study from tertiary eye care center in South India. Indian J Ophthalmol 2019;67:1544-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Cisneros-Franco JM, Voss P, Thomas ME, de Villers-Sidani E. Critical Periods of Brain Development. Handbook of Clinical Neurology. Vol 173. Elsevier; 2020. p. 75-88.  Back to cited text no. 3
    
4.
Newcomb S. The reliability of the CVI Range: A functional vision assessment for children with cortical visual impairment. J Vis Impair Blind 2010;104:637-47.  Back to cited text no. 4
    
5.
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. 5
    
6.
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
    
7.
Pehere N, Chougule P, Dutton GN. Cerebral visual impairment in children: Causes and associated ophthalmological problems. Indian J Ophthalmol 2018;66:812-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Salleh NM, Zainal K. Instructional model for social skills intervention children with visual impairment. J Creat Educ 2018;9:2325-33.  Back to cited text no. 8
    


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