At first glance, these patients can appear to have normal or near-normal visual acuity levels. However, in reality, many have perceptual visual deficits, which are not typically tested during a standard ophthalmology office evaluation.
Image Reviewed by Lotfi B. Merabet, OD, PhD
Cerebral visual impairment (CVI), the most common cause of visual impairment in pediatric patients in developed countries,1 is brain-based visual disorders that damage or cause maldevelopment of the retrochiasmal visual processing areas in patients without a major ocular disease. At first glance, these patients can appear to have normal or near-normal visual acuity levels. However, in reality, many have perceptual visual deficits, which are not typically tested during a standard ophthalmology office evaluation.
Lotfi Merabet, OD, PhD, from the Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School in Boston, explained that anecdotal evidence provided a strong clue that children with CVI can have difficulties identifying objects that are presented as abstractions or cartoons. These are “representations of images that depart from naturalistic forms and shapes [and] lack key associative information provided by color. In contrast, individuals with CVI are more likely to correctly identify these same objects when presented as colored photographs,” Merabet said.
Merabet described a recent study2 conducted in collaboration with local teachers of the visually impaired; investigators from the Department of Psychology in the Translational Vision Lab at Northeastern University in Boston, Massachusetts; and investigators from the Unit of Child Neurology and Psychiatry at Azienda Socio Sanitaria Territoriale Spedali Civili of Brescia in Italy. This team’s members have done pioneering work to unravel the intricacies of CVI in children in the United States (US) and Italy. The 2 countries employ different approaches investigating CVI, and the collaboration combines the strong points of both continents, according to Merabet.
The Europeans’ work is based on the medical model of CVI; children born with a brain injury are evaluated and diagnosed early at the hospital, followed through the national health care system, and remain under focus within that system. Conversely, in the US, visual concerns in a child with CVI are often first noticed by parents and teachers of the visually impaired. Many children with CVI can fall through the cracks because universal diagnostic criteria are lacking
In the United Kingdom, the NHS has taken things a step further, focusing on identifying and caring for at-risk mothers whose children may develop this neurodevelopmental disorder, effectively trying to cut the disease off at the knees. The US system is more reactionary: Once CVI is identified, resources are then focused on affected patients, which helps explain the socioeconomic bias of health care in the US. “Because investigations into CVI are in the early phases, the collaboration across the Atlantic is crucial,” Merabet said.
Matthew Tietjen, MEd, CTVI, a study coauthor and teacher of the visually impaired, noticed a difference in how children with CVI perceived images in classroom materials. Many of the illustrations were abstractions and cartoons. He noticed that the children would often misname the objects.
“This is interesting from a scientific standpoint because of the need to understand why this happens, as well as having important educational repercussions. In many cases, children with CVI have to work harder than typically sighted children to get through school material,” Merabet said.
In one anecdote, Tietjen showed a child a picture of a cartoon elephant in frontal view. The child identified the elephant as a Sony PlayStation remote control, presumably mistaking the ears of the elephant for the handles of the remote control and the dark joysticks for the elephant’s eyes.
“As the pictures get further and further from ‘reality,’ it is harder for children with CVI to understand what they are looking at. It has a lot to do with how information is taken into the brain, analyzed, processed, stored, and assigned meaning. The more abstract an image, the more tenuous the object identification,” Merabet said.
Tietjen’s observation resulted in his developing a more systematic standardized approach to test his observation, with the goal of identifying the drivers of the identifications expressed by the children that cause the misidentifications. Based on an object-naming assessment developed by Tietjen, he and Merabet put together a series of images matched for size, perspective, complexity, and familiarity, called the 2-Dimensional Image Study.2
The investigators chose 12 images of common animate and inanimate objects, each represented from 5 possible image categories. An example taken from the article is the 5 categories of a cat (ie, a color photo, a realistic color drawing, a black-and-white realistic outline drawing, a color abstract drawing, and a black-and-white abstract outline drawing). These representations would disentangle color from form cues and use the color photo as the benchmark for identification.
The representations of the 12 objects in the 5 categories were shown to children on a computer, who pressed the space bar when they named the objects. The investigators used an eye tracker to record where the children were looking at from the moment the image appeared to when they identified (or misidentified) an object. Eye tracking was used to quantify gaze behavior, such as the extent of the visual search area explored and the number of fixations made.
The children in the US (n = 50) and Italy (n = 50) who participated in the study were not statistically different in terms of age, sex, and disease manifestations. However, Merabet suspects that the children recruited from the US tended to be from a higher socioeconomic bracket than those from Europe, where the health care system tends to be more accessible.
Manley et al2 reported that compared with controls, those with CVI “showed significantly lower success rates and longer reaction times when identifying objects. In the CVI group, the success rate improved moving from abstract black-and-white images to color photographs, suggesting that object form [as defined by outlines and contours] and color are important cues for correct identification.”
Furthermore, the results obtained using eye tracking with the controls and patients in the study were markedly different. The controls exhibited tighter gaze patterns (ie, one fixation to the body and one to the head of the object). In patients with CVI, the area of the gaze pattern is larger and with a greater number of fixations, indicating that the children seem to explore a much larger area (Figure), particularly if the object was misidentified.
“Finally, the distribution of the eye gaze patterns in the CVI group was less aligned with the high saliency features of the image compared [with] controls,” he said. He noted the importance of having benchmarks to know which features in the images are important for the patients to correctly identify the pictures. The investigators used Graph-Based Visual Saliency (GBVS), a mathematical analysis that looks at an image and identifies the features in the image that can be considered the most salient from a “bottom-up” standpoint, such as color, luminance, and edges.
The investigators used the information (the predictive ability) provided by GBVS and combined it mathematically with the individual patient’s gaze pattern, yielding a mathematical comparison between a standard and a response that informs the investigators about how well the 2 agree. The results have implications for understanding the complex profile of visual perceptual difficulties of CVI. “The takeaway is that the patients with CVI fared worse than controls on all 5 outcomes,” he said.
Data analysis showed that the controls scored 100% on image identification. The children with CVI scored worse than controls on all outcomes. “As they moved from abstract to outline to color photo, they improved slightly and identified the images faster, the receiver operating curve trended upward, and the number of fixations decreased,” he said. The visual search area did not have a clear pattern as a function of the type of image. However, the patients with CVI searched a much larger area and when they erred in their identification of an image, they took more time to do so.
The exercises underscored the importance of listening to the observations of the community, such as teachers and parents who have insight into the visual difficulties of children. The experience showed that leveraging the international collaboration provided a larger sample size of patients, allowing more statistically robust findings. With larger study populations, there is also the potential to explore questions regarding differences in factors such as geographic location, disease manifestations, age, race, and socioeconomic differences.
The implications impact the choice of educational materials used in classrooms. Abstractions and outlines may represent a greater cognitive burden and lost learning time for those with CVI. “For these children to thrive, we must design a world for them that considers their visual needs,” Merabet said.
A pragmatic approach to address CVI is to simplify the visual world for these children by using images with high relevance, which is close to the real world, and minimizing clutter. It is important to give them more time to process images and check on them to see whether they are identifying things properly. “There are nuances in terms of education that are extremely important. The most important takeaway is that you cannot take for granted that they are following a lesson and understand the content just because their peers are following,” Merabet said.
He advised that research in CVI should move forward as a community endeavor and strive to answer questions that can have an impact on the lives of these individuals. Without this effort and collaboration, he believes his team would not have achieved the level of research that they did.
The investigators are currently working on a study in which patients with CVI are presented with a real-world image of a lamp and then instructed to find it in a picture of a room. In a second version of the task, a text cue is used—the word lamp—and the participant must read it and find the object in a picture of a room. This analysis is ongoing, but early results suggest that the success rate in CVI is lower and the reaction time is longer to carry out this task. However, one interesting finding was that using a text cue slowed the patients even more compared with a visual cue.3
He pointed out that for children with CVI, their verbal IQ score, which provides an index of an individual’s overall verbal intellectual abilities, related to performance. The higher the verbal IQ, the greater the success rate and lower reaction time in identifying objects. Thus, developmental outcomes, such as verbal IQ may be important indices of how an individual perceives and interacts with complex visual surroundings.
The goal is to understand how individuals with CVI interact with their visual world and improve accessibility to educational materials for all, regardless of visual abilities.•
Lotfi B. Merabet, OD, PhD,
Merabet is from the Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School in Boston. He is on the Board of Directors of Perkins School for the Blind in Watertown, Massachusetts. He has no financial interest in the subject matter.