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Running Head: CORTICAL VISUAL IMPAIRMENT
Cortical Visual Impairment:
A Case Study
Sixto Del Angel
Stephen F. Austin State University
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The following case study is adapted from a Full Individual and Initial Evaluation, a Functional
Vision Evaluation, and a Learning Media Assessment performed and compiled by special
education professionals in the Spring Branch Independent School District, Houston, Texas.
Date of Evaluation: 04/16/09
Benjamin is a 2 year, 11 month old boy who was referred for a functional vision evaluation as
part of full individual and initial evaluation by the School District. An ophthalmologist’s report
indicates that Benjamin has a severe visual impairment.
By parent, ECI and medical reports, Benjamin’s medical history is significant. He had a stroke
in utero and has had multiple complications, with his left side more affected than his right side.
Benjamin has documented microcephaly, chromosome 11-13 translocation, Dandy Walker,
micrognathia, a g-tube, tracheostomy, insufficient gag and swallow reflex, brandycardia, optic
nerve dysplasia, cortical blindness, bilateral hip dysplasia, allergies, and sleep apnea.
Benjamin stayed in the neonatal care unit for two months after birth and has been hospitalized
several times for respiratory infections and MRSA infections. He has also had repeated ear
infections. Surgeries have included a fundoplasty, bronchoscopy, salivary duct ligation, and
bilateral PE (Pressure Equalization) tube placement. When he was younger, he experienced
numerous 5-30 second focal seizures and had one seizure that lasted 1.5 hours and required
Benjamin is nonambulatory and is dependent on adults for positioning, mobility, and activities of
daily living. He has home nursing care and receives private occupational and physical therapies.
He receives oxygen as needed and a ventilator during sleep. He is fed every four hours (five
times daily) through his g-tube, and small amounts of baby food are placed in his mouth with a
cotton swab for taste. He requires frequent suctioning (2-10 per hour while awake) for his upper
airway obstruction and has the use of a Passy-Muir valve. He is scheduled to receive a repeated
ABR (Auditory Brainstem Response) test to determine the need for hearing aids. Assistive
technology includes a Kid Cart wheelchair, Tumble Form seat, and splints for his hands, elbows
and feet. He has just begun using a stander and is beginning to roll as well. He can restart an
activity by hitting a switch.
According to an eye report dated February 5, 2007 from Dr. John Smith, Benjamin is a child
with mild optic nerve dysplasia and a cortical visual impairment. A VER (Visual Evoked
Response) test was performed, with the results indicating that the optic nerve is transmitting a
signal. His visual acuity appears to be worse than 20/100 in both eyes. Benjamin does not wear
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Description of Evaluation Setting and Student:
The functional vision evaluation took place in a classroom at School. There was fluorescent
light overhead. Benjamin was observed in prone and supine positions on the floor, and in
supporting sitting in the nurse’s lap and in the evaluator’s lap.
Observation of Visual Functioning:
Papillary response: Directing a penlight into his eyes from approximately 6 to 12 feet away,
Benjamin’s left pupil constricted very slightly when the light was presented. The right pupil
appeared to be dilated most of the time.
Blink reflex: Benjamin did not blink in response to the visual stimulus of a hand moving toward
Focus: Benjamin appeared to briefly focus on some faces and brightly colored toys.
Tracking: Using a flashlight, a small blue light, and an 8-inch red ball, Benjamin was not
Convergence: Benjamin was not able to use both eyes together to focus on an object at close
Muscle Imbalance: A muscle imbalance was observed when a light was reflected in Benjamin’s
eyes from a distance of 12 inches.
Field Loss: When presented with a light and an 8-inch red ball from behind, Benjamin did not
respond to the items being presented.
Eye Preference: Benjamin did not appear to exhibit an eye preference. Some days he keeps his
head to the right, and other days to the left.
Eye-Hand Coordination: Benjamin inconsistently reached for small rattles, musical toys, and a
small vibrating animal. He would very briefly hold objects placed in his hands. He appeared to
have difficulty with tasks involving eye-hand coordination. When Benjamin came in contact
with a toy or object, he attempted to interact with it, but did not usually search out items
independently. When given choices between two different kinds of balls held at eye level,
Benjamin moved his hand to try to reach a ball, usually using the right hand. He appeared to
cross midline one time in an attempt to bat an object.
Shifting Visual Attention: When a light and a ball were presented, Benjamin was not able to
demonstrate a shift of gaze from one object to another. When noise or voices were also paired
with the objects, there was some inconsistent shifting of gaze.
Near Vision: A variety of brightly colored toys and objects were presented to Benjamin at
distances ranging from 3 to 18 inches. These objects included balls, penlights, baby rattles,
small musical toys, etc. He appeared to focus on the musical toy when the music was playing.
He also appeared to briefly focus on faces and toys, although this was inconsistent. Benjamin
will grab the evaluator’s finger, and allowed her to move his hands to explore objects. He
appeared to enjoy exploring a jungle animal toy.
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Distance Vision: Benjamin did not appear to be aware of people moving about the room from a
distance of 8 feet. If there was sound involved, the evaluator felt that sometimes he was
responding to the noise. On previous home visits, Benjamin appeared to respond to the sunlight
coming through the windows by a slight turn to the windows.
Motor Skills: Benjamin in unable to move about the room independently. He requires
positioning devices for sitting and keeping his head in midline. He does not independently grab
on to and hold objects.
Resonance activities may prove beneficial in helping Benjamin understand that his actions
generate reproducible effects (cause and effect). In these interactions, the adult engages his
attention through movements with the child. Use familiar movements since they are less
intrusive (Row, Row, Row Your Boat; Patty Cake, Patty Cake, etc.) The adult does something,
waits for the child’s reaction, and then responds to that action.
Encourage Benjamin by using tactile and verbal prompts when learning body parts. Encourage
him to visually look at the stimulated body part. Rub different textures on his body to make him
become more aware of himself. Place stickers or tape on his face and arms and encourage him to
attempt to get them off.
Continue to use an object to cue Benjamin to a change in activity. Present the same object for
the same activity (washcloth for bath, tube for feeding, etc.) Use the object during the activity.
Each time an object is presented, look for any meaningful interaction that may indicate that he
anticipated the forthcoming activity.
Use switch toys that utilize vibration, music, and lights.
Attempt to move objects and encourage Benjamin to look at them. Work on trying to establish
some brief tracking.
Continue to highlight objects with the penlight to encourage Benjamin to look at the objects for
extended periods of time.
Eligibility Criteria for Visual Impairment:
The results of the ophthalmologist’s examination indicate that Benjamin has a visual loss after
best correction. The results of the functional vision evaluation, performed by a certified teacher
of the visually impaired, confirm that his visual impairment affects his ability to benefit from his
educational program. Therefore, Benjamin qualifies for the educational designation of visually
impaired. He will be registered with the Texas Education Agency as a visually impaired student.