Ventral Stream

Cerebral Visual Impairment 

AZ AER Workshop 

April 8, 2011

Objec4ves 

• Defini9ons 

• Brain anatomy 101 

• Dorsal and ventral stream disorders 

• The CVI Range/Phases

Prevalence 

• Cor9cal visual impairment is the leading cause 

of visual impairment in children in developed 

countries (Hoyt, 2003).

Defini4ons

Cor4cal Visual Impairment 

• Historically used to primarily to describe poor 

visual acuity or visual fields due to damage of 

the brain. 

• Problem—cerebral cortex is rarely damaged 

on its own

Cogni4ve Visual Dysfunc4ons (CVD) 

• When primary visual deficit is not visual acuity 

loss, but visual percep9on and integra9on, 

some groups are calling it CVD 

• Many children have both CVI and CVD and 

the defini9ons for the two have not yet been 

clearly defined in the medical literature with 

some research groups using CVI as an 

umbrella term for CVI and CVD 

Good, W.V., Jan, J.E., Burden, S.K., Skoczenski, A., Candy, R. (2001). Recent advances in cor9cal visual impairment. Developmental 

Medicine & Child Neurology. 43, 56-‐60.

Cerebral Visual Impairment 

• Impaired vision due to damage to the brain. 

– Visual input and primary processing 

– Higher visual processing (Cogni9ve visual 

impairment)

CVI vs. DELAYED VISUAL 

MATURATION 

• DVM is characterized by visual unresponsiveness in 

early infancy which subsequently improves to 

normal levels. 

• These children may retain subtle mo9on or aben9on 

deficits. 

• Hoyt, D.C, Jastrzebski, G., Marg, E. (1983). Delayed visual matura9on in infancy. Bri9sh Journal of 

Ophthalmology. 67, 127-‐130. 

• Harris, C.M., Kriss, A., Shawkat, F., Taylor, D., Russell-‐Eggib, I., (1996). Delayed visual matura9on in infants: 

A disorder of figure-‐ground separa9on Brain Research Bulle9n. 40, 5/6, 365-‐369.

Why Does it MaLer 

• Medical professionals 

• Educators 

• Rehabilita9on professionals 

• Parents and family members

Brain Anatomy 101

The Brain and Vision 

• Over 40 percent of the brain is devoted to 

vision 

• Damage to different areas produces different 

effects 

From Dubon, G.N. (2003). Cogni9ve vision: Its disorders & differen9al diagnosis in adults & children. Knowing 

where & what things are. Eye, 17, 289-‐304

VISION INVOLVES MORE THAN 

THE EYES 

CEREBRUM 

4 LOBES WITH SPECIALIZED FUNCTIONS 

FROM SECRET LIFE OF THE BRAIN: PBS

LEFT HEMISPHERE 

FRONTAL LOBES: 

command center for decision making 

and executive tasks 


LEFT HEMISPHERE 

OCCIPITAL LOBES 

process vision 



PARIETAL LOBES 

analyze sensation 



TEMPORAL LOBES 

hearing, understanding speech, 

integrated sense of self 


Match that Lobe! 

• Occipital lobe 

• Parietal lobe 

• Temporal lobe 

• Frontal lobe 

• Discrimina9on and 

processing 

• Emo9ons and judgment 

• Vision 

• Hearing and speech

How Visual Informa4on is Processed 

• Reflect Visual Pathways: 

– SUBCONSCIOUS; PROTECTION 

• Higher level processing 

– Dorsal stream: WHERE PATHWAY 

– Ventral stream: WHAT PATHWAY

Reflex Visual Pathways 

Upper mid-‐brain (superior colliculi) and pulvinar 

Rains, G.D.(2001).Principles of Human Neuropsychology. New York: McGraw-Hill

REFLEX VISUAL PATHWAYS 

• Ability to perceive and react to moving targets 

at a subconscious level 

• Some children s9ll react to moving targets 

even though there is profound vision loss due 

to cerebral damage 

• Can see an object brought in from the side 

(blindsight) and can navigate without bumping 

into objects (travel vision) 

• Develops at around 4-‐5 years of age

HIGHER VISUAL FUNCTIONS 

What Happens to Informa4on that 

Reaches the Visual Cortex

Via Dorsal Stream information goes to the 

Posterior Parietal Lobes 

WHERE 

Dorsal 

Stream 

Ventral Stream 

WHAT 

From Dutton, G.N. (2003). Cognitive vision: Its disorders & differential diagnosis in adults & children. Knowing where & 

what things are. Eye, 17, 289-304.

POSTERIOR PARIETAL LOBES - WHERE 

Process whole visual scene and work with 

frontal lobes to give aLen4on to 

areas of interest and 

plan motor ac4on 

WHERE 

Dorsal 



WHAT 



Via Ventral Stream information goes to the 

Temporal Lobes 

WHERE 

Dorsal 



WHAT 



TEMPORAL LOBES - WHAT 

Facilitate recognition of what is being viewed 

WHERE 

Dorsal 



WHAT 



FRONTAL LOBES - Mediate choice 

MOTOR CORTEX -Receives input from the dorsal 

stream about where, how far, how to position body 

parts 

WHERE 

Dorsal 



WHAT 



Dorsal and Ventral Streams are linked 

WHERE 

Dorsal 



WHAT 



PERIVENTRICULAR LEUKOMALACIA 

Next to ventricle 

loss of white maLer 

• Periventricular leukomalacia (PVL), the most 

common cause of visual impairment due to 

brain damage (Dubon & Jacobson, 2001), is 

extremely common in small premature infants 

(Volpe, 2003). 

• PVL is seen in increasing frequency in 

premature children due to improved survival 

rates of very premature infant

VENTRICLES 

Fluid-‐filled cavi4es in the cerebral hemisphere,mid-‐brain, and behind the 

brainstem 

Neuroscience for kids - Ventricleshttp://faculty.washington.edu/chudler/vent.html 

AboutKidsHealth- http://www.aboutkidshealth.ca/clinicalAreas.asppageContent=BT-nh1-02

Periventricular Leukomalacia 

Next to ventricle loss of white maLer 

• Cap4on: Picture 7. Cranial MRI, T1-‐ 

weighted axial image, in an 18-‐ 

month-‐old with periventricular 

leukomalacia (PVL). The lateral 

ventricles are enlarged without 

hydrocephalus. The periventricular 

white maber is diminished. Courtesy 

Normal adult brain 

of Mabhew Omojola, MD. 

From emedicine http://www.emedicine.com/ped/topic1773.htm 

http://bissells.com/library/articles/pvl.htm

Dorsal Stream Disorders 

Dorsal Stream processes 

whole visual scene 

and works with frontal lobes to 

give aben9on to areas of 

interest and plan motor ac9on


• Incoming informa9on goes to: 

– Occipital cortex for processing 

– Dorsal stream sends the informa9on to posterior parietal 

visual cortex where whole scene is processed and a part of 

the scene is chosen 

– This informa9on goes to the frontal cortex which tells the 

head and eyes to look at the scene detail 

– The informa9on coordinates are also sent to the motor 

cortex which ini9ates movement to toward the scene 

detail and causes other motor adjustments to interact 

with the objects in the scene.


• Dorsal Stream processes whole visual scene 

and works with frontal lobes to give aben9on 

to areas of interest and plan motor ac9on 

• Damage can result in problems extrac9ng 

details from complex visual scenes 

– loca9ng objects on paberned background, 

– func9oning in busy environments, 

– reading small text


• Dorsal Stream processes whole visual scene 

and works with frontal lobes to give aben9on 

to areas of interest and plan motor ac9on 

• Damage can result in disordered visually 

guided movements (children with PVL) 

– Difficulty moving through space, differen9a9ng boundaries 

of floor surfaces, 

– Nego9a9ng curbs, stairs 

– Inaccurate reach and grasp 

– (Stereopsis may be intact)

Ventral Stream Disorders 

Ventral Stream facilitates 

recogni9on of WHAT is 

being viewed


• Ventral Stream facilitates recogni9on of 

WHAT is being viewed 

• Incoming informa9on goes to: 

– Occipital cortex for processing 

– Ventral stream sends the informa9on to temporal 

lobes which deal with visual recogni9on, 

orienta9on, and visual memory 

– If there is a match of informa9on, an object is 

recognized




• Damage can result in impaired 

– Recogni9on of faces, facial expressions 

(commonly via right ventral stream) 

– Ranges from not recognizing familiar people to 

not recognizing these people seen out of context 

– Incorrect iden9fica9on of strangers

A child may be or may not be able to match these cards of 

close friends, and may not recognize the faces if he or she can 

match them (Hyvarinen, 2003).




– Impaired recogni9on of objects (shape and form) 

– Difficulty with route finding-‐geqng lost 

– Difficulty with visual memory tasks such as 

copying and learning informa9on

CVI Characteris4cs 

Roman-‐Lantzy

Characteris4cs-‐ The Big 10… 

1. Strong color preference 

2. Need for movement to illicit visual response 

3. Visual latency 

4. Visual field preferences 

5. Difficul9es with visual complexity 

6. Light-‐gazing and non-‐purposeful gaze 

7. Difficulty with distance viewing 

8. Absent or atypical visual reflexes 

• Blink 

• Threat 

9. Difficulty with visual novelty 

10. Absence of visually guided reach

Which Array is more Complex

CVI Difficult to Iden4fy at Times 

• Visual acuity can be normal 

• Can have CVI without other manifesta9ons of 

brain damage 

• Such children are unaware of problem since 

they have not experienced anything else 

• Commonest associated clinical sign is a 

convergent or divergent eye turn 

• Difficult to iden9fy manifesta9ons of CVI in 

children who cannot communicate

Ranges 

• CVI Range 1-‐2: Student func9ons with minimal 

visual response 

• CVI Range 3-‐4: Student func9ons with more 

consistent visual response 

• CVI Range 5-‐6: Student uses vision for 

func9onal tasks 

Roman-‐Lantzy, C. (2007). Cor$cal visual impairment: An 

approach to assessment and interven$on. New York: AFB 

Press.

Ranges 

• CVI Range 7-‐8: Student demonstrates visual 

curiosity 

• CVI Range 9-‐10: Student spontaneously uses 

vision for most func9onal ac9vi9es

Phases for Program Planning and 

Interven4on 

• Phase I (Range 0-‐3): visual behavior building 

• Phase II (Range 4-‐7): Integra9ng vision with 

func9on 

• Phase III (Range 8-‐10): Resolu9on of 

remaining CVI characteris9cs

Collabora4ve Assessment 

• Jacobson and Dubon (2000) call for a 

mul9disciplinary assessment 

• ophthalmologists, optometrists, pediatric 

neurologists, neuroradiologists, psychologists, 

teachers. To this list we can add occupa9onal and 

physical therapists. 

• thorough knowledge of visual func9on, motor 

func9on, intellectual profile, and 

• knowledge of abili9es and disabili9es in verbal and 

performance to iden9fy most appropriate 

interven9on strategies.

Assessment 

Hyvarinen stresses the need for assessment in the 

following areas 

– Oculomotor func9ons 

– Quality of the image 

– Use of visual informa9on, percep9on 

– Visual memory func9ons 

– Comprehension 

• Hyvarinen, L. (2003).Lea Hyvarinen's lectures at San Francisco State 15. November 2003. hbp://www.lea-test.fi/

Structured History Taking 

• Seeking evidence of 

– Reduced acuity 

– Limita9ons in visual field 

– Dorsal and Ventral stream problems 

– Confirmed with neural imaging

Interven4ons for CVI 

Train to improve weak areas and 

provide compensatory methods that 

build on strong func$ons 

Hyvarinen (2003) 

Hyvarinen, L. (2003). Lea Hyvarinen's lectures at San Francisco State 15. November 2003. hbp://www.lea-‐test.fi/

Strategies Developed by Children 

COMPENSATORY STRATEGIES CAN BE EXHAUSTING 

• Coding and recognizing by color 

• Wayfinding by remembering a sequence of 

landmarks 

• Finding things on communica9on charts by 

memorizing the loca9on 

• Using other senses

Reading Solu4ons 

• Read print at most efficient size above threshold 

• Be certain that children have any accommoda9on 

problems corrected 

• If small eye movements (saccades) are affected, 

enlarge text and learn by whole word approach 

• If ventral stream pathology, problems iden9fying 

lebers/words need alterna9ve reading modes

Reading Solu4ons 

• If dorsal stream pathology, problems with impaired 

simultaneous percep9on leads to problems with 

crowding. 

– Acuity may be reduced for crowded as opposed to single 

lebers. Lower linear acuity at near. If single symbol or 

gra9ng acuity alone is tested, visual acuity can be 

overes9mated for some children. 

– To assist, mask off surrounding print: use typoscope or 

present words singly on a computer screen. 

• In some cases of alexia, braille or other non-‐visual 

reading media are recommended.

Recogni4on Solu4ons 

• Geqng Lost 

– Learning route by verbal cues related to 

landmarks 

– Using color coding in the home to label loca9ons 

things 

• Recognizing People/Objects 

– Use alterna9ve sensory channels -‐ voice of sound 

of footsteps 

– Recognize by touch

Main References 

Dubon, G.N. (2003).Cogni9ve vision, it’s disorders and 

differen9al diagnosis in adults and children: Knowing where 

and what things are, Eye. 17, 289-‐304. 

Dubon, G.N.& Jacobson, L.K. (2001). Cerebral visual impairment 

in children. Neonatology. 6, 477-‐485. 

Hyvarinen, L. (2003). Lea Hyvarinen's lectures at San Francisco 

State 15. November 2003. hbp://www.lea-‐test.fi/ 

Jacobson, L.K., & Dubon, G.N. (2000). Periventricular 

leukomalacia: An important cause of visual and ocular mo9lity 

dysfunc9on in children. Survey of Ophthalmology. 45(1), 1-‐13.

REFERENCES 

• Blind Babies Founda9on. (1998). Pediatric Diagnosis Fact Sheet: Cor9cal Visual Impairment. San 

Francsico: author. 

• Dubon, G.N. (2003). Cogni9ve vision, its disorders, and differen9al diagnosis in adults and 

children: knowing where and what things are. Eye, 17, 289-‐304. 

• Dubon, G.N., & Jacobson, L.K. (2001) Cerebral visual impairment in children. Seminars in 

Neonatology. 6, 47-‐485 

• Dubon, G.N., Saaed, S., Fahad, B., Fraser, R., McDaid, G., McDade, J., Mackintosh, A., Rane, T., 

Spowart, K. (2004). Associa9on of binocular lower visual field impairment, impaired 

simultaneous percep9on, disordered visually guided mo9on, and inaccurate saccades in 

children with cerebral visual dysfunc9on – a retrospec9ve observa9onal study. Eye, 18, 27-‐34. 

• Ek, U., Fellenius, K., Jacobson, L. (2003). Reading acquisi9on, cogni9ve and visual development, 

and self-‐esteem in four children with cerebral visual impairment. Journal of Visual Impairment 

& Blindness. 97 (12), 741-‐754. 

• Good, W.V., Jan, J.E., Burden, S.K., Skoczenski, A., Candy, R. (2001). Recent advances in cor9cal 

visual impairment. Developmental Medicine & Child Neurology. 43, 56-‐60. 

• Harris, C.M., Kriss, A., Shawkat, F., Taylor, D., Russell-‐Eggib, I., (1996). Delayed visual matura9on 

in infants: A disorder of figure-‐ground separa9on Brain Research Bulle9n. 40, 5/6, 365-‐369. 

• Hoyt, C.S. (2003). Visual func$on in the brain-‐damaged child. Eye 17, 369-‐384 

• Hoyt, D.C, Jastrzebski, G., Marg, E. (1983). Delayed visual matura9on in infancy. Bri9sh Journal 

of Ophthalmology. 67, 127-‐130.

• Hyvarinen, L. (2003). Lea Hyvarinen's lectures at San Francisco State 15. November 2003. 

hbp://www.lea-‐test.fi/ 

• Jacobson, L.K., Dubon, G.N. Periventricular Leukomalacia: An important cause of visual and 

ocular mo9lity dysfunc9on in children. (2000). Survey of Ophthalmology 45(1,) 1-‐13. 

• Jacobson, L., Ek, U., Fernell, E., Flodmark, O., & Broberger, U. (1996). Visual impairment in 

preterm children with periventricular leukomalacia – Visual, cogni9ve, and neuropaediatric 

characteris9cs related to cerebral imaging. Developmental Medicine and Child Neurology. 38, 

724-‐735. 

• Morse, M. T. (2004). Another view of cor9cal visual impairment: Issues related to facial 

recogni9on. (unpublished manuscript) 

• PBS (2001). Secret life of the brain. hbp://www.pbs.org/wnet/brain/ 

• Rains, G.D.(2001).Principles of Human Neuropsychology. New York: McGraw-‐Hill 

• S9ers, P. deCock, P., & Vandenbussche, E., (1999) Separa9ng visual percep9on and non-‐verbal 

intelligence in children with early brain injury. Brain and Development 21, 397-‐406. 

• Ungerleider, L.G., & Haxby, J.V., (1994). “What” and “where” in the human brain. Current 

Opinion in Neurobiology, 4, 157-‐165

Ventral Stream

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