Visuoperceptual profiles of children using the Flemish cerebral visual impairment questionnaire

Developmental coordination disorder and cerebral visual impairment: What is the association?

INTRODUCTION

Children with Developmental Coordination Disorder (DCD) experience impairments beyond motor planning, affecting visual perceptual and visual-motor integration abilities, similar to children with Cerebral Visual Impairment (CVI), making it challenging to distinguish between the two conditions. This study aimed to identify convergences and divergences in the clinical, neuropsychological, and functional vision-related skills of children with DCD and CVI.

METHODS

An assessment of the neuropsychological profile (cognitive, visual cognitive, and motor coordination skills) and visual acuity were conducted on 65 children with DCD (mean age: 8 years, 1 month; SD: 1 year, 6 months) and 35 children with CVI (mean age: 8 years, 5 months; SD: 2 years, 6 months) and compared between the two groups. The CVI-Inventory (CVI-I) was used to evaluate functional vision-related problems and to cluster subjects.

RESULTS

Visual attention, visual perception, global motor coordination, and visual constructive scores didn't differ between the two groups even if children with CVI showed lower scores in the intellectual, visual, visual cognitive, and motor abilities. The overlap index confirmed an overlap on most of the variables considered. Six discriminative questions from the CVI-I clustered subjects into two groups: the first, with more children with CVI (62.9 %) and a more compromised neuropsychological profile, and the second, with more children with DCD (86.7 %).

CONCLUSION

DCD and CVI share both similarities and differences. Low visual acuity, low IQ scores, severe visual-motor integration challenges, and difficulties with fine motor and balance skills should prompt clinicians to screen for CVI in children with DCD. Specific functional vision-related problems can assist in this differentiation.

The relation between clutter and visual fatigue in children with cerebral visual impairment

PURPOSE

Cerebral visual impairment (CVI) is a brain-based condition which can be exacerbated by clutter. This study aimed to explore the relation between clutter and visual fatigue in children with CVI and evaluate the effectiveness of clutter algorithm metrics in assessing visual clutter in photographs of children's play areas and the relation to visual fatigue.

METHODS

Visual clutter was measured using algorithmic metrics, subjective observations by a clinical researcher (who also observed visual fatigue) and a Qualtrics survey.

RESULTS

Seventy-two children (mean performance age = 7 years 4 months) were included. Visual fatigue was present in over 90% of children. Results revealed a relation between clutter and visual fatigue observations (rs = 0.29; p = 0.01) and between visual clutter observations from researchers and Qualtrics participants (rs = 0.32; p = 0.02). Certain metrics were correlated with visual clutter observations (rs ranging from -0.30 to 0.51, p-values ranging from <0.001 to 0.03), but not with visual fatigue.

CONCLUSIONS

Children with CVI presented with visual fatigue, particularly in cluttered environments. Therefore, parents, caregivers, teachers and clinicians should be attentive to visual fatigue signs, as early recognition and intervention can help address the child's needs more effectively. Algorithms that effectively quantify visual clutter are valuable tools that can be integrated to enhance the assessment of clutter and its relation with visual fatigue to advance CVI research methodology. However, a clinician is required to assess visual fatigue and to obtain detailed information on environmental clutter, which algorithms alone may not fully capture. Finally, we recognise that visual fatigue and the impact of clutter should be integrated into psychoeducation and the comprehensive assessment of individuals with CVI.

The effectiveness of an individualised and adaptive game-based rehabilitation, iVision, on visual perception in cerebral visual impairment: A triple-blind randomised controlled trial

BACKGROUND

Cerebral visual impairment (CVI) can negatively affect a child's functioning, emphasising the need for interventions to improve visual perception (VP), potentially translating into improved health-related quality of life (HRQOL).

AIMS

Assessing the effectiveness of an adaptive individualised game-based rehabilitation, iVision, on VP, visual function, functional vision, and HRQOL.

METHODS AND PROCEDURES

Seventy-three children with CVI (3-12 performance age) were randomised into the adaptive individualised or the non-adaptive non-individualised group (3 sessions/week; 12 weeks). Primary outcome was change score (post-intervention - pre-intervention) of the lowest VP dimension. Key secondary outcomes included change score (post-intervention - pre-intervention) of visual function (reaction time to fixation in a preferential looking eye-tracking paradigm), functional vision (success rate in the adapted virtual toy box paradigm; total Flemish CVI questionnaire score), HRQOL (total scale score of the paediatric quality of life inventory 4.0 child self-report), and the lowest VP dimension change score (short-term follow-up - pre-intervention).

OUTCOMES AND RESULTS

Both groups significantly improved on the primary outcome, maintaining at short-term. Between-group differences were not significant. No significant effect was found for other key secondary outcomes. Exploratory analyses revealed VP dimension improvements and clinically meaningful HRQOL improvements.

CONCLUSIONS AND IMPLICATIONS

Although children with CVI improved their VP and to some extent HRQOL, no differences were found between the groups.

Special Commentary: Cerebral/Cortical Visual Impairment Working Definition: A Report from the National Institutes of Health CVI Workshop

Cerebral/cortical visual impairment (CVI), a brain-based condition, has emerged as a leading cause of pediatric visual impairment in the United States and other industrialized nations. The National Eye Institute (NEI) recognized CVI as a priority area for research as part of their 2021 NEI Vision for the Future Strategic Plan and partnered with the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Neurologic Disorders and Stroke within the National Institutes of Health (NIH) to sponsor a CVI Workshop in November 2023. A panel consisting of a group of clinicians with expertise in diagnosing CVI convened to draft a working definition for this condition. Five key elements were identified: (1) CVI encompasses a spectrum of visual impairments caused by an underlying brain abnormality that affects the development of visual processing pathways and is characterized by deficits in visual function and functional vision; (2) the visual dysfunction in CVI is greater than expected by any comorbid ocular conditions alone; (3) the visual dysfunction in CVI may manifest as lower-order or higher-order afferent visual deficits, or both, leading to characteristic behaviors in affected individuals; (4) although CVI may be comorbid with other neurodevelopmental disorders, CVI is not primarily a disorder of language, learning, or social communication; and (5) the underlying neurologic insult of the developing brain may go unrecognized or undiagnosed until later in life. Future work is needed to achieve consensus on nomenclature, diagnostic criteria, and strategies for early identification and intervention. The NIH is developing a CVI registry to collect relevant demographic and clinical data prospectively and longitudinally to help inform future research questions and to provide insight into considerations for future clinical trials in the field of CVI.

Rasch analysis and targeting assessment of the teach-CVI survey tool in a cohort of CVI patients

Purpose

Cerebral Visual Impairment (CVI) is the leading cause of pediatric visual impairment. Given the diversity of clinical presentations of CVI, we are interested in whether questionnaires appropriately target the spectrum CVI cases, specifically the Teach-CVI Screening Tool. Rasch analysis is a standard psychometric technique for assessing the targeting of questionnaire items, however this analysis technique has not yet been applied to this questionnaire.

Methods

We performed a retrospective review of clinical CVI cases from the NECO Center for Eye Care at Perkins School for the Blind from January 2016 to December 2022. Electronic medical records were reviewed to identify patients with an ICD-9 or ICD-10 code of CVI or other neurological visual impairment. Age, gender, diagnoses, visual acuity, contrast sensitivity, visual fields, ocular alignment, and Teach-CVI responses were collected. We applied the method of successive dichotomizations, a polytomous Rasch model, to estimate item measures and person measures from the survey. Targeting of questionnaire items to the sample population was explored by comparing estimated item measures to person measures. Multiple linear regression was used to determine which factors influence patient visual ability (i.e., Teach-CVI person measure).

Results

119 patient records were included, 54% of which were male. The mean age was 8.9 years (SD = 6.12) with a range of 0 to 33 years of age. Mean visual acuity was 0.46 logMAR (SD = 0.40), or 20/57. The majority of patients in the sample had a co-occurring visual disorder in addition to CVI (84%), the most frequent being strabismus (69.9%) or visual field loss (25.3%). Item measures ranged from -2.67 to 1.77 logits (SD = 0.76), with a mean of 0 logit by convention. Estimated person measures ranged from -2.19 to 3.08 logits (SD = 1.10) with a mean of -0.03 logit. The range of item measures covered 93.3% of the person measures, and all person measures, except one, were within one logit of an item measure. Visual measures were not statistically significantly associated with Teach-CVI person measures.

Conclusion

The findings from this study suggest that the Teach-CVI survey is well targeted and an appropriate patient reported outcome measure for CVI.

An evaluation of health-related quality of life and its relation with functional vision in children with cerebral visual impairment

BACKGROUND

Health-related Quality of Life (HRQOL) and its relation with functional vision is understudied in cerebral visual impairment (CVI).

AIMS

Characterising HRQOL, comparing child self- and parent proxy-reports, and exploring relations with functional vision.

METHODS AND PROCEDURES

Seventy-three children with CVI (n females = 33; n males = 40; Mean performance age = 7y2m) were included. HRQOL was measured with Pediatric Quality of Life Inventory (PedsQL) child self- and parent proxy-reports and compared using Wilcoxon signed-rank tests. Risk for impaired HRQOL was evaluated using cut-off scores. Parents scored functional vision using the Insight Questions Inventory and the Flemish CVI Questionnaire.

OUTCOMES AND RESULTS

61 % (self-reported) or 66 % of children (proxy-reported) were at-risk for impaired total HRQOL. Ratings were correlated (rs = 0.305; p = 0.013); however, children rated higher total HRQOL compared to parent-proxy (r = 0.382; p = 0.002). The Insight Questions Inventory and the PedsQL proxy-report were correlated (rp = -0.454; p < 0.001), the Flemish CVI Questionnaire was negligibly correlated (rp = -0.244; p = 0.041).

CONCLUSIONS AND IMPLICATIONS

HRQOL is reduced in CVI, and both child and parent perspectives are crucial. HRQOL and functional vision are intricately related, and impairment in one negatively affects the other.

Understanding social cognition in children with cerebral palsy: exploring the relationship with executive functions and the intervention outcomes in a randomized controlled trial

Children with Cerebral Palsy (CP) experience Social Cognition (SC) difficulties, which could be related to executive functioning. While motor interventions are common, there is limited knowledge about the impact of cognitive interventions on SC in this population. This study examined the relationship between SC and Executive Function (EF) skills and the effectiveness of an EF intervention that included some SC tasks for improving SC in children with CP. SC and EF domains were assessed in 60 participants with CP (30 females; 8-12 years). The relationship between SC and EF baseline scores was analyzed by bivariate correlations and contingency tables. Participants were matched by age, sex, motor ability, and intelligence quotient and randomized into intervention or control groups. The intervention group underwent a 12-week home-based computerized EF intervention. Analysis of covariance was used to examine differences in SC components between groups at post-intervention and 9 months after. Significant positive correlations were found between the SC and EF scores. The frequencies of impaired and average scores in SC were distributed similarly to the impaired and average scores in EFs. The intervention group showed significant improvements in Affect Recognition performance post-intervention, which were maintained at the follow-up assessment, with a moderate effect size. Long-term improvements in Theory of Mind were observed 9 months after.

CONCLUSIONS

This study highlights the association between SC and EFs. A home-based computerized cognitive intervention program improves SC in children with CP. Including SC tasks in EF interventions may lead to positive short- and long-term effects for children with CP.

CLINICAL TRIAL REGISTRATION

NCT04025749 retrospectively registered on 19 July 2019.

WHAT IS KNOWN

• Executive functions and social cognition are associated with social and community participation in people with cerebral palsy. • A home-based computerized cognitive intervention can improve the executive functioning of children with cerebral palsy.

WHAT IS NEW

• Social cognition performance is related to core and higher-order executive functions. • A home-based computerized executive function intervention, including social cognition tasks, has positive short- and long-term effects on social cognition skills in children with cerebral palsy.

The relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy

BACKGROUND

Accurate visual information is needed to guide and perform efficient movements in daily life.

AIMS

To investigate the relation between visual functions, functional vision, and bimanual function in children with unilateral cerebral palsy (uCP).

METHODS AND PROCEDURES

In 49 children with uCP (7-15 y), we investigated the relation between stereoacuity (Titmus Stereo Fly test), visual perception (Test of Visual Perceptual Skills), visuomotor integration (Beery Buktenica Test of Visual-Motor Integration) and functional vision (Flemish cerebral visual impairment questionnaire) with bimanual dexterity (Tyneside Pegboard Test), bimanual coordination (Kinarm exoskeleton robot, Box opening task), and functional hand use (Children's Hand-use Experience Questionnaire; Assisting Hand Assessment) using correlations (rs) and elastic-net regularized regressions (d).

OUTCOMES AND RESULTS

Visual perception correlated with bimanual coordination (rs=0.407-0.436) and functional hand use (rs=0.380-0.533). Stereoacuity (rs=-0.404), visual perception (rs=-0.391 to -0.620), and visuomotor integration (rs=-0.377) correlated with bimanual dexterity. Functional vision correlated with functional hand use (rs=-0.441 to -0.458). Visual perception predicted bimanual dexterity (d=0.001-0.315), bimanual coordination (d=0.004-0.176), and functional hand use (d=0.001-0.345), whereas functional vision mainly predicted functional hand use (d=0.001-0.201).

CONCLUSIONS AND IMPLICATIONS

Visual functions and functional vision are related to bimanual function in children with uCP highlighting the importance of performing extensive visual assessment to better understand children's difficulties in performing bimanual tasks.

WHAT THIS PAPER ADDS

Previous findings showed that up to 62 % of children with unilateral cerebral palsy (uCP) present with visual impairment, which can further compromise their motor performance. However, the relation between visual and motor function has hardly been investigated in this population. This study makes a significant contribution to the literature by comprehensively investigating the multi-level relation between the heterogenous spectrum of visual abilities and bimanual function in children with uCP. We found that mainly decreased visual perception was related to decreased bimanual dexterity, bimanual coordination, and functional hand use while impairments in functional vision were only related to decreased functional hand use. Additionally, elastic-net regression models showed that visual assessments can predict bimanual function in children with uCP, however, effect sizes were only tiny to small. With our study, we demonstrated a relation between visual functions and bimanual function in children with uCP. These findings suggest the relevance of thoroughly examining visual functions in children with uCP to identify the presence of visual impairments that may further compromise their bimanual function.

Visual, perceptual functions, and functional vision in children with unilateral cerebral palsy compared to children with neurotypical development

AIM

To investigate visual (perceptual) function and functional vision in children with unilateral cerebral palsy (CP) and children with neurotypical development (NTD).

METHOD

Fifty children with unilateral CP (mean age 11 years 11 months, SD 2 years 10 months, range 7-15 years; 27 males; 26 left-sided unilateral CP; Manual Ability Classification System [MACS] levels: I, 27; II, 16; III, 7) and 50 age- and sex-matched children with NTD participated in a cross-sectional study. Visual acuity, stereoacuity, and visual-perceptual functions were measured with standardized clinical tests. Functional vision was assessed in children with unilateral CP with the Flemish cerebral visual impairment questionnaire (FCVIQ). Group differences were investigated with Mann-Whitney U tests, Kruskal-Wallis tests, and the relative effect sizes r, η2 respectively. Correlations between visual assessments and the FCVIQ were investigated with Spearman's rank correlations.

RESULTS

The total group of children with unilateral CP showed reduced visual acuity compared with children with NTD (p = 0.02, r = 0.23). Only children with left-sided unilateral CP scored lower than those with NTD on stereoacuity (p < 0.01, r = 0.36). Children with right/left-sided unilateral CP scored significantly lower than those with NTD on visual-perceptual functions (p = 0.001-0.02), with large effect sizes on visuomotor integration and visual closure (both r = 0.57). Children with unilateral CP classified in MACS level III showed significantly lower scores on visual-perceptual assessments than children classified in MACS level I. Stereoacuity and visual-perceptual functions negatively correlated with the FCVIQ, with the highest association with visual (dis)interest and anxiety-related behaviours.

INTERPRETATION

Multi-level visual profiling is warranted in the clinical intake of children with unilateral CP to detect visual impairments that further compromise their level of functioning.

Development and initial validation of a screening tool for visual ability/performance of people with polyhandicap

BACKGROUND

Visual impairments are common in people with polyhandicap although they are poorly assessed. However, evaluation of the visual abilities of these people is critical to determining treatment for impairments.

OBJECTIVES

To develop and validate an easy-to-use visual-behavioural scale for assessing the visual abilities of people with polyhandicap.

METHODS

The development of the Visual Assessment for People with Polyhandicap (VA-PLH) involved 2 steps: i) construction of the scale and ii) field validation. Participant selection criteria were aged > 3 years, age at onset of cerebral lesion < 3 years, a combination of motor impairment and profound intellectual impairment associated with restricted mobility (Gross Motor Function Classification System levels [GMFCS] III, IV or V), and everyday life dependence (Functional Independency Measure [FIM] <55). Vision assessment by both an orthoptist and an ophthalmologist was the reference against which were analysed the items of the scale completed by local health care workers. Acceptability, validity, and reliability were analysed.

RESULTS

Amongst the 232 participants included, 217 had a complete assessment, and 33% were < 18 years of age. Ocular abnormalities were reported in 83% of participants. Visual ability was altered or insufficient in 60% of participants. The final version of the VA-PLH included 3 items related to visual reaction (Area Under Curve Receiver Operating Characteristic = 0.83). Participants were considered at-risk if they had at ≥ 1 of 3 signs present (sensitivity 83% and specificity 73%). The scale's reliability was satisfactory CONCLUSION: The VA-PLH scale provides an easy-to-use, reliable and valid measure of visual status for people with polyhandicap and may be used both in clinical practice and clinical research. In addition, this study provides an overview of the diversity of visual impairments in a large population of people with polyhandicap, showing that most experience visual challenges.

Occupational Therapy Assessments of Cortical or Cerebral Visual Impairment: A Systematic Review

IMPORTANCE

Cortical or cerebral visual impairment (CVI), a leading cause of visual dysfunction in children across the globe, can result in delayed development of fine and gross motor skills, functional mobility, and socialization, which affects all areas of occupation. No assessments are recommended for occupational therapy practitioners working with children with CVI.

OBJECTIVE

To appraise the measurement properties and clinical utility of CVI assessments appropriate for use by occupational therapy practitioners.

DATA SOURCES

MEDLINE via PubMed, Scopus, and Web of Science.

STUDY SELECTION AND DATA COLLECTION

We followed the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews of patient-reported outcome measures for relevant studies.

FINDINGS

A total of 590 records yielded 15 studies of the measurement properties of 12 assessment tools, 8 patient-reported outcome measures and 4 clinician-reported or performance-based outcome measures. We report on the quality of measurement properties of 10 of the 12 outcome measures. None had high-quality evidence of content validity, structural validity, or test-retest reliability. Most had indeterminate internal consistency as a result of a lack of confirmatory factor analysis. Three instruments demonstrated high quality and sufficient construct validity.

CONCLUSIONS AND RELEVANCE

On the basis of the COSMIN guidelines, all 12 outcome measures have the potential to be recommended but require further study before definitive recommendations can be made. What This Article Adds: This is the first systematic review of assessments of CVI feasible for use by occupational therapy practitioners. High-quality studies of measurement properties are lacking. Further examination of the measurement properties of outcome measures is required.

The relation between visual orienting functions, visual perception, and functional vision in children with (suspected) cerebral visual impairment

BACKGROUND

Brain-based impairments in visual perception (VP), termed cerebral visual impairment (CVI), are heterogeneous.

AIMS

To investigate relations between functional vision and (1) visual orienting functions (VOF) and (2) VP.

METHODS AND PROCEDURES

Forty-four children (Males = 20; Mean age = 9y11m) with (suspected) CVI were tested with an adapted virtual toy box (vTB) paradigm (eye tracking visual search task (VST) and a recognition/memory task), VP tests, a preferential looking eye tracking (PL-ET) paradigm, and the Flemish cerebral visual impairment questionnaire. Relations were tested with Spearman correlations.

OUTCOMES AND RESULTS

Functional vision was related to VOF and VP. Children who performed poorly on the VST performed worse on the PL-ET paradigm (r success rate = 0.508-0.654; r reaction time (to fixation) = 0.327-0.633; r fixation duration = 0.532; r gaze fixation area/error = 0.565). Faster VST reaction time was related to higher recognition/memory task accuracy (r = -0.385) and better object/picture recognition (r = -0.371). Higher accuracy in the recognition/memory task was related to better object and face processing (r = -0.539), less visual (dis)interest (r = -0.380), and better clutter and distance viewing (r = -0.353).

CONCLUSIONS AND IMPLICATIONS

In CVI, VOF, VP, and functional vision are interlinked, and when one is impaired, it negatively affects the others. Hence, quantitatively profiling basic functioning, higher-order and daily life abilities is crucial.

Parent-Reported Visual Concerns in Children with Cerebral Visual Impairment Presenting to a Pediatric Neurology Clinic

Purpose

Children with cerebral visual impairment (CVI) present with delayed developmental milestones. Pediatricians and pediatric neurologists are usually the first point of contact, and eye exam largely remains referral based. This study documented the visual concerns reported by parents of children with CVI visiting a pediatric neurology clinic. Additionally, we investigated the association between visual concerns, functional vision measures and visual functions.

Patients and Methods

A cross-sectional study was undertaken in children with CVI (chronological age range: 7 months-7 years). Visual concerns reported by the parents/caregivers were documented as open-ended statements. Additionally, a functional vision assessment was conducted using the CVI Range instrument with phase 1, 2 and 3 indicating low, moderate and high visual functioning, respectively. Grating acuity and contrast sensitivity were measured using Teller acuity cards-II and Ohio contrast cards respectively.

Results

A total of 73 children (mean age of 2.84 ± 1.87 years) were recruited. Sixty-eight parents reported visual concerns that were broadly grouped into 14 unique concerns. Nineteen parents (27.9%) reported more than one visual concern. Difficulty maintaining eye contact and recognizing faces were the top two visual concerns in phases 1 and 2. Missing objects in the lower visual field was the top concern in phase 3. A larger number of visual concerns were reported in phase 1 (43%) than phase 2 (40.6%) and phase 3 (16.2%). Multiple regression analysis revealed that grating acuity, contrast sensitivity and chronological age were able to predict the functional vision, F (3, 55) = 63.0, p < 0.001, r² = 0.77.

Conclusion

Targeted questions enquiring about eye contact and face recognition can be included in history elicitation in children with CVI in pediatric neurology clinics. In the presence of visual concerns, it will be important to assess grating acuity and contrast sensitivity. A poor functional vision score requires referral for eye examination and vision rehabilitation services.

Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide

Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.

Visual Behaviours (ViBes) in Cerebral Visual Impairment: Validating a Descriptive Tool to Support Diagnosis and Monitoring

Introduction

Cerebral visual impairment (CVI) is the most common cause of visual impairment in children in the UK. Diagnosis is based on identification of visual behaviours (ViBes) relating to visual dysfunction. Examination techniques and inventories have been developed to elicit these in children with a developmental age of two years or more. The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis. The aim of the study was to develop a matrix of visual behaviours seen in pre-verbal and pre-motor children with visual impairment and establish its content validity and inter-rater reliability.

Methods

ViBe content validation:: Visual behaviour descriptors relating to visual function were collated and categorised by expert consensus of vision professionals into a matrix composed of three functions (attention, field/fixation, motor response) and five levels (0 = no awareness; 1 = visual awareness; 2 = visual attention; 3 = visual detection; 4 = visual understanding).ViBe inter-rater reliability:: The participants (two orthoptists, an optometrist, an ophthalmologist and two qualified teachers of the visually impaired) used the ViBe matrix to independently score each of 17 short video clips of children demonstrating visual behaviours seen in CVI.

Results

The ViBe matrix will be presented. Cohen's kappa for the matrix was 0.67, demonstrating moderate-to-strong inter-rater reliability.

Conclusion

The development of standardised descriptors can support clinicians and teachers in identifying areas of concern for children with complex needs. In addition, the ViBe matrix could be utilised in research, clinical and diagnostic reports to clearly communicate the areas of visual dysfunction and track progress resulting from interventions.

Key Points

The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis.The ViBe matrix offers descriptors relating to visual behaviours and has demonstrated acceptable inter-rater reliability.The tool may support the identification and diagnosis of cerebral visual impairment in a population of children who cannot access standard testing.

Make it easier: 3-word strategies to help children with cerebral visual impairment use their vision more effectively

INTRODUCTION

Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the United Kingdom. Management relies on identifying strategies and adaptations which enable the child to use their vision effectively and efficiently. The majority of published strategies involve lengthy inventories used in a specialist setting. Feedback from parent support groups cite the provision of immediate advice on strategies at the time of diagnosis as a key indicator of good care. The aim of the study was to use the Delphi technique to construct a set of three-word phrases to succinctly describe strategies for common visual dysfunctions in children with CVI.

METHOD

A panel of twelve experts across health, education and those with lived experience was recruited. Four rounds of questionnaires were used to reach consensus on candidates symptoms and suggestions for 3-word-phrases. Consensus was defined as 70% agreement.

RESULTS

Response rates were 92, 67, 92 and 91% for each round respectively. The 3-word phrases reaching consensus were: Big Bold Bright; Keep it Still; Eyes or Ears; Show It High; Better on Left/Right; Clear the Clutter; Keep It Short; Give Me Time, My Vision Varies, Just One Thing.

CONCLUSION

The intention is for the phrases presented to act as a 'starter' at the point of diagnosis and are appropriate for children of any developmental or visual ability. The real-life validation of this set of expert-consensus phrases will require further studies, evaluating both their effectiveness in terms of mapping to an intervention and impact on visual development.

Including visual orienting functions into cerebral visual impairment screening: Reliability, variability, and ecological validity

BACKGROUND

Cerebral visual impairment (CVI) is a heterogeneous brain-based visual processing disorder in which basic visual orienting functions (VOF) and higher-order perception can be impaired.

AIMS

To evaluate (1) the test-retest reliability and variability of an eye tracking-based VOF paradigm, and related clinical characteristics, and (2) the relations between VOF (variability) and daily visual functioning and visuoperceptual dimensions.

METHODS AND PROCEDURES

Thirty-three children with CVI (Males=14; mean age=9 years 10 months) underwent eye tracking thrice, completed a visuoperceptual battery, and parents completed the Flemish CVI questionnaire. VOF reliability and variability of reaction time (RTF), fixation duration and accuracy were assessed with intraclass correlation coefficient (ICC), Bland-Altman plots, and coefficient of variation. Relations were analysed with linear mixed models.

OUTCOMES AND RESULTS

Highly salient visual stimuli had good RTF reliability (ICCs=0.75) and triggered less variable VOF. Intermediate and low salience stimuli had poor-to-moderate reliability and triggered more variable VOF. Younger performance age related to more VOF variability. Greater visual (dis)interest, clutter and distance viewing impairments, and a weaker visuoperceptual profile related to slower RTF.

CONCLUSIONS AND IMPLICATIONS

Highly salient stimuli reveal a child's 'optimal' visual performance, whereas intermediate and low salience stimuli uncover VOF variability, which is a key CVI hallmark to detect.

A mixed-methods study into the effect of a psycho-educational programme for children with cerebral visual impairment (CVI)

Cerebral visual impairment (CVI) is one of the most common causes of visual impairment in children. CVI is a complex visual disorder to understand and explain to others. Understanding one’s diagnosis and being able to explain it to others may facilitate adaptive functioning. To educate children and young people on their CVI and accompanying needs, the computerized psycho-educational programme ‘My CVI’ has been developed.

A mixed-methods study was conducted to evaluate the effect of this programme. The aims of the programme are to increase participants’ knowledge of CVI, as well as self-esteem (SDQ), adaptive coping (SCQ), and well-being (Cantril, PERIK, HRQoL). Thirty-nine children (aged 7–16 years; 51% boys) participated in a pre-test, post-test, and follow-up assessment. Qualitative interviews were conducted for a subjective evaluation of the programme.

Participation in the psycho-educational programme resulted in increased knowledge of CVI, as well as a better teacher-reported social and academic self-concept and less self-reported feelings of social exclusion. No effects of participation were found on self-reported self-esteem, coping or other measures for well-being. An increase in knowledge of CVI was not associated with changes in psychosocial functioning. Qualitative data revealed that children enjoyed participating in the programme; they learned there are others with CVI, and gained more knowledge and practical tools on how to deal with their CVI.

The results provide preliminary evidence that participation in the psycho-educational programme ‘My CVI’ increases children’s knowledge of their visual impairment as well as improves social outcomes and feelings of inclusion. The highest gains may be achieved through a personalized approach, depending on a child’s (developmental) age and parental involvement.

Longitudinal neurological analysis of moderate and severe pediatric cerebral visual impairment

Introduction

Cerebral visual impairment (CVI) results from damage to cerebral visual processing structures. It is the most common cause of pediatric visual impairment in developed countries and rising in prevalence in developing nations. There is currently limited understanding on how neurologic, developmental, and ophthalmic factors predict outcome for pediatric CVI.

Method

A retrospective manual chart review of pediatric CVI patients seen at the tertiary pediatric hospital neurology and neuro-ophthalmology service between 2010 and 2019 was conducted. Patients were stratified into severity groups (based on a custom CVI grading score), and followed over time to identify outcome predictors. Collected baseline characteristics included perinatal, genetic, developmental, and neurologic history, along with neuroimaging and fundoscopic findings on examination. Longitudinal data collected included age, seizure control, and type of therapy received. Linear mixed-effect models were used for longitudinal CVI grade outcome analysis.

Results

A total of 249 individuals spanning 779 patient visits were identified. Mean age at diagnosis was 18.8 ± 16.8 months (2–108 months). About 64.3% were born at term age. Perinatal history revealed hypoxic ischemic encephalopathy (HIE) in 16.5%, intraventricular hemorrhage (IVH) in 11.6%, and seizures in 21.7%. At presentation, 60.3% had a diagnosis of cerebral palsy and 84.7% had developmental delay. Among all subjects, 78.6% had epilepsy; 33.8% had an epileptic encephalopathy, with spasms/hypsarrhythmia being most common. Abnormal neuroimaging was present in 93.8%. Genetic anomalies were present in 26.9%. Baseline visual examination revealed no blink-to-light (BTL) in 24.5%; only BTL in 34.5%, fixation/tracking in 26.5%, and optokinetic drum follow in 14.4%. Longitudinal data analysis showed that perinatal history of HIE, a positive epilepsy history, using multiple (≥3) epilepsy medications, cerebral palsy, and abnormal fundoscopic findings were all negatively associated with CVI grade change over time. After controlling for significant confounders, receiving any type of therapy [early childhood intervention (ECI), physical and occupational therapy (PT/OT), refractive error correction or glasses] was significantly associated with longitudinal improvement in CVI grade compared to patients who did not receive any therapy, with glasses yielding the largest benefit.

Conclusion

This study offers extensive insights into neurologic, developmental and ophthalmologic features in patients with moderate to severe CVI. In concordance with previous findings, aspects of perinatal history and epilepsy/seizure control may help inform severity and prognosis in the general neurology or ophthalmology clinic. Conversely, these aspects, as well as genetic and specific epilepsy traits may alert vision health care providers in the clinic to pursue visual evaluation in at-risk individuals. Longitudinal follow-up of CVI patients showed that interventional therapies demonstrated vision function improvement greater than no therapy and maturational development.

The Multidisciplinary Guidelines for Diagnosis and Referral in Cerebral Visual Impairment

Introduction

Cerebral visual impairment (CVI) is an important cause of visual impairment in western countries. Perinatal hypoxic-ischemic damage is the most frequent cause of CVI but CVI can also be the result of a genetic disorder. The majority of children with CVI have cerebral palsy and/or developmental delay. Early diagnosis is crucial; however, there is a need for consensus on evidence based diagnostic tools and referral criteria. The aim of this study is to develop guidelines for diagnosis and referral in CVI according to the grade method.

Patients and Methods

We developed the guidelines according to the GRADE method 5 searches on CVI (children, developmental age ≤ 18 years) were performed in the databases Medline, Embase, and Psychinfo, each with a distinct topic.

Results

Based on evidence articles were selected on five topics: 1. Medical history and CVI-questionnaires 23 (out of 1,007). 2. Ophthalmological and orthoptic assessment 37 (out of 816). 3. Neuropsychological assessment 5 (out of 716). 4. Neuroradiological evaluation and magnetic resonance imaging (MRI) 9 (out of 723). 5. Genetic assessment 5 (out of 458).

Conclusion

In medical history taking, prematurity low birth weight and APGAR (Appearance, Pulse, Grimace, Activity, Respiration) Scores (<5) are important. Different questionnaires are advised for children under the age of 3 years, older children and for specific risk groups (extremely preterm). In ophthalmological examination, eye movements, specially saccades, accommodation, crowding, contrast sensitivity and visual fields should be evaluated. OCT can show objective signs of trans-synaptic degeneration and abnormalities in fixation and saccades can be measured with eye tracking. Screening of visual perceptive functioning is recommended and can be directive for further assessment. MRI findings in CVI in Cerebral Palsy can be structured in five groups: Brain maldevelopment, white and gray matter lesions, postnatal lesions and a normal MRI. In children with CVI and periventricular leukomalacia, brain lesion severity correlates with visual function impairment. A differentiation can be made between cortical and subcortical damage and related visual function impairment. Additional assessments (neurological or genetic) can be necessary to complete the diagnosis of CVI and/or to reveal the etiology.

Visual Function and Neuropsychological Profile in Children with Cerebral Visual Impairment

Cerebral Visual Impairment (CVI) has become the leading cause of children’s visual impairment in developed countries. Since CVI may negatively affect neuropsychomotor development, an early diagnosis and characterization become fundamental to define effective habilitation approaches. To date, there is a lack of standardized diagnostic methods to assess CVI in children, and the role of visual functions in children’s neuropsychological profiles has been poorly investigated. In the present paper, we aim to describe the clinical and neuropsychological profiles and to investigate the possible effects of visual functions on neuropsychological performance of a cohort of children diagnosed with CVI. Fifty-one children with CVI were included in our retrospective analysis (inclusion criteria: verbal IQ > 70 in Wechsler scales; absence of significant ocular involvement). For each participant, we collected data on neuropsychological assessment (i.e., cognitive, cognitive visual, and learning abilities), basic visual functions (e.g., Best Corrected Visual Acuity—BCVA, contrast sensitivity, and ocular motor abilities) and global development features (e.g., neurological signs and motor development delay) based on standardized tests, according to patients’ ages. The results showed that oculomotor dysfunction involving saccades and smooth pursuit may be a core symptom of CVI and might have a significant impact on cognitive visual and other neuropsychological abilities. Furthermore, visual acuity and contrast sensitivity may influence cognitive, cognitive visual, and academic performances. Our findings suggest the importance of a comprehensive assessment of both visual and neuropsychological functions in children when CVI is suspected, which is needed to provide a more comprehensive functional profile and define the best habilitation strategy to sustain functional vision.

Age-Related Effects on the Spectrum of Cerebral Visual Impairment in Children With Cerebral Palsy

Background

Cerebral Visual Impairment (CVI) is a very common finding in children affected by Cerebral Palsy (CP). In this paper we studied the characteristics of CVI of a large group of children with CP and CVI, describing their neurovisual profiles according to three different age subgroups (subgroup 1: infants 6 months–2 years; subgroup 2: pre-school age 3–5 years; subgroup 3: school age ≥ 6 years).

Methods

We enrolled 180 subjects (104 males, mean age 66 ± 42.6 months; range 6–192 months) with CP and CVI for the study. We carried out a demographic and clinical data collection, neurological examination, developmental or cognitive assessment, and a video-recorded visual function assessment including an evaluation of ophthalmological characteristics, oculomotor functions, and basic visual functions. In school-aged children, we also performed an evaluation of their cognitive-visual profiles.

Results

There were signs of CVI in all the three subgroups. Subgroup 1 (62 children) and subgroup 2 (50 children) were different for fixation (p = 0.02), visual acuity (p = 0.03) and contrast sensitivity (p < 0.01), being more frequently impaired in younger children. Comparing subgroup 2 with subgroup 3 (68 children), the older children presented more frequently myopia (p = 0.02) while the younger ones esotropia (p = 0.02) and alteration in smooth pursuit (p = 0.03) and saccades (p < 0.01). Furthermore, fixation, smooth pursuit, visual acuity, contrast sensitivity and visual filed (p < 0.01) were more frequently impaired in younger children (subgroup 1) compared to the older ones. Multiple correspondence analysis (MCA) confirmed the different neurovisual profiles according to age: younger children with CP showed more signs of CVI compared to the older ones. 34 out of 68 children belonging to subgroup 3 underwent the cognitive visual evaluation; an impairment of cognitive visual skills was detected in 21 subjects.

Conclusion

Younger children with CP showed more signs of CVI compared to the older ones, likely for the physiological maturation of visual system and mechanisms of neuroplasticity. In this direction, we suggest an early neurovisual evaluation to detect any weak visual functions.

Visual Function Score: A New Clinical Tool to Assess Visual Function and Detect Visual Disorders in Children

INTRODUCTION

A comprehensive assessment of visual functioning at an early age is important not only for identifying and defining visual impairment but also for planning personalized rehabilitation programs based on the visual diagnosis. Since existing tools to evaluate visual functioning present some important limitations (e.g., they are based on qualitative reports, they do not take into account environmental adaptations of visual testing or they have not been formally validated as clinical instruments), the present work has the main aim to propose a new clinical tool (Visual Function Score, VFS) to detect and define visual disorders at an early age.

METHODS

The Visual Function Score was administered to one hundred visually impaired children (age range 4 months to 17.75 years old) in the form of a professional-reported protocol for a total of 51 items, each of which is assigned a score from 1 to 9 (or from 0 to 9 in some specific cases). The VFS produces three sub-scores and a global score (from 0 to 100), resulting in a quantitative evaluation of visual functioning.

RESULTS

The VFS can detect the well-known differences between different types of visual impairment (cerebral, oculomotor, and peripheral or grouped as central and peripheral) and takes into account different environments in the definition of a quantitative score of visual functioning.

DISCUSSION

Overall, the use of a quantitative tool to evaluate visual functions and functional vision such as the VFS would be fundamental to monitor the progresses of patients over time in response to rehabilitation interventions.

The relation between visual orienting functions, daily visual behaviour and visuoperceptual performance in children with (suspected) cerebral visual impairment

BACKGROUND

Children with cerebral visual impairment (CVI) present heterogeneous visual orienting functions (VOF) and higher-order perception. Multiple assessment methods evaluate CVI, but the relations between them remain unclear.

AIM

To investigate the relations between VOF and (1) daily life behaviour and (2) visuoperceptual tests in children with (suspected) CVI.

METHODS AND PROCEDURES

VOF were tested with a validated eye tracking-based paradigm. Visual perception was assessed using the children's visual impairment test for 3- to 6-year olds (CVIT 3-6) and (retrospective) visuoperceptual dimension results. Caregivers completed the Flemish cerebral visual impairment questionnaire (FCVIQ) and an expert panel scored relations between VOF and the other methods. We compared experts' survey responses with data-based results (linear mixed models and correlations).

OUTCOMES AND RESULTS

Fourty-four children (23 boys, 21 girls; median age = 7y11mo, SD = 2y7mo) participated. Twenty-one experts completed the survey. Slower VOF was significantly associated with (1) object and face processing impairments, (2) visual (dis)interest, (3) worse visual spatial perception (to local motion and form stimuli), and (4) worse CVIT 3-6 object and scene recognition (to cartoon stimuli).

CONCLUSIONS AND IMPLICATIONS

Integration of VOF with existing visual assessments provides a better clinical picture of CVI and can prevent misdiagnosing children as inattentive, incapable, or unmotivated.

Higher Visual Function Deficits in Children With Cerebral Visual Impairment and Good Visual Acuity

In clinical practice Cerebral Visual Impairment (CVI) is typically diagnosed by observation of abnormal visually guided behaviors which indicate higher visual function deficits (HVFDs) suggesting abnormal brain development or brain damage in a child with a suitable clinical history. HVFDs can occur even in the presence of good visual acuity and may remain undiagnosed because the good visual acuity does not prompt further investigation. This leads to a lack of understanding of the child's visual perceptual difficulties. In a prospective study, we determined the spectrum of HVFDs in a group of children with history suggestive of brain damage or disruption of brain development and an independent diagnosis of CVI in comparison with typically developing children with a structured 51 question inventory, the Higher Visual Function Question Inventory (HVFQI-51) adapted from the Cerebral Vision Impairment Inventory, CVI-I. Here, we show that the HVFQI-51 can detect a range of HVFDs in children with CVI with good visual acuity and clearly distinguishes these children from typically developing children. HVFDs in our study group could mostly be attributed to dorsal stream visual processing dysfunction though the spectrum varied between children. We report on the inclusion of the "not applicable" response option in analysis providing a picture of HVFDs more in tune with the overall disability of each child. We also propose a subset of 11 questions (Top-11) which discriminate between children with CVI vs. behaviors seen in typical children: this provides both a potential screening tool for initial assessment of HVFDs and a measure of CVI-related impairment, and needs further validation in a secondary independent sample.

Quantifying visuoperceptual profiles of children with cerebral visual impairment

The aim was to develop a visuoperceptual profile schema reflecting visuoperceptual strengths and weaknesses, using neuropsychological tests. Secondly, this schema was used to quantify individual visuoperceptual profiles of children with and without cerebral visual impairment (CVI), and to identify differences in their profiles. Clinical records (2001-2018) of 630 children (386 males, 244 females; median age 77 months; interquartile range 63-98 months) suspected for CVI were reviewed. Neurological history, visuoperceptual results, ophthalmological, and neuroimaging data were retrieved. To develop the visuoperceptual schema, exploratory factor analyses (EFAs) were performed, followed by a Delphi study. In individual interviews, six experts were asked to "name the different visuoperceptual dimensions" and "what visuoperceptual dimensions are targeted by each of the 24 visuoperceptual subtests." To reach consensus, two questionnaire rounds (44 statements and 20 statements, respectively, five experts) followed. EFAs showed clinically uninterpretable results. The Delphi study revealed seven visuoperceptual dimensions; (1) visual discrimination and matching, (2) object or picture recognition, (3) visual spatial perception, (4) figure-ground perception, (5) motion perception, (6) visual short-term memory, and (7) scene perception. The most discriminating dimensions between CVI and no CVI were object/picture recognition (r = 0.56), visual spatial perception (r = 0.52), visual discrimination and matching (r = 0.47), and figure-ground perception (r = 0.39). Motion perception and visual short-term memory (both r = 0.22) were less discriminating. Two case studies illustrate how to apply the visuoperceptual schema to characterize dysfunction and intact functions. Visuoperceptual profiling can serve as a basis for individualized therapies in heterogeneous disorders.

Implications of a Remote Study of Children With Cerebral Visual Impairment for Conducting Virtual Pediatric Eye Care Research: Virtual Assessment Is Possible for Children With CVI

The Pandemic of 2020 impacted conducting in-person research. Our proposed project already had an asynchronous online component but was later morphed to add a synchronous online component, thereby eliminating the need for in-person assessment. The project compares the results of various tests between a group of children with Cerebral Visual Impairments (CVI) (N = 4) and an age-matched sample of children without CVI (N = 3) from a pediatric low vision clinic. This model was trialed with a small convenient sample of typically developing children in the same age range (N = 4). Given the positive feedback, recruitment for the larger study was done via encrypted e-mail rather than through traditional mailing. The asynchronous components included recruitment, pre-assessment information, the Flemish CVI questionnaire, Vineland-3 comprehensive parent questionnaire for assessment of age equivalent, and vision function tests, such as contrast sensitivity. The synchronous components were administered via Zoom telehealth provided by necoeyecare.org and included assessment of visual acuity via the Freiburg Visual Acuity and Contrast Test (FrACT) electronic software and assessment of visual perceptual batteries via the Children’s Visual Impairment Test for developmental ages 3–6-years (CVIT 3–6). Our virtual testing protocol was successful in the seven participants tested. This paper reviews and critiques the model that we utilized and discusses ways in which this model can be improved. Aside from public health considerations during the pandemic, this approach is more convenient for many families. In a broader perspective, this approach can be scaled for larger N studies of rare conditions, such as CVI without being confined by proximity to the researcher.

Measure of early vision use: initial validation with parents of children with cerebral palsy

PURPOSE

To report initial psychometric evidence on the Measure of Early Vision Use.

METHOD

Data on performance of the Measure of Early Vision Use scale were collected from 100 parents of children with cerebral palsy aged 0-12 years via online survey. Psychometric evaluation included assessment of scale dimensionality using Classical Test Theory and hypothesis testing for evidence of construct validity.

RESULTS

Principal components analysis of the 14-item parent-rated Measure of Early Vision Use revealed one component with an eigenvalue of 9.343, explaining 66.7% of variance; internal consistency was high (Cronbach's α = 0.96). Total scores ranged from 15-56 (Mean 42.8, standard deviation = 10.6). The results support seven pre-defined hypotheses including statistically significant differences in MEVU-total scores between children with and without parent-reported cerebral visual impairment.

CONCLUSIONS

Measure of Early Vision Use is the first assessment tool to describe 'how vision is used' in children with cerebral palsy. Results provide preliminary evidence that the measure comprises a unidimensional construct, sufficient construct validity, and feasibility as a parent-completed online assessment. Findings on internal structure provide foundational evidence and require further testing with Confirmatory Factor Analysis or Rasch Analysis.IMPLICATIONS FOR REHABILITATIONThe Measure of Early Vision Use is a new instrument to describe the use of basic visual abilities and is feasible to use as a parent-completed online questionnaire.The Measure of Early Vision Use is a unidimensional scale with sufficient construct validity to supports its use as a measure of 'how vision is used' without confounding visual ability with the reason why it might be impaired (e.g., cerebral vision impairment, motor limitations, or cognition).There is potential for the Measure of Early Vision Use to support early intervention planning for children with (or at high risk of) cerebral palsy.

What assessments are currently used to investigate and diagnose cerebral visual impairment (CVI) in children? A systematic review

PURPOSE

Cerebral visual impairment (CVI) is the leading cause of childhood visual impairment in the developed world. Despite this, there are no agreed clinical guidelines for the investigation and diagnosis of the condition. Before development of such guidelines can commence, it is important to recognise which approaches are currently employed. This systematic review evaluated the literature to identify which methods of assessment are currently used to investigate and diagnose childhood CVI.

METHODS

Medline, Embase, CINAHL, Scopus and the Cochrane Library databases were systematically searched in January 2020 using defined search terms. Articles were included if they: (i) were research papers, conference abstracts or research protocols published in peer-reviewed scientific journals, or relevant textbooks; (ii) included a clinical investigation of CVI in children; (iii) provided an explanation or criteria to diagnose CVI and (iv) were specifically investigating cerebral/cortical visual impairment. Methods used to a) assess and b) diagnose CVI were extracted from included articles. 'Assessment scores' were assigned for each method employed by researchers to investigate and diagnose CVI to quantify and compare approaches between articles. A quality grading was also applied to each article.

RESULTS

Of 6454 identified articles, 45 met the inclusion criteria. From these, 10 categories of assessment utilised within included articles were identified: (1) Medical history, (2) Vision assessment/ophthalmologic examination, (3) Neuroimaging, (4) Visual behaviour and direct observation, (5) Structured history-taking, (6) Visual perception tests, (7) Ocular movement and posture assessment, (8) Intelligence/IQ assessment, (9) Clinical electrophysiology and (10) Neurodevelopmental tests. In terms of diagnostic criteria, the most commonly reported approach was one of exclusion, i.e., CVI was diagnosed when visual dysfunction could not be attributed to abnormalities detected in the anterior visual pathway.

CONCLUSION

There is a lack of common practice in the approaches used by clinicians to investigate and diagnose CVI in children. At present, a 'diagnosis of exclusion' remains the most common means to diagnose CVI. Development of clinical guidelines for assessment and diagnosis are necessary to ensure consistency in the diagnosis of CVI and the timely implementation of support to alleviate the impact of CVI on the child's daily living.