Characteristics of Cortical Visual Impairment Checklist
Children with other types of visual impairments may exhibit some of these characteristics.

CHILD’S NAME_____________________________ AGE________ DATE______

RESPONDENT’S NAME & RELATION TO CHILD________________________________

A child may be suspected of having a cortical visual loss when the extent of visual loss is unexplained by ocular abnormalities. Etiologies may include cerebral palsy, asphyxia, intracerebral hemorrhage, and meningitis.

Please check any areas below that pertain to the child.

APPEARANCE
___Does not look blind
___Blank facial expression
___Lack of visual communication skills
___Eye movements smooth, but aimless
___Nystagmus (rapid eye movement) rarely seen

VISION FUNCTION
___Visual function varies from day to day or hour to hour
___Limited visual attention and lacks visual curiosity
___Aware of distant objects, but not able to identify
___Spontaneous visual activity has short duration
___Visual learning tiring
___Closes eyes while listening
___Balance improved with eyes closed
___Look away from people and objects
___Consistently look to either side when visual looking
___When visually reaching looks with a slight downward gaze
___Turns head to side when reaching, as if using peripheral fields
___Uses touch to identify objects

MOBILITY SKILLS
___Occasionally "sees" better traveling in a car
___Difficulties with depth perception, inaccurate reach
___Unable to estimate distances
___Difficulties with spatial interpretation
___Avoids obstacles, but unable to use vision for close work

IMPROVED VISUAL PERFORMANCE
___When in familiar environments and when using familiar objects
___When told "what" to look for and "where" to look
___When objects are held close to eyes when viewing
___When objects are widely spaced
___When looking at one object verses a group of objects
___When color is used to assist in identification of objects or shapes
___When objects are against a plain background and paired with movement and sound


K. Appleby’s compiling information from article by: Jan, J.E., Groenveld, A., Sykanda, A.M., Hoyt, C.S. (1987) "Behavioral Characteristics of Children with Permanent Cortical Visual Impairment." Developmental Medicine & Child Neurology, 25,755-762.
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