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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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