Exploring cerebral visual impairment: functional vision classification and caregiver concerns

Abstract Background Cortical visual impairment (CVI) is an increasingly recognized cause of childhood visual impairment resulting from damage to the retrochiasmal visual pathways. Children with CVI experience difficulties in visual processing that can impact perception, mobility, learning, and interaction with their surroundings. Early diagnosis is often difficult because the clinical presentation is variable and conventional visual acuity assessments may not adequately reflect functional visual limitations. Functional assessment tools such as the CVI Range, together with caregiver-reported observations, provide important insights into everyday visual performance. However, data exploring the relationship between parental concerns and functional vision in children with CVI remain limited in low-resource settings such as Nepal. Methods This prospective cross-sectional study included children aged 7 months to 18 years diagnosed with cortical visual impairment (CVI) at a tertiary pediatric ophthalmology clinic. Caregiver-reported visual concerns were recorded, and functional vision was assessed using the CVI Range to classify children into three functional phases. Visual acuity and contrast sensitivity were measured using age-appropriate methods, and their associations with CVI phase and caregiver-reported concerns were analyzed. Results A total of 70 children with CVI were included, with a mean age of 4.66 ± 4.65 years; 67.1% were male. Nearly half (48.6%) were classified as Phase 1, 18.6% as Phase 2, and 32.9% as Phase 3, with mean age increasing across phases. The most common parental concern overall was difficulty maintaining eye contact (37.1%), followed by academic concerns (17.1%) and failure to look directly at objects (17.1%). Parental concerns varied by CVI phase, shifting from deficits in visual attention in Phase 1 to academic, mobility, and distance vision difficulties in later phases. Visual assessment methods also varied by phase, with fixation and following predominating in Phase 1 (79.4%), grating acuity in Phase 2 (76.9%), and Snellen visual acuity in Phase 3 (60.9%). Mean grating acuity improved across phases, while contrast sensitivity was poorer in Phase 1 compared with later phases. However, differences in grating acuity, contrast sensitivity, and LogMAR visual acuity across phases were not statistically significant (p > 0.05). Conclusion Parental concerns in children with CVI evolve with age and functional vision status, reflecting the changing nature of visual difficulties. Caregiver-reported concerns, combined with functional vision assessment using the CVI Range, may improve early identification of CVI and support individualized rehabilitation planning.