Why a normal eye exam can miss cerebral visual impairment

In recognition of CVI Awareness Day on September 29, 2026, and as part of the Eye Care Network’s CVI Awareness Month coverage, 3 experts discuss how cerebral visual impairment (CVI) presents, how it is diagnosed, and why eye care providers play a central role in getting children the right support.

For more on the history, science, and clinical signs of CVI, read, “When 20/20 vision hides a diagnosis: Understanding cerebral visual impairment.”

Christine Roman-Lantzy, PhD, director of the Pediatric VIEW Program at The Children's Home in Pittsburgh, began her career as a teacher of the visually impaired. A classroom teacher pointed her toward a child who stared at lights all day. At the time, clinicians called the condition cortical blindness and mostly associated it with adults who lost vision due to head injury. The children's eye exams were fairly normal, "and yet clearly they didn't see," Roman-Lantzy told the Eye Care Network. She explained that children born with CVI must build up what they can access and interpret. In contrast, people who had vision and then acquire CVI need something closer to rehabilitation.

Recognizing the mismatch

Jem Martin, OD, described an individual with uncorrected visual acuity of 20/20, a full visual field, and excellent contrast sensitivity and depth perception. That individual saw motion as a stop-motion effect, which made crossing the street a source of anxiety. Martin identified several red flags: variable use of vision, looking away when reaching for objects, and difficulty with visual novelty or clutter.

Lotfi Merabet, OD, PhD, MPH, director of the Laboratory for Visual Neuroplasticity at Massachusetts Eye and Ear, noted there is no universal algorithm to diagnose CVI. Diagnosis draws on the medical history of the child and mother, visual function measures, eye health, and functional vision. Not every child shows structural damage on standard imaging, so his lab is pursuing eye tracking as an objective measure. "Anytime you see a mismatch between visual function and functional vision in the context of early brain injury or a neurodevelopmental disorder, you should be really, really suspicious of CVI," Merabet told the Eye Care Network.

Roman-Lantzy explained that children are diagnosed with CVI based on 3 factors: an eye exam that does not explain how the child uses vision, a history of a significant neurologic condition, and a set of behavioral characteristics. Her assessment measures the presence and level of those characteristics to guide intervention planning. Those behaviors can be misread. Observers may mistake avoidance of eye contact for autism, for example, when children with CVI find the human face too complex to interpret.

The eye care provider as gatekeeper

Martin pointed to the National Eye Institute's work toward a longitudinal assessment of individuals with CVI. They also emphasized a multidisciplinary approach connecting eye care providers, neurologists, educators, and therapists. Merabet highlighted the resilience of the CVI community and the CVI Day at the Massachusetts State House, which takes place today. Roman-Lantzy cautioned that telling parents to "wait and see" after a normal exam can be frustrating, because time is everything due to neuroplasticity. She asked eye doctors to consider their exam part 1, with a functional vision assessment as part 2.

"The gatekeeper of the entire story is the eye care specialist. So please, please, please notice this, and please refer these children to those who can then take the story forward.” - Christine Roman-Lantzy, PhD