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

Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the UK and is defined as a verifiable visual dysfunction not attributable to a disorder of the anterior visual pathways or co-occurring ocular impairment. CVI encompasses a wide range of visual processing difficulties, including challenges with visual attention, visual fields, visual perception, recognition, movement, shape processing, and sensory integration. Interest in identifying and diagnosing children with CVI has increased, and although there is no cure, management focuses on identifying strategies that help children, carers, and teachers understand how the child uses vision and make habilitative adaptations to enable more effective and efficient visual use. Earlier intervention is associated with better visual outcomes. Providing clear, immediate information to families and teachers is key to bridging healthcare and education. Ophthalmologists often first communicate the diagnosis and are expected to offer actionable advice. However, there is a mismatch between the number of qualified teachers of the visually impaired and the number of children, and some services restrict support based on acuity thresholds or registration status. While detailed educational planning is beyond an ophthalmologist’s scope, clinicians should be familiar with global recommendations that support better functional vision. The Delphi technique, which promotes anonymous, iterative expert input to form considered consensus, is well-suited to generating creative, succinct strategies. The aim of this study was to use a Delphi methodology to construct a set of three-word phrases that succinctly describe commonly applicable strategies for children with CVI, to support ophthalmologists and families with immediate, easy-to-understand advice at diagnosis.

Design: Delphi consensus study with four iterative questionnaire rounds. Ethics approval was granted by the University of Bradford Research Ethics Panel. Recruitment and panel: Twelve participants were recruited, including experts known to the author (approached via email) and individuals with experience of CVI recruited via a Twitter post and through CVI Scotland and CVI Society channels. Participants provided informed consent. Data collection: Questionnaires were created in Microsoft Forms and emailed to participants; responses within two weeks were analyzed. Panel composition in Round 1 (n=11 respondents) included education (5; 45%), health professionals (4; 36%), and parents/carers (2; 18%). Consensus definitions and progression criteria: Overall consensus threshold was 70% agreement. Round-specific procedures: Round 1 included demographics and a collated list of CVI-related signs/symptoms from reviews/textbooks. Participants rated how useful strategies for each symptom would be using a 0–3 Likert scale (0=unlikely, 1=not sure, 2=likely, 3=very likely). Items rated 2 or 3 by at least 75% of participants were retained. Additional items suggested by at least two participants were to be added to Round 2 (none were suggested). Round 2 combined items from Round 1 into ten features and asked participants to propose a three-word phrase for each top-ranked option, with additional suggestions allowed. Items with phrases suggested by at least 75% of participants were advanced to Round 3. Round 3 presented all suggested three-word phrases verbatim for each item; participants voted on which phrase best represented a strategy for each symptom or could suggest another option. Items reaching 70% agreement were considered to have achieved consensus. Round 4 re-presented items not achieving consensus in Round 3, showing the most popular prior responses and their vote counts; only options with one or more Round 3 votes were included. Items not reaching consensus after Round 4 would be excluded. Response rates: R1 92% (11/12), R2 67% (8/12; two abstained citing no phrase suggestions), R3 92% (11/12; one withdrew after this round), R4 91% (10/11). Analysis: Responses were summarized by agreement percentages per item per round; items crossing the consensus threshold were retained as final phrases.

- Panel response rates: 92% (Round 1), 67% (Round 2), 92% (Round 3), and 91% (Round 4). - Round 1 identified commonly encountered CVI-related symptoms warranting strategies; items were consolidated into ten features for subsequent rounds. - Consensus threshold was 70% agreement. - Three items reached consensus in Round 3; the remaining seven reached consensus in Round 4; all ten features ultimately reached consensus. - Final consensus set of three-word strategy phrases: • Big Bold Bright (for small/low contrast visibility) • Keep it Still (for difficulty seeing moving objects) • Eyes or Ears (for difficulty using vision and hearing simultaneously) • Show it High (for inferior field use difficulties) • Better on Left/Right (for asymmetric/bilateral field use) • Clear the Clutter (for visual crowding/clutter intolerance) • Keep It Short (for limited sustained visual attention) • Give Me Time (for delayed visual responses/processing) • My Vision Varies (for fluctuating visual function) • Just One Thing (for simultanagnosia/limited multi-item attention) - The phrases are intended as immediately actionable guidance for families and clinicians at diagnosis, applicable across developmental and visual ability levels.

The study addressed the need for concise, accessible strategies that can be provided at the time of CVI diagnosis, bridging the gap between clinical identification and practical support in educational and home settings. By using a Delphi approach across experts in health, education, and those with lived experience, the study distilled complex, heterogeneous CVI-related difficulties into ten succinct three-word phrases. These phrases operationalize common management principles—reducing complexity (Just One Thing, Clear the Clutter), adjusting stimulus properties (Big Bold Bright), managing sensory load (Eyes or Ears), optimizing positioning and fields (Show it High, Better on Left/Right), and accommodating processing and attention limitations (Keep It Short, Give Me Time, Keep it Still, My Vision Varies). High response rates in most rounds are consistent with robust engagement in Delphi studies, and the set of phrases provides a pragmatic toolkit for ophthalmologists and families to implement immediately while awaiting comprehensive educational assessments. The approach emphasizes “make it easier” as an overarching theme to enhance functional vision and supports earlier intervention, which is associated with improved outcomes.

The study produced a consensus-based set of three-word phrases that succinctly communicate strategies to support common visual dysfunctions in children with CVI. These phrases are intended as a starter resource deliverable at diagnosis and suitable across developmental and visual ability levels. Further real-world validation is required to assess how well the phrases map to specific interventions and their impact on visual development.

- Small Delphi panel (n=12) drawn from diverse roles; while within recommended Delphi ranges, it limits generalizability. - Purposive sampling and expert familiarity with the topic may introduce selection bias. - Lower participation in Round 2 (67%), though two abstentions were explained by lack of suggested phrases. - Some divergence in early questionnaires indicates variability in perspectives; the Delphi process may not capture all nuances of CVI-related needs. - The phrases require real-life validation to confirm effectiveness, applicability across contexts, and linkage to specific interventions and outcomes.