By the next century the iconic depiction of the Virgin enthroned carrying the infant Christ was established, as in the example from the only group of icons surviving from this period, at Saint Catherine's Monastery, Mount Sinai. This type of depiction, with subtly changing differences of emphasis, has remained the mainstay of depictions of Mary to the present day. The image at Mount Sinai succeeds in combining two aspects of Mary described in the Magnificat, her humility and her exaltation above other humans.

At this period the iconography of the Nativity was taking the form, centred on Mary, that it has retained up to the present day in Eastern Orthodoxy, and on which Western depictions remained based until the High Middle Ages. Other narrative scenes for Byzantine cycles on the Life of the Virgin were being evolved, relying on apocyphal sources to fill in her life before the Annunciation to Mary. By this time the political and economic collapse of the Western Roman Empire meant that the Western, Latin, church was unable to compete in the development of such sophisticated iconography, and relied heavily on Byzantine developments.

The earliest surviving image in a Western illuminated manuscript of the Madonna and Child comes from the Book of Kells of about 800 (there is a similar carved image on the lid of St Cuthbert's coffin of 698) and, though magnificently decorated in the style of Insular art, the drawing of the figures can only be described as rather crude compared to Byzantine work of the period. This was in fact an unusual inclusion in a Gospel book, and images of the Virgin were slow to appear in large numbers in manuscript art until the book of hours was devised in the 13th century.

Very few early images of the Virgin Mary survive, though the depiction of the Madonna has roots in ancient pictorial and sculptural traditions that informed the earliest Christian communities throughout Europe, Northern Africa and the Middle East. Important to Italian tradition are Byzantine icons, especially those created in Constantinople (Istanbul), the capital of the longest, enduring medieval civilization whose icons participated in civic life and were celebrated for their miraculous properties. Byzantium (324-1453) saw itself as the true Rome, if Greek-speaking, Christian empire with colonies of Italians living among its citizens, participating in Crusades at the borders of its land, and ultimately, plundering its churches, palaces and monasteries of many of its treasures. Later in the Middle Ages, the Cretan school was the main source of icons for the West, and the artists there could adapt their style to Western iconography when required.