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![Page 1: The Ophthalmology of Childhood Vision Impairment Alistair Fielder City University, London This version probably has little stand-alone value but is meant.](https://reader035.fdocuments.in/reader035/viewer/2022070307/551ae437550346f70d8b47cc/html5/thumbnails/1.jpg)
The Ophthalmology of
Childhood Vision Impairment
Alistair Fielder
City University, London
This version probably has little stand-alone value but is meant as an
accompaniement to the lecture
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Topics
• Role of clinician
• Assessment of visual functions
• Causes and epidemiology of VI
• VI issues specific to children
• Patterns of presentation & development
• Impact of VI
• Clinical role
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“Ophthalmologists tell me what I can see,
but it has nothing to do with what I can do”
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Role of Clinician in VIOrthopist, Optometrist & Ophthalmologist
• Diagnosis & quantification• Treatment• Involve & link other agencies• Communication
– Client & family, others
• Registration• Monitor• Research• Maintain contact - be amenable
Through the ages
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What does he see?
How do I measure?
Approximation or precision?
& when can I do this?
How long for parents to wait?
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Paediatric OphthalmologyVision tests
• Visibilitysweets, fixation patterns, Catford drum
• Resolutionpreferential looking, acuity card procedure, Cardiff cards
• RecognitionSnellen, logMAR
• Sensitivity to detect vision impairment
amblyopia
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Vision Assessment - Infancy
• Birth– Fix & follow
• 6 weeks– Smile
• 4 months– Reach
• Anytime– Grating response– History
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Babies have an innate preference to look at patterns, such as a face
This is the basis of visiontesting in infancy
& why parents are such good historians
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What Visual Functions?Their development
• Visual acuity
• Contrast sensitivity
• Colour
• Binocular vision
• Visual field
• Movement
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Causes of VI in Working Years
• Diabetes mellitus• Retinitis pigmentosa• Glaucoma• Trauma• Macular degeneration
Survival
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Childhood Visual Impairment
• Prenatal 60%genetic 50%
intrauterine 10%
• Perinatal 23%ROP 5-10%
asphyxia 13%
• Childhood 13%male preponderance
• Prevalencedeveloped countries 0.3/1000developing countries 0.6 to 1.1/1000
• Additional disability in 40-70%Preterm birth
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Impact of Low Birth Weight on the Visual Pathway
• Severe visual impairment (VI)– all births - 1.25/1000– <1500 g BW - 25.9/1000 births
• 1% of all live births, BUT 17.5% childhood VI• X 26 for babies 2500-3499 g BW
• Associated impairments with VI– <1500 g BW 72%– >3500 g BW 44%
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Categories of VI
• Preventableinfections - trauma - cataract - ROP
anterior segment
• Partially preventableDR - glaucoma - ROP - ARMD - cataract
anterior & posterior segment
• Non-preventablemalformations - genetic - ROP - ARMD glaucoma - cataract
anterior & posterior segment
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Child Who Cannot See Classification
• Obvious ocular abnormality– Anterior & posterior segment
• Cataract• Optic atrophy• ROP +
• No obvious ocular abnormality– Mainly posterior segment or cerebral
• Optic nerve abnormalities– Atrophy - hypoplasia
• Delayed visual maturation• Cortical vision impairment• Retinal anomalies
– Retinoschisis, achromatopsia– Lebers amaurosis– Albinism
• Nystagmus
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Delayed Visual Maturation
• Type 1 - isolated abnormality– A Normal perinatal period– B Perinatal problems
• Type 2 - obvious & permanant neurodevelopmental delay
• Type 3 - nystagmus(albinism)
• Type 4 - severe developmental, structural ocular abnormalities
(not albinism)
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Cerebral Vision Impairment
• Reduced vision• Normal eye examination & pupil
responses• Absence of nystagmus• Natural history
– <75% show some improvement– Early improvement more likely to be
complete
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CVI – Aetiology
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Stage 3: Severe ROP
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Problems with Screening & Treatment
• CRYO-ROP study: intervention @ “threshold” (5 continuous or 8 cumulative clock hours of stage 3+)
• 1988
• Cryotherapy or laser
• Treatment “destroys evidence”
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ROP- End Stage
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Evaluation I
• History• Overview assessment• Full ophthalmic examination including
– Vision assessment– Ophthalmic examination
• Paediatric assessment• Investigations
– Ophthalmic– Paediatric
Children need referring
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Evaluation II
• Ophthalmic tests– Electrophysiology
• VEP• ERG• EOG
– Ultrasound– EUA
• Other tests - biochemical, etc• Neuroimaging• Referral(s)
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Electrophysiological test&
Neuroimaging
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Nystagmus
Is the pattern of nystagmus informative?• Vision• Localisation
– Anterior – Posterior
• Aetiology– Ocular– Neurological
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Patterns of Presentation
• Sudden & dramatic
• Insidious
• Masked
effect of attending an ophthalmic unit
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Predictive Value of Vision Tests
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Patterns of visual development
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Patterns of Visual Development
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Patterns of Visual Development
Vision deficit resulting from any obstacle to visual development
SquintBlurred vision Refractive
Opacity
Especially of 1 eye
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Impact of VI on the Child
• Visual functions• Cognitive
– Perception of objects in their totality & in environment– Spatial and intermodal interaction impaired
• Motor development - complex• Language• Social play, social interaction• Poor self-concept & low self-esteem• Other behaviours - eg sleep
Education, leisure, social, health
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Sleeping patterns of visually impaired
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Impact of VI on the Family
• Diagnosis generated– Phases of grief, anger, loss & fear
• More care required for daily living tasks
• Lack of responsiveness by child– Loneliness, anxiety, depression in parents
• Behavioural problems in siblings
• Marital stress
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“Ophthalmologists tell me what I can see,
but it has nothing to do with what I can do”
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VI - Impact on Child & Family
The 5 senses interact & are interdependent, so VI has widespread &
cumulative impact on development
In most instances -
VI is not stable during childhood,
thus its impact on life’s activities varies
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Impact of VI on the Child
• Visual functions• Cognitive
– Perception of objects in their totality & in environment– Spatial and intermodal interaction impaired
• Motor development - complex• Language• Social play, social interaction• Poor self-concept & low self-esteem• Other behaviours - eg sleep
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Disability & Divergence from Full Function
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Impact of VI on the Family
• Diagnosis generated– Phases of grief, anger, loss & fear
• More care required for daily living tasks
• Lack of responsiveness by child– Loneliness, anxiety, depression in parents
• Behavioural problems in siblings
• Marital stress
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Functional Effects of VI
• VI severity – Total - severe - mild
• What do these categories mean for each activity of life?– Education, leisure, social, health
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What is Functional Vision ?
• Acuitydistance & nearspeed of reading & information processing
• Contrast• Colour• Field of vision• Illumination• Movement
What do we measure?
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Role of Clinician in VI
• Diagnosis & quantification• Treatment?• Involve & link other agencies• Communication
– Client & family, others
• Registration• Monitor• Research• Maintain contact - be amenable
Through the ages
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VI Support
• Medicalphysicianophthalmic
• Opticalspectacles
LVAs
• Rehabilitation• Social services• Education• Registration
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Disability Through the Ages
• Diagnosis• Infancy• Preschool• School age• After school• Adult life
Much VI is not stable
Info forgotten, misheard, wrong, updatable
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Communication
• Between & within– Services - statutory and voluntary– Locations - community & hospital, etc– Professions
• When?– Depends on individual’s & family requirements
• Education, occupation, social, leisure, health, etc
• For whom?– Client & professional
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Treatment
the eye
Treatment
the child & family
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Components of Disability Care
• Specialist expertise• Always available & amenable• Affordable• Communication• Link - education, health, social services • Involve the client - parents• Key worker