Vision in children with hydrocephalus

Bi-allelic truncating variants in CASP2 underlie a neurodevelopmental disorder with lissencephaly

Lissencephaly (LIS) is a malformation of cortical development due to deficient neuronal migration and abnormal formation of cerebral convolutions or gyri. Thirty-one LIS-associated genes have been previously described. Recently, biallelic pathogenic variants in CRADD and PIDD1, have associated with LIS impacting the previously established role of the PIDDosome in activating caspase-2. In this report, we describe biallelic truncating variants in CASP2, another subunit of PIDDosome complex. Seven patients from five independent families presenting with a neurodevelopmental phenotype were identified through GeneMatcher-facilitated international collaborations. Exome sequencing analysis was carried out and revealed two distinct novel homozygous (NM_032982.4:c.1156delT (p.Tyr386ThrfsTer25), and c.1174 C > T (p.Gln392Ter)) and compound heterozygous variants (c.[130 C > T];[876 + 1 G > T] p.[Arg44Ter];[?]) in CASP2 segregating within the families in a manner compatible with an autosomal recessive pattern. RNA studies of the c.876 + 1 G > T variant indicated usage of two cryptic splice donor sites, each introducing a premature stop codon. All patients from whom brain MRIs were available had a typical fronto-temporal LIS and pachygyria, remarkably resembling the CRADD and PIDD1-related neuroimaging findings. Other findings included developmental delay, attention deficit hyperactivity disorder, hypotonia, seizure, poor social skills, and autistic traits. In summary, we present patients with CASP2-related ID, anterior-predominant LIS, and pachygyria similar to previously reported patients with CRADD and PIDD1-related disorders, expanding the genetic spectrum of LIS and lending support that each component of the PIDDosome complex is critical for normal development of the human cerebral cortex and brain function.

The prevalence of strabismus and visual outcomes in children with hydrocephalus and a ventriculoperitoneal shunt: medical record review

BACKGROUND

Many ophthalmological complications have been associated with hydrocephalus (HC), including ocular motility disorders, visual field defects, optic atrophy, and loss of visual acuity. No studies have investigated the prevalence of strabismus and visual outcomes of children with congenital HC after ventriculoperitoneal (VP) shunt in Saudi Arabia.

OBJECTIVES

Estimate the frequency of strabismic children diagnosed with HC who underwent a VP shunt procedure.

DESIGN

Medical record review SETTING: Tertiary care center PATIENTS AND METHODS: We reviewed the files of all pediatric patients diagnosed with hydrocephalus before the age of 2 years and treated with shunts during the period 2010 to 2020 at our institution.

MAIN OUTCOME MEASURES

Strabismus types and ophthalmic assessment (visual state, outcomes, and ocular motility state).

SAMPLE SIZE AND CHARACTERISTICS

190 children; 98 (51.5%) males.

RESULTS

Eighty-nine (46.8%) had congenital HC followed by intraventricular hemorrhage 36 (18.9%); 74 (38.9%) patients had regular follow-ups in ophthalmology. Sixty-five (34.2%) patients had no ophthalmic assessment or fundus examination records, while 63 (33.1%) were diagnosed with strabismus. At the initial assessment, 26 (13.6%) patients had exotropia (XT). At the final assessment, 7 (3.6%) patients had XT. The association between VP shunt and strabismus was statistically significant, (χ²=6.534, df=1, P<.01).

CONCLUSION

More than one-third of children diagnosed with HC who had surgical treatment in a tertiary hospital did not have any records of ophthalmic assessment, which highlights the need to implement a specific ophthalmological examination protocol in patients with HC. Further studies are needed to analyze the association between VP shunt and strabismus.

LIMITATIONS

Evaluating the ocular state and visual function before and after VP shunt was not possible.

CONFLICT OF INTEREST

None.

Clinimetric properties of visuo-perceptual and visuo-cognitive assessment tools used for children with cerebral visual impairment and cerebral palsy or developmental delay: a systematic review

PURPOSE

The aim of this systematic review is to evaluate the psychometrics and clinical utility of visuo-perceptual and visuo-cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP) or neurodevelopmental delay (DD).

MATERIALS AND METHODS

Five databases (PubMed, EMBASE, SCOPUS, CINAHL, and Cochrane Database) were comprehensively searched from 1970 till June 2021. The PRISMA checklist was utilised to report on the process of selecting eligible papers. The methodological quality of included studies was evaluated using COnsenus-based Standards for the selection of health Measurement INstrument (COSMIN) checklist.

RESULTS

Of the 26 assessment tools identified, only seven tools had psychometric evidence supporting their use. Based on COSMIN guidelines, 60% of included studies were rated as inadequate or doubtful for their methodological quality of measurement properties, with equal number being rated as indeterminate on the overall rating.

CONCLUSIONS

Cerebral visual impairment due to its varied clinical presentation is often missed in children with CP and DD. There is a paucity of studies reporting on the validity and reliability of functional vision tools. Further studies are needed to conduct high-quality psychometric reporting using the updated COSMIN guidelines to identify appropriate functional vision tools for children with CP or DD.Implications for rehabilitationThere are paucity of studies evaluating the validity and reliability of existing perceptual and cognitive assessment tools in children with cerebral visual impairment (CVI) and cerebral palsy (CP).Development of age-appropriate assessment tools evaluating all aspects of functional vision will assist in providing more holistic child-centric rehabilitation programs.A combination of detailed perinatal history, direct observation, and clinical assessments of functional vision are important to recognise CVI in children with CP.

Referral thresholds for an integrated learning disability eye care pathway: a consensus approach

INTRODUCTION

Local Optometric Support Unit (LOCSU) have published their refreshed clinical pathway for eye care for people with a learning disability. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for a person with learning disability attending a primary eye care assessment. The pathway specifically points to the need to retain patients in primary care where appropriate and 'reduce the number of people with learning disability who are inappropriately referred into the Hospital Eye Service (HES).' Pivotal to this refreshed pathway is the integration with secondary care, with local arrangements to facilitate referral and hospital management where appropriate. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability.

METHOD

A series of video interviews were undertaken with eye health professionals with a range of experience in eye care for people with learning disability. Each contributor commented on the usability and clarity of each element of the referral criteria. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. These were collated into the final document which was circulated and agreed by all participants.

RESULTS

A table setting out referral thresholds for commonly encountered eye conditions in adults with learning disabilities is presented.

CONCLUSION

We have presented a succinct set of consensus statements relating referral thresholds for common presentations of visual problems in adults with learning disability in the UK distilled from the collective experience of a group of eye health professionals. The intention was not to present a comprehensive review of management of each condition. Rather, the consensus statements may form the starting point from which each area could develop locally agreed criteria, as is suggested by the LOCSU pathway guidance.

Visual perception problems and quality of life in young adults with foetal alcohol spectrum disorders

PURPOSE

To investigate visual perception problems (VPPs), health-related quality of life (HRQoL) and vision-related quality of life (VRQoL) in young adults with foetal alcohol spectrum disorders (FASD) and to compare the results with healthy controls.

METHODS

Thirty young adults with FASD (13 female; mean age 23 years) and 29 controls (20 female; mean age 25 years) participated. Five areas of VPPs were assessed by a structured history-taking. In the FASD group, VPPs were investigated both in childhood (mean age 8 years) and in early adulthood in a prospective follow-up. Health-related quality of life (HRQoL) was investigated with the Pediatric Quality of Life Inventory™ (PedsQL) and VRQoL with the 25-item Visual Function Questionnaire (VFQ-25).

RESULTS

Visual perception problems (VPPs) in at least one area were reported by 16/30 FASD participants (53%) and 1/29 controls (3%) (p = 0.0001, Fisher's exact test), with a similar rate in the same individuals in childhood as in early adulthood (8/27 and 15/27, respectively p = 0.09, McNemar's test). PedsQL total score was lower in the FASD group (n = 20; median: 83; 95% confidence interval (CI) 76-88) compared with controls (n = 29; median: 91; 95% CI 90-95; p = 0.0001, Mann-Whitney U-test). VFQ-25 subscale general vision indicated lower VRQoL in the young adults with FASD (n = 19; median: 80; 95% CI 80-100) compared with controls (n = 29; median: 100; 95% CI 100-100; p = 0.003).

CONCLUSION

Young adults with FASD in the present study had more VPPs and worse VRQoL and HRQoL than healthy controls. In the FASD group, VPPs were reported in childhood as well as in early adulthood.

Cortical Visual Impairments and Learning Disabilities

Medical advances in neonatology have improved the survival rate of premature infants, as well as children who are born under difficult neurological conditions. As a result, the prevalence of cerebral dysfunctions, whether minimal or more severe, is increasing in all industrialized countries and in some developing nations. Whereas in the past, ophthalmological diseases were considered principally responsible for severe visual impairment, today, all recent epidemiological studies show that the primary cause of blindness and severe visual impairment in children in industrialized countries is now neurological, with lesions acquired around the time of birth currently comprising the commonest contributor. The resulting cortical or cerebral visual impairments (CVIs) have long been ignored, or have been confused either with other ophthalmological disorders causing low vision, or with a range of learning disabilities. We present here the deleterious consequences that CVI can have upon learning and social interaction, and how these can be given behavioral labels without the underlying visual causes being considered. We discuss the need to train and inform clinicians in the identification and diagnosis of CVI, and how to distinguish the diagnosis of CVI from amongst other visual disorders, including the specific learning disorders. This is important because the range of approaches needed to enhance the development of children with CVI is specific to each child's unique visual needs, making incorrect labeling or diagnosis potentially detrimental to affected children because these needs are not met.

Pattern of oculomotor and visual function in children with hydrocephalus

PURPOSE

To investigate the ocular motility disturbances, optic nerve changes, and refractive errors in children with or without surgically treated hydrocephalus.

METHODS

This retrospective study included 63 subjects diagnosed with hydrocephalus between 2007 and 2019 at the Baskent University Hospital. Full orthoptic and ophthalmic examination and brain magnetic resonance imaging were performed in all subjects.

RESULTS

The mean age of patients was 68.4±27.6 months, and the mean follow-up time was 21.3±5.2 months. Twenty-one (51.2%) patients had esotropia (ET), and 14 (34.1%) had exotropia (XT). Of the patients with ET, 9 (14.2%) had a sixth nerve palsy. Four patients (6.3%) had a fourth nerve palsy, and 1 had a superior rectus palsy. Eleven patients had manifest, and 2 latent, nystagmus. Thirteen (20.6%) patients had optic disc abnormalities. The mean BCVA was 0.4±0.2 (0.05-1.0) in the right eye and 0.5±0.2 (0.1-1.0) in the left eye. Of the 19 (30.1%) patients who had a significant refractive error, 9 (47.3%) had hyperopia. Thirty-six (57.1%) patients had ventriculoperitoneal shunt surgery, and 11 (30.5%) of them had shunt revision due to occlusion. Ocular motility disorders were found to be significantly more common in patients who underwent single shunt surgery and shunt revision than those who had no surgical procedure (P=0.041and P=0.032, respectively).

CONCLUSION

The evaluation of ocular motility disorders and visual dysfunction in hydrocephalic children can be a source of valuable information when diagnosing and following the disease.

Neuroophthalmological manifestations of congenital aqueductal stenosis

OBJECTIVE

Congenital aqueductal stenosis (CAS) is a common etiology of hydrocephalus that occurs in a subset of infants and may be linked to an increased incidence of ophthalmological abnormalities and delayed developmental milestones. Although hydrocephalus is common and widely studied, sparse literature exists on patients with isolated (no identifiable genetic link) CAS along with analysis of ophthalmological manifestations. In this study, the authors sought to describe the ophthalmological abnormalities and delayed developmental milestones of patients with isolated CAS.

METHODS

Data of patients with CAS were prospectively entered and monitored in a surgical database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh from January 2005 to October 2016. Patients with a family history of congenital hydrocephalus, positive testing for genetic forms of aqueductal stenosis, other congenital abnormalities suggesting an underlying genetic syndrome, and stenosis/obstruction due to secondary causes were excluded from this study. Prenatal and perinatal history, CSF diversion history, and a variety of outcomes, including ophthalmological deficits and developmental milestones, were collected and analyzed.

RESULTS

A total of 41 patients with isolated CAS were identified, with a mean follow-up duration of 6 years. Among that cohort, 26 patients (63.4%) developed neuroophthalmological complications, which were further stratified. Fourteen patients (34.1%) developed strabismus and 11 (26.8%) developed astigmatism, and 1 patient (2.4%) with papilledema was recorded. Among patients with ophthalmological abnormalities, 76.9% had delayed developmental milestones (p = 0.045).

CONCLUSIONS

Patients with CAS were found to have increased risk of ophthalmological abnormalities requiring correction, along with an increased risk of delayed developmental milestones. Importantly, there was a significant correlation between the development of ophthalmological abnormalities and delayed developmental milestones that was independent of CSF diversion history. Larger patient cohort studies are required to explore whether earlier development of hydrocephalus, as is the case in CAS, causes elevated rates of neurological and ophthalmological complications, and if earlier CSF diversion correlates with improved outcomes.

What assessments are currently used to investigate and diagnose cerebral visual impairment (CVI) in children? A systematic review

PURPOSE

Cerebral visual impairment (CVI) is the leading cause of childhood visual impairment in the developed world. Despite this, there are no agreed clinical guidelines for the investigation and diagnosis of the condition. Before development of such guidelines can commence, it is important to recognise which approaches are currently employed. This systematic review evaluated the literature to identify which methods of assessment are currently used to investigate and diagnose childhood CVI.

METHODS

Medline, Embase, CINAHL, Scopus and the Cochrane Library databases were systematically searched in January 2020 using defined search terms. Articles were included if they: (i) were research papers, conference abstracts or research protocols published in peer-reviewed scientific journals, or relevant textbooks; (ii) included a clinical investigation of CVI in children; (iii) provided an explanation or criteria to diagnose CVI and (iv) were specifically investigating cerebral/cortical visual impairment. Methods used to a) assess and b) diagnose CVI were extracted from included articles. 'Assessment scores' were assigned for each method employed by researchers to investigate and diagnose CVI to quantify and compare approaches between articles. A quality grading was also applied to each article.

RESULTS

Of 6454 identified articles, 45 met the inclusion criteria. From these, 10 categories of assessment utilised within included articles were identified: (1) Medical history, (2) Vision assessment/ophthalmologic examination, (3) Neuroimaging, (4) Visual behaviour and direct observation, (5) Structured history-taking, (6) Visual perception tests, (7) Ocular movement and posture assessment, (8) Intelligence/IQ assessment, (9) Clinical electrophysiology and (10) Neurodevelopmental tests. In terms of diagnostic criteria, the most commonly reported approach was one of exclusion, i.e., CVI was diagnosed when visual dysfunction could not be attributed to abnormalities detected in the anterior visual pathway.

CONCLUSION

There is a lack of common practice in the approaches used by clinicians to investigate and diagnose CVI in children. At present, a 'diagnosis of exclusion' remains the most common means to diagnose CVI. Development of clinical guidelines for assessment and diagnosis are necessary to ensure consistency in the diagnosis of CVI and the timely implementation of support to alleviate the impact of CVI on the child's daily living.

Brain Damage and Visuospatial Impairments: Exploring Early Structure-Function Associations in Children Born Very Preterm

BACKGROUND

To provide insight into early neurosensory development in children born very preterm, we assessed the association between early structural brain damage and functional visuospatial attention and motion processing from one to two years corrected age.

METHODS

In 112 children born at less than 32 weeks gestational age, we assessed brain damage and growth with a standardized scoring system on magnetic resonance imaging (MRI; 1.5 Tesla) scans performed at 29 to 35 weeks gestational age. Of the children with an MRI scan, 82 participated in an eye tracking-based assessment of visuospatial attention and motion processing (Tobii T60XL) at one year corrected age and 59 at two years corrected age.

RESULTS

MRI scoring showed good intra- and inter-rater reproducibility. At one year, 10% children had delayed attentional reaction times and 23% had delayed motion reaction times. Moderate to severe brain damage significantly correlated with slower visuospatial reaction times. At two years, despite attention and motion reaction times becoming significantly faster, 20% had delayed attentional reaction times and 35% had delayed motion reaction times, but no correlations with MRI scores were found. The presence of structural brain damage was associated with abnormal functional performance over age.

CONCLUSIONS

The present study indicates an association between moderate to severe brain damage and visuospatial attention and motion processing dysfunction at one year corrected age. This provides a new perspective on comprehensive MRI scoring and quantitative functional visuospatial assessments and their applicability in children born very preterm in their first years of life.

Functioning of the children with hydrocephalus

The objective of the study was to examine selected aspects of the functioning of children treated for hydrocephalus, with particular emphasis on their degree of independence. Analysis of the medical records of patients treated for hydrocephalus in the Department of Pediatric Neurosurgery in Katowice in 2000–2010. The Barthel scale was used to assess the children’s independence. Information on the children’s functioning was obtained directly from their parents using a questionnaire developed by the author. The parent group comprised 131 people, including 110 women (85%) and 21 men (15%). The study group comprised 131 children treated for hydrocephalus. In the examined group, 59 children (45%) were fully independent (first degree), 44 (34%) were partially independent (second degree) and 28 (21%) were completely dependent (third degree). Most of the children with congenital and post-inflammatory hydrocephalus attended the generally accessible school (public school), while the majority of the children with posthemorrhagic hydrocephalus attended rehabilitation and educational centers or special schools (p < 0.05) The lowest level of independence was found for children with hemorrhagic hydrocephalus who had undergone repeated operations. The child’s degree of independence and the etiology of hydrocephalus determined the type of school the child attended. The study’s results indicate that rehabilitation plays a key role in the lives of children with hydrocephalus.

Cerebral visual impairment captured with a structured history inventory in extremely preterm born children aged 6.5 years

PURPOSE

To investigate whether a questionnaire can identify cerebral visual impairment (CVI) in a group of 6.5-year-old children born extremely preterm (EPT) as accurately as direct assessments.

METHODS

This prospective population-based study included 120 children born before 27 weeks' gestational age (66 males; mean, 25.4 ± 1.0 weeks) and 97 full-term controls (56 males; mean, 39.9 ± 1.1 weeks) at the age of 6.5 years, as part of the Extremely Preterm Infants in Sweden Study (EXPRESS). A questionnaire for detection of CVI was evaluated and compared with visual, perceptual, and cognitive assessments.

RESULTS

Parents of children born EPT reported more CVI features than the parents of control children, with median sum scores of 25 (95% CI, 18.1-31.9) and 11 (95% CI, 8.8-13.2), respectively (P < 0.001), and a median difference of 14 (95% CI, 6.6-21.4). Low rates of reported CVI features were significantly associated with better results from direct assessments within the EPT group and with less pronounced differences compared to controls.

CONCLUSIONS

The questionnaire discriminated well between children born EPT and controls, and the scores were congruent with other evidence of visual, perceptual, and cognitive deficits. The easily used questionnaire compared favorably with direct assessment in identifying CVI in children born EPT and also provides valuable information to clinicians, and parents about the daily life problems associated with CVI.

Neuroplasticity in cerebral visual impairment (CVI): Assessing functional vision and the neurophysiological correlates of dorsal stream dysfunction

Cerebral visual impairment (CVI) results from perinatal injury to visual processing structures and pathways and is the most common individual cause of pediatric visual impairment and blindness in developed countries. While there is mounting evidence demonstrating extensive neuroplastic reorganization in early onset, profound ocular blindness, how the brain reorganizes in the setting of congenital damage to cerebral (i.e. retro-geniculate) visual pathways remains comparatively poorly understood. Individuals with CVI exhibit a wide range of visual deficits and, in particular, present with impairments of higher order visual spatial processing (referred to as "dorsal stream dysfunction") as well as object recognition (associated with processing along the ventral stream). In this review, we discuss the need for ongoing work to develop novel, neuroscience-inspired approaches to investigate functional visual deficits in this population. We also outline the role played by advanced structural and functional neuroimaging in helping to elucidate the underlying neurophysiology of CVI, and highlight key differences with regard to patterns of neural reorganization previously described in ocular blindness.

Ophthalmologic disorders and risk factors in children with autism spectrum disorder

PURPOSE

To report the results of our review of all children with autism spectrum disorder (ASD) who underwent complete pediatric ophthalmologic examination at our institution over a 10-year period.

METHODS

The medical records of all children (0-17 years of age) with a diagnosis of ASD seen at University of California, Davis, over a 10-year period were reviewed retrospectively. Demographic data, birth history, genetic testing results, neuropsychiatric comorbidities, and ophthalmologic findings were extracted from the record. Multiple logistic regression was used to identify risk factors for ophthalmologic disorders.

RESULTS

A total of 2,555 children with ASD were seen at the university over the study period, of whom 380 (15%) were evaluated in the ophthalmology clinic. Eye examination revealed an ophthalmic diagnosis in 71% of children, of which the most common were significant refractive error (42%), strabismus (32%), and amblyopia (19%). Optic neuropathy occurred in 14 children (4%). Cerebral palsy was a significant risk factor for refractive error (OR = 3.22; P = 0.016), strabismus (OR = 3.59; P = 0.012), amblyopia (OR = 3.49; P = 0.0097), and optic neuropathy (OR = 14.0; P = 0.0009).

CONCLUSIONS

Ophthalmic disorders were found in 71% of children with ASD evaluated at our university-based ophthalmology clinic. The rates of significant refractive error, strabismus, amblyopia, and optic neuropathy exceeded those of the general pediatric population. ASD and cerebral palsy may have additive risk for these disorders.

Association between improvement of clinical signs and decrease of ventricular volume after ventriculoperitoneal shunting in dogs with internal hydrocephalus

BACKGROUND

One of the remaining questions in treating dogs with internal hydrocephalus is the association between the decrease of ventricular volume and re-expansion of cerebral parenchyma with clinical improvement.

HYPOTHESIS

A decrease in ventricular volume and re-expansion of brain tissue occur after ventriculoperitoneal shunting (VPS). Clinical improvement defined by resolution of ≥1 clinical signs is associated with decreased size of cerebral ventricles and that the extent of change in ventricular size is associated with clinical improvement.

ANIMALS

Forty-five client-owned dogs with newly diagnosed communicating internal hydrocephalus.

METHODS

Ventricular volume, brain volume, and clinical status of dogs that underwent VPS were measured before and 3 months after surgery. Multiple logistic regression analysis was performed to assess the influence of decrease in ventricular size in addition to the covariates "age of the animal" and "duration of clinical signs before surgery" on improvement of clinical signs.

RESULTS

Decreased volume of cerebral ventricles was associated with resolution of ≥1 preoperative clinical sign (P < .003). The covariates "age of the animal" and "duration of clinical signs" were not associated with improvement of clinical signs. The percentage decrease in ventricular size was associated with resolution of ataxia (P = .008) and obtundation (P = .011).

CONCLUSION AND CLINICAL IMPORTANCE

The decrease in ventricular volume and increase in brain parenchyma after VPS are associated with improvement in clinical signs.

Towards population screening for Cerebral Visual Impairment: Validity of the Five Questions and the CVI Questionnaire

Introduction

Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the developed world and appears to be more prevalent in children with additional support needs (ASN). There is an urgent need for routine screening for CVI, particularly in children with ASN, however, current screening questionnaires for CVI have limited validation. The aim of this study was to evaluate two screening tools: the Five Questions and the CVI Questionnaire. Additionally, the distribution of CVI across neurodevelopmental disorders is unknown. This too was investigated.

Methods

An online survey was completed by 535 parents. The survey was advertised via social media, CVI websites and parent email systems of four schools. The survey comprised of the Five Questions, the CVI Questionnaire and additional questions regarding the child’s diagnoses. Whether or not a child had a diagnosis of CVI and/or additional neurodevelopmental disorders was based on parental report.

Results

Based on parent reports, both the screening tools accurately screened for CVI diagnoses in children. The Five Questions and the CVI Questionnaire have construct validity (as determined through factor analysis), high internal consistency (as determined by Cronbach’s alpha) and convergent validity (as determined by correlation analysis of the raw scores of each questionnaire). This study also highlights that among children with neurodevelopmental disorders, a large proportion have parent-reported CVI (23%-39%) and potential CVI (6.59–22.53%; as identified by the questionnaires).

Conclusion

The current study demonstrates that the Five Questions and CVI Questionnaire have good convergent validity, internal consistency and a reliable factor structure and may therefore be suitable as screening tools. The study also highlights that reported or potential CVI is evident in a large proportion of children with neurodevelopmental disorders.

Health-related Quality of Life in Children with Congenital Hydrocephalus and the Parental Concern: An Analysis in a Developing Nation

Purpose:

To analyze quality of life of children operated for congenital hydrocephalus and the concern of parents in taking care of these children.

Methods:

Thirty patients who underwent ventriculo-peritoneal shunt were randomly selected with minimum gap of 1 year between surgery and study. Canadian validated questionnaire was used. Overall health score (OHS) and parental concern score (PCS) were correlated with gender, family type and number of surgeries.

Results:

Mean OHS was 159.43 which was summation of physical health (mean 45.76), social-emotional (mean 80.03) and cognitive health scores (mean 33.66). Mean OHS was 151.57 for males and 177.77 for females (p-value 0.233). Nuclear and joint families had mean OHS of 160.36 and 158.89 respectively (p-value 0.944). Those who underwent one surgery had mean OHS of 167.48 and PCS of 23.10 whereas mean OHS was 140.66 and PCS was 27.78 for those with multiple procedures. Mean PCS for males was 26.71 and for females was 19.33 (p-value 0.036 statistically significant). This was not statistically significant between nuclear (24.73) and joint families (24.26).

Conclusions:

Quality of life of survivors of hydrocephalus is reasonably good even in developing countries due to keen parental involvement irrespective of gender, family type and number of surgeries.

Visual function in infants with congenital hydrocephalus with and without myelomeningocoele

OBJECTIVES

Congenital hydrocephalus without or with associated myelomeningocoele has impaired visual function as a potential complication. The present study was embarked on to determine the frequency of optic nerve deficits and refractive errors in this group of children and document any relationship to neuroradiological measurements.

MATERIALS AND METHODS

All infants with congenital hydrocephalus associated with myelomeningocoele (MHC) and congenital hydrocephalus without myelomeningocoele (HC) were prospectively studied. The children underwent clinical neuro-ophthalmological evaluation and neuroimaging. Radiological confirmation and severity of hydrocephalus was by Evans ratio (frontal and occipital) and third ventricular diameter.

RESULTS

There were 50 children (27 boys and 23 girls, median and mean age of 6 and 5.4 months, respectively) included in the study. Eighteen patients (36%) had no or poor visual tracking and fixation, while nine (18%) patients had optic atrophy. Optic atrophy was significantly associated with the HC group (p = 0.007), while the MHC group was significantly associated with a lower Evans ratio (occipital ratio, p = 0.000; frontal ratio, p = 0.000). Forty-nine patients had anisometropia. The refractive errors were more commonly hypermetropia (46 patients). This was not significantly associated with HC or MHC (0.309).

CONCLUSION

Optic atrophy rarity in MHC is probably due to early presentation of the patients and lower Evans ratio (occipital and frontal). Evans ratio is a good predictive index for optic atrophy in infantile congenital hydrocephalus. Refractive errors frequency is not dependent on an association of myelomeningocoele with or without hydrocephalus.

Quality of life in adults treated in infancy for hydrocephalus

PURPOSE

The objective was to analyze quality of life in a very long-term follow-up study of now adult individuals, treated for hydrocephalus (without spina bifida) during infancy.

METHODS

The entire series was population-based, and the subgroup under study consisted of the 29 individuals without intellectual disability, who consented to participate. About one third had concomitant mild cerebral palsy or epilepsy or both. A Finnish validated questionnaire, the 15D, was used to measure quality of life.

RESULTS

There was no significant difference between the study group and the controls with regard to the total quality of life score. Individuals with associated cerebral palsy and/or epilepsy had a lower total score compared with both those without associated impairments and controls. Most participants differed from controls in the dimension of mental/memory function which pertains to executive functions, an ability of considerable importance for daily life skills.

CONCLUSION

It is important to follow children with hydrocephalus over time--due to the different etiological panorama, interventions, and associated impairments this group displays. This is the only way to learn more about critical factors that require attention and that predict quality of life in adulthood.

Pediatric hydrocephalus outcomes: a review

The outcome of pediatric hydrocephalus, including surgical complications, neurological sequelae and academic achievement, has been the matter of many studies. However, much uncertainty remains, regarding the very long-term and social outcome, and the determinants of complications and clinical outcome. In this paper, we review the different facets of outcome, including surgical outcome (shunt failure, infection and independence, and complications of endoscopy), clinical outcome (neurological, sensory, cognitive sequels, epilepsy), schooling and social integration. We then provide a brief review of the English-language literature and highlighting selected studies that provide information on the outcome and sequelae of pediatric hydrocephalus, and the impact of predictive variables on outcome. Mortality caused by hydrocephalus and its treatments is between 0 and 3%, depending on the duration of follow-up. Shunt event-free survival (EFS) is about 70% at one year and 40% at ten years. The EFS after endoscopic third ventriculostomy (ETV) appears better but likely benefits from selection bias and long-term figures are not available. Shunt infection affects between 5 and 8% of surgeries, and 15 to 30% of patients according to the duration of follow-up. Shunt independence can be achieved in 3 to 9% of patients, but the definition of this varies. Broad variations in the prevalence of cognitive sequelae, affecting 12 to 50% of children, and difficulties at school, affecting between 20 and 60%, attest of disparities among studies in their clinical evaluation. Epilepsy, affecting 6 to 30% of patients, has a serious impact on outcome. In adulthood, social integration is poor in a substantial number of patients but data are sparse. Few controlled prospective studies exist regarding hydrocephalus outcomes; in their absence, largely retrospective studies must be used to evaluate the long-term consequences of hydrocephalus and its treatments. This review aims to help to establish the current state of knowledge and to identify conflicting data and unanswered questions, in order to direct future studies.

Adult outcome of pediatric hydrocephalus

INTRODUCTION

The outlook of pediatric hydrocephalus has spectacularly improved over the past decades; however, the adult outcome is still poorly documented. Determining the healthcare profile of these patients is important in order to organize the management of this growing population. We decided to review our pediatric hydrocephalus database for pediatric patients treated for hydrocephalus and followed up into adulthood.

METHODS

Our institution has a virtual monopoly for pediatric hydrocephalus, serving a four-million-plus population; the transition to adult care is also managed in the same institution. We retrospectively reviewed patients younger than 18 treated for hydrocephalus since 1980 and followed up beyond the age of 20.

RESULTS

We reviewed 456 patients, with a mean initial age of 55.6 months, and followed up for a mean of 24.2 years. In 81 patients (17.8%), the last shunt operation occurred after 20 years; 22 of these (4.9% of the total) having never been revised earlier. Sixteen patients (3.5%) could be weaned of their shunt. Thirteen patients died in adult age, 5 of these dying of shunt-related causes. The most prominent sequels were motor (46.5%) and cognitive (47.6%); only 82 patients (18.0%) had no sequel at all. Intelligence quotient values were ≥80 in 54.5% of tested patients; however, schooling was normal in only 41.4%, and only 33.7% was employed in the competitive labor market.

CONCLUSION

Adults treated for hydrocephalus in childhood require a life-long follow-up. Late mortality is low but not null, morbidity is high, and many patients require shunt surgery during adulthood. The transition from child to adult neurosurgery needs to be organized for these vulnerable patients.

Very long-term follow-up of adults treated in infancy for hydrocephalus

PURPOSE

The purpose of this study is to perform a population-based, very long-term follow-up of adults who had been shunt treated for hydrocephalus in infancy.

METHODS

The 72 children with hydrocephalus born in 1967-1978 in western Sweden, who had participated in a follow-up at school age, were re-examined at 30-43 years of age. The 29 with mental retardation were described in terms of developmental level and survival, whereas the remaining 43 were invited to take part in a follow-up and 28 accepted. The assessments included a semi-structured interview pertaining to medical issues, academic achievements and social function.

RESULTS

Six children had died, i.e. a mortality rate of 8%. Mental retardation was present in 29 (40%), severe (IQ <50) in 13 and mild (IQ 50-70) in 16. Four of the 28 (14%) had cerebral palsy and 8 (28%) had other motor problems. Five (18%) had epilepsy and nine (32%) had visual impairments. A total of 20 (71%) reported some kind of health problem. Repeated revisions of the shunt had been performed in 23 (82%). Many worried about their shunt and requested a systematic medical follow-up. Nineteen subjects (68%) lived with a partner and 16 (57%) were parents. The majority had completed secondary school and 9 (32%) had completed university studies, while 18 (64%) worked full time, equal to the general population.

CONCLUSION

In general, the group of normally gifted individuals with hydrocephalus, who had been shunt treated during infancy, was functioning well as adults and participated in society to the same extent as other people.

Visual perceptual difficulties and under-achievement at school in a large community-based sample of children

Introduction

Difficulties with visual perception (VP) are often described in children with neurological or developmental problems. However, there are few data regarding the range of visual perceptual abilities in populations of normal children, or on the impact of these abilities on children's day-to-day functioning.

Methods

Data were obtained for 4512 participants in an ongoing birth cohort study (Avon Longitudinal Study of Parents and Children; ALSPAC). The children's mothers responded to questions designed to elicit indications of visual perceptual difficulties or immaturity, when their children were aged 13 years. We examined associations with standardised school test results in reading and in mathematics at age 13–14 years (SATS-KS3), accounting for potential confounders including IQ.

Results

Three underlying factors explained half the variance in the VP question responses. These correlated best with questions on interpreting cluttered scenes; guidance of movement and face recognition. The adjusted parameter estimates (95% CI) for the cluttered-scenes factor (0.05; 0.02 to 0.08; p<0.001) suggested positive associations with the reading test results whilst that for the guidance-of-movement factor (0.03; 0.00 to 0.06; p = 0.026) suggested positive association with the mathematics results. The raw scores were associated with both test results.

Discussion

VP abilities were widely distributed in this sample of 13-year old children. Lower levels of VP function were associated with under-achievement in reading and in mathematics. Simple interventions can help children with VP difficulties, so research is needed into practicable, cost-effective strategies for identification and assessment, so that support can be targeted appropriately.

Visual field constriction in children with shunt-treated hydrocephalus

OBJECT

Many ophthalmological abnormalities are described in conjunction with hydrocephalus. The results of visual field diagnosis remain a matter of further discussion. The aim of this study was to investigate visual field deficits in children with shunt-treated hydrocephalus.

METHODS

All children over 6 years of age treated for hydrocephalus at the authors' institute between December 2007 and December 2008 were included in the study. The children underwent an ophthalmological investigation for strabismus and binocular function, ophthalmoscopy, visual acuity, and refraction. The special focus was the visual field diagnosis, which the authors established in all children with cognitive conditions. The investigation was made by using the Goldmann visual field examination (kinetic perimetry). Children with and without visual field defects were compared concerning age at the time of ophthalmological examination, genesis of hydrocephalus, and fronto-occipital horn ratio measured on current CT or MR images.

RESULTS

Complete investigations were undertaken in 56 children (24 girls and 32 boys, mean age 15.1 years). The following orthoptic pathological entities were diagnosed: 29 children have a strabismus in 29 cases, 17 of these have an exotropia, 12 an esotropia, 4 children a hypotropia, 2 a hypertropia and 3 children a heterophoria. A nystagmus was found in 10 children. The ocular fundus investigation showed 13 children with an optic nerve atrophy. A visual field diagnosis was possible in 44 of the 56 patients and was incomplete in 12 patients with cognitive deficits or inadequate compliance. In 24 of 42 children there was a concentric visual field constriction between 10° and 50° out of the center. Children with visual field deficits were older than those with a normal visual field (p = 0.051). Nine of 10 children with postmenigitic hydrocephalus had a visual field defect (p = 0.025). In children with visual field defects the fronto-occipital horn ratio was significantly higher (p = 0.013).

CONCLUSIONS

The results suggest that children with shunt-treated hydrocephalus have a higher risk of having ophthalmological abnormalities. Visual field deficits are often a problem in these patients. A diagnostic visual field examination can complete the ophthalmological monitoring in patients with hydrocephalus, especially in patients with large ventricles. Children with postmeningitic hydrocephalus should be ophthalmologically monitored more frequently and intensively.

Plasticity of the visual system after early brain damage

The aim of this review is to discuss the existing evidence supporting different processes of visual brain plasticity after early damage, as opposed to damage that occurs during adulthood. There is initial evidence that some of the neuroplastic mechanisms adopted by the brain after early damage to the visual system are unavailable at a later stage. These are, for example, the ability to differentiate functional tissue within a larger dysplastic cortex during its formation, or to develop new thalamo-cortical connections able to bypass the lesion and reach their cortical destination in the occipital cortex. The young brain also uses the same mechanisms available at later stages of development but in a more efficient way. For example, in people with visual field defects of central origin, the anatomical expansion of the extrastriatal visual network is greater after an early lesion than after a later one, which results in more efficient mechanisms of visual exploration of the blind field. A similar mechanism is likely to support some of the differences found in people with blindsight, the phenomenon of unconscious visual perception in the blind field. In particular, compared with people with late lesions, those with early brain damage appear to have stronger subjective awareness of stimuli hitting the blind visual field, reported as a conscious feeling that something is present in the visual field. Expanding our knowledge of these mechanisms could help the development of early therapeutic interventions aimed at supporting and enhancing visual reorganization at a time of greatest potential brain plasticity.

Visual function in congenital and childhood myotonic dystrophy type 1

OBJECTIVE

To investigate visual function in a group of individuals with congenital and childhood myotonic dystrophy type 1 (DM1), to correlate the results to the size of the cytosine-thymine-guanine (CTG) repeat expansion and the onset form, and to compare the results with those of a control group.

DESIGN

Cross-sectional study with age- and gender-matched control groups.

PARTICIPANTS AND CONTROLS

Forty-nine individuals with severe and mild congenital and childhood DM1 and controls matched for age and gender.

METHODS

The ophthalmologic examination included best-corrected visual acuity (BCVA), refraction, slit-lamp biomicroscopy, indirect ophthalmoscopy, and flash visual evoked potentials (VEPs).

MAIN OUTCOME MEASURES

Visual acuity, refractive error, pathology of lens, fundus, and VEP pathologic features.

RESULTS

The study shows a higher prevalence of low visual acuity, hyperopia, and astigmatism in the study population compared with the controls. The size of the CTG repeat expansion had an impact on BCVA in all subgroups with lower values in individuals with larger expansion size. In childhood DM1, individuals with high hyperopia and astigmatism had greater CTG repeat expansion size than those without. No true cataract was found. Subtle nonspecific fundus changes were present in addition to VEP pathology.

CONCLUSIONS

Children and adolescents with DM1 have a variety of visual function pathologies, and DM1 has an impact on the developing visual system, necessitating early ophthalmologic assessment and follow-up.

Endoscopic third ventriculostomy: predicting outcome with phase-contrast MR imaging

PURPOSE

To determine whether phase-contrast magnetic resonance (MR) imaging measurements of preoperative cerebral blood and cerebrospinal fluid (CSF) hydrodynamics can be used as a biomarker of response to endoscopic third ventriculostomy (ETV).

MATERIALS AND METHODS

Approval from the local research ethics committee and written informed consent were obtained for this prospective study. Thirteen patients (six female patients, seven male patients; median age, 43 years) with chronic obstructive hydrocephalus, 12 of whom went on to undergo ETV, were imaged with phase-contrast MR imaging at 1.5 T to determine rates of total cerebral blood flow (CBF) and ventriculostomy defect, foramen magnum (FM), and cerebral aqueduct CSF flow. Ten control subjects (10 men; median age, 37 years) were similarly imaged. Correlations between measured values were assessed by means of Pearson correlation coefficients. Measurements were compared between groups with a Mann-Whitney test, and measurements before and after surgical intervention were compared with a Wilcoxon test for paired samples.

RESULTS

Rates of CBF (356 mL . min(-1) +/- 73 [standard deviation] vs 518 mL . min(-1) +/- 79, P < .001) and CSF flow in the FM (17.62 mL . min(-1) +/- 13.12 vs 36.35 mL . min(-1) +/- 8, P < .05) were significantly lower in patients than in control subjects.

CONCLUSION

ETV induces changes in brain volume and CBF that can be predicted by using simple metrics. These pilot results support a formal trial of these techniques in a larger prospective study.

Strabismus, Binocular Functions and Ocular Motility in Children with Hydrocephalus

PURPOSE

To investigate heterotropia, heterophoria, head posture, nystagmus, stereo acuity, ocular motility and near point of convergence (NPC) in children with hydrocephalus treated surgically before 1 year of age. In addition, the effects of being born with hydrocephalus, the effect of the etiology of hydrocephalus, number of shunt revisions and the size of the ventricles on these variables were studied.

METHODS

A population-based study was performed in 75 children and the results were compared with the results of an age- and sex-matched group (comp group) (n = 140).

RESULTS

Heterotropia 68.9% (comp group 3.6%; p < 0.001), abnormal head posture 41.3% (comp group 0; p < 0.001), nystagmus 44.0% (comp group 0; p < 0.001), stereo acuity < or =60'' 33.8% (comp group 97.1%; p < 0.001) and ocular motility defects 69.7% (comp group 0.7%; p < 0.001) were more common among children with hydrocephalus than in the comparison group. Children with overt hydrocephalus at birth had significantly more heterotropia (p = 0.0006), esotropia (p = 0.002), abnormal head posture (p = 0.02) and motility defects (p = 0.003) compared to those with hydrocephalus developing during the first year of life. The etiology, number of shunt revisions and the size of the ventricles had no significant effect on any of the investigated variables.

CONCLUSIONS

Children with hydrocephalus surgically treated before the age of one year commonly present orthoptic abnormalities. The etiology of hydrocephalus, number of shunt revisions and ventricle size seem to be of minor importance compared with the age of onset of hydrocephalus with regard to the risk for orthoptic abnormalities.

Hydrocephalus in children born in 1999-2002: epidemiology, outcome and ophthalmological findings

OBJECTIVE

The purpose of this study was to monitor incidence and outcome in children with hydrocephalus.

MATERIALS AND METHODS

This is a population-based prospective study of all the children with hydrocephalus born in western Sweden in 1999-2002. Etiological and clinical information was collected from records, neuroimaging and ophthalmological examinations. Comparisons with 208 children born in 1989-1998 were made.

RESULTS

The incidence was 0.66 per 1,000 live births, 0.48 for infantile hydrocephalus and 0.18 for hydrocephalus associated with myelomeningocele. The corresponding rates for 1989-1998 were 0.82, 0.49 and 0.33. Ventriculo-peritoneal shunt treatment was used in 42 of the 54 children and endoscopic third ventriculostomy in 12. Revisions were performed in 33 (61%). Neurological impairments were present in 63%, and they were more common in children born preterm than in those born at term. The radiological extent of parenchymal lesions correlated significantly with outcome. Ophthalmological abnormalities were found in 80%, including visual impairment in one third.

CONCLUSION

The incidence of post-haemorrhagic hydrocephalus in children born extremely preterm increased; a group running a high risk of neurological sequelae. Ophthalmological abnormalities were frequent and need to be assessed in all children with hydrocephalus. The high rate of morbidity and complications necessitates the further development of preventive and treatment methods.