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Pilling RF, Allen L, Bowman R, Ravenscroft J, Saunders KJ, Williams C. Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide. Eye (Lond) 2023; 37:1958-1965. [PMID: 36258009 PMCID: PMC10333179 DOI: 10.1038/s41433-022-02261-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/01/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022] Open
Abstract
Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.
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Affiliation(s)
- Rachel Fiona Pilling
- University of Bradford, Bradford, England.
- Department of Ophthalmology, Bradford Teaching Hospitals, Bradford, UK.
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2
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Pinero-Pinto E, Romero-Galisteo RP, Sánchez-González MC, Escobio-Prieto I, Luque-Moreno C, Palomo-Carrión R. Motor Skills and Visual Deficits in Developmental Coordination Disorder: A Narrative Review. J Clin Med 2022; 11:jcm11247447. [PMID: 36556062 PMCID: PMC9784736 DOI: 10.3390/jcm11247447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/01/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Developmental coordination disorder (DCD) is a developmental disorder in which numerous comorbidities seem to coexist, such as motor and visual impairment and some executive functions; Methods: A narrative review on motor and visual deficits in children with DCD was carried out; Results and Discussion: Fine and gross motor skills are affected in children with DCD. In addition, they seem to be related to visual deficits, such as difficulty in visual perception, sensory processing and visual memory. Limitations have also been found in accommodation. Interventions in children with DCD should be aimed at improving both aspects, since vision affects motor skills and vice versa; Conclusions: In children with DCD, who present a marked deficit in global shape processing, it causes an association between deficiencies in visual perception and motor skills.
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Affiliation(s)
- Elena Pinero-Pinto
- Department of Physical Therapy. Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain
| | - Rita Pilar Romero-Galisteo
- Department of Physiotherapy, Faculty of Science Health, University of Málaga, 29016 Málaga, Spain
- Correspondence:
| | | | - Isabel Escobio-Prieto
- Department of Physical Therapy. Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain
- Instituto de Biomedicina de Sevilla (IBIS), 41013 Seville, Spain
| | - Carlos Luque-Moreno
- Department of Physical Therapy. Faculty of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain
- Instituto de Biomedicina de Sevilla (IBIS), 41013 Seville, Spain
| | - Rocío Palomo-Carrión
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain
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Cubillos-Bravo R, Avello-Sáez D. Tecnologías de apoyo a la rehabilitación e inclusión. Recomendaciones para el abordaje de niñas, niños y adolescentes con trastornos del neurodesarrollo. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bullaj R, Dyet L, Mitra S, Bunce C, Clarke CS, Saunders K, Dale N, Horwood A, Williams C, St Clair Tracy H, Marlow N, Bowman R. Effectiveness of early spectacle intervention on visual outcomes in babies at risk of cerebral visual impairment: a parallel group, open-label, randomised clinical feasibility trial protocol. BMJ Open 2022; 12:e059946. [PMID: 36130761 PMCID: PMC9494562 DOI: 10.1136/bmjopen-2021-059946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Hypoaccommodation is common in children born prematurely and those with hypoxic ischaemic encephalopathy (HIE), with the potential to affect wider learning. These children are also at risk of longer-term cerebral visual impairment. It is also well recognised that early intervention for childhood visual pathology is essential, because neuroplasticity progressively diminishes during early life. This study aims to establish the feasibility and acceptability of conducting a randomised controlled trial to test the effectiveness of early near vision correction with spectacles in infancy, for babies, at risk of visual dysfunction. METHODS AND ANALYSIS This is a parallel group, open-label, randomised controlled (feasibility) study to assess visual outcomes in children with perinatal brain injury when prescribed near vision spectacles compared with the current standard care-waiting until a problem is detected. The study hypothesis is that accommodation, and possibly other aspects of vision, may be improved by intervening earlier with near vision glasses. Eligible infants (n=75, with either HIE or <29 weeks preterm) will be recruited and randomised to one of three arms, group A (no spectacles) and two intervention groups: B1 or B2. Infants in both intervention groups will be offered glasses with +3.00 DS added to the full cycloplegic refraction and prescribed for full time wear. Group B1 will get their first visit assessment and intervention at 8 weeks corrected gestational age (B1) and B2 at 16 weeks corrected gestational age. All infants will receive a complete visual and neurodevelopmental assessment at baseline and a follow-up visit at 3 and 6 months after the first visit. ETHICS AND DISSEMINATION The South-Central Oxford C Research Ethics Committee has approved the study. Members of the PPI committee will give advice on dissemination of results through peer-reviewed publications, conferences and societies. TRIAL REGISTRATION NUMBER ISRCTN14646770, NCT05048550, NIHR ref: PB-PG-0418-20006.
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Affiliation(s)
- Raimonda Bullaj
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - Leigh Dyet
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Subhabrata Mitra
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Catey Bunce
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Kathryn Saunders
- Biomedical Sciences Research Institute, Ulster University, Coleraine, UK
| | - Naomi Dale
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London, London, UK
| | - Anna Horwood
- School of Psychology, University of Reading, Reading, UK
| | - Cathy Williams
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Richard Bowman
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Ophthalmology, University College London Institute of Child Health, London, UK
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Fazzi E, Micheletti S, Calza S, Merabet L, Rossi A, Galli J. Early visual training and environmental adaptation for infants with visual impairment. Dev Med Child Neurol 2021; 63:1180-1193. [PMID: 34813110 PMCID: PMC8518055 DOI: 10.1111/dmcn.14865] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/04/2022]
Abstract
AIM To evaluate the effectiveness of early visual training and environmental adaptation on visual function and neurological development in infants with visual impairment. METHOD This was a pilot intervention clinical trial study. Thirty infants (mean age 5.9mo, SD 2.1mo, range 4-11mo; 16 males, 14 females) with peripheral visual impairment (PVI, n=15) or cerebral visual impairment (CVI, n=15) participated in a 6-month visual intervention programme. Thirty matched infants (mean age 6mo, SD 1.4mo, range 4-9mo; 18 males, 12 females) served as a comparison group. Primary outcome measures were visual acuity, contrast sensitivity, and qualitative ocular motor functions. Secondary outcomes were scores on the Griffiths Mental Developmental Scales (GMDS). RESULTS The treatment group showed a significant improvement in all the primary outcomes (p<0.01). The comparison group improved only in visual acuity and contrast sensitivity (p<0.01). The treatment group showed greater improvement than the comparison group in visual fixation (p=0.033) and smooth pursuit (p<0.01). The CVI subgroup showed greater improvement in visual acuity than the PVI subgroup (p<0.01). GMDS subscales of hand-eye coordination (p=0.01) and performance (p<0.01) increased in the treatment group, while the total score of the comparison group decreased, driven by language (p=0.039) and hand-eye coordination (p=0.025) subscales. INTERPRETATION Results suggest that, in infants with visual impairment, visual function and certain developmental outcomes improve in response to early visual training and environmental adaptation, in an interactive context. What this paper adds Early visual training and environmental adaptation are associated with enhanced visual acuity and smooth pursuit. Early visual training and environmental adaptation are associated with an improvement of neurological developmental outcome. Performance, hand-eye coordination, and language scores in Griffiths Mental Developmental Scales increase after visual training. After training, visual acuity improves more in infants with cerebral rather than anterior visual impairment. Type and complexity of visual impairment contribute to determine infants' response to training.
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Affiliation(s)
- Elisa Fazzi
- Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly,Unit of Child Neurology and PsychiatryASST Spedali Civili of BresciaBresciaItaly
| | - Serena Micheletti
- Unit of Child Neurology and PsychiatryASST Spedali Civili of BresciaBresciaItaly
| | - Stefano Calza
- Unit of Biostatistics and BioinformaticsDepartment of Molecular and Translational MedicineUniversity of BresciaBresciaItaly
| | - Lotfi Merabet
- The Laboratory for Visual NeuroplasticityDepartment of OphthalmologyMassachusetts Eye and EarHarvard Medical SchoolBostonMAUSA
| | - Andrea Rossi
- Unit of Child Neurology and PsychiatryASST Spedali Civili of BresciaBresciaItaly
| | - Jessica Galli
- Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly,Unit of Child Neurology and PsychiatryASST Spedali Civili of BresciaBresciaItaly
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Pease A, Goodenough T, Borwick C, Watanabe R, Morris C, Williams C. Development of a core outcome set for evaluative research into paediatric cerebral visual impairment (CVI), in the UK and Eire. BMJ Open 2021; 11:e051014. [PMID: 34588256 PMCID: PMC8483040 DOI: 10.1136/bmjopen-2021-051014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Cerebral visual impairment (CVI) comprises a heterogeneous group of brain-related vision problems. A core outcome set (COS) represents the most important condition-specific outcomes according to patients, carers, professionals and researchers. We aimed to produce a COS for studies evaluating interventions for children with CVI, to increase the relevance of research for families and professionals and thereby to improve outcomes for affected children. DESIGN We used methods recommended by the Core Outcome Measures in Effectiveness Trials Initiative. These included a proportionate literature review of outcomes used in previous studies; qualitative interviews with children and families; a two-round Delphi survey involving parents, children and professionals and a consensus meeting to ratify the most important outcomes. SETTING Telephone interviews and online Delphi surveys of participants who all lived in UK or Eire. PARTICIPANTS Eighteen parents and six young people were interviewed. Delphi participants (n=80 did both rounds) included professionals working with children who have CVI (teachers, orthoptists, ophthalmologists, optometrists, qualified teachers for visually impaired, family members (parents and siblings) and affected children. RESULTS The literature review included 13 studies yielding 37 outcomes. Qualitative interviews provided 22 outcomes. After combining and refining similar items, the first round contained 23 outcomes and the second 46. At the consensus meeting, 5 attendees recommended 27 outcomes for inclusion in the CVI COS, of which 15 were ratified as most important, including 4 related to vision; 1 to family well-being; 1 to adults around the child being informed about CVI and the rest to the child's abilities to engage with people and surroundings. CONCLUSIONS Good engagement from participants led to the development of a COS. Future research will be useful to identify the best ways to measure COS items and potentially to update this COS as more interventions for CVI are developed. TRIAL REGISTRATION NUMBER ISRCTN13762177.
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Affiliation(s)
- Anna Pease
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Cath Borwick
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Rose Watanabe
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Cathy Williams
- Bristol Medical School, University of Bristol, Bristol, UK
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Oculomotor control in children with Special Educational Needs (SEN): the development and piloting of a novel app-based therapeutic intervention. HEALTH AND TECHNOLOGY 2021. [DOI: 10.1007/s12553-021-00571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractChildren with Special Educational Needs (SEN) often have impaired eye movement control which can impact on a wide range of everyday activities including in the classroom, socialising, participation in sport or crossing a road. Although some health practitioners offer eye movement therapies these tend not to have been systematically developed or evaluated. We have developed a new app to deliver eye movement training, based on detailed scientific understanding of eye movement control and extensive clinical experience with this patient group. We first investigated the acceptability of the app within several schools and made modifications based on detailed feedback from the children. Next, we conducted a pilot study to test the feasibility of using the app with 12 children (5–17 years old) who had SEN. The children successfully undertook app-based training for 10 min per day for 4–5 weeks. There was a high level of attendance and no attrition. We found some variation across participants in their ability to play on the app and the level of engagement. This indicates that pre-assessing children for ability and engagement may be important. This encouraging proof of concept study justifies the development of a full study. Given the time and money spent on existing commercially-offered or internet-based non-validated therapies, this would have substantial patient benefit regardless of the outcome: evidence of no effect could reassure parents that this kind of treatment was not needed, whilst evidence of effect suggests this as a useful treatment for children with poor oculomotor control.
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Martinec S, Cesarec G, Tomečak Krilić AM, Radošević T, Bakran Ž, Mejaški Bošnjak V. FUNCTIONAL CLASSIFICATION OF CHILDREN WITH CEREBRAL PALSY IN KRAPINA-ZAGORJE COUNTY. Acta Clin Croat 2021; 60:282-289. [PMID: 34744279 PMCID: PMC8564855 DOI: 10.20471/acc.2021.60.02.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/03/2019] [Indexed: 11/30/2022] Open
Abstract
The aim was to study functional abilities and to create functional classification of children with cerebral palsy (CP) in Krapina-Zagorje County, based on the classification of gross and fine motor skills and associated impairments. Classification was performed according to the SCPE (Surveillance of Cerebral Palsy in Europe) criteria. We used standardized and complementary functional classification systems for cerebral palsy to create a functional profile. Research included 44 children with CP in the age range of 4 to 18 years. The results showed that the majority of children had bilateral spastic CP (63.6%), followed by unilateral spastic (22.7%) while the representation of dyskinetic CP was 9.09% and ataxic CP 4.55%. Based on the classification of gross and fine motor skills, 43.2% of children had the ability to walk, 11% of children could walk with assistive mobility devices, while 45.4% of children had a low functional level. The study also analyzed the associated impairments where higher classification score of motor impairment correlated with the severity of impairment. The results showed that children with dyskinetic CP and severe motor impairment could have mild cognitive impairment. We systematically present the neuropsychological and functional profile according to the CP type.
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Affiliation(s)
| | - Gordana Cesarec
- 1Krapinske Toplice Special Hospital for Medical Rehabilitation, Department of Physical and Rehabilitation Medicine, Krapinske Toplice, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Department of Neuropediatrics, Zagreb Children's Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Ana Marija Tomečak Krilić
- 1Krapinske Toplice Special Hospital for Medical Rehabilitation, Department of Physical and Rehabilitation Medicine, Krapinske Toplice, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Department of Neuropediatrics, Zagreb Children's Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tomislav Radošević
- 1Krapinske Toplice Special Hospital for Medical Rehabilitation, Department of Physical and Rehabilitation Medicine, Krapinske Toplice, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Department of Neuropediatrics, Zagreb Children's Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Žarko Bakran
- 1Krapinske Toplice Special Hospital for Medical Rehabilitation, Department of Physical and Rehabilitation Medicine, Krapinske Toplice, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Department of Neuropediatrics, Zagreb Children's Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vlatka Mejaški Bošnjak
- 1Krapinske Toplice Special Hospital for Medical Rehabilitation, Department of Physical and Rehabilitation Medicine, Krapinske Toplice, Croatia; 2Josip Juraj Strossmayer University of Osijek, School of Medicine, Osijek, Croatia; 3Department of Neuropediatrics, Zagreb Children's Hospital, School of Medicine, University of Zagreb, Zagreb, Croatia
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Deramore Denver B, Froude E, Rosenbaum P, Imms C. Measure of early vision use: initial validation with parents of children with cerebral palsy. Disabil Rehabil 2021; 44:4066-4074. [PMID: 33651960 DOI: 10.1080/09638288.2021.1890243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To report initial psychometric evidence on the Measure of Early Vision Use. METHOD Data on performance of the Measure of Early Vision Use scale were collected from 100 parents of children with cerebral palsy aged 0-12 years via online survey. Psychometric evaluation included assessment of scale dimensionality using Classical Test Theory and hypothesis testing for evidence of construct validity. RESULTS Principal components analysis of the 14-item parent-rated Measure of Early Vision Use revealed one component with an eigenvalue of 9.343, explaining 66.7% of variance; internal consistency was high (Cronbach's α = 0.96). Total scores ranged from 15-56 (Mean 42.8, standard deviation = 10.6). The results support seven pre-defined hypotheses including statistically significant differences in MEVU-total scores between children with and without parent-reported cerebral visual impairment. CONCLUSIONS Measure of Early Vision Use is the first assessment tool to describe 'how vision is used' in children with cerebral palsy. Results provide preliminary evidence that the measure comprises a unidimensional construct, sufficient construct validity, and feasibility as a parent-completed online assessment. Findings on internal structure provide foundational evidence and require further testing with Confirmatory Factor Analysis or Rasch Analysis.IMPLICATIONS FOR REHABILITATIONThe Measure of Early Vision Use is a new instrument to describe the use of basic visual abilities and is feasible to use as a parent-completed online questionnaire.The Measure of Early Vision Use is a unidimensional scale with sufficient construct validity to supports its use as a measure of 'how vision is used' without confounding visual ability with the reason why it might be impaired (e.g., cerebral vision impairment, motor limitations, or cognition).There is potential for the Measure of Early Vision Use to support early intervention planning for children with (or at high risk of) cerebral palsy.
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Affiliation(s)
| | - Elspeth Froude
- School of Allied Health, Australian Catholic University, North Sydney, Australia
| | - Peter Rosenbaum
- Department of Paediatrics, McMaster University, Hamilton, Canada
| | - Christine Imms
- Department of Paediatrics,University of Melbourne, Parkville, Australia
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10
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Cotter SA, Donahue SP, Moore B, Baldonado KN. Letter to the Editor: The Power of Consensus for Children's Vision. Optom Vis Sci 2021; 98:100-101. [PMID: 33394937 DOI: 10.1097/opx.0000000000001635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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11
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Tsirka A, Liasis A, Kuczynski A, Vargha-Khadem F, Kukadia R, Dutton G, Bowman R. Clinical use of the Insight Inventory in cerebral visual impairment and the effectiveness of tailored habilitational strategies. Dev Med Child Neurol 2020; 62:1324-1330. [PMID: 32770793 DOI: 10.1111/dmcn.14650] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 07/10/2020] [Indexed: 12/12/2022]
Abstract
AIM To investigate the utility of the Insight Inventory (a structured clinical inventory completed by caregivers) for assessment of children with cerebral visual impairment; and to investigate effectiveness of tailored habilitational strategies derived from the responses to the Insight Inventory. METHOD Fifty-one eligible children (26 males, 25 females; mean age 9y 5mo, SD 3y, range 5-16y) were recruited from Great Ormond Street Hospital, London. They underwent baseline assessment including neuro-ophthalmological and neuropsychological evaluations, and parent- and child-reported ratings on a questionnaire-based measure of quality of life. Parents also completed the Insight Inventory. On the basis of responses to the Inventory, families received individualized habilitational strategies. Follow-up assessments 6 months later included repeating the Insight Inventory and quality of life questionnaires. RESULTS Correlations were found between the Insight Inventory and the Wechsler Intelligence Scale for Children, Fourth Edition, the Beery-Buktenica Test of Visual-Motor Integration, and the Benton Facial Recognition Test, suggesting that the Insight Inventory is an effective tool to estimate visual-perceptual difficulties. At 6 months follow-up, caregiver reports indicated significant improvements in the quality of life of children below the age of 12 years. INTERPRETATION The Insight Inventory is a simple questionnaire which covers practical aspects of cognitive visual function in everyday life. It provides in-depth information about the aspects that children struggle with. It can also guide programmes of individualized habilitation strategies, which may enhance the quality of life of younger children. WHAT THIS PAPER ADDS Questionnaire scores demonstrate biologically plausible correlations with formal neuropsychological tests of visual function. After administration of matched practical habilitational strategies, younger children showed improvement in quality of life and functional vision scores.
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Affiliation(s)
- Asimina Tsirka
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Alki Liasis
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children, London, UK
| | - Adam Kuczynski
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Clinical Neuropsychology, Great Ormond Street Hospital for Children, London, UK
| | - Faraneh Vargha-Khadem
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Clinical Neuropsychology, Great Ormond Street Hospital for Children, London, UK
| | - Roopen Kukadia
- Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children, London, UK
| | - Gordon Dutton
- Department of Vision Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Richard Bowman
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK.,Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children, London, UK
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12
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van Gils MM, Dudink J, Reiss IKM, Swarte RMC, van der Steen J, Pel JJM, Kooiker MJG. Brain Damage and Visuospatial Impairments: Exploring Early Structure-Function Associations in Children Born Very Preterm. Pediatr Neurol 2020; 109:63-71. [PMID: 32434705 DOI: 10.1016/j.pediatrneurol.2019.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/28/2019] [Accepted: 12/21/2019] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Maud M van Gils
- Vestibular and Oculomotor Research Group, Department of Neuroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Renate M C Swarte
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Johannes van der Steen
- Vestibular and Oculomotor Research Group, Department of Neuroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Johan J M Pel
- Vestibular and Oculomotor Research Group, Department of Neuroscience, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Marlou J G Kooiker
- Vestibular and Oculomotor Research Group, Department of Neuroscience, Erasmus Medical Center, Rotterdam, the Netherlands.
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Kooiker MJG, van der Linden Y, van Dijk J, van der Zee YJ, Swarte RMC, Smit LS, van der Steen-Kant S, Loudon SE, Reiss IKM, Kuyper K, Pel JJM, van der Steen J. Early intervention for children at risk of visual processing dysfunctions from 1 year of age: a randomized controlled trial protocol. Trials 2020; 21:44. [PMID: 31915035 PMCID: PMC6950993 DOI: 10.1186/s13063-019-3936-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 11/26/2019] [Indexed: 11/28/2022] Open
Abstract
Background An increasing number of children are suffering from brain damage-related visual processing dysfunctions (VPD). There is currently a lack of evidence-based intervention methods that can be used early in development. We developed a visual intervention protocol suitable from 1 year of age. The protocol is structured, comprehensive and individually adaptive, and is paired with quantitative outcome assessments. Our aim is to investigate the effectiveness of this first visual intervention program for young children with (a risk of) VPD. Methods This is a single-blind, placebo-controlled trial that is embedded within standard clinical care. The study population consists of 100 children born very or extremely preterm (< 30 weeks) at 1 year of corrected age (CA), of whom 50% are expected to have VPD. First, children undergo a visual screening at 1 year CA. If they are classified as being at risk of VPD, they are referred to standard care, which involves an ophthalmic and visual function assessment and a (newly developed) visual intervention program. This program consists of a general protocol (standardized and similar for all children) and a supplement protocol (adapted to the specific needs of the child). Children are randomly allocated to an intervention group (starting upon inclusion at 1 year CA) or a control group (postponed: starting at 2 years CA). The control group will receive a placebo treatment. The effectiveness of early visual intervention will be examined with follow-up visual and neurocognitive assessments after 1 year (upon completion of the direct intervention) and after 2 years (upon completion of the postponed intervention). Discussion Through this randomized controlled trial we will establish the effectiveness of a new and early visual intervention program. Combining a general and supplement protocol enables both structured comparisons between participants and groups, and custom habilitation that is tailored to a child’s specific needs. The design ensures that all included children will benefit from participation by advancing the age at which they start receiving an intervention. We expect results to be applicable to the overall population of children with (a risk of) VPD early in life. Trial registration Netherlands Trial Register: NTR6952. Registered 19 January 2018.
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Affiliation(s)
- Marlou J G Kooiker
- Department of Neuroscience, Erasmus Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Yoni van der Linden
- Royal Dutch Visio, Center of Expertise for Blind and Partially Sighted People, the Hague, The Netherlands
| | - Jenneke van Dijk
- Royal Dutch Visio, Center of Expertise for Blind and Partially Sighted People, the Hague, The Netherlands
| | - Ymie J van der Zee
- Royal Dutch Visio, Center of Expertise for Blind and Partially Sighted People, Rotterdam, The Netherlands
| | - Renate M C Swarte
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Liesbeth S Smit
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Department of Neurology, Division of Pediatric Neurology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sanny van der Steen-Kant
- Royal Dutch Visio, Center of Expertise for Blind and Partially Sighted People, Huizen, The Netherlands
| | - Sjoukje E Loudon
- Department of Pediatric Ophthalmology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Kees Kuyper
- Royal Dutch Visio, Center of Expertise for Blind and Partially Sighted People, Rotterdam, The Netherlands
| | - Johan J M Pel
- Department of Neuroscience, Erasmus Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Johannes van der Steen
- Department of Neuroscience, Erasmus Medical Center, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
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14
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Kulkarni S, Gilbert C, Kakade N, Dole K, Deshpande CM, Azad R. Habilitation services for children blind from retinopathy of prematurity: Health care professionals' perspective in Maharashtra. Indian J Ophthalmol 2019; 67:928-931. [PMID: 31124517 PMCID: PMC6552598 DOI: 10.4103/ijo.ijo_573_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Purpose: To explore the knowledge of retinopathy of prematurity (ROP) and habilitation services for children with visual loss from ROP, among health care professionals (HCPs) involved in care of preterm children and to explore their attitudes and practices in relation to referral for habilitation. Methods: A modified knowledge, attitude and practice questionnaire were administered to ophthalmologists and paediatricians associated with ROP care. Data were collected about their knowledge, beliefs and practices of ROP and referral to rehabilitation facilities. Data were analysed to establish level of knowledge, type of attitude and practices and its association with speciality. Results: Response rate was 78% (25/32). Most (14/25, 56%) were ophthalmologists. All (100%) participants knew that ROP can cause blindness. Knowledge about Indian ROP screening criteria was poor among a third (8/25, 32%), more so in paediatricians (5/11, 45.5%). Most (21/25, 84%) did not have knowledge of what a habilitation service entails and where such facilities are located. More than two-thirds (18/25, 72%) believed that special education should be preferred over inclusive education. Overall, 10/25 (40%) of the HCPs had never referred a child for rehabilitation. More than a half (13/25, 52%) were not confident of counselling parents of blind children. All agreed that rehabilitation services are not part of but should be included in medical curriculum. Conclusion: Indian guidelines for ROP screening are not universally known among HCPs. Educating medical undergraduates, providing counselling training to professionals and integration of rehabilitation into the health system will ensure continuity of care for children with visual loss and their families.
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Affiliation(s)
- Sucheta Kulkarni
- Department of Retina and Community Ophthalmology, H. V. Desai Eye Hospital, Pune, Maharashtra, India
| | - Clare Gilbert
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Nilesh Kakade
- Department of Retina and Community Ophthalmology, H. V. Desai Eye Hospital, Pune, Maharashtra, India
| | - Kuldeep Dole
- Department of Retina and Community Ophthalmology, H. V. Desai Eye Hospital, Pune, Maharashtra, India
| | - Col M Deshpande
- Department of Retina and Community Ophthalmology, H. V. Desai Eye Hospital, Pune, Maharashtra, India
| | - Rajvardhan Azad
- Department of Retina and ROP, Bharati Eye Hospital, Delhi; Raj Retina and Eye Care Centre, Patna, India
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15
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Donaldson LA, Karas M, O'Brien D, Woodhouse JM. Findings from an opt-in eye examination service in English special schools. Is vision screening effective for this population? PLoS One 2019; 14:e0212733. [PMID: 30856194 PMCID: PMC6411105 DOI: 10.1371/journal.pone.0212733] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/10/2019] [Indexed: 12/04/2022] Open
Abstract
Our objective was to present the findings of an opt-in, school-based eye care service for children attending 11 special schools in England and use these findings to determine whether a vision screening programme would be appropriate for this population. Data from eye examinations provided to 949 pupils (mean age 10.7 years) was analysed to determine the prevalence and aetiology of visual deficiencies and reported eye care history. For 46.2% (n = 438) of pupils, a visual deficiency was recorded. 12.5% of all the children seen (n = 119) had a visual deficiency that was previously undiagnosed. Referral for a medical opinion was made for 3.1% (n = 29) of pupils seen by the service. Spectacle correction was needed for 31.5% (n = 299) of pupils; for 12.9% (122) these were prescribed for the first time. 3.7% (n = 11) of parents/carers of pupils needing spectacles chose not to use the spectacle dispensing service offered in school. Eye care history was available for 847 pupils (89.3%). Of the pupils for whom an eye care history was available, 44% (n = 373) reported no history of any previous eye care and10.7% (n = 91) reported a history of attending a community optical practice/opticians. Only one pupil from the school entry 4–5 age group (0.6% of age group n = 156) would have passed vision screening using current Public Health England screening guidelines. Children with a diagnosis of autism were significantly less likely to be able to provide a reliable measurement of visual acuity. This study supports previously published evidence of a very high prevalence of visual problems in children with the most complex needs and a significant unmet need in this group. It demonstrates routine school entry vision screening using current Public Health England guidelines is not appropriate for this group of children and very low uptake of community primary eye care services.
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Affiliation(s)
| | | | | | - J Margaret Woodhouse
- School of Optometry & Vision Sciences, Cardiff University, Cardiff, United Kingdom
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16
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Deramore Denver B, Adolfsson M, Froude E, Rosenbaum P, Imms C. Methods for conceptualising 'visual ability' as a measurable construct in children with cerebral palsy. BMC Med Res Methodol 2017; 17:46. [PMID: 28320348 PMCID: PMC5359986 DOI: 10.1186/s12874-017-0316-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 03/01/2017] [Indexed: 11/23/2022] Open
Abstract
Background Vision influences functioning and disability of children with cerebral palsy, so there is a growing need for psychometrically robust tools to advance assessment of children’s vision abilities in clinical practice and research. Vision is a complex construct, and in the absence of clarity about this construct it is challenging to know whether valid, reliable measures exist. This study reports a method for conceptualising ‘visual ability’ as a measurable construct. Methods Using the items from 19 assessment tools previously identified in a systematic review, this study used a two-phase process: first, deductive content analysis linked items to the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY), and second, vision-specific ‘Activity’-level items were explored using inductive thematic analysis. Results The linking and content analysis identified that existing assessment tools are measuring vision across the ICF-CY domains of Body Functions, Activities and Participation, and Environmental and Personal Factors. Items specifically coded to vision at the Activity level were defined as measuring ‘how vision is used’, and these items form the basis of the conceptualisation that ‘visual ability’ is measurable as a single construct. The thematic analysis led to the identification of 3 categories containing 13 themes that reflect a child’s observable visual behaviours. Seven abilities reflect how a child uses vision: responds or reacts, initiates, maintains or sustains looking, changes or shifts looking, searches, locates or finds, and follows. Four interactions reflect the contexts in which a child uses their vision to purposefully interact: watches and visually interacts with people and faces, objects, over distance, and with hands. Finally, two themes reflect a child’s overall use of vision in daily activities: frequency of use, and efficiency of use. Conclusions This study demonstrates an approach to exploring and explaining a complex topic utilising World Health Organization language and building on existing research. Despite the complexity of vision, the concept of ‘how vision is used’ can be clearly defined as a measurable construct at the Activity level of the ICF-CY. This study has identified observable visual behaviours that may be developed into items assessing how vision is used in daily activities. Electronic supplementary material The online version of this article (doi:10.1186/s12874-017-0316-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Belinda Deramore Denver
- Australian Catholic University, School of Allied Health, Level 9, 33 Berry Street, North Sydney, NSW, 2060, Australia.
| | - Margareta Adolfsson
- Jönköping University, CHILD, School of Education and Communication, Box 1026, 551 11, Jönköping, Sweden
| | - Elspeth Froude
- Australian Catholic University, School of Allied Health, Level 9, 33 Berry Street, North Sydney, NSW, 2060, Australia
| | - Peter Rosenbaum
- McMaster University, IAHS Building, Room 408, 1400 Main Street West, Hamilton, ON, L8S 1C7, Canada
| | - Christine Imms
- Australian Catholic University, School of Allied Health, Level 2, Daniel Mannix Building, 17 Young Street, Fitzroy, VIC, 3065, Australia
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17
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Deramore Denver B, Froude E, Rosenbaum P, Wilkes-Gillan S, Imms C. Measurement of visual ability in children with cerebral palsy: a systematic review. Dev Med Child Neurol 2016; 58:1016-29. [PMID: 27098366 DOI: 10.1111/dmcn.13139] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/26/2022]
Abstract
AIM To identify and evaluate measures of visual ability used with children with cerebral palsy (CP). METHOD Eight databases were searched for measures of visual ability. Key selection criteria for measures were: use with children with CP; focus of visual ability measurement at the Activities and Participation domain of the International Classification of Functioning, Disability and Health (ICF). The Consensus-based Standards for the Selection of Measurement Instruments (COSMIN) Checklist was used to assess psychometric properties. RESULTS From 6763 papers retrieved, 25 were relevant and 19 measures of visual ability were identified. Only 10 measures were supported with evidence of validity or reliability. No discriminative measure analogous to existing CP functional classification systems was found. No outcome measure valid for evaluation of visual abilities of children with CP was found. INTERPRETATION Vision impairment is recognized as relevant to the functioning of children with CP; however, measurement of vision is most often focused at 'Body Function' levels, for example visual acuity. Measuring visual abilities in the Activities and Participation domain is important in considering how a child with CP functions in vision-related activities. The lack of psychometrically strong measures for visual ability is a gap in current clinical practices and research.
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Affiliation(s)
- Belinda Deramore Denver
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, Fitzroy, Vic., Australia.,Victorian Paediatric Rehabilitation Service, Monash Children's Hospital, Clayton, Vic., Australia
| | - Elspeth Froude
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, North Sydney, NSW, Australia
| | - Peter Rosenbaum
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, Fitzroy, Vic., Australia.,Department of Pediatrics and CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, Canada
| | - Sarah Wilkes-Gillan
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, North Sydney, NSW, Australia
| | - Christine Imms
- Faculty of Health Sciences, School of Allied Health, Australian Catholic University, Fitzroy, Vic., Australia
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18
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Boyce T, Dahlmann-Noor A, Bowman R, Keil S. Support for infants and young people with sight loss: a qualitative study of sight impairment certification and referral to education and social care services. BMJ Open 2015; 5:e009622. [PMID: 26685033 PMCID: PMC4691759 DOI: 10.1136/bmjopen-2015-009622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 11/13/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To examine the experience of infants, children and their parents, the role of ophthalmologists and other health, social care and education professionals in the certification and registration processes and examine the relationship between certification and referrals and pathways to support. DESIGN Qualitative study. SETTING Telephone interviews with health and, social care professionals, qualified teachers of children and young people with vision impairment (QTVIs) and parents of infants/children in England. PARTICIPANTS 52 health, social care and education professionals who are part of the certification or registration process. 26 parents of infants and children with vision impairment. RESULTS Referrals to education do not require a Certificate of Vision Impairment (CVI); however, the majority of parents received support from education and social services only after an offer of the CVI, which was often dependent on having a formal diagnosis. Parents stated they wanted support sooner, particularly parents of children with additional complex needs who experienced longer delays. Areas with multidisciplinary teams and support roles such as eye clinic liaison officers (ECLOs) appeared to have more reliable referral pathways. CONCLUSIONS For infants and children with vision impairment, there should be a consistent mechanism for triggering education and social care support even with uncertainty about diagnosis and/or prognosis. All professionals involved in the certification and registration processes (ophthalmologists, optometrists, ECLOs, orthoptists, social workers, QTVIs) can better communicate the value and benefits of certification and registration.
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Affiliation(s)
| | - Annegret Dahlmann-Noor
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Richard Bowman
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Institute of Child Health, London, UK
| | - Sue Keil
- Royal National Institute of Blind People (RNIB), Birmingham, UK
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19
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Puri S, Bhattarai D, Adhikari P, Shrestha JB, Paudel N. Burden of ocular and visual disorders among pupils in special schools in Nepal. Arch Dis Child 2015; 100:834-7. [PMID: 25900842 DOI: 10.1136/archdischild-2014-308131] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 04/04/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To determine detailed oculo-visual characteristics of children with intellectual disability studying in special schools and explore the burden of visual impairment. DESIGN OF THE STUDY Detailed ophthalmic examination was carried out in all pupils studying at the seven special needs schools of Kathmandu valley, Nepal. Ophthalmic examination included case history, presenting distance visual acuity, cycloplegic refraction, binocular vision examination, contrast sensitivity and anterior and posterior segment evaluation. MAIN OUTCOME MEASURES Ocular and visual status of children. RESULTS Refractive errors (40%) and strabismus (17%) were the commonest visual disorders in our study children. Ninety-five per cent of the children who had clinically significant refractive errors presented without any correction. Visual impairment was present in 25% of the children. Severe visual impairment or worse was present in 3% of the children. Other common ocular findings were conjunctivitis, blepharitis, chalazion and ectropion. CONCLUSIONS High prevalence of preventable visual impairment in this population requires immediate attention. It is hoped that the formulation of proper vision care guidelines at a national level may help in early detection and management of visual disorders in this special population and enhance their quality of life.
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Affiliation(s)
- Sudan Puri
- B P Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal
| | | | - Prakash Adhikari
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia
| | - Jyoti Baba Shrestha
- B P Koirala Lions Centre for Ophthalmic Studies, Institute of Medicine, Kathmandu, Nepal
| | - Nabin Paudel
- Department of Optometry and Vision Science, University of Auckland, Auckland, New Zealand
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