Development of an integrated telerehabilitation model in children with cerebral visual impairment in South India during the COVID-19 pandemic – A pilot study

Purpose: Coronavirus disease 2019 (COVID?19) pandemic affected the in?person rehabilitation/habilitation services in families with children with cerebral visual impairment (CVI) in India. This study aimed to develop a structured and family?centered telerehabilitation model alongside conventional in?person intervention in children with CVI to observe its feasibility in the Indian population. Methods: This pilot study included 22 participants with a median age of 2.5 years (range: 1–6) who underwent a detailed comprehensive eye examination followed by functional vision assessment. The visual function classification system (VFCS) was administered to the children and the structured clinical question inventory (SCQI) to the parents. Every participant underwent 3 months of telerehabilitation including planning, training, and monitoring by experts. At 1 month, the parental care and ability (PCA) rubric was administered to the parents. After 3 months, in an in?person follow?up, all the measures were reassessed for 15 children. Results: After 3 months of Tele?rehabilitation there were significant improvements noted in PCA rubric scores (P<0.05). Also, statistically significant improvements were noted in functional vision measured using SCQI and VFCS scores (P<0.05) compared to baseline. Conclusion: The outcomes of the study provide the first steps towards understanding the use of a novel tele?rehabilitation model in childhood CVI along?side conventional face?to?face intervention. The added role of parental involvement in such a model is highly essential.

Parental perception of facilitators and barriers to activity and participation in an integrated tele-rehabilitation model for children with cerebral visual impairment in South India – A virtual focus group discussion study

Purpose: This study utilized virtual focus group discussions to document the facilitators and barriers reported by the parents as part of the tele?rehabilitation service delivery model in India. Methods: This study included 17 participants who were enrolled into the Tele?rehabilitation program (16 mothers, 1 father) and the virtual focus group discussion (V?FGD) were conducted through a WhatsApp video call. Three V?FGDs were conducted involving two moderators and a note taker. The V?FGD, focused at extracting the perceptions of parents pertaining to facilitators, barriers and coping mechanisms to barriers related to the tele?rehabilitation model. Results: Thematic analysis resulted in four themes for barriers that included: family and support, time, parent and care taker, child and place of living related; facilitators reported included: continuous monitoring, accessibility to professional services, provision of resource materials and parental empowerment. Themes “family and support” and “child” were most reported by parents with children >3 years and ?3 years respectively. Finally, the barriers and facilitators were aligned with the chapters and codes of International Classification of Functioning, children and youth version (ICF?CY) environment and personal factors. Conclusion: This V?FGD highlights the importance of parental?centred and structured Tele?rehabilitation among children with CVI in India. The outcome of this study opens avenues for creating effective intervention.

Cerebral visual impairment in children: Multicentric study determining the causes, associated neurological and ocular findings, and risk factors for severe vision impairment

Purpose: To evaluate the causes, associated neurological and ocular findings in children with cerebral visual impairment (CVI), and to identify risk factors for severe vision impairment. Methods: A multicenter, retrospective, cross?sectional analysis was carried out from January 2017 to December 2019 on patients less than 16 years of age with a diagnosis of CVI. Results: A total of 405 patients were included of which 61.2% were male and 38.8% were female. The median age at presentation was 4 years (range 3 months to 16 years). Antenatal risk factors were present in 14% of the cases. The most common cause of CVI was hypoxic?ischemic encephalopathy (35.1%), followed by seizure associated with brain damage (31.3%). The most common neurological finding was seizure (50.4%), followed by cerebral palsy (13.6%). Associated ophthalmological findings were significant refractive error (63.2%), esotropia (22.2%), exotropia, (38%), nystagmus (33.3%), and optic nerve atrophy (25.9%). Severe visual impairment (<20/200) was associated with optic atrophy (odds ratio: 2.9, 95% confidence interval: 1.4–6.0; P = 0.003) and seizure disorder (odds ratio: 1.9, 95% confidence interval: 1.2–3.3; P = 0.012). Conclusion: The various ophthalmic, neurological manifestations and etiologies could guide the multidisciplinary team treating the child with CVI in understanding the visual impairment that affects the neuro development of the child and in planning rehabilitation strategies

Visual impairment in children with multiple disabilities in schools for children with special needs in South India

Purpose: To understand/assess ocular and functional vision impairment in children with multiple disabilities with a functional vision assessment battery in addition to standard ophthalmic examinations in an outreach setting. Methods: Seven schools for children with special needs, 243 children in total, were screened for ocular disorders and functional vision impairment through school camps. Results: Among them, 37% had refractive errors needing spectacle correction. With standard ocular testing methods, the visual impairment was around 32%, but when functional vision was assessed, the functional vision impairment amounted to 70% in these children. The presence of functional vision impairment was found to be independent of the associated disability. Assessment of visual capacities such as visual closure, saccade pursuits, optic ataxia, and developmental milestones early on can help in suspecting the presence of CVI. Conclusion: Children with multiple disabilities are more at risk of functional vision impairment, which significantly impairs their ability to function in daily life. A complete functional vision assessment becomes essential to plan early intervention for these children. The significant proportion of vision impairment and functional vision loss in our study indicates the need for coordinated structured programs to address vision?related problems in children with multiple disabilities.

Analysis of the etiology and clinical characteristics of infants with moderate-severe visual impairment / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To explore the etiology classification and clinical characteristics of infants with moderate-severe visual impairment aged 0-2 years old, and preliminarily formulate a set of process for grass-roots health-care institutions to carry out the screening and management of children visual impairment.METHODS: There were 245 cases of children aged 0-2 years with moderate-severe visual impairment who were admitted to the Children Eye Care Specialist Clinic in Nanjing Maternal and Child Health Hospital from January 2009 to December 2020 were retrospectively analyzed. A complete profile of visual development was established, including age, sex, medical history, vision, eye position and movement, anterior segment examination, fundus examination, refractive examination under cycloplegia with 1% atropine ophthalmic gel, if necessary, some special eye examinations such as fundus photography, eye A/B ultrasound and visual electrophysiology were received.RESULTS: The average visit age of 245 cases of infants was 1.82±0.79 years, including refraction error of 128 cases(52.2%), among them, 100 cases(40.8%)were high refraction error; 79 cases(32.2%)were eye diseases, most of which were congenital cataract(33 cases); and 38 cases(15.5%)were cerebral visual impairment(CVI)(15.5%).CONCLUSION: It is necessary to proceed classified managements according to the etiology and clinical characteristics of infant visual impairment to find early and diagnose and treat multidisciplinary,including drawing up screening plans for remediable eye diseases, carrying out necessary refractive correction and training children to use residual visual function.

Effect of acupuncture on pattern visual evoked potential of cerebral visual impairment in children aged 3-10 years / 中国针灸

OBJECTIVE@#To observe clinical effect of acupuncture combined with conventional visual stimulation on cerebral visual impairment (CVI) in children aged 3-10 years and influence on the pattern visual evoked potential (P-VEP).@*METHODS@#A total of 60 cases of children aged 3-10 years with CVI were randomly divided into an observation group and a control group, 30 cases in each group. The children in the control group received conventional visual stimulation therapy, 1 month as a course of treatment. On the basis of the control group, the children in the observation group was treated with acupuncture at Baihui (GV 20), Jingming (BL 1), Taiyang (EX-HN 5), Sibai (ST 2), etc. 3 times a week, and the treatment was given 4 weeks continuously as a course. Both groups received 3 courses of treatment. The visual acuity and P-VEP improvement were compared between the two groups before and after treatment.@*RESULTS@#After treatment, the incubation period (P100-L) of the two groups was shorter than before treatment, and the amplitude (P100-A) was higher than before treatment (@*CONCLUSION@#Acupuncture combined with conventional visual stimulation can improve the incubation period (P100-L) and amplitude (P100-A) of P-VEP in children with CVI, and improve the best corrected visual acuity in children, the clinical effect is better than the conventional visual stimulation alone.

Understanding low functioning cerebral visual impairment: An Indian context

For several reasons, cerebral visual impairment (CVI) is emerging as a major cause of visual impairment among children in the developing world and we are seeing an increasing number of such children in our clinics. Owing to lack of early training about CVI and it being a habilitation orientated subject, we need to become equipped to optimally help the affected children. In this paper we have explained our pragmatic approach in addressing children who present with low functioning CVI. Initially we explain briefly, how vision is processed in the brain. We then present what should be specifically looked for in these children in regular clinics as a part of their comprehensive ophthalmic examination. We discuss the process of functional vision evaluation that we follow with the help of videos to explain the procedures, examples of how to convey the conclusions to the family, and how to use our findings to develop intervention guidelines for the child. We explain the difference between passive vision stimulation and vision intervention, provide some common interventions that may be applicable to many children and suggest how to infuse interventions in daily routines of children so that they become relevant and meaningful leading to effective learning experiences.

Cerebral visual impairment is a major cause of profound visual impairment in children aged less than 3 years: A study from tertiary eye care center in South India

Purpose: The purpose of this study was to evaluate causes for profound visual impairment in children ?3 years of age at a tertiary eye care center in Andhra Pradesh, India. Methods: A retrospective study was conducted for all the children (?3 years) who attended the pediatric ophthalmology service between January 2012 and February 2017. Results: A total of 428 severely visually impaired children aged ?3 years were seen during the study period: 264 (62%) of them were boys and I64 (38%) were girls. The average age at presentation was 14.02 months. The causes of visual impairment were cerebral visual impairment (CVI) 142 (33%), a combination of CVI and ocular visual impairment (OVI) 48 (11%), and OVI only 236 (56%), which included congenital cataract 56 (13.1%), retinopathy of prematurity 52 (I2.6%), optic atrophy 17 (4.5%), congenital nystagmus (4.4%), congenital globe anomalies 2I (5.2%), and high refractive errors - 10 (2.8%). Delays in different areas of development were seen in 103 out of 142 children with CVI (72.5%), which included motor delay 53 (51.5%), cognitive delay 15 (14.6%), speech delay in 3 (2.9%), and delay in multiple areas of development (like combination of motor, cognitive, and speech delay) in 32 (31.1%). Conclusion: In children under 3 years of age, CVI is a major cause of profound visual impairment in our area and the majority of them manifest delay in several areas of development.

Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach. Part 1

Children with special needs form a unique subset with regards to visual function and examination techniques needed to assess them. With more awareness among the general public, neurologists, and pediatricians, these children are referred for assessment to the ophthalmologist or optometrist and sometimes even to the rehabilitation professional at an early age. This clinical practice guideline and review gives a systematic approach for examining the visual functions of a child with special needs. It outlines the procedures to be followed with equipment needed in clinical practice. Functional vision assessment guidelines are also included. This is the first part in a two-part series, with the first part presenting clinical examination guidelines and the second presenting intervention and vision enhancement techniques.

Cerebral visual impairment in children: Causes and associated ophthalmological problems

Purpose: The aim of this study is to identify common causes, associated ophthalmological abnormalities, and systemic comorbidities in children in Andhra Pradesh, India, with cerebral visual impairment (CVI). Methods: A retrospective review of case records of all children aged <16 years with diagnosis of CVI seen between January 2016 and December 2016 was carried out. Data were collected for their age, gender, cause of CVI, refraction, accommodation, anterior and posterior segment examination findings, and systemic problems. Results: A total of 124 patients were identified and studied (80 boys and 44 girls, mean age 5.23 years, 44.8% aged <2 years). The most common causes of CVI were hypoxic杋schemic encephalopathy (HIE) (34.4%), undetermined etiology (32.8%), neonatal seizures, and infantile spasms (16% each). The most common presenting complaints were poor vision (76%) and squint (11.2%). Profound visual impairment was seen in 88.8%, and 11.2% had high functioning CVI. Fifty-eight (46.4%) patients had significant refractive errors, 40 (32.25%) had strabismus, 4 (3.2%) had visually significant cataract, and 40 (32%) had optic atrophy. Motor delay was observed in 39.5%, speech delay was evident in 22.4%, and cognitive delay in 16%. Conclusion: HIE is the most common cause (one-third) of CVI in our population, and the majority of them presented at age <2 years (44.8%) with profound visual impairment (88.8%). A significant number of them have treatable ophthalmic conditions such as refractive errors (46.4%), accommodative insufficiency (12.1%), and cataract (3.2%), and more than one-third of them also have delay in other areas of development.

A pilot study regarding basic knowledge of 揷ortical visual impairment in children� among ophthalmologists

Purpose: A pilot study was done to evaluate knowledge regarding 揷ortical visual impairment (CVI) in children� among ophthalmologists. Methods: This study was conducted during the annual conference of a zonal ophthalmological society. All ophthalmologists who attended the conference were requested to participate in this study. Those who agreed were given a validated questionnaire to assess knowledge regarding CVI. Cronbach's alpha of the questionnaire was 0.6. Participants were asked to respond to multiple choice questions by choosing the single best option. The responses obtained were then evaluated. Results: The total number of registered delegates in the conference was 448. A total of 103 ophthalmologists showed interest to participate in the study with a response rate of 22.9%. Only 89/103 interested delegates were included in the study as remaining were unaware of CVI. No participant gave correct answers to all questions. Although more than 80% of them knew the most common association (87%) and site of pathology (84%), only 52% were sure about clinical features and even lesser respondents (39%) knew that magnetic resonance imaging is the correct investigation of choice. The majority responded correctly that these children need eye examination (89%) and can be managed by rehabilitation through multidisciplinary approach (82%), but only 58% could recognize differential diagnoses and had a correct idea regarding the prognosis of CVI. There was no correlation between the number of patients diagnosed per month by the respondent with knowledge of the disease. Conclusion: In this pilot study, ophthalmologists were found to have limited knowledge regarding clinical features, investigation, differential diagnosis, and visual prognosis of CVI in children. There is a need to improve awareness regarding CVI among ophthalmologists.

Prematuridad y visión / Prematurity and vision

La prematuridad extrema constituye un riesgo importante para la función visual, no sólo por los efectos potencialmente devastadores para el ojo de la retinopatía del prematuro, que puede llegar a la ceguera, sino porque se asocia además al desarrollo de miopía, estrabismo y déficit visual cerebral. A medida que sobreviven cada día prematuros más extremos por la mejoría del cuidado neonatal, estas patologías derivadas de la prematuridad aumentan en prevalencia en la población infantil. Hoy en día, la retinopatía del prematuro es la primera causa de ceguera infantil en los países en desarrollo como el nuestro. Aquellos niños que no quedan ciegos por ella, pueden presentar las otras complicaciones quedando con algún grado de déficit visual. La ceguera, o incluso limitación visual de un niño genera muchos más años de discapacidad que una catarata, un glaucoma o una maculopatía, patologías que se presentan en general en los últimos años de vida. Por esto, las patologías y secuelas oculares de la prematuridad deben ser pesquisadas y tratadas a tiempo, y así minimizar su proyección sobre la vida del niño y del adulto que llegará a ser. El propósito de este artículo es revisar las repercusiones de la prematuridad en la función visual

Extreme premature birth threatens visual function, not only because of Retinopathy of Prematurity's (ROP) potentially devastating effects on the eye, that can lead to blindness, not only because it can also be associated with myopia, strabismus and cerebral visual impairment. The increased survival of very low birth weight infants as neonatal care improves determines an increased incidence of these prematurity derived pathologies in infants. Nowadays, ROP is the leading cause of childhood blindness in median income countries like ours. Those premature infants that are not blinded by it can have its other sequelae with some degree of visual deficit. Childhood blindness, or even their visual limitation means many more years of disability than a cataract, glaucoma or a maculopathy that present late in life. For this reason, ocular pathologies associated with premature birth should be diagnosed and treated on time, and thus minimize their effect on the child and adult that he will eventually become. This article reviews repercussions of prematurity on visual function