Cost Analysis of a Comprehensive School Eye Screening Model from India.

PURPOSE: School eye screening is a crucial strategy in the elimination of childhood blindness because of its ability to reach out to children who are otherwise inaccessible to eye care needs. Comprehensive screening programs are recommended and are beneficial, but the economic aspects of such models remain to be understood. This study aimed to analyse the cost of a comprehensive school eye screening model while utilizing optometrists and optometry students. METHODS: This cross-sectional study was conducted for 295 schools screened in the academic year 2018-2019. The analysis was performed from the service provider's perspective including only the direct costs. Financial records were used for cost estimates. The outcome measures were cost per school and child, predictors for the cost, DALYs averted, cost of childhood blindness, and Benefit-Cost Ratio. RESULTS: A total of 65 094 children underwent screening from 295 schools. The median (IQR) cost per school and child for screening was $29.65 (29.65-44.34) and $0.66 (0.32-1.13). The regression model predicted that the cost of screening was dependent on school strength, number of screening personnel, distance of the schools, and deliverables. With the interventions to improve compliance, 14686.30 DALYs have been averted. Loss of productivity due to childhood blindness was estimated to be $339070.83. Screening for colour vision also had a Benefit-Cost ratio of greater than one. CONCLUSION: Cost of screening was low and the benefits were high while utilising optometrist and optometry students along with a comprehensive screening protocol.

Optometric education in the post-COVID-19 era: A time of forced change!

There is a massive disruption of the global economy and education due to the coronavirus disease-2019 (COVID-19) pandemic. This has posed significant challenges and threats to the academic community, especially in health care where the learning and assessment are patient centered. Though blended learning had its emphasis in the pre-COVID-19 era, innovations are required to meet up to the increased demands on learning and assessment. This article uses an inductive approach and outlines the existing challenges, impact of COVID-19 era, the need for a mindset reframe, and the potential opportunities for innovations that underlie during these challenging times.

Dalton's pseudo-isochromatic plates and congenital colour vision deficiency.

BACKGROUND: Diagnosing colour vision deficiency is vital, owing to its impact on the choice of career and activities of daily living. Conventional screening methods require frequent replacement due to soiling of the materials, and hence are expensive and not feasible for large-scale community screening. This study aims to construct and validate a new screening tool, Dalton's pseudo-isochromatic plates (PIP), addressing the disadvantages of the conventional methods. METHODS: The two phases of the study included the construction and validation of the Dalton's PIP. Construction involved utilising specific wavelengths based on spectral tuning, selection of numerals as targets for the chart and identification of a material with durability and resistance to wear and tear. Validation of the chart was done against the 38-plate edition of Ishihara's PIP by two masked examiners for 1,019 school children aged between 11-17 years (mean ± SD: 14 ± 2 years) as part of a school eye-health program. RESULTS: The sensitivity and the specificity of the Dalton's PIP was found to be 94.12 per cent (95% CI 71.31-99.85) and 99.60 per cent (95% CI 98.98-99.89) respectively and the positive and negative predictive values were 80 per cent and 99.90 per cent respectively. Dalton's PIP when used with a failure criterion of less than three plates correct in two screening sets had the maximum sensitivity and specificity and the area under the curve was 0.96 (95% CI 0.90-0.99, p < 0.05). CONCLUSION: The newly constructed Dalton's PIP is found to be a valid screening tool to detect congenital colour vision deficiency and is comparable to the Ishihara PIP. This screening tool with its shorter screening time, cost and longer durability would effectively serve in large-scale vision screening programs.

Environmental factors in school classrooms: How they influence visual task demand on children.

BACKGROUND: The key visual factors in a classroom environment include the legibility, angle subtended at the eye, illumination, contrast, and colour of the visual task. The study evaluated the visual environmental factors in the school classrooms. MATERIALS AND METHODS: The distance Visual Acuity (VA) demand was evaluated based on the size of visual task i.e. the smallest size of chalkboard writing and its viewing distance. The environmental factors which can have an effect on the visibility in classrooms such as illuminance on the chalkboard and at student's desk, chalkboard contrast, light sources and the student's perception of their classroom visual environment were measured. To quantify the distance VA demand and to compare with a standard high contrast VA chart measure, a validation of the measurements was performed by chalkboard simulation experiment. The "acuity reserve" to be included to the measured distance VA demand was evaluated. RESULTS: We included twenty-nine classrooms of eight schools. The median distance VA threshold demand was 0.28 logMAR(0.25,0.45). The median illuminance on front desk position and chalkboard contrast was 130 lux(92,208) and 40(36,50) respectively with 62% classrooms having low illumination (<150lux). The acuity reserve evaluated to be included to the distance VA demand was 0.13logMAR and 0.29 logMAR in classrooms with optimal and low chalkboard illumination respectively which was based on the results of the simulation experiment. The median distance VA demand including the acuity reserve was 0.09 logMAR(-0.03,0.23) [Snellen Equivalent: 20/25(20/19,20/34)]. CONCLUSION: The study findings highlight the increased visual task demand in school classrooms and the need for appropriate seating arrangements in classrooms based on the visual acuity of children. The study emphasises regular audit of the classroom environment along with the school eye screening.

Spectacle compliance among adolescents in Southern India: Perspectives of service providers.

Purpose: Compliance to spectacle wear is vital to elimination of avoidable blindness among schoolchildren. This study aims to understand the barriers to compliance and strategies to overcome the barriers from the perspectives of the service providers of the school vision-screening model. Methods: A snapshot qualitative study using focus group discussions (FGDs) was conducted among the service providers including eye care professionals (ECPs) and social workers that are part of the school screening program. Sessions were audio recorded and transcribed. Themes were formed following inductive coding using a conceptual framework. Results: Out of the three FGDs, two were with ECPs and one with social workers. Four subthemes identified under the barriers were poor awareness, spectacle-related, psychosocial, and financial barriers. Unique barriers according to the service providers included nonuse of spectacles by asymptomatic children, children with unilateral refractive errors and those with emmetropic parents. Service providers also brought out parent's feelings of guilt, doubts about their children's impaired vision, the negative self-image among children, and difficulties in obtaining funding to support the costs of screening. Solutions that emerged included the personal visit of professionals for spectacle distribution and counseling parents, demonstration of improvement in vision for activities that were difficult for the children without spectacles and rewarding, and role modeling of compliant children. Conclusion: This study had identified unique barriers and solutions from the perspectives of the service providers. The suggested strategies would aid in an effective schoolchildren vision screening practice to enhance compliance to spectacle wear.

Effectiveness of interventions in improving compliance to spectacle wear and referral in school vision screening.

BACKGROUND: Success of a school vision screening program depends on compliance with the advice that is offered to the children. This study evaluates the effect of an intervention package on compliance to spectacle wear and referral in a school vision screening program. METHODS: Among 8,442 children aged 13-17 years in 11 government schools in and around Chennai, India, 114 (2.2 per cent) children who required spectacles were allocated to the control arm (5,116 children) and 124 (3.7 per cent) children to the intervention arm (3,326 children). There were 44 (0.9 per cent) children in the control arm and 49 (1.5 per cent) children in the intervention arm who required referral for further management. Control schools received a conventional school screening protocol and intervention schools received 23-step interventions. Spectacle wear was noted in an unannounced direct observation after one, four and 12 months. Compliance to referral was noted based on the response of children with confirmation from medical records. RESULTS: Spectacle compliance was significantly higher for the intervention arm compared to the control arm based on direct observation in the first month (17.6 per cent versus 49 per cent, adjusted odds ratio [OR] = 4.4, 95 per cent confidence interval [CI] 2.3-8.5, p < 0.05); in the fourth month (23 per cent versus 56 per cent, OR = 4.2, 95 per cent CI 2.3-7.8, p < 0.05); and in the 12th month (13.3 per cent versus 38.8 per cent, OR = 4.1, 95 per cent CI 1.8-9.4, p < 0.05). Referral compliance was significantly higher in the intervention arm in the first month (17.5 per cent versus 70.5 per cent, OR = 10.9, 95 per cent CI 3.8-30.9, p < 0.001) and in the fourth month (31.7 per cent versus 75.6 per cent, OR = 6.2, 95 per cent CI 2.3-16.0, p < 0.001). CONCLUSION: A 23-step package of interventions was effective in improving compliance to spectacle wear and referral among adolescents in a school vision screening program.

Variant myopia: A new presentation?

Purpose: Variant myopia (VM) presents as a discrepancy of >1 diopter (D) between subjective and objective refraction, without the presence of any accommodative dysfunction. The purpose of this study is to create a clinical profile of VM. Methods: Fourteen eyes of 12 VM patients who had a discrepancy of >1D between retinoscopy and subjective acceptance under both cycloplegic and noncycloplegic conditions were included in the study. Fourteen eyes of 14 age- and refractive error-matched participants served as controls. Potential participants underwent a comprehensive orthoptic examination followed by retinoscopy (Ret), closed-field autorefractor (CA), subjective acceptance (SA), choroidal and retinal thickness, ocular biometry, and higher order spherical aberrations measurements. Results: In the VM eyes, a statistically and clinically significant difference was noted between the Ret and CA and Ret and SA under both cycloplegic and noncycloplegic conditions (multivariate repeated measures analysis of variance, P < 0.0001). A statistically significant difference was observed between the VM eyes, non-VM eyes, and controls for choroidal thickness in all the quadrants (Univariate ANOVA P < 0.05). The VM eyes had thinner choroids (197.21 ± 13.04 µ) compared to the non-VM eyes (249.25 ± 53.70 µ) and refractive error-matched controls (264.62 ± 12.53 µ). No statistically significant differences between groups in root mean square of total higher order aberrations and spherical aberration were observed. Conclusion: Accommodative etiology does not play a role in the refractive discrepancy seen in individuals with the variant myopic presentation. These individuals have thinner choroids in the eye with variant myopic presentation compared to the fellow eyes and controls. Hypotheses and clinical implications of variant myopia are discussed.

Construction and validation of logMAR visual acuity charts in seven Indian languages.

Purpose: The evaluation of visual impairment requires the measurement of visual acuity with a validated and standard logMAR visual acuity chart. We aimed to construct and validate new logMAR visual acuity chart in Indian languages (Hindi, Bengali, Telugu, Urdu, Kannada, Malayalam, and Assamese). Methods: The commonly used font in each language was chosen as the reference and designed to fit the 5 × 5 grid (Adobe Photoshop). Ten letters (easiest to difficult) around median legibility score calculated for each language based on the results of legibility experiment and differing by 10% were selected. The chart was constructed based on the standard recommendations. The repeatability of charts was tested and also compared with a standard English Early Treatment Diabetic Retinopathy Study (ETDRS) logMAR chart for validation. Results: A total of 14 rows (1.0 to -0.3 logMAR) with five letters in each line were designed with the range of row legibility between 4.7 and 5.3 for all the language charts. Each chart showed good repeatability, and a maximum difference of four letters was noted. The median difference in visual acuity was 0.16 logMAR for Urdu and Assamese chart compared to ETDRS English chart. Hindi and Malayalam chart had a median difference of 0.12 logMAR. When compared to the English chart a median difference of 0.14 logMAR was noted in Telugu, Kannada, and Bengali chart. Conclusion: The newly developed Indian language visual acuity charts are designed based on the standard recommendations and will help to assess visual impairment in people of these languages across the country.

Are children with low vision adapted to the visual environment in classrooms of mainstream schools?

PURPOSE: The study aimed to evaluate the classroom environment of children with low vision and provide recommendations to reduce visual stress, with focus on mainstream schooling. METHODS: The medical records of 110 children (5-17 years) seen in low vision clinic during 1 year period (2015) at a tertiary care center in south India were extracted. The visual function levels of children were compared to the details of their classroom environment. The study evaluated and recommended the chalkboard visual task size and viewing distance required for children with mild, moderate, and severe visual impairment (VI). RESULTS: The major causes of low vision based on the site of abnormality and etiology were retinal (80%) and hereditary (67%) conditions, respectively, in children with mild (n = 18), moderate (n = 72), and severe (n = 20) VI. Many of the children (72%) had difficulty in viewing chalkboard and common strategies used for better visibility included copying from friends (47%) and going closer to chalkboard (42%). To view the chalkboard with reduced visual stress, a child with mild VI can be seated at a maximum distance of 4.3 m from the chalkboard, with the minimum size of visual task (height of lowercase letter writing on chalkboard) recommended to be 3 cm. For 3/60-6/60 range, the maximum viewing distance with the visual task size of 4 cm is recommended to be 85 cm to 1.7 m. CONCLUSION: Simple modifications of the visual task size and seating arrangements can aid children with low vision with better visibility of chalkboard and reduced visual stress to manage in mainstream schools.

Reasons for spectacle reassessment in a tertiary eye care centre over a period of six years.

BACKGROUND: To determine the spectacle reassessment rates of dissatisfied patients returning to the optical services department of a tertiary eye centre in India over a period of six years. METHODS: A total of 169,567 spectacles were dispensed from the optical services department between January 2010 and December 2015. The spectacle reassessment forms of dissatisfied patients who returned to the optical services department with their spectacles were analysed. RESULTS: A total of 797 spectacle reassessment forms were analysed. The overall spectacle reassessment rate during the study period was found to be 0.5% (95% CI: 0.467-0.472). The mean age of patients returning back for spectacle reassessment was 48 years (SD 19.9, range 3-97 years). Error in refractive correction measurement was found to be the most common reason for spectacle reassessment (54.7%), followed by dispensing error (21.1%), documentation errors while writing the prescription from the medical records in the tertiary eye care centre (12.7%), transcription error occurring at the optical services department (10.8%) and ocular pathologies (0.8%). No statistically significant difference was observed in the year-wise spectacle reassessment rates during the study period (p = 0.14). CONCLUSIONS: The frequency of spectacle reassessment rate in a tertiary eye care centre was low, with errors in measuring refractive errors contributing the most to the reassessment and reorder of spectacles.

Efficacy of vision therapy in children with learning disability and associated binocular vision anomalies.

PURPOSE: To report the frequency of binocular vision (BV) anomalies in children with specific learning disorders (SLD) and to assess the efficacy of vision therapy (VT) in children with a non-strabismic binocular vision anomaly (NSBVA). METHODS: The study was carried out at a centre for learning disability (LD). Comprehensive eye examination and binocular vision assessment was carried out for 94 children (mean (SD) age: 15 (2.2) years) diagnosed with specific learning disorder. BV assessment was done for children with best corrected visual acuity of ≥6/9 - N6, cooperative for examination and free from any ocular pathology. For children with a diagnosis of NSBVA (n=46), 24 children were randomized to VT and no intervention was provided to the other 22 children who served as experimental controls. At the end of 10 sessions of vision therapy, BV assessment was performed for both the intervention and non-intervention groups. RESULTS: Binocular vision anomalies were found in 59 children (62.8%) among which 22% (n=13) had strabismic binocular vision anomalies (SBVA) and 78% (n=46) had a NSBVA. Accommodative infacility (AIF) was the commonest of the NSBVA and found in 67%, followed by convergence insufficiency (CI) in 25%. Post-vision therapy, the intervention group showed significant improvement in all the BV parameters (Wilcoxon signed rank test, p<0.05) except negative fusional vergence. CONCLUSION: Children with specific learning disorders have a high frequency of binocular vision disorders and vision therapy plays a significant role in improving the BV parameters. Children with SLD should be screened for BV anomalies as it could potentially be an added hindrance to the reading difficulty in this special population.

The minimum test battery to screen for binocular vision anomalies: report 3 of the BAND study.

PURPOSE: This study aims to report the minimum test battery needed to screen non-strabismic binocular vision anomalies (NSBVAs) in a community set-up. When large numbers are to be screened we aim to identify the most useful test battery when there is no opportunity for a more comprehensive and time-consuming clinical examination. METHODS: The prevalence estimates and normative data for binocular vision parameters were estimated from the Binocular Vision Anomalies and Normative Data (BAND) study, following which cut-off estimates and receiver operating characteristic curves to identify the minimum test battery have been plotted. In the receiver operating characteristic phase of the study, children between nine and 17 years of age were screened in two schools in the rural arm using the minimum test battery, and the prevalence estimates with the minimum test battery were found. RESULTS: Receiver operating characteristic analyses revealed that near point of convergence with penlight and red filter (> 7.5 cm), monocular accommodative facility (< 10 cycles per minute), and the difference between near and distance phoria (> 1.25 prism dioptres) were significant factors with cut-off values for best sensitivity and specificity. This minimum test battery was applied to a cohort of 305 children. The mean (standard deviation) age of the subjects was 12.7 (two) years with 121 males and 184 females. Using the minimum battery of tests obtained through the receiver operating characteristic analyses, the prevalence of NSBVAs was found to be 26 per cent. Near point of convergence with penlight and red filter > 10 cm was found to have the highest sensitivity (80 per cent) and specificity (73 per cent) for the diagnosis of convergence insufficiency. For the diagnosis of accommodative infacility, monocular accommodative facility with a cut-off of less than seven cycles per minute was the best predictor for screening (92 per cent sensitivity and 90 per cent specificity). CONCLUSION: The minimum test battery of near point of convergence with penlight and red filter, difference between distance and near phoria, and monocular accommodative facility yield good sensitivity and specificity for diagnosis of NSBVAs in a community set-up.

Spectacle Compliance among Adolescents: A Qualitative Study from Southern India.

PURPOSE: To understand the perceptions of adolescents and their parents about spectacle compliance of adolescents in Southern India. METHODS: Using a qualitative snapshot design, three focus group discussions were conducted each with parents and adolescents studying in schools located in and around Chennai, Tamil Nadu. Purposive sampling technique was used in the selection of participants. Separate focus group guides were developed for parents and adolescents. All focus group discussions were conducted in the school premises and audio recorded. These audio files were then transcribed verbatim and then translated into English. A framework analytical approach was used for data analysis that involved gaining familiarity with the data to identify a thematic framework. RESULTS: Two major themes that emerged were (1) perceptions on barriers to spectacle compliance that was further subdivided into physical, psychological, and societal barriers; and (2) solutions to improve spectacle use. Barriers identified included scars on the nose, unattractive frames contributing to poor appeal, adolescents feeling discriminated and set apart, fears of injury to eyes, lack of parental involvement, and negative attitudes of society toward those wearing spectacles. Solutions given by the stakeholders included provision of lightweight, well-fitting, trendy frames of adolescents' choice, importance and need for periodical eye examinations, including teachers in encouraging spectacle use and preventing bullying and teasing by other adolescents, provision of free spectacles along with periodic replacement, and inclusion of awareness sessions on spectacle use for both parents and adolescents. CONCLUSIONS: The study has identified both barriers and solutions for improving spectacle compliance among school adolescents from the viewpoint of the stakeholders involved. Implementing the solutions suggested by the stakeholders through planned intervention programs could possibly help in ensuring better compliance of spectacle use among school adolescents.

Do school classrooms meet the visual requirements of children and recommended vision standards?

BACKGROUND: Visual demands of school children tend to vary with diverse classroom environments. The study aimed to evaluate the distance and near Visual Acuity (VA) demand in Indian school classrooms and their comparison with the recommended vision standards. MATERIALS AND METHODS: The distance and near VA demands were assessed in 33 classrooms (grades 4 to 12) of eight schools. The VA threshold demand relied on the smallest size of distance and near visual task material and viewing distance. The logMAR equivalents of minimum VA demand at specific seating positions (desk) and among different grades were evaluated. The near threshold was converted into actual near VA demand by including the acuity reserve. The existing dimensions of chalkboard and classroom, gross area in a classroom per student and class size in all the measured classrooms were compared to the government recommended standards. RESULTS: In 33 classrooms assessed (35±10 students per room), the average distance and near logMAR VA threshold demand was 0.31±0.17 and 0.44±0.14 respectively. The mean distance VA demand (minimum) in front desk position was 0.56±0.18 logMAR. Increased distance threshold demand (logMAR range -0.06, 0.19) was noted in 7 classrooms (21%). The mean VA demand in grades 4 to 8 and grades 9 to 12 was 0.35±0.16 and 0.24±0.16 logMAR respectively and the difference was not statistically significant (p = 0.055). The distance from board to front desk was greater than the recommended standard of 2.2m in 27 classrooms (82%). The other measured parameters were noted to be different from the proposed standards in majority of the classrooms. CONCLUSION: The study suggests the inclusion of task demand assessment in school vision screening protocol to provide relevant guidance to school authorities. These findings can serve as evidence to accommodate children with mild to moderate visual impairment in the regular classrooms.

Prevalence of non-strabismic anomalies of binocular vision in Tamil Nadu: report 2 of BAND study.

BACKGROUND: Population-based studies on the prevalence of non-strabismic anomalies of binocular vision in ethnic Indians are more than two decades old. Based on indigenous normative data, the BAND (Binocular Vision Anomalies and Normative Data) study aims to report the prevalence of non-strabismic anomalies of binocular vision among school children in rural and urban Tamil Nadu. METHODS: This population-based, cross-sectional study was designed to estimate the prevalence of non-strabismic anomalies of binocular vision in the rural and urban population of Tamil Nadu. In four schools, two each in rural and urban arms, 920 children in the age range of seven to 17 years were included in the study. Comprehensive binocular vision assessment was done for all children including evaluation of vergence and accommodative systems. In the first phase of the study, normative data of parameters of binocular vision were assessed followed by prevalence estimates of non-strabismic anomalies of binocular vision. RESULTS: The mean and standard deviation of the age of the sample were 12.7 ± 2.7 years. The prevalence of non-strabismic anomalies of binocular vision in the urban and rural arms was found to be 31.5 and 29.6 per cent, respectively. Convergence insufficiency was the most prevalent (16.5 and 17.6 per cent in the urban and rural arms, respectively) among all the types of non-strabismic anomalies of binocular vision. There was no gender predilection and no statistically significant differences were observed between the rural and urban arms in the prevalence of non-strabismic anomalies of binocular vision (Z-test, p > 0.05). The prevalence of non-strabismic anomalies of binocular vision was found to be higher in the 13 to 17 years age group (36.2 per cent) compared to seven to 12 years (25.1 per cent) (Z-test, p < 0.05). CONCLUSION: Non-strabismic binocular vision anomalies are highly prevalent among school children and the prevalence increases with age. With increasing near visual demands in the higher grades, these anomalies could significantly impact the reading efficiency of children. Thus, it is recommended that screening for anomalies of binocular vision should be integrated into the conventional vision screening protocol.

Binocular vision anomalies and normative data (BAND) in Tamil Nadu: report 1.

BACKGROUND: This population-based, cross-sectional study was designed to determine normative data for binocular vision and accommodative testing in rural and urban populations of Tamil Nadu. METHODS: A sample of 936 was determined, based on a previous pilot study. The epidemiological field work included a comprehensive eye examination and a binocular vision and accommodative assessment carried out in a total of four public schools, two each in the rural and urban arms of Chennai. An overall sample of 3,024 children between seven and 17 years of age was screened in the four schools and 920 children were included in the study. RESULTS: We found significant differences in expected values from the current clinical criteria for near point of convergence (NPC) with penlight, distance and near horizontal phorias, vergence facility, accommodation convergence/accommodation (AC/A) ratio, accommodative amplitudes, monocular and binocular accommodative facility (t-test: p < 0.001). The mean and standard deviation break/recovery values for NPC (in centimetres) with an accommodative target and penlight with red filter was 3 ± 3/4 ± 4 and 7 ± 5/10 ± 7, respectively. The mean accommodative amplitudes for the population could be estimated from the linear regression equation 16 - 0.3 × (age). The vergence facility was 12 ± 4 cycles/minute and 14 ± 4 cycles/minute in the seven to 10 and 11 to 17 age groups, respectively. Monocular accommodative facility was 11 ± 4 cycles/minute and 14 ± 5 cycles/minute and binocular accommodative facility was 10 ± 4 cycles/minute and 14 ± 5 cycles/minute in the seven to 12 and 13 to 17 age groups, respectively. The mean calculated AC/A ratio was 5.4 ± 0.6/1. CONCLUSION: The normative data for vergence and accommodative parameters for the Indian children between seven and 17 years of age are reported. The developmental trend of accommodation and vergence differences and significant differences in cut-off between the current data and available literature are reported. These differences have clinical implications for the interpretation, diagnosis and management of anomalies of binocular vision.

Refractive error and vision-related quality of life in South Indian children.

PURPOSE: To understand the vision-related quality of life (QoL) of schoolchildren with uncorrected refractive error (URE). METHODS: A snapshot qualitative research design and homogeneous sampling strategy was adopted. Thirty-one, 27, and 22 eye care practitioners, children, and teachers participated in four, three, and two focus group discussions, respectively. The participants were recruited from various parts of Chennai, India. The discussions were audio recorded, transcribed, coded, and analyzed. RESULTS: Eight themes emerged: complaints and symptoms of children with URE, vision-related activity limitation, coping strategies, psychological impact, social impact, the perceived difference after first time refractive correction, reasons for refractive error remaining uncorrected, and the significant amount of refractive error. CONCLUSIONS: The study gives a holistic view of the vision-related QoL of children with URE by demonstrating the difficulties and problems that they face in their day-to-day life and also by describing the perceived difference in QoL after wearing refractive correction.

Acute adult onset comitant esotropia associated with accommodative spasm.

PURPOSE: Acute onset comitant esotropia associated with spasm of accommodation in children and adults is a rare clinical condition. When occurring with pupillary miosis and restricted ocular motility, it is referred to as "spasm of near reflex" (SNR) and may require neurological investigation. The natural history of SNR depends on its etiology. There is little information in the literature regarding the long-term follow-up of SNR and the stability of visual signs and symptoms following cessation of treatment. We report a case of SNR in an otherwise healthy young male, and discuss the presentation, clinical investigations, management, response to treatment, and 1-year follow-up. CASE REPORT: A 23-year-old male patient reported to the clinic with sudden onset of blurred vision, inward deviation of the eyes, and binocular diplopia. On examination, he was diagnosed to have acute onset esotropia resulting from SNR. He was treated with cycloplegic medications and vision therapy. The condition resolved following 1 year and there has been no recurrence. CONCLUSIONS: Acute adult onset esotropia occurring with accommodative spasm responds favorably to cycloplegic medications but may need a longer course of treatment for successful resolution and stability.

Impact of low vision care on reading performance in children with multiple disabilities and visual impairment.

BACKGROUND: Lack of evidence in literature to show low vision care enhances the reading performance in children with Multiple Disabilities and Visual Impairment (MDVI). AIM: To evaluate the effectiveness of Low Vision Care intervention on the reading performance of children with MDVI. MATERIALS AND METHODS: Three subjects who were diagnosed to have cerebral palsy and visual impairment, studying in a special school were recruited for the study. All of them underwent detailed eye examination and low vision care evaluation at a tertiary eye care hospital. A single subject multiple baseline (study) design was adopted and the study period was 16 weeks. The reading performance (reading speed, reading accuracy, reading fluency) was evaluated during the baseline phase and the intervention phase. The median of all the reading parameters for each week was noted. The trend of the reading performance was graphically represented in both the phases. RESULTS: Reading speed increased by 37 Word per minute, 37 Letters per minute and 5 letters per minute for the subject 1, 2 and 3 respectively after the intervention. Reading accuracy was 84%, 91% and 86.4% at the end of the baseline period and 98.7%, 98.4% and 99% at the end of 16 weeks for subject 1, 2 and 3 respectively. Average reading fluency score was 8.3, 7.1 and 5.5 in the baseline period and 10.2, 10.2 and 8.7 in the intervention period. CONCLUSION: This study shows evidence of noticeable improvement in reading performance of children with MDVI using a novel study design.