Perceptual visual dysfunction in children - An Indian perspective.

Perceptual visual dysfunction (PVD) comprises a group of vision disorders resulting from dysfunction of the posterior parietal and/or temporal lobes. Often, affected children have normal/near normal visual acuities and/or visual fields, but have difficulties in activities of daily living involving the use of vision. PVDs are known to be common among children with risk factors such as a history of prematurity and/or neurodevelopmental disorders. The inferior temporal lobes and ventral stream transform visual signals into perception, while the posterior parietal lobes and dorsal stream transform visual signals to non-consciously map the scene to guide action and facilitate attention. Dysfunction of these can lead to specific visual impairments that need to be identified during history taking, triggering ascertainment of further details by a structured inventory approach. Clinical tests to elicit dorsal and ventral stream visual dysfunctions have good specificity but low sensitivity. Neuropsychologists are rarely available in the developing world to perform detailed assessments, but there are a few tests that can be used by eye care professionals with some training. Optical coherence tomography (OCT) showing thinning of the ganglion cell layer and retinal nerve fiber layer is being explored as a potential tool for rapid assessment in the clinic. The behavioral outcomes of PVD can mimic psychological conditions including autism spectrum disorder, attention deficit hyperactivity disorder, specific learning disability, and intellectual impairment, and one needs to be aware of overlap among these differential diagnoses. A practical functional approach providing working solutions for each child's set of difficulties in day-to-day activities is needed.

Using street plays as a populist way to spread eye health awareness: An experience.

Street plays are a popular traditional medium of communication and entertainment in India. The objective of this paper is to communicate our experience about using street plays to raise awareness about children's eye health in a South Indian setting. Based on our experience of the prevailing misconceptions about children's eye health in our community, we selected some topics and prepared a blueprint of the scripts. We hired professional troupes who further refined these scripts into traditional street play scenarios by adding traditional songs, humor, and dialogues in the local dialect, leaving adequate room for improvisation during actual play. After a few rehearsals, we finalized the actual plays. Then, these were enacted in different parts of the city on different occasions, over a span of 3 years. In this descriptive paper, we share our experience of this exercise so that others may try and replicate this initiative in their areas. We found that the street plays were well attended by the people indicating the popularity of this medium in local communities. At the end of the street plays, a sample audience was interviewed about what they understood from the sessions, and most of them could reproduce the key messages. We found that instead of training our own staff, hiring a professional troupe was a more practical choice. Overall, it was a fruitful exercise in terms of the number of people that our plays reached out to effectively. Thus street play is an effective and popular means of disseminating eye health messages in our communities.

Causes of vision impairment and blindness among children in schools for the blind in South Indian States of Andhra Pradesh and Telangana.

Purpose: To study the causes of severe vision impairment (SVI) and blindness among children in Andhra Pradesh (AP) and Telangana State (TS) in South India. Methods: A total of 299 children from 10 schools for the blind were examined between January and December 2017. The schools were chosen from 3 districts of AP (Guntur, Krishna and West Godavari) and 2 districts of TS (Adilabad and Mahabubnagar). The World Health Organization Prevention of Blindness' eye examination protocol for children with blindness or visual impairment (VI) was followed. Results: Based on presenting visual acuity (PVA), 248 children (82.9%) were blind, 16 children (5.3%) had SVI, 18 (6%) had moderate VI, and 17 (5.7%) were normal. The most common anatomical cause of blindness or SVI was whole globe anomaly (32%), followed by an abnormality in the retina and vitreous (26.6%). While whole globe anomalies were high both in AP (33.8%) and TS (21.6%), lens-related pathologies were higher in TS (29.7%) and retina-related abnormalities were higher in AP (29.3%). The most common cause was related to heredity (40.5%). Etiology was unknown in 33.5% of cases. Overall, 37.1% of the causes were avoidable. In AP, 33.4% were avoidable whereas in TS nearly 60% were avoidable. Conclusion: Whole globe anomaly constitutes a major cause of SVI and blindness, especially in AP. Lens-related pathologies were higher in TS. Nearly 40% of the causes were avoidable. Hence, robust screening methods and strategies must be established for timely intervention to reduce the burden on VI in children.

Central Mini-tenotomy and Environmental Modifications to Correct "Macular Diplopia" due to Sickle Cell Retinopathy in a Resource-limited Setting.

Epiretinal membrane causing binocular diplopia, also denoted "macular diplopia," is a well-established entity, which is often difficult to treat. Mini-tenotomy is a surgical procedure to treat diplopia due to small-angle deviations. In this case report, we describe the successful management of a patient with "macular diplopia" secondary to sickle cell retinopathy using a central mini-tenotomy of the left superior rectus muscle and environmental adaptations to diminish peripheral retinal fusion.

La membrane épirétinienne causant une diplopie binoculaire, également appelée "diplopie maculaire", est une entité bien établie, qui est souvent difficile à traiter. La mini ténotomie est une procédure chirurgicale permettant de traiter la diplopie due aux déviations des petits angles. Dans ce rapport de cas, nous décrivons la prise en charge réussie d'un patient présentant une "diplopie maculaire" secondaire à une rétinopathie drépanocytaire, au moyen d'une mini-ténotomie centrale du muscle droit supérieur gauche et d'adaptations environnementales visant à diminuer la fusion rétinienne périphérique.

Management of Intra-orbital Wooden Foreign Bodies at a Resource-limited Setting in Sub-Saharan Africa.

Introduction: Wooden intra-orbital foreign bodies (IOrbFBs) have a high risk of microbial contamination needing timely diagnosis and treatment. We describe management of three cases of wooden IOrbFB at a resource-limited setting in Liberia. Materials and Methods: This is a retrospective case series of three patients with IOrbFB managed at the Liberia Eye Center, Monrovia, Liberia. Demographic details, mode of injury, ocular examination findings, neuroimaging, surgical treatment, and clinical findings on post-operative follow-up visits were noted for each patient. Results: All the three patients were young, male, and were involved in traumatic incidents (fall in two cases and road traffic accident in one case). Two patients with visible wooden FB presented within 48 h of injury and one patient with occult FB presented after 2 weeks. All patients underwent orbital imaging followed by surgical exploration for the removal of FB. One patient also had coexisting orbital cellulitis, which was successfully treated medically. One of these patients had best corrected visual acuity of 20/20, and the other two had no perception of light in the affected eyes. Conclusion: History of injury with a wooden material should raise a high index of suspicion for an occult IOrbFB. Timely diagnosis and treatment of wooden IOrbFB can be challenging in a resource-limited setting, but with a systematic approach they can be treated satisfactorily.

Introduction: Les corps étrangers intra-orbitaires en bois présentent un risque élevé de contamination microbienne nécessitant un diagnostic et un traitement rapides. Nous décrivons la prise en charge de 3 cas de corps étrangers intra-orbitaires en bois dans un pays aux ressources limitées tel quel le Libéria. Matériel et méthodes: Cest une étude rétrospective sur 3 cas de Corps étrangers intra orbitaire en bois prise en charge dans le centre oculaire du Libéria situé à Monrovia. Les détails démographiques, le mode de blessure, les résultats de l'examen oculaire, la neuro-imagerie, le traitement chirurgical et les résultats cliniques lors des visites de suivi post-opératoires ont été notés pour chaque patient. Résultats: Les 3 patients étaient jeunes, de sexe masculin et ont été impliqués dans des incidents traumatiques (chute dans 2 cas, et accident de la voie publique dans un cas). Deux patients avec un corps étranger en bois visible se sont présentés dans les 48 heures suivant la blessure et un patient avec un corps étranger occulte s'est présenté après 2 semaines. Tous les patients ont été soumis à une imagerie orbitaire suivie d'une exploration chirurgicale pour l'élimination du corps étranger. L'un de ces patients avait une acuité visuelle corrigée de 20/20 et les deux autres n'avaient aucune perception de la lumière dans les yeux affectés. Conclusion: La notion de traumatisme par un matériau en bois devrait faire craindre un Corps étranger intra orbitaire occulte. Le diagnostic et le traitement rapides des corps étrangers intra-orbitaire en bois peuvent être difficiles dans un contexte de ressources limitées, mais avec une approche systématique, ils peuvent être traités de manière satisfaisante.

An 8-month-old Baby Girl with Slight Drooping of Left Upper Eyelid.

An 8-month-old baby girl, who accompanied her sister with an eye problem, was incidentally noticed to have smaller left eye compared to the right. The mother said that it had been present for 2 months. The child showed no detectable focal neurological deficits. Her vision was age appropriate in both eyes. A slight left-sided ptosis was present. Her eye movements were full in both eyes and there was no evidence of strabismus. Bilateral fundus examination was normal. The child had anisocoria (left pupil being smaller than the right one) and left hemifacial anhidrosis, which prompted the diagnosis of Horner's syndrome. Magnetic resonance imaging of her chest showed a mass lesion in the apical region of the left lung which was later excised and found to be a neuroblastoma. This emphasizes the importance of having an eye on the siblings of children who come to the hospital.

Une petite fille de 8 mois, qui accompagnait sa soeur souffrant d'un problème oculaire, a par hasard été remarquée pour avoir un oeil gauche plus petit que le droit. La mère a dit qu'il était présent depuis 2 mois. L'enfant n'a montré aucun déficit neurologique focal détectable. Sa vision était adaptée à l'âge pour les deux yeux. Un léger ptosis gauche était présent. Ses mouvements oculaires étaient normaux pour les deux yeux et il n'y avait aucun signe de strabisme. L'examen bilatéral du fond d'oeil était normal. L'enfant avait une anisocorie (la pupille gauche étant plus petite que la droite) et une anhidrose hémifaciale gauche, ce qui a conduit au diagnostic de syndrome de Horner. Une IRM thoracique réalisée a montré une masse tissulaire de la région apicale du poumon gauche qui a ensuite été réséquée.L'examen anatomopathologique a révélé qu'ils agissait d'un neuroblastome. Cela souligne l'importance de garder un oeil sur la fratrie des enfants qui viennent consulter à l'hôpital.

Simultanagnosia as a cause of visual disturbance following Posterior Reversible Encephalopathy Syndrome (PRES): A case report.

Simultanagnosia resulting from dorsal stream dysfunction is an under recognized condition. In this case report we describe the case of a young woman who developed posterior reversible encephalopathy syndrome (PRES), and who recovered visual acuities of 20/20 in each eye, along with normal visual fields and contrast sensitivities, yet experienced persistent symptoms of perceptual dysfunction. Detailed and systematic history taking revealed consistent visual difficulties typical of dorsal stream dysfunction. After a detailed explanation of her symptomatology and training in a range of strategies to cope, the patient experienced a great improvement in her day-to-day functioning.

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.

Management of head tilt in infantile nystagmus syndrome: A case report.

Management of head tilt in infantile nystagmus syndrome (INS) is a challenge. In this case report, we have described successful management of right-sided head tilt in a child with INS by operating on three oblique muscles (superior oblique anterior tenectomy in the right eye, Harada-Ito procedure in the left eye, and inferior oblique recession in the left eye). The child had complete correction of head tilt without causing any cyclovertical strabismus or torsional diplopia postoperatively.

Prevalence of ophthalmic disorders among hearing-impaired school children in Guntur district of Andhra Pradesh.

PURPOSE: To estimate the prevalence, causes, and risk factors for visual impairment (VI) among children of school for hearing-impaired (HI) in Guntur district of Andhra Pradesh, India. METHODS: Children between 6 and 16 years of age available in all the 12 special schools for HI were examined. Visual acuity (VA) testing, ocular motility, and examination of anterior and posterior segment for all children were done. Those having VA of less than 6/12 in better eye underwent cycloplegic refraction. For definition of VI, as per World Health Organization (WHO), VA of better eye was considered. HI was also classified as mild, moderate, severe, and profound as per WHO definitions. Examination for systemic diseases and other associated disabilities was also done. RESULTS: In all, 402 children underwent examination. Ophthalmic abnormality was seen in 64 children with a prevalence of 15.9% [95% confidence interval (CI) 14.9%-16.8%], and VI was seen in 29 children with a prevalence of 7.2% (95% CI 4.9%-10.2%). Refractive errors [29 (7.2%)], retinitis pigmentosa (RP) [16 (4%)], and squint [8 (2%)] were the major ophthalmic abnormalities. Thirty-five (54.7%) of the abnormalities were either preventable or treatable. The major cause of VI was refractive error (18) followed by RP (5). Twenty of them (69%) with VI in this study group were treatable. Twenty-two (75.9%) children with eye problem were newly diagnosed. The only risk factor for VI was being mentally challenged (odds ratio: 5.63; 95% CI: 1.89-16.8). CONCLUSION: The prevalence of ophthalmic abnormalities and VI in school for HI was high, and the majority of them were not detected so far. As most of them are easily treatable, it is highly recommended to conduct regular eye examinations in these schools.

Consecutive cyclic esotropia - A case report.

Cyclic esotropia, a rare condition of obscure etiology characterized by regularly alternating periods of esotropia and orthophoria. We present a case of a 7-year-old boy who underwent surgical correction for intermittent exotropia elsewhere and developed esotropia with cyclic pattern post-operatively. Initially the cycle was of half-day orthophoria and half-day esotropia, which later became one full day of esotropia and one day of orthophoria. During re-surgery, right lateral rectus was found to have a stretched scar which was resected and then advanced and medial rectus was recessed. Post-surgery the child was orthophoric without cyclic pattern.

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-ischemic 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.

Agreement and diagnostic accuracy of vision screening in children by teachers, community eye-health workers and vision technicians.

BACKGROUND: To compare the agreement and diagnostic accuracy of vision screening conducted by trained community eye-health workers (CEHWs) and teachers with reference to vision technicians in Movva Mandal (sub-district) in Krishna District in the Indian state of Andhra Pradesh. METHODS: As part of a large epidemiological study on visual impairment in children, vision screening was conducted in all the schools in a sub-district. The children were screened using a screening card with 6/12 tumbling E optotypes by trained CEHWs, teachers and a vision technician. Teachers were included if they had screened at least 100 children and had at least five children identified with visual impairment. RESULTS: Of a total 6,197 children from 75 schools, 4,929 children were screened by all three categories of examiners (one vision technician, five CEHWs and 79 teachers). The overall agreement between the vision technician and CEHWs was 0.84 (95 per cent CI: 0.79-0.9) with a range of 0.77-0.9. Overall sensitivity of CEHWs to detect visual impairment was 83.3 per cent (95 per cent CI: 73.6-90.6) with a range of 71.4-87.1 per cent. Overall agreement of the five teachers with the vision technician was 0.81 (95 per cent CI: 0.74-0.88) with a range of 0.32-0.92. The overall sensitivity of teachers to detect vision problem was 72.3 per cent (95 per cent CI: 61.4-81.6) with a range from 20 per cent to 85.7 per cent and specificity was near 100 per cent. CONCLUSION: There was no significant difference in the agreement and diagnostic accuracy of CEHWs and teachers compared to those of the vision technician. There was a large variability among teachers, which needs to be considered in school vision screening programs.

Choroidal thickness profile in healthy Indian children.

PURPOSE: The purpose was to study choroidal thickness and its profile based on location in healthy Indian children using enhanced depth spectral-domain-optical coherence tomography (SD-OCT). METHODS: In this cross-sectional observational study 255 eyes of 136 children with no retinal or choroidal disease were consecutively scanned using enhanced depth SD-OCT. Eyes with any ocular disease or axial length (AXL) >25 mm or < 20 mm were excluded. A single observer measured choroidal thickness from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500-microns intervals up to 2500 microns temporal and nasal to the fovea. Generalized estimating equations were used to evaluate the correlation between choroidal thickness at various locations and age, AXL, gender and spherical equivalent (SEq). RESULTS: Mean age of the subjects was 11.9 ± 3.4 years (range: 5-18 years). There were 62 Females and 74 males. The mean AXL was 23.55 ± 0.74 mm. Mean subfoveal choroidal thickness was 312.1 ± 45.40 µm. Choroid was found to be thickest subfoveally, then temporally. Age, AXL and SEq showed a significant correlation with choroidal thickness, whereas gender did not affect choroidal thickness. CONCLUSION: Our study provides a valid normative database of choroidal thickness in healthy Indian children. This database could be useful for further studies evaluating choroidal changes in various chorioretinal disorders. Age and AXL are critical factors, which negatively correlated with choroidal thickness.

Measuring Health-Related Quality of Life in Strabismus: A Modification of the Adult Strabismus-20 (AS-20) Questionnaire Using Rasch Analysis.

PURPOSE: To evaluate the psychometric properties of the Adult Strabismus-20 (AS-20)- a health-related quality of life (HRQoL) questionnaire in adults with strabismus, and if flawed, to revise the AS-20 and its subscales creating valid measurement scales. METHODS: 584 adults (meanage, 27.5 years) with strabismus were recruited from an outpatient clinic at a South Indian tertiary eye care centre and were administered the AS-20 questionnaire.The AS-20 was translated and back translated into two Indian languages. The AS-20 and its two 10-item subscales - 'psychosocial' and 'function'were assessed separately for fit to the Rasch model, including an assessment of the rating scale, unidimensionality (by principal components analysis), measurement precision by person separation reliability, PSR, targeting, and differential item functioning (DIF; notable > 1.0 logits). RESULTS: Response categories were not used as intended, thereby, required re-organization and reducing their number from 5 to 3. The AS-20 had adequate measurement precision (PSR = 0.87) but lacked unidimensionality; however, deletion of the six multi-dimensionality causing items and an additional three misfitting items resulted in 11-item unidimensional questionnaire (AS-11). Two items failed to satisfy the model expectations in the 'psychosocial' subscale and were deleted - resulting in an 8-item unidimensional scale with adequate PSR (0.81) and targeting (0.23 logits). One item misfit in the 'function' subscale and was deleted-resulting in a 9 item Rasch-revised unidimensional subscale with acceptable PSR (0.80) and targeting (0.97 logits).None of the items displayed notable DIF by age, gender and level of education. CONCLUSIONS: The AS-11 and its two Rasch-revised subscales - 8-item psychosocial and 9-item function subscale may be more appropriate than the original AS-20 and its two 10-item subscales for use as unidimensional measures of HRQoL in adults with strabismus in India. Further work is required to establish the validity of the revised rating scale.

Treatment outcomes and clinicomicrobiological characteristics of a protocol-based approach for neonatal endogenous endophthalmitis.

PURPOSE: To describe the outcomes and clinicomicrobiological profile of 11 years of a protocol-based management in neonatal endogenous endophthalmitis. METHODS: This was a retrospective interventional study of endogenous endophthalmitis in 31 eyes of 26 neonates. The protocol for active infection included systemic antimicrobials, vitreous and/or aqueous tap, and intravitreal antimicrobials under topical or general anesthesia along with core vitrectomy in selected cases. Blood, urine, umbilicus, aqueous, and vitreous samples underwent microbiological evaluation. Retinopathy of prematurity screening and treatment were done when indicated. Primary outcome was anatomic status assessed by comprehensive eye examination and by fundus photography whenever possible. RESULTS: Twenty-one of 26 babies (81%) were preterm. Two types of presentations included those with a fulminant appearance (24 eyes) and those with focal retinitis detected during routine screening (7 eyes). Vitreous culture was positive in 12/20 eyes (60%). Pseudomonas aeruginosa (8) was the most common isolate. Incorrect initial diagnosis was common. Treatment included intravitreal injections in 26 eyes, 10 of which also underwent vitrectomy. Twenty-four of the 26 patients (92%) received parenteral antimicrobials and 17 had evidence of systemic infection. All eyes with a fulminant presentation developed phthisis, while all focal fungal cases were salvaged. CONCLUSIONS: Neonatal endogenous endophthalmitis has 2 distinct presentations. Focal retinal infections have good visual and anatomical outcomes while fulminant nosocomial cases do poorly. Management under topical anesthesia can be an alternative strategy for sick babies that cannot undergo surgery under general anesthesia due to systemic morbidity. Awareness about early diagnostic signs may help early referral.