Visual Behaviours (ViBes) in Cerebral Visual Impairment: Validating a Descriptive Tool to Support Diagnosis and Monitoring.

Introduction: Cerebral visual impairment (CVI) is the most common cause of visual impairment in children in the UK. Diagnosis is based on identification of visual behaviours (ViBes) relating to visual dysfunction. Examination techniques and inventories have been developed to elicit these in children with a developmental age of two years or more. The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis. The aim of the study was to develop a matrix of visual behaviours seen in pre-verbal and pre-motor children with visual impairment and establish its content validity and inter-rater reliability. Methods: ViBe content validation:: Visual behaviour descriptors relating to visual function were collated and categorised by expert consensus of vision professionals into a matrix composed of three functions (attention, field/fixation, motor response) and five levels (0 = no awareness; 1 = visual awareness; 2 = visual attention; 3 = visual detection; 4 = visual understanding).ViBe inter-rater reliability:: The participants (two orthoptists, an optometrist, an ophthalmologist and two qualified teachers of the visually impaired) used the ViBe matrix to independently score each of 17 short video clips of children demonstrating visual behaviours seen in CVI. Results: The ViBe matrix will be presented. Cohen's kappa for the matrix was 0.67, demonstrating moderate-to-strong inter-rater reliability. Conclusion: The development of standardised descriptors can support clinicians and teachers in identifying areas of concern for children with complex needs. In addition, the ViBe matrix could be utilised in research, clinical and diagnostic reports to clearly communicate the areas of visual dysfunction and track progress resulting from interventions. Key Points: The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis.The ViBe matrix offers descriptors relating to visual behaviours and has demonstrated acceptable inter-rater reliability.The tool may support the identification and diagnosis of cerebral visual impairment in a population of children who cannot access standard testing.

Make it easier: 3-word strategies to help children with cerebral visual impairment use their vision more effectively.

INTRODUCTION: Cerebral Visual Impairment (CVI) is the most common cause of visual impairment in children in the United Kingdom. Management relies on identifying strategies and adaptations which enable the child to use their vision effectively and efficiently. The majority of published strategies involve lengthy inventories used in a specialist setting. Feedback from parent support groups cite the provision of immediate advice on strategies at the time of diagnosis as a key indicator of good care. The aim of the study was to use the Delphi technique to construct a set of three-word phrases to succinctly describe strategies for common visual dysfunctions in children with CVI. METHOD: A panel of twelve experts across health, education and those with lived experience was recruited. Four rounds of questionnaires were used to reach consensus on candidates symptoms and suggestions for 3-word-phrases. Consensus was defined as 70% agreement. RESULTS: Response rates were 92, 67, 92 and 91% for each round respectively. The 3-word phrases reaching consensus were: Big Bold Bright; Keep it Still; Eyes or Ears; Show It High; Better on Left/Right; Clear the Clutter; Keep It Short; Give Me Time, My Vision Varies, Just One Thing. CONCLUSION: The intention is for the phrases presented to act as a 'starter' at the point of diagnosis and are appropriate for children of any developmental or visual ability. The real-life validation of this set of expert-consensus phrases will require further studies, evaluating both their effectiveness in terms of mapping to an intervention and impact on visual development.

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

INTRODUCTION: Local Optometric Support Unit (LOCSU) have published their refreshed clinical pathway for eye care for people with a learning disability. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for a person with learning disability attending a primary eye care assessment. The pathway specifically points to the need to retain patients in primary care where appropriate and 'reduce the number of people with learning disability who are inappropriately referred into the Hospital Eye Service (HES).' Pivotal to this refreshed pathway is the integration with secondary care, with local arrangements to facilitate referral and hospital management where appropriate. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability. METHOD: A series of video interviews were undertaken with eye health professionals with a range of experience in eye care for people with learning disability. Each contributor commented on the usability and clarity of each element of the referral criteria. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. These were collated into the final document which was circulated and agreed by all participants. RESULTS: A table setting out referral thresholds for commonly encountered eye conditions in adults with learning disabilities is presented. CONCLUSION: We have presented a succinct set of consensus statements relating referral thresholds for common presentations of visual problems in adults with learning disability in the UK distilled from the collective experience of a group of eye health professionals. The intention was not to present a comprehensive review of management of each condition. Rather, the consensus statements may form the starting point from which each area could develop locally agreed criteria, as is suggested by the LOCSU pathway guidance.

Are all children with visual impairment known to the eye clinic?

INTRODUCTION: There is a growing body of evidence that children with special needs are more likely to have visual problems, be that visual impairment, visual processing problems or refractive error. While there is widespread provision of vision screening in mainstream schools, patchy provision exists in special schools. The aim of the study was to determine the unmet need and undiagnosed visual problems of children attending primary special schools in Bradford, England. METHODS: Children attending special schools who were not currently under the care of the hospital eye service were identified. Assessments of visual function and refractive error were undertaken on site at the schools by an experienced orthoptist and/or paediatric ophthalmologist. RESULTS: A total of 157 children were identified as eligible for the study, with a mean age of 7.8 years (range 4-12 years). Of these, 33% of children were found to have visual impairment, as defined by WHO and six children were eligible for severe sight impairment certification. DISCUSSION: The study demonstrates significant unmet need or undiagnosed visual impairment in a high-risk population. It also highlights the poor uptake of hospital eye care for children identified with significant visual needs and suggests the importance of providing in-school assessment and support, including refractive correction, to fully realise the benefits of a visual assessment programme.

Validity of ophthalmology surgical competency assessment rubric for strabismus surgery in resident training.

The Accreditation Council for Graduate Medical Education (ACGME) requires US residency programs to assess ophthalmology residents for competency in 6 core areas. Ophthalmic surgical skills are currently part of the ACGME "Patient Care" competency, although some have advocated for a seventh competency, "Surgical Skills." The Ophthalmology Surgical Competency Assessment Rubric for Strabismus Surgery in Resident Training ( OSCAR: Strabismus) tool was designed to aid in the assessment of surgical skills using procedure specific behavioral anchors. The present study evaluated inter-rater agreement of the OSCAR: Strabismus tool in the assessment of resident performance. OSCAR: Strabismus evaluations of resident surgical strabismus cases were performed by a multinational group of faculty strabismus surgeons. Cronbach α statistical analysis of the completed evaluations revealed high inter-rater agreement, indicating the OSCAR: Strabismus is a reliable tool to facilitate assessment of resident strabismus surgical skills.

Assessing visual function in children with complex disabilities: the Bradford visual function box.

BACKGROUND: Assessment of children with complex and severe learning disabilities is challenging and the children may not respond to the monochrome stimuli of traditional tests. The International Association of Scientific Studies on Intellectual Disability recommends that visual function assessment in poorly or non-cooperative children should be undertaken in an objective manner. We have developed a functional visual assessment tool to assess vision in children with complex and multiple disabilities. METHODS: The Bradford visual function box (BVFB) comprises a selection of items (small toys) of different size and colour, which are presented to the child and the response observed. The aim of this study is to establish its intertester validity in children with severe learning disability. The visual function of 22 children with severe learning disability was assessed using the BVFB. The children were assessed by experienced practitioners on two separate occasions. The assessors were unaware of each other's findings. RESULTS: In 15/22 of the children, no difference was found in the results of the two assessors. The test was shown to have a good intertester agreement, weighted κ=0.768. CONCLUSIONS: The results of this clinical study show that the BVFB is a reliable tool for assessing the visual function in children with severe learning disability in whom other tests fail to elicit a response. The need for a tool which is quick to administer and portable has previously been highlighted. The BVFB offers an option for children for whom other formal tests are unsuccessful in eliciting a response.

An audit of the Royal College of Ophthalmologists strabismic amblyopia treatment protocol: a departmental review.

INTRODUCTION: Children presenting with strabismus and mixed (anisometropic/strabismic) amblyopia are managed by a local protocol as per guidelines from the Royal College of Ophthalmologists. Decisions regarding intervention for occlusion are currently delayed until a 22 week review allowing for refractive adaptation, with intermediate reviews at 6 and 14 weeks. PURPOSE: The purpose of this audit was to determine adherence to the protocol and the benefit of the 14 week review. MATERIALS AND METHODS: We performed a prospective data collection of all children attending the orthoptic department with strabismus without pathology, both with and without unequal vision, from October 2007 to July 2008 managed using the protocol. RESULTS: 26 patients were eligible. Mean age at presentation was 3.3 years (1.4 to 6.5). Cycloplegic spherical equivalent (SE) mean was 2.6 dioptres (-2.25 to +7.25). Five patients failed to comply with the protocol; one patient was listed surgery, four patients commenced premature occlusion. At presentation 8 patients had equal vision (defined as < 0.1 logMAR difference) between the two eyes or would only perform BEO vision, by week 14, over 60% were found to have a difference in vision between the eyes, despite refraction correction (mean 0.4 logMAR, range 0 to 1.4 logMAR). In a subgroup of patients (n = 8 at 6 weeks) with a small discrepancy of vision between the eyes (0.1 to 0.5 logMAR) there was no progressive worsening of vision during the period of observation and 50% of patients improved spontaneously, although two patients were lost to follow up. In the subgroup (n = 10 at 6 weeks) with a large discrepancy between the eyes (> 0.5 logMAR), all patients ultimately required occlusion, and there was minimal improvement in only three patients. CONCLUSION: Recorded vision at 6 weeks is more informative for making treatment decisions than that recorded at presentation. The 14 week review confers no benefit to those with reliable and improving visual acuity. Those patients presenting with a large discrepancy in visual acuity do not improve after 14 weeks and we feel that these patients could be occluded at 6 weeks. We propose a new algorithm for the treatment of this patient group.