Causes of severe visual impairment in children and their prevention

Retinopathy of prematurity: the continuing threat to vision in preterm infants. Dutch survey from 1986 to 1994

From January 1st 1986 until January 1st 1994, 82 infants were registered in The Netherlands as partially sighted or blind due to retinopathy of prematurity (ROP). Compared with the previous Dutch survey (1975-1987) an increasing number of registered infants had been screened for ROP during their initial hospitalization (95.1% vs. 54.1%) and had ophthalmic treatment in the acute stages of the disease (43.9% vs. 24.5%). Nevertheless, an increase in the annual incidence of partial sight or blindness due to ROP from 4.2/100,000 live births (1975-1987) to 5.1/100,000 live births (1986-1994) was found. This increase seemed to be associated with a higher number of surviving premature infants of less than 28 weeks gestational age.

Multihandicapped blind and partially sighted children in south Germany. II: Aetiology and pathogenesis

The results of a classification of the aetiology of visual impairment and mental retardation in a series of 239 multihandicapped blind and partially sighted children are reported. These children had been born between 1981 and 1987 and were examined in a population-based study in South Germany. There was marked aetiological heterogeneity. Most prominent were causes related to the perinatal period and late gestation which were found in 41% of the children. Among these, lesions of the visual pathways in preterm children were especially frequent and could be explained by periventricular leukomalacia in a large proportion. The distribution of the major aetiologic groups is different from populations with isolated mental retardation and populations with isolated visual impairment but similar to a Swedish population with spastic quadriplegia. The implications for the prevention of severe multiple impairments in children are discussed.

Infantile cataracts

Cataracts are one of the most treatable causes of visual impairment during infancy. Recent epidemiological studies have shown that they have a prevalence of 1.2 to 6.0 cases per 10,000 infants. The morphology of infantile cataracts can be helpful in establishing their etiology and prognosis. Early surgery and optical correction have resulted in an improved outcome for infants with either unilateral or bilateral cataracts. While contact lenses continue to be the standard means of optically correcting an infant's eyes after cataract surgery, intraocular lenses are gaining in popularity as an alternative means of optically correcting these eyes. Post-operative complications occur more commonly after infantile than adult cataract surgery and many of these complications do not develop until years later. As a result, it is critical that children be followed closely on a long term basis after infantile cataract surgery.

Incidence of registered visual impairment in the Nordic child population

A collaborative, population based, prospective register study on the incidence of visual impairment in children during the year 1993 was carried out in five Nordic countries with a total population of 17 million inhabitants. The child population was 3.8 million individuals aged 0-17 years. The following variables were taken into account: nationality, age, sex, diagnoses, aetiology, degree of visual impairment, and additional impairments. Classification routines from an earlier prevalence study were used. The present study included 304 children corresponding to an incidence of notification of 8/100,000 children, varying from 5.7 to 11.1 in the five countries. Fifty per cent of the visually impaired children were reported before they were 3 years of age. In approximately 45% of the children, visual impairment was due to various brain disorders, with cerebral amblyopia and secondary optic atrophy as the two leading causes. The relative impact of retinopathy of prematurity had decreased from the third most frequent cause (10%) in the prevalence study to seventh place (4%) in the incidence study. Two thirds of the children had additional impairments and these children also suffered from the most severe visual impairments. Among aetiological factors the majority (64%) were prenatal. The overall male:female ratio of 1.4:1 was identical to the sex ratio of the prevalence study.

Hereditary disease as a cause of childhood blindness: regional variation. Results of blind school studies undertaken in countries of Latin America, Asia and Africa

There is evidence from developed countries that genetic disease is the major cause of childhood blindness. Little data are available from most developing and newly industrialised countries concerning the relative importance of hereditary diseases as a cause of childhood blindness. Children in schools for the blind in 13 countries of Africa, Latin America and Asia were examined between 1990 and 1994 using a standardised method The anatomical site of abnormality and underlying aetiology were analysed for children with a corrected acuity in the better eye of less than 6/60 (severe visual impairment and blindness, svi/BL). In these countries II-39% of svi/BL was attributed to genetic disease. Genetic diseases were responsible for a higher proportion of childhood visual loss in countries with higher levels of socio-economic development. An autosomal recessive mode of inheritance was reported in 22-52% of children with genetic disease. Retinal dystrophies were the commonest form of genetic eye disease (49-80%) in all countries apart from Thailand and the Philippines where cataract was the commonest (43.9%). The role of consanguinity, and opportunities for further research are discussed.

Visual impairment in Nordic children. III. Diagnoses

The diagnoses, according to type and site and the degree of visual impairment, responsible for severe visual impairment in children below the age of 18, were analyzed in a material compiled from the national registers of visually impaired in Denmark, Finland, Iceland and Norway. Among 2527 children the predominant causes of visual impairment are ascribed to congenital malformations, neuro-ophthalmological diseases and retinal diseases. Optic atrophy is the leading single cause of severe visual impairment when all diagnoses are compared, and this also applies when all categories of visual impairment are included. Retinopathy of prematurity is the second principal cause of severe visual impairment, while cerebral amblyopia rates as the third most significant cause. Congenital cataract is also of considerable importance when all categories of visual impairment are compared. The differences registered between the Nordic countries were found to be within reasonable limits, except for a preponderance of neuro-ophthalmological diseases in the Danish material. This could be explained by a better medical supervision of mentally retarded patients in Denmark. Additional impairments occur in a large percentage of patients, but are unevenly distributed in the disease groups. A high frequency of additional impairments are found in the neuro-ophthalmological group and in the groups with congenital malformations, emphasizing the importance of a multidisciplinary evaluation when dealing with the visually impaired child.

Visual impairment in Nordic children. II. Aetiological factors

Careful clinical-aetiological assessment of visually impaired children is one of the prerequisites for prevention of future, 'unavoidable' cases of visual impairment of children in the industrialized part of the world. In a collaborative study (NORDSYN) between four Nordic national registers of visual impairment, we analysed and classified some of the factors considered to be essential components for the development of low vision or blindness in children. We discuss the conceptual basis for aetiological classification of eye disorders and visual impairment. An aetiological classification system, based on the type and debut of an essential causal factor is introduced. We present data on 2527 visually impaired children from the Nordic countries. In accordance with several other reports from the last twenty years it is demonstrated that prenatal factors, including genetic aetiologies, were involved in a large proportion (66%) of the cases. In children without additional impairments the corresponding fraction was 74%. Genetic factors accounted for a little over half of the prenatal cases, and in a substantial number of children (40%) with visual impairments of prenatal origin, the causes were obscure. In 1/5 of the material some peri-neonatal causal or modifying factor was identified. In 7% only, the presumed aetiological factor was introduced in the infantile-juvenile period of life. Further prevention of visual impairment among children of the industrialized countries would benefit most from a more comprehensive understanding of prenatal, nongenetic causal factors, further knowledge about regulating mechanisms responsible for gene expression, and additional improvements in perinatal care.

Blindness and partial sight due to retinopathy of prematurity in The Netherlands: 1975-1987

In 1975-1987 at least 84 children developed blindness or impaired vision due to retinopathy of prematurity (ROP) in the Netherlands. Neonatal data were obtained on 74 (86%). Unexpectedly most children (40 i.e. 54%) had been in level I and II hospitals after birth. Screening for ROP had been either insufficient or not timed according to present recommendations in 33 out of 40 children in level I and II hospitals and 25 out of 34 in level III hospitals. As the number of children with ROP has not changed appreciably over the last 40 years, while birth rates in the Netherlands have steadily decreased, the incidence of blindness/impaired vision due to ROP has probably increased. In the current population at risk of ROP which differs considerably from the one during the first epidemic, the disease may not be completely preventable. We conclude that improvements in screening procedures and timely treatment are crucial in order to improve the present situation.

Pericentral retinal dystrophy

A diagnosis of pericentral retinal dystrophy was made in 28 patients from four families, all living in North Norway. Patients from two and three generations were examined, establishing the relatively benign but progressive course of the disease. The advanced stage of pericentral retinal dystrophy could not be differentiated from the advanced stage of 'classical' retinitis pigmentosa. Three families demonstrated an autosomal dominant pattern of inheritance. In one family the mode of inheritance probably was autosomal recessive. Fluorescein angiography in the initial stage of the disease was normal, without evidence of pathological changes in the pigment epithelium or choroidal vessels, indicating that the pathological process may start in the photoreceptors.

Estimation of prognosis and prevalence of retinitis pigmentosa and Usher syndrome in Norway

Retinitis pigmentosa was diagnosed in 101 persons from 53 families. The prognosis for visual function was most favourable for the autosomal dominant group (38 patients from 8 families). The autosomal recessive group (40 patients from 25 families) and the 19 solitary cases were very heterogeneous, with prognosis ranging from favourable to very bad. There was a higher intrafamiliar correlation in the autosomal recessive than in the autosomal dominant group. In 28 patients from 18 families with Usher syndrome, almost all had good visual function until 30 years of age, and few had useful visual function after the age of 50. The age when the patients were registered varied between the different genetic types of retinitis pigmentosa, reflecting differences in prognosis. Therefore, ascertainment probability and prevalence were calculated for each genetic group separately. The prevalence of retinitis pigmentosa in Norway, all genetic groups included, was calculated to be 1/4440, the autosomal dominant type of the disease being the most frequent. The prevalence of Usher syndrome was calculated to be 3.6/100,000. Both retinitis pigmentosa and Usher syndrome were more prevalent in Laps.

Visual impairment in Danish children 1985

In 1985 150 children aged 0-18 were reported to the Danish National Register for Visually Impaired Children. Cross tabulation of the ophthalmological diagnoses by site and type of affection was performed with respect to year of birth, aetiology, visual acuity and birth weight. Finally the relations between aetiology and the presence of additional handicaps are demonstrated. The 'incidence of notification' (IN) was calculated for each birth year as the number of notified children per 100,000 within each birth year group showing variations between 46 in the 1984 birth year group and 3 in the 1970 birth year group with a mean value of 14. The figures stress the impact of congenital and neonatal visual impairment. The significance of IN is discussed with respect to other concepts of incidence. It is concluded that the presented epidemiological method is useful as a tool of analysis in the planning of preventional strategies. From the tables the following main features may be highlighted: Nearly 90% of the blinding causes anatomically are located in the posterior segment of the eye, the optic pathways or in the brain. Isolated visual handicap was notified in 34% of the children, while another 48% presented central nervous system involvement. From an aetiological point of view it is noteworthy that no specific aetiology could be encircled in 38% of the material. In conclusion, it is proposed that future lines of ophthalmological work in the prevention of visual handicap in childhood should concentrate on a higher degree of specificity in diagnostic procedures and an intensified search for specific aetiologies in every single child with visual impairment.

Partially sighted Swedish schoolchildren

812 visually handicapped children aged 7-21 years and educated by black print are investigated with regard to the degree and cause of visual impairment. The rate of visually handicapped children amounted to around 0.7 o/oo, boys being more frequently afflicted than girls. The causes were most often prenatal; 30% of genetic origin, 15% caused by pre- or perinatal damage and 40% of prenatal origin which could not be specified. Some of the more common clinical entities are discussed. The importance of preventing an additional functional amblyopia in the visually handicapped child is stressed.