Babies Count: the national registry for children with visual impairments, birth to 3 years

Validation of the "TWO-ROP" Algorithm at a Multi-NICU Tertiary Referral Center

PURPOSE

We aim to validate the previously published TWO-ROP algorithm on an external dataset.

DESIGN

Retrospective consecutive study.

SUBJECTS

Infants screened for retinopathy of prematurity (ROP) between January 2013 and August 2023 at a tertiary referral multi-site.

METHODS

Infants with higher birth weight (BW) and longer gestational age (GA) were included and stratified into three groups as follows: group 1 (BW<1500 g, GA≥30 weeks), group 2 (BW≥1500g, GA< 30 weeks), and group 3 (BW≥1500g, GA≥30 weeks).

MAIN OUTCOME MEASURES

The rate of ROP, treatment-warranted ROP (TW-ROP), and number of inpatient examinations were evaluated in the three groups.

RESULTS

1,095 (33.8%) patients met the inclusion criteria. The number of patients in groups 1, 2, and 3 were 837 (76.4%), 72 (6.6%), and 186 (17.0%), respectively. ROP was detected in 120 (11.0%) patients; the rate was 9.8% in group 1, 20.8% in group 2, and 12.4% in group 3 (p=0.013). The overall mean number of inpatient examinations for patients undergoing traditional, TWO-ROP 36-week, and TWO-ROP 40-week screening systems were 1.95, 1.43, and 0.99, respectively (p<0.001). Stage 3 was found in 9 eyes of 5 patients (0.5%, all zone II). Three eyes of 2 patients (0.2%) had plus disease. Two patients had bilateral laser treatment at 44 and 39.4 weeks postconceptional age; 3 out of 4 of these eyes met Type 1 treatment criteria. Overall, the ROP screening burden saved was 9.0% and 16.7% for the TWO-ROP 36-week and 40-week systems, respectively. The sensitivity for TW-ROP was 100% for TWO-ROP 36-week system and 99.4% for TWO-ROP 40-week system.

CONCLUSION

The TWO-ROP algorithm can reduce the number of inpatient examinations while maintaining safety. To ensure timely management, we recommend that the single first ROP examination occurs at 38-39 weeks postconceptional age.

Aberrant gene expression yet undiminished retinal ganglion cell genesis in iPSC-derived models of optic nerve hypoplasia

BACKGROUND

Optic nerve hypoplasia (ONH), the leading congenital cause of permanent blindness, is characterized by a retinal ganglion cell (RGC) deficit at birth. Multifactorial developmental events are hypothesized to underlie ONH and its frequently associated neurologic and endocrine abnormalities; however, environmental influences are unclear and genetic underpinnings are unexplored. This work investigates the genetic contribution to ONH RGC production and gene expression using patient induced pluripotent stem cell (iPSC)-derived retinal organoids (ROs).

MATERIALS AND METHODS

iPSCs produced from ONH patients and controls were differentiated to ROs. RGC genesis was assessed using immunofluorescence and flow cytometry. Flow-sorted BRN3+ cells were collected for RNA extraction for RNA-Sequencing. Differential gene expression was assessed using DESeq2 and edgeR. PANTHER was employed to identify statistically over-represented ontologies among the differentially expressed genes (DEGs). DEGs of high interest to ONH were distinguished by assessing function, mutational constraint, and prior identification in ONH, autism and neurodevelopmental disorder (NDD) studies.

RESULTS

RGC genesis and survival were similar in ONH and control ROs. Differential expression of 70 genes was identified in both DESeq2 and edgeR analyses, representing a ~ 4-fold higher percentage of DEGs than in randomized study participants. DEGs showed trends towards over-representation of validated NDD genes and ONH exome variant genes. Among the DEGs, RAPGEF4 and DMD had the greatest number of disease-relevant features.

CONCLUSIONS

ONH genetic background was not associated with impaired RGC genesis but was associated with DEGs exhibiting disease contribution potential. This constitutes some of the first evidence of a genetic contribution to ONH.

A Scoping Review of Intervention for Pediatric Cerebral Visual Impairment: Calling All Pediatric Occupational Therapists

Cerebral visual impairment is the leading cause of low vision in children, and functional gains can be achieved with intervention. To date there exists no evidence-based intervention protocol to guide rehabilitation therapists. This scoping review was conducted to synthesize the evidence currently available and explore current interventions in order to guide future research. This review identified five types of interventions for cerebral visual impairment; habilitation, visual stimulation, video game, color tent, and medical and also evidenced the need for standardized, objective measures of function for this population.

Considerations for the identification of autism spectrum disorder in children with vision or hearing impairment: A critical review of the literature and recommendations for practice

OBJECTIVE

There is higher risk for autism spectrum disorder (ASD) across many pediatric neurological conditions characterized by vision impairment or hearing loss. Early and accurate identification of ASD is imperative in promoting access to appropriate and early evidenced-based intervention; however, differential diagnosis can be particularly challenging in children with sensory impairment given the heterogeneity of ASD combined with the impact of vision impairment or hearing loss/deafness on development and behavior. A neuropsychologist's unique expertise and appreciation of the interplay between sensory and behavioral manifestations can be valuable for making an early and accurate ASD diagnosis in children who are blind/visually impaired or deaf/hard-of-hearing. This article highlights clinical considerations when identifying ASD within the context of vision impairment or hearing loss/deafness.

METHOD

We discuss clinical considerations for the early identification of ASD in children who are blind/visually impaired and deaf/hard-of-hearing. Information presented in the article is based on a critical review of the literature and the expertise of the author group.

CONCLUSION

Ongoing development of clinical expertise and evidence-based assessment methods are important when informing the early differential diagnosis of ASD in individuals with sensory impairment. Accurate identification is also vital for the development of targeted interventions across the lifespan.

Working with children with cortical visual impairment who use augmentative and alternative communication: implications for improving current practice

The aim of this study was to describe how professionals from multiple disciplines (e.g., speech-language pathologists, teachers, occupational therapists) in the United States reported challenges they face in delivering services to children with cortical visual impairment (CVI) who use augmentative and alternative communication (AAC). Three surveys were utilized to identify barriers to and priorities for improving educational and clinical services and in-service and preservice education from the perspectives of professionals in school, community, and university settings. Results suggest that current service delivery models may not be meeting the needs of either children with CVI who use AAC or the professionals whose job it is to provide them with services. Professionals in community-based settings appeared to encounter more barriers. Findings help to support a discussion about approaching AAC interventions for children with CVI who use AAC by adopting interprofessional collaborative practice (IPCP) and interprofessional education (IPE) models, which reflect long-standing best practice guidelines for AAC service delivery and are encouraged by multiple professional organizations.

Visual habilitation in young children with visual impairment

PURPOSE

To evaluate the effectiveness of the visual habilitation programme in improving the visual functions of visually impaired children under 3 years old.

METHODS

Case records of children with visual impairment (VI) who had at least 1 follow-up visit were reviewed. Children's visual functions were scored between 0 and 15 based on mainly fixation and following skills. Differences in patients' visual function score (VFS) between the time of the presentation and the last follow-up visit were recorded.

RESULTS

One hundred thirty children with VI (63 male and 67 female) were identified. The mean age at the presentation was 13.94 ± 9.23 months, and the mean follow-up was 12.79 ± 9.4 months. Forty of the patients had ocular, 70 of them had cerebral, and 20 of them had combined VI. Correlations were found between the age of the patients at the presentation and the initial VFS; and gestational age and the initial VFS (p ˂ 0.001, r = 0.332; p ˂ 0.05, r = 0.262, respectively). Vision improvement was noted in ocular, cerebral and combined VI groups. No significant difference among the groups was found (p = 0.430). There was a significant difference between the change in the VFSs of those who attended the special education and rehabilitation centre regularly for 2 h a week and had regular visual stimulation for 8-10 sessions every day at home and those who did not go to the centre and did not receive any visual stimulation by their parents at home (p ˂ 0.001).

CONCLUSIONS

The visual functions of visually impaired children can be improved by habilitation, which includes visual stimulation programmes.

Ocular and cerebral causes of visual impairment in young children and a new scoring system to evaluate visual function

PURPOSE

Childhood blindness is important cause contributing to the burden of blindness. It is necessary to identify the most frequently observed diseases in different populations. We aimed to demonstrate clinical features of low vision children and to evaluate the factors affecting visual function by a new visual function scoring system.

METHODS

Two hundred forty nine children between the age of 6 months and 3 years were included. Visual function was scored from 0 to 15 according to; response to threat, light, object, presence of fixation, duration of fixation, following of light and object in horizontal, vertical, oblique, and circular gazes, optokinetic nystagmus. Patients were classified according to neurological diagnosis and cranial magnetic resonance imaging findings. Correlation between visual function score and ocular and neurologic findings were evaluated.

RESULTS

While 136 patients (54.6%) had cerebral visual impairment (CVI), 89 (35.7%) had ocular pathology, 24 patients (9.6%) had combined pathology. The most common ocular and cerebral pathologies were oculocutaneous albinism (23.9%) and hypoxic ischemic encephalopathy (HIE) (27.5%), respectively. Patients with CVI had lower visual function than ocular pathologies. Neurological structural disorders and HIE had worse visual function. Widespread involvement of brain had lower visual function score. Seizure negatively affected visual function.

CONCLUSIONS

Cerebral causes were found in approximately half of infants and children with low vision who were referred to our center for visual habilitation. The visual function scoring system we developed in this study will provide an opportunity to be objective in the follow-up of babies and in evaluating the effectiveness of visual habilitation programs.

Tracking-Based Interactive Assessment of Saccades, Pursuits, Visual Field, and Contrast Sensitivity in Children With Brain Injury

Visual deficits in children that result from brain injury, including cerebral/cortical visual impairment (CVI), are difficult to assess through conventional methods due to their frequent co-occurrence with cognitive and communicative disabilities. Such impairments hence often go undiagnosed or are only determined through subjective evaluations of gaze-based reactions to different forms, colors, and movements, which limits any potential for remediation. Here, we describe a novel approach to grading visual health based on eye movements and evidence from gaze-based tracking behaviors. Our approach—the “Visual Ladder”—reduces reliance on the user’s ability to attend and communicate. The Visual Ladder produces metrics that quantify spontaneous saccades and pursuits, assess visual field responsiveness, and grade spatial visual function from tracking responses to moving stimuli. We used the Ladder to assess fourteen hospitalized children aged 3 to 18 years with a diverse range of visual impairments and causes of brain injury. Four children were excluded from analysis due to incompatibility with the eye tracker (e.g., due to severe strabismus). The remaining ten children—including five non-verbal children—were tested multiple times over periods ranging from 2 weeks to 9 months, and all produced interpretable outcomes on at least three of the five visual tasks. The results suggest that our assessment tasks are viable in non-communicative children, provided their eyes can be tracked, and hence are promising tools for use in a larger clinical study. We highlight and discuss informative outcomes exhibited by each child, including directional biases in eye movements, pathological nystagmus, visual field asymmetries, and contrast sensitivity deficits. Our findings indicate that these methodologies will enable the rapid, objective classification and grading of visual impairments in children with CVI, including non-verbal children who are currently precluded from most vision assessments. This would provide a much-needed differential diagnostic and prognostic tool for CVI and other impairments of the visual system, both ocular and cerebral.

Pre- and Postnatal Damage to the Retro-Geniculate Visual Pathways Cause Retinal Degeneration Predictive for Visual Function

To increase the understanding of the relationship between structure and function in individuals with damage to the brain from different stages of maturation of the visual system, we examined 16 teenagers and young adults. We used diffusion-weighted magnetic resonance imaging (MRI) and fiber tractography of the optic radiation (OR) and optical coherence tomography (OCT) of the peripapillary retinal nerve fiber layer (pRNFL) and the ganglion cell layer + inner plexiform layer (GC+IPL) in the macula. Visual field (VF) function was assessed with the Humphrey Field Analyzer (HFA). Injuries to the immature OR were associated with thinning of the pRNFL and GC+IPL, and corresponding VF defects irrespectively of timing of the lesion. However, in cases with bilateral white-matter damage of immaturity (WMDI) we noticed a well preserved central VF despite a very thin GC+IPL. We speculate that this is due to plasticity in the immature visual system. Similar results were not noticed among cases with unilateral damage, acquired pre- or postnatally, in which the central VF was affected in most cases. OCT has proved to be a valuable targeted tool in children with damage to the retro-geniculate visual pathways, and that focal thinning of the GC+IPL predicts VF defects. This brief research report includes a review of four previously published papers. In addition, we present one new case and apply a recently developed classification system for CVI. The classification was applied on cases with bilateral WMDI to investigate its relation to retinal structure.

Identifying when children with visual impairment share attention: A novel protocol and the impact of visual acuity

BACKGROUND

In Coordinated Joint Engagement (CJE), children acknowledge that they and their social partners are paying attention to the same object. The achievement of CJE, critical for healthy development, is at risk in infants with visual impairment (VI). Research on CJE in these children is limited because investigators use a child's gaze switch between social partner and object to index CJE. Research is needed that identifies CJE in children with VI using behaviors that do not require normal vision and that explores the relationship between CJE and visual function. This study aimed to (a) develop a protocol for identifying CJE in children with VI, and (b) explore the relationship between CJE and infants' visual acuity (VA) and contrast sensitivity (CS), measured with Preferential Looking (PL) techniques and Visual Evoked Potential (VEP).

METHODS

A protocol that included 9 indices of CJE that did not require normal vision was developed to code videos of 20 infants with VI (mean age =1 year, 6 months, 27 days) and their caregivers. The percentage of CJE episodes in which each index was observed was calculated. Inter-coder reliability was measured using Cohen's Kappa. Linear regression analysis was used to examine the relationship between the infants' visual function and CJE.

RESULTS

Inter-rater reliability between a first coder and each of two second coders were 0.98 and 0.90 for determining whether the child participated in CJE. The following indices were observed the most (in 43-62 % of CJE): child's body orientation to caregiver, gaze switch between caregiver and object, and vocalization to caregiver. The only significant model included VA (measured with PL) as a single predictor and explained 26.8 % of the variance in CJE.

CONCLUSIONS

The novel protocol can be used to identify CJE in children with VI with good inter-coder reliability. The data suggest that children with lower VA exhibited less CJE.

What assessments are currently used to investigate and diagnose cerebral visual impairment (CVI) in children? A systematic review

PURPOSE

Cerebral visual impairment (CVI) is the leading cause of childhood visual impairment in the developed world. Despite this, there are no agreed clinical guidelines for the investigation and diagnosis of the condition. Before development of such guidelines can commence, it is important to recognise which approaches are currently employed. This systematic review evaluated the literature to identify which methods of assessment are currently used to investigate and diagnose childhood CVI.

METHODS

Medline, Embase, CINAHL, Scopus and the Cochrane Library databases were systematically searched in January 2020 using defined search terms. Articles were included if they: (i) were research papers, conference abstracts or research protocols published in peer-reviewed scientific journals, or relevant textbooks; (ii) included a clinical investigation of CVI in children; (iii) provided an explanation or criteria to diagnose CVI and (iv) were specifically investigating cerebral/cortical visual impairment. Methods used to a) assess and b) diagnose CVI were extracted from included articles. 'Assessment scores' were assigned for each method employed by researchers to investigate and diagnose CVI to quantify and compare approaches between articles. A quality grading was also applied to each article.

RESULTS

Of 6454 identified articles, 45 met the inclusion criteria. From these, 10 categories of assessment utilised within included articles were identified: (1) Medical history, (2) Vision assessment/ophthalmologic examination, (3) Neuroimaging, (4) Visual behaviour and direct observation, (5) Structured history-taking, (6) Visual perception tests, (7) Ocular movement and posture assessment, (8) Intelligence/IQ assessment, (9) Clinical electrophysiology and (10) Neurodevelopmental tests. In terms of diagnostic criteria, the most commonly reported approach was one of exclusion, i.e., CVI was diagnosed when visual dysfunction could not be attributed to abnormalities detected in the anterior visual pathway.

CONCLUSION

There is a lack of common practice in the approaches used by clinicians to investigate and diagnose CVI in children. At present, a 'diagnosis of exclusion' remains the most common means to diagnose CVI. Development of clinical guidelines for assessment and diagnosis are necessary to ensure consistency in the diagnosis of CVI and the timely implementation of support to alleviate the impact of CVI on the child's daily living.

Causes of Blindness and Visual Impairment in Early Childhood at a Low Vision Service in Mexico City: A 15-year Review

Purpose: To evaluate the causes of blindness and visual impairment in children aged 0-7 years attending a Low Vision Centre in Mexico City, Mexico.Methods: Clinical records for patients aged 0-7 years attending the Centre from 2001 to 2015 were retrospectively reviewed. Causes of blindness and visual impairment, affected anatomy, and suspected time period of insult were recorded.Results: 1487 patients were included, 45.9% girls and 54.1% boys. Mean age of presentation was 39 months (SD 27.9 months). 36.0% had associated co-morbidities in addition to their ophthalmic pathology. 39.7% presented with developmental or psychomotor delay. Leading diagnoses were Retinopathy of Prematurity (ROP) (19.6%), optic nerve atrophy (11.5%), and congenital cataract (9.5%). The most affected anatomical regions were retina (33.8%), optic nerve (16.6%), and lens (10.5%). Half of all cases (50.9%) had insults in the prenatal period. Children with developmental delay were more likely to present before the age of one. There is a significant difference in risk of delayed presentation according to diagnosis. Only 13.5% of children with optic nerve atrophy presented to the Centre before the age of one, compared to 28.4% of children with ROP and 23.4% of children with cataract.Conclusion: The most common diagnoses for blindness and visual impairment among children were ROP, optic nerve atrophy, and congenital cataract. Late presentation to the Centre was common. There were significant differences in risk of delayed presentation depending on diagnosis. Co-existing systemic conditions and developmental and psychomotor delay were also common among patients attending the Centre.

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

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.

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.

Predisposing Factors, Ophthalmic Manifestations, and Radiological Findings in Children With Cerebral Visual Impairment

PURPOSE

To describe predisposing factors, ophthalmic manifestations, and magnetic resonance imaging (MRI) findings in children with cerebral visual impairment.

METHODS

A retrospective cross-sectional analysis of patients younger than 16 years with neuroradiological and clinical evidence of retrogeniculate visual pathway pathology was performed. Detailed histories, ophthalmic examinations, and MRI findings were compiled and analyzed.

RESULTS

Of the 88 cases included in the study, the median age was 32 months (range: 1 to 180 months). Ante-natal history and preterm delivery was positive in 25.0% and 37.5% of patients, respectively. A simple myopic astigmatism was the most common refractive error. Accommodative anomalies were noted in 6 children.

CONCLUSIONS

The demographic trends found in the study were similar to those of developed nations, but the frequency of the predisposing factors varied. A comprehensive knowledge of cerebral visual impairment in the developing world can aid an earlier diagnosis, appropriate management, and the development of better rehabilitation teams. [J Pediatr Ophthalmol Strabismus. 2019;56(5):313-318.].

Applicability and attachment findings of the Strange Situation Paradigm in infants with visual impairment

Attachment studies with diverse populations enrich the understanding of infants' socioemotional development by documenting both universal and idiosyncratic aspects of attachment. Given the effects of attachment in children's socioemotional outcomes, such studies are necessary to investigate the impact of children's sensory impairments on attachment development. Yet, very little attachment research has focused on infants with visual impairment (VI infants), a population in which infant-caregiver emotional exchanges through visual means are reduced/absent. We investigated the applicability of the Strange Situation Paradigm (SSP), with added instructions to compensate for degraded visual input, in 20 VI infants (with no additional disabilities and who were receiving developmental counseling). In all but 1 of the SSPs coded, VI infants displayed observable attachment behavior that was classifiable. Nineteen VI infants showed attachment by 12 months of age. Across the ages tested (fractional age range = 0.9-2.33 months), most VI infants' attachment patterns were classified as secure and organized.

Cortical Visual Impairment in Congenital Cytomegalovirus Infection

PURPOSE

To describe the presentation, evolution, and long-term outcome of cortical visual impairment (CVI) in patients with symptomatic congenital cytomegalovirus (CMV) infection, and to identify risk factors for the development of CVI in patients with symptomatic congenital CMV.

METHODS

Retrospective subanalysis of a long-term prospective cohort study with data gathered from 1982 to 2013.

RESULTS

Eleven of 77 (14.3%) patients with symptomatic CMV, 0 of 109 with asymptomatic CMV, and 51 control patients had CVI. Overall, patients with symptomatic CMV had worse vision than patients with asymptomatic CMV, who in turn had worse vision than control patients. Microcephaly, intracranial calcification, dilatation of ventricles, encephalomalacia, seizure at birth, optic atrophy, chorioretinitis/retinal scars, strabismus, and neonatal onset of sensorineural hearing loss were risk factors associated with CVI.

CONCLUSIONS

CVI may result from symptomatic congenital CMV infection. The relationship of CVI and its risk factors in patients with CMV suggests the potential to predict the development of CVI through predictive modeling in future research. Early screening of CVI in children born with symptomatic congenital CMV can facilitate educational, social, and developmental interventions. [J Pediatr Ophthalmol Strabismus. 2019;56(3):194-202.].

[Optic nerve hypoplasia and septo-optic dysplasia]

Optic nerve hypoplasia (ONH) is one of the most common causes of congenital visual impairment. It was first described in 1915 and represents a developmental disorder of the central nervous system. It is often associated with intracranial midline defects and is then referred to as septo-optic dysplasia (SOD). The symptoms of ONH range from minimal visual dysfunction to significant visual impairment with sensory defect nystagmus and even blindness. The ONH is often associated with further systemic, endocrinological and neurological abnormalities requiring a close interdisciplinary treatment of the patients.

The Reliability of the CVI Range: A Functional Vision Assessment for Children with Cortical Visual Impairment

Children who are identified as visually impaired frequently have a functional vision assessment as one way to determine how their visual impairment affects their educational performance. The CVI Range is a functional vision assessment for children with cortical visual impairment. The purpose of the study presented here was to examine the reliability of the CVI Range.

Severe Visual Impairments in Infants and Toddlers in the United States

Introduction

This article describes the most prevalent visual conditions and other demographic characteristics of 5,931 young children with severe visual impairments in 28 states in the United States, the largest sample reported to date. The information presented in this article can assist in planning and implementing programs.

Method

The data were collected at the time of entry into specialized early intervention programs for young children with visual impairments through reviews of records, interviews, and direct observations. They were sent to Babies Count: The National Registry for Children with Visual Impairments, Birth to 3 Years at the American Printing House for the Blind. The data were collected and entered between January 2005 and April 2011.

Results

Cortical visual impairment, retinopathy of prematurity (ROP), and optic nerve hypoplasia were the three most prevalent diagnoses. Approximately 60% were identified as being legally blind, and 65% had disabilities in addition to visual impairments. The mean age of the children at the time of diagnosis was 4.9 (SD = 5.7) months, referral to specialized programs was at 10.5 (SD = 7.8) months, and entry into specialized programs was at 11.6 (SD = 8.0) months. There was an average lag of 5.6 months between the diagnosis and referral.

Discussion

Cortical visual impairment, ROP, and optic nerve hypoplasia continue to be the leading causes of severe, uncorrectable visual impairments in children in the United States. ROP appears to be decreasing in prevalence; however, more children with ROP appear to have additional disabilities. The lag of 5.6 months between diagnosis and referral, a longer lag than was previously reported, is of concern.

Implications for practitioners

Information about the characteristics of children with severe uncorrectable visual conditions is valuable for communicating with families, planning and implementing early intervention and educational programs, and collaborating with medical professionals.

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.

Children with optic nerve hypoplasia face a high risk of neurodevelopmental disorders

AIM

Optic nerve hypoplasia (ONH) is a congenital ocular malformation that has been associated with neurodevelopmental disorders, but the prevalence in unilateral disease and less severe visual impairment is unknown. We studied intellectual disability and autism spectrum disorders (ASDs) in patients with ONH.

METHODS

This was a population-based cross-sectional cohort study of 65 patients (33 female) with ONH below 20 years of age, living in Stockholm in December 2009, with data analysed in January 2016. Of these 35 were bilateral and 30 were unilateral. Neurodevelopmental disorders were diagnosed or confirmed by neurological assessments, the Five to Fifteen parent questionnaire and reviewing previous neuropsychological investigations or conducting neuropsychological tests.

RESULTS

Bilateral ONH patients had lower mean full scale intelligence quotient scores than unilateral patients (84.4 and 99.4, respectively, p = 0.049). We assessed intellectual disability in 55 eligible patients, and it was more common in patients with bilateral ONH (18 of 32, 56%) than unilateral ONH (two of 23, 9%, p < 0.001). ASDs were diagnosed in seven of 42 (17%) patients.

CONCLUSION

Children with bilateral ONH had a high risk of neurodevelopmental disorders, especially intellectual disability. The risk was lower in unilateral ONH, but the levels of neurodevelopmental disorders warrant screening of both groups.

Congenital anomalies of the optic disc: insights from optical coherence tomography imaging

PURPOSE OF REVIEW

Congenital anomalies of the optic nerve are rare but significant causes of visual dysfunction in children and adults. Accurate diagnosis is dependent on a thorough funduscopic examination, but can be enhanced by imaging information garnered from optical coherence tomography (OCT). We review common congenital optic nerve anomalies, including optic disc pit, optic nerve coloboma, morning glory disc anomaly, and hypoplasia of the optic nerve, review their systemic associations, and discuss insights from OCT imaging.

RECENT FINDINGS

Optic disc pits are a result of a defect in the lamina cribrosa and abnormal vitreomacular adhesions have been shown to cause maculopathy. In patients with optic nerve colobomas, OCT can be instrumental in diagnosing choroidal neovascularization, a rare but visually devastating complication. The pathogenesis of morning glory disc anomaly has been more clearly elucidated by OCT as occurring from a secondary postnatal mesenchymal abnormality rather than only the initial neuroectodermal dysgenesis of the terminal optic stalk in isolation. OCT studies of optic nerve hypoplasia have demonstrated significant thinning of the inner and outer retinal layers of the perifoveal region and thicker layers in the fovea itself, resulting in a foveal hypoplasia-like pathology, that is, significantly correlated to poorer visual outcomes.

SUMMARY

OCT provides detailed in-vivo analysis of these anatomic anomalies and their resulting pathologies, shedding new insights on the pathogenesis, diagnosis, and potential visual outcomes of these conditions in children. Further study employing OCT to elucidate structure-function relationships of congenital optic nerve anomalies will help expand the role of OCT in clinical practice related to diagnosis, prognosis, and management of these entities.

Neuroimaging and endocrine disorders in paediatric optic nerve hypoplasia

Purpose

Optic nerve hypoplasia (ONH) is one of the leading causes of blindness among children. The purpose of this retrospective study is to determine the risk factors and association between brain MRI findings, pituitary abnormalities and endocrine disorders with the presence of ONH.

Methods

A retrospective review of patients seen at paediatric ophthalmology clinics from January 2006 to December 2016 at Children’s Hospital and Medical Center and the University of Nebraska Medical Center was performed. All patients with a documented diagnosis of ONH or septo-optic dysplasia were identified. MRI and endocrinology results were analysed by masked examiners.

Results

Out of 77 patients, overall incidence of abnormal pituitary on MRI was 35.1% and the incidence of endocrine abnormalities was 37.7%. Of the 57 patients with bilateral ONH, 23 (40.4%) had an abnormal pituitary while 4 of the 20 patients (20.0%) with unilateral ONH had an abnormal pituitary on MRI. The sensitivity and specific of brain MRI as signs of endocrinopathy are 67.9% and 83.3%, respectively.

Conclusion

This study has determined that abnormal MRI findings do not have the sensitivity to predict endocrinopathy, nor does a normal MRI rule out possible endocrine abnormalities. When patients with ONH present with normal neurological examinations, normal endocrine workup and normal developmental milestones, a MRI of the brain may be deferred until new indications arise. Regardless of the MRI status, children with ONH should have a comprehensive endocrine evaluation and continue to have routine endocrine follow-up.

VEP analysis methods in children with optic nerve hypoplasia: relationship to visual acuity and optic disc diameter

PURPOSE

Assessing vision in young children with optic nerve hypoplasia (ONH) is challenging due to multi-directional infantile nystagmus, the range of optic nerve loss, and cognitive delay. This study examined visual evoked potential (VEP) responses and averaging techniques in children with ONH. The assumption is that EEG epochs with inconsistent temporal phase would be associated with nystagmus, signal reduction due to axon loss, and visual inattention.

METHODS

A retrospective chart review was performed on 44 children (average age 2.2 years; SD 1.9). Optic disc diameter was estimated by ophthalmoscopy. Visual function was measured under binocular viewing and then compared to the eye with the larger optic disc to exclude secondary amblyopia. Visual acuity was measured by Teller cards or by recognition optotypes, and both measures were converted into log minimum angle of resolution (logMAR). VEPs were recorded to onset/offset of horizontal gratings and to reversing checkerboards. Signal-to-noise ratios (SNRs) were estimated from phase consistency across epochs in the Fourier domain. VEPs were also averaged after (1) correction of epochs for phase shifts across a limited bandwidth, or (2) selection of only epochs showing phase consistency.

RESULTS

Optic disc diameter, logMAR, VEP amplitudes, and VEP SNR were all significantly inter-correlated. Optic disc diameter correlated best with VEP SNR (Spearman rho = 0.82; p < 0.001). Age-corrected logMAR correlated with optic disc diameter and VEP SNR (Spearman rho = -0.695 and 0.70, respectively; p < 0.001). VEP latency poorly correlated with optic disc diameter or logMAR. Correction of phase shifts or selection of epochs based on phase consistency significantly increased VEP amplitude and SNR for children with optic disc diameters <1000 microns. Correction of phase inconsistency did not improve the correlation of VEP parameters with optic disc diameter or with logMAR.

CONCLUSIONS

In ONH, the size of the optic nerve is correlated with VEP SNR and logMAR. The results imply a direct relationship between the reduction in optic nerve axons and generalized reduction in visual function. Our calculation of VEP SNR provides objective assessment of optic nerve function that is independent of subjective scoring of VEP peaks.

Factors Associated with Comfort Level of School-Based Occupational Therapists in Providing Low-Vision Services

This study identified factors associated with the comfort level of school-based occupational therapists in providing services to children with visual impairments. Sixty-one school-based occupational therapists completed an on-line survey. Fifty-four percent of respondents were comfortable or somewhat comfortable when choosing assessments and 84% were comfortable or somewhat comfortable in providing occupational therapy services for children with visual impairments. Multivariable linear regression analyses indicated years of professional experience, history of a caseload of children with visual impairments, and training received in treating children with visual impairments from continuing education were uniquely and significantly associated with the respondents' comfort level. Though not included in the final model, collaboration with other low vision service providers (e.g., teachers, optometrists, ophthalmologists, and orientation/mobility specialists) was also significantly associated with respondents' comfort level in the univariate analysis. Findings provide an initial direction and strategies to improve occupational therapists' comfort level in providing services to children with visual impairments in school settings.

A functional approach to cerebral visual impairments in very preterm/very-low-birth-weight children

BACKGROUND

Cerebral visual impairment (CVI) is a major cause of visual impairment, with very preterm birth/very low birth weight (VP/VLBW) being a major risk factor. There is no generally accepted definition of CVI. This study aims to investigate the usefulness of an empirically-based functional definition of CVI.

METHODS

One-hundred-five VP/VLBW children and 67 controls participated. CVI was defined after comprehensive oculomotor, visual sensory and perceptive assessment, and validated against vision problems in daily life and in terms of intellectual, behavioral, emotional and social functioning, as well as use of therapeutic services.

RESULTS

Twenty-four per cent of the VP/VLBW children met criteria for CVI, compared to 7% of controls (P = 0.006, OR: 3.86, 95% CI: 1.40-10.70). VP/VLBW children with CVI had lower performance IQ, but not verbal IQ, than those without CVI. Visual problems in daily life were confirmed in VP/VLBW children classified with CVI. Additionally, difficulties in behavioral and social functioning were most prominent among VP/VLBW children with CVI.

CONCLUSION

In VP/VLBW children, CVI defined in terms of visual function deficits is accompanied by intellectual, behavioral, and social impairments, validating our operational definition of CVI. CVI might act as a marker for developmental problems in VP/VLBW children.

Endocrine and pubertal disturbances in optic nerve hypoplasia, from infancy to adolescence

Background

Endocrinologic abnormalities are a common co-morbidity in patients with optic nerve hypoplasia (ONH), however the impact on puberty is unknown. The purpose of this study was to examine rates of endocrine dysfunction and pubertal disturbances in a pediatric population of ONH.

Methods

A retrospective chart review was conducted on a cohort of children with ONH between January 2005 and March 2013. Endocrine dysfunction was determined based on laboratory evidence of hormone deficiency or hormone replacement. Pubertal disturbances were characterized based on presence of micropenis, tanner staging, menarche and hormone replacement. Pituitary abnormalities were classified using MRI findings. Descriptive statistics were used, and comparisons between groups were performed using the chi-square test.

Results

During the study period, 101 patients underwent an endocrine evaluation (median age: 2.3 years [0.76 – 6.5]). Hypopituitarism was present in 73% of patients with growth hormone deficiency (56%) and hypothyroidism (54%) being the most common. Pubertal disturbances (n = 19) were common; micropenis in 31% (13/42) of males and 2% with precocious puberty. Half of adolescents (n = 4/8) were diagnosed with gonadotropin deficiency. Patients with MRI pituitary abnormalities were more likely to have endocrine dysfunction than those without (p = 0.004). The sensitivity and specificity of MRI pituitary abnormalities for hypopituitarism was 54% and 92%, respectively.

Conclusions

A significant proportion of children with ONH have endocrine dysfunction. The high frequency of pubertal disturbances in this study emphasizes the need for long-term monitoring of developing endocrinopathy. While pituitary gland abnormalities are a good predictor of endocrine dysfunction, a normal pituitary gland does not rule out endocrinopathy.

The role of magnetic resonance imaging in diagnosing optic nerve hypoplasia

PURPOSE

To establish objective lower limits of normal optic nerve (ON) size in children based on high-resolution orbital magnetic resonance imaging (MRI).

DESIGN

Case-control study of patients with ON hypoplasia vs normal controls.

METHODS

A neuroradiologist made 4 measurements of each ON at 2 locations (5 mm posterior to the optic disc and just posterior to the optic canal) in patients with ON hypoplasia and controls aged 0-17 years from an academic eye center and children's hospital. Primary analyses were performed using mixed linear models.

RESULTS

Measurements were made in 26 cases of clinically confirmed ON hypoplasia and 31 controls (median age: ON hypoplasia, 1 year; controls, 5.5 years). Nine of 26 cases (35%) and 19 of 31 controls (61%) underwent high-resolution T2-weighted imaging of the orbits. Mean ON diameter was 1.36 mm (95% CI: 1.19-1.54; P < .001) smaller for clinically hypoplastic ONs than for controls. Optic nerve diameter increased by 0.05 mm per year of age (95% CI: 0.03-0.07; P < .001). A lower bound to the 95% prediction interval for normal optic nerves was (2.24 mm + 0.052 × [age in years]) mm and excluded all but 1 case.

CONCLUSIONS

Age was independently associated with normal ON size by MRI and should be taken into consideration when evaluating ON hypoplasia, based on MRI criteria. We have provided a formula to assist clinicians in objectively determining if ON hypoplasia is present.

Optic nerve hypoplasia in children and adolescents; prevalence, ocular characteristics and behavioural problems

PURPOSE

To report prevalence, ocular characteristics and coexisting behavioural problems in children and adolescents with optic nerve hypoplasia (ONH), which is a common cause of visual impairment in children in western countries, often associated with neurological or endocrinological problems and where autism has been reported in severe cases with blindness.

METHODS

This is a population-based cross-sectional study of patients <20 years of age who had been diagnosed with ONH and lived in the county of Stockholm in December 2009. Ophthalmological assessments including fundus photographs with optic disc analyses were made. A questionnaire was used to screen for behaviour and development.

RESULTS

The prevalence of ONH in all living children <18 years of age in Stockholm was 17.3/100 000 with a prevalence of visual impairment (<0.3) of 3.9/100 000. In total, 66 patients, median age 9.3 years (0.6-19.4), 36 with bilateral and 30 with unilateral ONH, were included in the current study; 53 were re-examined clinically, group A, and 13 agreed to retrospective analyses of existing medical records, group B. Analyses of the optic discs were made in fundus photographs from 53 patients comparing a semi-automated (Retinal Size Tool) and a manual method (Zeki). There was a strong curvilinear correlation (r(S)  = -0.91 p < 0.0001 for both eyes). Behavioural problems were more common (p < 0.05) in bilateral ONH.

CONCLUSION

Optic nerve hypoplasia is a common ocular malformation with a prevalence of 17.3/100 000 children and adolescents <18 years of age in Stockholm. Unilateral ONH seems as common as bilateral.

Development of the Preverbal Visual Assessment (PreViAs) questionnaire

BACKGROUND

Visual cognitive functions of preverbal infants are evaluated by means of a behavioral assessment. Parents or primary caregivers may be appropriate to certify the acquisition of certain abilities.

AIMS

To develop the PreViAs (Preverbal Visual Assessment) questionnaire to assess visual behavior of infants under 24 months of age and to assess the normative outcomes for each item at each age.

STUDY DESIGN

The process was divided into three phases: scale development (items and domains generation), pilot testing, and exploratory analysis.

RESULTS

The final version of the PreViAs questionnaire consisted of 30 items, each related to one or more of four domains (visual attention, visual communication, visual-motor coordination, and visual processing). For the exploratory analysis, 298 children (159 boys and 139 girls) were recruited. Their ages ranged from 0.1 to 24 months (mean, 11.2 months). Internal consistency of the questionnaire was high for all domains (Cronbach's α coefficients of 0.85-0.94).

CONCLUSIONS

The PreViAs questionnaire is a useful scale for assessing visual cognitive abilities of infants under 24 months of age. It is easy and feasible to complete by primary caregivers.

Using Constant Time Delay to Teach Braille Word Recognition

Introduction

Constant time delay has been identified as an evidence-based practice to teach print sight words and picture recognition (Browder, Ahlbrim-Delzell, Spooner, Mims, & Baker, 2009). For the study presented here, we tested the effectiveness of constant time delay to teach new braille words.

Methods

A single-subject multiple baseline across behaviors design was used to investigate the use of constant time delay to teach recognition of highly motivating braille words to four students with visual impairments and intellectual disabilities.

Results

Each participant learned all words taught (9–12 words each). A functional relation was demonstrated for all four participants by immediate changes in trend from baseline to intervention.

Discussion

This is the first published report of the successful use of constant time delay to teach braille word recognition to students with visual impairments and intellectual disabilities. An attending cue was introduced into the procedures for students with a low number of unprompted correct responses, and results were positive. Possible sources of variability in word retention are discussed.

Implications for practitioners

Results suggest constant time delay can be adapted and implemented with braille readers in typical teaching environments.

Prenatal determinants of optic nerve hypoplasia: review of suggested correlates and future focus

Optic nerve hypoplasia (ONH), a congenital malformation characterized by an underdeveloped optic nerve, is a seemingly epidemic cause of childhood blindness and visual impairment with associated lifelong morbidity. Although the prenatal determinants of ONH are unknown, early case reports have led to a longstanding speculation that risky health behaviors (e.g., prenatal use of recreational drugs, alcohol) are a likely culprit. There has yet to be a systematic review of the epidemiology of ONH to assess the common prenatal features that may help focus research efforts in the identification of likely prenatal correlates. A review of the past 50 years of epidemiologic research was conducted to examine the prenatal features linked with ONH and provide direction for future research. There are select prominent prenatal features associated with ONH: young maternal age and primiparity. Commonly implicated prenatal exposures (recreational or pharmaceutical drugs, viral infection, etc.) were rare or uncommon in large cohort studies of ONH and therefore unlikely to be major contributors to ONH. Familial cases and gene mutations are rare. The preponderance of young mothers and primiparity among cases of ONH is striking, although the significance is unclear. Recent research suggests a potential role for prenatal nutrition, weight gain, and factors of deprivation. With the rapidly increasing prevalence of ONH, future research should focus on investigating the relevance of young maternal age and primiparity and exploring the recently suggested etiologic correlates in epidemic clusters of ONH.

Autism assessment in children with optic nerve hypoplasia and other vision impairments

AIM

This study examined the utility of standard autism diagnostic measures in nine children (aged 5-9y) with severe vision impairment and a range of social and language functioning.

METHOD

The Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview, Revised (ADI-R) were systematically modified and used to assess symptoms of autism in children with vision less than or equal to 20/800, the majority of whom had optic nerve hypoplasia. The results of the assessments, including analysis of symptom patterns, were compared with expert autism diagnoses.

RESULTS

Modified autism measures demonstrated good agreement with clinical diagnoses. Symptoms found to be most and least reliable in discriminating autism from behaviors common to most children with congenital vision impairment are described. Comparisons of current behavior with parent-reported behaviors from a younger age suggested that some symptoms of autism in very young children who are congenitally blind may improve with age.

INTERPRETATION

The ADOS and ADI-R are useful for clinical assessment and for advancing research efforts to understand autism symptoms in children with vision impairment. However, some autistic symptoms in very young children may change over time, and developmental changes should be closely monitored.

Failure of stem cell therapy to improve visual acuity in children with optic nerve hypoplasia

PURPOSE

To evaluate the effectiveness of stem cell therapy in improving visual acuity or optic nerve function in children with optic nerve hypoplasia (ONH).

METHODS

Subjects with ONH aged 7-17 years who voluntarily elected to undergo stem cell therapy in China were matched with controls on age, visual acuity, and communication level. Visual acuity, optic nerve size, and sensitivity to light were assessed before stem cell therapy and twice after. Controls were evaluated on the same schedule.

RESULTS

Two case-control pairs were enrolled. There were no clinically significant changes in pupillary constriction or optic nerve measurements in any participant eye. Improvement in visual acuity was noted in study participants regardless of treatment status.

CONCLUSIONS

On the basis of this small sample, there is no evidence that stem cell therapy improves visual acuity in children with ONH.

Infantile hemangiomas and retinopathy of prematurity: clues to the regulation of vasculogenesis

Retinopathy of prematurity (ROP) and infantile hemangiomas are vascular disorders that may share common mechanisms. This study examined a potential clinical association between these disorders in populations of preterm infants at two hospitals in the USA and Hungary. Clinically collected data from infants with gestational ages less than 32 weeks born between May 1, 2007 and December 31, 2010 seen in the University of Iowa Children's Hospital or the Department of Obstetrics and Gynecology, University of Pécs, were abstracted from electronic medical records and entered into a study database. Demographic and clinical variables were examined as potential covariates to the disorders of interest. Data were initially analyzed by center and then combined through meta-analysis. Six hundred eighty-four subjects were studied: 236 from Pécs and 448 from Iowa. There were no significant demographic differences between populations. Univariate analysis on each study population yielded covariates to ROP in each population, including infantile hemangioma, which were entered into a logistic regression model. These models were combined through random-effects meta-analysis and demonstrated a significant relationship between infantile hemangioma and ROP (odds ratio = 1.84, 95 % confidence interval 1.08-3.12).

CONCLUSION

Infantile hemangioma and ROP co-occur in premature infant populations. Further studies are needed to investigate the pathogenesis of both disorders.

Optic nerve hypoplasia syndrome: a review of the epidemiology and clinical associations

OPINION STATEMENT

BACKGROUND

Optic nerve hypoplasia (ONH) has developed into a leading cause of congenital blindness. The frequently associated features of hypopituitarism and absent septum pellucidum were felt to have embryonic linkage as "septo-optic dysplasia" or "de Morsier's syndrome." More recent studies have suggested these associations are independent of one another. This review provides an assessment of the historical and recent evidence linking neuroradiologic, endocrinologic and developmental morbidity in patients with ONH. The prenatal risk factors, heritability, and genetic mutations associated with ONH are described.

RESULTS

Recognition of the critical association of ONH with hypopituitarism should be attributed to William Hoyt, not Georges de Morsier. De Morsier never described a case of ONH or recognized its association with hypopituitarism or missing septum pellucidum. Hypopituitarism is caused by hypothalamic dysfunction. This, and other more recently identified associations with ONH, such as developmental delay and autism, are independent of septum pellucidum development. Other common neuroradiographic associations such as corpus callosum hypoplasia, gyrus dysplasia, and cortical heterotopia may have prognostic significance. The predominant prenatal risk factors for ONH are primiparity and young maternal age. Presumed risk factors such as prenatal exposure to drugs and alcohol are not supported by scrutiny of the literature. Heritability and identified gene mutations in cases of ONH are rare.

CONCLUSION

Children with ONH require monitoring for many systemic, developmental, and even life-threatening problems independent of the severity of ONH and presence of brain malformations including abnormalities of the septum pellucidum. "Septo-optic dysplasia" and "de Morsier's syndrome" are historically inaccurate and clinically misleading terms.

Reappraisal of the optic nerve hypoplasia syndrome

BACKGROUND

Optic nerve hypoplasia (ONH) has been described as an increasingly prevalent cause of congenital blindness. Its association with hypopituitarism and absent septum pellucidum has been recognized for more than 40 years as "septo-optic dysplasia" or "de Morsier syndrome." More recent studies have suggested that these associations are independent of one another. This review was designed to assess the historical and recent evidence for associations of neuroradiologic, endocrinologic, and developmental problems in patients with ONH.

EVIDENCE ACQUISITION

Historical and contemporary literature review.

RESULTS

The medical literature does not support the notion that Georges de Morsier ever described a case of ONH or recognized its association with hypopituitarism or missing septum pellucidum. Recognition of the critical association of ONH with hypopituitarism should be attributed to William Hoyt. Hypopituitarism and other more recently identified associations with ONH, such as developmental delay, hypothalamic dysfunction, and autism, are independent of septum pellucidum development. Other common neuroradiographic associations, such as corpus callosum hypoplasia, gyrus dysplasia, and cortical heterotopia, may have prognostic significance.

CONCLUSIONS

Children with ONH need to be monitored for many systemic, developmental, and even life-threatening problems independent of the status of the septum pellucidum. "Septo-optic dysplasia" and "de Morsier syndrome" are historically inaccurate and clinically misleading terms that should be abandoned.

Improving detection of blindness in childhood: the British Childhood Vision Impairment study

OBJECTIVES

In industrialized countries, there are established programs of childhood vision screening and surveillance, but little is known about their performance. We investigated the patterns of presentation/detection and early treatment of a nationally representative cohort of children with severe visual impairment or blindness (SVI/BL) in 1 year (2000) in the United Kingdom.

METHODS

All children who were younger than 16 years and had a new diagnosis of SVI/BL were identified by active surveillance through the British Ophthalmological and Pediatric Surveillance Units. Data that were collected up to 1 year after diagnosis included sociodemographic characteristics, detection of SVI/BL, nonophthalmic disorders/impairments, ophthalmic findings, and early management.

RESULTS

Of 439 identified children, 65% were younger than 1 year at diagnosis, 28% were of nonwhite ethnicity, and 40% in the worst quintile of deprivation score. A total of 77% had associated nonophthalmic disorders/impairments. Although 70% had established symptoms or signs at diagnosis by a health professional, parents had suspected blindness in only 47%. A quarter of isolated SVI/BL was detected through routine vision screening; however, 46% of children's SVI/BL and associated nonophthalmic disorders/impairments were diagnosed through a clinical surveillance examination undertaken because of high risk for a specific eye disease.

CONCLUSIONS

The "patient journey" of children with visual impairment is markedly influenced by the presence of additional impairments/chronic diseases. Parents' understanding of normal visual development needs to be improved. Increasingly, new evidence-based formal programs of clinical (ophthalmic) surveillance are needed in response to the changing population of children who are at risk for blinding eye disease.

Optic nerve hypoplasia in North America: a re-appraisal of perinatal risk factors

PURPOSE

The purpose of this study is to describe and clarify the birth and prenatal characteristics of a large cohort of children with optic nerve hypoplasia.

METHODS

This is a descriptive report of 204 patients aged

RESULTS

Birth characteristics were unremarkable for birthweight and gestation, but significant for increased frequency of caesarean delivery and fetal and neonatal complications. Young maternal age and primaparity were dominating maternal features. Preterm labour, gestational vaginal bleeding, low maternal weight gain and weight loss during pregnancy were prevalent.

CONCLUSIONS

These findings confirm young maternal age and primaparity as associated risk factors, challenge many other suggested factors such as alcohol and drug abuse, and introduce potentially significant prenatal characteristics such as maternal weight loss and early gestational vaginal bleeding as aetiological correlates.

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Key Words

• aetiology
• de morsier syndrome
• optic nerve hypoplasia
• perinatal
• prenatal
• septo-optic dysplasia

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MESH Headings

• Birth Weight
• Child, Preschool
• Eye Abnormalities/epidemiology
• Female
• Gestational Age
• Humans
• Infant
• Infant, Newborn
• Infant, Premature
• Male
• Maternal Age
• North America/epidemiology
• Optic Nerve/abnormalities
• Parity
• Pregnancy
• Prospective Studies
• Registries/statistics & numerical data
• Risk Factors
• Sweden/epidemiology

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Grants

• M01 RR000043-44 NCRR NIH HHS
• UL1 RR031986 NCRR NIH HHS
• M01 RR00043 NCRR NIH HHS
• UL1 RR031986-01 NCRR NIH HHS
• M01 RR000043 NCRR NIH HHS

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Affiliation(s)

Pamela Garcia-Filion The Vision Center at Childrens Hospital Los Angeles, and Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA.
Cassandra Fink
Mitchell E Geffner
Mark Borchert

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