The inter-relationships between cerebral visual impairment, autism and intellectual disability

Testing the Hard to Test: A Pilot Study Examining the Role of Questionnaires in Eliciting Visual Behaviours in Children with Autistic Spectrum Disorder

PURPOSE

There is a higher prevalence of visual problems in children with Autistic Spectrum Disorder (ASD) compared with the neuro-typical population. Issues relating to visual perception can be evident as atypical visual behaviours (ViBes). The aim of the study was to compare findings of parents and eye health professionals using questionnaires to describe visual function in young children with ASD.

MATERIALS AND METHODS

Parents/Caregivers of patients diagnosed with ASD attending routine hospital eye clinics were invited to participate. A questionnaire to draw out presence of ViBes was completed by the parent prior to attending clinic. The clinician independently completed the same questionnaire and undertook a clinical ocular assessment.

RESULTS

32 children were recruited (mean age 7 years, range 4-11). Most caregivers indicated they had noted at least one atypical ViBe (97%, median 5, range 0-8). Parental-reported ViBe8 scores were higher than clinician-reported scores (p = 0.04). The most commonly reported ViBes by both groups related to use of vision at the same time as other senses, and atypical fixation (e.g. looking away during speech or side viewing). There was weak correlation between visual acuity and parental ViBe8 score (rho = 0.364) and no correlation between refractive error and parental ViBe8 score (rho = 0.047).

CONCLUSION

Clinicians were likely to under-report atypical visual function compared with parent. Refraction and visual acuity alone do not detect all visual problems in children with ASD. A Visual Behaviour (ViBe) questionnaire offers a structured approach and shared language to allow documentation of functional visual assessment for both parents, carers, and educational professionals. Use of the ViBe questionnaire may promote understanding between caregiver and professional and provide a baseline for visual behaviours.

The Impact of Cerebral Visual Impairment on Social Skills and Sensory Processing

Limited evidence exists on the impact of cerebral visual impairment (CVI) on developmental domains in toddlers. This study investigated whether CVI influences social skills and sensory processing in toddlers with cerebral palsy (CP). The study included toddlers with CP, with or without CVI, and typically developing (TD) toddlers. All parents completed the demographic information form. Social skills were assessed by the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Sensory processing was evaluated by the Infant/Toddler Sensory Profile (ITSP). Analysis of covariance was employed to assess the disparity in BITSEA and ITSP scores. Toddlers with CP and CVI group demonstrated lower social competence than the other groups (p < .05). Having CVI did not cause a statistically significant difference in sensory processing among toddlers with CP (p > .05). CVI significantly affects social competence in toddlers with CP but does not affect sensory processing.

Cerebral visual impairment: genetic diagnoses and phenotypic associations

BACKGROUND

Cerebral visual impairment (CVI) is the most common form of paediatric visual impairment in developed countries. CVI can arise from a host of genetic or acquired causes, but there has been limited research to date on CVI in the context of genetic disorders.

METHODS

We carried out a retrospective analysis of genotypic and phenotypic data for participants with CVI within the DECIPHER database and 100 000 Genomes Project (100KGP).

RESULTS

158 individuals with CVI were identified across both cohorts. Within this group, pathogenic or likely pathogenic sequence variants in 173 genes were identified. 25 of these genes already have known associations with CVI, while the remaining 148 are candidate genes for this phenotype. Gene ontology analysis of the CVI gene sets from both DECIPHER and 100KGP suggests that CVI has a similar degree of genetic heterogeneity to other neurodevelopmental phenotypes, and a strong association with genetic variants converging on ion channels and receptor functions. Individuals with a monogenic disorder and CVI have a higher frequency of epilepsies and severe neurodisability than individuals with a monogenic disorder but not CVI.

CONCLUSION

This study supports the availability of genetic testing for individuals with CVI alongside other neurodevelopmental difficulties. It also supports the availability of ophthalmological screening for individuals with genetic diagnoses linked to CVI. Further studies could elaborate on the links between specific genetic disorders, visual maturation and broader neurodevelopmental characteristics.

Impacts of visual impairment on pragmatic impairment: A systematic review and meta-analysis

BACKGROUND

Consideration for patients with visual impairment, from low vision to blindness, is an important part of building a barrier-free society. Some authors have elaborated that visual impairment can indeed lead to delayed development in theory of mind, thereby causing pragmatic knowledge deficiency. Verifying whether those with eye conditions have pragmatic impairment is an essential way for their clinical evaluation, intervention and rehabilitation.

OBJECTIVE

We primarily carry out a meta-analysis of visual impairment from low vision to blindness and pragmatic impairment in people with low vision or blindness to verify visual impairment may cause pragmatic impairment.

DATA SOURCES

Electronic databases Pubmed, Medline, MesH, Psychinfo, Ovid, EBSCO and CNKI and the reference sections of previous reviews.

STUDY ELIGIBILITY CRITERIA

Studies were included when they built on primary data from clinical questionnaire surveys or field trials anywhere in the world, and when they reported impacts of visual impairment on social cognition, communication, skills, behavior and intelligence. In total, 25 original studies were included, in which 25735 people were evaluated.

RESULTS

Statistically, visual impairments and pragmatic impairment exist correlation due to the significant p value(p = 0.0005 < 0.05) in group and the subgroup sorted in the light of 18 years old (p < 0.0001 and p = 0.003 < 0.05). Psychologically, because people with visual impairment can not normally get non-verbal information, they can not get a complete pragmatic knowledge system. Pragmatic knowledge deficiency leads to abnormal in executive functions and development delay from the perspective of theory of mind, inducing pragmatic impairment. Therefore, visual impairment has an impact on pragmatic impairment.

CONCLUSION

The meta-analysis reveals robust evidence on the relationship of vision impairment and pragmatic impairment in children or adults. Such evidence may help to gradually improve the clinical evaluation, intervention and rehabilitation of these people.

Association between Autism Spectrum Disorder (ASD) and vision problems. A systematic review and meta-analysis

AIM

To conduct a systematic review and meta-analysis assessing whether vision and/or eye disorders are associated with Autism Spectrum Disorder (ASD).

METHOD

Based on a pre-registered protocol (PROSPERO: CRD42022328485), we searched PubMed, Web of Knowledge/Science, Ovid Medline, Embase and APA PsycINFO up to 5th February 2022, with no language/type of document restrictions. We included observational studies 1) reporting at least one measure of vision in people of any age with a diagnosis of ASD based on DSM or ICD criteria, or ADOS; or 2) reporting the prevalence of ASD in people with and without vision disorders. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Random-effects meta-analyses were used for data synthesis.

RESULTS

We included 49 studies in the narrative synthesis and 46 studies in the meta-analyses (15,629,159 individuals distributed across multiple different measures). We found meta-analytic evidence of increased prevalence of strabismus (OR = 4.72 [95% CI: 4.60, 4.85]) in people with versus those without ASD (non-significant heterogeneity: Q = 1.0545, p = 0.7881). We also found evidence of increased accommodation deficits (Hedge's g = 0.68 [CI: 0.28, 1.08]) (non-significant heterogeneity: Q = 6.9331, p = 0.0741), reduced peripheral vision (-0.82 [CI: -1.32, -0.33]) (non-significant heterogeneity: Q = 4.8075, p = 0.4398), reduced stereoacuity (0.73 [CI: -1.14, -0.31]) (non-significant heterogeneity: Q = 0.8974, p = 0.3435), increased color discrimination difficulties (0.69 [CI: 0.27,1.10]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890), reduced contrast sensitivity (0.45 [CI: -0.60, -0.30]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890) and increased retinal thickness (=0.29 [CI: 0.07, 0.51]) (non-significant heterogeneity: Q = 0.8113, p = 0.9918) in ASD.

DISCUSSION

ASD is associated with some self-reported and objectively measured functional vision problems, and structural alterations of the eye, even though we observed several methodological limitations in the individual studies included in our meta-analyses. Further research should clarify the causal relationship, if any, between ASD and problems of vision during early life.

PROSPERO REGISTRATION

CRD42022328485.

Trends in the prevalence of common ocular conditions and comparison of ophthalmic outpatient utilisation related to these conditions in children with and without various types of disabilities: analysis of nationwide population-based data from Taiwan, 2014-2019

OBJECTIVE

The study objectives were to investigate trends in the prevalence of common ocular conditions among children with and without disabilities; to compare the prevalence of these conditions in children with various disabilities; and to compare ophthalmic outpatient utilisation related to these ocular conditions in children with and without disabilities.

DESIGN

Repeated cross-sectional nationwide population-based study.

SETTING

Nationwide analysis in Taiwan based on National Health Insurance (NHI) claims data and the National Disability Registry, from 2014 to 2019.

PARTICIPANTS

All children (aged under 18 years) with a disability in any given year between 2014 and 2019 were included in our analysis. All children with a disability (experimental group) were matched 1:1 with a child of the same age without a disability (control group). Data regarding the children's disability type and status and ocular conditions were obtained from the National Disability Registry and NHI database of Taiwan.

OUTCOME MEASURES

(1) The prevalence of myopia, strabismus, astigmatism, amblyopia and hyperopia over time; (2) the prevalence of myopia, strabismus, astigmatism, amblyopia and hyperopia in children with various disabilities; and (3) the association between disability and the use of outpatient vision care. All outcome measures were assessed using data from 2014 to 2019.

RESULTS

Among children with disability, the prevalence of myopia increased from 15.97% in 2014 to 18.07% in 2019. The prevalence of strabismus (2.06-3.90%), astigmatism (8.25-9.24%), amblyopia (4.13-4.95%) and hyperopia (3.36-4.58%) also increased over the study period in children with disabilities. The prevalence of strabismus, astigmatism, amblyopia and hyperopia was significantly higher in children with disabilities than in those without disabilities in all years. For example, in 2019, the prevalence values for strabismus, astigmatism, amblyopia and hyperopia were 3.90%, 9.24%, 4.95% and 4.58%, respectively, among children with disabilities, and 0.67%, 5.84%, 1.33% and 1.70%, respectively, for those without disabilities. The prevalence of these conditions varied considerably across disability types. For example, in 2019, the prevalence of strabismus was highest in children with visual disabilities (10.66%; p<0.001); these children also exhibited a high prevalence of amblyopia (24.34%; p<0.001). The prevalence of myopia was high in children with autism (24.77%), but the prevalence of other ocular conditions was not elevated in this group. Regression results indicated that for myopia, children with disability had 0.48 fewer outpatient clinic visits than those without disability (p<0.001).

CONCLUSIONS

The prevalence of common ocular conditions and the corresponding vision care required vary across types of disabilities among children. Healthcare policies must account for children at high risk of various ocular conditions, including those with less common disabilities.

Commentary: Profiling Children With Cerebral Visual Impairment (CVI) Using Multiple Methods of Assessment to Aid in Differential Diagnosis

PROFILING CHILDREN WITH CEREBRAL VISUAL IMPAIRMENT USING MULTIPLE METHODS OF ASSESSMENT TO AID IN DIFFERENTIAL DIAGNOSIS: Amanda H. Lueck , Gordon N. Dutton , Sylvie Chokron Seminars in Pediatric Neurology Volume 31, October 2019, Pages 5-14 Cerebral (cortical) visual impairment (CVI), the primary cause of visual impairment in chil dren in high-income countries, is increasing globally due to improved life-saving measures for premature and full-term infants. Yet the consequences of this condition are only begin ning to be understood and addressed. According to the topography, site, and the extent of the pathology, the deficit may variably concern central visual functions, visual field, percep tion of movement, visual analysis, visual exploration, attention, or visual memory, as well as visual guidance of movement. Each affected child has a unique clinical picture, which needs to be identified and individually profiled. This is probably the underlying reason that CVI is commonly underdiagnosed or misdiagnosed, especially in children, and, as a consequence, the full range of potential behavioral outcomes are not identified and adequately addressed. The present paper shows how the use of multiple methods of assessment can improve understanding of children with CVI.

The effects of abnormal visual experience on neurodevelopmental disorders

Normal visual development is supported by intrinsic neurobiological mechanisms and by appropriate stimulation from the environment, both of which facilitate the maturation of visual functions. However, an offset of this balance can give rise to visual disorders. Therefore, understanding the factors that support normal vision during development and in the mature brain is important, as vision guides movement, enables social interaction, and allows children to recognize and understand their environment. In this paper, we review fundamental mechanisms that support the maturation of visual functions and discuss and draw links between the perceptual and neurobiological impairments in autism spectrum disorder (ASD) and schizophrenia. We aim to explore how this is evident in the case of ASD, and how perceptual and neurobiological deficits further degrade social ability. Furthermore, we describe the altered perceptual experience of those with schizophrenia and evaluate theories of the underlying neural deficits that alter perception.

Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide

Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.

Embryonic mercury exposure in zebrafish: Alteration of metabolites and gene expression, related to visual and behavioral impairments

The widespread presence of mercury, a heavy metal found in the environment and used in numerous industries and domestic, raises concerns about its potential impact on human health. Nevertheless, the adverse effects of this environmental toxicant at low concentrations are often underestimated. There are emerging studies showing that accumulation of mercury in the eye may contribute to visual impairment and a comorbidity between autism spectrum disorders (ASD) trait and visual impairment. However, the underlying mechanism of visual impairment in humans and rodents is challenging. In response to this issue, zebrafish larvae with a cone-dominated retinal visual system were exposed to 100 nM mercury chloride (HgCl₂), according to our previous study, followed by light-dark stimulation, a social assay, and color preference to examine the functionality of the visual system in relation to ASD-like behavior. Exposure of embryos to HgCl₂ from gastrulation to hatching increased locomotor activity in the dark, reduced shoaling and exploratory behavior, and impaired color preference. Defects in microridges as the first barrier may serve as primary tools for HgCl₂ toxicity affecting vision. Depletion of polyunsaturated fatty acids (PUFAs), linoleic acid, arachidonic acid (ARA), alpha-linoleic acid, docosahexaenoic acid (DHA), stearic acid, L-phenylalanine, isoleucine, L-lysine, and N-acetylputrescine, along with the increase of gamma-aminobutyric acid (GABA), sphingosine-1-phosphate, and citrulline assayed by liquid chromatography-mass spectrometry (LC-MS) suggest that these metabolites serve as biomarkers of retinal impairments that affect vision and behavior. Although suppression of adsl, shank3a, tsc1b, and nrxn1a gene expression was observed, among these tsc1b showed more positive correlation with ASD. Collectively, these results contribute new insights into the possible mechanism of mercury toxicity give rise to visual, cognitive, and social deficits in zebrafish.

Visual Autism

Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder characterized by deficits in social communication and restricted, repetitive behaviors. It affects approximately 2.2% of children. Both genetic and environmental risk factors have been identified for ASD. Visual comorbidities are relatively common among children with ASD. Between 20 and 44% of ASD children have visually significant refractive error, on-third have strabismus, and one-fifth have amblyopia. In addition, ASD is 30 times more common in children with congenital blindness. It is unknown whether the association of ASD with visual morbidity is causal, comorbid, or contributing. Structural and functional abnormalities have been identified in MRIs of ASD children, and ASD children have been noted to have aberrant eye tracking. ASD children with visually significant refractive errors and poor spectacle compliance (present in 30% of ASD children) offer the opportunity for investigation into how improved visual acuity influences ASD behaviors. In this review, we focus on what is known of the visual system, refractive surgery, and ASD.

From vision to cognition: potential contributions of cerebral visual impairment to neurodevelopmental disorders

Vision has a crucial role to play in human development and functioning. It is, therefore, not surprising that vision plays a fundamental role in the development of the child. As a consequence, an alteration in visual function is, therefore, likely to hinder the child's development. Although ocular disorders are well known, diagnosed and taken into account, cerebral visual impairments (CVI) resulting from post-chiasmatic damage are largely underdiagnosed. However, among the disorders resulting from an episode of perinatal asphyxia and/or associated with prematurity, or neonatal hypoglycaemia, CVIs are prominent. In this article, we focus on the role of the possible effects of CVI on a child's learning abilities, leading to major difficulty in disentangling the consequences of CVI from other neurodevelopmental disorders (NDD) such as dyslexia, dyscalculia, dysgraphia, attention-deficit/hyperactivity disorder (ADHD), developmental coordination disorder (DCD) and autism spectrum disorders (ASD). Although we focus here on the possible overlap between children with CVI and children with other NDD, De Witt et al. (Wit et al. Ear Hear 39:1-19, 2018) have raised exactly the same question regarding children with auditory processing disorders (the equivalent of CVI in the auditory modality). We underline how motor, social and cognitive development as well as academic success can be impaired by CVI and raise the question of the need for systematic evaluation for disorders of vision, visual perception and cognition in all children presenting with a NDD and/or previously born under adverse neurological conditions.

Cerebral visual impairment in children: Multicentric study determining the causes, associated neurological and ocular findings, and risk factors for severe vision impairment

Purpose

To evaluate the causes, associated neurological and ocular findings in children with cerebral visual impairment (CVI), and to identify risk factors for severe vision impairment.

Methods

A multicenter, retrospective, cross-sectional analysis was carried out from January 2017 to December 2019 on patients less than 16 years of age with a diagnosis of CVI.

Results

A total of 405 patients were included of which 61.2% were male and 38.8% were female. The median age at presentation was 4 years (range 3 months to 16 years). Antenatal risk factors were present in 14% of the cases. The most common cause of CVI was hypoxic-ischemic encephalopathy (35.1%), followed by seizure associated with brain damage (31.3%). The most common neurological finding was seizure (50.4%), followed by cerebral palsy (13.6%). Associated ophthalmological findings were significant refractive error (63.2%), esotropia (22.2%), exotropia, (38%), nystagmus (33.3%), and optic nerve atrophy (25.9%). Severe visual impairment (<20/200) was associated with optic atrophy (odds ratio: 2.9, 95% confidence interval: 1.4-6.0; P = 0.003) and seizure disorder (odds ratio: 1.9, 95% confidence interval: 1.2-3.3; P = 0.012).

Conclusion

The various ophthalmic, neurological manifestations and etiologies could guide the multidisciplinary team treating the child with CVI in understanding the visual impairment that affects the neuro development of the child and in planning rehabilitation strategies.

Emerging signs of autism spectrum disorder in infancy: Putative neural substrate

Autism spectrum disorder (ASD) is characterized by altered development of the social brain with prominent atypical features in the fronto-temporo-parietal cortex and cerebellum. Early signs of ASD emerge between 6 and 12 months: reduced social communication, slightly less advanced motor development, and repetitive behaviour. The fronto-temporo-parietal cortex and cerebellum play a prominent role in the development of social communication, whereas fronto-parietal-cerebellar networks are involved in the planning of movements, that is, movement selection. Atypical sensory responsivity, a core feature of ASD, may result in impaired development of social communication and motor skills and/or selection of atypical repetitive behaviour. In the first postnatal year, the brain areas involved are characterized by gradual dissolution of temporary structures: the fronto-temporo-parietal cortical subplate and cerebellar external granular layer. It is hypothesized that altered dissolution of the transient structures opens the window for the expression of early signs of ASD arising in the impaired developing permanent networks. WHAT THIS PAPER ADDS: The early social and motor signs of autism spectrum disorder emerge between the ages of 6 and 12 months. Altered dissolution of transient brain structures in the fronto-temporo-parietal cortex and cerebellum may underlie the emergence of these early signs.

The contribution of whole-exome sequencing to intellectual disability diagnosis and knowledge of underlying molecular mechanisms: A systematic review and meta-analysis

Whole-exome sequencing (WES) is useful for molecular diagnosis, family genetic counseling, and prognosis of intellectual disability (ID). However, ID molecular diagnosis ascertainment based on WES is highly dependent on de novo mutations (DNMs) and variants of uncertain significance (VUS). The quantification of DNM frequency in ID molecular diagnosis ascertainment and the biological mechanisms common to genes with VUS may provide objective information about WES use in ID diagnosis and etiology. We aimed to investigate and estimate the rate of ID molecular diagnostic assessment by WES, quantify the contribution of DNMs to this rate, and biologically and functionally characterize the genes whose mutations were identified through WES. A PubMed/Medline, Web of Science, Scopus, Science Direct, BIREME, and PsycINFO systematic review and meta-analysis was performed, including studies published between 2010 and 2022. Thirty-seven articles with data on ID molecular diagnostic yield using the WES approach were included in the review. WES testing accounted for an overall diagnostic rate of 42% (Confidence interval (CI): 35-50%), while the estimate restricted to DNMs was 11% (CI: 6-18%). Genetic information on mutations and genes was extracted and split into two groups: (1) genes whose mutation was used for positive molecular diagnosis, and (2) genes whose mutation led to uncertain molecular diagnosis. After functional enrichment analysis, in addition to their expected roles in neurodevelopment, genes from the first group were enriched in epigenetic regulatory mechanisms, immune system regulation, and circadian rhythm control. Genes from uncertain diagnosis cases were enriched in the renin angiotensin pathway. Taken together, our results support WES as an important approach to the molecular diagnosis of ID. The results also indicated relevant pathways that may underlie the pathogenesis of ID with the renin-angiotensin pathway being suggested to be a potential pathway underlying the pathogenesis of ID.

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.

Visual Function and Neuropsychological Profile in Children with Cerebral Visual Impairment

Cerebral Visual Impairment (CVI) has become the leading cause of children’s visual impairment in developed countries. Since CVI may negatively affect neuropsychomotor development, an early diagnosis and characterization become fundamental to define effective habilitation approaches. To date, there is a lack of standardized diagnostic methods to assess CVI in children, and the role of visual functions in children’s neuropsychological profiles has been poorly investigated. In the present paper, we aim to describe the clinical and neuropsychological profiles and to investigate the possible effects of visual functions on neuropsychological performance of a cohort of children diagnosed with CVI. Fifty-one children with CVI were included in our retrospective analysis (inclusion criteria: verbal IQ > 70 in Wechsler scales; absence of significant ocular involvement). For each participant, we collected data on neuropsychological assessment (i.e., cognitive, cognitive visual, and learning abilities), basic visual functions (e.g., Best Corrected Visual Acuity—BCVA, contrast sensitivity, and ocular motor abilities) and global development features (e.g., neurological signs and motor development delay) based on standardized tests, according to patients’ ages. The results showed that oculomotor dysfunction involving saccades and smooth pursuit may be a core symptom of CVI and might have a significant impact on cognitive visual and other neuropsychological abilities. Furthermore, visual acuity and contrast sensitivity may influence cognitive, cognitive visual, and academic performances. Our findings suggest the importance of a comprehensive assessment of both visual and neuropsychological functions in children when CVI is suspected, which is needed to provide a more comprehensive functional profile and define the best habilitation strategy to sustain functional vision.

Effects of Congenital Blindness on Ultrasonic Vocalizations and Social Behaviors in the ZRDBA Mouse

Mice produce ultrasonic vocalizations (USVs) at different ages and social contexts, including maternal-pup separation, social play in juveniles, social interactions, and mating in adults. The USVs' recording can be used as an index of sensory detection, internal state, and social motivation. While sensory deprivation may alter USVs' emission and some social behaviors in deaf and anosmic rodents, little is known about the effects of visual deprivation in rodents. This longitudinal study aimed to assess acoustic communication and social behaviors using a mouse model of congenital blindness. Anophthalmic and sighted mice were assayed to a series of behavioral tests at three different ages, namely, the maternal isolation-induced pup USV test and the home odor discrimination and preference test on postnatal day (PND) 7, the juvenile social test on PND 30-35, and the female urine-induced USVs and scent-marking behavior at 2-3 months. Our results evidenced that (1) at PND 7, USVs' total number between both groups was similar, all mice vocalized less during the second isolation period than the first period, and both phenotypes showed similar discrimination and preference, favoring exploration of the home bedding odor; (2) at PND 30-35, anophthalmic mice engaged less in social behaviors in the juvenile play test than sighted ones, but the number of total USVs produced is not affected; and (3) at adulthood, when exposed to a female urine spot, anophthalmic male mice displayed faster responses in terms of USVs' emission and sniffing behavior, associated with a longer time spent exploring the female urinary odor. Interestingly, acoustic behavior in the pups and adults was correlated in sighted mice only. Together, our study reveals that congenital visual deprivation had no effect on the number of USVs emitted in the pups and juveniles, but affected the USVs' emission in the adult male and impacted the social behavior in juvenile and adult mice.

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.

The relation between visual orienting functions, daily visual behaviour and visuoperceptual performance in children with (suspected) cerebral visual impairment

BACKGROUND

Children with cerebral visual impairment (CVI) present heterogeneous visual orienting functions (VOF) and higher-order perception. Multiple assessment methods evaluate CVI, but the relations between them remain unclear.

AIM

To investigate the relations between VOF and (1) daily life behaviour and (2) visuoperceptual tests in children with (suspected) CVI.

METHODS AND PROCEDURES

VOF were tested with a validated eye tracking-based paradigm. Visual perception was assessed using the children's visual impairment test for 3- to 6-year olds (CVIT 3-6) and (retrospective) visuoperceptual dimension results. Caregivers completed the Flemish cerebral visual impairment questionnaire (FCVIQ) and an expert panel scored relations between VOF and the other methods. We compared experts' survey responses with data-based results (linear mixed models and correlations).

OUTCOMES AND RESULTS

Fourty-four children (23 boys, 21 girls; median age = 7y11mo, SD = 2y7mo) participated. Twenty-one experts completed the survey. Slower VOF was significantly associated with (1) object and face processing impairments, (2) visual (dis)interest, (3) worse visual spatial perception (to local motion and form stimuli), and (4) worse CVIT 3-6 object and scene recognition (to cartoon stimuli).

CONCLUSIONS AND IMPLICATIONS

Integration of VOF with existing visual assessments provides a better clinical picture of CVI and can prevent misdiagnosing children as inattentive, incapable, or unmotivated.

Higher Visual Function Deficits in Children With Cerebral Visual Impairment and Good Visual Acuity

In clinical practice Cerebral Visual Impairment (CVI) is typically diagnosed by observation of abnormal visually guided behaviors which indicate higher visual function deficits (HVFDs) suggesting abnormal brain development or brain damage in a child with a suitable clinical history. HVFDs can occur even in the presence of good visual acuity and may remain undiagnosed because the good visual acuity does not prompt further investigation. This leads to a lack of understanding of the child's visual perceptual difficulties. In a prospective study, we determined the spectrum of HVFDs in a group of children with history suggestive of brain damage or disruption of brain development and an independent diagnosis of CVI in comparison with typically developing children with a structured 51 question inventory, the Higher Visual Function Question Inventory (HVFQI-51) adapted from the Cerebral Vision Impairment Inventory, CVI-I. Here, we show that the HVFQI-51 can detect a range of HVFDs in children with CVI with good visual acuity and clearly distinguishes these children from typically developing children. HVFDs in our study group could mostly be attributed to dorsal stream visual processing dysfunction though the spectrum varied between children. We report on the inclusion of the "not applicable" response option in analysis providing a picture of HVFDs more in tune with the overall disability of each child. We also propose a subset of 11 questions (Top-11) which discriminate between children with CVI vs. behaviors seen in typical children: this provides both a potential screening tool for initial assessment of HVFDs and a measure of CVI-related impairment, and needs further validation in a secondary independent sample.

Motion Processing Deficits in Children With Cerebral Visual Impairment and Good Visual Acuity

Purpose

We sought to characterize neural motion processing deficits in children with cerebral visual impairment (CVI) who have good visual acuity using an objective, quantifiable method (steady-state visual evoked potentials [SSVEPs]).

Methods

We recorded SSVEPs in response to three types of visual motion – absolute motion and more complex relative and rotary motion, comparing them to form-related vernier and contour responses. We studied a group of 31 children with CVI diagnosed via detailed clinical examinations and 28 age-matched healthy controls.

Results

Using measurements made at the appropriate response harmonics of the stimulation frequency, we found significant deficits in cerebral processing of relative and rotary motion but not of absolute motion in children with CVI compared with healthy controls. Vernier acuity, in keeping with good recognition acuity in both groups, was not different, nor were contour-related form responses.

Conclusions

Deficits for complex motion but relative sparing of elementary motion and form-related signals suggests preferential damage to extra-striate visual motion areas in children with CVI. The fact that these preferential losses occur in the absence of significant acuity loss indicates that they are not secondary to reduced visual acuity, but rather are an independent vulnerability in CVI. These results corroborate parental and caregivers’ reports of difficulties with tasks that involve motion perception in children with CVI.

Cortical Visual Impairments and Learning Disabilities

Medical advances in neonatology have improved the survival rate of premature infants, as well as children who are born under difficult neurological conditions. As a result, the prevalence of cerebral dysfunctions, whether minimal or more severe, is increasing in all industrialized countries and in some developing nations. Whereas in the past, ophthalmological diseases were considered principally responsible for severe visual impairment, today, all recent epidemiological studies show that the primary cause of blindness and severe visual impairment in children in industrialized countries is now neurological, with lesions acquired around the time of birth currently comprising the commonest contributor. The resulting cortical or cerebral visual impairments (CVIs) have long been ignored, or have been confused either with other ophthalmological disorders causing low vision, or with a range of learning disabilities. We present here the deleterious consequences that CVI can have upon learning and social interaction, and how these can be given behavioral labels without the underlying visual causes being considered. We discuss the need to train and inform clinicians in the identification and diagnosis of CVI, and how to distinguish the diagnosis of CVI from amongst other visual disorders, including the specific learning disorders. This is important because the range of approaches needed to enhance the development of children with CVI is specific to each child's unique visual needs, making incorrect labeling or diagnosis potentially detrimental to affected children because these needs are not met.

The Clinical Dilemma of Autism Spectrum Disorder Diagnosis in a Child with 9p Deletion

We reported on a 3-year-old girl child patient with the presence of trigonocephaly, broad nasal bridge, flattened occiput, and midface hypoplasia. Formal assessment of her development profile demonstrated expressive and receptive language delays, fine and gross motor delays, and no imaginative or symbolic representative play. Investigation of the etiology of her developmental delays revealed a genetic diagnosis of a 9p24 deletion by chromosomal microarray analysis. The possibility of an additional co-occurring disorder of autism spectrum disorder (ASD) was also raised by a referring clinician. This case report highlighted the clinical dilemma of diagnosing ASD in those with existing genetic syndromes.

Early motor skills predict the developmental trajectory of problem solving in young children with motor delays

INTRODUCTION

The purpose of this study was to quantify the relationship between early motor skills, such as sitting, and the development of problem-solving skills in children with motor delays.

METHODS

Motor (Gross Motor Function Measure) and problem-solving (Assessment of Problem-Solving in Play) skills of 134 children 7-16 months adjusted age at baseline with motor delay were assessed up to 5 times over 12 months. Participants were divided into two groups: mild and significant motor delay.

RESULTS

Motor and problem-solving scores had large (r's = 0.53-0.67) and statistically significant (p's > .01) correlations at all visits. Baseline motor skills predicted baseline and change in problem solving over time. The associations between motor and problem-solving skills were moderated by level of motor delay, with children with significant motor delay generally having stronger associations compared to those with mild motor delay.

CONCLUSIONS

These findings suggest that overall baseline motor skills are predictive of current and future development of problem-solving skills and that children with significant motor delay have a stronger and more stable association between motor and problem-solving skills over time. This highlights that children with motor delays are at risk for secondary delays in problem solving, and this risk increases as degree of motor delay increases.

Neurodevelopmental and Neurodegenerative Similarities and Interactions: A Point of View About Lifelong Neurocognitive Trajectories

Neurodevelopmental and neurodegenerative disorders are both growing major public health topics with similarities and frequent complex interactions with each other. Taking these aspects into account can provide a new point of view on lifelong neurocognitive trajectories. Assessing both neurodevelopmental and neurodegenerative dimensions during cognitive and behavioral clinical assessments is challenging but might improve diagnostic accuracy and physiopathological understanding. It is therefore necessary to understand the lifelong specific neurocognitive trajectory of each patient in order to develop personalized precision cognitive medicine.

Emotional face recognition in autism and in cerebral visual impairments: In search for specificity

Autism spectrum disorder (ASD) is characterized by difficulties in the social domain, but also by hyper- and hypo-reactivity. Atypical visual behaviours and processing have often been observed. Nevertheless, several similar signs are also identified in other clinical conditions including cerebral visual impairments (CVI). In the present study, we investigated emotional face categorization in groups of children with ASD and CVI by comparing each group to typically developing individuals (TD) in two tasks. Stimuli were either non-filtered or filtered by low- and high-spatial frequencies (LSF and HSF). All participants completed the autism spectrum quotient score (AQ) and a complete neurovisual evaluation. The results show that while both clinical groups presented difficulties in the emotional face recognition tasks and atypical processing of filtered stimuli, they did not differ from one another. Additionally, autistic traits were observed in the CVI group and symmetrically, some visual disturbances were present in the ASD group as measured via the AQ score and a neurovisual evaluation, respectively. The present study suggests the relevance of comparing ASD to CVI by showing that emotional face categorization difficulties should not be solely considered as autism-specific but merit investigation for potential dysfunction of the visual processing neural network. These results are of interest in both clinical and research perspectives, indicating that systematic visual examination is warranted for individuals with ASD.

A Multidimensional, Multisensory and Comprehensive Rehabilitation Intervention to Improve Spatial Functioning in the Visually Impaired Child: A Community Case Study

Congenital visual impairment may have a negative impact on spatial abilities and result in severe delays in perceptual, social, motor, and cognitive skills across life span. Despite several evidences have highlighted the need for an early introduction of re-habilitation interventions, such interventions are rarely adapted to children’s visual capabilities and very few studies have been conducted to assess their long-term efficacy. In this work, we present a case study of a visually impaired child enrolled in a newly developed re-habilitation intervention aimed at improving the overall development through the diversification of re-habilitation activities based on visual potential and developmental profile, with a focus on spatial functioning. We argue that intervention for visually impaired children should be (a) adapted to their visual capabilities, in order to increase re-habilitation outcomes, (b) multi-interdisciplinary and multidimensional, to improve adaptive abilities across development, (c) multisensory, to promote the integration of different perceptual information coming from the environment.

Autistic-Like Features in Visually Impaired Children: A Review of Literature and Directions for Future Research

There remains great interest in understanding the relationship between visual impairment (VI) and autism spectrum disorder (ASD) due to the extraordinarily high prevalence of ASD in blind and visually impaired children. The broad variability across individuals and assessment methodologies have made it difficult to understand whether autistic-like symptoms shown by some children with VI might reflect the influence of the visual deficit, or represent a primary neurodevelopmental condition that occurs independently of the VI itself. In the absence of a valid methodology adapted for the visually impaired population, diagnosis of ASD in children with VI is often based on non-objective clinical impression, with inconclusive prevalence data. In this review, we discuss the current state of knowledge and suggest directions for future research.