1
|
Chang MY, Borchert MS. Comparison of Eye Tracking and Teller Acuity Cards for Visual Acuity Assessment in Pediatric Cortical/Cerebral Visual Impairment. Am J Ophthalmol 2024; 260:115-121. [PMID: 38065248 PMCID: PMC10981560 DOI: 10.1016/j.ajo.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/10/2023] [Accepted: 11/26/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE To compare eye tracking and Teller acuity cards (TAC) for assessment of visual acuity in children with cortical, or cerebral, visual impairment (CVI). DESIGN Reliability and validity study. METHODS We recruited 41 children with CVI from a single academic pediatric neuro-ophthalmology clinic. All children performed eye tracking to measure visual acuity, and 26 children completed TAC assessment by a masked examiner. Additionally, 2 pediatric neuro-ophthalmologists graded visual behavior using the 6-level Visual Behavior Scale (VBS). Eye tracking and TAC were performed at baseline and at 1 month. Test-retest reliability of eye tracking and TAC were assessed using the intraclass correlation coefficient (ICC). Eye tracking and TAC visual acuities were correlated with one another and VBS scores using the Spearman correlation coefficient. RESULTS Test-retest reliability was excellent for eye tracking measurement of visual acuity (ICC = 0.81, P < .0001). For pediatric CVI, TAC test-retest reliability was fair (ICC = 0.42, P = .04). There was a moderate correlation between eye tracking and TAC (r = 0.43, P = .03) and between TAC and VBS score (r = 0.50, P = .009), and a strong correlation between eye tracking grating acuity and VBS score (r = 0.72, P < .0001). CONCLUSIONS In our cohort of children with CVI, grating acuity measured by eye tracking demonstrated higher test-retest reliability and stronger correlation with pediatric neuro-ophthalmologic assessment of visual behavior than Teller acuity. Objective determination of gaze direction by an eye tracking camera may be more accurate than human assessment in this population. Future research is needed to determine the optimal methods of longitudinal assessment of visual function and functional vision in children with CVI.
Collapse
Affiliation(s)
- Melinda Y Chang
- From The Vision Center at the Children's Hospital Los Angeles (M.Y.C., M.S.B.), Los Angeles, California, USA; Roski Eye Center, University of Southern California (M.Y.C., M.S.B.), Los Angeles, California, USA.
| | - Mark S Borchert
- From The Vision Center at the Children's Hospital Los Angeles (M.Y.C., M.S.B.), Los Angeles, California, USA; Roski Eye Center, University of Southern California (M.Y.C., M.S.B.), Los Angeles, California, USA
| |
Collapse
|
2
|
Hokken MJ, van der Zee YJ, van der Geest JN, Kooiker MJG. Parent-reported problems in children with Cerebral Visual Impairment: Improving the discriminative ability from ADHD and dyslexia using screening inventories. Neuropsychol Rehabil 2024:1-21. [PMID: 38502713 DOI: 10.1080/09602011.2024.2328875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 03/02/2024] [Indexed: 03/21/2024]
Abstract
Daily problems of children with Cerebral Visual Impairment (CVI) are often misinterpreted as symptoms of behavioural disorders or learning disabilities instead of higher order visual function (HOVF) deficits. It is difficult to differentiate between various paediatric clinical groups based on daily manifestations. We used two CVI inventories (V-CVI-I, HVFQI) and an ADHD questionnaire (AVL) to compare parent-reported visual and behavioural problems of children with CVI, ADHD, dyslexia and neurotypical children (Age 6-15, Verbal Intelligence > 70). Our results show a higher percentage of parent-reported visual problems in children with CVI compared to all other groups, which was not affected by their visual acuity levels. On most HOVF categories, a higher percentage of parent-reported visual problems was also found in children with ADHD or dyslexia compared to neurotypical children. Children with ADHD had significantly more parent-reported behavioural problems, but more behavioural problems were reported by the parents of children with CVI compared to neurotypical children as well. Our findings complicate using the existing inventories for initial screening and referral of children with potential CVI. We propose a shortened screening list to improve the potential differentiation between CVI and ADHD or dyslexia based on parent-reported visual problems in everyday life.
Collapse
Affiliation(s)
- Marinke J Hokken
- Erasmus MC, Department of Neuroscience, Rotterdam, the Netherlands
- Royal Dutch Visio, Huizen, the Netherlands
| | | | | | - Marlou J G Kooiker
- Erasmus MC, Department of Neuroscience, Rotterdam, the Netherlands
- Royal Dutch Visio, Huizen, the Netherlands
| |
Collapse
|
3
|
McDowell N, Butler P. Validation of the Austin Assessment: A screening tool for cerebral visual impairment related visual issues. PLoS One 2023; 18:e0293904. [PMID: 37917596 PMCID: PMC10621811 DOI: 10.1371/journal.pone.0293904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/21/2023] [Indexed: 11/04/2023] Open
Abstract
Cerebral visual impairment is the most common cause of vision impairment affecting children in the economically developed world with a prevalence rate of approximately 3.4%. Currently there are limited options for screening for cerebral visual impairment, resulting in many children going undiagnosed, especially those that have normal visual acuity. The aim of this research was to validate an iPad App called the Austin Assessment, which was developed as a potential screening tool for cerebral visual impairment related visual issues. The research involved three separate phases: (1) creating a database of normative ranges for children aged 5-18 across the different variables of the Austin Assessment, (2) using the Austin Assessment to screen children aged 5-13 to assess the effectiveness of the Austin Assessment as a screening tool for CVI related visual issues, and (3) conducting specific validation research assessing children using the Austin Assessment and an already validated visual search tool. Each phase used different quantitative research methodologies to help show the effectiveness of the Austin Assessment as a screening tool for cerebral visual impairment related visual issues. From phase one of the research, thresholds were established for three variables of the Austin Assessment for the age groupings of 5-8, 9-12 and 13-18. If a child meets one of these thresholds this indicates further assessment is required to determine if they do in fact have cerebral visual impairment related visual issues. Phase two identified 17 children out of 270 who had clinical findings indicating visual issues; potentially indicative of CVI; investigation into the nature of these visual issues is ongoing. Phase three found that the Austin Assessment has moderate diagnostic value for each age group, with good sensitivity and specificity, making it effective at distinguishing those children who have visual issues from those who have typical vision. Further investigation is needed to confirm this initial validation.
Collapse
Affiliation(s)
- Nicola McDowell
- Institute of Education, Massey University, Auckland, New Zealand
| | - Philippa Butler
- Institute of Education, Massey University, Auckland, New Zealand
| |
Collapse
|
4
|
Lim HW, Pershing S, Moshfeghi DM, Heo H, Haque ME, Lambert SR. Causes of Childhood Blindness in the United States Using the IRIS® Registry (Intelligent Research in Sight). Ophthalmology 2023; 130:907-913. [PMID: 37037315 PMCID: PMC10524509 DOI: 10.1016/j.ophtha.2023.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/12/2023] Open
Abstract
PURPOSE To investigate causes of childhood blindness in the United States using the IRIS® Registry (Intelligent Research in Sight). DESIGN Cross-sectional study. PARTICIPANTS Patients ≤ 18 years of age with visual acuity (VA) 20/200 or worse in their better-seeing eye in the IRIS Registry during 2018. METHODS Causes of blindness were classified by anatomic site and specific diagnoses. MAIN OUTCOME MEASURES Percentages of causes of blindness. RESULTS Of 81 164 children with 2018 VA data in the IRIS Registry, 961 (1.18%) had VA 20/200 or worse in their better-seeing eye. Leading causes of blindness were retinopathy of prematurity (ROP) in 301 patients (31.3%), nystagmus in 78 patients (8.1%), and cataract in 64 patients (6.7%). The retina was the leading anatomic site (47.7%) followed by optic nerve (11.6%) and lens (10.0%). A total of 52.4% of patients had treatable causes of blindness. CONCLUSIONS This analysis offers a unique cross-sectional view of childhood blindness in the United States using a clinical data registry. More than one-half of blind patients had a treatable cause of blindness. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Han Woong Lim
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
- Department of Ophthalmology, Hanyang University School of Medicine, Seoul, Republic of Korea
| | - Suzann Pershing
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
- Ophthalmology and Eye Care Services, VA Palo Alto Health Care System, Palo Alto, CA
| | - Darius M. Moshfeghi
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
| | - Hwan Heo
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
- Department of Ophthalmology, Chonnam National University Medical School and Hospital, Gwangju, Republic of Korea
| | - Md Enamul Haque
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
| | - Scott R. Lambert
- Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, CA
| |
Collapse
|
5
|
Zhang X, Manley CE, Micheletti S, Tesic I, Bennett CR, Fazzi EM, Merabet LB. Assessing visuospatial processing in cerebral visual impairment using a novel and naturalistic static visual search task. RESEARCH IN DEVELOPMENTAL DISABILITIES 2022; 131:104364. [PMID: 36334401 DOI: 10.1016/j.ridd.2022.104364] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 07/15/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Cerebral visual impairment (CVI) is a brain based visual disorder associated with the maldevelopment of central visual pathways. Individuals with CVI often report difficulties finding a target of interest in cluttered and crowded visual scenes. However, it remains unknown how manipulating task demands and other environmental factors influence visual search performance in this population. AIM We developed a novel and naturalistic virtual reality (VR) based static visual search task combined with eye tracking called the "virtual toy box" to objectively assess visual search performance in CVI. METHODS AND PROCEDURES A total of 38 individuals with CVI (mean age 13.18 years ± 3.58 SD) and 53 controls with neurotypical development (mean age 15.25 years ± 5.72 SD) participated in the study. In a first experiment, study subjects were instructed to search for a preselected toy presented among a varying number of surrounding distractor toys (set size ranging from 1 to 36 items). In a second experiment, we assessed the effects of manipulating item spacing and the size of the visual area explored (field of view; FOV). OUTCOMES AND RESULTS Behavioral outcomes collected were success rate, reaction time, gaze error, visual search area, and off-screen percent (an index of task compliance). Compared to age-matched controls, participants with CVI showed an overall impairment with respect to all the visual search outcomes of interest. Specifically, individuals with CVI were less likely and took longer to find the target, and search patterns were less accurate and precise compared to controls. Visual search response profiles were also comparatively less efficient and were associated with a slower initial pre-search (visual orienting) response as indexed by higher slope and intercept values derived from the analysis of reaction time × set size functions. Search performance was also more negatively affected in CVI at the smallest as well as largest spacing conditions tested, while increasing FOV was associated with greater decreased gaze accuracy and precision CONCLUSIONS AND IMPLICATIONS: These results are consistent with a general profile of impaired visual search abilities in CVI as well as worsening performance with increased visual task demands and an overall sensitivity to visual clutter and crowding. The observed profile of impaired visual search performance may be associated with dysfunctions related to how visual selective attention is deployed in individuals with CVI.
Collapse
Affiliation(s)
- Xin Zhang
- The Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Claire E Manley
- The Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Serena Micheletti
- Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Isidora Tesic
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Christopher R Bennett
- The Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Elisa M Fazzi
- Unit of Child Neurology and Psychiatry, ASST Spedali Civili of Brescia, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Lotfi B Merabet
- The Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA.
| |
Collapse
|
6
|
Manley CE, Bennett CR, Merabet LB. Assessing Higher-Order Visual Processing in Cerebral Visual Impairment Using Naturalistic Virtual-Reality-Based Visual Search Tasks. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1114. [PMID: 35892617 PMCID: PMC9331719 DOI: 10.3390/children9081114] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022]
Abstract
Cerebral visual impairment (CVI) is a brain-based disorder associated with the maldevelopment of central visual pathways. Individuals with CVI often report difficulties with daily visual search tasks such as finding a favorite toy or familiar person in cluttered and crowded scenes. We developed two novel virtual reality (VR)-based visual search tasks combined with eye tracking to objectively assess higher order processing abilities in CVI. The first (virtual toybox) simulates a static object search, while the second (virtual hallway) represents a dynamic human search task. Participants were instructed to search for a preselected target while task demand was manipulated with respect to the presence of surrounding distractors. We found that CVI participants (when compared to age-matched controls) showed an overall impairment with visual search on both tasks and with respect to all gaze metrics. Furthermore, CVI participants showed a trend of worsening performance with increasing task demand. Finally, search performance was also impaired in CVI participants with normal/near normal visual acuity, suggesting that reduced stimulus visibility alone does not account for these observations. This novel approach may have important clinical utility in helping to assess environmental factors related to functional visual processing difficulties observed in CVI.
Collapse
Affiliation(s)
| | | | - Lotfi B. Merabet
- The Laboratory for Visual Neuroplasticity, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA; (C.E.M.); (C.R.B.)
| |
Collapse
|
7
|
Boonstra FN, Bosch DGM, Geldof CJA, Stellingwerf C, Porro G. The Multidisciplinary Guidelines for Diagnosis and Referral in Cerebral Visual Impairment. Front Hum Neurosci 2022; 16:727565. [PMID: 35845239 PMCID: PMC9280621 DOI: 10.3389/fnhum.2022.727565] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Cerebral visual impairment (CVI) is an important cause of visual impairment in western countries. Perinatal hypoxic-ischemic damage is the most frequent cause of CVI but CVI can also be the result of a genetic disorder. The majority of children with CVI have cerebral palsy and/or developmental delay. Early diagnosis is crucial; however, there is a need for consensus on evidence based diagnostic tools and referral criteria. The aim of this study is to develop guidelines for diagnosis and referral in CVI according to the grade method. Patients and Methods We developed the guidelines according to the GRADE method 5 searches on CVI (children, developmental age ≤ 18 years) were performed in the databases Medline, Embase, and Psychinfo, each with a distinct topic. Results Based on evidence articles were selected on five topics: 1. Medical history and CVI-questionnaires 23 (out of 1,007). 2. Ophthalmological and orthoptic assessment 37 (out of 816). 3. Neuropsychological assessment 5 (out of 716). 4. Neuroradiological evaluation and magnetic resonance imaging (MRI) 9 (out of 723). 5. Genetic assessment 5 (out of 458). Conclusion In medical history taking, prematurity low birth weight and APGAR (Appearance, Pulse, Grimace, Activity, Respiration) Scores (<5) are important. Different questionnaires are advised for children under the age of 3 years, older children and for specific risk groups (extremely preterm). In ophthalmological examination, eye movements, specially saccades, accommodation, crowding, contrast sensitivity and visual fields should be evaluated. OCT can show objective signs of trans-synaptic degeneration and abnormalities in fixation and saccades can be measured with eye tracking. Screening of visual perceptive functioning is recommended and can be directive for further assessment. MRI findings in CVI in Cerebral Palsy can be structured in five groups: Brain maldevelopment, white and gray matter lesions, postnatal lesions and a normal MRI. In children with CVI and periventricular leukomalacia, brain lesion severity correlates with visual function impairment. A differentiation can be made between cortical and subcortical damage and related visual function impairment. Additional assessments (neurological or genetic) can be necessary to complete the diagnosis of CVI and/or to reveal the etiology.
Collapse
Affiliation(s)
- Frouke N. Boonstra
- Royal Dutch Visio, National Foundation for the Visually Impaired and Blind, Huizen, Netherlands
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Centre Nijmegen, Nijmegen, Netherlands
- Behavioral Science Institute, Radboud University, Nijmegen, Netherlands
- *Correspondence: Frouke N. Boonstra,
| | | | - Christiaan J. A. Geldof
- Royal Dutch Visio, National Foundation for the Visually Impaired and Blind, Huizen, Netherlands
| | - Catharina Stellingwerf
- Royal Dutch Visio, National Foundation for the Visually Impaired and Blind, Huizen, Netherlands
| | - Giorgio Porro
- Department of Ophthalmology, UMC Utrecht and Amphia Hospital Breda, Breda, Netherlands
| |
Collapse
|