Ocular disorders in children with learning disabilities in special education schools of Pune, India

Approaches for delivery of refractive and optical care services in community and primary care settings

BACKGROUND

Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states.

OBJECTIVES

To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery.

SELECTION CRITERIA

We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme.

MAIN RESULTS

We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services.

AUTHORS' CONCLUSIONS

We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels.

FUNDING

This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership.

REGISTRATION

The protocol of this scoping review was published in the Open Source Framework.

Prevalence of visual dysfunction and ocular motility disorders in developmentally delayed patients

Objective

To evaluate the prevalence of reduced visual acuity (VA), refractive errors (RE), reduced contrast sensitivity and strabismus in developmentally delayed (DD) patients.

Methods

This descriptive cross sectional study was carried out in Ophthalmology Departments of Mayo Hospital, Lahore, The Children's Hospital, Lahore and The Children's Hospital, Multan from June 2019 to December 2019. We recruited 257 patients of either gender, between the ages of 06-16 years having intelligence quotient (IQ) ≤ 80 by Wechsler Intelligence Scale for Children (WISC) from the out-patient departments. Detailed systemic and ophthalmic history was taken and through anterior and posterior segment examination was carried out. VA was assessed with age matched VA charts. Cycloplegic refraction with 1% cyclopentolate was carried out. Contrast sensitivity was measured with hiding Heidi charts. Strabismus was assessed with Hirschberg and covers /uncover tests.

Results

The mean age of the patients was 8.88 years with standard deviation (SD) of ± 2.70. The prevalence of reduced VA, RE, strabismus and reduced contrast sensitivity in these children were 43.58%, 52.92%, 52.14% and 32.7% respectively. Out of these 52.92% RE, 56 (21.79%) were myopic, 66 (25.68%) were hyperopic and 14 (05.45%) were astigmatic. The percentage of esotropia was 72 (28.02%) and exotropia was 62 (24.12%).

Conclusion

The results of our study in DD children have shown that a significant number of children have reduced VA, RE, strabismus and reduced contrast sensitivity. Apart from general management of DD children by a pediatrician, the ophthalmic management of these problems must be carried out by a pediatric ophthalmologist to improve their quality of life.

Ocular abnormalities in children with developmental delay

Purpose

To describe the presence of ocular abnormalities in children with developmental delay (DD) and compare with normal children; to analyze associated risk factors, systemic problems, and the possible treatment that can be delivered.

Methods

This was a cross sectional, observational study. We included children between one and 18 years, diagnosed as developmental delay in DD group, and next immediate age- and sex-matched children without developmental delay on the same day or during the same period in the control group. Detailed history and neuroimaging findings were noted. Uncorrected visual acuity, best-corrected visual acuity for distance and near, cycloplegic refraction, anterior, and posterior segment examination was carried out. Various ocular problems, delayed visual maturation (DVM), and cortical visual impairment (CVI) were diagnosed based on examination. Data were analyzed statistically, and P value <0.05 was considered as statistically significant.

Results

Ninety-four children were included in each group. Mean age was 4.97 ± 3.84 years, and 64.89% were males. In DD group: Most common abnormal neuroimaging finding was gliotic changes; systemic associations: 39 children; 83 children had ocular problems: refractive error-70, strabismus-39, cataract-five, amblyopia-16; DVM-13; CVI-13 children; glasses and vision stimulation were advised in 39 and 65 children, respectively; whereas, in control group: refractive error-36, strabismus-15, cataract-two; amblyopia-20 children.

Conclusion

88.29% of developmental delay children had ocular abnormalities, commonest was refractive error (74.47%); these values were higher than in control group; common risk factors were low birthweight and consanguineous marriage; epilepsy was the most common systemic association.

Myopia in India

India is a culturally and geographically diverse nation. Its vast demographic nature does not allow a single definition for any of the given medical conditions in its territory. One important clinical condition which has created an uproar in the rest of the world is myopia. Its cause, prevalence, etiopathogenesis and other factors are being explored constantly; however, data with respect to Indian subcontinent are genuinely missing. Hence, in this review, we enumerate the country’s myopia journey from last 4 decades. The epidemiology, genetics, ocular/systemic association, quality of life, imaging, and management in myopia with necessary future directives are discussed to augment the overall management in future.

Ocular manifestations in children with developmental delay at a tertiary center in South India

PURPOSE:

Developmental delay occurs when a child exhibits a significant delay in the acquisition of milestones, in one or more domains of development. This study was planned to determine the distribution of ocular disorders and to assess the correlation between ocular findings and systemic co morbidity, antenatal and postnatal factors, and perinatal history.

METHODS:

This cross-sectional study included children with developmental delay <16 years of age. All children underwent complete ophthalmological evaluation including full cycloplegic refraction. Vision assessment was done as appropriate for age. Spearman's correlation test was used to analyze the correlation between ocular findings and causes for developmental delay and antenatal, perinatal, and postnatal history.

RESULTS:

A total of 128 children were evaluated. Mean age of the study group was 5.59 ± 2.12 years, 64.8% were males, and 76.6% of children were from rural area. Ocular findings were seen in 110 (85.93%) children, refractive error being the most common finding seen in 87 children (astigmatism n = 47, hypermetropia n = 28, and myopia n = 12). Strabismus was seen in 65 children, esotropia being the most common (n = 36). Vision impairment was present in 39.84% of children. Other ocular findings included disc pallor, cataract, ptosis, amblyopia, keratoconus, telecanthus, lagophthalmos, blepharitis, retinitis pigmentosa, and morning glory syndrome. Spearman's correlation showed no statistical association between ocular findings and various causes for developmental delay. There was a weak negative correlation between antenatal history, mode of delivery, gestational age, and ocular findings.

CONCLUSION:

More than three-fourths of children with developmental delay had ocular findings which necessitates the need for ocular evaluation.

Observations on Refractive Status and Risk Factors for Visual Impairment in Children with Disabilities

Vision integrates all the senses and plays a fundamental role in the acquisition of different skills and the general development of a child. Recently, refractive errors and visual impairment have become serious health problems among children. Background and Objectives: The aim of this study was to identify the prevalence of refractive errors and visual impairment in children with disabilities. Moreover, this study aimed to explore the risk factors for visual impairment in children with respect to vitamin D levels, parental smoking, and the use of spectacles. Materials and Methods: We retrospectively analyzed 161 children aged 5–16 years old, divided into two groups: a group of 80 children with disabilities and a control group consisting of 81 clinically healthy children. All the children underwent refraction measurements, visual acuity testing, and plasmatic vitamin D level dosing, measured in ng/mL. Results: Refractive errors and visual impairment were found to have a higher prevalence in the group of children with disabilities than in the control group. Moreover, the plasma level of vitamin D was lower in the group of children with special health needs. Conclusions: Given the present results, children with disabilities should undergo special eye examinations as soon as possible to ensure the quality of their socio-academic lives.

Visual Status in a Portuguese Population with Intellectual Disability

BACKGROUND

Neurosensory deprivation associated with vision is a well-known fact in people with intellectual disability (ID). This work aims to report the visual status of a population with ID in Portugal.

METHODS

A vision screening protocol was conducted during two Special Olympics events. The vision protocol included personal medical history, ocular health evaluation, and clinical measures, such as visual acuity (VA), binocular vision, colour vision, refractive error, and intraocular pressure. This protocol was administered to 134 subjects.

RESULTS

Half of the subjects reported that they had never attended or they did not remember having attended a previous eye exam. Additionally, 10% of them had not attended an eye exam in the immediate past three years. Half the subjects failed the VA test and 13% presented moderate Visual Impairment (VI) (VA worse than 0.5 logMAR in the best eye). Manifest ocular deviation was found in 25% of the subjects and the most common ocular health dysfunction conditions were conjunctiva hyperaemia, meibomian gland dysfunction, and lens anomalies. Refractive error correction allowed a reduction in the level of moderate VI to 3.7%.

CONCLUSIONS

The population analysed showed a poor eye care attendance rate and vision-related conditions are in agreement with previous reports. The development of national strategies to promote the awareness for routine eye care in people with ID and improving accessibility to eye care services may mitigate many of the most prevalent conditions encountered.

Parents and teachers of children in special education settings value in-school eyecare and written reports of visual status

Objectives

To evaluate parent and teacher opinion of the provision of in-school eyecare and jargon-free written reporting of visual status for children in special educational settings.

Participants and methods

A nationally-agreed, in-school eyecare framework for children attending special schools which recommends a full eye examination, dispensing of spectacles and provision of a jargon-free written report of visual outcomes to parents and teachers, was provided to 200 children (mean age 10 years, 9 months; 70% male) attending a special school in the UK. The written ‘Vision Report’ detailed, in lay-language, results from the eye examination and provided practical advice to alleviate the impact of vision difficulties both at home and in the classroom. Following implementation of the framework, parents and teachers completed a feedback questionnaire to determine their opinion of the in-school eye examination and utility of the Vision Report.

Results

Parents of 123 participants returned a feedback questionnaire. Eighty-eight participants were represented by the 23 teachers who returned a questionnaire. The in-school eyecare was rated positively for children in special education by 82.4% of parents and 80.9% of teachers. Key benefits included the familiarity of the in-school setting (81.3% of parents and 100% of teachers agree), the convenience of the setting for parents (74.0% of parents and 100% of teachers agree), and the opportunity for teachers to speak directly to eyecare providers regarding a child’s visual needs (82.6% of teachers agree). The information provided by the Vision Report was deemed useful day-to-day by 78.3% of parents and 100% of teachers. The majority (80%) of teachers implemented classroom modifications suggested in the report, whereas only 47.9% of parents reported implementation of modifications at home.

Conclusions

Provision of in-school eyecare is valued by parents and teachers of children in special education settings. Jargon-free, written reports of visual status are valued and utilised by parents and teachers. Further support is required to aid parents in implementing vision modifications at home.

In-school eyecare in special education settings has measurable benefits for children's vision and behaviour

OBJECTIVES

To determine whether implementation of comprehensive in-school eyecare results in measurable benefits for children and young people in terms of visual status, classroom behaviours and how well their visual needs are met.

DESIGN

School-based observational study.

PARTICIPANTS & METHODS

200 pupils [mean age 10 years 9 months, 70% male, majority moderate (40%) or severe (35%) learning difficulty] of a special education school in the UK. A sector-agreed in-school eyecare framework including full eye examination and cycloplegic refraction, dispensing of spectacles (as appropriate) and written reporting of outcomes to parents/teachers was applied. Classroom behaviours were observed and recorded prior to, and after, the in-school eyecare. Surveys were employed to obtain visual histories from parents/teachers. School records and statutory documents were reviewed for diagnostic and learning disability classifications. Visual function and ocular health were profiled at baseline and significant visual deficits identified. Where such deficits were previously unrecognised, untreated or not compensated for (e.g. correction of refractive error, enlargement of educational material) they were recorded as 'unmet visual need'. At follow-up, 2-5 months after initial (baseline) measures, eye examinations, parent/teacher surveys and behaviour observations were repeated. Follow-up measures were used to determine if measurable improvements were evident in visual function, ocular health, the level of unmet need and classroom behaviour following implementation of in-school eyecare.

RESULTS

199 participants completed baseline and follow-up measures. 122 (61%) participants presented with at least one significant visual or ocular health deficit and 90 (45%) participants had at least one unmet visual need. Younger pupils and those with no previous history of eyecare were more likely to demonstrate unmet visual needs at baseline (OR 1.12 95% CI 1.03 to 1.21) p = 0.012; (OR 4.44 95% CI 1.38 to 14.29 p = 0.007 respectively). On follow-up, the number of pupils with unmet visual needs dropped significantly to 36 (18%) (McNemar's test p<0.001). Visual and behavioural metrics of participants without significant visual deficits or whose visual needs were adequately addressed at baseline remained relatively unchanged between baseline and follow-up (Wilcoxon signed rank p>0.05). Where significant refractive deficits were corrected at follow-up, near visual acuity improved significantly (Wilcoxon signed rank p = 0.013), however, poor spectacle compliance was a persistent cause of unmet visual need. Off-task behaviour reduced significantly after actions to address unmet visual needs were communicated to parents and teachers (Wilcoxon signed rank p = 0.035).

CONCLUSIONS

The present study demonstrates for the first time measurable visual and behaviour benefits to children in special education settings when they receive comprehensive in-school eye examinations, on-site spectacle dispensing and jargon-free reporting of outcomes to teachers and parents.

Vision screening services in special needs schools in Western Saudi Arabia

Objectives:

To evaluate the current status of vision screening services in special educational needs (SEN) schools in the western region of Saudi Arabia.

Methods:

This was a cross-sectional study that involved distribution of a questionnaire to all 30 SENs schools in the western region of Saudi Arabia between April and May 2018.

Results:

Twenty-three schools responded to the questionnaire (77% response rate). The number of pupils represented in the surveyed schools was 1831. On average, 10.8% of pupils were reported to wear eyeglasses. Approximately 60.9% of schools reported that vision screening was not offered at their schools. The percentage of students who used optical, non-optical, or high-technology low-vision aids was <2.7%. Most participants (78.3%) reported that no one in their schools had received some form of training to work with and support students with visual impairments.

Conclusion:

In the western province of Saudi Arabia, the vision care status of individuals with intellectual disabilities (ID) in SEN schools is poor. To better serve this underprivileged group, the necessity of implementing vision screening programs on a larger scale should be considered.

Near vision in individuals with Down syndrome: a vision screening study

OBJECTIVES

Children with Down syndrome are known to have reduced focusing ability for near vision (hypoaccommodation). Through a vision screening study we investigated the correlation between hypoaccommodation and near visual acuity in individuals with Down syndrome.

METHODS

A cross-sectional vision screening study was conducted on individuals with Down Syndrome. The screening was done in 4 city schools and 1 screening was conducted as a part of the Special Olympics Bharat program. In addition to the conventional vision screening tests, Nott dynamic retinoscopy was also performed. Both adults and children (age < 18 years) were included.

RESULTS

A total of 55 participants (33 children: age 6 to 17 years, 22 adults: age 18 to 41 years) with Down syndrome were screened. Twenty-two participants had visual impairment. Accommodative accuracy was assessed in 29 children and 13 adults. Accommodative lag ( ≥1.00D) was present in 12 children (41.37%) and 7 adults (53.84%). No correlation was found between the lag of accommodation and near visual acuity (ρ_Spearman = 0.15, p = 0.54). LogMAR near visual acuity was inversely correlated (ρ_Spearman = -0.841, p < 0.001) to the near viewing distance.

CONCLUSION

Near visual acuity by itself is not a sensitive indicator of accommodative dysfunction. In addition, a closer viewing distance may not indicate adequate amplitude of accommodation. These findings strongly suggest the need for including dynamic retinoscopy in the clinical practice while examining individuals with Down syndrome.

Findings from an opt-in eye examination service in English special schools. Is vision screening effective for this population?

Our objective was to present the findings of an opt-in, school-based eye care service for children attending 11 special schools in England and use these findings to determine whether a vision screening programme would be appropriate for this population. Data from eye examinations provided to 949 pupils (mean age 10.7 years) was analysed to determine the prevalence and aetiology of visual deficiencies and reported eye care history. For 46.2% (n = 438) of pupils, a visual deficiency was recorded. 12.5% of all the children seen (n = 119) had a visual deficiency that was previously undiagnosed. Referral for a medical opinion was made for 3.1% (n = 29) of pupils seen by the service. Spectacle correction was needed for 31.5% (n = 299) of pupils; for 12.9% (122) these were prescribed for the first time. 3.7% (n = 11) of parents/carers of pupils needing spectacles chose not to use the spectacle dispensing service offered in school. Eye care history was available for 847 pupils (89.3%). Of the pupils for whom an eye care history was available, 44% (n = 373) reported no history of any previous eye care and10.7% (n = 91) reported a history of attending a community optical practice/opticians. Only one pupil from the school entry 4–5 age group (0.6% of age group n = 156) would have passed vision screening using current Public Health England screening guidelines. Children with a diagnosis of autism were significantly less likely to be able to provide a reliable measurement of visual acuity. This study supports previously published evidence of a very high prevalence of visual problems in children with the most complex needs and a significant unmet need in this group. It demonstrates routine school entry vision screening using current Public Health England guidelines is not appropriate for this group of children and very low uptake of community primary eye care services.

Refractive error and ocular findings among infants and young children with severe problem behavior and developmental disabilities

The prevalence of refractive error and ocular disorders among infants and young children with severe behavioral problems and developmental disorders is not well defined, particularly in developing countries. We performed a retrospective review of ophthalmic examinations performed during a National Institutes of Health-funded cohort study of very young children in Peru with behavioral problems and at risk for developmental disorders. 222 children between the ages of 0 and 4 years (mean 2.2 ± 0.9 years) were examined and 100 (45.0%) had an abnormal ocular exam. Overall, the prevalence of refractive error was 33.3%, nystagmus was 12.2%, and strabismus was 10.9%. Among children with Down syndrome, refractive error ranged from 46.2% at age 2 to 85.7% at age 4. Refractive error and ocular disorders are highly prevalent even at a young age in children with behavioral problems and developmental disorders. Much of the visual impairment in this population is treatable; early identification and intervention can have a lifelong positive impact on neurodevelopment.

Vision Profile and Ocular Characteristics of Special Olympics Athletes: Report from India

PURPOSE

Previous reports, albeit isolated, of vision and ocular screening of athletes with intellectual disability participating in the Special Olympics, UK, indicated high rates of refractive error and ocular morbidity; however, there have been no reports of similar sports events for this population from India. This study set out to evaluate the vision profile and ocular characteristics of athletes with intellectual disability attending the Special Olympics Lions Club International Opening Eyes (SOLCIOE) event in 2012 in India.

METHODS

A cross-sectional study was conducted, where a protocol-based ophthalmological assessment was performed by trained optometrists at a tertiary eye care center.

RESULTS

Overall, 172 athletes (mean age 18.6 years, 70% male) with intellectual disability participated, and 138 (80%) were able to cooperate for complete or nearly complete vision and ocular assessment. A total of 56 (32%) had never had a previous vision or ocular health status examination. A total of 46 (32%) presented with low vision (World Health Organization definition <6/18 to 3/60 in the better eye), 21% needed a first or updated spectacle prescription, and 28% had significant ocular pathology as the cause of visual loss.

CONCLUSIONS

The proportions of refractive errors and ocular disorders in athletes with intellectual disability attending the SOLCIOE program in South India are similar to those reported for able-bodied school-aged children in urban and rural India. Like that of their able-bodied peers, the visual needs of children with intellectual disability are also not adequately being met.

Visual Function and Ocular Status in Children with Disabilities in Special Schools of Northern India

INTRODUCTION

Children with disabilities (other than visual impairment) are at a higher risk of visual impairment as compared to normal population. Majority of the ocular disorders, like refractive errors and strabismus, are easily treatable. As these children depend on their visual inputs for social and academic activities, an early detection and prompt treatment of even a minor visual problem is of utmost importance for them.

AIM

To assess the visual function and ocular status of children with disabilities other than visual impairment and to identify the preventable and treatable causes of visual impairment.

MATERIALS AND METHODS

The study was conducted on children aged 3-16 years who were studying in special schools/ rehabilitation centers in Ludhiana. After prior permission, detailed ocular examination of all the children was done using standard examination techniques. Cycloplegic retinoscopy and refraction was also done and spectacles were prescribed. Children requiring further evaluation were referred to base hospital.

RESULTS

A total of 404 children with disabilities (other than visual disabilities) studying in 7 rehabilitation centers/ special schools were enrolled. These included children with Cerebral palsy (12.1%), with Hearing impairment (35.3%), with Attention Deficit Hyperactive Disorder (ADHD) (3.7%), with Autism (8.6%), with Down syndrome (12.8%) and with Mental retardation (27.2%). Ocular disorders were seen in 174(43%) children. The most common ocular disorders seen in these children were refractive errors (23%) and strabismus (18.1%). A total of 93(23%) children were prescribed spectacles and 37(9.2%) children were referred for further evaluation.

CONCLUSION

Ocular problems are common in children with other disabilities. Delay in the detection and treatment of these disorders compounds the already existing disability in these children. Lack of awareness and sensitization among the parents and teachers is a matter of great concern. Therefore, strategies regarding increasing awareness, mandatory ocular examination in these children and early detection and treatment of the ocular disorders is the need of the hour.

Ocular disorder in children with mental retardation

BACKGROUND

Ocular problems are common in mentally retarded children. Due to population growth these problems are increasing. Prevalence rate is variable from region to region. Data on ocular problems in mentally retarded school children is lacking in this region.

AIM

The aim of the present study was to identify the ocular disorders in children with mental retardation attending special schools in a district and to study their relationship with the degree of retardation.

MATERIALS AND METHODS

A total of 241 mentally retarded school children in the age group of 6-16 years attending special schools for the mentally retarded children in a district in central India were examined by a team of ophthalmologist, psychiatrist, and a resident in ophthalmology department of a medical college. Complete ocular examination was done. Ocular problems were identified and categorized according to the intelligent quotient.

RESULTS

One hundred and twenty four children (51.45%) had ocular problems. Strabismus (10.37%) and refractive error (20.75%) were the common ocular problems seen in this study. An association was found between the severity of mental retardation and ocular problems (P<0.005). However, no association was seen between the severity of mental retardation and strabismus and refractive error.

CONCLUSION

A high prevalence of ocular problems was seen in mentally retarded school children. Children with mental retardation should undergo annual ophthalmological check up. Early detection and correction of ocular problems will prevent visual impairment in future.