The document discusses visual impairment in children and its evaluation and diagnosis. It defines various types of visual impairment including reduced visual acuity and visual field loss. It describes examining a child's visual acuity, contrast sensitivity, and visual field. Common causes of visual impairment in children mentioned include congenital glaucoma, leucocoria (white eye reflex), cataracts, retinopathy of prematurity, and refractive errors. The evaluation process involves taking a history, performing eye examinations, and conducting investigations to confirm diagnoses. Treatment aims to detect issues early to prevent vision loss and may include optical devices, non-optical methods, and visual rehabilitation.

1. Penaksiran dan Diagnosis Kanak-kanak Bermasalah Penglihatan Dr Safinaz Mohd Khialdin Pensyarah & Pakar Oftalmologi Jabatan Oftalmologi PPUKM

3. Visual impairment or low vision reduction in vision that cannot be corrected with standard glasses or contact lenses reduces a person's ability to function at certain or all tasks Visual Impairment

4. Functional limitation of the eye(s) or visual system Can manifest as Reduced visual acuity Reduced contrast sensitivity Visual field loss Photophobia Diplopia Visual distortion Visual Impairment

5. Clearness of vision dependent on the sharpness of the retinal focus within the eye the sensitivity of the interpretative parts of the brain. Visual acuity

6. VISION TESTING IN CHILDREN

7. Contrast sensitivity How well your eyes function in dim light How well you can distinguish objects from similarly colored or shaded backgrounds.

8. The total area in which objects can be seen in the peripheral vision while you focus your eyes on a central point. Visual field

9. PHOTOPHOBIA – glaring DIPLOPIA – double vision VISUAL DISTORTION

10. Definition: Visual impairment : visual acuity of less than 6/18, but equal or better than 3/60 in the better eye Visual field less than 20 degree from fixation Blindness: visual acuity is less than 3/60 in the better eye Visual field less than 10 degree from fixation Visual Impairment

11. 6/60 6/18

12. HISTORY TAKING – SYMPTOMS EXAMINATIONS – SIGNS INVESTIGATIONS – CONFIRM DIAGNOSIS EVALUATION & DIAGNOSIS OF VISUAL IMPAIRMENT

13. Ocular History Diagnosis and onset of symptoms Past, current, or planned surgeries or treatments Stability of vision Family history of eye disease Previous history of eye disease or vision problems Current or previous use of spectacles, contact lenses, or low vision aids EVALUATION & DIAGNOSIS: HISTORY

14. Visual Functioning Ability to read print and specific reading needs (schooling) Intermediate visual ability and needs (e.g., use of computer, reading music) Distance visual ability and needs Photophobia, glare sensitivity, and lighting requirements EVALUATION & DIAGNOSIS: HISTORY

15. Medical History General health review Current medications Hearing impairment or other disability Developmental delay EVALUATION & DIAGNOSIS: HISTORY

16. EXAMINATION Visual acuity Visual field Refraction Eye movement Detailed examination of the eye structures EVALUATION & DIAGNOSIS: EXAMINATION

17. To confirm eye problem Ultrasound CT scan To assess visual impairment Contrast sensitivity testing Colour vision testing Visual evoked potential EVALUATION & DIAGNOSIS: INVESTIGATIONS

18. Eye problems in children Importance Early detection & treatment of peadiatric ocular disease is critical Delay in diagnosis results in irreversible vision loss Assessment should begin at birth

19. Eye pathology : Structural impairment or damage to one or more parts of the eye Refractive errors : or an inability of the eye to sharply focus images on the back of retina Cortical visual impairments : damage to the part of the brain that interprets visual information CAUSES OF VISUAL IMPAIRMENT IN CHILDREN

20. Eye problems in children causing visual impairment

21. Anatomy of the eye

22. Congenital glaucoma Rare (1:10000), 65% males Diagnosed shortly after birth or during 1 st year of life Improper development of the eye drainage channel Leads high pressure in the eye Causing damage to optic nerve and results in vision loss Symptoms: Tearing Photophobia (glaring) Excessive squeezing of the eye Buphthalmos (ox eye)

23. Leucocoria White eye reflex Differential diagnosis R etinoblastoma C ongenital c ataract Retinopathy of P rematurity C oat’s disease P ersistent Hyperplastic Primary Vitreous (PHPV)

24. 1.Leucocoria: Retinoblastoma Most common intraocular malignancy of childhood Rare (1 in 14000-20000) 3% of all childhood cancers Bilateral in 30-35% Age at diagnosis : 18 months (90% less than 3 years old) May be inherited

25. 1.Leucocoria: Retinoblastoma Present with: Leucocoria (white reflex) Squint Poor vision Eye redness, pain Proptosis : forward bulging of the eye Systemic metastases Incidental ocular exam

27. Retinoblastoma Sight threatening Life threatening Treatment option Radiotherapy Chemotherapy Surgical removal of the eye Genetic counselling

28. 2. Leucocoria: Cataract Definition of cataract : Opacity involving the lens

29. Leucocoria: Cataract Leading cause of blindness Interferes with normal visual develoment Inherited –1/3 Associated with other diseases – 1/3 Idiopathic – 1/3

30. Nuclear cataract Lamellar cataract Cortical cataract CONGENITAL CATARACT

31. SECONDARY Ocular - Anterior subcapsular – Atopic dermatitis Systemic – oil droplet cataract – Galactossaemia Vossius ring in traumatic cataract

32. Presentations of childhood cataract Lack of visual interest Strabismus/squint Nystagmus : abnormal movement of the eye Developmental delay Associated with systemic/ ocular abnormalities

33. Action Prompt detection & dedicated screening Referral to Ophthalmologist (urgent) Why? Monocular/ binocular cataract in infants results in significant visual deprivation Early visual rehabilitation can prevent amblyopia (lazy eye)

34. Eye disease that affects prematurely born babies Caused by disorganized growth of retinal blood vessels May be mild and resolves spontaneously Severe cases can lead to scarring and retinal detachment. 3. Leucocoria: Retinopathy of prematurity

35. Leucocoria: Retinopathy of prematurity

36. Risk factor for ROP Pre-term babies – screening Low birth weight Exposure to oxygen Screening of premature babies has to continue till school-going age Risk of myopia, even with no ROP Leucocoria: Retinopathy of prematurity

37. Strabismus/squint Definition: Deviation of the eyes so that their visual axes are no longer parallel

38. Causes of squint Muscle imbalance Refractive errors Ocular abnormalities – cataract, macular scar, optic disc pathology Special syndromes – Duanes, Brown Associated disease – hydrocephalus, cerebral palsy, meningitis

39. Other presenting features Symptoms None Noted by parents Poor vision Funny eye movements Signs Poor vision Abnormal head posture

40. Management for squint Refer to ophthalmologist (urgent) Treatment of refractive errors Treatment of amblyopia (lazy eye) Ocular exercise Surgery – mucsle imbalance Why? Amblyopia (Lazy eye) Loss of binocular single vision Cosmetic blemish

41. REFRACTIVE ERROR Physiological condition whereby the refracting system of the eye does not focus objects on the retina A corrective lens has to be placed in front of the eye to enable a sharp image to be seen.

42. Myopia Hyperopia Astigmatism Refractive errors

43. Refractive errors Various presentations: Squeezing eyes Squint Headache – ocular/ frontal/ diffuse Tearing Complains of tired eyes Child is slow at school Has problems with attentiveness Strong family history of myopia or other refractive error Importance: Untreated or undertreated will cause AMBLYOPIA

44. Visual acuity screening in schools Performed in Standard 1 Referral to Ophthalmologist/Optometrist Refractive errors

45. Amblyopia ‘ Lazy eye’ Definition: Unilateral/ bilateral decrease of best corrected visual acuity Is potentially reversible during the critical period (before 7-9 years old)

46. Critical period: Why is visual development important? Sensory function continues to develop after birth Requires proper visual stimulation Normal vision – receptive cells, clear media and normal retina Normal alignment Normal brain development

47. How does amblyopia develop? Brain receives stimuli from both eyes Child’s maturing brain will select the better image and ignore the blurry image Vision not properly developed in the bad eye (AMBLYOPE)

48. Causes of amblyopia Ammetropia (bilateral high refractive error) Anisometropia (large/ asymmetrical refractive error difference between eyes) Strabismic (squint) Occlusional / form deprivation (media problem)

49. Treatment Can be treated or reversed if detected earlier (critical period) Treat underlying condition – cataract, squint Prescribe spectacles correction – refractive error Force to use the amblyopic eye Patching the good eye Putting atropine eye drops to blur image in the good eye

50. Visual pathway

51. As a result of the damage to the brain. Cerebral palsy Seizure disorder Hydrocephalus, Microcephaly Infants and children with cortical vision impairment Delayed in reaching developmental milestones Sensory motor & activities and social development. Intellectual disability Cortical visual impairments

52. The process of treatment and education that helps individuals who are visually disable attain maximum function, a sense of well being, a personally satisfying level of independence, optimum quality of life. Visual Rehabilitation

53. OPTICAL DEVICES NON OPTICAL DEVICES HOLISTIC APPROACH Clinicians – ophthalmologist, peadiatrician, optometrist Teachers, Education ministry Occupational therapist Counsellors : psychologist, psychiatrist, social worker Vocational Rehabilitation centers Visual Rehabilitation

54. OPTICAL DEVICES Reduced Visual Acuity Magnification for near Magnification for distance Central visual field defect Peripheral visual field defect Reduced contrast sensitivity Glare sensitivity Visual Rehabilitation

55. HAND HELD MAGNIFIERS MAGNIFICATION FOR NEAR STAND MAGNIFIERS SPECTACLE-MOUNTED MAGNIFIER CLOSE-CIRCUIT TELEVISION SYSTEM

56. TELESCOPE MAGNIFICATION FOR FAR

57. TREATMENT OF CENTRAL VISUAL FIELD LOSS MODIFIED TEXT Training for eccentric viewing- avoid fixating using the fovea Using large print material Using prism relocation

58. TREATMENT OF PERIPHERAL VISUAL FIELD LOSS MIRROR PRISMS Acts like a side mirror of a car Able to view objects at the non-seeing area of the eye when glancing into the mirror or prism

59. TREATMENT FOR REDUCED CONTRAST SENSITIVITY AND GLARE TINTED LENSES COLOUR CONTRAST TYPOSCOPE : reduce reflected glare from printed pages

60. NON-OPTICAL METHODS Move CLOSER : use an angled reading desk Use COLOUR to show objects more clearly Use CONTRAST : eat white rice off a coloured plate Pay attention to LIGHTING : sit near a window in class Make objects LARGER: write with larger letters Use a LINE-GUIDE such as a ruler when reading and writing. Visual Rehabilitation

61. Prognosis for success depends on: Ocular condition Vision loss – nature & extent Patient – physical & mental abilities, attitude, expectation, motivation Clinician – attitude & motivation Visual rehabilitation

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