case study child low vision

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Vision-related tasks in children with visual impairment: a multi-method study

Fatemeh ghasemi fard.

1 Department of Occupational Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Hooshang Mirzaie

2 Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Seyed Ali Hosseini

Abbas riazi.

3 Department of Optometry, School of Rehabilitation Sciences, Iran university of Medical Sciences, Tehran, Iran

Abbas Ebadi

4 Behavioral Sciences Research Center, Life style institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran

Associated Data

The original contributions presented in the study are included in the article/ Supplementary material , further inquiries can be directed to the corresponding author.

Functional Vision (FV) is vital for the successful growth of children with visual impairment. However, tasks related to measuring FV have not been thoroughly studied for this population. To address this gap, this study seeks to establish a comprehensive set of vision-related tasks that consider both the difficulty levels of activities and the ages of children with visual impairment.

This study utilized a sequential multi-method design, including a scoping review, a qualitative content analysis, and a focus group. Firstly, a scoping review was conducted to identify vision-related tasks based on the literature. Then, to contextualize the vision-related tasks, a qualitative content analysis was carried out. Subsequently, a focus group was conducted to categorize the identified tasks based on their difficulty levels and the children’s level of dependency. We utilized the directed content analysis method to analyze the data, using the occupational domain of the Occupational Therapy Practice Framework 4th edition (OTPF-4) as the primary framework.

During the review phase, which included 22 studies, and the interview phase, which involved 16 participants, a total of 95 and 85 vision-related tasks were identified, respectively. These tasks were then categorized into 17 activities and five occupations, which included activities of daily living (ADL), instrumental activities of daily living (IADL), education, play, and participation in social activities. Among these occupations, ADL was the easiest, while participation in social activities was the most challenging. Finally, the tasks were arranged based on their difficulty level for children with visual impairment.

A comprehensive list of vision-related tasks has been developed based on the difficulty level of the tasks and the degree of dependency of children with visual impairment. This list can be used to develop standardized instruments for assessing FV in children with visual impairment.

• The study identified vision-related tasks and categorized them under the components of the occupational domain of the Occupational Therapy Practice Framework 4th edition (OTPF-4).
• The identified tasks were then sorted based on their difficulty levels.
• The study categorized children with visual impairment into four age groups (0–3, 3.1–7, 7.1–10, and 10.1–16) based on their developmental stages to determine their level of dependency on vision-related tasks.

1. Introduction

Vision is a critical sensory function that is essential for a child’s overall neurodevelopment. It plays a crucial role in neuromotor, cognitive, and emotional development ( Purpura and Tinelli, 2020 ). Any disruption in visual function, which pertains to the physiological aspects of the visual system, as well as functional vision (FV), which refers to the ability to use vision in practical tasks, has the potential to hinder the growth and development of children ( Colenbrander, 2010 ; Silva et al., 2022 ). As visual function and FV require different assessment and management approaches ( Purpura and Tinelli, 2020 ), this study specifically focused on the FV by exploring vision-related tasks.

Visual impairment is defined as a best-corrected visual acuity below 20/70 or a visual field of 10 degrees or less in the best eye ( Prajna et al., 2015 ). The international classification of diseases 11th revision (ICD-11) ( Pezzella, 2022 ) classifies the severity of visual impairment based on visual acuity as follows: no visual impairment (visual acuity ≤20/40), mild visual impairment (20/70 ≤ visual acuity < 20/40), moderate visual impairment (20/200 ≤ visual acuity < 20/70), severe visual impairment (20/400 ≤ visual acuity < 20/200), blindness (visual acuity of 20/1200 or counts fingers), blindness (light perception), and blindness (no light perception).

Globally, it is estimated that by 2050, 360 million and 474 million people will have mild and moderate-to-severe visual impairments, respectively ( Bourne et al., 2020 ). In Iran, the prevalence of visual impairment was reported to be 5.57% in 2020 ( Afarid et al., 2020 ).

Occupational therapy, occupation, activities, and tasks are all related concepts in occupational therapy, but they have different meanings and implications for the therapeutic process. Occupational therapy is a health profession that uses occupation as a therapeutic tool to promote health and well-being. Occupation encompasses all the activities people engage in to occupy themselves, including self-care, leisure pursuits, and meaningful contributions to their communities. Occupational therapists may use activities and tasks as therapeutic interventions to help clients develop skills, improve their physical and cognitive abilities, and promote overall well-being. Activities are purposeful actions related to a person’s interests and goals, such as cooking and exercising, while tasks are smaller units of action, such as pouring a glass of water or writing a letter ( Thomas, 2012 ).

Occupational and rehabilitation professionals must identify limitations in FV and implement effective interventions to maximize it ( Zemina et al., 2018 ). Although previous studies have emphasized examining FV in children with visual impairment to provide appropriate rehabilitation services ( Colenbrander, 2010 ; Riazi et al., 2011 ; Silva et al., 2022 ), a comprehensive list of vision-related tasks for children with visual impairment has not been reported. Instruments have been developed to measure vision-related tasks in adults ( Szlyk et al., 1990 ; Turco et al., 1994 ; Katsumi et al., 1995 ; Ross et al., 1999 ; van Dijk et al., 1999 ; Haymes et al., 2001 ), and in children with visual impairment ( Gothwal et al., 2003 ; Khadka et al., 2010 ; Gothwal et al., 2012 ; Tadić et al., 2013 ; Pitakova and Zlatarova, 2018 ; Grumi et al., 2022 ; Wadhwani et al., 2022 ). However, the latter are self-reported and not age-specific. Our research indicates that Robertson et al. (2020) developed the only age-specific assessment tool for children between the ages of 8–18 with visual impairment. However, children under the age of 8 were excluded due to their inability to self-report ( Robertson et al., 2020 ). Also, there are some lists of vision-related tasks available for adults, such as those in the International Classification of Functioning, Disability, and Health (ICF) ( WHO, 2012 ) and Massof’s activity inventory ( Massof et al., 2007 ). Massof et al. (2005b) developed a comprehensive functional assessment tool for adults, consisting of 337 vision-related tasks categorized into 41 activities and 3 occupations, namely: daily living, social interactions, and recreation. Each occupation represents a different set of activities, including daily living activities such as using public restrooms, maintaining personal hygiene, dressing, managing personal healthcare, eating, and other similar activities. Social interactions cover entertaining guests, preparing food for visitors, dining out, among others, and recreation encompasses leisure activities like sewing, needlework, knitting, crocheting, woodworking, metalwork, painting, drawing, and more. Subsequently, each activity represents a group of tasks ( Massof, 2005b ). In contrast, the ICF for Children and Youth (ICF-CY) is a classification tool specifically designed for children and youth aged from birth to 18 years. It provides a description of the functioning of children and youth from various perspectives, including body functions, anatomical characteristics, activities, and participation ( WHO, 2007 ).

As previously indicated there is a dearth of comprehensive vision-related tasks and standardized tools available to assess FV in children with visual impairment. This can harm the successful management and rehabilitation of FV. Furthermore, the difficulty levels of vision-related tasks have not been determined based on children’s abilities, which can result in inaccurate outcomes in rehabilitation services ( Gothwal et al., 2003 ; Colenbrander, 2010 ). Additionally, children’s age has not been considered, despite their varying levels of dependency on such tasks according to their developmental stage ( Eccles, 1999 ; Keenan et al., 2016 ). Moreover, the utilization of the Occupational Therapy Practice Framework 4th edition (OTPF-4) can augment the credibility of the study ( AOTA, 2020 ). Therefore, this study aimed to address the aforementioned gaps by exploring age-specified vision-related tasks in children with peripheral visual impairment based on task difficulty level, using the occupational domain of the OTPF-4. We specifically focused on the FV of children with peripheral visual impairment, as the type of injury and subsequent effects on FV may differ compared to cerebral visual impairment ( Ortibus et al., 2019 ). To achieve the study’s occupations, a multi-method design was employed to gain a comprehensive and in-depth understanding of the phenomena under investigation ( Chaboyer et al., 2004 ).

2. Materials and methods

2.1. study design.

The study utilized a sequential multi-method approach, which began with a scoping review, followed by a qualitative content analysis, and concluded with a focus group ( Figure 1 ). Sequential multi-method is a research design that involves the use of multiple methods to investigate a single research question or hypothesis. This approach uses different research methods, such as literature review, interviews, and focus groups, in a specific sequence to complement each other’s results and build a more comprehensive understanding of the phenomenon under study ( Subedi, 2016 ). This approach has been widely employed in prior studies to integrate scoping review data with qualitative data ( Jolivet et al., 2021 ; Qiu et al., 2021 ; Claessens et al., 2022 ; Salifu et al., 2022 ).

The three phases of the study.

Qualitative content analysis is a research method used to analyze large amounts of raw verbal data collected through interviews and condense them into categories or themes based on valid inference and interpretation via inductive or deductive reasoning ( Mayring, 2004 ). The study, which is a subset of a larger study entitled “Developing an FV tool for children with visual impairment,” was conducted from September 2021 to September 2022 in Iran.

We used the occupational domain of OTPF-4 as the study framework which includes several occupations such as activities of daily living (ADL), instrumental activities of daily living (IADL), health management, rest and sleep, work, education, play, leisure, and social participation ( AOTA, 2020 ). Moreover, in line with the works of Thomas (2012) and the American Occupational Therapy Association (AOTA) ( Thomas, 2012 ; AOTA, 2020 ), the present study categorized vision-related tasks into three levels: tasks as the lowest level, activities as a group of tasks, and occupations as broad categories of activities such as daily living, social, recreational, and educational activities.

2.2. Scoping review

2.2.1. participants and sampling.

In the review phase, all relevant articles published in international journals, as well as grey literature, were included. The inclusion of grey literature ensures that researchers do not overlook relevant information and can obtain a more complete picture of the current state of knowledge on a topic. Table 1 outlines the eligibility criteria for each part of the study participants.

The inclusion and exclusion criteria for each part of the study participants.

2.2.2. Data collection

In the review phase, we conducted thorough searches on electronic databases including PubMed, Scopus, Web of Science, and Cochrane, as well as on internal databases such as Magiran, SID, Irandoc, and Elmnet from the time of inception until April 2022. Our search strategy involved the use of both Medical Subject Heading (MeSH) and non-MeSH terms. Additionally, we reviewed relevant search results on Google and Google Scholar. To access research materials that are not traditionally published in academic journals or books, such as reports, theses, dissertations, conference proceedings, and government documents, we also searched grey literature. Furthermore, we screened the reference lists of the included articles to identify more studies and conducted hand-searching for a few key journals. The keywords and search strategies are provided in Supplementary file S1 . Two investigators (F.G. and H.M.) screened the titles and abstracts of related studies, followed by reading the full texts. Any uncertainties were resolved through discussion. We utilized a data form to gather relevant information, including author name, year of study, country of origin, study design, age of participants (in years), visual status, and type of instrument used. Quality assessment was not performed, since it was not necessary for scoping review ( Levac et al., 2010 ; Peters et al., 2015 ).

2.2.3. Data analysis

The data were analyzed using Elo and Kyngäs’ method ( Elo and Kyngas, 2008 ), by two authors (F.G. and H.M.), considering the occupational domain of the OTPF-4 as the primary framework. To report the results, we organized vision-related tasks identified from the literature into subdomains of the occupational domain of the OTPF-4 and constructed a primary data matrix.

2.2.4. Trustworthiness

The scoping review was guided by the PRISMA extension for scoping reviews (PRISMA-ScR) ( Tricco et al., 2018 ) ( Supplementary file S3 ).

2.3. Qualitative content analysis

2.3.1. participants and sampling.

In the qualitative content analysis phase, we conducted in-depth individual interviews with a purposive sample of participants that included teachers and parents of children with visual impairment, as well as rehabilitation experts. The participants were recruited from schools of children with visual impairment and rehabilitation centers in Tehran, Iran. To identify potential participants, we contacted these centers via email or phone, provided them with detailed information about the study, and asked for their assistance in identifying eligible participants. We used purposive sampling to ensure that the participants had diverse backgrounds and experiences and could provide rich and varied perspectives on the topic under investigation.

2.3.2. Data collection

To collect rich and valid data, we utilized a combination of semi-structured, in-depth, face-to-face interviews, descriptive writing, and field notes. The interviews were conducted by two authors, F.G. (a doctoral student of occupational therapy) and H.M. (an associate professor of occupational therapy), both of whom possess over 10 years of research experience. The interviews were conducted between May and July 2022. The researchers explained the study’s purpose and obtained permission to record the interviews, as well as the possibility of a re-referral to confirm the findings. We used a semi-structured interview guide ( Supplementary file S3 ), which was followed by more exploratory questions to obtain deep and rich data. Individual interviews lasted 40–60 min and were conducted in a quiet and private location, either in-person or remotely, depending on the participants’ preferences and availability. The interviews were audio-recorded with the participants’ consent. We continued conducting individual interviews until we reached data saturation, which occurs when information is repeated, and no further new information is obtained ( Fusch and Ness, 2015 ). The researchers also took descriptive notes during the interviews and wrote field notes immediately after the interviews to capture their initial thoughts and impressions. The notes were used to supplement the data collected from the interviews and to aid in the analysis process.

2.3.3. Data analysis

During the interview phase, audio recordings were transcribed verbatim and then carefully reviewed multiple times to identify meaning units and codes. The codes were then sorted and added to a primary matrix based on their similarities and differences. Any codes that did not align with the subdomains of the occupational domain of OTPF-4 were considered for new categories ( Lewis, 2018 ). MAXQDA software version 10 was used for data analysis. The analysis process was iterative, with the researchers constantly refining and revising the codes and categories to ensure accuracy and rigor. The analysis was performed by two researchers independently and any discrepancies were discussed and resolved through consensus.

2.3.4. Trustworthiness

The qualitative aspect of the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines ( Tong et al., 2007 ), which are outlined in Supplementary file S4 . In addition, Lincoln and Guba’s four criteria, including credibility, dependability, confirmability, and transferability, were used to establish trustworthiness. To maintain credibility, we utilized triangulation of data sources, peer review, and engaged with the study for over 8 months. Co-author checks and member checks were also conducted to establish dependability. Furthermore, all study steps were thoroughly documented to ensure confirmability, allowing others to track all research-related activities. To ensure transferability, we clearly described the data collection, data analysis, and sample settings. This allowed readers to understand the context and setting of the study and assess whether the findings could be applied to other settings or populations.

2.4. Focus group discussion

2.4.1. participants and sampling.

The focus group discussion was conducted with a select group of experts in occupational therapy, consisting of professors with specialized knowledge in the field, as well as a visual expert with relevant expertise.

2.4.2. Data collection and analysis

The focus group consisted of two consecutive sessions, each lasting one and a half hours. In these sessions, a panel of experts evaluated the expected level of dependence of children with visual impairment in performing specific tasks across 17 activities, grouped into four age categories (0–3, 3.1–7, 7.1–10, and 10.1–16). The experts were also asked to rank the difficulty of these tasks, taking into account factors such as the severity of the visual impairment, the use of non-visual senses, environmental conditions, and the distance between the children and the objects of interest. Participants were allowed to consult with one another as needed, and all findings were carefully recorded.

2.4.3. Data analysis

The focus group recordings were transcribed verbatim. The expected level of dependence of children with visual impairment was then assessed and ranked on a four-point scale, including high dependence, low dependence, independent, and high independence, for each of the previously mentioned age groups. In addition, the tasks were ranked in terms of difficulty.

3.1. Characteristics of samples

3.1.1. phase 1: characteristics of primary studies.

In the scoping review, 422 articles were initially identified as potentially relevant. After removing duplicate and unavailable records, the titles and abstracts of 53 articles were reviewed. Subsequently, 40 studies underwent full-text assessment, and ultimately, 23 articles met the inclusion criteria. The study selection process is illustrated in Figure 2 .

Study selection process.

All studies were published between 2003 and 2022 and originated from various countries, including the United Kingdom ( Khadka et al., 2010 ; Tadić et al., 2013 , 2017 ; Dahlmann-Noor et al., 2017 ; Tailor et al., 2017 ; Dahlmann-Noor et al., 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 , 2021 , 2022 ), the United States ( Castañeda et al., 2016 ; Kaiser and Herzberg, 2017 ; Hatt et al., 2019 , 2020 ; Leske et al., 2019 , 2021 ), India ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ), Turkey ( Çakmak et al., 2016 ; Tunay et al., 2016 ), and Bulgaria ( Pitakova and Zlatarova, 2018 ). Supplementary file S5 provides detailed characteristics of the studies.

3.1.2. Characteristics of participants in the section of qualitative content analysis

Sixteen participants took part in the interview phase, comprising nine teachers from low-vision schools, four occupational therapists, and three parents. On average, the interviews lasted approximately 45 min. The majority of participants (75%) were female and the average age range was 40–45 years old. Table 2 presents detailed information about the participants.

Participants’ characteristics.

3.1.3. Characteristics of experts in the focus group discussion

The focus group consisted of five occupational and visual therapists, all of whom held qualifications as either full or associate professors. Out of the five expert participants, two were female and the remaining three were male.

3.2. Vision-related tasks yielded from scoping review and interviews

The scoping review and qualitative content analysis initially identified 496 vision-related tasks. After integrating similar ones, a total of 180 tasks remained, categorized under the following five occupations: ADL, IADL, education, play, and participation in social activities ( Table 3 ). No codes emerged for other components of the occupational domain of the OPTF-4, including health management, rest and sleep, leisure, and work. A narrative description of each occupation and activity is outlined as follows:

Dependency level of children with visual impairment based on their age groups in each row of occupations, activities, and tasks.

† HD, high dependence; LD, low dependence; I, independent; HI, high independence; **, not achieved.

ADL refer to self-care tasks that children with visual impairment should perform to take care of themselves. These activities were classified into four activities: dressing, feeding, personal hygiene and grooming, and toilet hygiene. The description of each goal is as follows:

3.2.1.1. Dressing

Dressing and undressing multiple times per day is an important ADL for children with visual impairment. Studies have reported that lacing shoes is one dressing task ( Gothwal et al., 2003 ; Nirmalan et al., 2004 ; Gothwal et al., 2012 ; Ganesh et al., 2013 ; Pitakova and Zlatarova, 2018 ).

According to participants’ data, children with visual impairment often need to locate clothes and accessories in closets and drawers, put them on or remove them, and fasten and adjust their clothing and shoes. However, dressing independently can be extremely challenging for children with severe visual impairments. Some participants explained:

“Some routine dressing activities are wearing clothes or taking them off; tying a scarf…” – P 1, teacher.

“Finding clothes that are suitable and accessible can be very challenging for near-to-blind cases. Many others struggle with buttons, zippers, and snaps.” – P 12, occupational therapist.

“Putting on clothes the right way, fixing mistakes, and making adjustments independently is challenging for most children with visual impairment.” – P 16, parent.

3.2.1.2. Feeding

A qualitative study revealed that a 15-month-old infant with visual impairment independently fed herself small pieces of avocado while seated in a high chair. She picked up her fork and used her hand to place a tiny piece of food on the tines, and then brought the fork to her mouth to take a bit ( Smyth et al., 2014 ).

According to participants’ experiences, children with visual impairment can name food on a plate, pour water into a glass without spilling, and eat without dropping food, although the quality of their task may vary. Regarding feeding a participant described how children with visual impairment eat independently:

“To feed themselves, mild to moderate children with visual impairment typically sit at the dining table and use a spoon and fork to eat food or fill a glass to drink water.” – P 3, teacher.

Moreover, a parent explained:

“My son is becoming increasingly independent with feeding himself. He can recognize the most common foods by touch and smell. However, identifying utensils and holding them properly is still challenging for him.” – P 16, parent.

3.2.1.3. Personal hygiene and grooming

Several studies reported vision-related tasks related to personal hygiene and grooming, including: combing or trimming hair; shaving and removing body hair using a laser or tweezers (especially for older children ages 15–18); applying and removing cosmetics by girls ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ); applying paste to a toothbrush and brushing teeth; and identifying dirty stains on clothes ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Pitakova and Zlatarova, 2018 ).

A few participants additionally mentioned tasks like cleaning glasses, arranging scarves, flossing teeth, and trimming nails. For example:

A teacher explained:

“some severely visually impaired students find basic tasks like brushing their hair thoroughly to be challenging, while others can do them easily.” - P8, teacher.

A mother described:

“My son cleans his glasses as necessary.” –P 16, parent.

Another teacher said:

“Here, we see that low vision girls check their scarves to make sure they are arranged properly.” –P 7, teacher.

3.2.1.4. Toilet hygiene

Only interview data revealed various vision-related tasks regarding toileting, such as: finding the bathroom, locating the toilet seat, preparing, sitting, and using the toilet, rinsing the toilet or water closet, flushing, finding and using the sink, locating soap, washing hands, finding toilet paper or paper towels, and drying hands with a towel or tissue. For instance, two participants said:

“ My daughter needs assistance finding the toilet and sink in unfamiliar bathrooms. At home, she knows her way around but still struggles with tasks like aiming into the toilet and washing her hands properly. ” – p 16, parent.

“ Toileting consists of multiple sub-tasks that can be performed independently or dependently by these kids” – P. 14, occupational therapists.

3.2.2. IADL

Participants and literature indicate that children with visual impairment perform more complex activities beyond ADL. This domain consists of three activities: “meal preparation,” “using electronic devices,” and “shopping,” which are described below:

3.2.2.1. Meal preparation

Depending on their capabilities, children with visual impairment may prepare and serve meals, identify foods’ nutritional value, clean food, and wash dishes ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

According to participants’ experiences, children with visual impairment can peel fruits and vegetables like potatoes. They are also able to locate food items and utensils, pour or mix food materials without spilling, read package labels, and judge the preparedness of foods. According to the participants, children’s ability to complete these tasks depends on their age, with older children typically performing them more easily than younger ones. Two occupational therapists stated:

“My 7-year-old case struggles with meal preparation tasks, while my other 10-year-old case can make sandwiches, slice apples, and open most food packages independently.” – P 13, occupational therapist.

“Even simple meal preparation tasks like peeling a cucumber, cutting an orange in half, or slicing a potato into sticks are within the capabilities of many children with visual impairment. With the proper adaptive tools and techniques, and some guidance initially, they can accomplish independent meal preparation activities that are appropriate for their age and development.” – P 5, occupational therapist.

3.2.2.2. Using electronic devices

Children with visual impairment can participate in activities involving technology, such as turning a television on and off or changing channels ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ). They can also use home computers for online learning ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Moreover, many participants mentioned that children with visual impairment use smartphones or tablets, especially during COVID-19 when virtual learning occurred via these devices. Other tasks were also reported, such as dialing phone numbers, researching phone numbers, watching television, listening to music while wearing headphones, and understanding stories in movies. However, additional support and accommodations from teachers and parents may still be necessary, depending on the severity of a child’s visual impairment. For instance, two participants stated:

“Most visually impaired students like to use their iPad to listen to music and play games. As they have gotten older, they learned how to navigate the device more independently.” – P 9, teacher.

“With tools like screen readers, text enlargement software, and audio descriptions, visually impaired students can navigate online learning interfaces, read assigned readings, watch instructional videos, and complete and submit assignments independently.” – P 15, teacher.

3.2.2.3. Shopping

According to the literature, children with visual impairment can go grocery shopping. At stores, they can read signs and posters; at restaurants, read menus and price tags, at pharmacies, select a payment method and complete transactions ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Furthermore, participants mentioned additional tasks like locating products in the store, navigating an outdoor store independently, and walking around a store. One mother said:

“My 14-year-old son needs assistance finding specific items in big stores, but in our neighbourhood market she knows where everything is and can get what we need on her own.” – P 16, mother.

3.2.3. Education

The education occupation was made of various activities including reading, face and object recognition, participating in class, mobility, writing and drawing, and reading. These activities are explored in detail below:

3.2.3.1. Face/object recognition

Several studies found that children with visual impairment can distinguish their peers and teachers by face. Despite their visual impairment, these children can also find their belongings within the classroom. However, their ability to recognize faces and find objects greatly depends on their visual acuity ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Moreover, teachers agreed that visually impaired students exhibited varying levels of accuracy in identifying objects in the classroom, such as balls or colors. For instance, a participant said:

“‘Students with milder low vision can identify simple shapes and objects, while those with more severe vision loss often require physical or verbal prompts.” – P 7, teacher.

3.2.3.2. Participation in classes

According to a literature review, children with visual impairment attend a variety of classes including science, geography, math, physical activity, English/Dutch, and gymnastics ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Colenbrander, 2010 ; Ganesh et al., 2013 ; Tadić et al., 2017 ; Tailor et al., 2017 ; Pitakova and Zlatarova, 2018 ; Hatt et al., 2019 ).

The interview data did not suggest any new tasks that children with visual impairment perform in the classroom setting.

3.2.3.3. Mobility

Several studies found that children with visual impairment can walk around their school independently or with assistance ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ) as well as navigate hallways without colliding with people or objects ( Gothwal et al., 2003 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ). Besides, from the perspective of a participant, children with visual impairment can walk outside of school with or without assistance. A teacher said:

“Under the supervision and guidance of teachers, our visually impaired students navigate the building while learning how to safely avoid obstacles.” – P 3, teacher.

3.2.3.4. Writing, drawing, and coloring

Current evidence has demonstrated that children with visual impairment are capable of writing on blackboards, taking notes from their peers’ notebooks, drawing, coloring, and sorting information ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Colenbrander, 2010 ; Ganesh et al., 2013 ; Tadić et al., 2017 ; Tailor et al., 2017 ; Pitakova and Zlatarova, 2018 ; Hatt et al., 2019 ). They also use computers when doing assignments at school ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Furthermore, according to some parents and teachers, some children with visual impairment can type their homework themselves using laptops or computers. One teacher said:

“My visually impaired students need enlarged text and speech output on their laptops, tablets, and computers. Once they have the right adaptive technology, they can complete written assignments just like their sighted peers.” –P 7, teacher.

3.2.3.5. Reading

Reading tasks for children with visual impairment included reading textbooks, worksheets, exams, handwriting, and information on the board in the classroom ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

However, participants reported that many children with visual impairment struggled with reading tasks and offered strategies to make them more achievable, such as using enlarged print, high-quality photocopied materials, braille font, magnified electronic text with reduced glare, or audio books. One participant stated:

“Reading from regular print sources can be frustrating for extreme low-vision cases; while Adjusting text size, font, and color contrast can make a huge difference for my visually impaired students when they are doing independent reading.” – P 9, teacher.

3.2.4. Play

Play was another occupation, with two activities: indoor and outdoor play activities.

3.2.4.1. Indoor activities

Children engage in indoor play activities at home for entertainment. According to the literature, some of the play activities that children with visual impairment participate in include watching television, playing video and computer games, and drawing or painting ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ), and listening to music ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Further, interviews identified additional activities like solving puzzles, playing with talking dolls, and braille sudoku puzzle game s. For example, a participant stated:

“My son loves playing puzzle games, ball games, and hopscotch and listening to audio storybooks at home.” – p 14, A father.

3.2.4.2. Outdoor activities

Studies have identified various items that include mutual play, team games such as football, hide-and-seek, and playing tennis or cricket ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

One participant reported that outdoor activities included games such as tennis, hopscotch, playing with balls or marbles, and shadow games. Two other participants also mentioned.

“Some children with visual impairment in my program enjoy outdoor games like hopscotch, playing with balls, marbles, or shadows.” – P 11, occupational therapist.

“Here in our school, some low-vision kids even enjoy playing tennis” – P 7, teacher.

3.2.5. Participation in social activities

Social participation involves interactions with family, friends, peers, and community members. This occupation was made up of three activities: virtual activities, in-person activities, and community mobility.

3.2.5.1. Virtual activities

Studies found that children with visual impairment primarily participate in virtual social activities through smartphones and apps like Facebook and Twitter ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Interview results confirmed that children with visual impairment communicate primarily in virtual forms. A parent stated:

“My son uses social media applications and text messaging on his smartphone to stay in contact with his friends regularly. Since he has low vision, the enlarged text options, light or dark color themes, and voiceover accessibility features on his apps allow him to communicate independently through social media “ – P 16, parent.

3.2.5.2. In-person activities

According to primary research, children with visual impairment can participate in academic classes and engage in general conversations with classmates, teachers, and peers both inside and outside of the classroom. However, the difficulty in recognizing facial expressions or identifying individuals, particularly among those with severe visual impairment, can have a significant impact on their social interactions and relationships ( Tadić et al., 2013 , 2017 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

Interviews with participants did not reveal additional codes for this domain.

3.2.5.3. Community mobility

Children with visual impairment frequently utilize public transportation, such as trains and busses, to visit places like the cinema or theater, often with the assistance of parents or caregivers. They may also navigate through unfamiliar areas, using elevators, crossing the street, and walking on uneven roads with assistance. Furthermore, when accompanied by family members, children with visual impairment can navigate around obstacles and avoid other people, ascend and descend stairs, and detect moving objects like cars ( Gothwal et al., 2003 , 2012 ; Nirmalan et al., 2004 ; Ganesh et al., 2013 ; Tadić et al., 2013 , 2017 ; Çakmak et al., 2016 ; Dahlmann-Noor et al., 2017 , 2018 ; Pitakova and Zlatarova, 2018 ; Elsman et al., 2019b ; Robertson et al., 2020 ).

No additional tasks were identified during the interview phase.

3.3. Classifying vision-related tasks based on children’s age

Experts suggest that children with visual impairment may perform vision-related tasks at varying levels of dependency depending on their age. In the present study, the children’s ages were classified into four developmental stages: 0–3, 3.1–7, 7.1–10, and 10.1–16, based on previous research ( Eccles, 1999 ; Keenan et al., 2016 ) and the opinions of the focus group. The ability of children to perform vision-related tasks was categorized as high dependence (HD), low dependence (LD), independence (I), or high independence (HI), according to these age groups.

3.4. Vision-related tasks based on the difficulty levels

The vision-related tasks identified across the 17 activities were ranked according to their level of difficulty. Factors such as the child’s environment, the distance from an object, the involvement of non-visual senses, and the degree of visual impairment were taken into account during the sorting process. Experts suggested that children with visual impairment may find indoor vision-related tasks easier than outdoor ones, as they are more familiar with indoor environments. As a result, ADL tasks were considered the easiest, while social participation tasks were viewed as the most challenging, as shown in Table 4 .

Arrangement of vision-related tasks based on their difficulty levels in 17 activities.

4. Discussion

Visual impairment has been shown to have a negative impact on children’s learning and daily activities, according to multiple studies. For instance, one study revealed that teachers can gain insights into students’ reading difficulties, lack of motivation, low self-esteem, and difficulty concentrating by understanding the visual attributes and their impact on learning ( Wilhelmsen and Felder, 2022 ). Other studies have indicated that children with visual impairment may face challenges in developing spatial abilities, including auditory and proprioceptive spatial localization, haptic orientation discrimination, and reach on sound ( Cappagli et al., 2017 , 2019 ). They may also experience delays in various motor abilities, as well as reduced walking speed due to a longer stance phase ( Hallemans et al., 2011 ). Visual deprivation from birth to adulthood can cause functional abnormalities in the cortical areas responsible for cross-modal information processing. Specifically, visual impairment can affect multisensory processes and impede the exchange of sensory data during the exploration and identification of the immediate environment ( Purpura et al., 2021 ).

However, an appropriate rehabilitation program can assist children with visual impairment to improve their growth and quality of life. For instance, a systematic review study revealed that sports camps, low vision device prescription and training can be effective in improving the functioning, participation, and quality of life of children with visual impairment ( Elsman et al., 2019a ). Another study found that perceptual development in individuals who are blind can be enhanced by utilizing auditory feedback that is naturally associated with bodily movements ( Hallemans et al., 2011 ).

Given the importance of proper vision-related tasks for overall development ( Prechtl et al., 2001 ; Ganesh et al., 2013 ), this study was conducted in three phases: a literature review, individual interviews, and a focus group. The occupational domain of the OPTF-4 was used as a framework. Vision-related tasks previously identified for children with visual impairment were extracted from the literature and organized into a primary data matrix based on subdomains. Context-specific tasks were then identified through qualitative content analysis and added to the matrix. Finally, the levels of dependence for different age groups of children with visual impairment in performing vision-related tasks were determined.

Our study identified five occupations, 17 activities, and 180 tasks. The occupations were comparable to those reported for adults by Massof et al. (2005a) , except for vocational activities, which are typically performed by adults ( Massof et al., 2005a ). However, notable differences were observed in the level of activities and tasks. For instance, activities such as attending social functions, managing personal finances, dining out, and woodworking are beyond children’s abilities ( Massof et al., 2007 ). Similarly, tasks such as hammering nails, writing checks, or taking pills are not expected of children. Examples of similar tasks between children and adults include finding clothes in the closet, finding soap or towels, or brushing their teeth ( Massof et al., 2005b ).

Based on our findings, children with visual impairment primarily performed ADL related to dressing, feeding, personal hygiene, grooming, and toilet hygiene. The ADL-related activities in our study were comparable to the subdomains in the OTPF, except for bathing, eating, functional mobility, and sexual activity ( AOTA, 2020 ). Evaluation of ADL-related activities in children with visual impairments and implementation of habilitation practices, if necessary, is crucial. The Melbourne Low-Vision ADL Index is a test that can be used to evaluate ADL-related tasks in the general low-vision population ( Haymes et al., 2001 ). Children with visual impairments may experience delays in acquiring the crucial skill of dressing due to the absence or reduction of visual input, as revealed in a study ( Hayton et al., 2019 ). Therefore, training in independent living skills is a component of habilitation practice that aims to promote autonomy in children and adolescents with visual impairments, preparing them for adulthood ( Hayton et al., 2019 ).

Our study identified three IADL-related activities for children with visual impairments: meal preparation, electronic device use, and shopping. The occupational domain of the OPTF-4 includes several subcategories related to caregiving, child rearing, driving, managing finances, maintaining safety, and expressing religious beliefs, which are typically associated with adults rather than children ( AOTA, 2020 ). It’s important to acknowledge that children with visual impairments may have different abilities in these areas compared to typically developing children. They may require additional support and training to perform IADL independently.

This study found that children with visual impairment primarily perform tasks related to education, such as face and object recognition, class participation, mobility, writing, drawing, and reading. However, they may encounter difficulties accessing and leaving school, reading, writing, and navigating obstacles such as ramps and slopes on sidewalks ( Taşkin et al., 2020 ). Students with visual impairment may access information through Braille, audio-tape, or enlarged print, and may require additional time to process information ( Lombardi, 2021 ). Effective management of visual limitations can improve educational success, and interventions such as assistive technology, modified learning environments, and specialized instruction or support can be beneficial ( Maćkowski et al., 2022 ). Teachers’ attitudes toward students with disabilities in inclusive schools can influence their academic success, and it is crucial to ensure that teachers are supportive and accommodating ( Temesgen, 2018 ). However, a survey conducted in Ethiopia revealed that teachers were reluctant to care for disabled children ( Dagnew, 2013 ). Vision screening by teachers in schools is also important to ensure that children with visual impairments receive the necessary support to achieve their academic potential ( Wilhelmsen and Felder, 2022 ).

Additionally, our study found that children with visual impairment enjoy playing both indoors and outdoors. Play is crucial for developing social-emotional, cognitive, and physical skills, and parents and peers can play a significant role in promoting appropriate play ( Sacks et al., 1992 ). Children with visual impairment spend a higher proportion of their playtime alone compared to their typically developing peers ( Schneekloth, 1989 ). They also tend to interact more with adults and have limited experiences with complex or social games that involve rules or creativity ( Rettig, 1994 ; Tzvetkova-Arsova and Zappaterra, 2017 ). Therefore, it is important to support and encourage developmentally appropriate play for children with visual impairment.

Participation in social activities among children with visual impairment involved virtual and in-person activities, as well as community mobility. Our findings showed that community participation for these children mostly relied on mobile devices and social media. Digital technologies, along with entertainment features, can help meet some of their social needs, such as connecting with friends and classmates virtually ( Pacheco et al., 2018 ). Children with visual impairment tend to participate virtually in social activities and have friends from school or relatives, as interacting with people outside their virtual world may pose systemic barriers such as discrimination or bullying ( Woodgate et al., 2020 ). A recent study developed the Visual Impairment Developmental Autonomy (VIDA) scale to evaluate children’s autonomy in areas such as mobility, communication, daily living skills, socialization, and learning, using patient and parent-reported outcome measures ( Grumi et al., 2022 ). However, unlike our study, this study focused on children with peripheral visual impairment who were blind or severely visually impaired.

Our study found that children with visual impairment perform indoor activities, such as ADL, more easily than outdoor activities, likely due to the controlled and familiar indoor environment. Similarly, other studies have shown that the environment plays a significant role in the vision-related tasks of children with visual impairment, particularly when tasks involve senses other than vision, such as touch ( Leffert and Jackson, 1998 ; Gur, 2014 ).

Our study developed a dependence continuum for vision-related tasks based on the age spectrum of children with visual impairment. While previous studies did not determine how to divide these activities, Alexandrea et al. measured vision-related tasks overall for children aged 8–18 ( Robertson et al., 2020 ). In our study, experts in focus groups agreed that there is no rigid boundary based on children’s ages, and the division is based on developmental stage and the complexity of vision-related tasks. Younger children may require more assistance to complete basic vision-related tasks independently, while older children may perform more complex tasks with reduced dependence. However, the relationship between age, developmental stage, and independence in performing vision-related tasks is complex and individualized for each child based on their visual impairment, comorbidities, and environment. Future research exploring this dependence continuum for children with visual impairment across developmental periods could provide valuable insights to optimize interventions that promote independence and quality of life.

This study presents, for the first time, a ranking system for vision-related tasks based on the task’s difficulty and the age group of children with visual impairment. Children with visual impairment experience more difficulty performing tasks that rely on vision compared to other senses, and they must learn to compensate for their visual deficits by using other skills such as hearing and touch. Reading is an example of a task that relies solely on vision and is particularly challenging for children with visual impairment ( Gothwal et al., 2003 ). Factors such as the severity of the visual impairment, the utilization of non-visual senses, environmental factors, distance to objects, and self-esteem can affect children’s ability to perform vision-related tasks. Effective management of these factors can optimize the visual ability of children with visual impairment. Early intervention and personalized support that address each child’s unique abilities and needs may enhance their proficiency in performing vision-related tasks and lead to improved outcomes. Further research is necessary to validate this ranking system and identify the most effective targets for intervention to maximize independence in children with visual impairment.

4.1. Limitation

Our study exclusively focused on vision-related tasks in children with visual impairment, excluding those with total blindness or light perception vision. Additionally, this study only investigated vision-related tasks in children and no other age groups. Our sample may not have been representative of the population studied, and caution should be implemented when applying our findings to other contexts with different social, economic, and geographic characteristics due to the context-based nature of our interview data. However, we provided a comprehensive list of vision-related tasks for children with visual impairment under the age of 16 based on difficulty levels and the degree of independence for children with visual impairment, using a multi-method design and applying the OPTF-4 rehabilitation model.

5. Conclusion

Our study aimed to contribute to rehabilitation knowledge by identifying vision-related tasks according to difficulty levels and age groups of children with visual impairment, based on literature and participants’ viewpoints. We identified five occupations: ADL, IADL, education, play, and social participation, with education requiring the most vision-related tasks. Our study arranged the tasks by difficulty and dependency levels according to age groups, which can guide future studies in selecting task samples based on type, difficulty, and age. Our findings can inform rehabilitation programs and interventions for children with visual impairment, providing insight into specific vision-related tasks, their difficulty levels, and dependency levels. Healthcare professionals can tailor interventions to support FV, and our findings can be useful in developing assessment tools to evaluate FV and its progress over time in children with visual impairment. Currently, we are developing performance-based instruments to measure FV in this population.

Data availability statement

Ethics statement.

This study was approved by the Ethics Committee of the University of Social and Welfare Rehabilitation (USWR) with the ID of IR.USWR.REC.1400.187, Tehran, Iran. Written and verbal consent was obtained from all participants to record their interviews. Participants in the study were assured that their information would be kept confidential and they could withdraw from the study at any time.

Author contributions

HM, FGF, SAH, AR, and AE: designing and performing tests, collecting the data, and co-writing the paper. HM and FGF: performing the analysis. HM, SAH, AR, and AE: supervising the research. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors gratefully acknowledge the help provided by the authorities of the University of Social, Welfare, and Rehabilitation Science (USWR) and the schools of children with visual impairment. We are also grateful to all the participants for their contributions.

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2023.1180669/full#supplementary-material

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• Published: 23 August 2021

Childhood visual impairment and blindness: 5-year data from a tertiary low vision center in Israel

• Claudia Yahalom   ORCID: orcid.org/0000-0001-7747-3568 1 ,
• Ron Braun 2 ,
• Rani Patal 1 ,
• Ibrahim Saadeh 1 ,
• Anat Blumenfeld 1 ,
• Michal Macarov 2 &
• Karen Hendler 1  

Eye volume  36 ,  pages 2052–2056 ( 2022 ) Cite this article

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• Paediatrics
• Population genetics

To assess the main causes leading to childhood visual impairment/blindness in a center for low vision in Israel and to analyze the literature on pediatric blinding diseases in developed countries.

Retrospective study based on observational case series. Data were obtained from medical records of visually impaired children, seen at a national referral low vision center. Children were divided into two groups: moderate visual impairment (6/18 to 6/60) and severe visual impairment (SVI)/blindness (<6/60). Inherited eye diseases (IED) were grouped together for analysis. Data from the Israeli blind registry from the same period of time were analyzed for comparison. A review of literature on childhood blindness in developed countries since 2000 was conducted.

A total of 1393 children aged 0–18 years were included in the study. Moderate visual impairment was seen in 1025 (73.6%) and SVI/blindness in 368 (26.4%) of the studied children. Among blind children, IED accounted for at least 51% of all diagnoses, including mainly albinism and retinal dystrophies. IED prevalence was equally high in both main ethnic groups (Jewish and Arab Muslims). Non-IED (22.6%) included mainly patients with cerebral visual impairment and retinopathy of prematurity.

Conclusions

The leading cause of childhood visual impairment and blindness in our patient cohort was IED. Analyses of the literature from the last two decades show that IED are a major cause for SVI/childhood blindness in other developed countries as well. Updated patterns of global childhood blindness may suggest a need for new approach for screening programs and modern tactics for prevention.

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Introduction

Childhood blindness causes a significant economic burden on the family and community because blind and visually impaired children have a lifetime of blindness ahead of them [ 1 ]. Globally, nutritional and infectious causes of blindness in children have declined substantially in developing countries, although these persist in some focal settings [ 2 ]. In the least developed countries, congenital and developmental cataract, retinal dystrophies, and congenital anomalies are gaining prominence as causes of blindness in children [ 3 ]. For children in developed countries, cerebral visual impairment (CVI) and optic nerve anomalies are classically described among the most common causes of blindness [ 4 ]. Inherited eye diseases (IED) are known to be common, accounting for 14% of all childhood blindness cases in African countries and up to 53% of cases in developed countries such as Europe and the United States [ 1 , 3 , 4 , 5 , 6 ], but there is not enough emphasis on how prevalent they have become during the last decade.

The World Health Organization (WHO) defines blindness as a best corrected visual acuity (BCVA) worse than 3/60. Visual impairment is divided into mild (6/12–6–18), moderate (worse than 6/18), and severe (SVI) worse than 6/60. Israel has a nationwide blindness registry since 1987 [ 7 ]. The definition of blindness used in Israel is slightly less rigid (3/60 and worse). Patients are identified by ophthalmologists and are registered if they have legal blindness. The standard registration form has a list of some of the most common diseases causing blindness but not all of them are enumerated, so an important number of pathologies are not mentioned on the list and, instead, are grouped as “others.” CVI was added to the list in 2009, but other common diseases such as Best disease, Stargardt disease, congenital stationary night blindness, achromatopsia, aniridia, and others are still not included separately [ 8 ].

Our study presents an analysis of the main causes for visual impairment and blindness in children, based on the database of a national referral center for low vision. Our center has a team composed of optometrists, ophthalmologists, social workers, and genetic counselors and offers a multidisciplinary approach for patients diagnosed with visual impairment or blindness. The team provides a comprehensive approach including diagnosis, visual rehabilitation and visual aids training, access to social services, complementary “special teachers” for children at school and governmental benefits, genetic tests, treatment, and prevention options. Children are referred to our center (unique of its kind in Israel) from ophthalmologists from all over the country in order to reach the comprehensive low-vision assistance given by our team. The cost of the visit to our center is covered by the Israeli ministry of welfare.

Materials and methods

We conducted a retrospective study with review of medical records of children aged 0–18 years, referred to the Michaelson Institute for low vision, at Hadassah-Hebrew University Medical Center in Jerusalem, from January 2015 to December 2019.

Approval for this study, according to the Helsinki tenets, was obtained from the Institutional Review Board at Hadassah-Hebrew University Medical Center, Jerusalem.

Inclusion criteria included children with visual impairment defined as BCVA of 6/18 or less (better eye), or children with unknown exact visual acuity who had a diagnosis known to severely affect vision or visual field (for example, early onset retinitis pigmentosa, achromatopsia). Details extracted from children’s medical files included: age, ethnic origin (when available), gender, ocular diagnosis, inheritance, BCVA, and associated diseases. Genetic counseling and testing were routinely offered to patients with suspected IED.

Data from the Israeli blind registry from the same period of time were analyzed for comparison, and a review of the literature on childhood blindness from the last decade was conducted.

Diseases causing visual impairment/blindness were divided into two main groups: IED and non-IED, in order to study the incidence of IED as a cause of visual impairment in children. Visual acuity was assessed for distance using a computerized monitor with linear Lea symbols for young children and numerical linear optotypes for older children. The data were divided into two main groups according to BCVA patients: “moderate visual impairment” with BCVA from 6/18–6/60 and “SVI/blindness” (BCVA < 6/60) or a visual field worse than 20° in cooperative children.

Statistical analysis was performed using the Mann–Whitney U test (nonparametric test), Pearson and chi-square tests.

A total of 1393 patients were included in the study; 58.1% male and 41.9% female. Mean age was 8.1 years (+/−5.1), median 8 (range 0.6–18). Mean visual acuity was logMAR 0.7 (+/−0.3), median 0.7 (range 0.2–2.3). Verbal visual acuity was possible to assess in 1312/1393 studied children (Lea symbols for distance); 81 (5.8%) children were not cooperative for quantitative visual acuity tests.

Associated non-ophthalmic disorders were present in 159 patients (11.4%). The most common systemic associations were cerebral palsy and Usher syndrome.

Ethnic origin showed a majority of Jewish patients (67.8%) followed by Arab Muslims (26.9%) and others, mainly Druze and Christian Arabs (5.2%). There was a statistically significant correlation between the most common eye diseases and ethnicity; among Jewish, albinism was the most common disease (48.4%) and among Arab Muslims, inherited retinal diseases (IRD) were the most common (50.6%) ( P : <0.001) (Table  1 ).

IED included: albinism, IRD [retinitis pigmentosa (RP), achromatopsia, cone-rod dystrophies, congenital stationary night blindness, Stargardt disease, Best disease], Aniridia and patients with confirmed inherited optic atrophy (OA), retinoblastoma, and congenital cataract. IED as a group was the cause of visual impairment/blindness (vision 6/18 or less) in 1078/1393 (77.4%) of children in our study (Table  2 ).

Non-IED included mainly CVI, retinopathy of prematurity (ROP), myopic maculopathy, congenital glaucoma and some of the patients with OA (secondary to nongenetic diseases as hydrocephalus), and congenital cataract with no genetic background identified. There were six children diagnosed with congenital glaucoma; none of the families had a familial history of glaucoma and they disagreed to perform genetic testing so they were left out of the IED group.

Moderate visual impairment was found in 1025 patients (73.6%); the most prevalent disorders in this group were albinism, IRD, and nystagmus (Table  2 ). IED accounted for at least 77.7% of all diagnoses in this group.

SVI/blindness was present in 368 (26.4%) of studied children. The most common ocular pathologies were IRD followed by albinism and CVI; at least 51% of ocular pathology in this group was due to IED (Table  2 ). According to the WHO definition of blindness, a lower number of children belonged to the <3/60 group (Table  1 ).

The ocular pathologies that accounted for the poorest mean visual acuity included CVI and IRD, mainly Leber’s congenital amaurosis.

Data collected from a review of the literature on childhood visual impairment and blindness in developed countries were summarized in Table  3 .

Data provided by the Israeli national registry for the blind were analyzed for comparison during the same time period (2015–2019); main causes leading to childhood blindness were OA and RP (both of them 16%), “other retinal pathology” (15%) and CVI (10%) (Table  4 ). Main causes for childhood blindness in children aged 0–5 years were retinal disease (IRD other than RP), OA, and CVI. In children aged 6–18 years, the main causes were RP, IRD, and OA.

Hereby, we present an analysis of the main causes for visual impairment and blindness in children, based on the database of a national referral center for low vision located in a tertiary hospital in Jerusalem. We aimed for this data (and not for the national registry of blind) to include children not only with blindness but also with visual impairment, to evaluate the correlation with ethnicity and to be able to analyze all diagnoses independently.

Two main retinal pathologies were among the most common causes and include two relatively large areas of childhood visual problems (retinal dystrophies and albinism) accounting for the substantial numbers in accordance to the literature [ 9 ]. Albinism was among the most common causes for visual impairment (BCVA 6/18 to 6/60), followed by retinal dystrophies. The most common ocular pathologies leading to blindness (BCVA < 6/60) were IRD, albinism, and CVI, in decreasing order. Interestingly, there was a statistically significant correlation between the most common eye diseases and ethnicity; albinism was the most common disease among Jews and IRD was the most common among Arab Muslims.

A previous publication based on the Israeli registry for blindness published in 2015, referred a decreasing rate of childhood blindness in Israel, raising the possibility that the cause was a lower incidence of IED over the years of the study [ 8 ]. Interestingly, if we group RP (13%), albinism (4%), and “other retinal pathologies” (11%) taken from their table, we reach 28% which makes IED the main cause of blindness [ 8 ]. Analysis of recent data (2015–2019) from the same Israeli registry for the blind, shows that when grouping the same diagnoses as above, (RP, other retinal pathology (all IRD other than RP) and albinism) IED reaches 37% of childhood blindness causes, showing a rising percentage of IED as a cause of childhood blindness in Israel. Furthermore, IED prevalence reaches 43% if we take similar data from 2019 alone (Table  4 ). As previously discussed, other IED are not included separately in the blind registry’s list (such as aniridia, or diseases that might be genetic such as OA, congenital cataract/glaucoma) and cannot be documented, reducing the real number of IED. Also details regarding pathology origin (genetic or not), as in OA, congenital cataracts, and glaucoma are not provided, reducing further the total estimation for IED prevalence. Stratification of data from the national registry in two age groups showed as expected, that CVI was most prevalent in the 0–5 age group compared with the 6–18 age group. IED were the most common cause of blindness in both age groups.

CVI incidence reached only 10.7% of causes. One possible explanation for the relative low percentage of CVI might be that the diagnosing ophthalmologists documented this cause of blindness as OA, causing an apparently lower incidence of CVI and higher incidence of OA as an etiology for childhood blindness. In our center, CVI percentage reached 22% as a cause of blindness, which is relatively close to the published percentage in England in 2010 [ 9 ].

We can also appreciate that we have seen through our center, around half the number of children that got a blind certificate through the Israeli blind registry, during the same period of time, making our cohort representative.

Rates of blindness secondary to ROP are falling in the developed world because of the success of screening and treatment protocols. ROP is now becoming an avoidable cause of blindness in middle-income countries owing to improvements in perinatal medicine [ 10 ].

Several authors have reported that CVI is the leading cause of SVI/ blindness in children in the developed world [ 9 , 11 , 12 ]. In 2010, Durnian published that CVI was the most common cause (27%) for visual loss in children in England. However, when grouping “genetic causes” of vision impairment from Durnian’s publication, retinal dystrophies, aniridia, albinism, and the “hereditary” OA (2.3% of all OA described in the article) together reach a higher percentage (29.2%) of blindness than that caused by CVI (27%) (Table  3 ). Furthermore, in the latter publication, if we take into consideration that among other common causes of childhood blindness like congenital cataract (3.5%), congenital nystagmus (2.3%) and congenital glaucoma (1.2%) many are inherited, the number of IED might be even higher. We may say that also in England, IED as a group is the leading cause of childhood blindness. Similarly, in a publication by de Verdier in 2018, IED “grouped together” reach a higher number (17.3%) compared to CVI (8%) in Sweden [ 13 ].

In 2016, Bosch et al. published interesting data regarding the genetic basis of CVI [ 14 ]. They found that 5 of 25 children with CVI (20%) who were investigated by whole-exome sequencing, had variants in four genes known to be associated with CVI (AHDC1, NGLY1, NR2F1, PGAP1) establishing a conclusive genetic diagnosis for CVI. This knowledge shows us the importance of monogenetic disorders in the pathogenesis of CVI, so far mainly investigated as an “acquired brain damage”, highlighting the necessity to test for genetic defects using genome-wide diagnostic tools. Furthermore, if a certain percentage of CVI has genetic grounds, it might further increase the number of IED in developed countries.

Rudanko reported in 2004, that the main cause for visual impairment in 431 full-term children born in Finland were “genetic eye diseases” reaching 53%, emphasizing the lack of treatment for these genetic eye disorders over two decades covered by the study [ 15 ]. Kong et al. reported in 2012 that hereditary eye diseases accounted for 44% of blindness in childhood in Europe based on literature searches [ 16 ]. Boonstra et al. reported in their 2012 study that during the last two decades in the Netherlands, untreatable disorders such as genetic eye diseases and CVI have become the major causes for children’s blindness as a result of increased survival of preterm children and improved diagnostic possibilities [ 17 ].

One of the major difficulties in comparing incidence of blindness between published studies in the literature is that different criteria for defining and grouping visual impairment and blindness are used. Many studies group SVI and blindness together, others include even moderate visual impairment and yet others use a more strict criteria for blindness [ 9 , 11 , 13 ]. When considering strictly the definition of blindness by the WHO (<3/60) in our 2019 patients, the percentage of blindness was higher in the Arab Muslims and others ethnic groups compared to Jewish.

Possible biases in our study include the fact that this was a retrospective study and that it was based on a single multidisciplinary tertiary low vision center database, and not on a national registry. However, analysis of our data compared to the Israeli national registry for the blind leads to similar conclusions. Another limitation in our study is the lack of consistent information regarding ethnic origin in all the studied years as well as the fact that we cannot differentiate Muslims Arabs from Israel, from those from the Palestinian Authority, limiting the information regarding the possible higher rate of IED due to frequent consanguineous marriages in the Palestinian Authority.

We believe that reporting only the primary ocular diagnoses to describe the leading causes of blindness can be misleading. When “IED” are analyzed as a major group, it can allow priorities to be determined and appropriate strategies to be delineated in order to adapt the system toward prevention of childhood blindness.

In conclusion, IED as a group is a major cause for childhood visual impairment and blindness in Israel as well as in other developed countries of the world. Despite many advances in our understanding of IED, treatment options remain limited with the best hopes for treatment lying in the use of gene therapy, growth promotion therapies for degenerative diseases, and possibly the grafting of retinal cells. However, improved methods for identifying disease-causing mutations together with genetic counseling, genetic testing, and prenatal and/or preimplantation genetic diagnosis provide a feasible approach for preventing the recurrence of these blinding diseases in the same family [ 18 ]. Awareness among physicians regarding the possibility of prevention of these severe blinding diseases is of crucial importance. Changing patterns of global childhood blindness calls for a need for reassessment of research, screening programs, prioritization of examinations, and tactics for prevention.

What was known before

Analysis of isolated causes of childhood blindness in developed world during the last two decades points toward CVI as the main cause in many countries.

What this study adds

Main causes leading to childhood blindness are changing.

Grouping IED together shows that genetic eye diseases are far more common than previously reported and represent the main cause for childhood blindness in developed countries.

Reassessment of screening and prevention tactics might be needed.

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The authors thank the Israeli National Registry for the Blind and the Ministry of Welfare in Israel for providing access to the national data on childhood blindness.

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Yahalom, C., Braun, R., Patal, R. et al. Childhood visual impairment and blindness: 5-year data from a tertiary low vision center in Israel. Eye 36 , 2052–2056 (2022). https://doi.org/10.1038/s41433-021-01743-3

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Visual Rehabilitation for Children with Vision Impairment

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Visual impairment at a young age has lifelong consequences for the child, family, and society as a whole. To aim for the global development of such children in an inclusive manner and to ensure a good quality of life, children should be offered effective rehabilitation programs at an early age. This brief review aims to address the need and options for early visual rehabilitation for children with moderate to severe visual impairment.

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Dhillon, H.K., Ichhpujani, P. & Muralidharan, S. Visual Rehabilitation for Children with Vision Impairment. SN Compr. Clin. Med. 4 , 137 (2022). https://doi.org/10.1007/s42399-022-01214-0

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Vision loss in children whose eyesight may be 20/20 requires new diagnostic and teaching strategies

Ellen Mazel, M. Ed., oversees the CVI assessment program at Perkins, where she estimates that 60% of the entire student body has CVI. Credit: Burju Sari

Nearly two decades ago, Ellen Mazel, M.Ed., a teacher for children with visual impairment at Perkins School for the Blind noticed a shift in her ability to meet her students’ needs. 

"Increasingly, my usual teaching methods were not working for many of my students,” she said.

In hindsight it’s clear that her teaching methods, which were geared toward people with ocular causes of vision loss, were not as effective for a growing group of students with low vision due to cerebral (cortical) visual impairment (CVI). CVI is a condition that interferes with the ability of the brain to process information from the eyes.

A person with CVI has difficulty with visual processing – turning light from their eyes into meaningful information about the complex visual world around them. CVI can co-occur with ocular impairment, but the visual deficits cannot be explained by the eye condition alone because the functional vision deficits are predominately brain-based.

Today, Mazel oversees the CVI assessment program at Perkins, where she estimates that 60% of the entire student body has CVI.

Hiding in plain sight

Mounting evidence suggests that CVI has become a leading cause of visual impairment in children in developed countries, 1-3 as well as in lower and middle income nations, making it a growing global health concern. In a national registry that collected data on 2,155 children with visual impairment in the U.S., from birth to age 3, CVI was the most prevalent diagnosis (24%), followed by retinopathy of prematurity (ROP) (16%) and optic nerve hypoplasia (10%). 4

In countries with national healthcare systems that more widely track causes of visual impairment, such as the United Kingdom, CVI accounts for up to 48% of cases of severe childhood visual impairment and blindness. 5,6 CVI accounted for 27% of such cases in the Netherlands. 7

Children with CVI can have a range of visual deficits and every case is unique. They may have poor visual acuity or limited field of vision.  In addition, they may have higher-order visual processing deficits that interfere with attention and recognition. A person with CVI may miss important details. In a crowd, even family faces may be unrecognizable; a favorite toy may be undetectable in a cluttered box. Difficulty coordinating motor movements using visual cues can be challenging for some with CVI. 

Michael Jackel. Credit: Bernadette Jackel

As a child, Michael Jackel would frequently fall when he encountered stairs because he couldn’t see anything in his lower visual field. Eventually, he learned that handrails were a cue to be alert for them. At age 30, he uses a cane in unfamiliar environments to detect stairs and manage his lack of depth perception.

CVI’s impact on functional vision may be more evident in certain environments or under certain conditions. For Jackel, noisy rooms interfere with his ability to see things directly in front of him. Other people with CVI have difficulty seeing in unfamiliar or cluttered environments.

What causes CVI and why might its prevalence be increasing?

Magnetic resonance imaging scan shows an adolescent with CVI associated with prematurity. Enlarged ventricles with irregular sulcal patterns (folds) in the occipital pole (a hallmark sign of periventricular leukomalacia, PVL) are apparent (arrow). Credit: Lotfi Merabet

Complications from premature birth are one of the leading causes of CVI. During the second half of pregnancy the brain is rapidly developing, making it particularly vulnerable to certain types of injury such as periventricular leukomalacia (PVL). PVL is associated with damage to the developing neurons and support cells in many parts of the brain, especially in areas responsible for motor function and visual processing. As a result, infants with PVL have a higher likelihood of developing cerebral palsy and CVI.

CVI can also be caused by complications during a full-term pregnancy or childbirth, such as infection and prolonged oxygen deprivation and brain malformations during fetal development. Shaken baby syndrome or any type of traumatic brain injury later in life can disrupt the visual processing centers. Metabolic and genetic disorders have also been linked with CVI.

Advances in neonatal care have dramatically improved survival rates of extremely premature infants (less than 28 weeks gestation). Between 1993 and 2012, the percentage of surviving infants born at 23 weeks’ gestation increased from 52% to 65%. 8

Higher survival rates after premature birth may mean that more children are at potential risk for CVI.

At the same time, rates of pediatric vision loss from preventable ocular causes, such as retinopathy of prematurity and congenital cataracts, have declined precipitously in developed countries. As a result, CVI now accounts for a greater percentage of vision impairment among children in the community and also in schools such as Perkins.

Diagnosing CVI

Evidence-based guidelines for CVI diagnosis are lacking. “Diagnosis really depends on the healthcare provider’s level of experience and suspicion that a child is having difficulty seeing because of functional vision deficits due to neurological damage,” said Lotfi Merabet, O.D., Ph.D., MPH, associate professor of ophthalmology at Massachusetts Eye and Ear and Harvard Medical School.

If a child is not meeting age-appropriate visual developmental milestones, such as holding direct eye contact, following a slow-moving object, or reaching for objects, CVI should be considered along with eye problems.

CVI assessment should consider both visual function and functional vision. Visual function measures eye health, visual acuity, contrast sensitivity, visual field, color perception, and eye mobility. Functional vision gauges ability to use vision for daily activities. Many people with CVI have normal visual function but still have problems with functional vision.

Evaluating functional vision should incorporate contextual-based behavioral testing , Merabet said. There are very few tools that provide objective measures of functional vision in individuals with CVI.

Currently, CVI assessment relies primarily on questionnaires and observational tools. One such example is the CVI Range, which uses interviews and trained observation to infer how various visual features, such as color, movement, and visual complexity impact a child’s ability to perceive their visual environment. Other screening tools or history taking tools developed in Europe, such as the CVI Questionnaire and CVI Inventory, also help clinicians understand how functional vision is impacted throughout a child’s day.

Complicating diagnosis is the fact that CVI often coexists with other conditions that may be more evident to the external observer, such as cerebral palsy, autism, and attention deficit hyperactivity disorder. Rehabilitative strategies for these conditions are often visually dependent, a fact that underscores the importance of addressing the underlying CVI.  

Not surprisingly, CVI is commonly misdiagnosed. “I can’t tell you how many times I’ve heard parents say that they’ve been told ‘Your child’s eyes look fine. The problem is behavioral, or the child has a learning disability.’ It’s an incredibly frustrating scenario for parents who can’t get the right diagnosis,” said Merabet.

Yet getting a CVI diagnosis can be crucial to qualifying for educational services under Part B of the Individuals with Disabilities Education Act (IDEA), which opens access to educational services and accommodations for children with disabilities, including blindness and low vision. 

“CVI in high-functioning children often gets written off as a behavioral problem,” said Linda Lawrence, M.D., an ophthalmologist from Salina, Kansas. Lawrence recalled a “clumsy” fourth grader who was doing poorly in school. “Her CVI had been missed for years in part because she had 20/20 vision. It wasn’t until she was diagnosed that her grades improved. She was given a cane to manage her limited lower field of vision and an individualized education program (IEP) that addressed her visual needs. It was life changing,” said Lawrence, who is a consultant member of the Pediatric Low Vision Rehabilitation Committee for the American Association for Pediatric Ophthalmology and Strabismus.

Similarly, Michael Jackel was denied accommodations because standard vision testing failed to show a problem. According to his mother, Bernadette Jackel, none of Jackel’s teachers were prepared to instruct a child with CVI. “School was a nightmare,” she said. “By seventh grade, Michael was convinced that he was stupid and couldn’t learn.”

Schools often lack the expertise to teach children with CVI, said Amanda Lueck, Ph.D., professor emerita of special education at San Francisco State University. Standard educational and rehabilitative approaches for people with low vision—such as magnifying text or improving contrast—fail to address the brain-based issues of CVI. “We are in the very early days when it comes to figuring out what rehabilitative strategies work in CVI. And what works for one child with CVI, doesn’t necessarily work for another,” she said.

Lacking evidence-based approaches, the best current strategy is to involve a multidisciplinary team with expertise in neurology, occupational and physical therapy, and orientation and mobility training, she said.

Desperate for an environment that could address his needs, Jackel enrolled as a boarding student at Perkins where he stayed until he graduated high school. Perkins made a huge difference in Jackel’s ability to progress academically, according to his mother. His typical class size went from 20 to four students. Classrooms were less cluttered. And lessons accommodated his needs; for example, teachers helped him read by presenting one word at a time.  

New research may hold key to successful rehabilitation

With funding from the National Eye Institute (NEI), part of the National Institutes of Health, Merabet is attempting to quantify CVI-related changes to the brain and functional vision deficits, and compare those changes with ones that occur in ocular-based visual impairment, as a step toward gauging which rehabilitative strategies might eventually work best. 

Using brain imaging studies, he also hopes to better define CVI neurologically and physiologically.

The work is based on an earlier study with Corinna Bauer, Ph.D., also of Massachusetts Eye and Ear and Harvard Medical School. Together, they used a combination of imaging tests to explore the effect of blindness on the brain. They found that people who lose their vision very early in life due to ocular blindness tend to have reorganized structural and functional connections in their brains, relative to those of sighted individuals. Early blindness caused reductions in the size of visual processing structures. But brain regions involved in other functions, such as hearing and language processing, showed enhanced brain connectivity. As of yet, it is unclear how the brain changes in the setting of CVI. “Studies that provide clues about how the brain functions and adapts could bring evidence-based strategies to CVI rehabilitation,” said Merabet. 10

Merabet hopes to find out if people with CVI have similar indications of brain plasticity. “We are comparing brain plasticity in CVI with individuals with ocular based impairment,” he said.

Diffusion based imaging reveals that dorsal (white arrow) and ventral (black) visual processing streams remain intact in people with ocular causes of visual impairment, but are markedly reduced in individuals with CVI (particularly the dorsal stream implicated with spatial processing). 9

Merabet has also developed a virtual reality-based platform to assess CVI’s impact on a person’s functional vision. The system tracks and records a person’s eye movements as they explore and look for a specific target in a simulation of a real-world setting. For example, users are asked to identify a specific toy in a cluttered virtual toy box as various features of the visual scene are changed to make the task more difficult. In an another NEI-funded study, Merabet is validating the system’s usefulness for quantifying functional vision deficits, which will help lay the groundwork for developing adaptive tools and strategies to meet an individual's specific rehabilitative needs.

Other NEI-funded research is aimed at objectively evaluating what people with CVI can and cannot see, especially in situations where a significant intellectual disability interferes with the ability to communicate or read an eye chart.

It can be difficult to quantify functional vision deficits among people with CVI. This heat map shows visual search patterns for a virtual toy box task with yellow representing more time spent looking at an area and blue indicating less time. Note how in CVI the extent of visual area explored increases with greater task demand. Merabet hopes that such virtual reality (VR) based tools will help better assess functional vision impairments in CVI. 9

Toward that end, with NEI funding, Glen Prusky, Ph.D., director of the Laboratory for Visual Disease and Therapy at Burke Neurological Institute, White Plains, New York, developed a system that tracks eye movement to gauge how well a child with CVI can see.

His system is based on observation of a reflexive behavior: When our eyes track an object gliding across our field of vision, they move smoothly. Take the object away, and without anything to focus on, our eyes are unable to move smoothly. Building on that idea, Prusky’s system assesses how well a child sees by presenting him or her with a large visual stimulus drifting across a computer screen. An infrared eye tracker plots where the child is looking, and an algorithm determines whether the child’s eye movements are smooth, indicating their fixation on the stimulus. When the child smoothly tracks, they are incentivized to keep trying to focus by being rewarded with a favorite song. The stimulus becomes increasingly difficult to see in order to identify the limit of a child’s functional vision.

“It’s really remarkable to see a child lying in bed not looking at much or tracking. And then you put this screen in front of them and you move stuff and almost like a light bulb you see them become engaged,” Prusky said.

Merabet’s research is funded by NEI grants R21EY030587 and R01EY031300 . Prusky’s research is supported by NEI grant R01EY030156 .

References:

1              Chang, M. Y. & Borchert, M. S. Advances in the Evaluation and Management of Cortical/Cerebral Visual Impairment in Children. Survey of Ophthalmology , doi: https://doi.org/10.1016/j.survophthal.2020.03.001 (2020).

2              Khan, R. I., O'Keefe, M., Kenny, D. & Nolan, L. Changing pattern of childhood blindness. Ir Med J 100 , 458-461 (2007).

3              Kong, L., Fry, M., Al-Samarraie, M., Gilbert, C. & Steinkuller, P. G. An update on progress and the changing epidemiology of causes of childhood blindness worldwide. Journal of American Association for Pediatric Ophthalmology and Strabismus 16 , 501-507, doi: https://doi.org/10.1016/j.jaapos.2012.09.004 (2012).

4              Hatton, D. D., Schwietz, E., Boyer, B. & Rychwalski, P. Babies Count: The national registry for children with visual impairments, birth to 3 years. Journal of American Association for Pediatric Ophthalmology and Strabismus 11 , 351-355, doi: https://doi.org/10.1016/j.jaapos.2007.01.107 (2007).

5              Rahi, J. S. & Cable, N. Severe visual impairment and blindness in children in the UK. The Lancet 362 , 1359-1365, doi: https://doi.org/10.1016/S0140-6736(03)14631-4 (2003).

6              Durnian, J. M. et al. Childhood sight impairment: a 10-year picture. Eye 24 , 112-117, doi:10.1038/eye.2009.32 (2010).

7              Boonstra, N. et al. Changes in causes of low vision between 1988 and 2009 in a Dutch population of children. Acta Ophthalmologica 90 , 277-286, doi:10.1111/j.1755-3768.2011.02205.x (2012).

8              Stoll, B. J. et al. Trends in Care Practices, Morbidity, and Mortality of Extremely Preterm Neonates, 1993-2012. JAMA 314 , 1039-1051, doi:10.1001/jama.2015.10244 (2015).

9              Bennett, C. R., Bauer, C. M., Bailin, E. S. & Merabet, L. B. Neuroplasticity in cerebral visual impairment (CVI): Assessing functional vision and the neurophysiological correlates of dorsal stream dysfunction. Neuroscience & Biobehavioral Reviews 108 , 171-181, doi: https://doi.org/10.1016/j.neubiorev.2019.10.011 (2020).

10           Bauer, C. M. et al. Multimodal MR-imaging reveals large-scale structural and functional connectivity changes in profound early blindness. PLOS ONE 12 , e0173064, doi:10.1371/journal.pone.0173064 (2017).

Resources for more information about CVI

CVI information from the National Eye Institute

https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/cerebral-visual-impairment-cvi

CVI Now, Perkins School for the Blind

https://www.perkins.org/cvi-now

CVI Now, Q&A with Dr. Lotfi Merabet

https://www.perkins.org/cvi-now/understanding-cvi/cvi-brain-dr-lotfi-merabet

CVI Scotland

https://cviscotland.org/ ,

Cortical/Cerebral Visual Impairment, Traumatic Brain Injury, and Neurological Vision Loss  (American Foundation for the Blind) https://www.afb.org/blindness-and-low-vision/eye-conditions/cortical-visual-impairment-traumatic-brain-injury-and

Cortical Visual Impairment (American Association for Pediatric Ophthalmology and Strabismus)

https://aapos.org/browse/glossary/entry?GlossaryKey=b1bcb5d7-98a8-4938-b9fd-bbf73fdeb386

Cortical Visual Impairment: What Is It? (Discovery Eye Foundation)

http://discoveryeye.org/cortical-visual-impairment-what-is-it/

Anxiety in Children with Low Vision Secondary to Refractive Errors

Affiliations.

• 1 Department of Ophthalmology, University of Health Sciences Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey.
• 2 Department of Neonatology, University of Health Sciences Dr. Behcet Uz Child Disease and Pediatric Surgery Training and Research Hospital, Izmir, Turkey.
• 3 Department of Ophthalmology, Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey.
• PMID: 35098087
• PMCID: PMC8784455
• DOI: 10.14744/bej.2020.76993

Objectives: This study aimed to evaluate the anxiety status of children with low vision due to refractive errors using a questionnaire survey.

Methods: Between July and November 2019, the Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire was administered to children with refractive errors (≥3D) and amblyopia who presented to the ophthalmology clinic. Children with low vision were evaluated based on their answers to the SCARED questionnaire.

Results: This study included 38 children (22 girls, 16 boys) with low vision. The average age of the participants was 9.74±2.65 (7-12) years. The average binocular vision was 0.28±0.21 LogMAR. The mean total anxiety score was 21.68±10.55. At least one type of anxiety was detected in 18 (47.4%) children. A positive correlation and statistical significance were found between binocular low vision and anxiety (r=0.63, p<0.001). Boys were more susceptible to anxiety than girls, and a positive moderate correlation and statistical significance were found (r=0.50, p=0.002).

Conclusion: Anxiety may develop in children with low vision, and this anxiety more commonly occur in boys than in girls (p=0.002). In addition, psychological disorders can be seen in children with low vision. To better evaluate this connection, large case series studies including visual impairment due to different reasons are needed.

Keywords: Anxiety; SCARED survey; blindness; child; low vision.

Copyright: © 2020 by Beyoglu Eye Training and Research Hospital.

I evaluated her distance vision with several different powers of bioptic telescopic glasses and prescribed 5 X VES Sport II bioptic glasses from Ocutech, Inc. The Sport is a monocular, focusable, Keplarian design bioptic. Lauren read 10/60 OD with the Sport.

I also evaluated Lauren’s near vision with telemicroscopic glasses, but they did not improve her ability to see the iPad.

I did show her how to connect the iPad to her TV so she can read from the large TV screen. That allowed her to use less magnification on the iPad resulting in more words on the screen for easier reading.

Occasionally, people see better with their final bioptic glasses than they did during the low vision evaluation. When Lauren returned to receive her Sport bioptic we were pleasantly surprised to find that with them her acuity was 20/60 OD. She was able to recognize faces at about 30 feet and read license plates from 20 feet. Lauren and her father were very pleased with the improvement that the bioptics made in her vision.

Lauren is a good example of a person with a very significant, life-long vision loss who is capable of improved vision by using low vision glasses. Her pediatric ophthalmologist recognized that a referral to a low vision optometrist could result in greater independence for this nice young lady.

The International Academy of Low Vision Specialists (IALVS) believes in life after vision loss.

We are a group of optometrists who are specially trained in low vision to help patients suffering from: Macular Degeneration: Wet or Dry, Albinism, Glaucoma, Stargardt’s Disease, Diabetic Retinopathy, Retinitis Pigmentosa, and other Vision-Limiting Conditions

Study record managers: refer to the Data Element Definitions if submitting registration or results information.

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Double-blind, Placebo-controlled, Randomized Study of the Tolerability, Safety and Immunogenicity of an Inactivated Whole Virion Concentrated Purified Vaccine (CoviVac) Against Covid-19 of Children at the Age of 12-17 Years Inclusive"

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Recruitment of volunteers will be competitive. A maximum of 450 children aged 12 to 17 years inclusive will be screened in the study, of which it is planned to include and randomize 300 children who meet the criteria for inclusion in the study and do not have non-inclusion criteria, data on which will be used for subsequent safety and immunogenicity analysis.

Group 1 - 150 volunteers who will be vaccinated with the Nobivac vaccine twice with an interval of 21 days intramuscularly.

Group 2 - 150 volunteers who will receive a placebo twice with an interval of 21 days intramuscularly.

In case of withdrawal of volunteers from the study, their replacement is not provided.

Inclusion Criteria:

• Volunteers must meet the following inclusion criteria:

Type of participants • Healthy volunteers.

Age at the time of signing the Informed Consent

• from 12 to 17 years inclusive (12 years 0 months 0 days - 17 years 11 months 30 days).

Paul • Male or female.

Reproductive characteristics

• For girls with a history of mensis - a negative pregnancy test and consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Girls should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).
• For young men capable of conception - consent to adhere to adequate methods of contraception (use of contraceptives within a month after the second vaccination). Young men and their sexual partners should use methods of contraception with a reliability of more than 90% (cervical caps with spermicide, diaphragms with spermicide, condoms, intrauterine spirals).

Research procedures

• Written Informed consent of a volunteer (14 years and older) and one of the parents to participate in a clinical trial.
• Volunteers who are able to fulfill Protocol requirements (i.e. answer phone calls, fill out a Self-observation Diary, come to control visits).

Non-inclusion criteria:

• Volunteers cannot be included in the study if any of the following criteria are present:

SARS-CoV-2 infection

• A case of established COVID-19 disease confirmed by PCR and/or ELISA in the last 6 months.
• History of contacts with confirmed or suspected cases of SARS-CoV-2 infection within 14 days prior to vaccination.
• Positive IgM or IgG to SARS-CoV-2 detected on Screening.
• Positive PCR test for SARS-CoV-2 at Screening / before vaccination.

Diseases or medical conditions

• Serious post-vaccination reaction (temperature above 40 C, hyperemia or edema more than 8 cm in diameter) or complication (collapse or shock-like condition that developed within 48 hours after vaccination; convulsions, accompanied or not accompanied by a feverish state) to any previous vaccination.
• Burdened allergic history (anaphylactic shock, Quincke's edema, polymorphic exudative eczema, serum sickness in the anamnesis, hypersensitivity or allergic reactions to the introduction of any vaccines in the anamnesis, known allergic reactions to vaccine components, etc.).
• Guillain-Barre syndrome (acute polyradiculitis) in the anamnesis.
• The axillary temperature at the time of vaccination is more than 37.0 ° C.
• Positive blood test for HIV, syphilis, hepatitis B/C.
• Acute infectious diseases (recovery earl

Exclusion Criteria:

- • Withdrawal of Informed consent by a volunteer and/or a parent of a volunteer;

• The volunteer was included in violation of the inclusion/non-inclusion criteria of the Protocol;
• Availability of inclusion/non-inclusion criteria before vaccination;
• Any condition of a volunteer that requires, in the reasoned opinion of a medical researcher, the withdrawal of a volunteer from the study;
• The established fact of pregnancy before the second vaccination;
• Taking unauthorized medications (see section 6.2);
• The volunteer's incompetence with the study procedures;
• The volunteer refuses to cooperate or is undisciplined (for example, failure to attend a scheduled visit without warning the researcher and/or loss of communication with the volunteer), or dropped out of observation;
• For administrative reasons (termination of the study by the Sponsor or regulatory authorities), as well as in case of gross violations of the protocol that may affect the results of the study.
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