University of Edinburgh

The Assessment of Visual Functions in Children with Visual Impairment

Presented on Saturday, 11 December 2010

Case scenarios

Case Scenario 1

Jonnie (age 5) is a lively little boy who has just started school. He is blonde with beautiful blue eyes and was diagnosed as having nystagmus shortly after birth. His parents feel his vision has improved over the last few years.

Jonnie hates to wear his glasses and regularly breaks them (Rt +3.50/-2.00 x 180, Lt +5.00/-3.00 x 180).

The parents aren't sure the glasses make much of a difference. They don't really get much time to ask questions at the eye clinic and Jonnie creates a fuss about drops. They ask you for your opinion on spectacle wear and the use of optical corrections.

What do you advise?

You will need to discuss:

  1. The need for glasses during the visual plastic period and longer in cases of developmental delay.
  2. Compromise spectacle wear during visually demanding activity.
  3. Possible orthoptics intervention to control and prevent strabismus and amblyopia.
  4. Astigmatism and anisometropia will never go away, hypermetropia might.
  5. Cycloplegic refraction – explain why.
  6. May need advice on the use of low vision aids (dome mags/binoculars/contact lenses).
  7. Will need advice on educational materials, contrast and lighting.
  8. If he has albinism, may need a tint and advice on sun protection.

Case Scenario 2

Charles (age 13) has been told he has optic atrophy and that his vision will never be any better than it is now.

He has worn glasses since age 4 but really doesn’t like to have to use them (Rt +5.75/-0.50 x 90, Lt +4.50). He no longer brings them to school regularly. He was initially a bright, interactive student but over the last couple of years has become disruptive and easily distracted and, at times, disruptive.

He attends a mainstream secondary school, has visual acuities of 6/18 Rt and 6/12 Lt. With glasses, he reads N6 fairly easily. He has normal contrast senstivity and no obvious problems with colour discrimination. Visual fields are full to confrontation.

Through statementing, he has access to copied blackboard material, special graph paper and some assistance with science, all of which he claims not to need.

What are the key issues here?

You will need to discuss:

  1. Denial and the possible reasons
  2. Peer pressure and the need for acceptance
  3. Uncorrected hypermetropia (inattention/headaches)
  4. Planning for driving/mobility
  5. Should you offer to help by being involved in the next hospital visit?
  6. How can you support the introduction of low vision aids?
  7. Can the glasses be aesthetically better?
  8. Will contact lenses help?
  9. How will you encourage the use of support materials and assistance at school?

Case Scenario 3

Emma (age 15) had retinitis pigmentosa diagnosed 5 years ago.

She is finding it difficult to get about outdoors at night and finds playground activity stressful. She also has some difficulty with a combination of educational tasks.

Someone has suggested her parents should take her along to the low vision clinic.

What do you think will be done for her?

You will need to discuss:

  1. Refraction (myopia)
  2. Visual assessment - particularly CS and VF and low luminance vision
  3. LVAs - probably not now, later. CCTV/Dome mag/Reverse telescope
  4. Discuss mobility and night blindness
  5. Discuss educational issues (contrast/lighting)
  6. Associated pathology (ophthalmic/medical)

Case Scenario 4

Mary (age 8) was born prematurely and has since been diagnosed as having cerebral palsy.

She has massive motor problems and, in addition, has communication difficulties. She is confined to a wheelchair and is relatively non-communicative and disruptive when seen in a clinical environment.

The paediatrician feels that all possible is being done but there is no record of a formal visual assessment.

Why might Mary benefit from this type of referral and who should see her?

You will need to discuss:

  1. Prevalence of refractive error
  2. Prevalence of squint/amblyopia
  3. Prevalence of impaired acuity
  4. Need for glasses and how to monitor their impact Need for appropriate dispensing
  5. LVAs unlikely
  6. Advice on Big, Bright and Bold
  7. Specialist team approach