Ocular status and functional adaptation of visually challenged children of a special school in Oman.

INTRODUCTION: We assessed the ocular status and visual adaptation among children studying at a school for visually disabled children in Muscat, Oman.
MATERIALS AND METHODS: This descriptive study was conducted in 2009-2010. We assessed the visual and ocular status of the participants. They were interviewed to elicit the past history of eye problems and management. They also expressed their visual adaptation in their 'day-to-day' life, and their ambitions. RESULT: We examined and interviewed 47 participants (29 male and 18 female). The mean age of the participants was 19.7 years (Standard deviation 5.9 years). Twenty-six of them were blind since birth. Phthisical eyes, disfigured eyes and anophthalmic sockets were noted in 19, 58, and six eyes of participants. Twenty-six (55.5%) participants had visual disabilities due to genetic causes, since birth. In 13 participants, further investigations were needed to confirm diagnosis and determine further management After low vision training, 13 participants with residual vision could be integrated in the school with normal children. One participant was recommended stem cell treatment for visual restoration. Five children were advised reconstructive orbital surgery. The participants were not keen to use a white cane for mobility. Some participants, 16 / 28 (57%), with absolute blindness, were not able to read the Braille language. Singing and playing music were not very well-accepted hobbies among the participants. Nineteen participants were keen to become teachers.
CONCLUSIONS: Children with visual disabilities need to be periodically assessed. The underlying causes of visual disabilities should be further explored to facilitate prevention and genetic counseling. Participants had visual adaptation for daily living and had ambitions for the future.

Introduction

Persons with visual challenges are underprivileged in the society. It is their right to get rehabilitated.[1] This is more important when the issue is childhood blindness, as it exerts a life-time economic burden on the family and society. The VISION 2020 initiative, therefore, is committed to address the avoidable blindness and blinding eye diseases in children.[23] Many studies have focused on estimating the number of children with visual disabilities, and to determine their causes.[4] Those in need of treatment might be offered services depending upon the availability, but those with absolute blindness are seldom visited by the eye care professionals subsequent to their initial diagnosis.

We conducted a study in Oman to follow the children studying in the Omar Bin Khattab school for the blind. It is the only school for the blind and is managed by the Ministry of Education, Oman. It is a day care center for the local children and has a residential facility for children from other regions. All children are evaluated by a qualified ophthalmologist before their enrollment. Although it is a school for the blind, a section rehabilitates children with low vision. It has an in-house capacity to print text books in large fonts to help children with low vision. The services are offered free of cost and are easily accessible to all children, less than18 years of age, in Oman.

The present study was undertaken with the objective of determining the participants′ current ocular status, the influence of their visual limitations on daily living, and their goal toward life.

Materials and Methods

The study was approved by the administrators of the ‘Omer Ben Khatab School’ and the health committee of the Al-Noor Association for the Blind, in Oman. We conducted the study between December 2009 and February 2010. The students of this school were our participants. This was a case series-type descriptive study. Two ophthalmologists, one optometrist, and two low vision care providers were the study investigators.

The personal profile including age, sex, and area of residence were collected by holding interviews, in Arabic, with the participants. The health records of each participant were referred, to confirm the findings regarding blindness, possible causes of visual disability and previous medical / ocular surgical history.

The optometrist recorded distant visual acuity on ‘tumbling E’ using the projection Snellen's chart held at a distance of 3 m from the participant. Near visual acuity was recorded by a logMAR chart at a distance of 40 cm. Dynamic retinoscopy was performed to estimate the amount of refractive error at a distance of 1 m. Dull fundus reflex was found in some cases. For them, working distance was reduced to 50 cm, from the trial frame. Subjective refraction was done and was later cross-checked with dilated pupil retinoscopy. The pupils were dilated using 1% Tropicamide. One drop was instilled twice at an interval of 30 minutes.

Ophthalmologists evaluated the anterior segment using a slit lamp bio-microscope (Topcon-Japan). The posterior segment was examined using an indirect ophthalmoscope (Keeler-UK) and + 30D Volk lens. The provisional clinical diagnosis based on the evaluation enabled the ophthalmologists to recommend further investigations or management, if any, to the school authorities.

The field staff asked questions to find out the participant's ability to perform certain daily living tasks, hobbies, and adaptive skills to overcome the functional vision loss [Table 1]. The responses of the participants were either positive or negative.

Table 1

Daily living skills and functional vision adaptations

The pre-tested form was used to collect the data. It was transferred on a spreadsheet using EpiData (Denmark). To calculate frequencies and percentage proportions, we conducted univariate analysis with the Statistical Package for Social Science (SPSS - 16).

Results

We examined 47 participants. Of them, 29 (61.7%) were males and 18 (38.3%) were females. Their mean age was 19.7 years (Standard deviation - 5.9 years). The participants were divided in three age groups. In the age group of 6–10 years, 11–18 years, and 18 years and older, there were one (2%), 20 (42.6%), and 26 (55.3%) participants, respectively.

History and earlier documents suggested that 26 (55.3%) participants had reduced vision since birth [Table 2]. Five (10.6%) participants experienced deterioration of vision during the first year of their life, and 16 (34%) participants experienced deterioration of vision after the first year of life. Six participants had undergone surgery for one eye (three persons had absolute blindness and three had residual vision) and 10 participants had undergone surgery for both eyes (seven had absolute blindness and three had residual vision).

Table 2

Profile of participants of Omar bin Qatar school for visually challenged in Oman

On examination, 19 (20.2%) eyes were phthisical, 58 (61.7%) eyes were disfigured and six (6.4%) were anophthalmos [Table 3]. Thirty-four 34 (72.3%) participants had absolute blindness (Light Perception PL), whereas, 13 (27.7%) had functional low vision (visual acuity < 6 / 18 to PL with navigational vision). The later group was recommended for low vision rehabilitation [Table 4]. There were eight participants for whom further investigations were recommended, for management. There was one participant for whom YAG laser was recommended. Cosmetic correction in the form of prosthetic shell was suggested for five participants and there were no treatments possible for the remaining 24 persons.

Table 3

Ocular status of visually challenged participants

Table 4

Recommendations of the ophthalmologist for investigation and management of participant with visual disability

Questions [Table 1] were also asked to know about their quality of life. These questions were based on their ability to perform daily living skills and adaptation to functional vision loss. Of the 36 participants who gave reliable answers, 28 had absolute blindness and eight had residual vision. Participants of both the categories; blind and low vision were able to perform their daily living skills. Participants with absolute blindness showed slightly poor adaptation to the functional vision loss compared to participants with low vision disability.

On interview of 47 participants, 19 wanted to become teachers and five wanted to become engineers. Five participants expressed their liking toward sports. Two wanted to be sports persons and three wanted to be sports commentators. Two participants wanted to be pilots of airplanes.

Discussion

Globally, there are 314 million people with blindness and low vision.[5] Many of them are amenable to treatment. If left untreated, they would exert an economic burden on the society. The rest of the visually disabled should be rehabilitated to improve their quality of life, so that they can contribute to the nation's prosperity. The people with absolute blindness (no perception of light) are rehabilitated differently than those with some residual vision. The persons with residual vision are provided optical, non-optical devices and trained in adaptive skills so that they can function as normal-sighted individuals in most of the situations. With a prevalence of 8 / 10,000 childhood blindness, there would be around 1,000 children who would need such rehabilitative services in Oman.[6] With 2.58% annual incidence of birth defects in Oman, the risk of low vision disability will also be higher in this underprivileged group of society.[78] Thus the need for low vision and rehabilitative services in Oman is huge and will further increase in the coming years.

In the present study, we followed up the students of a sole school in Oman, where children with absolute blindness and low vision disability are given care. These children are assessed by ophthalmologists at the time of their enrollment and then if they face any eye problem. Unfortunately, these children are not assessed in detail subsequently in many countries. Therefore, the outcome of our study will be crucial in formulating a policy for periodic assessment of children with visual disabilities.

The proportion of male to female was significantly higher among our study participants. In Oman, the male to female ratio in < 15-year-old Omani children is 1.04: 1; such a high number of males with visual disability need further explanation. Higher rates of birth defects among male children compared to females have been reported in Oman. Thus visual disabilities in children due to birth defects could also be higher in males. It is also possible that more males attend day care facilities compared to females and therefore our study could have picked up more males. Mirdehghan et al., in Iran, had also reported a male / female ratio of 1.4: 1 among blind children in special schools.[9]

The mean age of children in our study (19.7 years) was significantly higher than that reported by Mirdehghan et al., in Iran (13.5 years).[9] Absence of early intervention for the visually disabled could be responsible for late admissions in day care centers in Oman. One should compare the age profile of our study participants with other studies with caution, as children with only visual disability are admitted in the blind school in Oman. This may not be the case in many developing countries where children with multiple disabilities, including visual disabilities, are included in the study.

More than half of the participants were blind since birth and another 11% had lost their eyesight in the first year of life. Kansakar et al., in Nepal, found that 52.3% of the participants had blindness since birth and another 20.7% had lost their vision within the first year of life.[10] Ntim-Amponsah et al., in a study in Ghana had reported that 47.7% of the participants had lost their vision within the first year of life.[11] It seems that the pattern of blindness at birth and during the first year of life is similar in different countries.

One-fourth of the children in our study had low vision disability. Hornby et al., found 39.2% participants in their study had functional low vision.[12] In addition to the children from blind schools they included children from schools with the integrated education programs. The chances of having residual vision in the later study group were high compared to the participant profiles of our study.

Two-thirds of the children in our study had a disorganized eyeball. Another 20% had phthisical eyes. Such eyes are known to hide melanomas and other malignancies.[1314] Therefore, periodic examination of phthisical and disfigured eyes is essential even in the absence of symptoms. Disfigured eyes in our study are comprised of eyes having either aphakia, keratoconus or congenital anomalies like microcornea, microphthalmos or colobomas. Studies done by Pal et al., and Hornby et al., have documented that children having aphakia and congenital anomalies, benefit from low-vision services.[1516] Anophthalmia may lead to serious problems in a child, due to the absence of a seeing eye and secondary disfigurement of the orbit, the lids, and the eye socket. Orbital reconstruction by using various expanders helps in decreasing orbital asymmetry and cosmetic deformities.[1718] The prosthetic shell in an enucleated or eviscerated eye can also help as an aesthetic correction.[19] The ophthalmologist in our study recommended corneal reconstruction using stem cells, to restore vision in one participant. Advances in restoring corneal transparency, and thus eyesight, in corneal blindness are well-documented.[20]

Participants with absolute blindness and low vision disability experienced difficulties in performing daily living skills. Visual adaptation skills acquired through training were very useful in overcoming such difficulties.[21] Surprisingly many children with absolute blindness were not using a white cane for mobility and were not well versed with the Braille language. The training of these children in a blind school should focus more on these issues.

Medical research is advancing day by day. There can be newer treatments and rehabilitative modalities for enhancing vision, which were unheard of at the time of admission in the blind school. This justifies the periodic follow-up of children in the blind school by ophthalmologists and low vision care experts.