Making Blind Children See: Impact of Correcting Moderate and Severe Visual Impairment in Schools for the Blind.

PURPOSE: Childhood blindness and visual impairment accounts for enormous burden of blindness. This study aimed to analyze the causes of severe visual impairment and blindness in students attending schools for the blind and to identify those whose vision could be improved by optical aids. On dispensing such aids, the study also aimed to analyze the improvement in their vision function.
METHODS: This was a prospective interventional study of 428 certified students from four special schools for blind. All the students underwent a comprehensive ophthalmic examination by a team of four ophthalmologists and four optometrists. The World Health Organization-Prevention of Blindness forms were used to record history and examination details. Spectacles and low-vision aids (LVAs) were dispensed to those whose vision could be improved. The main outcome measure was L V Prasad- Functional Vision Questionnaire (LVP-VFQ), which was used to compare the vision function before and 6 months after the intervention.
RESULTS: Two hundred and thirteen (49.5%) students were girls. The causes of blindness in 370 children (<18 years) with vision <6/60 were whole globe involvement in 117 (31.6%) students (this included anophthalmos 47 [12.7%], microphthalmos 61 [16.4%], both 9 [2.4%]), nystagmus 29 (7.8%), optic atrophy 22 (5.9%), retinal causes 42 (11.3%), cataract 18 (4.9%), phthisis bulbi 24 (6.4%), corneal scarring in 40 (10.8%), and retinopathy of prematurity in 4 (1.1%). Fifty-four (12.6%) students were given spectacles and 41 (9.57%) LVA. There was a statistically significant difference in all questions (P < 0.01) of LVP-VFQ for the students dispensed with optical aids 6 months after the intervention. Twenty-four students had their vision improved to 6/60 or better, whereas 26 could now identify letters and print.
CONCLUSION: A significant proportion of students in schools for the blind can be helped to improving vision function using optical aids. Students in schools for the blind, nay all visually impaired individuals, need periodic ocular examination and ophthalmic care. Copyright:

RCT Entities:   Population Interventions Outcomes

Introduction

Causes of blindness and severe visual impairment have changed over the past decades.[1234] Blindness and visual impairment in children does not affect just their ability to see and it also has profound negative impact on their education, mental growth, and development – not just the child, but also the entire family and the community and the country at large. In terms of the burden of blindness, measured in blind-person years, childhood blindness is second only to cataract in terms of the burden of blindness to the world population.[1] Socially, children with visual impairment have limitations in interacting with the environment, as they cannot see the facial expressions of parents and teachers, cannot perceive social behaviors, and sometimes are unaware of the presence of others unless a sound is made.[2] Psychologically, low vision has consequences that often lead children to become confused, fearful, anxious, and depressed. Furthermore, denial and withdrawal are common psychological problems that restrict the children from being socially as well as educationally integrated.[3] In the educational field, most of the information is available in visual forms: books, blackboard, and liquid-crystal display projections, in addition to the teacher's verbal and nonverbal communications.[4] Blind children are usually educated in special schools for the blind. Children in these special schools for the blind are considered completely blind, unable to see anything at all, and deserving only for rehabilitation and utilization of aids. They are taught braille, a touch-feel-based language. However, knowledge and literature in braille is limited, that too mostly in European languages. The literature in Hindi, Marathi, and other Indian languages in braille is meager.

However, studies from 34 schools for the blind in Maharashtra from 2002 to 2004, 24 schools for the blind in Karnataka, 24 schools in Delhi and across four northeastern Indian states showed that around 25%–30% of legally blind children had some residual vision which can be utilized.[5678] Another study from Pune, Maharashtra, India, showed that giving spectacles and low-vision aids (LVAs) to children could help them read print.[9] Seeing print and learning a written language improves the chances of getting on in the world – to learn better in schools, write examinations, get degrees, recognize and count money, do office jobs, and even start and run a business.

While numerous studies from India, Middle East, Asian and African countries have shown that many children in schools for the blind have some residual vision, vision more than hand movements.[10111213] Some children even have treatable causes and blindness. However, there are few publications on how these visually impaired children were helped.[11] The literature shows that there were very few publications discussing how much students improved their vision functioning.[141516]

This study aimed to detect the causes of blindness in students attending schools for the blind, identify those with residual useful vision, treat them with optical aids, and compare their vision function before and after dispensing such devices or aids.

A blind child is not just an individual affected, but he/she affects the entire family and the community. There is an opportunity to high probability of not only in seeing and learning from the world but also a potential loss of educational, personal, social, and economic advancement.

Methods

We have chosen all the four schools for the blind in Pune city. They were chosen because they have children who are certified as blind and visually impaired in one place. The study was approved by the Ethics Committee of Bharati Vidyapeeth Medical College.

All the students have been examined in detail by a team of four doctors and four optometrists over 2 weeks. Inclusion criteria were all blind or visually impaired students in these schools. Exclusion criteria were students with multiple disabilities. The schools had a criterion to exclude students with multiple disabilities and those with curable causes of blindness. Each student was examined using a pen torch, a handheld slit lamp, direct and indirect ophthalmoscopy (wherever needed), I-kare tonometer, and visual acuity examination by Landolt C chart, if vision was >1/60. They were given spectacles, magnifiers, and telescopes for both near- and distance-vision aids. The near-vision devices would help the children to read, write, answer mobiles, make calls, thread a needle, clean vice, identify coins, and look at small paintings. The distance-vision devices would help them cross roads and identify bus numbers, road signs, people from the same distance more easily and safely. The World Health Organization-Prevention of Blindness forms were used to record history and examination details.[17]

Few students who were having potential to utilize their residual vision among them were given spectacles and LVAs along with required training and advices.

Screening of blind schoolchildren for causes of low vision is as follows:

A detailed history including age of onset, incidence of family history, which family member is similarly affected, history of consanguinity, history of previously done treatments

Vision was taken separately for both the eyes either with habitual correction or unaided. “Snellen's Distance Acuity charts” were used from 3-m distance and vision was documented as per the code described in the workup sheet

Gross functional vision was estimated by asking the students about their ability on walking alone, face reorganization, print reorganization, and using residual vision in daily life activity with both eyes open

Visual field was tested very roughly in few students monocular with simple confrontation tests. The main binder for performing this test was their habitual fixation pattern. They won’t fix their head when performing visual field test

Then, anterior and posterior (dilated) segment examination was done. Causes of low vision were derived from the underlying pathology

A general systemic association was also considered when examining a student

All these findings were used to plan the future steps such as surgical intervention or providing optical correction and LVAs and predict prognosis rate after intervention or academic consequences as well as.

Assessment of vision function is as follows:

The first step of this portion was reassessing the students having potential to improve their visual status with optical correction

Thorough refraction was done. Uniocular and binocular vision were taken with the correcting lens on the trial frame

The selection of the students for a low-vision trail was a multifactorial consideration. Ability to use the residual vision, daily life activities, need, enthusiasm, and ability to handle and take care of the device properly were the few important factors

The students who would receive LVAs (either of near or distance or for the both) were verbally asked L V Prasad Eye Institute Functional Vision Questionnaire containing 21 questions. A baseline idea about their functional vision was made by how they rate their ability to perform a particular task

Along with the optometrist, a bilingual (Marathi and English) person was always there with a questionnaire in Marathi (translated and back validated) to help the students to understand the questions or specifically what were they being asked

Using nonoptical devices such as cap and umbrella was also encouraged

After 6 months of giving those devices, a follow-up was made

Again, that questionnaire was asked to every individual student

Pre- and postrating were then compared and analyzed by Stasistical package for Social Sciences (SPSS) version 16 by IBM India, Bangalore, India. P < 0.001 was considered statistically significant. (All students were thoroughly taught how to use LVA). Statistical analysis was done using SPSS software version 16.

Intervention

Intervention was dispensing spectacles and low vision aids for distance and near vision.

Distance telescopes

The initial magnification power used for testing was predicted from the ratio of the denominator of the measured visual acuity to the denominator of the desired visual acuity.

The eye with better contrast acuity or visual field was preferentially fitted. Binocular telescopes were used for children who exhibited binocular vision.

Near-vision aids

The required starting addition was determined using the precalculated magnification values printed in the Keeler's chart. The starting addition required for near vision was determined using the Kestenbaum's rule (using the reciprocal of the distance visual acuity to calculate the dioptric power of the addition).

×2.75 and × 4 Galilean telescopes were used for distance, whereas handheld LED/non-LED magnifier, dome magnifier, spectacle magnifier, and bar magnifier were used for near trail

A device which is providing optimal visual performance with suitable posture was selected to prescribe after assessing their vision with those devices both at near and distance

Then, the spectacles and LVAs were distributed. Students were thoroughly given training and advices on how to use those devices.

Using the L V Prasad Eye Institute Functional Vision Questionnaire, a baseline idea about their functional vision was made.[18] After 6 months, the same questionnaire was asked to them by trained optometrists. On the basis of their personal realizations and feelings, how they rate (no difficulty, little difficulty, moderate difficulty, tough, and impossible), their performance, the difference between their functional vision performance before using LVAs and after using LVAs. The L V Prasad Functional Vision Questionnaire.

The students were again revisited and reexamined to observe what difference the intervention had made to their vision function after 6 months. Their functional vision was assessed through a longitudinal study process.

Statistical analysis

The data were entered into an excel worksheet and Statistical Package for the Social Sciences (SPSS Version 16) software was used for data analysis.

Results

A total of 428 children enrolled in four schools for the blind underwent comprehensive eye examination in 2015–2016 with a follow-up after 6 months. Two hundred and fifteen (50.2%) children were boys and 213 (49.8%) were girls. Their ages ranged from 4 to 36 years. When calculating the causes of blindness, data of age group between 4 and 18 years were taken into consideration. Visual acuity was assessed separately for each eye.

Out of this series, 135 (31.5%) children had been blind since birth, 184 (43.0%) became blind in the 1st year of life, and 82 (19.2%) became blind after infancy. Ninety-five (22.2%) children had another blind member in the immediate family, whereas 29 (6.7%) children reported a consanguineous marriage of their parents. Out of 428 students, 219 (51.1%) reported that they saw enough to walk around, 183 (42.7%) reported that they could recognize faces, and 149 (34.8%) reported that they could read print. The visual acuity details of the children are enumerated in Table 1.

Table 1

Visual acuity of the student’s in each eye

Visual acuity	Number of students, n (%)
	Right eye	Left eye
No PL	159 (37.1)	153 (35.7)
PL, PR to <3/60	222 (51.9)	221 (51.6)
3/60-6/60	37 (8.6)	37 (8.6)
6/60-6/18	15 (3.5)	15 (3.5)
6/18-6/6	1 (0.2).	1 (0.2)

PL: Perception of light, PR: Projection of light

Additional disability was not noted in 405 (94.6%) children. Only 4 (0.9%) children had hearing loss, whereas learning disability was seen in 5 (1.2%) students. Out of all 428 students, 370 were bilaterally blind, with vision <6/60, aged <18 years.

The causes of blindness and severe visual impairment in the students are shown in Table 2. There were 15 (3.5%) students who had undergone cataract surgery, nonetheless, had poor vision after surgery due to posterior segment pathology (high myopia) in 2 (13.3%) and/or amblyopia in 9 (60%). Two (13.3%) students had nystagmus, 1 (6.6%) had corneal scar, and 1 (6.6%) had anterior staphyloma. Five (18%) students had high astigmatism which was the cause of visual impairment in these students. Six (3.7%) children were recommended cataract surgery and 9 (2.10%) were recommended corneal transplant.

Table 2

Causes of blindness and severe visual impairment in the students <18 years

Causes of blindness	Number of students, n (%)
Microphthalmos	61 (16.4)
Anophthalmos	47 (12.7)
Microphthalmos and anophthalmos	9 (2.4)
Retinal causes	42 (11.3)
Corneal scarring	40 (10.8)
Nystagmus	29 (7.8)
Phthisis bulbi	24 (6.4)
Optic atrophy	22 (5.9)
Cataract	18 (4.9)
ROP	4 (1.1)
Total	370 (100)

ROP: Retinopathy of prematurity

Fifty-four out of 428 children were given spectacles and/or LVAs, where their age ranged 7–23 years, of which 27 (50%) were girls. Only spectacles were given to 15 students, LVAs for distance to 11 students (8 of whom also received spectacles), LVAs for near to 17 students (of whom 13 also received spectacles), and LVAs for distance and near to 11 students (6 of whom also received spectacles). The spectacles given to students had refractive power ranging from +10.0 to −22.0 D sphere and from −7.0 to +1.75 cylinder. Twenty-three students attained N6-N12 acuity. After dispensing LVAs, 10 students could identify the font of N6, 5 students the font of N8, 1 student the font of N10, 7 students the font of N12, 2 students the font of N18, and 1 student the font of N36, 26 in all could identify letters or numbers. With spectacles and LVAs, 1 student improved to 6/6, 3 to 6/9, 2 to 6/12, 6 to 6/18, 5 to 6/24, 5 to 6/36, and 2 to 6/60. Three more students had their vision improved from 3/60 to <6/60.

The details of the low vision devices dispensed are in Table 3. The selection of the students for low-vision trial was a multifactorial consideration. Ability to use the residual vision, daily life activities, need, enthusiasm, and ability to handle and take care of the device properly were the important factors.

Table 3

Distribution of the low-vision devices

	n (%)
Low-vision aids: Distance
×2.75 Galilean telescope	9 (16.6)
×4 Galilean telescope	12 (22.22)
Low-vision aids: Near
×2.5 dome magnifier	8 (15)
×4 stand magnifier	1 (1.85)
Handheld magnifier×10	1 (1.85)
×3 handheld magnifier with LED	4 (7.40)

LED: Light emitting diode

The students who would receive spectacles and/or LVAs (either of near or distance or for the both) were verbally asked L V Prasad Eye Institute Functional Vision Questionnaire containing 21 questions by the same team of optometrists. A baseline data about their functional vision was recorded before they were given spectacles and LVAs.

After 6 months of dispensing, the 54 students were again asked to complete the questionnaire. Their replies were recorded and pre- and post-rating were then compared and analyzed by SPSS (version 16). P < 0.01 was considered statistically significant.

The before and after comparison of functional vision in the students receiving intervention is shown in Table 4. All of these students showed a significant improvement in their vision function for all the 21 questions, but there was a significant difference in following questions: differentiating whether a person across the street was a boy or girl, if someone was waving across the road, difficulty of walking home at night, reading the bus number, reading other details on the bus, locating a ball when playing, writing in a straight line, and reading the text book at an arm's length.

Table 4

Change in the scores in L V Prasad Eye Institute Functional Vision Questionnaire for students who were dispensed spectacles and/or low-vision aids

	Preintervention		Postintervention		P
	Minimum-Maximum	Median	Minimum-Maximum	Median
Q1. Do you have any difficulty in making out whether the person you are seeing across the read is a boy or a girl, during the day?	0-4	1	0-1	0	<0.001
Q2. Do you have any difficulty in seeing whether somebody is calling you by waving his or her hand from across the road?	0-3	0.5	0-1	0	<0.001
Q3. Do you have difficulty in walking alone in the corridor at school without bumping into objects or people?	0-3	0	0-0	0	0.006
Q4. Do you have any difficulty in walking home at night (from tuition or a friend’s house) without assistance when there are streetlights?	0-3	2	0-3	1	<0.001
Q5. Do you have any difficulty in copying from the blackboard while sitting on the first bench in your class?	1-4	2	0-4	1	0.001
Q6. Do you have difficulty in reading the bus numbers?	1-4	2	0-4	1	<0.001
Q7. Do you have any difficulty in reading the other details on the bus (such as its destination)?	1-4	3	0-4	1	<0.001
Q8. Do you have any difficulty in reading your textbooks at an arm’s length?	0-4	2	0-4	1	<0.001
Q9. Do you have any difficulty in writing along a straight line?	0-3	1	0-2	0	<0.001
Q10. Do you have any difficulty in finding the next line while reading when you take a break and then resume reading?	0-2	1	0-4	0	0.006
Q11. Do you have any difficulty in locating dropped objects (pen, pencil, and eraser) within the classroom?	0-3	0	0-3	0	0.016
Q12. Do you have any difficulty in threading a needle?	0-4	2.5	0-4	1	0.026
Q13. How much difficulty do you have indistinguishing between 1 rupee and 2 rupee coins (without touching)?	0-4	0	0-1	0	0.002
Q14. Do you have difficulty in climbing up or down stairs?	0-3	0	0-2	0	0.041
Q15. Do you have difficulty in lacing your shoes?	0-4	0	0-1	0	0.010
Q16. Do have difficulty in locating a ball while playing in the daylight?	0-4	1	0-3	1	<0.001
Q17. Do you have difficulty in applying paste on your toothbrush?	0-2	0	0-0	0	0.034
Q18. Do you have difficulty in locating food on your plate while eating?	0-2	0	0-0	0	0.011
Q19. Do you have difficulty in identifying colors (e.g., while coloring)?	0-4	0	0-3	0	0.006
Q20. Do you have difficulty watching television properly	0-3	0	0-3	0	0.007
Q21. How do you think your vision is compared with that of your normal-sighted friend?	1-3	2	1-3	1	0.007

These schools were examined by us twice earlier in the past two decades.[59] The comparison with earlier publications is given in Table 5.

Table 5

Comparison of the results demonstrating causes of blindness among schools examined across past 15 years

Common causes of blindness	2002-2005[5]	2010-2012[8]	2015-2016
Microphthalmos, anophthalmos (%)	41.3	30.9	31.6
Corneal conditions (%)	22.2	13.0	16.2
Lens (cataract, aphakia) (%)	6	16.9	9.5
Retinal disorders (%)	11.2	9.3	11.5

Discussion

A significant number (31.7%) of students in schools for the blind were congenitally blind due to abnormality of the globe. More than a third (35%) of students had no perception of light in either eye. However, some students had residual vision that could be used for functional purposes. Some of the students could see to walk around and recognize faces and prints. The purpose of the prescribing LVAs was to improve their residual vision for functional use. On dispensing optical aids, 54 students had marked improvement in their vision function. With improvement in visual functioning, they can have a better and more integrated education, recognize numbers, perform simple mathematics, and read regional languages and/or English, all of which would result in better opportunities, in work and social life. The students who were given optical aids reported significant improvements in distance-vision activities such as recognizing far objects and in near ones such as writing in a straight line. There was no significant improvement for activities such as walking down the corridor, applying toothpaste on the toothbrush, or tying of shoelaces, as the children would have adapted to and mastered these activities of daily living even without significant vision.

While numerous studies across the globe have reported students of schools for the blind having residual useful vision and recommending correction, we believe that this is the first study to report the actual improvement in vision function after provision of LVAs after 6 months of follow-up.[911141516] The earlier in life a special child is examined and dispensed low vision aids and spectacles, the greater would be the chances of their learning better and developing diverse set of skills.

In parallel with the results of some African and Asian studies, there were 12 students with operable congenital or developmental cataracts in the students of the schools for the blind.[19] There were 15 (3.5%) students who had undergone cataract surgery, but nonetheless that poor vision after the surgery due to coexisting ocular morbidity. However, 9 out of 15 (60%) students had amblyopia. This again underlined the fact that mere cataract surgery in blind children is not enough. A regular, active, long-term follow-up with optical correction and anti-amblyopia treatment was needed; otherwise, the gains of a good surgical intervention would be nullified.[20]

Whole globe anomalies, anophthalmos and microphthalmos were the most common causes of blindness in children, like the studies published from these schools for the blind earlier.[5678921] While their exact cause is a matter of conjecture, a genetic and environmental interaction has been proposed.[2223] More research is needed in this important field, as these relatively common conditions can be so far managed only by rehabilitation and LVAs.[1024]

Retinopathy of prematurity, as a cause of blindness that was not observed in these schools 2002–2004 series and seen in only one child in 2011–2012, was now an established cause of blindness in children in school for the blind. Four students were blind because of it. Children blind with retinopathy of prematurity lose their vision in early infancy, but most children join a special school for blind when they are 5–8 years of age. Thus, there is a time lag of half a decade between such children losing their vision and being seen in special schools for the blind. However, India's burgeoning population, vast increase in neonatal care coverage, its uneven quality, and relatively poor awareness and opportunities for early screening of neonates at risk make retinopathy of prematurity an avoidable and iatrogenic cause of childhood blindness that would need enormous effort and coordination between the numerous public, private, and not-for-profit stakeholders to eliminate retinopathy of prematurity as a cause of blindness in children.[252627] Moreover, to ensure that not many need special education in schools for the blind.

Most residential schools for the blind offer not only free schooling but also free lodging, boarding, food, books, and other educational aids. The parents pay practically nothing as governments and philanthropists pick up the tab. This may be a vicarious incentive for many parents to keep the children in such special schools, even if they can see enough to attend normal schools. Also from parents’ viewpoint, such schools offer a modicum of safety, allow socializing with similar peers, and take complete responsibility of the child. However, while some stakeholders may not be enthusiastic about integrated education, all schools for the blind children should undergo a comprehensive eye examination that is repeated every other year and are prescribed and dispensed optical devices to maximize their limited visual potential and are taught to recognize and read print.

A limitation of our study was that the outcome was assessed subjectively, in the form of a questionnaire. There may have been a floor and ceiling effect. However, the vision function questionnaire was the only tool available to have an idea of comprehensive visual function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.