Visual Impairment & Eye Health in Children. Susan Cotter, OD, MS So CA College of Optometry Marshall B Ketchum University Fullerton, CA
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1 Visual Impairment & Eye Health in Children Susan Cotter, OD, MS So CA College of Optometry Marshall B Ketchum University Fullerton, CA
2 Consequences of Childhood VI Social Emotional Physical Educational Economical Quality of Life
3 Consequences of Childhood VI Unilateral congenital cataract associated with delayed motor functioning at 4.5 years - may adversely affect social and academic functioning* If unilateral, risk of 5-year incident VI in betterseeing eye (RR = 2.7 X) *Celano et al. Dev Med Child Neurol in press (from Infant Aphakia Trial)
4 Leading Causes of Childhood Blindness in US Cortical visual impairment Optic nerve hypoplasia Retinopathy of prematurity (ROP) risk if minority, low SES, low birth weight Kong et al. J AAPOS 2012;16:
5 Retinopathy of Prematurity: US Incidence Overall = 0.17% Premature infants in NICU = 7.35% If >28 days NICU = 15.5% Lad et al. Am J Ophthalmol 2009;148:
6 Leading Causes of Visual Impairment Infants, Toddlers, Preschoolers Amblyopia Refractive Error Strabismus The BIG THREE
7 Amblyopia Reduced best-corrected VA with amblyogenic factor in healthy eye(s) Abnormal visual experience interferes with normal development of visual pathways - impaired form vision Most common cause of vision loss in children
8 Strabismus
9 Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo mo Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* MEPEDS. Ophthalmology 2008;115: McKean-Cowdin et al. Ophthalmology 2013;120:
10 Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo mo* Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% 2.5% 3.2% 3.6% Amblyopia* 2.6% 1.5% 1.8% 1.8% MEPEDS. Ophthalmology 2008;115: McKean-Cowdin et al. Ophthalmology 2013;120:
11 Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo mo Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% 2.5% 3.2% 3.6% Amblyopia* 2.6% 1.5% 1.8% 1.8% MEPEDS. Ophthalmology 2008;115: McKean-Cowdin et al. Ophthalmology 2013;120:
12 Risk Factors for Strabismus & Amblyopia Unilateral Amblyopia Hispanic ethnicity Esotropia Anisometropia Bilateral Amblyopia Lack of health insurance Lower primary caregiver education Astigmatism Hyperopia 4.00D SE Strabismus Prematurity Maternal smoking during pregnancy Hyperopia MEPEDS/BPEDS: 9970 Children 6-72 months; Ophthalmology 2011;118(11): and
13 Risk of Esotropia Associated with Bilateral Hyperopia MEPEDS/BPEDS: 9970 AA, Hispanic, White Children 6-72 months Bilateral SE Hyperopia Odds Ratio* 95% CI 0.0 to <+1.00 D reference <0.00 (myopia) to <+2.00 D to <+3.00 D to <+4.00 D to <+5.00 D D Based on multivariate stepwise logistic regression model; adjusted for age, anisometropia, maternal smoking, gestational age. Level of hyperopia defined by less hyperopic eye Cotter et al. Ophthalmology 2011;118(11):
14 Refractive Error
15 MEPEDS. Ophthalmology 2010;117:140-7;Fozailoff et al. Ophthalmology 2011;118:284-93; Wen et al. Ophthalmology 2013;120: Refractive Error Prevalence MEPEDS: Children 6 to 72 Months of Age Refractive Error (SE*) Hisp n=3030 Afr Am n=2994 NHW n=1501 Asian n=1507 Myopia D* 3.7% 6.6% 1.2% 4.0% Hyperopia 2.00 D* 26.9% 20.8% 25.7% 13.5% Astigmatism 1.50 D 16.8% 12.7% 6.3% 8.3%
16 WHO Visual Impairment Definition Presenting Visual Acuity
17 Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116: ; Ophthalmology 2013;120:1220-6
18 Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116: ; Ophthalmology 2013;120:1220-6
19 Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116: ; Ophthalmology 2013;120:1220-6
20 Visual Impairment: Young Children MEPEDS: Children 6 to 72 months of Age Better Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 3.5% 3.9% 1.0% 0.9% With ophthalmic etiology (VI) 2.5% 2.8% 0.8% 0.8% VI: Resolving RE* 1.7% 1.9% 0.3% 0.5% VI: Best-Measured Not RE * Refraction & retest 0.7% 0.8% 0.3% 0.2%
21 Wearing Spectacle Correction? MEPEDS Hispanic & Afr-Am = 1.6% Asian & NHW = 2.2% BPEDS NHW & Afr-Am = 1.7%
22 VI is Not Always Present in Isolation
23 Children with Developmental Disabilities Increased risk of VI (10.5% vs. 0.16%)* - & other ocular disorders, including RE & strabismus Preterm Cerebral palsy Down syndrome Severe hearing impairment Learning difficulties Other neurodevelopmental disorders VI Not Always Recognized *Salt et al. Arch Dis Child 2014;99:
24 Developmental Impact of VI Directly related to level of VI: Spatial awareness, posture, movement skills Use of hands & fine movement coordination Early concept development (e.g., object permanence) Locating sound in space Understanding meaning of words and thus speech / language development Social interaction and communication Self-care skills Salt et al. Arch Dis Child 2014;99:
25 Refractive Error
26 Hyperopia: Other Concerns? Uncorrected hyperopic 4-& 5-yr old children with to D & no strabismus / amblyopia, vs. emmetropic controls? Visual acuity (distance & near) Stereoacuity Accommodative response (accuracy) Test of Preschool Early Literacy (TOPEL) Kulp et al. VIP-HIP ARVO May 2015; Ciner et al. ARVO May 2015
27 School-Age Children & VI
28 Refractive Error Prevalence School-aged Children CLEERE: Children 5-17 Years of Age (%) Refractive Error (both meridians)* Hisp (463) Af-Am (534) NHW (1035) Asian (491) Total (2523) Myopia D* Hyperopia +1.25D* Astigmatism 1.00 D Kleinstein et al. Arch Ophthalmol 2003:121:
29 Are Decreased Vision & RE the Only Concerns for School-Age Children? Vergence Disorders Accommodative Disorders
30 Symptoms Associated with Reading in Children w/ Convergence Insufficiency Frequent loss of place Loss of concentration Double vision Blurred vision Headaches Reading slowly Eyestrain Tired eyes Sleepiness Trouble remembering was read Need to re-read same line of words what CITT Group. Arch Ophthalmol 2008;126: Barnhardt et al. Optom Vis Sci 2012;89:
31 Conclusion Childhood Visual Impairment Definition dependent & age dependent Infants & Early Childhood Amblyopia Strabismus Refractive error Middle Childhood & Adolescence Refractive error Accommodative disorders Vergence disorders Ocular disease at all ages
32
33 Extra Slides Have 95% Confidence Intervals
34 Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence (95% CI) Aged 6 to <72 Months Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% ( ) 2.5% ( ) 3.2% ( ) 3.6% ( ) Amblyopia* 2.6% ( ) 1.5% ( ) 1.8% ( ) 1.8% ( ) MEPEDS. Ophthalmology 2008;115: McKean-Cowdin et al. Ophthalmology 2013;120:
35 Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence (95% CI) Aged 6 to <72 Months Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% ( ) 2.5% ( ) 3.2% ( ) 3.6% ( ) Amblyopia* 2.6% ( ) 1.5% ( ) 1.8% ( ) 1.8% ( ) MEPEDS. Ophthalmology 2008;115: McKean-Cowdin et al. Ophthalmology 2013;120:
36 Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% ( ) 5.9% ( ) 2.6% ( ) 3.4% ( ) VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured 2.2% ( ) 1.8% ( ) 1.3% ( ) 1.2% ( ) *Refraction & retest. Ophthalmology 2009;116: ; Ophthalmology 2013;120:1220-6
37 Visual Impairment: Young Children MEPEDS: Children 6 to 72 months of Age Better Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 3.5% 3.9% 1.0% 0.9% With ophthalmic etiology (VI) 2.5% ( ) 2.8% ( ) 0.8% ( ) 0.8% ( ) VI: Resolving RE* 1.7% 1.9% 0.3% 0.5% VI :Best-Measured 0.7% ( ) 0.8% ( ) 0.3% ( ) 0.2% ( ) * Refraction & retest
38 Refractive Error Prevalence School-aged Children CLEERE: Children 5-17 Years of Age Refractive Error (both meridians)* Hisp (463) Af-Am (534) NHW (1035) Asian (491) Total (2523) Myopia D* Hyperopia +1.25D* Astigmatism 1.50 D ( ) 12.8 ( ) 28.4 ( ) Kleinstein et al. Arch Ophthalmol 2003:121:
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