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Year : 2019  |  Volume : 57  |  Issue : 1  |  Page : 8-11

Burden of visual disability in children with other disabilities

1 Department of Ophthalmology, Aarupadai Veedu Medical College and Hospital, Puducherry, India
2 Department of Paediatric Ophthalmology and Squint, Aravind Eye Hospital and Postgraduate Institute, Puducherry, India

Date of Web Publication10-Jun-2019

Correspondence Address:
Dr. Ganapathy Kalaiselvi
Aarupadai Veedu Medical College and Hospital, Kirumampakkam, Puducherry - 607 403
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_115_18

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Aim: The aim of the study was to assess the visual function of children with other disabilities and to identify the preventable and treatable ocular comorbidities. Materials and Methods: This study was a cross-sectional study included children aged 3–16 years who were on speech therapy sessions. After consent from parents or guardian who accompanied the child, relevant medical history was noted. Distant visual acuities were measured using picture chart, Snellen tumbling E-chart or Cardiff preferential looking cards, and complete ocular examination was performed. Cycloplegic retinoscopy was done in all children. Spectacles and low-vision aids were prescribed appropriately. Results: Out of 83 children with learning disabilities attending speech therapy clinics who were enrolled, fifty four (65%) had ocular disorders. Refractive error was identified in 31 children(37.34%), Strabismus and nystagmus in 12 children (14.45%), cataract in 4 children (4.81%), disc pallor and retinal detachment in 2 children each (2.4%), while microphthalmos, congenital glaucoma and coloboma were noted in one child each (1.2%). Thirty-five children were not cooperative for visual acuity assessment while 13 of them had more than one ocular abnormality. Only two of the 31 students with refractive errors were using spectacles. Conclusion: The poor communication and poor cooperation of these children with disabilities add on to the burden of their disabilities as the ocular abnormalities are not recognized early. Therefore, a multidisciplinary treatment approach needs to be stressed, while the awareness among the parents and caregivers needs to be developed to help these children in their learning process and rehabilitation.

Keywords: Children with disabilities, refractive error, strabismus

How to cite this article:
Dinukumar A, Kalaiselvi G, Fredrick M, Veena K. Burden of visual disability in children with other disabilities. TNOA J Ophthalmic Sci Res 2019;57:8-11

How to cite this URL:
Dinukumar A, Kalaiselvi G, Fredrick M, Veena K. Burden of visual disability in children with other disabilities. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2021 Dec 3];57:8-11. Available from: https://www.tnoajosr.com/text.asp?2019/57/1/8/259873

  Introduction Top

In India as per the census conducted in 2011, there are 26.8 million people suffering from one or the other type of disability. This is equivalent to 2.21% of the total population. Out of these, there were 7.8 million children aged 0–19 years constituting 29% of the total disabled population. The number of disabled persons is highest in the age group of 10–19 years, 46.2 lakhs, 17% of the disabled population. Out of the total disabled, in the age group of 0–19 years, 18% of them have visual problems, whereas in the age group of 0–6 years, it is as high as 30%.[1] The types of disabilities commonly noted are disabilities in seeing, hearing, speech, movement, and mental illness.

In children with disabilities other than visual disability, the visual problems are relatively common;[2],[3],[4],[5],[6],[7] however, as the priorities are on the primary disability, the visual impairment and its assessment are often overlooked. On the other hand, the ocular examination in these children with learning disabilities needs patience, broader range of assessment instruments, and indeed a challenge to ophthalmologist.[2] Early identification and intervention of the visual problems are very much in need for these children as they depend on their visual cues for understanding the world and for their social communication.[2],[6]

The aim of the present study is to assess the visual function of children with other disabilities and to identify the preventable and treatable ocular comorbidities.

  Materials and Methods Top

The study was approved by the Institutional Ethical Committee. All children (children <16 years, as defined by the WHO) with disabilities other than visual impairment and who were attending speech therapy clinics in our institution between September 2016 and August 2017 were enrolled in our study. The examination process was explained to the parent or guardian accompanying the children. Those children whose parents did not give consent for the examination were excluded from the study. Written informed consent was taken from the parent or guardian who accompanied the child. Details regarding disability, family history, birth history, history of consanguinity, intensive care unit admission after delivery, seizure episodes, physical disability, and hearing abnormality if any were recorded.

External ocular examination was carried out in diffuse illumination with a torch light. Head posture, facial anomalies, and ocular motility were noted. Orthoptic examination was performed using Hirschberg's reflex, and if this was abnormal, cover/uncover tests were performed. Cardiff's preferential looking test was used to measure visual acuity in more disabled and younger children. Snellen chart in English or numbers was used for children who could cooperate for the visual acuity assessment. Snellen “E” chart was used for children who did not know how to read but were able to interpret symbols.

Subjective correction of refractive errors was attempted in children who were cooperative. Cycloplegic retinoscopy was done in all children using 0.3% cyclopentolate eye drops after ascertaining that the child did not have seizures. In case of history of seizures, 0.5% homide eye drops were used. A detailed fundus examination after dilatation was done by a direct ophthalmoscope. Myopia was defined as spherical equivalent of ≥−0.5 diopter (D), hypermetropia as ≥+1.0 D, and astigmatism as ≥±0.5 D. Spectacle prescription was given to all children with refractive errors. The data were entered using an excel sheet and analyzed using SPSS 22, IBM, Armonk, NY, United States of America. The data were expressed using descriptive statistics.

  Results Top

A total of 83 children with learning disabilities who were attending speech therapy clinics were examined. Out of the 83 children, 38 (45.78%) were in the age group of 3–9 years and 45 (54.22%) were in the age group of 10–16 years. There were 59 (71.1%) males as compared to 24 (28.9%) females in the study.

A stormy perinatal history was seen in 64 (77.1%) children as in [Figure 1]; 12 (14.5%) had positive family history of learning disability/cognitive impairment, 23 (27.7%) had positive history of consanguinity, 39 (47%) had been in Intensive care unit after birth, 12 (14.5%) had been detected with hearing impairment, and 35 (42.2%) had seizure disorder.
Figure 1: Distribution of perinatal insult among the children

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The study covered children with six different types of disabilities – cerebral palsy, global developmental delay (GDD), attention-deficit hyperactive disorder (ADHD), autistic feature, Down syndrome, and mental subnormality. [Figure 2] shows the distribution of children according to the disabilities and the ocular problems noticed in them.
Figure 2: Children in each disability types and their ocular disorders

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Out of 83 children examined, 54 (65%) children had ocular disorders and 13 children had more than one ocular abnormality. Fifty-four children with ocular disorder included 25.9% with mental retardation, 16.67% with autistic feature, 20.37% with cerebral palsy, 9.26% with ADHD, 16.67% with Down syndrome, and 11.11% with GDD. The children with ocular abnormality among the disability types are represented in [Table 1].
Table 1: Distribution of the children in each disability types with ocular abnormalities

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The burden of the visual problems faced by children in each disability is found in [Table 2].
Table 2: Frequency of ocular findings in children with other disabilities

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The most common ocular manifestation observed in the study was refractive errors, present in 31 (37.34%) children. Strabismus and nystagmus were the second most common findings, seen in 12 (14.45%) children followed by cataract in 4 (4.81%) and disc pallor and retinal detachment in 2 (2.4%). Microphthalmos (uniocular) and congenital glaucoma were noted in one child each, and coloboma of iris, lens, choroid, and retina was seen in a child [Figure 3].
Figure 3: Distribution of ocular abnormalities noticed in the children with other disabilities

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Forty-one children were not cooperative for visual acuity assessment, 11 were corporative for Snellen optotypes, 22 children responded to Snellen E-chart, while nine responded to Cardiff charts.

Refractive error was seen in 31 children (37.34% of ocular problem). Of them, refractive error was present in both eyes in 26 children (83.87%) whereas five children (16.13%) had in one eye only. The most common type of refractive error was simple myopia in 26 eyes (45.61%), followed by astigmatism in 18 eyes (31.58%), hypermetropia in 9 eyes (15.79%), and high myopia in 4 eyes (7.02%) Only four of the 31 children (12.9%) had been previously corrected for their refractive error. Spectacles were prescribed to all 27 children who had been found to have refractive error and new corrected prescription of glasses was given to the rest four children who were using glasses.

Of the 12 (14.45%) children who had strabismus, 7 (58.33%) had exotropia and 5 (41.67%) had esotropia. Of these children with strabismus, 5 (41.67%) had an associated refractive error. Four children with cataract, two with retinal detachment, and one with congenital glaucoma were advised to undertake surgical intervention.

  Discussion Top

Children with disabilities place a strain on their parents and their financial resources. The unattended visual impairment adds on to the burden of their existing disability, in these children. Their social, communication skills and in turn their overall development will be affected.

Our study found that 65% of the children with other disabilities had ocular problem. Gogate et al. in special schools of Pune reported 45.3%[2] while Kaur et al. in special schools of North India reported 43%.[7] Among the disability type, 70% of mentally subnormal children in our study were found having ocular problem while Joshi and Somani in Nagpur[8] reported 51.45% and Kalaiselvi and Kumar in Puducherry had reported 76% of children with mental retardation having ocular problems.[9] Among the children with autistic features, 50% of them were found to have ocular problems similar to 52% reported by Black et al.,[10] while Kaur et al. had reported 25.7%.[7] 78.57% of the children with cerebral palsy were noted with ocular problems in our study while Kaur et al. reported 69.3%.[7] Among the children with ADHD, 38.46% were noted having ocular problems in our study, while Gogate et al.[2] had reported as 45.3% and Kaur et al.[7] had reported as 53.3%. In Down syndrome, there were 75% in our study, while 95.4% in Akinci et al.[11] and 69.2% in Kaur et al.[7] had been reported to have ocular problems. All the six children in the GDD had ocular problems while Welinder and Baggesen[3] had reported 11% of them having visual impairment.

Refractive error (54.5%) followed by strabismus (19.3%) were the most common ocular problems noted in our study. A similar observation was noted in Gogate et al. with refractive error 27.3% followed by strabismus 15.8%.[2] In a series of 134 intellectually challenged students in Nepal, refractive errors were found in 67.9%.[12] Vora et al. had reported 58.5% of refractive error among the special children in Oman.[13]

In our study, 14.45% of children had strabismus. Similar observation was noted by Gogate et al. in 15.8%,[2] Kaur et al. in 18.1%,[7] and Vora et al.[13] in 14.3% of children with special needs. Strabismus could be due to amblyopia; binocularity is usually lost. Binocular vision disruption at early age affects the development of the child and hinders the learning process.

The fact that majority of the causes of visual impairment such as refractive errors and strabismus, leading to amblyopia, are easily treatable signifies the need for regular ocular assessment in these children with disabilities.[2],[13] There were only 12.9% children who were evaluated earlier and were using spectacles in our study, while Gogate et al.[2] reported as low as 6% and Vora et al.[13] reported 13.6%. Das et al.[14] stated that “the manner in which an eye test is conducted is most important” and emphasized the importance of carrying out tests in a familiar environment. Many parents and care providers believed that someone needs to be verbally competent to undergo an eye examination. The awareness among the parents and caretakers are still lacking. To meet the visual needs of children with disability, stronger links are needed between child development and community pediatric services, ophthalmology, and specialist education services for children with special needs. If the visual status of these special children could be improved, it would benefit their education and training.

  Conclusion Top

The majority of the ocular abnormalities in these children with learning disabilities are treatable and which would reduce their burden of difficulties. Annual ophthalmic assessments for these vulnerable groups of children are necessary.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Disabled Persons in India a Statistical Profile 2016. Social Statistics Division, Ministry of Statistics and Programme Implementation. Government of India. Available from: http://www.mospi.gov.in. [Last accessed 2017 Jan 11].  Back to cited text no. 1
Gogate P, Soneji FR, Kharat J, Dulera H, Deshpande M, Gilbert C, et al. Ocular disorders in children with learning disabilities in special education schools of Pune, India. Indian J Ophthalmol 2011;59:223-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Welinder LG, Baggesen KL. Visual abilities of students with severe developmental delay in special needs education – A vision screening project in Northern Jutland, Denmark. Acta Ophthalmol 2012;90:721-6.  Back to cited text no. 3
Woodhouse JM, Davies N, McAvinchey A, Ryan B. Ocular and visual status among children in special schools in wales: The burden of unrecognised visual impairment. Arch Dis Child 2014;99:500-4.  Back to cited text no. 4
Salt A, Sargent J. Common visual problems in children with disability. Arch Dis Child 2014;99:1163-8.  Back to cited text no. 5
Ostadimoghaddam H, Mirhajian H, Yekta A, Sobhani Rad D, Heravian J, Malekifar A, et al. Eye problems in children with hearing impairment. J Curr Ophthalmol 2015;27:56-9.  Back to cited text no. 6
Kaur G, Thomas S, Jindal M, Bhatti SM. Visual function and ocular status in children with disabilities in special schools of Northern India. J Clin Diagn Res 2016;10:NC01-4.  Back to cited text no. 7
Joshi RS, Somani AA. Ocular disorder in children with mental retardation. Indian J Psychiatry 2013;55:170-2.  Back to cited text no. 8
[PUBMED]  [Full text]  
Kalaiselvi G, Kumar D. Ocular disorders in children with learning disabilities in a tertiary Hospital, Pondicherry. Indian J Clin Exp Ophthalmol 2018;4:347-51.  Back to cited text no. 9
Black K, McCarus C, Collins ML, Jensen A. Ocular manifestations of autism in ophthalmology. Strabismus 2013;21:98-102.  Back to cited text no. 10
Akinci A, Oner O, Bozkurt OH, Guven A, Degerliyurt A, Munir K, et al. Refractive errors and strabismus in children with down syndrome: A controlled study. J Pediatr Ophthalmol Strabismus 2009;46:83-6.  Back to cited text no. 11
Ghising R, Shakya S, Rizyal A, Shrestha R, Shrestha S, Wang-Harris S, et al. Prevalence of refractive error in mentally retarded students of Kathmandu valley. Nepal Med Coll J 2007;9:262-5.  Back to cited text no. 12
Vora U, Khandekar R, Natrajan S, Al-Hadrami K. Refractive error and visual functions in children with special needs compared with the first grade school students in Oman. Middle East Afr J Ophthalmol 2010;17:297-302.  Back to cited text no. 13
[PUBMED]  [Full text]  
Das M, Spowart K, Crossley S, Dutton GN. Evidence that children with special needs all require visual assessment. Arch Dis Child 2010;95:888-92.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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