Srijana Adhikari

Visual development is an important aspect of infant and child development. Vision is a complex sensorineural process, the development of which begins soon after the birth. Healthy eyes and good vision are key components to achieve many important developmental milestones in children. Hence Paediatric eye care should be started as soon as the child is born and continue throughout childhood and adolescence. It is an important public health component as childhood blindness carries a lifetime of economical and psychosocial impact.

Background: Poor vision compromises quality of life and participation in different daily life activities of children such as, sports, leisure time, interactive play and social interaction. The purpose of this cross - sectional study is to investigate participation and quality of life of children with visual impairment (VI) and blindness compared with normally sighted peers. Methodology: Children aged 7–17 years with blindness (n = 100), moderate to severe VI (n = 100) and normal sight (n = 100) completed Nepalese versions of the Participation and activity inventory children and youth (PAI-CY 7–12 and 13–17), L. V. Prasad functional vision questionnaires (LVP-FVQ II) and Pediatric Eye Questionnaires (PedEyeQ 5–11 and 12–17). The measurement properties of PAI -CY was studied. All (sub) scores were compared between three groups. Associations between the severity of VI and outcomes were assessed with age and sex adjusted linear regression analyses. Results: Children with blindness scored worse than children with VI, who scored worse than normally sighted children on the PAI-CY 7–12, the physical functioning subscale of the PAI-CY 13–17 and the LVP-FVQ II(p = < 0.001).However, for the psychosocial functioning subscale of PAI-CY 13–17, children with blindness scored better than children with VI(p = < 0.01). On the PedEyeQ, young children (5–11) with blindness on all subscales, and older children (12–17 years) with blindness on the functional vision subscale scored worse than children with VI(p = < 0.01).Regression models showed that both moderate/severe VI and blindness were significantly associated with worse PAI-CY, LVP-FVQ II, PedEyeQ 5–11 and PedEyeQ 12–17 functional vision subscale scores(p = < 0.01). Conclusion: Younger children with blindness showed worse participation and quality of life compared to children with VI, whereas results for older children showed a mixed pattern with children with blindness showing better participation in psychosocial domain. Appropriate low vision rehabilitation interventions are needed for children with VI and blindness to increase their participation and quality of life to the level of their normally sighted peers as far as possible. Future studies could include children who do not attend school and may have worse participation and quality of life than children in our study.

Purpose: To compare objective physical activity (PA) levels of children with visual impairment (VI) and children with normal sight. Methods: One hundred children with VI and 100 age- and gender-matched normal-sighted peers 7 to 17 years of age wore an ActiGraph for 1 week. Activity count per minute (cpm) was modeled using a series of generalized linear mixed-effects models including vision, age, sex, time of day, and vision by time of day interaction. PA outcomes included mean counts per minute and proportion of time spent on sedentary, light, moderate, and vigorous intensity PA. Results: Data of 83 children with VI and 77 normal-sighted peers were included. Mean counts per minute were lower in children with VI (P < 0.001), especially during and after school. Children with VI were less sedentary (55%; 95% confidence interval [CI], 53–57) than children with normal sight before school (62%; 95% CI, 60–64) and over weekends: children with VI, 41% (95% CI, 39–43); children with normal sight, 45% (95% CI, 43–47). Yet, children with VI were more sedentary during school (36%; 95% CI, 34–37) compared with children with normal sight (30%; 95% CI, 29–32). They also spent more time performing light PA and less time performing moderate PA at school and vigorous PA across all periods of day (P < 0.001). Conclusions: Children with VI participated in light and moderate PA but did not perform as much vigorous PA as children with normal sight, especially during school hours. Translational Relevance: There is a need to promote more intense PA programs in schools tailored for children with VI.

Introduction: Myopia is emerging as a public health emergency worldwide. Low dose atropine has been proven to be safe and efficacious in halting the progression of myopia. Objectives: Aim of this study was to evaluate safety and efficacy of low dose atropine in Nepalese children with progressive myopia. Materials and methods: It is a prospective non randomized interventional study. Children with myopia progression of >0.5D in the last six months with baseline myopia of -1.5 to -8 Diopter and astigmatism of 3 D or less were prescribed 0.01% atropine daily at bedtime for two years. Demography including age, gender, race, and examinations including anterior and posterior segment, axial length, near point of accommodation and near vision were recorded in all the children. Ocular and systemic side effects were documented. Results: A total of 200 children were enrolled in the study. Mean age was 11.9±2.97 years with 41% female. Baseline mean axial length was 24.47±1 and mean spherical equivalent was 3.69±1.33. Average increase in axial length was 0.18(±0.02), 0.17(±0.02), and 0.19(±0.04) mm in six months, one year, and two years respectively. The increase in spherical equivalence was 0.2 (±0.01), 0.3(±0.02), and 0.3(±0.02)) diopter in six months, one year, and two years respectively. The myopia progression was found more in the Mongolian race compared to the Aryan race. No ocular or systemic side effects were documented. Conclusion: Topical low dose atropine appears to be safe and efficacious in halting the progression of myopia in a cohort of Nepalese children. Further randomized control trial on various doses of atropine are recommended.

Response to Letter in regards to Causes of Moderate to Severe Visual Impairment and Blindness Among Children in Integrated Schools for the Blind and Visiting a Tertiary Eye Hospital in Nepal: The Nepal Pediatric Visual Impairment (NPVI) Study [Letter]

Purpose: To study the causes of moderate and severe visual impairment (VI) and blindness and its changing trends in Nepalese children. Patients and Methods: A cross-sectional descriptive study was conducted. Participants, aged 7 to 17 years were recruited from integrated schools for the blind and the outpatient department of a tertiary eye hospital in Kathmandu. VI and blindness were categorized according to World Health Organization (WHO) categories and its protocol for eye examination of children with blindness and VI was followed. Findings were compared to former studies from Nepal. Results: A total of 200 children were included, of whom 45% had moderate VI, 5% had severe VI, and 50% were blind. Mean age of children with VI and blindness was 11.1 (SD = 3.3) and 12.9 (SD = 3) years, respectively. Forty percent of children with VI and 38% of blind children were female. In our study, retina (39%) and whole globe (32%) were the most common anatomical site of involvement in children with VI and blindness, respectively, while cornea was the most common anatomical site of involvement in former studies. Heredity (43%) was the most common etiological factor although in 24.5% of all children, etiology was unknown. In 43.5% of children, blindness and VI was due to avoidable causes. Conclusion: In relatively many children, the etiology of VI and blindness could be either prevented or treated. Compared to former studies from Nepal, there is a changing trend in the etiology of severe VI and blindness.

Background: Visual impairment is an important cause of disability in children. There is a lack of information on rehabilitation needs and low vision support services for children with visual impairment in Nepal. This is a pilot study designed to translate, culturally adapt and pre-test the Dutch version of the Participation and Activity Inventory for Children and Youth (PAI-CY) with visual impairment aged 7–17 years to develop a Nepali version. Questionnaires (PAI-CY versions for 7–12 and 13–17 years) were translated using standardized methods and were culturally adapted by a panel of experts. They were pretested to evaluate comprehensibility and relevance among six children with visual impairment and blindness. Finally, participants completed a questionnaire evaluation form. Results: The translation and cultural adaptation process resulted in the adaptation of nine items to make them suitable for Nepali culture. Most children had comprehensibility problems with some specific items because of vocabulary, sentence structure and the composition of items. Most of the children were satisfied with the questionnaires. Conclusion: The study resulted in the development of a Nepali version of the PAI-CY. We worked with a small group of content experts and a small but representative sample of children which allowed us to use rigorous translation procedures to address language and cultural differences. A population based study has been planned to investigate the psychometric properties of these questionnaires.

Background: Genetic eye diseases constitute a large and heterogeneous group of childhood ocular morbidity. Individual diseases may cause multiple structural anomalies and developmental features. Nepal Pediatric Ocular Disease Study (NPODS) was a population-based epidemiological study conducted across three ecological regions of Nepal to determine the prevalence and etiology of childhood ocular morbidity and blindness. In Phase II of this study, genetic analysis was performed for children who were found to have congenital ocular anomalies. Method: It was a cross sectional descriptive study. A total of 10,270 children across three different ecological regions in Nepal (Low lands, hills, and mountains) underwent ocular examinations in NPODS. Out of 374 (3.6%) of children with ocular abnormalities, 30 were thought to be congenital in nature. Targeted genetic analysis, including genotyping for genes specific to presenting phenotype, was performed for 25 children using serum samples. Results: Out of 25 children, 18 had meaningful genetic results. Analysis revealed one missense alteration G12411T of Zinc Finger Homeobox 4 (ZFHX4) gene in one participant among 10 with congenital ptosis and another missense variation T > C P. Y374 C of Signaling Receptor and Transporter Retinol 6 (STRA6) gene in one participant among 3 with microphthalmos. Conclusion: The study is first of its kind from Nepal and mutant genes were unique to Nepalese Population. Further analysis of genetic factors is crucial to better understand genetic association with ocular diseases and conditions. This helps further in genetic counseling and probably gene therapy to prevent blindness from these conditions.