Indian J Pediat 48 : 703-708, 1981

Blindness in children and its management

Madan Mohan, M.S., F.A.M.S., and J.S. Saini, M.D.

Blindness among children is a colossal problem, both in magnitude and its economic effects. Prevention of blindness is more gratifying than attempts to cure or rehabilitate those already blind. Under the Indian National Plan .for the Control of Blindness launched in 1976, emphasis has been laid on imparting eye care education and delivery of primary eye care services as an integral part of general health services. Common causes of blindness in children, their prevention, treatment and rehabili- tation are detailed.

Key words : Blindness in children; causes; Management; Rehabilitation

Children are the assests of a country. Next to the prime physical needs, good health is most vital for their growth and development. Ocular health and hygiene forms an integral part of general health. Proper care of the eyes of the infants, pre-school and school going children can prevent most of the ocular and visual disorders.

Causes of blindness

Exact magnitude of the problem arrd epidemiological factors responsible for visual impairment and blindness in

From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, A.I.I.M.S. New Delhi-29.

Reprint requests : Dr. Madan Mohan, Chief Organiser and Professor of Ophthalmology, Dr. Rajendra Prasad Centre for Ophthalmic Sciences.

children for the whole country are not available. However, some studies of children in schools for the blind and a few limited surveys of school children in different parts ofthe country are available. In general causes of blindness ia children may be congenital or acquired.

Acquired causes include infections of con- junctiva and cornea (including ophthalmia neonatorum), injuries, nutritional defici- encies and involvement of eye in general diseases like measles, tuberculosis and other systemic infections. Factors affect- ing fetal development may also affect the eye e.g., irradiation, drugs and infections during pregnancy. Prematurity renders neonatal eyes prone to develop retrolen- tal fibroplasia. Among the genetically determined disorders are some which have i) single gene inheri!ance e.g. colour

704 THE INDIAN JOURNAL OF PEDIATRICS V o l . 48, No. 395

blindness, congenital cataract, retinobla- stoma, keratoconus, retinitis pigmentosa or Marfan's syndrome, and ii) Chromo- somal abnormalities such as Down's syndrome.

In surveys of school children in Delhi, 1-8 Madurai, 4 and Sivakasi, 4 defe-

ctive vision is seen to vary from 10.3 to 52.1~ (Table I). The commonest prob- blems were refractive errors, trachoma, muscle imbalance and squint. Next in incidence were xerophthalmia, cataract, corneal opacities, colour blindness and congenital defects etc.

Table-I Ophthalmic Findings in School Children in Indian Studies (~)

Disorder Old Delhi, New Delhi, Delhi, Madurai, Sivakasi' Agarwal Dada, Gupta Venkata- Venkata-

et al, (1966) (1970) (1940) swamy, swamy (1970) (1970)

Refractive error

Trachoma and conjunctivitis

Muscle imbalance and squint

Colour blindness

Xerophthalmia

Cataract

Corneal opacity

Other diseases

Visual defects

17.8 12.2 44 4 --

46.8 -- 43.7 5.1 4,4

13.4 5.65 6.1 -- 1.1

0.3 3.3 3.3 - -

1.8 0.5 0.9 22.0 22.5

- - - - 0 . 3 - -

0.9 0.3 0.4 - -

9.9 1.2

23.4 18.3 52.1 15.1 10.3

In a case study of children aged 5-15 years in residential blind schools of Delhi 5 it was observed that 75~ of children had blindness due to corneal involvement while 17~ had posterior segment patho- logy and 8~o / suffered from gross ocular congenital abnormalities. Among the congenital causes were congenital cataract (63~o), macular coloboma (15~o), micro- phthalmos with iris coloboma (5.5~) , microphthalmos with cataract (5.5~o), total aniridia (5.5%) and buphthalmos (5.5~). These studies though done on

somewhat selected population yet give insight into the etiological problems of blindness amongst children.

S o c i o - e e o n o m i c p r o b l e m s

The blind population causes socio- economic loss in two ways. Firstly, the blind cannot be fully productive, thus nation suffers a direct productivity loss. Secondly, a blind has to be sustained and rehabilitated. The nation further suffers indirectly on his maintenance and reha- bilitation. Another dimension that can

M O H A N A N D SAINI -" M A N A G E M E N T OF BLINDNESS 705

be added to this is the man years of active life lost due to blindness. In its totality, economic loss to the country is colossal. Therefore there is an urgent need to take proper measures for preven- tion of blindness in children.

Visually impaired children invariably develop social and psychological prob- lems. Their mental development is also affected due to loss of the most important afferent stimuli necessary for the growth and development of brain and its faculties.

Visual information is first received by the retina and then transmitted along the optic nerves to visual cortex. Information received is then analysed, coded and stored instantaneously while the system matures in an orderly fashion parallel with the development of other motor and sensory faculties. 6

There is a popular belief of "sensory compensation" in childhood blindness but it has been scientifically proven that training cannot enhance the acuity of hearing, touch, smell or taste of the blind except that these senses can be utilised and coordinated more efficient- ly.7, s Many of the visually impaired persons are not able to use their perce- ptions of hearing, touch, smell and taste effectively simply because they did not receive adequate sensory training to do so during early childhood. Blind children not only need to be encouraged but actively taught from early childhood to enrich their experience by relying more on the sense of hearing, smell, taste and touch.

Medical diagnosis

The diagnosis of visual impairment due to local eye diseases is relatively easy because of direct observation of pupillary response, cataract, corneal opacities, glaucoma, chorioretinitis, optic atrophy etc., while the diagnosis becomes difficult when local ocular findings are minimal. If the damage is beyond the geniculate bodies, then neurological examination and EEG can be helpful.

Two techniques can be very useful in the evaluation of visual impairment, electroretinogram (ERG) and visually evoked responses (VER) 9. The ERG abnormalities are seen mostly in retinal disorders. Abnormal VER is indicative of abnormal transmission along the visual pathways. These tests are specially useful when the eyes, otherwise, appear normal or when visual loss is not explainable by the findings of clinical examination.

Early diagnosis of blindness in child- ren is important for reasons already mentioned. Many a times progressive deterioration of sight can be prevented or vision improved by prescribing appro- priate corrective lenses or medical or surgical treatment. In many cases diagno- sis and treatment is delayed because of lack of awareness or parental neglect.

Psychological assessment

Scales measuring achievement, aptitude, interest personality, dexterity and social maturity can be used for evaluation of children's psychomotor capabilities and are very useful in assigning appropriate rehabilitative measures to different children.

706 "mE INDIAN JOURNAL OF ]PEDIATRICS Vol. 48, NO. 395

Visually impaired children usually have many other motor and sensory handicaps. It is, therefore, most impor- tant to realise that a multidisciplinary approach involving a physician, neuro- logist, psychologist and ophthalmologist is very often required for their comprehen- sive treatment.

Prevention

The need for preventive measures varies in different parts of the world, Millions of children become blind in Asia, Africa and Latin America by infections such as measles, tuberculosis, trachoma and onchocerciasis among others, lo Mal- nutrition coupled with nonspecific infe- ctions, vitamin A deficiency and even home made remedies are frequent causes of severe visual impairment.

Prevention, therefore, should involve two major steps:

1. Intensification of eye care through health education.

2. Deploying simple remedies for the common preventable diseases and early treatment of ocular infections.

Health education for eye care should aim at making parents aware of the common blinding eye problems so that they seek early treatment. All the primary health care workers such as indigenous dais, village health guides and multipur- pose health workers should be trained in imparting nutrition education to mothers and education for eye care to school children and school teachers.

Prophylactic oral intake of 200,000 units vitamin A every six month for

children 1-6 years has already commenced in India as a component of National MCH Programme. Such nutrition pro- grammes for children will help to reduce incidence of keratomalaeia.

Timely institution of therapy for con- junetivitis, corneal ulcers, traumatic wounds, uveitis, should prevent avoid-: able blindness.

In India under the National Plan for Control of Blindness peripheral ophthal- mic services are being improved to under- take early treatment. Strategy of the National Plan to contain blindness includes (a) measures to disseminate widely information on eye health care through as many modes of media as possible; (b) rapid deployment of ophthal- mic services (mobile eye camps) to under- take surgery for cataract and other easily curable blindness; and (c) develop step by step a permanent institutional infra- structure to take up comprehensive ophthalmic care of the population. An intensive eompaign is on to publicise common preventable causes by all possible means. Special leaflets and posters in many regional languages have been printed, on subjects like conjunctivitis, ocular injuries, vitamin A deficiency and squint, which particularly affect the child's eye.

Eighty mobile units (approximately one unit for five districts) are in t h e offing. These mobile units are in fact comprehensive eye care units with provision for surgery, refraction, school surveys, limited village surveys, health education and publicity and medical treatment of common eye ailments. Each

MOI-/AN AND SAINI ." MANAGEMENT OF BLINDNESS 707

mobile units holds 12-15 eye camps in a year. The relevance of this mobile unit approach in the Indian set-up is immense as this is the only practical way to reach the masses and deliver effective ophthal- mic services in a short time. The empha- sis on school and village surveys, eye health education and medical treatment in these comprehensive eye camp approach is vastly different from earlier hurried camps for cataract surgery alone. It is now increasingly felt that additional auxiliary mobile units need to be deployed particularly to augment the surgical component of ophthalmic care for cleaning the backlog of cases of cataract. For early detection of visual defects in children by school surveys, early adminis- tration of proper treatment, or making early referrals, these auxiliary units will hold mini-eye camps during the non- operative seasons.

To strengthen the peripheral services ophthalmic assistants are being trained for P.H.C.'s and district hospitals. These ophthalmic assistants will have adequate training to detect early visual defects. They will also be able to render early primary ophthalmic services like prescrip- tion of spectacles, treatment of external eye infections and minor injuries. After two years of institutional (6 months) and field training (18 months), ophthalmic assistants will be required to work under the supervision of P.H.C. medical doctor. Ophthalmic assistants will help conduction of school eye health surveys and also repeatedly emphasize important aspects of eye care education.

Institutional infrastructure for optimum ophthalmic care will necessarily take time

to develop. It is hoped that in 20 years time it will be possible to fully develop all the P.H.C.'s, district and taluk hospi- tals, medical colleges, regional institutions and the apex institution. As this perma- nent infrastructure develops, mobile units will gradually be phased out. Institutional set up will help optimising the utilization of man-power and meagre resources besides ensuring an orderly referral system.

It is hoped that by the above mea- sures the existing prevalance rate of blindness will be reduced from 1.5% to 0.7~o by 1990, 0.5% by 1995 and 0.3% by the year 2000.

Genetic counseling for heritable dis- orders should be given to persons suff- ering from X-linked (red-green colour blindness) or autosomal dominant dis- eases (congenital cataract, retinob]as- toma). To reduce the chances of autosomal recessive inherited diseases (albinism, degenerative myopia, retinits pigmentosa, keratoconus and other dystrophies) consanguinous marriages should be avoided.

Treatment and rehabilitation

Specialised modalities of treatment for cases of corneal, lenticular and some posterior segment pathologies exist. How- ever, often majority of these children have to be rehabilitated so that they can make the best use of their residual vision. Provision of appropriate low vision aids has helped many partially sighted children to overcome their handicap. It is that group of children who cannot be helped by any visual aid where the problems of rehabilitation become acute. These children need special training to be able

708 THE INDIAN JOURNAL OF PEDIATRICS

to develop their other sensory modalities in a manner that they can "be rehabilitated at least to carry out independently activi- ties of daily life and overcome social and economic dependence.

References

1. Agarwal LP, Prakash P. Mathur A, Pathak M: Visual defects in children, Orient Arch Ophthalmol 4:1, 1966

2. Dada VK; Proceedings of the IVth Annual Conference of National Society for Preven- tion of Blindness, 1970, p. 57

3. Gupta UC: Annual Report of National Society for Prevention of Blindness, 1980

4. Venkataswamy G: Proceedings of the IVth Annual Conference of National Society for Prevention of Blindness, 1970, p. 1

5. Mohan M, Gupta AK, Agarwal LP: A ease study of blind children in residential schools

Vol. 48, No. 395

of Delhi, Orient Arch Ophthalmol 4:270, 1966

6. Jan JE, Rabinson GC, Scott E; A multidis- ciplinary approach to the problems of mul- tihandicapped blind child. Can Med Assoc J 109:705, 1973

7. Illingwotth RS: The Development of the Infant and Young Child, 4th Ed. E and S Li~,ingstone, Edinburgh. 1970

8. Rice CF: Research Bulletin No. 22 Ameri- can Foundation for Blind, 1970

9. Brarelton TB, School ML, Robey JS: Visual responses in the newborn, Pediatrics 37:284, 1966

10. Jain IS: Research Bull No. 27, American Foundation for Blind, 1974

11. Oomen I-IAPC: Vitamin A deficiency p. 45 Xerophthalmia and blindness. Nutr Rev 32:161, 1974

Sel f -care versus profess ional care

On the basis of household surveys,

Dunnel and Cartwright and Elliot-~inns

estimated that between 75~'o and 80% of

all symptomrelated care is self-provided

in London. In 1977 Bradshaw estimated

that 80% to 85% of all illnesses in Britain

were managed without doctor consulta-

tions. A recent survey in the United

States indicated that nearly half of all

acute conditions are treated without physi- cian consultation. Another study found the percentage of symptoms treated with- out a doctor visit to be 80~o. One study found no difference in outcome between self-care and professional care for minor illnesses.

Moore SH et al :

J Amer Med Assoc 243"2317, 1980