Teller Acuity Cards Research Articles

Assessment of Cortical Visual Impairment in Infants with Periventricular Leukomalacia: a Pilot Event-Related fMRI Study

ObjectiveWe wanted to investigate the usefulness of event-related (ER) functional MRI (fMRI) for the assessment of cortical visual impairment in infants with periventricular leukomalacia (PVL).Materials and MethodsFMRI data were collected from 24 infants who suffered from PVL and from 12 age-matched normal controls. Slow ER fMRI was performed using a 3.0T MR scanner while visual stimuli were being presented. Data analysis was performed using Statistical Parametric Mapping software (SPM2), the SPM toolbox MarsBar was used to analyze the region of interest data, and the time to peak (TTP) of hemodynamic response functions (HRFs) was estimated for the surviving voxels. The number of activated voxels and the TTP values of HRFs were compared. Pearson correlation analysis was performed to compare visual impairment evaluated by using Teller Acuity Cards (TAC) with the number of activated voxels in the occipital lobes in all patients.ResultsIn all 12 control infants, the blood oxygenation level-dependent (BOLD) signal was negative and the maximum response was located in the anterior and superior part of the calcarine fissure, and this might correspond to the anterior region of the primary visual cortex (PVC). In contrast, for the 24 cases of PVL, there were no activated pixels in the PVC in four subjects, small and weak activations in six subjects, deviated activations in seven subjects and both small and deviated activations in three subjects. The number of active voxels in the occipital lobe was significantly correlated with the TAC-evaluated visual impairment (p < 0.001). The mean TTP of the HRFs was significantly delayed in the cases of PVL as compared with that of the normal controls.ConclusionDetermining the characteristics of both the BOLD response and the ER fMRI activation may play an important role in the cortical visual assessment of infants with PVL.

Occlusive Patch Therapy for Reduction of Seizures in Dravet Syndrome

A 2-year-old Caucasian male presented with a history of nystagmoid eye movements. He also had a history of seizures that were poorly controlled with medications. The parents felt the seizures were exacerbated by exposure to light as they were worse on waking up from a nap. The patient was born at 38 weeks gestational age with a birth weight of 8 lbs 13 oz and birth height of 20.25 inches. His gestational history was complicated only by preeclampsia, for which his mother underwent induction of labor. At 9 months of age, he had his first febrile seizure leading to status epilepticus. His past medical history until that time was only significant for recurrent acute otitis media, for which he had been on amoxicillin treatment at the time of his seizure. He was evaluated by neurology, underwent an electroencephalogram (EEG), and was diagnosed with generalized epilepsy of unknown origin. His parents were given a prescription for diazepam by rectal suppository to be given at the onset of a seizure. The patient continued to have seizures and was placed on multiple anti-epileptic medications, including topiramate (Topamax), levetiracetam (Keppra), clonazepam (Klonopin), and lamotrigine (Lamictal). These were all ineffective and he was finally started on valproic acid (Depakene), which was changed to divalproex sodium (Depakote), which partially controlled his seizures. Around 15 to 18 months of age, the patient began regressing developmentally. Although he had been walking previously, he resorted back to crawling and could no longer verbally communicate with his parents with wellformed words. His receptive language skills surpassed those of expressive language. The parents continued to notice that the seizures appeared to be triggered by exposure to bright light and began to keep him in totally dark environments and made him wear sunglasses constantly. Given the intractable seizures and photosensitivity, genetic testing was performed, which revealed that the patient had a severe-type mutation in the SCN1A gene. Both parents tested negative for the same SCN1A gene mutation indicating a de novo mutation. The patient was diagnosed with Dravet syndrome previously known as severe myoclonic epilepsy of infancy. At his first consultation with ophthalmology, a complete examination could not be performed because of seizure activity with exposure to light when attempting a Hirschberg examination. It was noted that he had jerky nystagmoid movements of the eyes and that his eyes crossed. A trial of alternating monocular patching was initiated where each eye was patched for 6 hours in an alternating pattern. The patient’s parents noted a dramatic improvement in his seizure activity after a few months of starting the patching. The number of seizures decreased from 20 seizures in 2007 to 12 seizures in 2008, the year he was being patched. All these seizures occurred while he was not wearing the eye patch. In addition, his tolerance for dim, low-wattage light had also improved. He returned for another eye examination in 2008 and had been seizure-free for 5 months prior to the examination, which was a marked improvement. At this examination his vision was estimated to be 20/80 in the right eye (9.8 cy/cm at 38 cm) and 20/150 in the left eye (4.8 cy/cm at 38 cm) using Teller acuity cards. At a subsequent examination, 3 months later, his vision had improved to 20/50 (9.8 cy/cm at 55 cm) in each eye. He could also tolerate a full eye examination without seizure activity with each eye evaluated separately and the other eye patched.

Vernier Acuity Cards: Examination of Development and Screening Validity

Because vernier acuity seems to be limited by the visual cortex, it possesses excellent potential as a clinical/screening tool to detect amblyopia in infants and toddlers. Thus, we developed the vernier acuity cards specifically for this age group. We compared developmental data gathered using this new test and the Teller Acuity Cards. In addition, we compared the clinical/screening validity of the two tests by testing children old enough to complete optotype acuity testing (6.2 ± 2.5 years). Vernier acuity and grating acuity were assessed in 98 children and 18 adults with normal vision (age range = 2.8 months to 35.8 years). The developmental time course of the two visual functions was compared. In addition, vernier acuity and grating acuity were measured in 43 children with amblyopia and 30 nonamblyopic children with an amblyogenic condition. Each child's grating acuity and vernier acuity were classified as normal/abnormal based on age-appropriate norms. These classifications were compared with amblyopia diagnoses by crowded HOTV or Early Treatment Diabetic Retinopathy Study (ETDRS) testing. Vernier acuity and grating acuity follow different developmental time courses in normal infants and children. Vernier acuity is initially poorer than grating acuity but surpasses it by the age 5 years and is adult-like by the age 8 years. Compared with the Teller Acuity Cards, the vernier acuity cards yielded higher sensitivity (81 vs. 44%) and similar specificity (73 vs. 93%) and were more sensitive to all amblyopia subtypes/levels of severity. The developmental time course of vernier acuity differed from that of grating acuity, implying that it is not mediated by the retina. Also, the impressive validity of the vernier acuity cards suggests that they are an effective tool for detecting amblyopia.

Long‐term outcome and morphology/function correlates in cases of shaken baby syndrome

Abstract Purpose Shaken Baby Syndrome(SBS) presents with acute encephalopathy,subdural and retinal haemorrhages,with inconsistent history,in &lt; 2 years old.Long‐term sequelae are still under study.Aim is to present the long‐term outcome in a case series of SBS followed‐up by a multidisciplinary team. Methods Case series of 14 children(9 M,5 F)with confirmed SBS has been examined and followed‐up.Patients underwent fundus evaluation (indirect ophtalmoscopy) and wide‐field digital ophthalmic camera (RetCam II) until bleeding reabsorption.Assessment was repeated at follow‐up combined with ocular motility evaluation, visual field(BEFIE test),visual acuity(Teller acuity cards),refractometry, cognitive‐behavioral evaluations (Griffiths scales,Child Behaviour Check List), and family stress measurement(Parenting Stress Index),segmentation analysis of MRI. Results Mean age at acute episode of SBS: 6.5 months (range 2‐20), 9/14 in the first 6 months of life. Mean age at last follow‐up evaluation: 32 months (range 8‐65). 4 cases were lost to follow‐up. At last follow‐up evaluation: 4 out of 10 had a decreased visual acuity (cortical visual impairment), 4 out of 10 had visual field deficits, 3 out of 10 had strabismus. None of the cases showed significant refractive errors. Cognitive/behavioural assessment demostrated global delay and impairments in neuromotor ability, speech/language development and attention problems. MRI analysis showed atrophic alterations in several brain areas. Conclusion Multidisciplinary assessment including ophthalmologic examination and neuro behavioural evaluation provides crucial prognostic information in cases of suspected SBS.Functional outcome is largely dependent on brain injury and atrophy.

Recognition Acuity, Grating Acuity, Contrast Sensitivity, and Visual Fields in 6-Year-Old Children

To measure monocular distance visual acuity (VA), grating VA, contrast sensitivity, and visual field extent in full-term, 6-year-old children. Subjects were 59 healthy full-term children aged 5.8 to 6.3 years who had no ocular abnormalities and no myopia of 1.00 diopter (D) or greater, hyperopia of 4.00 D or greater, astigmatism of 1.50 D or greater, or anisometropia of 1.50 D or greater spherical equivalent or cylinder, as evaluated by a standard eye examination with cycloplegic refraction. All were tested monocularly for recognition acuity (Early Treatment Diabetic Retinopathy Study VA charts), grating acuity (Teller acuity cards), contrast sensitivity (Pelli-Robson contrast sensitivity charts), and visual field extent (white-sphere kinetic perimetry). Right and left eye values did not differ significantly. Mean values for the right eye were 0.040 logMAR (SD, 0.075 log units) for Early Treatment Diabetic Retinopathy Study VA, 24.5 cycles per degree (SD, 0.3 octaves) for grating acuity, and 1.63 (SD, 0.12 log units) for contrast sensitivity. Mean visual field extent for the inferonasal, superonasal, superotemporal, and inferotemporal meridians was 59.1 degrees (SD, 9.7 degrees), 57.8 degrees (SD, 9.6 degrees), 71.2 degrees (SD, 12.3 degrees), and 100.4 degrees (SD, 6.6 degrees), respectively. The results provide additional normative monocular data on visual function in 6-year-old children and indicate that their thresholds are less than those of adults for distance recognition VA, grating VA, and contrast sensitivity, but similar to those of adults for white-sphere kinetic perimetry.

Charlie Brown, Amblyopia, and Me: A (Not so Short) Personal History of the Past Forty Years of Diagnosing and Treating Amblyopia

IntroductionDuring the past forty-plus years there have been many advances in our understanding of amblyopia. It has been my privilege to be able to have a close relationship with many of the people that made these contributions. It is the purpose of this paper to trace these changes as they developed from 1965 to the present.Amblyopia Through the Decades1950s and 1960sBeginning with the introduction of electrodes that could record from a single cell in the mammalian visual cortex, researchers began to map out the normal physiology of the visual cortex, the lateral geniculate bodies and the retinal ganglion cells. Amblyopia, especially stimulus deprivation amblyopia, became a focus of many of these studies. As more and more information became available, clinicians began to understand the problems that they had been facing in such cases as congenital cataracts, unilateral congenital corneal opacities, etc. This led to a significant change in our approach to such cases with emphasis on earlier and earlier intervention to achieve better visual results.1970s and 1980sScientific studies of patients using techniques such as Contrast Sensitivity Function, Teller Acuity Cards, and Neutral Density filters allowed us to begin to look at development of vision in infants, to characterize the differences between the various types of amblyopia and to better understand the need for amblyopia treatment. At about the same time, interest in vision screening in children allowed us to detect amblyopia at an earlier time of life, which then gave us a better chance of successful treatment.1990s and the 21st centuryA renewed interest in developing evidence-based results in keeping with the rest of the scientific medical community led to large multicenter trials looking at different modes of amblyopia treatment with the result of a wider armamentarium available to the practitioner.ConclusionWhile there have been many improvements in our knowledge of the etiology of amblyopia and its treatment, we still find that it is the practitioner, the orthoptist, the patient's family, and the child that make the final difference in success or failure. However, our ability to explain what and why we are doing has made this job easier and given us the tools we need to feel confident in our approach to this still common condition.

The ‘mirror test’ for estimating visual acuity in infants

ObjectiveThe authors aimed to investigate the association between the distance at which infants fixate their own reflections and visual acuity card testing, and to determine whether this could form the...

Cortical Visual Impairment

1. Luis H. Ospina, MD* 1. *Assistant Professor, Pediatric Ophthalmology and Neuro-ophthalmology, Ste-Justine Hospital, University de Montreal, Montreal, Quebec, Canada After completing this article, readers should be able to: 1. Recognize cortical visual impairment (CVI) as an important cause of pediatric visual loss. 2. Identify the most frequent causes of pediatric CVI and, more specifically, understand the role of hypoxia as a cause of central visual damage. 3. Describe the different patterns and implications for future vision of hypoxic central visual damage occurring in preterm compared with term babies. 4. Know the clinical signs suggestive of CVI in children. 5. Discuss the involvement of visual functions other than visual acuity (ie, cognitive visual aspects) in CVI and correlate them with the likely affected neuroanatomic substrates. 6. Explain the value of using a multidisciplinary approach in rehabilitating children who have CVI early in their development. Vision loss caused by central nervous system damage often is referred to as CVI but also may be referred to as cerebral visual impairment or neurologic visual impairment. These terms refer to the fact that the primary defect may not necessarily be limited to the striate (primary visual) cortex and may affect other areas subserving vision, such as the visual associative cortex, optic radiations, and visual attention pathways. Although it is not yet certain which of these three terms best describes the visual deficit, it is clear that use of the label cortical blindness must be abandoned. That term not only evokes negative connotations for the child and the family but is inaccurate because in almost every instance, some degree of residual vision remains, and visual improvement can occur. CVI has become the greatest cause of pediatric visual impairment in developed countries (1)(2)(3)(4)(5) and is becoming increasingly prevalent in developing nations. CVI is a problem of increasing frequency for two primary reasons. First, the progress in neonatal care has resulted in improved survival of …

Failure to detect deaf‐blindness in a population of people with intellectual disability

Early identification of deaf-blindness is essential to ensure appropriate management. Previous studies indicate that deaf-blindness is often missed. We aim to discover the extent to which deaf-blindness in people with intellectual disability (ID) is undiagnosed. A survey was made of the 253 residents of an institute offering residential and occupational facilities for people with IDs. Data are included for the 224 individuals who were able to complete both auditory and visual assessments. Otoacoustic emissions were used to screen for hearing impairment; those who did not pass were assessed by behavioural audiometry. Visual acuity was assessed with one of the following: EH-Optotypes, LH-Optotypes, Teller Acuity Cards, Cardiff Acuity Cards or the Stycar Ball Vision Test. Prior to the study hearing impairment had been diagnosed in 12.5% of the 224 subjects, and visual impairment in 17%. Upon completion of the study these figures rose to 46% and 38.4% respectively. Deaf-blindness was diagnosed in 3.6% of the subjects before, and in 21.4% after, the study. Most (87.5%) of the deaf-blind individuals had profound ID. Deaf-blindness is most often not identified either by standard medical screening or by care staff. Individuals with this disability, however, require provision of special kinds of care. Four categories of deaf-blindness are proposed, according to the severity of sensory impairment in each modality. The tests used in this study are non-invasive and are appropriate for individuals with ID and children. Early and periodic screening for visual and hearing impairment in individuals with ID is recommended.

Ocular features and management in the mucopolysaccaridoses

Abstract Purpose To evaluate the ocular findings and the visual outcome in a group of patients with mucopolysaccaridoses(MPS) followed and treated with new therapeutic options. Methods 18 pazients with MPS (9 males and 9 females) were examinated: 3 cases with MPS type I, 4 with MPS type II,7 with MPS type III, 1 with MPS type IV and 3 with MPS type VI. The patients underwent an ophthalmological assessment with : visual acuity (with Teller Acuity Cards, Lea Symbols o letter chart, depending on patient age or degree of cohoperation), slit‐lamp examination, fundus ophthalmoscopy, intraocular pressure, refractometry, electroretinography and eye echography. Results The mean follow‐up was 48 months (ranged from 3 to 190 months).The mean age at first ophtalmologic evaluation was 6,9 years ( ranged from 1 to 20 years). 8 case presented progressive corneal clouding, 5 case retinal pigmentary degeneration, and 1 papilledema. Visual acuity worsened severely in 3 cases with MPS type I: 1 case from 10/10 to 5/10, 1 case from 5/10 to 1/10; in another case visual acuity decreased to 1/20 and underwent to corneal transplantation with good visual outcome (RE 5/10 and LE 7/10). The other cases showed slightly reduction of visual function. 3 patients had ocular hypertension and were treated with hypotensive eye drops. 8 patients underwent enzyme replacement therapy. Conclusion The mucopolysaccaridoses(MPS) are rare systemic disorders caused by accumulation of glycosaminoglycans. Ophthalmological manifestations are frequent in MPS, particularly in MPS I, II and VI, characterized by corneal clouding, retinal distrophy and blindness.Regular ophthalmic monitoring to determine disease progression and management of complications are necessary as a part of multidisciplinary approach.

The Teller Acuity Cards Are Effective in Detecting Amblyopia

Detection of amblyopia in infants and toddlers is difficult because the current clinical standard for this age group, fixation preference, is inaccurate. Although grating acuity represents an alternative, studies of preschoolers and schoolchildren report that it is not equivalent to the gold standard optotype acuity. Here, we examine whether the Teller Acuity Cards (TAC) can detect amblyopia effectively by testing children old enough (7.8 +/- 3.6 years) to complete optotype acuity testing. Grating acuity was assessed monocularly in 45 patients with unilateral amblyopia, 44 patients at risk for amblyopia, and 37 children with no known vision disorders. Each child's grating acuity was classified as normal/abnormal based on age-appropriate norms. These classifications were compared with formal amblyopia diagnoses. Grating acuity was finer than optotype acuity among amblyopic eyes (medians: 0.28 vs. 0.40 logMAR, respectively, p < 0.0001) but not among fellow eyes (medians: 0.03 vs. 0.10 logMAR, respectively, p = 0.36). The optotype acuity-grating acuity discrepancy among amblyopic eyes was larger for cases of severe amblyopia than for moderate amblyopia (means: 0.64 vs. 0.18 logMAR, respectively, p = 0.0001). Nevertheless, most cases of amblyopia were detected successfully by the TAC, yielding a sensitivity of 80%. Furthermore, grating acuity was relatively sensitive to all amblyopia subtypes (69 to 89%) and levels of severity (79 to 83%). Although grating acuity is finer than optotype acuity in amblyopic eyes, most children with amblyopia were identified correctly suggesting that grating acuity is an effective clinical alternative for detecting amblyopia.

Paper Tools for Assessing Visual Function

Instruments for assessing visual function are valuable tools for optometry, ophthalmology, vision science, education, and public health. Inspired by my observations in the Teller lab, with Dobson, on the process of developing a useful clinical tool from laboratory work, I present four examples of functional vision tests that are made of paper and currently used in the field: the Amsler Grid, the Pelli-Robson Contrast Sensitivity Chart, the Teller Acuity Cards, and the Developmental Eye Movement Test. All are characterized by ease of use and rigorous design. All are either being used with children or have the potential to be so. Each tool is reviewed in terms of its development, with a view toward similarities in the steps or process taken. The goal is to encourage the further development of the functional vision assessments already in existence, and to urge scientists and clinicians alike to consider ways in which their own work can be translated into clinically useful, simple paper tools.

Evaluation of Infant Accommodation Using Retinoscopy and Photoretinoscopy

To compare PlusOptix PowerRefractor (PR) and Monocular Estimation Method (MEM) for measurement of infant accommodation and to assess the usefulness of applying individual calibration factors to PR data. Subjects were 41 infants aged 3 to 12 months. Accommodative response was measured by MEM and PR at 33 and 57 cm, acuity by Teller Acuity Cards, and cycloplegic refractive error (RE) (tropicamide 1%) by retinoscopy (Wet Ret) and PR (PR C). Monocular wear of a +2.00 diopter (D) and +4.00 D lens established a PR calibration factor for each subject. The median individual calibration slope was significantly different from 1.0 (+0.91; Wilcoxon signed-rank test: p = 0.03), yet there was no correlation between individual calibration slopes and the difference in RE by Wet Ret and PR C (rs = 0.05, p = 0.76). For 19 infants with an accommodative response slope by PR of >0.50, the mean lag was not significantly different between methods (0.50 D PR, 0.48 D MEM; p = 0.92; 95% LoA = +/-1.78 D). Despite the improvement in acuity with age (rp = -0.56, p < 0.0001), neither age nor acuity had a significant effect on accommodative error. Lag was greater at 57 cm (0.69 D) than 33 cm (0.30 D, F1, 18 = 6.3, p = 0.022), but lag was unrelated to RE (F1, 17 = 3.3, p = 0.09). Accommodative response slopes for boys were larger (1.5) than for girls (1.0; F1, 17 = 9.5, p = 0.007). MEM and PR provided similar estimates of RE and of accommodative lag once the PR data were screened for inattention using an accommodative response slope criterion. Adult-like accommodative responses between 3 and 12 months of age suggest that acuity at these ages is not limited by accommodative immaturity. Further, mature accommodation may attenuate RE-related defocus signals for emmetropization.

Teller II and Cardiff Acuity Testing in a School-Age Deafblind Population

To compare Teller Acuity Cards II (TAC II) and Cardiff Acuity Test (CAT) acuities, test-retest reliability and testability in children with visual, auditory, motor and cognitive impairments. Twenty-one children designated as "Deafblind" were tested under binocular conditions. Visual acuity was measured with both the TAC II and CAT in two sessions, with test order randomized and counterbalanced between sessions. Visual acuity, examiner confidence in the acuity result (3 point scale), testing time, and level of motor impairment (3 point scale) were recorded. Information about visual and auditory function and ocular and medical diagnoses were obtained by record review. The success rate was high (95%) and test time similar (p = 0.267) for both tests (TAC II, 204 +/- 111 s; CAT, 222 +/- 111 s). Mean LogMAR acuities were not significantly different (TAC II, 0.82 +/- 0.47; CAT, 0.72 +/- 0.47; p = 0.068). The 95% limits of agreement for LogMAR test-retest differences were +/-0.60 for TAC II and +/-0.70 for the CAT and there was a trend for increased variability with poorer acuity for the CAT test only. The TAC II and CAT give similar estimates of acuity, test-retest reliability, and testing time in this small population of "Deafblind" children. Future studies should be designed to explore whether these results are consistent in subpopulations, such as Deafblind children with very poor vision and/or significant motor impairment. Moreover, additional study is necessary to evaluate the effect of patient characteristics on the examiner's ability to make threshold acuity judgements.

Optical Treatment Reduces Amblyopia in Astigmatic Children Who Receive Spectacles Before Kindergarten

To examine the effect of spectacle correction of astigmatism during preschool on best-corrected recognition visual acuity (VA), grating VA, and meridional amblyopia (difference between acuity for vertical versus horizontal gratings) once the children reach kindergarten. Comparative case series. Seventy-three astigmatic (right eye > or =1.50 diopters [D] cylinder) Native American (Tohono O'odham) children 5 to 7 years of age. All had with-the-rule astigmatism. In 28 children, the astigmatism was simple myopic, compound myopic, or mixed (M/MA), and in 45 children, it was simple or compound hyperopic (HA). Thirty-nine children (Treated Group) had spectacle correction of refractive error, prescribed for full-time wear, in preschool (0.8-2.4 years before testing). Thirty-four children (Untreated Group) had no prior correction. Comparison of Treated versus Untreated Groups for mean best-corrected right-eye recognition VA, measured with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the Lea Symbols chart, for grating VA, measured with modified Teller acuity card stimuli, and for meridional amblyopia, based on grating acuity results. Mean ETDRS VA was significantly better in the Treated Group (20/37) than in the Untreated Group (20/48; P<0.003), but the difference between mean Lea Symbols VA in the Treated Group (20/33) and in the Untreated Group (20/38) was not significant. No significant Treated versus Untreated Group differences were found for either vertical or horizontal grating acuity. Meridional amblyopia differed between the M/MA group, which showed better acuity for vertical than for horizontal gratings, and the HA group, which showed better acuity for horizontal than for vertical gratings. However, in neither the M/MA group nor the HA group was there a significant difference in magnitude of meridional amblyopia in the Treated versus the Untreated Group. Spectacle correction during the preschool years results in a significant improvement in best-corrected letter recognition acuity in astigmatic children by the time they reach kindergarten. However, grating acuity was not improved and magnitude of meridional amblyopia was not reduced in children who had received early spectacle correction. Proprietary or commercial disclosure may be found after the references.

Factors Affecting Development of Motor Skills in Extremely Low Birth Weight Children

Purpose: The aim of this study is to analyze the impact of ophthalmic and neonatal factors on motor development in extremely low birth weight (ELBW) children. Methods: Sixty-four ELBW children at least 3 years of age were recruited. Visual acuity (VA) was assessed using the Teller acuity cards (TACs) and a letter test, if possible. A validated questionnaire assessing 25 fine (part A) and 20 gross motor (part B) skills was administered to the parents. Data were collected on retinopathy of prematurity (ROP) zone, intraventricular haemorrhage (IVH), length of stay in hospital, and number of days on oxygen. Results: Abnormal TAC acuity was associated with significantly lower scores on both parts A and B (part A: 21.5 versus 11.8, p < 0.001; part B: 17.5 versus 13.2, p < 0.001). Linear regression demonstrates a significant direct relationship between letter acuity and score A only (p = 0.03, r2 = 0.179). Neither length of hospital stay, number of days ventilated, nor a history of IVH were associated with score A or B. However, the presence of ROP zone 1 was associated with a lower score A (p = 0.03). Conclusion: In this ELBW cohort VA and ophthalmic factors were the only factors associated with scores of development, particularly fine motor development.

Improvement of visual acuity and visual evoked patterned potentials done at different spatial frequencies after rehabilitation in 45 subjects affected by Cerebral Visual Impairment.

Abstract Purpose To analyze improvement of visual acuity(VA) and visual evoked patterned potentials (pVEP) in children diagnosed by MR as cerebral visual impaired (CVI) after rehabilitation (refractive correction and occlusion terapy). Methods In 45 CVI infants(mean age 5.6)we analysed VA and pVEPs improvement after 1 year of follow up. Teller Acuity Cards and/or optotype were used for decimal visual acuity. P‐VEPs were recorded at Oz,O1,O2, referenced to Fz. At least two spatial frequencies (among 300’,120’,60’,30’,15’).Statistical analysis were made between VA and pVEP improvement. Results VEP and VA percentage of success was 100% and 89% respectively at the beginning; after 1 year VA percentage of success rised 100%. Mean VA before treatment was 2,29/10(0.2‐10); after treatment was 3,61/10(0.1‐10). VA improvement was statistically significant(z=0,00) VA improvement occurred in 68,89%, while 31,11% were unimproved. Improved VEP were 80% and unimproved 20%. We considered improved VEP when children were able to detect lower spatial frequencies or when, in the same spatial frequency, we found higher amplitudes and reduced latencies. Differences between VEP amplitude and latency were not statistically significant in all frequencies but in L60’ (T‐test L60':0.02). There was an association between VA improvement and therapy,(Pr = 0.02) There wasn’t association (Pr = 0.76) between VEP improvement and therapy. There wasn’t correlation between VA and VEP improvement. Conclusion We found an improvement both in VA and VEP.VEP improvement is independent of therapy,VA improvement is correlated with therapy.

The lot of shaken baby syndrome (SBS) cases: Follow‐up of visual outcome and congnitive function

Abstract Purpose To study long‐term outcome of SBS on visual and cognitive functions. Methods Case series of 10 children (7 M, 3 F) with confirmed SBS has been examined and followed‐up. All chldren underwent a fundus evaluation by indirect ophtalmoscopy and wide‐field digital ophtalmic camera (RetCam II) in the acute phase and until retinal hemorrhage resorption. The assessment was repeated at follow‐up combined with ocular motility evaluation, visual field (BEFIE test), visual acuity by preferential looking tecnique (teller acuity cards), refractometry, cognitive‐behavioural evaluations (Griffiths scales, Child Behaviour Check List), and family stress measurement (Parenting Stress Index). Results Mean age at acute episode of SBS: 6 months (range 2‐20). Mean age at last follow‐up evaluation: 27.6 months (range 4.5‐41). At last follow‐up evaluation: 1 out of 6 had a decreased visual acuity (cortical visual impairment), 3 out of 6 had mild‐severe visual field deficits, 3 out of 6 has strabismus. None of the cases showed significant refractive errors. Due to age or severity of impairment and delay in global development, in any of the cases we were able to perform a recognition acuity test by symbols or E‐charts. Cognitive and behavioural assessment demonstrated global delay and impaiments in speech/language development and attention problems. Conclusion SBS is characterized by severe long‐term sequelae both in visual and cognitive function. Several visual impairments are observed, mainly related to cortial injury of visuo‐spatial area. Although follow‐up is difficult due to family history, there is strong indication for global assessment until scholar age where other impairments are demonstrated.

VEP maturation and visual acuity in infants and preschool children

Visual processes continue to mature well into childhood, due to the development of the retina, optic nerve, visual pathway and visual cortex. Normal development of visual acuity and maturation of visual evoked potentials (VEPs) have been well studied, although rarely for their correlation. The purpose of this study was to investigate the same population of infants and preschool children for their VEP maturation to flash, pattern-reversal (reversal) and pattern-onset (onset) stimulation, which are normally used in our everyday clinical protocol, and to determine the relationships between the VEP parameters obtained and the development of visual acuity. Forty-one healthy children from 1.5 months to 7.5 years old were included. Their visual acuity for distance was tested with Teller Acuity Cards (<2 years of age) and Cambridge Visual Acuity Crowding Cards (>2 years of age). VEP latencies and amplitudes were evaluated to flash (P2 wave), reversal (P100 wave) and onset (C1 wave) binocular stimulation. For reversal and onset stimulation, checkerboard pattern (check) sizes of 25', 50' and 100' were used. Age-dependent exponential decreases in latencies to flash, reversal and onset stimulation were seen. For amplitudes, there was an age-dependent increase only to onset stimulation. There was a significant correlation between VEPs and visual acuity (P < 0.05) for latencies to flash, reversal and onset stimulation and amplitudes to onset stimulation. These findings indicate the expected maturation of flash, reversal and onset VEPs, and demonstrate their correlation to normal development of visual acuity. Maturation of VEP latencies is associated with development of visual acuity.

Paediatric cataract surgery

Bilateral congenital cataract is the most common cause of treatable childhood blindness. Nuclear cataract is usually present at birth and is non-progressive, while lamellar cataract usually develops later and is progressive. Prompt surgery has to be performed in cases with dense congenital cataract: if nystagmus has developed, the amblyopia is unfortunately irreversible. A treatment regime based on surgery within 2 months of life, combined with prompt optical correction of the aphakia and occlusion therapy with frequent follow-up, have been successful in both unilateral and bilateral cases. The surgery ought to include anterior and posterior capsulorexis in all children at the present time. Intraocular lens implantation has been safely performed below the age of 1 year and has also been successfully performed in bilateral cases. Anterior dry vitrectomy should be performed in preschool children to avoid visual axis opacification. Visual axis opacification is the most common complication found after cataract surgery in children. Secondary glaucoma is by far the most sight-threatening complication and is, unfortunately, common in the newborn so lifelong follow-up is essential in these cases.