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Low-vision rehabilitation methods in children: a systematic review

2014; Elsevier BV; Volume: 49; Issue: 3 Linguagem: Inglês

10.1016/j.jcjo.2014.03.011

1715-3360

Swati Chavda, William Hodge, Francie Si, Karim Diab,

Ophthalmology and Visual Health Research

Low vision is a prevalent issue that many Canadians face, and it has implications on social and economic costs. There are various definitions of low vision. The Canadian National Institute for the Blind defines low vision as vision from 20/60 or lower and is not correctable by standard eyeglasses or contact lenses, whereas the World Health Organization has several categories ranging from mild to severe low vision based on visual acuity.1Maberly D.A. Hollands H. Chuo J. et al.The prevalence of low vision and blindness in Canada.Eye. 2006; 20: 341-346Crossref PubMed Scopus (127) Google Scholar However, a wider definition of low vision would include any vision that is not correctible by standard spectacles or contact lenses and affects the patient’s quality of life. Of 836 000 Canadians who were estimated to have low vision in 2007, 19 700 (2.4%) were children younger than 14 years, and this number is projected to increase in the next decade.2Foundations for a Canadian Vision Health Strategy. National Coalition for Vision Health 2007. Available at: http://www.visionhealth.ca/projects/documents/Foundations-For-A-Canadian-Vision-Health-Strategy.pdf. Accessed October 18, 2013.Google Scholar Many conditions, congenital and acquired, that affect any ocular structure can lead to low vision. For persons who are affected with low vision, there is an inverse relation between the extent of visual impairment and functional independence.3Burmedi D. Becker S. Heyl V. Wahl H.W. Himmelsbach I. Emotional and social consequences of age-related low vision.Vis Impair Res. 2002; 4: 47-71Crossref Scopus (124) Google Scholar Children with low vision face many challenges in school, with orientation and mobility, and with social interactions. Impairment of visual function leads to children who are not physically active because of a lack of functional independence and appropriate programming by schools.4Lieberman L.J. McHugh E. Health-related fitness of children who are visually impaired.J Vis Impair Blind. 2001; 96: 272-287Google Scholar Low vision can lead to social isolation, which can eventually lead to depression and diminished self-esteem.5Cochrane G. Lamoureux E. Keeffe J. Defining the content for a new quality of life questionnaire for students with low vision.Ophthal Epidemiol. 2008; 15: 114-120Crossref PubMed Scopus (47) Google Scholar Children with low vision often fall behind in reading rate6Lovie-Kitchin J.E. Bevan J.D. Hein B. Reading performance in children with low vision.Clin Exp Optom. 2001; 84: 148-154Crossref PubMed Scopus (24) Google Scholar and algebra skills. Most literature syntheses and assessments of low-vision rehabilitation methods and quality have dealt with the adult population7Fok D. Polgar J.M. Shaw L. Jutai J.W. Low vision assistive technology device usage and importance in daily occupations.Work. 2011; 39: 37-48PubMed Google Scholar, 8Hooper P. Jutai J.W. Strong G. Russell-Minda E. Age-related macular degeneration and low-vision rehabilitation: a systematic review.Can J Ophthalmol. 2008; 43: 180-187Abstract Full Text PDF PubMed Scopus (213) Google Scholar Various rehabilitation methods aim to increase quality of life of children with low vision. These methods include low-vision aids, exercise therapy, and use of optical aids such as closed circuit television (CCTV). It is important to determine how effective various rehabilitation methods within this population are so that an appropriate plan is made by policy-makers to address low vision in children in Canada. This study aims to systematically review the evidence of how varying low-vision rehabilitation techniques effectively improve quality of life for those ≤18 years old. To identify benefits of low-vision rehabilitation in children, we performed a systematic literature search. The following databases were searched: MEDLINE, Embase, Cochrane, CINAHL, Biosis, Web of Knowledge, Scopus, PsycINFO, and ERIC. Databases were searched based on categories of low-vision rehabilitation, age younger than 18 years, and population. Low vision included eye diseases and vision disorders common to children, and all synonyms were taken into account with the help of an information specialist. The same strategy was used for a Grey literature search in online seminars from Association for Research in Vision and Ophthalmology, Canadian Ophthalmology Society, American Academy of Ophthalmology, European Ophthalmology, and clinical trial database registries. The cutoff date was August 31, 2013, for the search. A total of 2854 articles were retrieved that were screened in a 2-level screening process by 1 of the authors (S.C.) and a second standardized screener based on the following inclusion criteria: (i) eye disease that cannot be completely treated by surgery, medication, standard eye glasses, or contact lenses; (ii) rehabilitation techniques other than surgery, medication, standard eye glasses, or contact lenses; (iii) subjects younger than 18 years; (iv) treatment of subjects with a rehabilitation method; (v) original research paper; or (vi) study based in North America, Western Europe, Australia, New Zealand, Japan, or Singapore. These populations were chosen because they are likely relatively homogenous with respect to low-vision assessments and services. For the 28 final articles that satisfied our screening process, a data extraction was carried out. The data extraction form was designed to extract information such as study objective, study design, data collection technique, inclusion and exclusion criteria, participant characteristics, quality-of-life outcome(s) before rehabilitation, intervention details, and quality-of-life outcome(s) after rehabilitation. A modified Downs and Black instrument was used to assess study quality. Table 1 summarizes the studies to date on low-vision rehabilitation in children. Of the 27 studies, 22 were full studies that could have data abstracted (shown in Table 1)9Beal C.R. Rosenblum P.L. Smith D.W. A pilot study of a self-voicing computer program for prealgebra math problems.J Vis Impair Blind. 2011; 3: 157-169Google Scholar, 10Bieger E. Effectiveness of visual perceptual training on reading skills of non-readers, an experimental study.Percept Motor Skill. 1974; 38: 1147-1153Crossref PubMed Google Scholar, 11Bieger E. Effectiveness of visual training of letters and words on reading skills of non-readers.J Educ Res. 1978; 71: 157-161Google Scholar, 12Blanksby D. The use of video to facilitate visual attention in preschool children.J Vis Impair Blind. 1992; 86: 72-73Google Scholar, 13Cox R.F.A. Reimer A.M. Verezen C.A. et al.Young children’s use of a visual aid: an experimental study of the effectiveness of training.Dev Med Child Neurol. 2009; 51: 460-467Crossref PubMed Scopus (17) Google Scholar, 14Farmer J. Morse S.E. Project Magnify: increasing reading skills in students with low vision.J Vis Impair Blind. 2007; 101: 763-768Google Scholar, 15Geruschat D.R. Deremeik J.T. Whited S.S. Head-mounted displays: are they practical for school-age children?.J Vis Impair Blind. 1999; 93: 485Google Scholar, 16Koenig A.J. Layton C.A. Ross D.B. The relative effectiveness in large print and with low vision devices for students with low vision.J Vis Impair Blind. 1992; 86: 48-53Google Scholar, 17Lackey G.H. Efron M. Rowls M.D. For more reading: large print books or the Visolett?.Educ Visual Handicap. 1982; 14: 87-94Google Scholar, 18McLeish E. A study of the effect of letter spacing on the reading speed of young readers with low vision.Br J Vis Impair. 2007; 25: 133-143Crossref Scopus (12) Google Scholar, 19Miller J. The use of self-reports and parent observations in assessing performance outcomes for teenagers who received vision rehabilitation services.J Vis Impair Blind. 2001; 95: 229-233Google Scholar, 20Miller-Wood D.J. Efron M. Wood T.A. Use of closed-circuit television with a severely visually impaired young child.J Vis Impair Blind. 1990; 84: 559-565Google Scholar, 21Muranaka Y. Furuta N. Aoki S. Gohke K. Use of the simplified colour video magnifier by young children with severely impaired vision.J Vis Impair Blind. 1985; 79: 391-395Google Scholar, 22Jones G.M. Minogue J. Oppewal T. et al.Visualizing without vision at the microscale: students with visual impairments explore cells with touch.J Sci Educ Technol. 2006; 15: 345-351Crossref Scopus (44) Google Scholar, 23Patillo S.T. Heler K.W. Smith M. The impact of modified repeated-reading strategy paired with optical character recognition on the reading rates of students with visual impairments.J Vis Impair Blind. 2004; 98: 28-46Google Scholar, 24Raisamo R. Patomäki S. Hasu M. Pasto V. Design and evaluation of a tactile memory game for visually impaired children.Interact Comput. 2007; 19: 196-205Crossref Scopus (34) Google Scholar, 25Reimer A.M. Cox R.F.A. Nijhuis-Van der Sanden M.W.G. Boonstra F.N. Improvement of fine motor skills in children with visual impairment: an explorative study.Res Dev Disabil. 2011; 32: 1924-1933Crossref PubMed Scopus (23) Google Scholar, 26Roman C.A. Zimmerman G.J. Using mediated learning experiences in orientation and mobility.Rehabil Educ Blind Vis Impair. 1994; 26: 83-91Google Scholar, 27Sonksen P.M. Petri A. Drew K.J. Promotion of visual development of severely visually impaired babies: evaluation of a developmentally based programme.Dev Med Child Neurol. 1991; 33: 320-335Crossref PubMed Scopus (94) Google Scholar, 28Toussaint K.A. Tiger J.H. Teaching early braille literacy skills within a stimulus equivalence paradigm to children with degenerative visual impairments.J Appl Behav Anal. 2010; 43: 181-194Crossref PubMed Scopus (33) Google Scholar, 29Zammitt N. O’Hare A. Mason J. Elliot G. Use of low vision aids by children attending a centralized multidisciplinary visual impairment service.J Vis Impair Blind. 1999; 3: 351-359Google Scholar, 30Zanandrea M. Play, social interaction, and motor development: practical activities for preschoolers with visual impairments.J Vis Impair Blind. 1998; 92: 176-188Google Scholar and 5 were abstracts from conferences. Of the 22 studies, 14 were case series, 2 were surveys, 5 were randomized controlled trials, and 1 was a cohort study. Sample sizes were typically small, with the largest nonsurvey study having 56 participants. Most studies had less than 20 subjects. Using a modified Downs and Black 26-point instrument for study quality, only 2 studies scored greater than the median of 13, with most of the other studies scoring less than 10 of a possible 26 quality points. In terms of content area studied, reading was the most studied outcome (9 studies), and large-print, magnifiers, and CCTVs were the most common interventions studied. However, the studies were typically small, heterogenous, and case series, making any definitive conclusions impossible. From a qualitative scan of these reading studies, children seemed to read better with a magnifier they could control over a more passive large-print system, but this is more of a hypothesis from very sparse data and not in any way a definitive conclusion. Other areas studied were visual-motor skills, visual-attention skills, visual-memory skills, and pattern recognition typically in small, single case series studies.Table 1Qualitative summary of low vision studies in childrenIDAuthor, Location, YearStudy DesignStudy FocusPopulationInstruments UsedResultsValidity1Beal,9Beal C.R. Rosenblum P.L. Smith D.W. A pilot study of a self-voicing computer program for prealgebra math problems.J Vis Impair Blind. 2011; 3: 157-169Google Scholar Arizona, 2011Case seriesMath skills14 students in grades 5–12AnimalWatchVI- BetaStudents scored well on easy and medium math questions. Students had fewer correct answers for the harder stage.22Beiger,10Bieger E. Effectiveness of visual perceptual training on reading skills of non-readers, an experimental study.Percept Motor Skill. 1974; 38: 1147-1153Crossref PubMed Google Scholar New York, 1974RCTVisual perception and reading skills48 students from grades 2 and 3Perceptual training and remedial instructionVisual perceptual training had no effect on reading achievement.63Beiger,11Bieger E. Effectiveness of visual training of letters and words on reading skills of non-readers.J Educ Res. 1978; 71: 157-161Google Scholar New York, 1978RCTReading skills43 students from grades 2 and 3Training in visual analysisSignificant mean gain in the achievement of reading skills for those with visual training.114Blanksby,12Blanksby D. The use of video to facilitate visual attention in preschool children.J Vis Impair Blind. 1992; 86: 72-73Google Scholar Maryland, 1992Case seriesVisual attention (fixation time)16 students from kindergarten to grade 2VideoImproved attention time. Patterns that required more active viewing had significantly higher average attention.05Cox,13Cox R.F.A. Reimer A.M. Verezen C.A. et al.Young children’s use of a visual aid: an experimental study of the effectiveness of training.Dev Med Child Neurol. 2009; 51: 460-467Crossref PubMed Scopus (17) Google Scholar the Netherlands, 2009RCTTask performance33 children (mean age: 4.8 y)Magnifier, magnifier trainingSignificant increase in number of trails followed for group with magnifier training. 5/33 children did not improve their performance qualitatively.156Farmer and Morse,14Farmer J. Morse S.E. Project Magnify: increasing reading skills in students with low vision.J Vis Impair Blind. 2007; 101: 763-768Google Scholar South Carolina, 2007Prospective cohortReading levels16 students from preprimer to grade 8Large-print texts, magnifiersImproved postlevel Bright Reading Index for magnifier group compared with large-print group. Increased comprehension for magnifier group.57Geruschat,15Geruschat D.R. Deremeik J.T. Whited S.S. Head-mounted displays: are they practical for school-age children?.J Vis Impair Blind. 1999; 93: 485Google Scholar Maryland, 1999Case seriesVisual acuity, contrast, general viewing distance10 students (mean age: 17 y)HMDsVisual acuities improved significantly while using HMDs. Contrast improved for some students. Control of illumination aided when switching between environments with varying levels of light.88Jones,22Jones G.M. Minogue J. Oppewal T. et al.Visualizing without vision at the microscale: students with visual impairments explore cells with touch.J Sci Educ Technol. 2006; 15: 345-351Crossref Scopus (44) Google Scholar North Carolina, 2006Case seriesBiological cells21 students (mean age: 15.5 y)Haptic tool – PHANToMSignificant gain in cell parts’ recognition between pre and post use of haptic technology/ High engagement rating (8.65/10). Training helped students provide more qualitative information.09Koenig,16Koenig A.J. Layton C.A. Ross D.B. The relative effectiveness in large print and with low vision devices for students with low vision.J Vis Impair Blind. 1992; 86: 48-53Google Scholar Pennsylvania, 1992Case seriesSilent and oral reading6 students (12.6 y old)Optical devices, electrical devices, large print booksSubjective analysis showed differing preference for each individual. Proper instructions are necessary to make low vision devices equivalent to large print books.310Lackey,17Lackey G.H. Efron M. Rowls M.D. For more reading: large print books or the Visolett?.Educ Visual Handicap. 1982; 14: 87-94Google Scholar South Carolina, 1982RCTAmount of reading55 students fromgrades 4–9Large-print textbook, VisoletteSignificantly more effective in fostering an increase in amount of reading.1111McLeish,18McLeish E. A study of the effect of letter spacing on the reading speed of young readers with low vision.Br J Vis Impair. 2007; 25: 133-143Crossref Scopus (12) Google Scholar United Kingdom, 2007Case seriesReading rate14 children from 10–15 y of ageMS Word softwareIncreased letter spacing causes an increase in reading speed. Decreases after a certain amount of spacing. Letter spacing better benefits those with lowest reading speeds.012Miller,19Miller J. The use of self-reports and parent observations in assessing performance outcomes for teenagers who received vision rehabilitation services.J Vis Impair Blind. 2001; 95: 229-233Google Scholar New York, 2001Case seriesPerformance outcome in orientation and mobility7 students younger than 18 yOrientation and mobility training85% of population performed well in activities for which they received training.513Miller-Wood,20Miller-Wood D.J. Efron M. Wood T.A. Use of closed-circuit television with a severely visually impaired young child.J Vis Impair Blind. 1990; 84: 559-565Google Scholar Massachusetts, 1990Case seriesDevelopmental tasks1 child that is 5 y of ageCCTV: Apollo Electronic Visual Aid with 19-inch monitorSignificant gain in ability to perform developmental tasks. Results were replicated for 4 other visually impaired children. Cost-effective compared to large print textbook.814Muranaka,21Muranaka Y. Furuta N. Aoki S. Gohke K. Use of the simplified colour video magnifier by young children with severely impaired vision.J Vis Impair Blind. 1985; 79: 391-395Google Scholar Tokyo, 1985Case seriesReading ability of picture books7 students younger than 18 yCCTV: video signal terminals and 20-inch screenCamera stand with illuminationMagnification was sufficient for picture books. CCTV stimulates children’s interest and pleasure in looking at image, along with increasing attention.015Patillo,23Patillo S.T. Heler K.W. Smith M. The impact of modified repeated-reading strategy paired with optical character recognition on the reading rates of students with visual impairments.J Vis Impair Blind. 2004; 98: 28-46Google Scholar Georgia, 2004Case seriesReading rate5 students from grades 6–8 (mean age: 12.4 y)Repeated reading training, Kurzweil 1000 OCR voiced reading softwareModified repeated reading strategy paired with optical character recognition can increase reading rates without increasing error or decreasing comprehension level. Increase in self-perception of reading abilities was also found. Words per minute improvement ranged from 38% to 109% with an average of 70%.416Raisamo,24Raisamo R. Patomäki S. Hasu M. Pasto V. Design and evaluation of a tactile memory game for visually impaired children.Interact Comput. 2007; 19: 196-205Crossref Scopus (34) Google Scholar Finland, 2007Case seriesMemory games7 children between age 12 and 13 yHaptic device: tangle memory gameTangible model aided in conceptualization of the game space. Excellent scores were achieved in the game.617Reimer,25Reimer A.M. Cox R.F.A. Nijhuis-Van der Sanden M.W.G. Boonstra F.N. Improvement of fine motor skills in children with visual impairment: an explorative study.Res Dev Disabil. 2011; 32: 1924-1933Crossref PubMed Scopus (23) Google Scholar Netherlands, 2011Case seriesFine-motor skills22 children (mean age: 4.3 y)Stand magnifier trainingSignificant improvement in skills of using magnifier. Improvement in performance speed and accuracy in 5 tests.518Roman,26Roman C.A. Zimmerman G.J. Using mediated learning experiences in orientation and mobility.Rehabil Educ Blind Vis Impair. 1994; 26: 83-91Google Scholar Pennsylvania, 1994Case seriesFunctional ability1 child of age 15 yOrientation and mobility trainingAids in carrying over specific learning to novel situations.619Sonksen,27Sonksen P.M. Petri A. Drew K.J. Promotion of visual development of severely visually impaired babies: evaluation of a developmentally based programme.Dev Med Child Neurol. 1991; 33: 320-335Crossref PubMed Scopus (94) Google Scholar UK, 1991RCTVisual development58 babies younger than 2 yDevelopmental-based visual trainingEffective in promoting visual development of severely visually impaired babies.1620Toussaint,28Toussaint K.A. Tiger J.H. Teaching early braille literacy skills within a stimulus equivalence paradigm to children with degenerative visual impairments.J Appl Behav Anal. 2010; 43: 181-194Crossref PubMed Scopus (33) Google Scholar 2010Case seriesBraille reading skills4 students (mean age: 8.97 y)Training in braille readingTeaching procedures were effective in helping children who have residual vision.421Zammitt,29Zammitt N. O’Hare A. Mason J. Elliot G. Use of low vision aids by children attending a centralized multidisciplinary visual impairment service.J Vis Impair Blind. 1999; 3: 351-359Google Scholar Scotland, 1999SurveyEffective use of LVAs52 students (mean age: 10.91 y)LVA: 8-D bar magnifier, 24-D COIL stand magnifier, 12-D dome magnifier, 12-D stand magnifiers and focusing distance telescopesStudents who used LVAs found them helpful at school. Providing LVAs at a younger functional age can help increase use.722Zanandrea,30Zanandrea M. Play, social interaction, and motor development: practical activities for preschoolers with visual impairments.J Vis Impair Blind. 1998; 92: 176-188Google Scholar Utah, 1998SurveyLocomotor skills116 students from grades 3 to 49 play activities modified for children with low visionSurvey of teachers saw improvement in independence, social interactions, and orientation and mobility skills.0RCT, randomized controlled trial; HMD, head-mounted display; CCTV, closed circuit television; LVA, low-vision aid. Open table in a new tab RCT, randomized controlled trial; HMD, head-mounted display; CCTV, closed circuit television; LVA, low-vision aid. Low-vision rehabilitation in children is an important area that is severely understudied. To date, most studies are descriptive case series with small sample sizes, making the science in this field very rudimentary. Reading is the only area that has been studied in several article, but few conclusions can be drawn because of the collective limitations of these studies. More in-depth study will need to be funded and undertaken to make appropriate clinical, rehabilitory, and policy decisions in this important area. This work was supported by the Academic Medical Organization of Southwestern Ontario, Alternate Funding Plan Innovation Fund ( INN12-010 ).