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Profile of students with Low Vision in integrated

education across three districts of South India in 2006-


2007.
Chandradoss H Sa, Prasad N Mb
a
Cheran Region Christian Society for Disabled Children, Coimbatore, India
b
SPARKIAN Society, Coimbatore India
Abstract. This cross-sectional study describes the demographic profile, visual acuity, use
of low-vision aids and functional vision status of children with low vision who were
studying in the integrated education stream. Three hundred and fifty-eight students who
have low vision (2/60 or LogMAR 0.5 or worse for distance) underwent functional vision
assessments using the LV Prasad Functional Vision Questionnaire. Clinical and
demographic data was collected from medical records. Boys comprised 67.04% of the
group; uncorrected distance and near visual acuity averaged 1.2 LogMAR (0.2 SE),
marginally improving with correction. Fifty-eight children underwent visual function
assessments, scoring on average 24.67 (95% CI 22.29, 27.05). The majority felt their
visual status was only ‘a little worse’ than that of a normally sighted friend.
Children who have very poor vision prefer not to use prescribed low vision aids. Further
investigation is required into coping mechanisms adopted by these children.
Keywords: Low Vision, pediatric visual function, epidemiology.
1. Introduction
The prevalence of low vision and blindness is relatively low (2% to 2.4%) in the general
population1; extrapolations from other survey data and from a previous pilot survey done
in the area2 suggest that (0.1% to 0.6%) of people under 50 years of age have
presenting visual acuity less than 6/18. Early intervention and low vision care are
advocated to maximize the individual’s visual function capacity; cost effective
mechanisms are available through optical and non-optical devices.
Clinical tests that are used to measure visual acuity have been standardized and the
advantage of using LogMAR charts has previously been demonstrated.3 However other
aspects of visual function such as colour vision, contrast sensitivity, dark adaptation and
stereopsis are difficult to assess in a systematic, standardized manner, therefore
deterring measurement of their combined impact on visual disability and the extent of
adaptation by the affected individual.
This study describes the demographic profile, morbidity, visual acuity, use of low vision
aids and functional vision of children in Coimbatore, Dindigul and Erode districts of
Tamilnadu state in southern India, who were in the integrated education stream during
2007-2008. It aims to provide information on the relationship if any, between clinically
assessed visual disability and the functional status of the affected persons, and to
provide baseline data for a cohort of persons on whom the impact of various
interventions can be assessed. This would also identify gaps in service provision and help
plan for more effective implementation of low vision services in the target population.
Identifying determinants of good adaptation to visual loss would lead to the recognition
of interventions that could maximize functional status despite visual disability.

2. Methods
The 358 students from the rolls at schools providing integrated education during the
2007-2008 academic year who had been diagnosed to have visual acuity below 6/60 in
the better eye with best correction were included in this cross-sectional survey. Visual
acuity and function were both assessed with both eyes open, so as to simulate the real-
life situation.
The children were assessed for their functional vision status using the LVPVFQ4 during
their term break. The questionnaire was administered by the low vision services co-
ordinator, a rehabilitation worker trained in special education.
Clinical and demographic data was collected from medical records of each child that are
maintained by Cheran Region Christian Society for Disabled Children. The use of low
vision aids was confirmed with each individual prior to administering the questionnaire.
Data was entered in MS Excel and cleaned prior to performing summary statistical
analyses, the results of which are reported here. STATA was used for correlation and
regression analysis to measure the association between possible determinants such as
visual disability and the functional visual status.

3. Results
The gender distribution showed a preponderance of males (67.04%) over females
(32.96%). Children using some form of optical device for sight enhancement on the day
they were evaluated were 20.63% (72/349). The uncorrected visual acuity (UCVA) for
near (n=329) averaged 1.24 LogMAR (95% CI 1.20, 1.28) and marginally changed to an
average best corrected visual acuity (BCVA) of 1.16 LogMAR (n=274, 95% CI 1.12,
1.21). When assessed for distance acuity, the average uncorrected LogMAR value was
1.17 (SE 0.01, n=342) and that for BCVA distance averaged 0.96 (SE 0.14, n=342).
Visual function was evaluated through a validated instrument comprising 20 questions,
administered by an interviewer individually and scored by a Likert scale or multiple-
choice responses. The responses are presented in Table 1. The range of possible total
scores assigned in response to this questionnaire was a minimum of 19 and a maximum
of 57.
Table 1: LVPVFQ response frequency distribution. (n=58)

Do you have any difficulty in making out whether the person you are seeing across the
road is a boy or a girl during the day? YES (48) NO (10)
If yes, how much difficulty do you have? Little (17) A moderate amount (17)
A great deal (12) Unable to do the activity (2)
Do you have any difficulty in seeing whether somebody is calling you by waving his or
her hand from across the road? YES (33) NO (25)
If yes, how much difficulty do you have? Little (12) A moderate amount (5)
A great deal (12) Unable to do the activity (4)
Do you have difficulty in walking alone in the corridor at school without bumping into
objects or people? YES (47) NO (11)
If yes, how much difficulty do you have? Little (28) A moderate amount (11)
A great deal (8) Unable to do the activity (0)
Do you have any difficulty in walking home at night (from tuition or a friend's house)
without assistance when there are streetlights? YES (42) NO (16)
If yes, how much difficulty do you have? Little (22) A moderate amount (7)
A great deal (10) Unable to do the activity (2)
Do you have any difficulty in copying from the blackboard while sitting on the first bench
in your class? YES (38) NO (20)
If yes, how much difficulty do you have? Little (13) A moderate amount (7)
A great deal (15) Unable to do the activity (3)
Do you have difficulty in reading the bus numbers? YES (41) NO (17)
If yes, how much difficulty do you have? Little (14) A moderate amount (15)
A great deal (10) Unable to do the activity (2)
Do have any difficulty in reading the other details on the bus (such as its destination)?
YES (35) NO (23)
If yes, how much difficulty do you have? Little (7) A moderate amount (10)
A great deal (14) Unable to do the activity (3)
Do you have any difficulty in reading your textbooks at an arm's length? YES (37) NO
(21 )
If yes, how much difficulty do you have? Little (5) A moderate amount (6)
A great deal (19) Unable to do the activity (7)
Do you have any difficulty in writing along a straight line? YES (40) NO (18)
If yes, how much difficulty do you have? Little (12) A moderate amount (12)
A great deal (16) Unable to do the activity (0)
Do you have any difficulty in finding the next line while reading when you take a break
and then resume reading? YES (42) NO (16)
If yes, how much difficulty do you have? Little (20) A moderate amount (10)
A great deal (11) Unable to do the activity (1)
Do you have any difficulty in locating dropped objects (pen, pencil, eraser) within the
classroom? YES (43) NO (15)
If yes, how much difficulty do you have? Little (12) A moderate amount (14)
A great deal (16) Unable to do the activity (0)
Do you have any difficulty in threading a needle? YES (20) NO (38)
If yes, how much difficulty do you have? Little (3) A moderate amount (6)
A great deal (8) Unable to do the activity (3)
How much difficulty do you have in distinguishing between 1 rupee and 2 rupee coins
(without touching)? YES (42) NO (16)
If yes, how much difficulty do you have? Little (22) A moderate amount (15)
A great deal (5) Unable to do the activity (0)
Do you have difficulty in climbing up or down stairs? YES (42) NO (16)
If yes, how much difficulty do you have? Little (28) A moderate amount (10)
A great deal (4) Unable to do the activity (0)
Do you have difficulty in lacing your shoes? YES (35 ) NO (23)
If yes, how much difficulty do you have? Little (19) A moderate amount (10)
A great deal (2) Unable to do the activity (3)
Do you have difficulty in locating a ball while playing in the daylight? YES (41) NO (17)
If yes, how much difficulty do you have? Little (3) A moderate amount (22)
A great deal (11) Unable to do the activity (5)
Do you have difficulty in applying paste on your toothbrush? YES (38) NO (20)
If yes, how much difficulty do you have? Little (22) A moderate amount (12)
A great deal (4) Unable to do the activity (0)
Do you have difficulty in locating food on your plate while eating? YES (39) NO (19)
If yes, how much difficulty do you have? Little (22) A moderate amount (10)
A great deal (7) Unable to do the activity (0)
Do you have difficulty in identifying colours (e.g. while colouring)? YES (36) NO (22)
If yes, how much difficulty do you have? Little (21) A moderate amount (8)
A great deal (5) Unable to do the activity (2)
How do you think your vision is compared with that of your normal sighted friend? Do
you think your vision is (N=57)
As good as your friend's (3) A little bit worse than your friend's (50) Much worse
than your friend's (4)

Fifty eighty students (63.79% boys) participated in the assessment of visual function.,
and the group scored an average of 24.67 (95% CI 22.29, 27.05). Fifty-three of the 57
respondents (92.98%) felt that their vision was as good as or only a little worse than
that of their normally sighted friends; the average functional vision score was 2.04 (SE
0.08) with a score of 1 indicating ‘a little difficulty’ and 3 being ‘a great deal of difficulty
with regard to carrying out the rest of the tasks described in questions numbered one
through nineteen.
No statistically significant association between near acuity (neither for UCVA nor for
BCVA) and the scores obtained for functional vision was found. There was a significant
association for distance visual acuity both uncorrected (slope 0.71 (95%CI 0.06, 1.36), r-
squared 0.09, n=52) and best corrected (slope 0.99 (95%CI 0.27, 1.71), r-squared 0.15,
n=45) on univariate regression. When the association between visual function score and
best-corrected distance vision was tested controlling for the uncorrected visual acuity
status, this association was not statistically significant (slope 0.72 (95%CI -0.13,1.57), r-
squared 0.15, n=45).

4. Discussion
Resnikoff et al.1 estimated the prevalence of low vision at 2% to 2.4% in the general
population. It was also noted that most survey data available was from the age group
over 50 years. The ‘older’ sub-population contributes most of the blindness in the general
population, but the ratio of low-vision to blindness is higher in populations with a low
prevalence of blindness. This explains the possible underestimation of the burden of low
vision when extrapolating results of studies done in older populations to people of all
ages.
The group included in this study is likely to be representative of all children with low
vision in this age group because of the state-level policy of Education for All enforced
since 2004, of which the Ministry of Education reports 95% coverage over the period
2006-2008.
There are three previous studies on the link between visual functioning and various
assessments of visual disability. The SEE project was for a group of elderly (65-84 years)
African Americans and found that most persons were not functionally disabled until they
had a significant acuity loss (LogMAR less than1.0) and for visually intensive tasks such
as reading, visual acuity less than 0.2 was disabling.
The study by Gothwal et al4 to validate the LVPVFQ included 78 visually impaired
subjects, of whom 28.2% (n=22) had severe visual impairment (<20/200 to 20/400),
and 56.4% (n=44) had moderate visual impairment (<20/60 to 20/200). They reported
that overall, vision may not be as critical when subjects are required to do tasks that can
be managed by other cues such as tactual (locating food on a plate and applying paste to
a toothbrush). This is consistent with the finding of this study that perceived functional
vision status is better than that suggested by the visual acuity of the individual child.
Poor visual acuity may not be as disabling where non-visual cues can be relied upon to
perform certain functions; therefore further investigation is required into coping
mechanisms adopted by these children.
The other study using the same instrument in people over 16 years of age5 validated the
same instrument (LVPVFQ) as a measure of functional vision across a range of visual
problems among older adults. And concluded that ‘presenting visual acuity in the better
eye’ was associated with functional vision in this population. Decrease in functional vision
was associated with the presence of glaucoma, corneal disease, or retinal disease
independent of visual acuity, and with cataract as a function of visual acuity. It would
therefore also be of interest to record major causes of visual loss using a standardized
format6 and comparing the morbidity of the group evaluated in this study with that of
school-age children who develop low vision over the next few years to identify change in
trend.
References
1. Pascolini, D., Mariotti, S.P., Pokharel, G.P., Pararajasegaram, R., Etya'ale, D., Négrel,
A.D., et al. (2004 April). 2002 global update of available data on visual impairment: a
compilation of population-based prevalence studies. Ophthalmic Epidemiol. 11 (2), 67-
115.
2. Prasad, N.M., (2005) Visual Impairment among people under 50 years of age in
Coimbatore District, India. (A pilot survey of need and resources), MSc Dissertation.
Submitted to University of London.
3. Consultation on development of standards for characterization of vision loss and visual
functioning. Geneva, 4-5 September 2003
http://whqlibdoc.who.int/hq/2003/WHO_PBL_03.91.pdf
4. Gothwal, V.K., Lovie-Kitchin, J.E., Nutheti, R., (September 2003). The development of
the LV Prasad-Functional Vision Questionnaire: a measure of functional vision
performance of visually impaired children. Invest Ophthalmol Vis Sci. 44 (9), 4131-9.
5. Nutheti, R., Keeffe, J.E., Shamanna, B.R., Nirmalan, P.K., Krishnaiah, S., Thomas, R.,
(2007 August) Relationship between visual impairment and eye diseases and visual
function in Andhra Pradesh., Ophthalmology. 114 (8), 1552-7.
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form for recording causes of visual loss in children. Bull World Health Organ. 71 (5), 485-
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P.S. Some material from this paper was presented in 2008 at a Low Vision Conference in Monteal,
Canada.