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Therapist gently holds the back of an older baby's hed as he looks at her. He is cradled in his mother's arms
Occupational therapist evaluation

Supporting children with irreversible vision impairment

Some preterm infants become totally blind, from Stage 5 ROP or cerebral vision impairment. Others have vision impairment which cannot be fully corrected with spectacles or managed by surgery or other treatments: this is called low vision.

A child’s visual system (eyes, nerves and brain) continue to develop over several years. Parents need advice on creating the best environment for their visually impaired or blind child: how to select appropriate toys or objects, create contrast, control light and glare and the importance of parents explaining the world to their child.

A child with low vision should be regularly reviewed by a low vision professional who can provide educational needs assessments as the child grows, so that an appropriate educational environment can be developed, preferably in an inclusive setting.

Vision rehabilitation

Vision rehabilitation for a child with retinopathy of prematurity (ROP) is very specific to the individual. Services can help identify the best interventions and strategies for the type and degree of vision loss.

Children who have had ROP may develop:

  • Refractive errors Bifocal and magnifying reading glasses are often helpful to correct severe myopia (near sightedness). Contact lenses may be used when the refractive errors are different in each eye (severe anisometropia). This can occur after laser treatment to just one eye, or after surgery when the lens or cataract is removed. These corrective measures are particularly important to avoid the development of reduced vision in one or both eyes (amblyopia or lazy eye) as this is irreversible.

  • Constriction of the visual fields (“tunnel vision”) after laser treatment meaning that the child can only see objects directly in front of them. These children need orientation, mobility training and possibly a mobility aid such as a white cane.

  • Some children develop central visual impairment and require additional magnification for reading and close-up (near) activities.

In more significant cases of visual impairment, Braille instruction or sensory substitution, such as text to speech conversion and auditory input for extended reading, may be necessary even if some vision is preserved.

Small boy wearing spectacles is sitting at a desk and pointing at the magnified letters ABCD on a large computer screen whilst a woman operates the computer mouse standing behind him Learning to read with an electronic magnifier
© Rajan Shrestha CC BY-NC-SA 2.0 flic.kr/p/yrbXxJ

Eye safety issues

Children with visual impairment from ROP frequently have one better eye - protecting this eye is very important. If a child has just one functional eye they should wear protective eyewear all the time. Polycarbonate lenses are preferred due to their high impact resistance. Physical education in school and other recreational activities must be limited to safe, non-traumatic activities to reduce the risk of retinal detachment.

Information for parents and caregivers

Children with low vision need to enjoy the same experiences that all children enjoy and should not be overprotected. They should be taught and allowed to walk and take care of themselves independently and encouraged to join in with household chores. They need to play and interact daily with other children who may have different abilities and needs.

Guidance for parents

Things to keep in mind as you play with your child:

One of the most important things you can do for your child is to become the ‘narrator’ of the things they cannot easily see, even though they may not be old enough to understand what you are saying. This may seem awkward at first, but early conversational skills enhance learning and will soon become natural for you. Have fun, talk, and learn from everyday experiences.

Try to incorporate a multi-sensory approach to learning. Toys that make noises when they are moved or manipulated are excellent for this. Gradually, begin to relate new objects and experiences to familiar ones but limit the number of objects - too many make it difficult to focus on a task. Real life activities like sorting clothes and vegetables are good for toddler-age children. The more familiar your child is with a toy or household objects, the better they will be at looking at smaller parts of the object.

Present large and small versions of familiar things. Use small models or pictures for things that are too big to touch explaining that the real object is much larger. Present unfamiliar objects with unusual textures - prickly, smooth, bumpy, cold, warm, slimy, sticky - and make comparisons. Touching a variety of textures will encourage your child to confidently explore new objects on their own. Go outside in all kinds of weather and explore the textures and smells of nature.

Try to use colour words to describe things. Choose objects that are red, blue, green, yellow or black and white. Watch your child to see if there is a colour that they respond to more.

Remember that it is easier to see objects when there is good contrast between the object and the background on which the object is presented. You can change the colour of the surface you are working on by placing either a plain light or dark cloth over it.

Always try to place your child in a position where the light is coming from behind him/her, without creating shadow. Avoid direct indoor lighting or sunlight coming in through the windows. Provide additional lighting for activities such as playing with a puzzle or drawing ensuring that the light is not shining in the child’s eyes. If you have the choice of a bright, shiny or wooden surface to play on, choose wood, to avoid glare.

It is extremely important to allow your child to spend time playing on the floor. This is how children learn to move their bodies. When your child begins to crawl and later to walk, they will create a mental map of their environment.

illustration of a small boy sitting on a mat on the floor, holding a tupperware box and reaching for a book. More books and a jigsaw are beside him  Playing on the floor

Low vision services are often not an integral part of an ophthalmic clinic. What are some of the challenges in your setting? Who within the eye care team can be trained to deliver supporting advice for parents?

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This article is from the free online course:

Retinopathy of Prematurity: Practical Approaches to Prevent Blindness

London School of Hygiene & Tropical Medicine