Background The WHO's Vision 2020 global initiative against blindness, launched in 2000, prioritises children. Progress has been hampered by the global paucity of epidemiological data about childhood visual disability. The British Childhood Visual Impairment and Blindness Study 2 (BCVIS2) was undertaken to address this evidence gap. Methods UK-wide prospective population-based observational study of all those aged under 18 years newly diagnosed with visual impairment or blindness between Oct 1, 2015 and Nov 1 2016. Eligible children were notified simultaneously but independently by their managing ophthalmologists and paediatricians via the two national active surveillance schemes, the British Ophthalmic and Paediatric Surveillance Units. Standardised detailed data were collected at diagnosis and one year later. Incidence estimates and relative rates by key sociodemographic factors were calculated. Descriptive analyses were undertaken of underlying ophthalmic disorders and nonophthalmic comorbidities. FindingsOf 784 cases, 72% had additional non-ophthalmic impairments/disorders and 4% died within the year. Annual incidence was highest in the first year of life, 5•2 per 10,000 (95% CI 4•7-5•7) with cumulative incidence by 18 years of 10•0 per 10,000 (95% CI 9•4 to 10•8). Rates were higher for those from any ethnic minority group, the lowest quintile of socio-economic status, born preterm or with low birthweight. Only 44% had a single ophthalmic condition: disorders of the brain/visual pathways affected 48% overall. Prenatal or perinatal aetiological factors accounted for 84% of all conditions. InterpretationBCVIS2 provides a contemporary snapshot of the heterogeneity, multi-morbidity and vulnerability associated with childhood visual disability in a high income country, and the arising complex needs. These findings will facilitate developing and delivering healthcare and planning interventional research. They highlight the importance of including childhood visual disability as a sentinel event and metric in global child health initiatives.

Carotid cavernous fistula is an abnormal communication between the carotid arterial system and the cavernous sinus. We present an interesting, rare case of bilateral spontaneous ‘Barrow type- C’ fistula treated presumptively as conjunctivitis. A 66 year old patient presented in the eye casualty at North Devon District Hospital in January 2016, referred from her General practitioner complaining of bilateral red eyes. She was found to have large, prominently diffused and engorged scleral blood vessels on both sides along with raised intraocular pressures of 26mm of Hg bilaterally. The patient was diagnosed with an indirect carotic cavernous fistulas bilaterally in view of the clinical and radiology findings. Barrow type - C dural fistulas were reported to be seen bilaterally on radiology findings. Patient was referred for interventional treatment to the closest neurosurgical center where she had four failed attempts of coil embolization after which she was referred to a second neurosurgery center at Bristol where she underwent successful coil catheterization as the treatment for her carotid cavernous fistula. Indirect carotid cavernous fistula most commonly occur spontaneously. Bilateral spontaneous indirect carotid cavernous fistula is a very rare diagnosis and and there are very few cases reported in the literature without an underlying etiology or a known cause like Ehlers -Danlos syndrome or diabetes mellitus. Bilateral spontaneous carotid cavernous fistulas are difficult to diagnose due to mild symptoms and no history of trauma. We conclude that carotid cavernous fistulas are a threat to the vision if left untreated due to delayed diagnosis. We recommend considering bilateral carotid cavernous fistula as a differential diagnosis in patients with an ongoing history of red eyes or those unresponsive to conventional topical treatment for conjunctivitis like symptoms.

Aims: To show the refractive outcomes, accuracy of intraocular lens power selection, and visual outcomes and complications in infants undergoing cataract surgery. Methods: The refraction (spherical equivalent) of 14 operated eyes in 8 children aged ,1 year was plotted over time. Preoperative and final recorded visual acuities were assessed. Results: The median follow-up was 37.25 months. The median initial postoperative refraction was +6.75 dioptres. Conclusions: Refractive outcomes for each eye were not entirely predictable and were variable between infants. However, there was a consistent pattern in each infant who underwent bilateral surgery, with both eyes following a similar pattern of refractive change with time: a decreasing myopic shift was seen in 8 eyes, possibly demonstrating emmetropisation. The two unilateral cases appeared to show a linear myopic shift. 4 eyes in 2 patients did not follow a myopic shift curve and one of these patients showed an early trend towards increased hyperopia. Definite causes for this erratic refractive change were not identified. A postoperative refraction .4.5 dioptres avoided early onset myopia. The range of difference between postoperative and predicted refraction using SRK-T was 22.85 to 2.97 dioptres. Most of the visual results are encouraging compared with historical data in older children.

Childhood visual impairment confers significant potential adversity on the individual, their family, and on wider society. 1,2 To address this at societal and individual levels, primary (preventing blinding disease from occurring), secondary (treatment of established disease to reduce negative impact), and tertiary prevention approaches are required. [3][4][5] Tertiary prevention approaches comprise interventions that mitigate the impact of established visual disability or associated disorders on the life of the child and the adult they become. These interventions may be simple, such as the provision of low vision aids, or more complex, such as the provision of parenting support, or the development of individualized 'packages' of multidisciplinary care for the additional physical, educational, psychological, and social developmental needs of the affected child. 6 In recognition of the high burden of the numerous developmental and non-ophthalmic disorders that coexist in children with impaired vision, multidisciplinary assessment of children newly diagnosed with visual disability is advocated. 1,3,7 Almost two decades ago, the British Childhood Visual Impairment and Blindness Study (BCVIS; 2003) confirmed that in the UK most children newly diagnosed with severe visual impairment and blindness (SVIBL; vision worse than 1.0 logMAR [logarithm of the minimum angle of

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