Clinical judgement of near pupil responses provides a useful indicator of focusing ability in children with cerebral palsy

Abstract

Accommodation is often reduced in cerebral palsy (CP). Knowledge about accommodative facility is valuable when investigating a child's visual needs and developing strategies for education. With normal accommodation, changing focus from distance to near results in pupil constriction. We compared quality of near pupil responses (NPR) with objective measures of accommodative function obtained with dynamic retinoscopy (DR) to investigate the utility of NPR in indicating accommodative facility. NPR and accommodative function of 90 children with CP (56 males, 34 females; median age 11y, range 4-18y) were assessed. A total of 93% of participants had spastic CP (71.3% bilateral involvement, 28.7% hemiplegia). The severity of motor impairment ranged from very mild (n=7) to severe (no independent walking, n=28). NPR was classified subjectively as normal, reduced, or absent and compared with DR measures of accommodative response. A total of 9.8% of pupil responses were judged absent, 25.6% reduced, and 64.6% normal. Participants with reduced or absent pupil responses demonstrated significantly poorer levels of accommodation with DR (one-way analysis of variance p<0.01). Sensitivity and specificity of NPR in identifying participants with reduced accommodation were 83% (95% confidence interval [CI] 65.5-92.4%) and 72% (95% CI 58.4-82.0%) respectively. NPR provides a rapid, useful indicator of accommodative function in children with CP.

Children with fetal alcohol spectrum disorder show an amblyopia‐like pattern of vision deficit

“…In addition, accommodation was not assessed in these children, and there is evidence that deficits in spatial vision can be exacerbated by the poor accommodation that is typical of some children with neurological disorders. 28,29 This limitation should be addressed in a future replication of our findings.…”

Identifying and characterising cerebral visual impairment in children: a review

“…Impaired focusing or accommodation has been found in over 50 per cent of children with cerebral palsy in Northern Ireland and spectacle correction improved academic performance in affected children . Looking for poor pupil constriction when looking at a near target is a good way of identifying affected children . Hyoscine skin patches are sometimes used to treat excessive salivation but they also paralyse accommodation and a near spectacle correction may be required.…”

Cerebral Visual Impairment in Children

“…If pupil constriction does not take place as a visible target (matched to the child's visual acuity) is moved towards the eyes, lack of accommodation is likely, and referral for refraction is required (Saunders et al 2008 ). The resulting converging and diverging movements of the eyes are observed.…”

“…Many children with cerebral palsy have poor accommodation, and an appropriate near correction may be needed (McLelland et al 2006); otherwise near vision is reduced. A poor pupil reaction when looking at a near target is a clear sign that impaired accommodation may be present (Saunders et al 2008 ). A poor pupil reaction when looking at a near target is a clear sign that impaired accommodation may be present (Saunders et al 2008 ).…”