|Year : 1988 | Volume
| Issue : 2 | Page : 88-91
Visual disorders in cerebral palsy
Amita Govind, PA Lamba
Melamal Sood Rotary Hospital, Maranda-176 102, India
Melamal Sood Rotary Hospital, Maranda-176 102
Source of Support: None, Conflict of Interest: None
Seventy children with cerebral palsy were examined for aetiological factors responsible, type of disorder and ocular abnormalities. The overall incidence of ocular abnormalities was 68.69%, the highest frequency being of squint (35.7%). Other anomalies detected included refractive errors (28.5%), optic atrophy (10%) and coloboma (2.9%).
Most children were spastic quadriplegics with asphyxia as the major aetiological factor. The study created an awareness amongst parents of these children. The visual status of those affected could be improved for imparting education and training in a better way.
|How to cite this article:|
Govind A, Lamba P A. Visual disorders in cerebral palsy. Indian J Ophthalmol 1988;36:88-91
Cerebral palsy denotes a disorder of movement and posture resulting from a permanent non-progressive defect or lesion of the immature brain . It is classified on the basis of motor abnormality and its topography. Thus various motor types described include spastic, athetoid ataxic or atonic types while topography denotes the description of a limb or limbs involved eg monoplegia, diplegia, hemiplegia, tetra or quadriplegia.
These patients usually have associated mental subnormality (50%), emotional instability and convulsive disorders (25%). In addition ocular, speech (50%) and hearing defects and dental problems also occur. Little  mentioned that there was an association of strabismus with cerebral palsy and both had a common origin. Several authors ,,, have reported ocular defects associated with cerebral palsy since then.
A high incidence of ocular defects like refractive errors (50%), squint (52%), squint with amblyopia (15%) and visual field defects (11%) have been reported . Other ocular defects reported include nystagmus, amblyopia, gaze palsies, optic atrophy and ptosis. It is frequently impossible to determine the precise cause of cerebral palsy in individual patients. However various factors influencing the different clinical types of cerebral palsy are known . Some of the prenatal factors include cerebral agenesis due to clear genetic factors of unknown origin, rubella in first trimester of pregnancy, toxoplasmosis, X-irradiation and blood group incompatibility. Some severe cases of spastic tetraplegia with mental deficiency belong to this group. On the other hand milder cases with spastic tetraplegia, paraplegia and diplegia show a high incidence of premature birth and low birth weight Anoxia is the most important natal aetiological factor. Other postnatal causes include bio chemical disturbance such as hypernatraemia or hypoglycemia, acute infantile hemiplegia, meningitis and encephalitis.
These group of children have their visual disabilities ignored or overlooked. It is important to examine all children with this kind of multi system involvement as the incidence of ocular abnormalities is high and corrective measures at the right stage may help in overall development of the child.
We present here ocular findings in a group of children with cerebral palsy observed from this country.
| Material and Methods|| |
A total of 70 children who were diagnosed as cerebral palsy by the paediatrician were studied at the Paediatric Ophthalmology Clinic of Lady Hardinge Medical College & Associated Hospitals. Their age range was 5 months to 5 years. There were 41 male & 29 female children.
A detailed history was taken at the first visit with regards to age of the mother, parity and antenatal, birth and postnatal history to elicit any aetiological factor contributing to cerebral palsy. A note was made of other associated findings with cerebral palsy. Ocular examination included of the anterior segment, gross ocular motility, visual acuity, pupillary reactions and cover test Refraction was performed after use of 1 % atropine eye ointment The media and posterior segment were examined at the same time. Excluding 4 cases none of the children required sedation or anaesthesia for examination.
| Results|| |
The various types of cerebral palsy cases studied in the present group is depicted in [Table - 1] In order of frequency spastic quadriplegia was seen to be the most common (82.8%).
The various aetiological factors contributing to cerebral palsy were elicited in 42 patients out of 70 (60%). Majority of the parents gave a history of birth asphyxia. This formed the largest group of the various antenatal factors [Figure - 1]. The overall incidence of ocular abnormalities in the 70 cases studied was 68.6%. The various types of ocular abnormalities detected are shown in [Figure - 2]. Out of the various types of anomalies observed the highest incidence was of squint (35.7%). This included 15.7% of the paralytic and 20% of the concomitant type. All cases with paralytic squint had a limitation of movements of lateral rectus muscle. 2 cases had a bilateral lateral rectos palsy [Figure - 3]. There were 12 patients of squint with associated refractive errors and 2 children had associated primary optic atrophy. There were 4 cases with amblyopia but this figure may be low as all children with squint were below the age of 2 years and it was not easy to detect amblyopia.
The distribution of refractive status in group of children is shown in [Figure - 4]. Most of them had a tendency to hyperopia (taken as spherical equivalents). There were 28.5% cases with refractive errors which included 50% cases with astigmatism, 25% with myopia and 25% with hypermetropia. Twelve patients were prescribed spectacles and there was good acceptance in majority of the cases [Figure - 5].
Other ocular abnormalities detected included optic atrophy in 10%, nystagmus (5.7%), ptosis (1.43%) and coloboma of the iris and choroid 2.9% [Figure - 6].
The 10% cases with optic atrophy included only those who had definite evidence of optic atrophy on ophthalmoscopy. Some children who had pale discs but followed torch light were not included.
Other associated problems that these children had included microcephaly (30%) mental retardation (32.9%), hearing defect (12.9%) and convulsions (8.6%).
| Discussion|| |
Ocular abnormalities are very common in children with cerebral palsy. Breakey  reported a 56% incidence while Douglas' found 58.4% children with abnormal ocular findings. Incidences reported by Black , are still higher 70% and 80% respectively. In the present series as well the incidence of ocular anomalies is high (68.6%). This emphasizes the need for a proper examination of all children diagnosed as cerebral palsy.
Squint and refractive errors form the largest group of abnormalities. It has therefore been stressed that there is need for early detection, finding methods for special education, as well as methods of prevention for progression of these defects in such cases. Various reports have mentioned incidence of squint and refractive errors around 50% ,,, Both these conditions are treatable to some extent It is also important to assess amblyopia as it can be prevented if detected early but it is not easy to detect amblyopia in these children with accuracy especially on a single examination.
Hiles et al  emphasized that the treatment of squint in children with cerebral palsy by conventional methods gives 90% satisfactory results with regard to ocular alignment These children also have visiospatial difficulties which are exaggerated by presence of squint Even if treated purely for cosmetic reasons it assumes importance for the parent and patient.
The various ocular defects also show some variation depending on the type of cerebral palsy. Spastic children are more likely to have ocular defects than athetoid and ataxic children because of more extensive diffuse involvement of brain'. The squint may be essentially similar as in a normal child but deviation is always greater and also the incidence of squint increases with brain damage. Similarly the type of refractive error may vary with the aetiological type. Thus premature children, affected by toxemia and dystocia generally have myopia though overall hypermetropia is more common In the present series most children belonged to the category of spastic quadriplegia of severe type with mental retardation and low IQ. (31%). This group of children are likely to have ocular abnormalities of a more severe type and therefore is an added reason for an ophthalmological examination.
Usually children with cerebral palsy are not examined with care due to a difficulty in making an assessment because of their mental and physical disability or with the idea that nothing much can be done to help them cope up with their already poor condition But a proper examination with patience makes one detect various abnormalities and help the child in some way in his overall development more so because they relys heavily on visual stimulation for their education.
| References|| |
Hutchison JH, Practical Paediatric Problems London Lloyd-Luke 521, 1975.
Little WJ. Treatment of flat foot or spurious valgus Lancet 1843-44; 1 : 679-84.
Breakey AS. Ocular findings in cerebral palsy. Arch OphthaL 53 : 852-6, 1955.
Douglas AA The eyes and vision in infantile cerebral palsy. Trans Ophthal SOC UK 80: 311-25, 1960.
Black P. Ocular defects in children with cerebral palsy. Br. Med J. 16:487-488, 1980.
Black P. Visual disorders associated with cerebral palsy. Br. J. Ophthai 66: 46-52, 1982.
Schacat WS, Wallace HM Palmer M, Slater a Ophthalmological findings in children with cerebral palsy. Pediatrics 19 : 623-8, 1957.
Hiles DA, Walla PH, McFarlane F. Current concepts in management of strabismus in children with cerebral palsy. Ann Ophthal. 7 : 78998, 1975.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]
[Table - 1]