this clinic has been set up in a multispecialty tertiary care hospital in south india that already has a specialized unit for developmental pediatrics , pediatric neurology , and pediatric psychiatry .
the author underwent specialized cvi vision assessment training abroad . the training involved vision assessment and rehabilitation of children with cvi in hospital and community setup .
our cvi clinic was set up in the eye department of the parent institution in india in february 2011 .
assessment to identify and characterize cvi requires dedicated space , time , and an interdisciplinary team approach .
our existing examination rooms have been modified to reduce surrounding noise and to make it more appealing to these children .
the clinic waiting area has walls painted with cartoon characters , space to run around , play with toys , and drawing materials to keep the child entertained .
the examination rooms have been modified to be more child - friendly and are clutter and noise free .
resources required for setting up cerebral visual impairment clinic all children presenting to our hospital , < 18 years of age , with cp , learning disability , autism , neurodegenerative diseases , and brain trauma are referred to the clinic .
each child is referred to the cvi clinic by his / her pediatrician , neurologist , psychiatrist , occupational therapist , or ophthalmologist .
the child 's referring clinician provides the necessary information regarding the neurological and developmental / cognitive assessment and radiological input .
the pediatric ophthalmologist gathers this information from the hospital 's electronic medical records ( emr ) . in the cvi clinic
this begins when the child comes into the waiting room of the clinic accompanied by the parents / caregivers and includes observing the children 's activities in the waiting area .
the child is observed for what he / she is looking at , and the size and nature of the object that gains and maintains the child 's attention , as well as the distance the child can appreciate the object of regard .
initial identification of visual - perceptual disorders is carried out , based initially on in - depth history taking , first eliciting spontaneously volunteered information about visual behaviors , then using a structured clinical question inventory as a guide to ensure that key issues are not omitted .
visual acuity is evaluated using the best - corrected dioptric correction by the pediatric orthoptist .
depending on the age and severity of physical disability , different tests are used . for children with severe cp , in whom visual acuity can not be quantified , we look for responses to light and high contrast pictures / toys , such as movement of limbs or heading toward the visual target , postural reactions , avoiding reactions , and changes in facial expression . eliciting optokinetic nystagmus also provides information on the visual potential in the child
. children with mild - to - moderate cp are assessed with age and ability appropriate visual acuity tests .
these include lea grating paddles , cardiff visual acuity cards , kay pictures , and snellen visual acuity chart .
oculomotor functions including fixation , saccadic eye movements , accommodation , visual axis alignment , and stereopsis are also assessed . the visual field in children
is assessed based on the behavioral responses , reflecting the child 's ability to locate targets presented in different areas of the visual field .
neuropsychological tests were not employed in our subset of patients due to their multiple neuropsychological disabilities , rendering their administration impossible .
all children presenting to our hospital , < 18 years of age , with cp , learning disability , autism , neurodegenerative diseases , and brain trauma are referred to the clinic .
each child is referred to the cvi clinic by his / her pediatrician , neurologist , psychiatrist , occupational therapist , or ophthalmologist .
the child 's referring clinician provides the necessary information regarding the neurological and developmental / cognitive assessment and radiological input .
the pediatric ophthalmologist gathers this information from the hospital 's electronic medical records ( emr ) .
in the cvi clinic , the trained pediatric ophthalmologist performs the neuro - ophthalmological assessment .
this begins when the child comes into the waiting room of the clinic accompanied by the parents / caregivers and includes observing the children 's activities in the waiting area .
the child is observed for what he / she is looking at , and the size and nature of the object that gains and maintains the child 's attention , as well as the distance the child can appreciate the object of regard .
initial identification of visual - perceptual disorders is carried out , based initially on in - depth history taking , first eliciting spontaneously volunteered information about visual behaviors , then using a structured clinical question inventory as a guide to ensure that key issues are not omitted .
visual acuity is evaluated using the best - corrected dioptric correction by the pediatric orthoptist .
depending on the age and severity of physical disability , different tests are used . for children with severe cp , in whom visual acuity can not be quantified , we look for responses to light and high contrast pictures / toys , such as movement of limbs or heading toward the visual target , postural reactions , avoiding reactions , and changes in facial expression . eliciting optokinetic
children with mild - to - moderate cp are assessed with age and ability appropriate visual acuity tests .
these include lea grating paddles , cardiff visual acuity cards , kay pictures , and snellen visual acuity chart .
oculomotor functions including fixation , saccadic eye movements , accommodation , visual axis alignment , and stereopsis are also assessed . the visual field in children
is assessed based on the behavioral responses , reflecting the child 's ability to locate targets presented in different areas of the visual field .
neuropsychological tests were not employed in our subset of patients due to their multiple neuropsychological disabilities , rendering their administration impossible .
from the inception of the clinic in february 2011 to september 2015 , 1478 patients have been referred .
the international patients have come from bangladesh , nepal , sri lanka , uae , and kuwait . of
the patients referred into the clinic , 61% had cp , 28% had seizure disorders , autism was seen in 9.5% , and learning disabilities , neurodegenerative conditions , and brain injury together constituted 1.5% . of the 902 children with cp , 39% had severe cp ( gmfcs level 5 , macs level 5 , and cfcs level 5 ) , 45% had moderate cp , and 16% had mild cp .
the most common perinatal cause of cvi in our clinic was birth asphyxia ( 40% ) , but there were about 20% of cases where a cause of the cvi could not be established .
1 . there was a mixed picture of higher visual dysfunction similar to that previously reported in the literature . visual acuity assessment ( number of patients ) t2 axial and t1 sagittal images showing gliosis in bilateral parietal lobe , thinning of the gray matter and volume loss in the white matter ( arrowhead ) , marked thinning involving the body ( posterior portion ) , splenium of the corpus callosum ( long arrow ) of the 1478 patients seen in the clinic , 295 ( 20% ) of the patients have returned for review .
of these , 70% ( 206 patients ) were utilizing strategies recommended in the cvi clinic , and all reported significant progress in their child 's visual abilities .
this was corroborated on clinical examination where the children were found to have gained improved eye contact , greater interest in toys and puppets , and enhanced interest in their surroundings .
of the remainder , 5% had carried out the visual strategies suggested for a few months but had discontinued the training as they did not find any improvement in their child 's condition .
a description of one of the cases presented to our clinic is described in box 1 .
clinical presentation of a case seen in cerebral visual impairment clinic liaison between team members was conducted through telephonic conversations and hospital emr .
as the clinical service has expanded , another pediatric ophthalmologist and pediatric orthoptist have gained in - house training in cvi assessment .
the visual brain reconstructs a dual internal emulation of the visual scene , with the ventral stream : temporal lobes creating the imagery and the dorsal stream ; posterior parietal lobes mapping it in space and time .
disorders of this process are unique to each child and involve incomplete mapping of the scene , which necessitates a dedicated quiet environment for optimum assessment .
vision fundamentally facilitates learning throughout a child 's development , resulting in knowledge , skills , and traits that will shape the child 's personality and cognition .
cvi is the preferred term as it is the result of damage to both gray and white matter of the brain . despite its absence from icd 10 ,
cvi is one of the leading causes for visual impairment in children both in the developed and developing world .
visual dysfunctions are one of the main features of cp and are on a par with the motor disorders . up to 60%70% of children with cp
in many western countries , such as the united kingdom , italy , the netherlands , germany , and sweden , this specialized service is routinely available for affected children . there is also involvement of governmental and nongovernmental organizations in their rehabilitation and follow - up .
such services can also help maintain a database of visual impairment in cp children for the nation .
in india , such specialized services or databases have yet to be developed . according to the published literature from india ,
the estimated incidence of cp is 3 per 1000 live births and cvi in cp is reported at 28% , this is just the tip of the iceberg .
it is likely to be higher if visual perceptual dysfunction is included in the study .
training in cvi is not yet part of postgraduate ( pg ) ophthalmology training program in india , neither is there any fellowship offering this facility .
development of this specialized care will improve pg training and care for these neglected children .
of late , there has been a growing awareness of cvi among pediatric ophthalmologists in the country . in spite of the availability of all the personnel in our hospital ,
the combined travel and discussion time currently renders setting up a clinic where all the multidisciplinary team ( mdt ) specialists are physically present is a challenge .
currently , the pediatric ophthalmologist assessing cvi has access through hospital 's emr to the child 's systemic condition , intelligent quotient scoring , medication , physiotherapy and occupational therapy , and also neuroimaging . the primary clinician and the therapist also have access to the cvi assessment reports for further management of the child .
we are developing a regular fortnightly meeting of the mdt to discuss and manage difficult cases .
examination of a child with cvi is time consuming , and for any clinical examination to be fruitful , it is important that the child is comfortable throughout .
children with cvi are at ease in a quiet environment with fewer distractions , which is not possible in a regular busy pediatric ophthalmology clinic .
the examination rooms are accordingly designed to be spacious , uncluttered , and child - friendly with minimum background auditory noise . making the required modifications to our examination rooms was a challenge as the existing concrete structure needed to be refurbished with limited funds .
it is important to remember that the needs and well - being of children with cvi and their families are central to establishing such a service . for appropriate service delivery to provide accurate and useful vision assessment of the child
cvi assessment necessitates giving an assessment report to the referring clinician and therapists / teachers [ table 2 ] that includes the information needed by teachers to ensure that their teaching is accessible to the child .
key links to the cvi clinic include community health - care workers , special educators , voluntary organizations , and parents / caregivers support groups .
our limitation is a poor rate of return to the clinic , principally owing to low socioeconomic background and distant locations from where these children come , rendering regular review impracticable , and necessitating the development of alternative approaches to follow - up .
assessment in cvi clinics is fruitless if recommended strategies are not understood nor implemented at home .
the support groups have an important role to address the following issues : report of cerebral visual impairment clinic assessments and strategies for habilitation for mast x 
 spread education and awareness about cviit is a daunting task for parents not only to accept the physical condition of their wards but also to carry out the strategies suggested . they need constant motivation , with regular encouragement and support . engaging with support groups and voluntary organizations proves beneficialthere is a constant need for economically viable tools and equipment to be developed because affected families are commonly under financial strainan important role of these organizations is to give feedback on services provided by the cvi clinic to assist in service improvements . 
 
spread education and awareness about cvi it is a daunting task for parents not only to accept the physical condition of their wards but also to carry out the strategies suggested .
engaging with support groups and voluntary organizations proves beneficial there is a constant need for economically viable tools and equipment to be developed because affected families are commonly under financial strain an important role of these organizations is to give feedback on services provided by the cvi clinic to assist in service improvements .
there is a need to set up specialized clinics in all parts of the country for patient care and training . for a holistic and successful management of cvi
 aim : the aim of this study is to describe the setting up of a cerebral visual impairment ( cvi ) clinic in a tertiary care hospital in south india and to describe the spectrum of cases seen.materials and methods : the cvi clinic , set up in february 2011 , receives interdisciplinary input from a core team involving a pediatrician , neurologist , psychiatrist , occupational therapist , pediatric ophthalmologist , and an optometrist . 
 all children , < 18 years of age , with cerebral palsy ( cp ) , learning disability , autism , neurodegenerative diseases , and brain trauma are referred to the clinic for functional vision assessment and opinion for further management.results:one thousand four hundred and seventy - eight patients were seen in the cvi clinic from february 2011 to september 2015 . 
 eighty - five percent of the patients were from different parts of india . in the clinic , 61% had cp , 28% had seizure disorders , autism was seen in 9.5% , and learning disability , neurodegenerative conditions , and brain injury together constituted 1.5% . 
 most of the children ( 45% ) had moderate cp . 
 forty percent of cvi was due to birth asphyxia , but about 20% did not have any known cause for cvi . 
 seventy percent of patients , who came back for follow - up , were carrying out the habilitation strategies suggested.conclusions:average attendance of over 300 new patients a year suggests a definite need for cvi clinics in the country . 
 these children need specialized care to handle their complex needs . 
 although difficult to coordinate , an interdisciplinary team including the support groups and voluntary organizations is needed to facilitate the successful implementation of such specialized service . 
Materials and Methods
Selection and description of the participants
Running of the clinic
Results
Discussion
Conclusions
Financial support and sponsorship
Conflicts of interest