Love you Mam, but where are you?

The family had travelled a long way from a small city in Bangladesh. Amit was their only child, a precious one born after ten years of marriage. The mother was a home maker and father was in the textile business with a modest income.

Amit was shy but eagerly entered my consulting room with a charming smile. He extended his hand in my general direction without making much eye contact, to say hello. I asked about Amit’s past medical problems and visual challenges. The father spoke at length. Amit was six years old and had just started primary school. He was not able to see the blackboard despite being seated in the first bench. But he enjoyed interacting with his teachers and classmates and had made quite a few friends at school.

Amit was born full term and delivered through a Cesarian section because the labor was prolonged. He did not cry immediately and cried weakly after about 5 minutes. He was admitted to the Neonatal Intensive Care for a week. He developed seizures on the second day after birth, but they quickly settled down and currently he was doing well on just one medication for the seizures.

Parents noticed that there was some delay in his milestones. By age two he was walking and talking appropriately. However, his eye contact was poor. Amit struggled with locating toys in a pile. He was also not confident of navigating stairs and new places. The mother said that when she went to pick him up after school, he could not readily locate and identify her.

I examined Amit and looked at the MRI that the parents had brought. Amit had a condition called Hypoxic Ischemic Encephalopathy(HIE) which is a very important cause of Cerebral Visual Impairment (CVI)

Most people think that the occipital lobe in the brain serves visual function and that is where all the action is. However due to a lot of advancement in visual function research, we now know that visual acuity or the ability to read down a chart is just one aspect of vision. There are other pathways in the brain which help with the ‘where’ and ‘what’ of vision. In other words to locate objects and then to identify their nature (color, contrast) are separate visual functions which are affected in CVI.

Oxygen is crucial to the functioning of the brain. When there is delay in a child’s cry at birth, the lack of oxygen to the brain can result in HIE. Not only does this affect portions of the visual cortex (occipital lobe) but also the other pathways serving vision. Some of these children may also have other delays, such as walking and speech.

Some children with CVI may have almost normal vision but struggle with many seemingly easy visual functions. They may be labelled as slow learners or being clumsy. It may take years to identify them. The good news is that we know a lot about CVI, ways to identify and how to improve the visual function.

The simple screening questions to ask and how to offer visual rehabilitation will be covered in the next blog.