1. Introduction & Literature Review
Misdiagnosed low vision pediatric: Prospective study in Riyadh and Al-Ahsa
Alhanouf Albluwi and Asmaa Al-Mutairi, MS. Noha Alsaleem. King Saud University and Al Noor Association In Riyadh and Dammam.
Introduction & Literature Review
Hypothesis
The last question was (why you did not use the visual aid?) In (Riyadh) the ones that received the low vision aids didn’t like it for several reasons as the magnifiers were heavy, slows their learning process and gives them a headache when use it for long period of time. Few patients realize that the aid prescription is not correct but they have no other options. Unfortunately the evaluation procedures for the effectiveness of low-vision aids for children with visual impairments is not yet conducted, some of the children did not find suitable devises for them.
In Al-Ahsa, Question 9 analyses the reason for not using the aids , and the results analyze the main reason is some children refuse to use it, the parents did not have any idea about the LV aids, and some of them mention that there were not useful for their children.
 So far, there are no low vision clinics in some cities like Al-Ahsa, due to the lack of specialists, the ministry of health only focus on the big cities like Riyadh and Dammam . furthermore, one main problem that the parents face is that the appointments have long period between them which discourage the parents for the follow up visits.
Moreover, in this study some children didn’t received the correct measures which made it difficult due to the bad experience and others refuse to use it ever again thinking that it didn’t work. They prefer burial in learning process instead of the aids.
The explanation for the 5%+3% in Riyadh and 46%+4 % Al-Ahsa that were misdiagnosed is that they prefer to be in Al Noor Association because the learning process that provided to them has a positives psychological effect on visual impairment children rather than going to the normal schools. As it is known being a low vision can have a psychological and cognitive effect on the children (as the parent explain in the last question).
There are multiple studies discussed the difference between LV and blindness, but there are no previous studies about the misdiagnoses of LV and blindness. This problem is special in Saudi Arabia because of the lake of clinics and specialist numbers. For that, our study highlighted an important aspect in children vision care services. We recommend to do further studies on another cities in Saudi Arabia to have a bigger picture and analyzes further causes and provide good solution
Many children are misdiagnosed as blindness while they are not, due to a variety of reasons.
A lot of children that are identified and diagnosed with blindness even though they are not. They should be considered as low patients.  This misdiagnose can affect a child’s cognitive, physical, emotional, and neurological development and can adversely affect the child’s family and community and we should avoid that.
The study will be conducted in two of the leading blind organization found in two cities in Saudi Arabia which are Riyadh and Al-Ahsa. It's a prospective study that will be held between Jun and Dec Our population will be a blind pediatric population that is dealing with these organizations; sample size will include all the patients from age 6 to 18 years old.
Null Hypothesis
There is no statistical significance number of misdiagnosed blindness.
Questioner
To know the cause of the misdiagnosed, we prepare a questioner for the children and the parents, as:
Are they living in Riyadh, Al-Ahsa or somewhere else?
Aare there LV clinic nearby?
Did they visit LV clinic or only optometry or nether?
Did they have a history of LV?
Did the patient or his parents know the difference between LV and blindness?
Did they know about LV clinic?00
Does the patient know they are LV not blind?000
If No, would they like to visit LV clinic and bay LV aids?000
If Yes, why they didn’t accept LV aids?  
Methodology
It's a prospective study which will be conducted in Riyadh and AlAhsa, at Al Noor Association, during Juley The sample size will be (100 or more), Inclusion criteria, all participants between the age of 6 to 18-year-old, that has been diagnosed as blind and the exclusion criteria, is all patients under 6 and above 18. The screening of visual acuity and visual filed will be conducted by using Lea Symbols Chart and Tangent screen test receptively. The classification into low vision group and the blind group going to be based on World Health Organization criteria for defining low patients (WHO).
Low vision patients are defined based on (WHO) is a person who has an impairment of visual functioning even after treatment and/or a standard refractive correction and has a visual acuity of less than 6/18 to light perception, or a visual field of less than 10º from the point of fixation.
Lea Symbols Chart:
In the over 3 to 5-year-old age population, the LEA chart have high testability. And good reliability in both children and adults. Furthermore, the Log MAR LEA Symbols Chart allowing good controlling of the crowding phenomenon, and advantage of the availability of a lap card, for a non-verbal matching test. The VA recoding is the smallest symbol that the child can detect.
Aim Of The Study
To know the percentage and causes of the misdiagnosed children and educate the public about low vision services. 
Results
Conclusion
Low vision services in Saudi Arabia is still in its infancy stage especially in small cities ,which cause limited services for visually impairment patients. We found that there are no misdiagnosis in Noor Association in Riyadh, but in Al-Ahsa (small city) 50% of the children were misdiagnose due to lack of low vision clinics and awareness.
Figure (1): Lea Symbols Chart.
Tangent screen test.
Visual field testing will be completed under standard conditions in a dedicated testing room with ambient indoor lighting.
Acknowledgment
Special thanks to Dr.Balsam Alabdulkreem for highlighting this problem regrading low vision services for children
References
1. Gur, S.L., Pediatric Low Vision Management. Delhi Journal of Ophthalmology, (2).
2. Pascolini, D. and S.P. Mariotti, Global estimates of visual impairment: British Journal of Ophthalmology, (5): p. 614.
3. Vashist, P., et al., Definition of blindness under National Programme for Control of Blindness: Do we need to revise it? Vol
4. Leat, S., G. Legge, and M. Bullimore, What Is Low Vision? A Re-evaluation of Definitions. Vol
5. Gao, G., et al., Demographic and clinical characteristics of a paediatric low vision population in a low vision clinic in China. Vol
6. Visual impairment and blindness WHO.
7. Stevens, G.A., et al., Global Prevalence of Vision Impairment and Blindness. Ophthalmology. 120(12): p
8. Labib, T., et al., Assessment and management of children with visual impairment. Middle East African Journal of Ophthalmology, (2): p
9. Schurink, J., et al., Low vision aids for visually impaired children: A perception-action perspective. Research in Developmental Disabilities, (3): p
10. <A_correlation_between_measurem.pdf>.
11. Amos, J.F., Clinical Procedures in Primary Eye Care, 4th ed. Optometry and Vision Science, (1): p. e22.
12. Fuller, M.L., et al., Tangent screen perimetry in the evaluation of visual field defects associated with ptosis and dermatochalasis. PLoS One, (3): p. e
13. Figures (1,2,3) :
Community Eye Health Journal.
15. Haddad, M. F., Bakkar, M. M., & Abdo, N. (2017). Public awareness of common eye diseases in Jordan. BMC ophthalmology, 17(1), 177.
16. Jose, J., Thomas, J., Bhakat, P., & Krithica, S. (2016). Awareness, knowledge, and barriers to low vision services among eye care practitioners. Oman journal of ophthalmology, 9(1), 37.
Discussion
We noticed that in Al Noor Association in Riyadh, almost all of the blind and low vision cases are successfully diagnosed as the WHO criteria. The results show 92% were blind, And 8% are misdiagnosed (5% as low vision and 3% considered normal). On the other hand, in Al Noor Association in Al-Ahsa we found that 50% were blind, and 50% are misdiagnosed (46% should diagnosed as to be low vision and 4% are normal).
Figure (2): Tangent Screen Test
Statistics
Data analysis will be performed using Excel (Version (181110) 2018 Microsoft ).