Visual Development

Department of Ophthalmology
Medical Faculty Sriwijaya University

Normal Visual Development

Normal baby 6 weeks: should be able to maintain eye contact with other human and react with facial expression Infant 2-3 months: interested in bright object Infant 4 months: disconjugate eye movement disappear Skew deviation and sunsetting: transient deviation in the newborn period

Poor Visual development

Wandering eye movement Lack of response to familiar faces and objects Nystagmus Staring at bright light Forceful rubbing of the eyes (oculodigital reflex)

Refractive state
Refractive state depend on
Corneal power
Starting 52 D at birth Flattening 46 D by 6 months Reaching their adult power of 42 44 D by age 12

Axial length
Increases by about 4 mm in the first 6 months of life Until 13 years growth slows only about 1 mm

The power of lens

Decreases dramatically

Visual Acuity
Methods used to determine visual acuity in preverbal infants and toddlers:
Visual Evoke Potential (VEP) Preferential Looking (PL)

PL Studies estimate the vision of a new born 20/600 Improving to 20/120 by 3 months To 20/60 by 6 months VEP: to 20/20 by age 6 7 months

Stereoacuity
Stereoacuity reaches 60 sec arc by about 5 6 months

Refractive Errors
Infants are hyperopic at birth Become slightly more hyperopic until age 7 Myopic shift until age 16 Changes in refractive error very widely If myopia presents before age 10: high risk of eventual progression to myopia of 6 D or greater Oblique astigmatism is common in infant and often regresses

Approach to the infant with decreased vision

A careful history
Detail of pregnancy
Maternal infection Radiation Drugs Trauma

Perinatal problems
Prematurity Intrauterine growth retardation Fetal distress

Approach to the infant with decreased vision

A careful history
Perinatal problems
Meconium staining Oxygen deprivation

Examinations
Visual fixation Crispness and equality of pupillary light responses Ocular alignment and motility Presence of nystagmus or roving eye movements A detailed fundus examinations

Approach to the infant with decreased vision

Unresponsive to very bright light
Immature visual system

Sluggish pupillary responses

Optic nerve hypoplasia or atrophy Optic nerve coloboma

Paradoxical pupillary phenomenon

Diffuse retinal disease (cones dystrophy)

Nystagmus
Decreased vision begin at age 2-3 months not at birth

Approach to the infant with decreased vision

Nystagmus
Presence of at least some visual function

In infant younger than 1 year

The most common misalignment: exotropia

Beyond the age of 1 year

Esotropia is more common

Electroretinography (ERG)
Can aid in diagnosis of a number of retinal disorder

Approach to the infant with decreased vision

Additional testing
VEP, USG, CT Scan, MRI

Specialized laboratory studies

In some cases

Consultation with other disciplines

Pediatric neurologist, endocrinologist, neurosurgeon, geneticist

The most common causes

Of reduced vision in infants
Anterior segment anomaly (complete ptosis, lens/corneal opacification) Glaucoma Cataract Optic nerve hypoplasia Optic atrophy Leber congenital amaurosis Achromatopsia (rod monochromatism)

The most common causes

Of reduced vision in infants
Congenital infection syndrome/TORCH syndrome Cortical visual impairment Delay in visual maturation Retinopathy of prematurity X link retinoschisis Congenital motor nystagmus Albinism Coloboma