TM

Visual Development in
Children

Muhammad Asroruddin, MD
[email protected]
EMBRYOLOGY
• The eye is derived from three of the primitive embryonic layers:
1. Surface ectoderm (including derivative neural crest)
2. Neural ectoderm
3. Mesoderm
Surface ectoderm
The surface ectoderm gives rises to: The neural crest
• The lens • The corneal keratocytes,
• The lacrimal gland • The endothelium of the cornea and
• The epithelium of the cornea, trabecular meshwork
conjunctiva, and adnexal glands • The stroma of the iris and choroid
• The epidermis of the eyelids. • The ciliary muscle
• The fibroblasts of the sclera,
• The vitreous, and the optic nerve
• The orbital cartilage and bone
• The orbital connective tissues and nerves
• The extraocular muscles
• The subepidermal layers of the eyelids.
Neural Ectoderm
• The optic vesicle and optic cup
• The retina and retinal pigment epithelium,
• The pigmented and nonpigmented layers of ciliary epithelium,
• The posterior epithelium,
• The dilator and sphincter muscles of the iris, and
• The optic nerve fibers and glia
Mesoderm
• The vitreous
• Extraocular and lid muscles
• The orbital and ocular vascular endothelium
Brief Overview of Ocular Anatomy, Physiology
and Terminology
Retinal Anatomy
Eye Movements
Visual Development

How does the visual system work?

Look at how it develops over time

- what do neonate babies see?

- at what age do various abilities appear?

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Visual systems:

Geniculo-striate pathway
Lat e ral
ge niculat e
nucleus
( LGN)

St riat e
cort e x
Object Ey e

Basis for conscious vision

-relatively late to develop (2-3 years)
-relatively late to evolve
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Development of area V1 - synaptic connections
- age 0-8 months: increasing connectivity
.

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11 )
16

Synapses in V1 (x 10

12

0 3 6 9 12 2 7 12 30 70
months years years
inf ancy childhood adult hood
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Development of area V1 - synaptic connections
- age 8 months - 12 years: neuronal pruning

20 .

11 )
16
Synapses in V1 (x 10

12

0 3 6 9 12 2 7 12 30 70
months years years
inf ancy childhood adult hood
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Development of area V1 - synaptic connections
- age 12-30 years: stable connectivity

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Development of area V1 - synaptic connections
- age 30+ years: gradual loss (aging)

20

11 )
16
Synapses in V1 (x 10

12

0 3 6 9 12 2 7 12 30 70
months years years
inf ancy childhood adult hood
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Measuring performance of babies

Need a way to measure responses to stimuli

- how can babies communicate what they see?

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A second visual system:
Tecto-pulvinar pathway
Ext ra-
Front al eye st riat e
fields ( FEF) cort e x
Pulvinar

Te ct um
( supe rior
colliculus)
St riat e
Object Ey e
cort e x

Basis for eye movements

-relatively early to develop (2-3 months)
-relatively early to evolve
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Stages of increasing neural connectivity

At birth:
• brightness perception
• red-green color vision
• motion — objects moving around
• looming — objects getting nearer

At 1.5 months
• depth via accommodation
• collision avoidance

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At 2 months:
• perception of blue (tritanopia ends)

• perception of familiar objects (face recognition)

- prefer coherent faces over scrambled ones
(same parts, different arrangements)

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At 3 months:
• depth via binocular disparity
• depth via vergence

At 4 months:
• depth via motion (kinetic depth)
• biological motion perception

At 5 months:
• depth via pictorial cues (T-junctions)
• relative size

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 At 6 months:
• Gestalt grouping
• size constancy

At 7 months:
• familiar size
• shading cues

-> Most processes in operation at 8 months of age

-> Subsequent development (neuronal pruning)

leads to refinement of visual abilities
- better control of visual attention?
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Nature vs. Nuture

What governs the development of vision?

Possibility 1: Innate mechanisms

- people are born with a fixed program
- this program unfolds regardless of environment
- cf. Rationalist (Nativist) philosophers

Possibility 2: Environmental influences

- people born only with general ability to learn
- vision results via interaction with environment
- cf. Empiricist philosophers
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Milestones
• 30 weeks - Blink to light
• 31 weeks - Pupils react
• 2 to 3 weeks - Early fixation
• Horizontal gaze - Birth
• Vertical - 2 months
• Fixate - Birth to 3 months
• Follow - 3 months
Other Visual Functions
• Color ? (3 months)
• Field – Adult-like 1 year
Normal Development of Vision and Eye
Movements

BIRTH – Term

 Fixation
 Poor following
 Intermittent strabismus frequently present
 Visual acuity 20/400 to 20/600
One Month
 Horizontal following to midline
 Improving alignment
 Visual acuity 20/300
Two Months
 Vertical following begins
 Improving alignment
 Visual acuity 20/200
Three Months
 Good horizontal & vertical following
 Normal alignment
 Visual acuity 20/100
 Accommodation begins
 Binocularity detectable
Six Months

Visual acuity 20/30–20/40

Binocularity well developed
Eight to Ten Years?
 End of sensitive period for amblyopia
Basic Techniques for Examining Children’s Eyes
• Age specific
• Start with HISTORY
• Moms are great diagnosticians!
• Common EXAM components
• Assessment of vision
• External anatomy
• Pupil function
• Motility
• Ocular fundus/Red Reflex testing
Ocular History
• Does child appear to see well distance and near?
• Any crossing?
• Family history of eye disorders?
• Recurrent discharge or redness?
• Extreme photophobia?
• NOT to worry about:
• “Sits close to TV a lot”
External Examination
• Are eyelids symmetric?
• Pupil symmetry?
• Any redness, inflammation,
or discharge?
• Cornea clear?
• Are the eyes aligned?
Pupil Exam
• Are the pupils round?
• Symmetric?
• If asymmetric, is it more asymmetric in dark or light?
• Reactive to light?
Motility Assessment
• Is the pupil light reflex
central?
• Do the eyes move fully
in all directions?
• Pseudostrabismus vs.
true strabismus
Vision Assessment
• Infants: Eye contact, follows face, smiles
• Toddlers: Cover each eye and follows objects (fix
and follow)
• Verbal: Visual acuity screening with appropriate
optotype (symbol/letters)
 TM

Pediatric Vision Screening

Muhammad Asroruddin, MD
[email protected]
Introduction: Questions We Hope to Answer
• Why is pediatric vision screening important?
• When should I be screening children’s eyes?
• What is the best way to screen?
• Is there any new and improved pediatric vision
screening technology I should be adopting?
The Importance of Pediatric Vision Screening

• Amblyopia affects up to 5% of the

population (>10 million Americans).
• In the first 4 decades of life amblyopia
causes more vision loss than all other
ocular diseases combined!
• Amblyopia has a “window period” for treatment in
early childhood.
• Screening can prevent otherwise fatal disorders such
as retinoblastoma.
 Vision Screening: Scope of Problem
Only 21% of preschool children and even fewer children
below preschool age are screened for these conditions.

Ottar WL, Scott WE, Holgado SI. Photoscreening for amblyogenic factors. J Pediatr Ophthalmol Strabismus. 1995;32(5):289–295
Amblyopia is Very Cost-Effective to Treat
• Membrano, et al: Cost/QALY $2,281 for Amblyopia Tx
• Comparisons:
• Hypertension screening/therapy in asymptomatic 49 yo =
$25,000/QALY
• Annual screening for Diabetic Retinopathy in high risk
diabetics = $41,700/QALY
Pediatricians Are the Natural First
Line of Defense – The Medical
Home
• Children already come to Pediatrician.
• Vaccinations and screening are
already a part of care protocol.
• Screening in pediatrics should be
most cost effective (no separate office visit, no
extra-time off work for parent).

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Refractive Errors

• Nearsighted
• Farsighted
• Astigmatism
• Anisometropia
Myopia (Near-sightedness)
 Eyeball too long
 Can’t see far away
 Correct with specs,
contact lens, or excimer
laser (adults)
Hyperopia (Far-sightedness)
 The eyeball is too short
 “Accommodation” will
increase the effective
lens power in the eye
and focus at both near
and far
 Crossing may occur

Accommodation Glasses
Astigmatism

 “Warpage” of the
cornea like a football
 Light rays in one axis
are not focused the
same as in opposite
axis
 Corrected with glasses
What is Amblyopia?

Unilateral or bilateral decrease of visual acuity caused

by form vision deprivation
and/or
Abnormal binocular interaction for which no organic
cause can be detected
Amblyopia
The Physician sees nothing
and the Patient very little
Amblyopia…In Other Words:
• The camera (eye) is capable of taking the picture but
the computer (brain) doesn’t recognize that there is
an image.

• “Either use it or lose it!”

Children are Different
• Developing cortical connections
• Window of opportunity for diagnosis and
treatment…just like with language development
Classification

1. Strabismic amblyopia:
• common ( ± 90%)
• affect at deviated eye
Classification

2. Anisometropic amblyopia:
• secondary common
• unequal refractive error in the two eyes  good eye and
brain will suppress the eye with the blur
• reduction VA < 20/30 or 20/40 in one eyes
• Myopic anisometropia usually mild & amendable to
treatment even in the late childhood
• Hypermetropic anisometropia is often difficult to treat
past 4 or 5 yrs
3. Isometropic amblyopia:
Large, equal and uncorrected refractive error both eyes
 lack of proper visual stimuli to promote development of vision during part or
all of the first seven years
4. Deprivation amblyopia:

• media opaque
• less common but severe
Early detection of amblyopia

• Deviated and deprived eyes as cause of amblyopia should be detected in early

years during normal visual development
• These conditions could be setected with several examinations

Abnormal of the ocular media Red reflex test

Strabismus Hirscberg/cover testing

Refractive error & amblyopia VA screening

Daily visual habit (
squinting,frowning,headache,nausea)
Anisometropia or strabismus Bruckner test
Photo screening 56
Amblyopia : Treatment Rationale

Involves the following steps:

• Eliminating (if possible) any obstacle to vision such as a cataract

• Correcting refractive error

• Forcing use of the poorer eye by limiting use of the better eye

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Cataract removal

• Cataracts capable of producing amblyopia require surgery without unnecessary

delay.

• Removal of significant congenital lens opacities during the first 2-3 months of life
is necessary for optimal recovery of vision

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Cataract removal

• In symmetrical bilateral cases, interval between operations on the first and

second eyes should be no more than 1-2 weeks.

• Acutely developing severe traumatic cataracts in children younger than 6 years

should be removed within a few weeks of injury, if possible.

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Occlusion and optical degradation

• most powerful means of treating of amblyopia by enforced use of the defective

eye.

• Full time patching should generally be used only when constant strabismus
eliminates any possibility of useful binocular vision.
Management Refractive Amblyopia

• In generally, optical prescription for amblyopic eyes should correct the full
refractive error as determined with cyclopagic

• Anisometropic Ambliopia
Child or infant should be given full cyclopegic correction difference between the
two eyes, regardless of age, present or amount strabismus or degree of
anisometropia
• Full time occlusion carries the greatest risk of this complication and requires close
monitoring, especially in the younger child

• Spectacle-mounted occluser or special opaque contact lenses can be used as an

alternative to full-time patching if skin irritation or poor adhesion proves to be a
significant problem

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Screen for Causes of Amblyopia
• Refractive errors
• Obstruction of optical pathway (e.g. cataract or
corneal scar)
• Strabismus
• Other—anything that blocks input of
visual information to the brain
When Should We Screen?
• Begin at birth and during all subsequent well child
visits.
• Think of vision screening like vaccinations!
• Different screening at different developmental/age levels.
Summary
• Vision screening should begin at birth and continue
throughout well child visits.
• Vision screening is age-appropriate
• Early Red Reflex testing mandatory
• VA testing in verbal children
• Objective screening technology is effective, improving,
but needs to be reimbursed for widespread adoption.
• Pediatricians are our best line of defense for
preventable blindness!
Thank You