Infant’s VisionInfant’s VisionHéctor Santiago, OD, PhD, FAAOHéctor Santiago, OD, PhD, FAAOInter American University of PRInter American University of PR

School of OptometrySchool of Optometry

Bebé Héctor

Infant’s Exam

• Early detection reduces vision loss

• We can make the difference through early diagnosis and intervention

Recommended schedule Age Asymptomatic At risk

Newborn to 6 months a 6 meses

At 6 months At 6 m or as recommended

2 to 5 years 3 yo 3 yo or as recommended

6 a 18 years Before first grade and every 2 years

Annually or as recommended

AOA Pediatric Eye and Vision Examination Practice Guideline, 2000

Visual acuity Preferential Looking

(Forced choice)

http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page9.html

Spatial Acuity

• 1 degree = 60’• 1’ = 60”

Visual Acuity

»1 cycle/ degree (20/600 newborn)

»3 cycles/ degree (20/200) at 3 m

»6 cycles/degree (20/100) at 6 m»12 cycles/degree (20/50) at 12

m»30 cycles/degree (20/20) at

3-5 yo

http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html

Saccadic eye Movements• Newborn: Horizontal hypometric

– Increased latency, less speed

• Normal by 1 yo

Accommodation• Less than 2 months: Fixed

accommodation, 30 cm• More than 2 months: Good

accommodation (worst for hyperopes and myopes)

Vergence• 3 months: 70% have accurate

convergence and divergence

• Primastic fusional vergence: Well developed by 6 months

Pursuits• Presence for newborns if:

– Big stimuli ( > 12 degrees)– Slow speed

• Present at 6-8 weeks

Optokinetic Nystagmus (OKN)

• Present at birth• Poor nasal to• Temporal• Better temporal to

nasal• Symmetric by 3-6

mhttp://www.opt.indiana.edu/ce/infant/graphics/okn.jpg

Contrast sensitivity

http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html

http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html

Face perception

http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page38.html

Object perception

Color vision • Cones : L (Red-Orange) , M (Yellow-

Green), S (Blue)• 1 week: Discriminate L and M• Newborn to 1 month: Difficulties

with S (blue)• By 2 months: S are functional• By 4 months: Normal trichromatic

vision

focused correctly.

Nearsightedness is a very common vision condition that affects nearly 30 percent of the U.S. population. Some evidence supports the theory

MYOPIA

focused correctly.

Common signs of farsightedness include difficulty in concentrating and maintaining a clear focus on near objects, eye strain, fatigue and/or headaches after close work, aching or burning eyes, irritability or

HYPEROPIA

distances.

People with severe astigmatism will usually have blurred or distorted vision, while those with mild astigmatism may experience headaches, eye strain, fatigue or blurred vision at certain distances.

ASTIGMATISM

Disorders Pediatric Popualtion

Desorden 6 m to 5 y -11 m 6 y to 18 yo

Hyperopia 33% 23%

Astigmatism 22.5% 22.5%

Myopia 9.4% 20.2%

Binocular disorders (Non strabismic)

5% 16.3%

Visual DisordersType 6 m to 5 y - 11 m 6 y to 18 yo

Strabismus 21.1% 10.0%

Amblyopia 7.9% 7.8%

Accommodative Disorders

1% 6%

Retinal disorders 0.5% 2%

Equipment

Trial case Prisms Lens bars Transilluminator Ophthalmoscope

Toys

Brilliant colors With sound Without sound With movement Without movement

Toys

Transilluminator

Angle Kappa (monocular)

Hirschberg Test (binocular)

Measuring Angle Kappaand Hirshberg

Catch attention Use source of light Occlude one eye: Angle

Kappa Both eyes open:

Hirschberg angle

Cover test

Extraocular motility

Auditive-visual stimulus

Extraocular motility

Pursuits

Visual, non-auditive stimulus

Convergence

10 pd Base-Up Test

Requires binocular attention An eye sees one image, a second eye sees

an image displaced downwards If both images are clear, eyes switch from

one to the other If one image is blurry, both eyes will look to

the clear image

Confrontation (Visual Field)

Use noisy stimulus to catch central attention

Use interesting peripheral stimulus (eg puppet)

Wait patiently for a response!

Bruckner Test

Bruckner Test

Symmetry, brightness, clarity between eyes

Subjective measure of visual acuity, deviation, refractive error

Pupillary reflexes

External Eye Exam

Transilluminator 20 D lens or

magnifier

Mohindra’s Refraction

Monocular 50 cm distance Introduce lenses to neutralize Decrease by 1.25 D Use lens bar

Pearls

Normal infants: hyperopic (Mean about 2.00 D)

Emmmetropizatin between 2-5 yo 5-6 yo leptokurtic distribution, peak at low

hyperopia

Anisometropia

Anisometropic kids at risk of amblyopia

– Astigmatism > 1.50D - Hyperopic anisometropia > 1 D - Myopic anisometropia > 3 D

Prescription

Anisometropia– Correct if > 1D with acuity reduction – Hyperopic anisometropia particularly

harmful

Prescription guides

Myopia: – < 1 D generally ignore, only correct

symptomatic and > 4 yo– 1 to 3 D: correct if > 3 yo– 3 to 5 D: correct > 1 yo

Prescription guide

Hyperopia

– In general, correct if > 2.50D – School children, correct hyperopias >

1 D

Internal eye exam

Monocular ophthalmoscope DFE Fixation, pursuits and lack of

aversion to occlusion well signs of equal visual acuity

Common cause lecucocoria

Congenital cataracts Persistent primary hyperplastic Retrolental fibroplasia Tumors: retinoblastoma Coat’s disease Corioretinal Coloboma Old retinal detachment Intraocular inflammation: Toxoplasmosis

Congenital Cataracts

Persistent hyperplastic primary vitreous

Choroidal coloboma

Retinoblastoma

Depósitos de calcio en retinoblastoma que pueden ser demostradas como radio-opacidades

Pueden tener un origen único o múltiples orígenes en el mismo ojo

Retrolental fibroplasia

Temporal retinal traction

Paton et al - Introduction to ophthalmoscopy

Coat’s disease

Anormalidad progresiva de los vasos acompañados de gran cantidad de exudados duros y muchas veces hemorragia. A la izquierda, la anomalía ha sido tratada con foto-coagulación.

Congenital Toxoplasmosis

Cicatriz de toxo en el polo posterior. Nótese la pigmentación y la atrofia del epitelio pigmentario.

Toxocara canis

Traction on retinal vessels

Macular Granuloma with nematode

Spalton –Atlas de Oftalmologia Clinica, 1984

Infant’s Vision

Early detection is keyLet’s work together to

save vision – and may be life!