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