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Infant's vision
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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
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Infant’s Exam
• Early detection reduces vision loss
• We can make the difference through early diagnosis and intervention
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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
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Visual acuity Preferential Looking
(Forced choice)
http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page9.html
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Spatial Acuity
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• 1 degree = 60’• 1’ = 60”
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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
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http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html
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Saccadic eye Movements• Newborn: Horizontal hypometric
– Increased latency, less speed
• Normal by 1 yo
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Accommodation• Less than 2 months: Fixed
accommodation, 30 cm• More than 2 months: Good
accommodation (worst for hyperopes and myopes)
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Vergence• 3 months: 70% have accurate
convergence and divergence
• Primastic fusional vergence: Well developed by 6 months
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Pursuits• Presence for newborns if:
– Big stimuli ( > 12 degrees)– Slow speed
• Present at 6-8 weeks
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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
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Contrast sensitivity
http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html
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http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page35a.html
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Face perception
http://www.psych.ucalgary.ca/PACE/VA-Lab/Marcela/Pages/page38.html
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Object perception
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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
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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
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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
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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
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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%
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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%
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Equipment
Trial case Prisms Lens bars Transilluminator Ophthalmoscope
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Toys
Brilliant colors With sound Without sound With movement Without movement
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Toys
Transilluminator
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Angle Kappa (monocular)
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Hirschberg Test (binocular)
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Measuring Angle Kappaand Hirshberg
Catch attention Use source of light Occlude one eye: Angle
Kappa Both eyes open:
Hirschberg angle
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Cover test
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Extraocular motility
Auditive-visual stimulus
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Extraocular motility
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Pursuits
Visual, non-auditive stimulus
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Convergence
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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
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Confrontation (Visual Field)
Use noisy stimulus to catch central attention
Use interesting peripheral stimulus (eg puppet)
Wait patiently for a response!
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Bruckner Test
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Bruckner Test
Symmetry, brightness, clarity between eyes
Subjective measure of visual acuity, deviation, refractive error
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Pupillary reflexes
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External Eye Exam
Transilluminator 20 D lens or
magnifier
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Mohindra’s Refraction
Monocular 50 cm distance Introduce lenses to neutralize Decrease by 1.25 D Use lens bar
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Pearls
Normal infants: hyperopic (Mean about 2.00 D)
Emmmetropizatin between 2-5 yo 5-6 yo leptokurtic distribution, peak at low
hyperopia
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Anisometropia
Anisometropic kids at risk of amblyopia
– Astigmatism > 1.50D - Hyperopic anisometropia > 1 D - Myopic anisometropia > 3 D
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Prescription
Anisometropia– Correct if > 1D with acuity reduction – Hyperopic anisometropia particularly
harmful
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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
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Prescription guide
Hyperopia
– In general, correct if > 2.50D – School children, correct hyperopias >
1 D
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Internal eye exam
Monocular ophthalmoscope DFE Fixation, pursuits and lack of
aversion to occlusion well signs of equal visual acuity
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Common cause lecucocoria
Congenital cataracts Persistent primary hyperplastic Retrolental fibroplasia Tumors: retinoblastoma Coat’s disease Corioretinal Coloboma Old retinal detachment Intraocular inflammation: Toxoplasmosis
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Congenital Cataracts
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Persistent hyperplastic primary vitreous
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Choroidal coloboma
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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
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Retrolental fibroplasia
Temporal retinal traction
Paton et al - Introduction to ophthalmoscopy
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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.
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Congenital Toxoplasmosis
Cicatriz de toxo en el polo posterior. Nótese la pigmentación y la atrofia del epitelio pigmentario.
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Toxocara canis
Traction on retinal vessels
Macular Granuloma with nematode
Spalton –Atlas de Oftalmologia Clinica, 1984
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Infant’s Vision
Early detection is keyLet’s work together to
save vision – and may be life!