Can my baby see?
Vision screening in infants and children
by Manolette R. Roque, M.D.
“Can my baby see? Is his
vision normal for his age? How can you tell? How often should I have my baby
seen?” These are some of the frequent questions that anxious new parents ask me
in clinic. I will attempt to answer them in simple terms in order to provide the
readers of BABY magazine enough useful information to guide them with their new
role.
It is extremely important to
remember that pediatric visual screening uses simple yet powerful techniques to
detect ocular disorders at a young age when treatment is most effective.
Unbeknownst to many parents, the developing visual system of infants and
children can be permanently damaged by an abnormal visual image which may be
caused by ocular misalignment (strabismus or squint), obstructed ocular media
(lid ptosis, corneal opacity, cataract, and vitreous hemorrhage), high or
unequal refractive error (anisometropia), or unsteady visual images (nystagmus).
Significant ocular disease may often be missed, especially if only one eye is
affected. Sometimes, vision-, as well as, life-threatening (retinoblastoma)
disease may present with ocular signs.
When identifying visual
abnormalities, it is important to understand the normal visual development. If
you know what is normal for a child’s age, it would be easier to detect abnormal
visual function. Visual acuity is expressed as a fraction. The top number refers
to the distance you stand from the chart, usually 20 feet. The bottom number
indicates the distance at which a person with normal eyesight could read the
same line you correctly read. The less the bottom number in the visual acuity
ratio, the better the acuity; and the greater the bottom number, the worse the
acuity. Visual acuity at birth is quite poor, typically 20/1600, due to the
immaturity of the central nervous system visual pathways and visual processing
areas. Visual acuity improves to 20/100 by four months of age, and theoretically
reaches nearly 20/20 by 12 months of age. A cooperative three year old should be
able to demonstrate a visual acuity of 20/40, and a five year old 20/30. Many
newborns show variable ocular alignment, with 70% showing exotropia (outward
turning of eyes) and 30% having straight eyes. Esotropia (inward turning of
eyes) is rare. By two or three months of age, most infants would have straight
eyes. Misaligned eyes beyond three months of age require ophthalmic evaluation.
On more than one occasion, a
general ophthalmologist will confess to seeing a parent distraught over the
thought of not being able to improve the vision, despite proper spectacle
correction, of his school aged child after having gone through an initial visual
test at age ten or above! Abnormal visual development (amblyopia) is due to
abnormal visual stimulation by blurred, misaligned, or unsteady visual image(s).
It may be classified into several types, namely: (1) deprivation, from cataract,
corneal opacity; (2) anisometropic, from unequal refractive error, (3)
strabismic, from ocular misalignment, (4) bilateral deprivation, from cataract
of both eyes, nystagmus, (5) bilateral ametropic, from high refractive error of
both eyes, and (6) occlusion, from excessive patching of the good eye. The
treatment of amblyopia is step-wise in fashion. First, the obstruction in light
entry is addressed. Ocular media is cleared by cataract surgery, corneal
transplantation, etc. Once the media is clear, the image is focused with
glasses, contact lenses, or occasionally intraocular lenses. Finally, ocular
dominance is corrected by patching or blurring the better seeing eye.
A lot of parents inquire as
to when they should bring in their baby for eye examination. We recommend that
pediatricians, the front liners (!), screen at birth, six months, three years
and five years of age. It is further recommended that children be subjected to
an annual screening at school age until secondary school. An effective pediatric
vision screening examination involves (1) inspection, (2) visual acuity testing,
(3) ocular alignment testing, and (4) fundus red reflex testing.
Ophthalmologists may be seen directly for this purpose.
Allow me to give you a brief
overview of each of the four distinct components of an effective pediatric
vision screening examination. INSPECTION may be performed by the parents even
before consultation. It is obtained by the physician as the child is greeted and
while the history is taken from the parents. The following findings are
determined: asymmetry of corneal size, pupil size or eyelid position, head turn
or head tilt, nystagmus, obvious strabismus, tearing, ocular redness, ocular
discharge, and abnormal eye structure. VISUAL ACUITY TESTING can be tricky in
babies and children. It is initially done binocularly, followed by monocular
(patching one eye) testing. The test method depends on the age of the child. In
newborns, one looks for a glare response to a bright light stimulus. A three
month old baby should fix upon and follow the examiner’s face. A six month old
should fix and follow a brightly (red/yellow) colored toy, sometimes attached to
a bright light. One can be more ingenious with one year olds by allowing them to
reach out for goodies (candy/cereal) placed in one of two outstretched hands.
The examiner has to be quick in determining the response of babies at this age.
Any asymmetry in response between the two eyes requires repeat testing,
sometimes on a different clinic visit, or immediate referral to an
ophthalmologist for further testing. Occlusion of one eye may sometimes result
in a crying fit, a big red flag for monocular preference. Preferential gaze or
use of one eye should also alert the parent or physician of poor vision on one
eye. Verbal children (three years or older) are much easier to test
quantitatively with games of matching symbols. A lot of pediatric charts are now
out in the market for this purpose. Poor results with these standardized tests
warrants a comprehensive eye examination with an ophthalmologist. OCULAR
ALIGNMENT TESTING may be performed by the corneal light reflex test, cover test,
and fundus red reflex test. The parent may initially perform the corneal light
reflex test, using a bright light in a dimmed room, by searching for the corneal
light reflex in the middle of both pupils. A decentration of the reflex heralds
the presence of strabismus. Lateral (temporal) decentration means the eye is
turned inward (esotropia), while medial (nasal) decentration means the eye is
turned outward (exotropia). Vertical deviations (hypertropia and hypotropia) may
also be identified this way. The second and third tests are more difficult
procedures requiring skilled examiners. The cover test is the gold standard for
diagnosing strabismus. Ophthalmologists use a combination of prisms and covers
to check for shifting or refixation of eyes. The fundus red reflex test (Bruckner
Test), is a simple yet powerful test to detect unequal refractive error, media
opacity, strabismus, corneal abrasions, and foreign bodies. This test is an
integral part of newborn examination. The use of eyelid speculums may be needed
in order to complete this test.
I hope this summary is clear
and concise enough to be of use to our new parents out there! The benefit of
early detection of eye disease, through early treatment with improved outcomes,
far outweighs the mild hassle of pediatric vision screening. Go see your
pediatrician and ophthalmologist today.
There are several ways of reaching the ophthalmologists of EYE REPUBLIC Ophthalmology Clinic:
Hover note: Please place your mouse cursor over the red box
to click on the web and email links. For websites, a new browser
window will open. For emails, your default email program will
open. You may cut and paste the URLs or email addresses if you
prefer not to open new windows.
ONLINE ACCESS
WEBSITES.
http://www.EyeRepublic.com.ph - EYE REPUBLIC
Ophthalmology Clinic
http://www.OCP.com.ph - Ophthalmic
Consultants Philippines Co. -
http://www.LASIK.com.ph - Refractive
Surgery Resource
http://www.Cataract.com.ph - Cataract Surgery Resource
http://www.Eye.com.ph - Eye
Information Online
http://www.EyeDoc4Kids.com.ph - Eye Information for Kids
http://www.Retina.com.ph - Retina
Surgery Resource
http://www.Glaucoma.com.ph - Glaucoma
Online
http://www.Uveitis.com.ph - Uveitis Online
EMAIL. After writing down your comments,
suggestions, problems and/or questions, kindly tell us how
to get in touch with you by providing your name, email,
home/office numbers, and mobile phone.
General inquiries - help@EyeRepublic.com.ph
Refractive Surgery Service - refractive.surgery@EyeRepublic.com.ph
Glaucoma Service - glaucoma@EyeRepublic.com.ph
Cataract Service - cataract@EyeRepublic.com.ph
Doctors - eyemd@EyeRepublic.com.ph
Administrative - president@EyeRepublic.com.ph
Website - webmaster@EyeRepublic.com.ph
Newsletter -
newsletter@EyeRepublic.com.ph (receive
news and updates, discounts and promotions)
BLOG. Send us your comments.
EYE REPUBLIC
Ophthalmology Atlas
CLINIC INFORMATION
Mobile E-Yellow Pages. Via
SMS, text LUK4 EYEREPUBLIC
(send to 2851 for Globe and Sun Cellular, and 2951 for Smart). |
EYE REPUBLIC Ophthalmology Clinic
Manila
3/F Don Santiago Building Units 309-310
1344 Taft Avenue, Ermita
Manila, 1000 Philippines
Direct and Fax: (632) 536-2398
Trunk Line: (632) 523-8271 to 79 local 30
Mobile: (63917) 899-2020
Map and directions
|
EYE REPUBLIC
Ophthalmology Clinic
Asian Hospital
and Medical Center
5/F Medical Office
Building (MOB) Suite 509
2205 Civic Drive,
Filinvest, Alabang
Muntinlupa City,
1781 Philippines
Direct:
(632) 771-9253
Direct and Fax:
(632) 771-9254
Mobile: (63917) 795-2020
Map and Directions
|
EYE REPUBLIC Ophthalmology Clinic
Medical City
6/F Medical Arts Tower Inc (MATI) Suite 602
MERALCO Compound, Ortigas Avenue
Pasig City, 1604, Philippines
Direct and Fax: (632) 632-7846
Mobile: (63917) 537-2020
Map and directions
|
EYE REPUBLIC
Ophthalmology Clinic
St. Luke's
Medical Center
6/F
Cathedral Heights Building Complex (CHBC)
North Tower Suite 614
279 E. Rodriguez
Sr. Boulevard
Quezon City, 1102
Philippines
Direct and Fax:
(632) 407-3883
Mobile: (63917) 855-2020
Map and directions
|
CLINIC HOURS
First-Come, First-Served
Monday to Saturday 9:00 AM to 6:00 PM
All clinics are closed on Sundays and Holidays
|
|
Back to Top
VISION SCREENING IN INFANTS AND CHILDREN
information compiled by
Dr. Manolette R.
Roque and initially uploaded on May 1, 2005.
Last updated on
January 02, 2009. |
