Importance of a Comprehensive Pediatric Vision and Eye Evaluation Tamara Petrosyan, O.D. Importance of a Comprehensive Pediatric Vision and Eye Evaluation

Why have a comprehensive vision exam? Vision disorders are the 4th most common disability in the U.S. and the most prevalent handicapping condition during childhood 2006 analysis of 1,051 infants (0-12mo) checked for 'visual risk factors' ocular or visual complication requiring careful follow up or treatment 17% had a positive risk factor 25% if premature, minority, or family income below $41K

Why have a comprehensive vision exam? Risk factors for many eye conditions have no signs or symptoms Estimated 1 in 10 children (age 6 and below) is at risk for an undiagnosed eye or vision problem Only 13% of parents make sure their child receives a comprehensive eye assessment

Why have a comprehensive vision exam? If left untreated, eye and vision problems can lead to difficulties in development, education, and potential permanent vision loss Majority of learning in school is done through reading, especially after 3rd grade Distance vision tests only catch myopes (nearsighted), high hyperopes (farsighted) and high astigmatism. Vision screenings miss many potentially problematic issues

Why have a comprehensive vision exam? Good vision involves the ability to take incoming visual information, process that information, and obtain meaning from it Simply having 20/20 vision is not enough For good incoming visual information you must have Clear distance vision Clear near vision - through use of the focusing system Good eye teaming - so you do not see double Good eye tracking - so you can follow an object or jump from one object to another

Why have a comprehensive vision exam? For fluent reading, a person must focus on the page to make it clear comfortably keep that focus for a long period of time coordinate eye teaming so both eyes point at the same place at the same time accurately and quickly jump from one word to another or from the end of one line to the start of another interpret and accurately process and decode what is read to give it meaning

Essential Health Benefit Starting January 1st 2014, yearly comprehensive pediatric eye and vision evaluations are considered one of the ten essential health benefits under the ACA Pediatric eye health care is defined as an annual comprehensive eye exam and treatment, including medical eye care All new health plans - both inside and outside of state exchanges – are required to provide fully integrated coverage for pediatric eye health care and must recognize optometrists as providers of medical eye care

What we are trying to catch during a vision exam? Amblyopia (lazy eye) Strabismus (cross eye) Significant Refractive Error farsighted, nearsighted, or astigmatism accommodative problems Eye Disease

What is tested during a comprehensive vision exam? Amblyopia (lazy eye) The loss or lack of development of central, detailed vision in an otherwise healthy eye Vision not correctable to 20/20 with glasses or contacts Due to a lack of proper visual nerve pathway connection between the eye and the brain high or asymmetric refractive error strabismus Occurs in 2.5 – 6.5 % of the population Can happen in one or both eyes Treatable: early intervention of glasses and/or therapy

What is tested during a comprehensive vision exam? Convergence Insufficiency / Strabismus (cross eye) When the two eyes do not point at the same place at the same time causing either diplopia or binocular vision suppression Strabismus can cause amblyopia Occurs in 4 – 6% of the population Can be one or both eyes constant or intermittent Treated with glasses, therapy, and/or surgery

What is tested during a comprehensive vision exam? Oculomotor and Pursuit Dysfunction (eye tracking) Inability to accurately jump from one target to another Inability to smoothly and properly follow a moving object Treated with therapy

What is tested during a comprehensive vision exam? Significant Refractive Error Myopia / Nearsighted Rays from a distant object focus in front of fovea Hyperopia / Farsighted Rays from a distant object focus behind the fovea, eye must accommodate to make image clear Astigmatism Rays from an object at any distance will focus in different areas on the retina giving a blurred image

What is tested during a comprehensive vision exam? Significant Refractive Error Accommodative Insufficiency and In-facility Inability of the eyes focusing / accommodative system to properly focus images falling behind the fovea Inability to sustain the focus of the eye or inability to quickly and accurately change focus on objects at different distances

What is tested during a comprehensive vision exam? Ocular Disease (less than 2% in pedes) Eyelid or eyeball infections Entropion / Ectropion Ptosis Nasolacrimal Duct Obstruction Nystagmus Cataract Glaucoma Color Vision Deficiency Retinopathy of prematurity Retinoblastoma Shaken Baby Syndrome / Retinal Hemorrhages

What is tested during a comprehensive vision exam? If the above mentioned problems are not caught early, they can impede development A comprehensive eye and vision evaluation tests for all of these problems The sooner the problem is caught, the easier and more successful the treatment will be

Children at increased risk for eye problems Difficult or assisted labor, associated with fetal distress or low APGAR scores Premature birth, low birth weight, or oxygen use following birth Drug or alcohol use during pregnancy Sexually transmitted disease, CMV, HIV Brain Injury / Trauma

Children at increased risk for eye problems Developmental delay, Downs syndrome, Fragile X syndrome, Fetal alcohol syndrome, Autism spectrum, Cerebral Palsy, Spina Bifida Family history of eye disease such as retinoblastoma, congenital cataract, congenital glaucoma, metabolic or genetic disease Family history of high refractive error, cross eye or lazy eye

Symptoms requiring a comprehensive eye exam Symptoms commonly associated with refractive error, focusing, eye teaming, or eye tracking dysfunctions blurred vision                        difficulty reading blurry vision after reading         blurry vision at end of the day headache with reading     ocular discomfort ‘pulling’ sensation around eyes   eye tiredness or fatigue double vision                        rubbing eyes when reading avoidance of reading                sleepiness when reading squinting, rubbing, closing eye    motion sickness loss of concentration                   skipping words / lines problems understanding what is read    problems remembering what is read problems copying from the board           difficulty with math difficulty with sports                     seeing words move on a page        burning or tearing of the eyes               poor eye-hand coordination difficulty following a moving target          poor judgment in depth decreased efficiency or productivity       need to use finger to keep place

Normal Visual Development Newborn 1 month 2 month 4 month 6 month 9 month 12 month 18 month 24 month 3 years OCULOMOTOR Fixate to face H Saccades V Saccades Pursuits Visually Directed Reaching Face Regard OKN + ACUITY Preferential Looking OU Visually Evoked Response OU 20/400-20/1200 20/100 20/300-20/1200 20/200 20/150-20/600 20/80 20/50-20/200 20/40 20/40-20/100 20/30-20/80 20/20 BINOCULARITY Alignment Convergence Near Point Fixation of Moving Target 10^ Response Stereopsis To 10” To nose 70% ACCOMMODATION Accuracy Lag @30cm (+)0.75 @75-150cm PUPIL RESPONSE Sluggish COLOR VISION Developing BLINK RESPONSE TO VISUAL THREAT CONTRAST SENSITIVITY 3-5yo Normal Visual Development By 6 months of age, many portions of visual function are on their way to being fully developed

Normal Visual Development 0 – 2 months Prefers large high contrast targets and faces Eyes do not always align or track together Concern if eyes are never aligned or if alignment does not gradually improve Tear drainage ducts not fully developed and may cause excess tearing 2 – 4 months Eyes start to track together Shifts gaze between objects with minimal head movement

Normal Visual Development 4 – 6 months Begins to track and reach for objects Depth perception (3D) begins to develop 6 – 8 months Nasolacrimal duct open in most Color vision improved Visual acuity potential 20/25 Eye teaming, tracking, and focusing improved 8 – 12 months Eye teaming, tracking, and focusing close to adult level

Limitations of vision screening No full, comprehensive ocular history and symptomatology No quantification of the problem vision refractive error / asymmetry accommodative function / facility binocular or eye teaming function No assessment of stamina of the visual system accommodative system binocular system oculomotor system

Comprehensive Eye Exam vs. Screening Only comprehensive eye exams fully identify eye problems, provide diagnosis, and ensure a linkage to treatment for all of the vision and eye health issues that can impact a child’s ability to meet important developmental and educational milestones Even the most highly-trained vision screeners using the top-of-the-line screening equipment will miss one-third of all learning-related eye and vision problems in children

Comprehensive Eye Exam vs. Screening Once missed by vision screening, children may be misdirected toward Individualized Education Plans (IEPs) and/or treatment for disorders like Attention Deficit Hyperactivity Disorder (ADHD) without ever receiving the vision care they need to help them succeed

What is done during an infant and pediatric comprehensive eye and vision evaluation Comprehensive medical and family history Measure visual performance / function at various distances both objectively and subjectively Evaluate refractive error, eye teaming, eye tracking, and eye focusing of the eyes both individually and together Evaluate for any eye disease, including dilated fundus evaluation if indicated

evaluation at 6 months, at age 3, before school, What is done during an infant and pediatric comprehensive eye and vision evaluation Manage any abnormality found by either close monitoring, treatment, or referral American Optometric Association recommends a child be seen for a comprehensive ocular and vision evaluation at 6 months, at age 3, before school, and every two years after that

When bringing a patient for a pediatric exam The baby should be Well fed Changed Has had a normal nights sleep Is not getting ready for a nap Is not sick Try to avoid siblings in the exam room Bring snacks and one or two of the baby’s favorite toys to use as distractors or part of the exam.

eyecare.org or njsop.org For more information or to find a pediatric optometric physician near you visit eyecare.org or njsop.org