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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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.

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