1. BABY WATCH EARLY INTERVENTION VISION SCREENING TRAINING Part III.. Misalignment Part III.. Misalignment  Developed by: Darla Fowers, R.N., M. Ed.

2. Instructions for completing the Vision Screen Training by CD Instructions for completing the Vision Screen Training by CD

3. III. IS MISALIGNMENT OBSERVED?

4. MISALIGNMENT Eyes that do not appear to be looking in the same direction at the same time, or.. Eyes that do not appear to be looking in the same direction at the same time, or.. Eyes that do not appear to be positioned in the eye sockets in the way you would anticipate, or.. Eyes that do not appear to be positioned in the eye sockets in the way you would anticipate, or.. Eyes that do not appear to be lined up quite right, in any way Eyes that do not appear to be lined up quite right, in any way … may be misaligned as seen in the following picture: … may be misaligned as seen in the following picture:

6. MISALIGNMENT It is not unusual to observe that the eyes of a very young infant do not always work together, or they drift in and out of position It is not unusual to observe that the eyes of a very young infant do not always work together, or they drift in and out of position –Both eyes are usually working together, and no longer drifting by the time the baby is about 6 months of age However, parent(s) may report the eyes continue to drift beyond 6 months, when the child is tired, or when the child is ill (that information needs to be noted on the assessment form) However, parent(s) may report the eyes continue to drift beyond 6 months, when the child is tired, or when the child is ill (that information needs to be noted on the assessment form)

7. MISALIGNMENT As one observes a child for possible misalignment it will be important to not be fooled by: As one observes a child for possible misalignment it will be important to not be fooled by: – a child with wide epicanthal folds as seen in children of oriental decent or with a diagnosis of Down Syndrome, or … –A child with a wide bridge of the nose ***In the conditions noted above, straight eyes may actually appear crossed/misaligned***

8. MISALIGNMENT Misalignment of the eyes is of great concern. The brain will not tolerate the reception of two conflicting images. In such a case the brain will shut one of the images down, effectively blinding the eye which is shut down. Misalignment of the eyes is of great concern. The brain will not tolerate the reception of two conflicting images. In such a case the brain will shut one of the images down, effectively blinding the eye which is shut down. This condition is known as amblyopia This condition is known as amblyopia

9. How To Check for Misalignment Observe the child to see where the eye(s) usually rest Observe the child to see where the eye(s) usually rest Complete the assessment form as follows: Complete the assessment form as follows:

10. MISALIGNMENT Continued …. DDraw a circle to indicate the where the eye usually rests. DDraw a circle to indicate the where the eye usually rests.

11. MISALIGNMENT If misalignment appears to be a new or isolated happening wait 2 weeks, then rescreen. If misalignment appears to be a new or isolated happening wait 2 weeks, then rescreen. In the meantime have family/caregivers watch for any signs of the misalignment, especially at times when the child may be tired or ill. If the behavior is noted during the observation period or at the time of rescreening, refer to PIP and an ophthalmologist. In the meantime have family/caregivers watch for any signs of the misalignment, especially at times when the child may be tired or ill. If the behavior is noted during the observation period or at the time of rescreening, refer to PIP and an ophthalmologist.

12. MISALIGNMENT The second part of assessing for eye misalignment involves determining if light is reflected from the same place in each eye The second part of assessing for eye misalignment involves determining if light is reflected from the same place in each eye

13. Is the light reflected from the same place in both eyes? –This test helps to determine whether the child is using binocular vision, (the ability of the eyes to work together) or if the child has eye muscle problems.

14. Is the light reflected from the same place in both eyes? Continued … Shine a penlight into the eyes from about 18”. The light should be centered on the bridge of the nose. Shine a penlight into the eyes from about 18”. The light should be centered on the bridge of the nose.

15. Is the light reflected from the same place in both eyes? The light should reflect back as seen in the following picture … The light should reflect back as seen in the following picture …

17. light reflection Note any difference in the light reflection on the assessment form Note any difference in the light reflection on the assessment form

18. light reflection –Indicate, by drawing a dot, whether the light reflection is centered in both eyes, centered in one eye and off- center in the other, or off-centered in both. –The following demonstrates some examples of this …

20. light reflection If any misalignment is noted, refer to PIP and an ophthalmologist If any misalignment is noted, refer to PIP and an ophthalmologist