By Norman B. Medow, MD, FACS

Case study: Tommy is a four-month-old whose parents are concerned about his vision. They have two other children with normal vision, but they also had experienced some visual problems in the first year of life. Upon examination, Tommy is found to have poor visual responses, although his pupils, retina and optic nerves all appear normal. How does a pediatric ophthalmologist evaluate such a child and discuss his concerns with the child's family?

Evaluating a Child's Vision

As children reach various visual developmental milestones, some develop more quickly while others take more time. For this reason, visual and physical development is charted on a curve - with most children in the center and some falling to the left or right.

Vision and its manifestations - such as following objects, recognizing faces, smiling and grasping - all are parts of this developmental picture. If there are no other abnormalities and the condition simply is a time-wise delay, we refer to it as delayed visual maturation. Some children show delay, even markedly, but ultimately develop normal visual pathways and have normal vision. Other children, who appear not to have ocular abnormalities but exhibit delayed visual maturation, might show some visual abnormalities ultimately.

Discussing a Vision Condition With Parents

The pediatric ophthalmologist balances clinical impressions with experience when discussing an analysis with parents and making a recommendation. If some abnormality is found during an ocular examination - such as wandering gaze, to and fro oscillations of the eyes (nystagmus), optic nerve irregularities, retinal disturbances, pupillary abnormalities or abnormalities referred to the visual system by neurological developmental irregularities - the pediatric ophthalmologist may wish to explore these findings with further testing or consultation. The doctor also may ask a pediatric neurologist to see the child or request an imaging study of the eye and/or brain.

In addition, the doctor may consider having an electroretinogram or a visual evoked response (VEP) test performed. Each of these studies requires, in general, some degree of sedation. The electroretinogram and the VEP may not be reliable until six to seven months of life, so oftentimes these tests are not utilized in very young infants.

Tommy, for example, is a child who is otherwise normal but shows some delay in his visual responses. As his two siblings had similar delays and nothing else abnormal can be found, it is reasonable to speak with his parents about the probability of delayed visual maturation, and the expectation that normal milestones will be reached over the next few months. I refer to this form of treatment as "judicious neglect" (i.e., frequent observation, monitoring and examination). If normal milestones do not occur, the pediatric ophthalmologist would then consider further testing to evaluate the persistence of what was thought to be normal developmental delay.

On the other hand, if an infant does show visual pathway abnormalities, the doctor, likely in consultation with a pediatric neurologist, tries to clarify the cause of this defect. Once clarified, the pediatric ophthalmologist discusses the problem with the parents, what its long-term effect is and what can be done to optimize their child's development.

The pediatric ophthalmologist stands in a unique position to:

  • provide the family with information about the child's visual condition and clarify it in appropriate terms;

  • give parents the educational and social resources to help the child develop to his/her fullest extent;

  • evaluate the child periodically, so that any change in visual status is detected early and intervention can be provided.

It's important to realize that children cannot be isolated from their surroundings. They need care through the developmental years, as well as nurturing and adult contact. Children with impaired vision require much more input in all stages of development, and it's essential that the doctors who care for them understand the importance of multidisciplinary awareness and input.

Norman B. Medow, MD, FACS, is Director of Pediatric Ophthalmology, Manhattan Eye, Ear and Throat Hospital, New York, NY.

Source: Lighthouse International's EnVision newsletter

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