University of Gondar

College of MHS
Department of Optometry
l e ke
at Fe
i y
Neb
Course : Pediatric Optometry
Credit=2
• What is pediatric age group?

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 OUTLINE:
Introduction
Ocular development
Development of visual functions
Summary

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 Introduction
• Child development is described in three
distinct phases:
• 1) the prenatal phase (development of tissues
prior to birth),
• 2) the perinatal phase (around birth) and
• 3) the post natal phase (post birth).

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Fertilization ---- morula(20 cells) ---- 5-6
days blastocyte(hundred cells)------ gastrula
• ‘gastrula’, gives rise to the three main
germinal layers (ectoderm, mesoderm and
endoderm) which, in turn, are responsible for
the formation of specific ocular structures

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• At 3rd week the primitive streak - a linear opacity of
ectodermal thickening, that forms longitudinally over
the dorsal (back) surface of the embryo.

• The ectodermal cells detach and migrate cranially

(towards the head) into the potential space between
the ectoderm and endoderm to form the mesoderm.
•
• primitive streak gives rise to the cranio caudal (head to
tail) axis of the developing embryo.

• The eye and the brain developed from neuroectoderm

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• Note that at 4 weeks, every few features are
clearly distinguishable. The major organs
have begun to form. The embryo at this time
is strangely vulnerable to a variety of dangers
from drugs to radiation.
• Would you give cigarate
For your unborn child?

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 Ocular development
• Vision is a dynamic process that is far more
complex than just being able to see clearly
when looking at a stationary object.
• Although the eye is one of the most fully
developed sensory organ at birth, there are still
profound growth and change in the
composition of many of its structures
• The visual system matures only later in life
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• Why emphasis needed to pediatrics

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 Ocular dev.

because:

1. the eye care taker must differentiate normal

developmental changes from pathological states

2. Early detection for early management

3. To Intervene the problem before critical period

passes since there is immature cortical
connection
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 The globe dimensions
o The weight of the term infant is 2.3-3.4k.g
o The volume of globe is 2-3.5 cm³
o Axial length: 15-17 mm
o An average of 4mm increase in AL in 1st yr
o Then the rate of increment decreases
o At 1st yr AL=20.5
o At 2nd yr AL=21.5, 3rd yr=22
o Reaches adult size at 5th yr
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 Anterior Segment
Cornea

• The tissue that is closer to adult dimension that

any other in the body
• Goes intracellular and macroscopic changes to
allow transparency and refraction but minimal
dimension changes
• newborn HCD=9.5-10.5 mm
• VCD=9.9-10.5 mm
• Macro cornea >2 sd from mean
• Micro cornea<9 mm
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 Cornea

• To maintain emmetropia changes in corneal

curvature must be balanced with lenticular, AL
changes
• Corneal curvature is steeper in infants
• New born radius of corneal curvature: 6.6-7.4mm
• Corneal power at birth: 52.00D, At 6months :
46.00D
• Reaches adult power:42.00D around age
12months

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 Cornea

Corneal endothelium at 12 week of

gestation=14000cells/mm²
• At birth 6800 cells/mm²
• Reduction of endothelial cells as age increases
• That’s why age match donors for PK vital
• Mild corneal clouding newborns, & expected in
premature
• Resolves when cornea thins from central
thickness 0.96mm at birth to 0.52mm at 6
months

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 AC Depth

• a/c depth increase till adolescence=3.6mm

• Depth higher in myopic pts

• Depth slightly higher in boys

• Normally symmetric depth between eyes

• important for IOL calculations

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 Iris

• Iris crypts dev. till early post natal period

• The iris lacks pigment and may have a gray or bluish
appearance; natural color develops as pigment forms.
• Iris color change ends at 6m-12months
• 14 genes responsible for iris color has been
identified

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 Pupil
• The pupillary membrane forms early in
gestation and atrophies near term
• Pupil response to light is expected at 31wks of gestation
• pupils are not able to dilate fully at birth.
• Size of infant pupil is large as compared to adults but
diameter <1.8mm and >5.4mm is abnormal
• Physiologic anisocoria of 0.5-1mm
• Always check size in dim and bright light

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 Lens

• Tunica vasculosa lentis essential for

development and nourishment of embryonic
lens
• TVL regresses completely at 35w of gestation
• This is used to estimate G.A:
27w-entire lens surface covered with vessels.
29-30w central vessels atrophy.
31-32 central lens visible. 33-34 only peripheral
vessels of TVL remains
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 Lens…

• Crystalline lens most responsible for adapting to

increase in AL
• AL increases ↑↑ till 3y
• CK flattens 3-5D during first year
• the lens is left to maintain emmetropia
• The refractive index at child 1.427
• Adult 1.416

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 Lens…

• Even though constant production of lens

fibers throughout life, axial thickness
decreases in the 1 st decade by 0.5mm

• That is due to equatorial growth that cause

passive stretching of the lens with flattening
of the lens surface
• reduction in dioptric power.
• The optical density of lens increases through
life, increasing light absorption
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 Sclera

• 4 times more pliable in infants than adults

• Half tensile strength
• Example buphthalmous in cong GL
• Thickness ↑from 0.45 at birth to 1.09 adult
• Three major proteoglycans: aggrecan, biglycan
decorin
• At birth the anterior sclera is more
pronounced than the posterior
• Remember thickness- strabismus surgery
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 Retina
• Retina equivalent to a film in a camera
• Has to modify as the eye grows
• Change in RPE cells density
• The retinal area seems to grow more relative to
the equatorial globe diameter
• Retinal and RPE area from 6m ga to 2y increase
by a factor of 2.7 (no mitosis after 6 m ga)
• In adult the fovea has no inner retinal layers or
ganglion cells thus creating the foveal pit

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 Retina…

• There are no rods within 350ɱ of foveola

• Only cones in central fovea so each cone
communicates with some ganglion and bipolar
cells explaining the high foveal V.A
• In term the fovea isn’t developed; still has
ganglion cell layer and inner nuclear retinal layer
• The process of fovea arrangement till 1y
• Cones becomes higher in fovea post nataly and
rods pushed to the periphery, foveal maturation
at work until 4 y

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 Retina…

• ERG is used to evaluate retinal function

• ERG measures retinal electric amplitudes in
response to light, check board pattern
• Waves; a,b for inner and outer retina
• Dark and light adapted tests
• Oscillatory potentials
• ERG tests reach adult normal values at 5y
• Very useful for evaluation of low vision or
Nystagmus child w/o visible retinal pathology

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 Retina…

• ERG evaluates retinal function only, it can be

used in the presence of cataract, vit. opacities.
• It is diagnostic for RP, and others
• However in order to examine the retro bulbar
visual system the VEP is used
• Normative VEP matures at 4-5y

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 Neurological development

• Visual acuity is dependent on optics, physiologic and

psychologic development
• Especially relevant in kids
• Normal development of the lateral geniculate
nucleus is complete by 1y
• However amblyopia results in atrophy of neurons in
LGN of the amblyopic side, and decrease of cortical
neurons

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 Cont…

• Deprivation amblyopia affects not only Visualacuity but

also contrast sensitivity, streopsis and scotopic and
photopic sensitivity
• The earlier the deprivation the more pronounced are
the effects
• The binocularity driven cortical cells have been shown
to become almost exclusively monocular in
experimental monocular visual deprivation

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 Cont…

• In non deprived monkeys, 81% of cortical neurons are

binocularly driven, but only 25% in mono deprived
monkeys
• Scotopic sensitivity was reduced in deprivation in
younger<1m but not if deprivation occur>3m
• Photopic sensitivity has longer window
• Different critical window for different visual functions

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 Cont…

• Interestingly there is evidence that visual

cortical recovery exist following cortical
damage. This phenomenon is unique to children

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 Orbital structures
• The eye is located in the orbit so all changes
have to be coordinated
• Computed studies revealed that the orbit
grows linearly and angularly throughout life
• Differences exist between male/female
• Binocular width increase from adolescence to
adult by 4mm in M but only 1.5mm in F
• Very important in oculoplastics.

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 Orbital structures

• Enucleation affects orbital growth ipsilateraly and

retard orbital growth.
• Orbital implant minimize the effect, w/o implant the
difference between the orbits volume was 7mm³,
with implant only 1.5mm³
• Even in adults after enucleation there is globe
shrinkage that is time dependent
• Eye lids are fused till 28 weeks gestation

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 Cont…

• The crease is formed by LP apponeurosis into

preseptal orbicularis
• Unilateral congenital ptosis= no crease
• Tear production develops post nataly
• Reduced tear production in premies but more
lipid content so break up time normal
• Probably d/t hyper meimobian glands and
smaller palpebral fissures so less evaporation
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 Development of visual functions

• Measuring visual functions

• Methods : - VEP
- ERG
- Optokinetic nystagmus (OKN)
- Behavioral techniques(e.g PL)

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 Visual functions

1- What are visual functions?

2- What is Visual acuity?

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 What are visual functions?

• Visual acuity
• Contrast sensitivity
• Binocular vision(steriopsis)
• Color vision
• Visual field
• Eye movement
• Ocular reflexes
• Accommodation
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 Visual acuity development

What is Visual acuity?....

- “The ability of the infant to resolve information about

form” can be assessed by measuring visual acuity

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 Electrophysiological method

- VEP= Tests the integrity of the visual pathway by recording

brain activity through electrodes placed on the scalp

- the spatial frequency at which no VEP is recordable is the

=Estimated VA

- limited by structural and neural changes in the media & Visual

pathway

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 Behavioral techniques

• Acuity in infancy is measured by Preferential

looking with black/white gratings.
- look fixation preference
- No fixation preference i.e. both appear identical
= Estimated VA
- Need attention, motivation and examiner’s
ability
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 VA assessment :

preferential looking method

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 Visual acuity

• VA= Represents the limit of spatial resolution at

maximum contrast

• Visual acuity is poor at birth . WHY?

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 Cont…

• What are the possible limiting factors?

1. Immature ocular structures
2. Immature retina
3. Immature cortical system
4. Immature contrast sensitivity

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 Development of visual acuity as measured by PL

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 contrast sensitivity

• What is contrast sensitivity ? (discuss)

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 Contrast sensitivity
• CS = Gives an over all representation of visual
functioning at different spatial frequencies
• Using Both techniques (PL&VEP) CS has been found to
be extremely immature at birth.
• Sensitivity to low spatial frequencies (large targets)
develops much earlier than sensitivity to high spatial
frequencies.
• contrast sensitivity for high spatial frequencies(smaller
target) reach adult level within 3-4yrs

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 Binocular vision
• In the first two months of life, vision appears to be
monocular
• By three months, some infants show a preference and
demonstrate recognizable binocular cortical potentials
• ‘cyclopean stimuli’ when inputs from the two eyes are
combined (such as random dot stereograms).
• majority of children show binocular vision by four
months

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• The ability to combine the input from both eyes
is dependent, not only on binocular cortical
processing, but also on accurate alignment of
the eyes’ axes

• most infants’ vergence system is developed by

four months of age.

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 Binocular function

Classified into:
- Bifoveal fixation
- stereopsis and
- fusion

The presence of these functions can be used to

describe binocular function ( not present @birth)

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a. Bi-foveal fixation – prerequisite for binocular function
- inaccurate alignment of the eyes results in
degradation of Stereopsis and fusion

- only occur in orthotropia, which most normal infants

achieve b/n 3 and 6 months

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 Stereopsis

– relates the visual systems ability to process

information about depth perception as a result of
simultaneous , but slightly disparate , images presented
to the two eyes
_Studies show that the development of stereopsis
demonstrated at age of 5months

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Infants have binocular to random dot stereograms at 3-4
months
-Dev’t almost entirely complete by the 5 months
-Once stereopsis emerges, stereoacuity improves rapidly

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 c. Fusion

separate and slightly dissimilar images arising in each eye

are appreciated as a single image by the process of
fusion.

Investigated using both PL and VEP and is seen to develop

over a similar time course as that of stereopsis

No fusion can be seen before 3½ months , but can be

consistently demonstrated by 6months
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 Orientation detection

• Infants can detect changes in the orientation of

stimulus
• Sensitivity highest in horizontal grating poorest for
oblique gratings
• Better acuity for H and V than oblique - Exposure
matters
• P cells responsible for color and oreintation ----adult
level at 12 months

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 Eye movements

• Normal movements of the eyes = normal visual

development
• Abnormal movement - sign of visually impaired
infant
• Infants can fixate stationary objects, follow a moving
target or move their eyes towards a stimulus

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1. Saccades – while adults use small corrective EMs
of varying size to maintain fixation, newborns can
only direct their eyes with a series of small saccades
 Adults =accurate fixation with one saccade, but
infants take longer to reach the target
 Relatively efficient adult –like saccades achieved
by 5months
 Horizontal SEM develop before Vertical saccades

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2. Smooth pursuit – not present till 2months
• By 2 yr and half months of age the ability to
follow the moving target with reasonable
accuracy has developed

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3. Optokinetic Nystagmus = slow and fast phases
can be induced visually from birth, but
immaturity in Monoc OKN
i.e. infants < 2months only in a temporal to
nasal direction
- symmetry for both directions achieved after 5
months of age

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4. Vestibulo-ocular reflex
- when a target is presented unexpectedly in the VF,
SEMs align the eye with the target & head rotates
towards the target .

- As the head rotates the semicircular canals of the

vestibular system sense a movement and initiate a
reflex rotation of the eye in the opposite direction to
maintain fixation
- Present at birth

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• Generally Children’s responses to eye
movement assessment such as motility testing
are very variable and highly dependent on the
target used

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 accommodation
 No accommodation at birth only fixed focus
 Recent studies adult levels of accuracy in
accommodation are present by 2-3months
 Accurate focus < 75 cm
 Greater depth of focus
 Infants have less sensory stimulus to control
accommodation accurately

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 Convergence
Two types of vergences :
Convergence and divergence
a.Accommodative – to a near target present by
1month of age, but improves by 2 months
b.Fusional - intermittent at 2 months and
improves in accuracy with age

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o Both vergence involve pathways b/n the cortex and
the oculomotor centers

o Immaturity in the pathways with in the visual system

underlies poor performance in the task

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 Color vision

- Testing color vision in infants is challenging,

because of the difficulty in determining that a
PL response is triggered by a chromatic
difference between the stimuli rather than a
luminance difference

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• Most studies show that no color response
manifests in infants before two months of age

• The first clear response is recorded to red-green

discriminations
• The tritan system develops a month later

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 Ocular reflexes

• Young infants blink response to noises, sudden

bright

• Corneal response to touch develop by 3months

• Pupillary light and near response present at

birth but immature

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