Visual functions & Developmental Milestones

Dr. Amr Abdulaziz Hamzah

MBBS, CABO, JBO, FICO, FPOS
Pediatric ophthalmology consultant
 Outline
• Post natal development
A. Globe size & Axial length.
B. Orbits, lids & ocular adnexa.
C. Cornea.
D. Iris.
E. Retina.
F. Refractive errors.
• Visual development & milestones
 Globe size & Axial length
• Globe size and axial length undergo dramatic changes in the first years of life.
• Although anterior segment is 75-80% of that in adult size, the posterior segment at birth is less than
half the size in a normal adult eye.
• Average scleral surface area in neonates (812 mm²) which is almost one third of adult scleral surface
area (2450 mm²).
• Sclera in infants is much more cellular, median scleral thickness in neonates 0.45 mm compared to
1.09 mm in adults.
• Axial length of a neonate eye is 16.8 mm. longitudinal growth of axial length occurs up to
approximately 13 years of age, at which point the axial length is similar to that in emmetropic adults.
• The change in axial length can be divided into three growth periods:
A. Rapid postnatal growth phase in the first 18 months of life : increase in axial length 4.3 mm(from
16.0 to 20.3 mm).
B. Infantile growth phase between ages of 2 and 5 years : 1.1 mm increase in axial length.
C. Juvenile phase from 5 to 13 years : 1.3 mm increase in axial length.
 Orbits, lids and ocular adnexa
• Volume of orbit at birth is 10.3 ml.
• Doubled by age of 1 year to 22.3 ml.
• Reached 39.1 ml by age of 6 to 8 years.
• Volume of adult orbit is 59 ml in men and 52.4 ml in women.
• Palpebral fissure is narrow at birth .
• Development of Nasolacrimal Duct is almost complete at birth.
• Congenital impatency of NLD 2-4 % .
• Spontaneous resolution of Nasolacrimal duct obstruction in 75%-90%
of cases with the age of 1 year.
 Cornea

• Cornea undergo dramatic changes in size, shape and appearance during first year
of life.
• Corneal changes occurring in first year of life include enlargement, flattening,
thinning and an increase In transparency.
• Vertical and Horizontal dimensions of cornea in infants 9.8 mm & 10.4 mm
respectively.
• Cornea flattens causing keratometric readings to drop from 51.2 diopters (D) at
birth to 45.2 D at 6 months of age.
• Central Corneal thickness at birth 0.96 mm and decreased to 0.52 mm at the age
of 6 months.
• Minimal corneal clouding in newborn infants improves during first months of life.
 Iris development
• Iris color change dramatically over first 6 months.

• Stromal pigmentation of the iris increases over the first year of life.
 Retina
• Of all ocular structures, the macula is the least developed at birth.
• Although peripheral retina of infants is well developed histologically and
functionally, the posterior pole especially macular area is immature at birth.
• Dramatic growth and development of macula happened until age of 4 years.
• Most notable changes in:
A. Macular pigmentation.
B. Annular ring development.
C. Foveal reflex differentiation.
D. Cone photoreceptor differentiation.
 Refractive Errors
• The refractive state of the eye is dependent on the relationship between the
axial length and the combined refractive power of the cornea & lens.
• Axial length changes during life from a mean of 16.8 mm at birth to 23.6 mm
in adults.
• To compensate this increase in axial length, the cornea and lens flatten. So
that mean refractive power of the cornea and the lens decreases from a
mean of 51.2 D (Cornea) and 34.4 D (Lens) to adult values of 43.2 D (Cornea)
and 18.8 D (Lens).
• At birth, a full-term infant is generally hyperopic.
• studies suggest a gradual trend towards hyperopia through early childhood
that peaks at approximately age 7 years, thereafter a myopic shift occurs and
continues till adulthood.
 Refractive Errors
The change of mean refractive error with age
 Development of visual acuity
Visual acuity contrast sensitivity

Birth ≈ 6/300 unknown

3 months 6/90 --- 6/60 ≈ 6/60
1 yr ≈ 6/24 ≈ 6/9

2 yrs ≈ 6/12 --- 6/9 ≈ 6/6

3 yrs ≈6/9 ---6/6 ≈ 6/6

•Saccadic system
•Smooth pursuit system
•Optokinetic nystagmus
 Visual Development
• Babies are not born with all the visual abilities
they need in life .
• The ability to focus their eyes, move them
accurately, and use them together as a team must
be learned .
• Eye and vision problems in infants can cause
developmental delays.
 Visual milestones

•Not every child is the same and some may

reach certain milestones at different ages.
 Birth-4 months
• Up to about 3 months of age, babies' eyes do not focus on objects
more than 2-3 meters from their faces.

• By eight weeks, babies begin to focus their eyes on the faces of a

parent or other person near them. But they still cannot follow.

• For the first two months of life, an infant's eyes are not well
coordinated , However, if an eye appears to turn in or out constantly,
an evaluation is warranted.

• Babies should begin to follow moving objects with their eyes and reach
 5-8 months
• During these months, control of eye movements and eye-body coordination
skills continue to improve.
• Depth perception is not present at birth. It is not until around the fifth
month that the eyes are capable of working together to form a three-
dimensional view of the world and begin to see in depth.
• it is generally believed that babies have good color vision by five months of
age.

• Most babies start crawling at about 8 months old, which helps further
develop eye-hand-foot-body coordination.
 9-12 months
• At around 9 months of age, babies begin to pull themselves up to a standing
position. By 10 months of age, a baby should be able to grasp objects with
thumb and forefinger.

• By twelve months of age, most babies will be crawling and trying to walk.
Parents should encourage crawling rather than early walking to help the child
develop better eye-hand coordination.

• Babies can now judge distances fairly well and throw things with precision
 12-24 months
• By two years of age, a child's eye-hand coordination and depth perception
should be well developed.

• Children this age are highly interested in exploring their environment and in
looking and listening.

• They recognize familiar objects and pictures in books and can scribble with
pencil.
Visual Milestones