The Development of Vision (Studies in Development Paediatrics)

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All visual acuity measurements in our patients. Serial measurements in an individual are connected by lines. The ordinates are a log base 2 scale; cpd indicates cycles per degree. The courses of the patients who had 4 or more measurements of both preferential looking PL and visual evoked potential VEP acuities.

The lower limits of the normal interval for PL and VEP acuities are indicated by the dotted and dashed lines, respectively. The patients are described in table 1. Figure 3. Every patient is represented, and individual patients contribute 1 to 5 points. The diagonal lines have a slope of 1. The dashed lines are 1 octave above and below the solid line. The ordinate and the abscissa are a log base 2 scale. Arch Ophthalmol. Longitudinal measures of grating acuity were obtained using preferential looking PL and visual evoked potential VEP. Visual acuities at first and last visits were compared.

The courses of acuity development in the 9 children who underwent both VEP and PL acuity assessment at 4 or more ages were compared with normal development. For both PL and VEP measures, acuity at the last visit was, on average, 1 octave better than at the first visit, with a rate of improvement lower than normal. The rate of increase is lower than normal.

Visual development in infants: physiological and pathological mechanisms.

Little is known about the course of development of acuity in cerebral visual impairment CVI , the most common cause of bilateral visual impairment in infants and children. Anomalous behaviors in children with CVI include avoidance of faces, light gazing, and preference for moving rather than stationary objects and familiar rather than novel objects. Visual response to complex visual displays is reduced, delayed, or suppressed, especially in the presence of competing auditory or tactile stimuli.

Preferential looking PL and visual evoked potential VEP measures of visual acuity are feasible and deemed reliable and valid in infants and children with CVI. Visual evoked potential acuity depends on the integrity of the pathway from the eye to the visual cortex. It is well established that normal grating acuity, whether measured by PL or VEP, increases during early childhood.

Reports of young children with CVI often present the acuities as cross-sectional data and include patients with diverse causes of CVI.

Emory Eye Center

The aim of this study is to determine whether a developmental increment in visual acuity occurs in children with neonatal hypoxic-ischemic encephalopathy and poor visual behavior consistent with CVI. Herein we report longitudinal measures of visual acuity in children with moderate to severe neonatal hypoxic-ischemic encephalopathy who were born at term and were referred because of CVI-like behaviors.

All patients were referred because of parental concern about visual impairment and behaviors consistent with CVI. Clinical inclusion criteria for this report were a history of birth at term, antenatal or perinatal distress or both, moderate to severe neonatal encephalopathy with seizures, and magnetic resonance imaging evidence of brain injury in a pattern typical of hypoxic-ischemic encephalopathy. Each had assessment of his or her developmental quotient using the Bayley Scales of Infant Development.

Pediatric milestones mnemonic

The magnetic resonance imaging findings showed diffuse signal abnormality in the subcortical gray matter, including the thalamus and basal ganglia, and in the cerebral gray and white matter, including portions of the optic radiations and visual areas of the occipital cortex. Neurological features are listed in Table 1. Every patient had some persistent motor abnormality; only 3 became ambulatory during the period of observation. Six patients had seizures after the neonatal period. All but 2 patients had a developmental quotient below A normal developmental quotient 16 is SD, Head circumference was below the second percentile in most of the patients.

We considered unfavorable neurological features to be seizures after the neonatal period, a developmental quotient less than 50, and acquired microcephaly with head circumference below the second percentile. Each of these features was scored, with 1 indicating unfavorable and 0, favorable. The severity of neurological outcome was taken as the sum of these scores table 1. Thus, those with the most severe overall neurological outcome had a score of 3, and those with less severe disease had a lower score.

Ophthalmic features Table 2 included mild disc pallor in 7 patients. All but 2 patients had strabismus. Most patients were exotropic, typically with variable angle.


All strabismus was alternating. Four patients had nystagmus. None had anisometropia greater than 1 D. Throughout their course, all except patient 19 had spherical equivalents within the Visual acuity testing in patient 19 was performed with correction in place.

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We included only patients who met the inclusion criteria described in the previous section, had both PL and VEP measurements of acuity at the same session on at least 1 date, and had visual acuity PL or VEP or both measured at more than 1 session. Visits occurred during an 8-year period from March through February The median age at the first acuity test was 15 months range, months.

Common screening and assessment tests

For the 9 patients who had both PL and VEP acuity tests in the same session at 4 or more ages, the median duration of follow-up was 29 months range, months , during which time as many as 16 PL and 6 VEP acuities were measured. Grating acuities were obtained with binocular viewing. Such modifications minimize the effects of visual field defects and eye movement abnormalities. The stimuli were The gratings had the same space-averaged luminance as the background of the gray cards.

The tester, unaware of the right-left position of the stripes, presented the cards at a distance of 38 to 55 cm from the patient. This was taken as the acuity, expressed in cycles per degree cpd. For the sample reported herein, between- and within-tester variations were no greater than 1 card interval 0.

To accommodate the large range of acuities, the test distances were 50 to cm. Electrodes were placed 3 cm above the inion O z and 3 cm to the left O 1 and right O 2 , with a reference electrode at the vertex and a ground electrode on the forehead.

The average of 5 or more sweeps was used. Acuity was estimated by linear extrapolation to estimate the spatial frequency that produced a zero microvolt VEP.

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Visual acuity log 2 cpd, ie, an octave scale was plotted as a function of age and compared with the normal course of development. Mayer and colleagues 26 reported that in healthy children aged 6 through 48 months, monocular PL acuity increased 2. Birch 27 found that from 6 to 18 months of age, average normal binocular VEP acuity increased from An acuity of For all 19 patients, the first and last acuities were compared and expressed as octave change per year.

For those 9 patients who had 4 or more sessions at which both PL and VEP acuities were measured, the rate of change in acuity per year was determined by linear regression. Nearly all visual acuities were below normal for age. Individual children underwent 2 to 16 measurements median, 8 measurements of PL acuity and 1 to 7 measurements median, 4 measurements of VEP acuity. One octave is often considered a clinically significant change. Optometrists who wish to differentiate their practice by introducing a speciality into their practice.

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