Dr. L and her newborn daughter. photo credit to Melissa DeLorme Photography

Try to picture what the world is like for a newborn entering the world.  Suddenly they go from the warm, cozy, darkness of mother's womb to a loud, cold world of bright lights and blurry shapes. And yet, research suggests that newborns are not paralyzed by sensory overload, but their visual skills that have been developing throughout their time in the womb immediately are ready to kick into gear! Full term and even some premature infants can fixate their eyes on a near object immediately in the delivery room.  This early visual alertness is used by doctors and nurses in the delivery room to assess the robustness and function of the central nervous system.

We can separate visual development in infancy into 5 main stages:

1. Awakening to the World 
Visual alertness occurs in the first hours/days/weeks of your newborn's life. What your baby can see, and what you as parents can do to support visual development in this stage is the subject of this article!

2. Learning to Look
In the first 1-2 months the eyes are learning to move and work together by following and tracking objects.

3. Eyes/Brain/Hands
Around 4 months old, your baby is integrating vision into motor control. Hand-eye coordination and balance are all being developed at this stage.

4. Adjusting Focus
At 6 months old it's time for the baby's first trip to the optometrist! At this visit, the doctor will use retinoscopy to assess how your child is focusing on objects near and far, check for any differences between the two eyes, and determine if a prescription is needed to prevent against lazy eye (amblyopia) or strabismus (eye turn).

5. See to Move
At ages 8 months to 1 year old, babies are actively moving and navigating their world using visual cues like depth perception.

Why is it so important to have an eye exam at 6 months of age?  There are so few people taking advantage of the great InfantSEE program that offers free eye exams for children age 6 months to 12 months, but the conditions that can be found during this exam can influence a lifetime.  During the exam your optometrist will be able to find life and vision threatening tumors, large prescriptions or eye muscle anomalies that could result in severe eye turns or vision loss, and congenital conditions that can result in permanent blindness and be associated with serious systemic health issues.  Yes, all that is what is taking place at your eye examination. It is so much more than "which is better, 1 or 2."

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Many of my optometrist/optometry school readers have likely already heard about the AOA backed Think About Your Eyes media campaign, and I am hoping that other readers have to -- either by seeing their ads on TV, magazines, or over the radio.  With healthcare changes just beginning to take effect, more Americans than ever will have vision coverage, but vision isn't even the best reason to get an eye exam!  The health of the eyes is so complex, and your eye doctor can find potentially blinding conditions years before they have time to cause permanent damage, as well as systemic health conditions like hypertension, cholesterol issues, and diabetes (just to name a few!).  Unfortunately due to years of difficulties fighting for recognition with insurances and others even in the medical profession, optometrists have been rather hidden from patient access due to insurance panel black-balling (which is now illegal with great legislature like the Harkin Act) and the important health aspects of an eye exam have been widely unpublished.

No more is this the case, and it is time for us to get behind the AOA's latest campaign to help bring the real benefit of optometry to the masses!

In the exam room, I get asked so many questions that surprise me -- the average American really knows very little about their eyes!  Here's an overview of some of my most frequently asked questions, and how optometrists can help:

What Age Should My Child Have Their First Eye Exam?

Infant's eyes are developing so quickly from birth -- going from seeing just blurry shapes to increasing clarity, depth perception, and the ability of the eye muscles to track and move together.  That is a lot of skills developing at once, and no surprise that many issues can result if this development is slowed or stalled.  As such I recommend taking advantage of a wonderful program called InfantSEE that provides a FREE eye exam for anyone under 1 year of age.  I recommend having that first eye exam at around 6 months to ensure the eyes are developing equally, and check for blinding congenital conditions like tumors and childhood cataracts and glaucoma.

Maybe your child is already older and has gone without an eye exam to this point. At worst, I recommend an exam before entering kindergarten to ensure your child is using their eyes equally.  If your child only sees clearly out of one eye, they are immediately at an unfair disadvantage to their fellow classmates in learning how to read, write, and do math. Eye screenings at your primary care doctor are incapable of finding inequality between the eyes at the rates to which they exist because children hate getting things wrong and will typically memorize letters or take a sneak look with their better eye to "pass a test". Make sure that you are helping your child perform their absolute best by making sure they can use both eyes with a real eye exam!

Should I have an eye exam if I have perfect vision?

Yes!  The vision component of your exam is just a small part, and the ability to see clearly is unfortunately no way to ensure that your eyes are healthy.  Most health conditions of the eye, like glaucoma, macular degeneration, ocular tumors, and destruction of tissue due to hypertension or diabetes does not cause vision loss until the condition is advanced enough to be irreversible in most cases.  If you wait to go to your doctor until you have vision loss, you will never be able to see clearly again!  Yes, let that sink in because for many people that is a shocking fact.

Your doctor is assessing your ocular health at every visit to find these issues years or decades before they can damage your ability to see, and that is why a yearly exam is essential to every single person. Remember, the retinal cells inside the eye are not fully visible without dilation or retinal photography, and these cells that allow us to see have no pain receptors so you want be able to feel any discomfort if you have a retinal disease!  You won't have a red eye; you won't have watering.  Ocular diseases cause painless, permanent vision loss!  These ocular conditions are treatable, and there is no excuse in today's age of medicine that so many people go blind due to ocular disease. With regular check-ups early risk factors or diseases will be found and treated before hopefully any vision loss can occur.

My eyes are red/itchy/watery/infected/have something stuck in them.  Should I go to the ER (or urgent care clinic for that matter)?

Well you most certainly can, but it is more expensive, more time consuming, and likely you won't be seen by anyone with specific eye training.  If you have a problem with your eyes, please don't waste your time and money going to someone that is not an eye specialist unless it is truly an emergency (like you got stabbed in the eye with a knife for example).  Your eye doctor has the proper training, equipment, and likely in-office samples to treat your condition quickly and accurately, without any long waits or excessive price to you out of pocket.

Allergies? Pink eye? Dry eye? Foreign body sensation?  Yes, I can help.  And I can accept your medical insurance as well!

Oh yes, and I can get you seeing as clearly as your eyes are capable of seeing too.

Please America, optometrists love this career and love helping people, so let us help you.

I had the pleasure of attending Dr. Glen Steele's course at this year's AOA meeting last June, and was truly inspired by the research being done with the InfantSEE program.  For those of you who do not know, InfantSEE is a program with the American Optometric Association where a FREE eye examination is provided for children 6 to 12 months of age.  These exams are aimed at detecting eye turns, high prescriptions that could lead to poor visual development, and diseases of the eye like potentially deadly retinal tumors.  Click here for more details about this program.

photo via InfantSee program site with AOA

InfantSEE is not just at the leading edge for detecting childhood visual disorders, its founder Dr. Steele envisions using the program for detecting and intervening when infants express early autistic tendencies.  I'm not about to jump into the internet debate concerning what causes autism and how to treat autism.  But what we do know is that autism is a spectral disorder where children express hampered abilities for social interactions.  How do children learn their social skills?  Well, most of an infant's ability to learn comes from direct visual input.  As optometrists, we are the experts on vision and vision development, so looking for early issues can make a big difference in a child (and a parent's!) life.

AUTISM AND THE EYE EXAM:  Evaluating Eye Contact Patterns

Photo Via Vision Aakriti

Patients often ask me how I can perform an infant eye exam since I can't check an infant's vision.  Doctors can, in fact, take a gross measurement of the infant's visual ability.  Of course a baby can't read anything, so doctors use a method called "Forced Choice" or "Preferential Looking" task. A common used tool is a set of 2 paddles: one with a face or other interesting stimulus, one with nothing.  You hold the two paddles up side by side, and it can be assumed that the child will spend more time looking at the paddle with the face.  A lot of the time, the infant is just going to look at the doctors face and not the paddles at all, but that is ok too.  Eye contact and interest in focusing on faces is a big clue that the child's vision and social skills are developing on target.  Studies have shown that a normal infant will spend more time looking at a persons eyes and mouth, versus a child with autism who will devote an equal amount of time to all areas, without any real preference for the face.  Link here for one recent study investigating eye contact and autism

Dr. Steele's advice to parents with a child who seems to avoid eye contact:  more face time with mom and dad, less texting during critical parent/child interactions

What to do if you see an infant who seems disinterested or appears to avoid eye contact?  One thing that is important to remember is that optometrists are not charged to diagnose autism in their chair.  But when you see the warning signs, it is perfectly reasconable and encouraged to discuss activities to increase visual development.  The word autism doesn't even have to be mentioned!  Dr. Steele recommends discussing "face time" activities.  In the world of social media, smart phones, and texting, parents are often multi-tasking while spending time with their infants during activities like nursing or changing diapers. During these activities, it is so important to focus on the child, look them in the eye and develop that important "face time."  Simple interventions like this could make a big difference in the child's developmental skills in the future.  Referral to area specialists is always another option, but autism is typically not diagnosed before the age of 2.

The first time I heard about InfantSEE I was still a student at the Southern College of Optometry.  One of my staff doctors, the lauded Dr. "Bubba" Steele, is a co-founder of the program.  Training with Dr. Steele was a huge asset to my career, and I can't express enough what a huge benefit it was that I was able to work under both him and Dr. W.C. Maples, two of the most well-known names in Pediatric Optometry.  But to get back on track, the InfantSEE program is a great initiative dedicated towards promoting ocular health for infants between 6 months and a year old.  Providers in the InfantSEE program offer FREE eye exams for infants, so every new parent should consider finding a provider in their area!

Infants will readily follow lights, so checking eye muscle movement and alignment is relatively easy for your doctor.  To get a complete look at the back of the eye, dilation will be needed.  Rest assured, there will be no damage to your child's eyes from these drops.  Photo from The Eye Care Center in Royal Falls, Virginia.

Why is an infant exam important?
Most children don't get visual screenings until they enter kindergarten, but the eyes are developing from the time your child opens them for the first time.  Remember, the eyes have to transfer information to the brain in order for you to see, so there are a multitude of important connections developing in newborns. The retinal photoreceptors respond to light, the optic nerve delivers this information to the brain, and the brain processes and interprets the information.  Not to mention the eye muscles that have to work together for eye movements and binocular vision (using both eyes together, creating depth perception).   If there is any breakdown in the flow of information, permanent vision loss results.  Detecting problems early (WAY before your child is being asked to learn to read) is obviously essential!

Retinoblastoma is a dangerous cancer that quickly passes from the eye to the brain.  It can best be detected with a dilated eye exam.

What conditions will be screened for?

• Retinoblastoma or other ocular tumors
• Congenital cataracts.  Yes, you can be born with cataracts!  If you notice a white reflection in photos of your child's eyes, take them to a doctor immediately.  A red reflex is normal, but a white reflex could be evidence of cataracts or even more dangerous cancerous growths.
• Strabismus (Eye Turns)  Sometimes a child's eyes can look like they are turning, but are actually normally aligned due to the poorly developed nasal bridge of an infant.  Your eye doctor will be able to differentiate a real eye turn from a "pseudo" strabismus.
• Amblyopia (Lazy Eye) In order to see depth, both eyes have to work together equally.  If prescriptions are greatly different between the eyes or an eye turn exists, the child will ignore that eye's blurry image.  The risk is that the brain connections to that eye will NEVER develop.  That means even with the best pair of glasses or contact lenses, if this condition is not caught early the child will NEVER have good vision out of the "lazy" eye.  The earlier amblyopia is caught, the better chance of getting the vision of the lazy eye back to normal.

Leukocoria is an ominous white reflex indicating a vision threatening (and sometimes life threatening) ocular condition.

This picture shows a cross-section of your eye, diagramming the lens which has developed a cataract in this case.  The lens is located INSIDE the eye, sitting behind the iris (or the colored part of the eye).  Picture courtesy seewithlasik

This patient has a nuclear cataract, characterized by yellowing of the lens.   This is one of the most common types of cataracts caused by aging, smoking, and UV damage.  Picture courtesy drhlis.com

This child's parents are truly protecting them from dangerous UV damage by using a brimmed hat and sunglasses!  You can purchase sunglasses for children and babies through companies like Baby Banz.