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The Problem
“My baby doesn’t see.”
Common Causes
Otherwise normal baby: delayed visual maturation
Central nervous system problems: cortical visual impairment
Underlying eye problem with decreased vision
KEY FINDINGS
History
Other medical problems?
Family history of vision loss in young children?
Examination
Any response to light
Nystagmus
Pupil reactions
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If history and examination are otherwise normal, wait 2 months to refer.

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If nystagmus or abnormal pupils are present, refer.

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What Shouldn’t Be Missed

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Septo-optic dysplasia should not be missed owing to the potential for pituitary dysfunction.

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During the first 1 to 2 months of life, visual behavior in infants varies widely. Some babies fixate immediately after birth, whereas others take several weeks to begin tracking. At the 1-month well-child examination parents may specifically express concern if their baby is not fixating. Others may not be aware of any problems, but you will notice poor tracking on your examination. If everything else is normal (see the following sections), an appropriate plan is to wait until 2 months of age to see whether the tracking spontaneously improves, which will occur in most cases.

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By 2 months of age, the absence of fixation does not necessarily mean that there is an underlying problem, but the level of concern is raised. Referral to a pediatric ophthalmologist is appropriate at this time. Items from the history and ocular examination can help determine what additional steps are indicated.

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There are 3 main categories for infants who are not fixating by 2 months of age:

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  • 1. Infants who are otherwise normal, and have no other ocular abnormalities.
    • These children most commonly have delayed visual maturation (DVM) (also known as cortical inattention). The eyes themselves are fine in these babies, but the cortical connections that allow the brain to perceive images and make appropriate behavioral responses are underdeveloped. Most of these children will improve by 4 to 6 months of age, and further workup by the ophthalmologist is not indicated early in life, unless other abnormalities are found on the eye examination. If the infants continue to demonstrate poor fixation when they return for their follow-up examination with the ophthalmologist, additional testing will be necessary.
  • 2. History of serious systemic disease.
    • Any significant illness, particularly one that affects the central nervous system, may cause a delay in visual tracking in infants (Table 3–1). Common diseases include prematurity (especially less than 30 weeks gestation), perinatal hypoxia, hydrocephalus, and seizure disorders. Children with other severe systemic diseases, such as cardiac or pulmonary disorders, may also not track well initially.
    • Children with developmental delay, regardless of the etiology, also frequently take longer than usual to begin tracking normally. However, because of the wide variability in normal development in the first few months of life, and because isolated poor visual tracking may ...

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