|“My baby doesn’t see.”|
|Otherwise normal baby: delayed visual maturation|
|Central nervous system problems: cortical visual impairment|
|Underlying eye problem with decreased vision|
|Other medical problems?|
|Family history of vision loss in young children?|
|Any response to light|
If history and examination are otherwise normal, wait 2 months
If nystagmus or abnormal pupils are present, refer.
Septo-optic dysplasia should not be missed owing to the potential
for pituitary dysfunction.
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.
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.
There are 3 main categories for infants who are not fixating
by 2 months of age:
- 1. Infants who are otherwise normal,
and have no other ocular abnormalities.
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
- 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