1. The Importance of Good Vision for Children

2. Presentation provided by:
Randolph E. Brooks, O.D.
AOA Member
Ledgewood, NJ

3. Importance of Good Vision to Learning
Approximately 80% of all learning during a child’s first 12 years comes through vision
Undetected and untreated vision problems can interfere with ones full learning potential
Vision disorders are the fourth most common disability in the United States and the most prevalent handicapping condition in children
Courtesy of AOA

4. Importance of Good Vision to Learning
Only 14% of children have had an eye exam by age 5
Only half of all children will have an eye examination before completing high school
20% of children age 9-15 need glasses, and 90% of those have not received them
75,000 3 year olds develop amblyopia each year
Courtesy of AOA

5. Statistics
American Optometric Association recommends a child gets his/her first eye exam at 6 months
5% of children were identified as having a vision problem using the Snellen Chart
18 Million children will not have had an eye examination by an Eye Doctor by the time they enter school
60% of students identified as problem learners have undetected vision problems
Statistics courtesy of AOA

6. Role of Vision In Learning
The eyes must see clearly, without double vision, and with accurate focus control
The brain must interpret the visual image from its background, make assumptions as to its figure, and integrate the information gathered from peripheral vision and from other senses
Processing must occur without flaws
A child must have visual ability to learn to read prior to reading to learn

7. Symptoms of Children Struggling in the classroom
Trouble finishing written assignments
Losing their place when reading
Having a short attention span when doing close work
Skipping words when reading
Making errors when copying from the board
Underperforming

8. What is good vision? Good vision includes: Visual acuity Eye health
Visual Integration
Eye teaming
Eye focusing
Eye motility

9. Visual Acuity
The ability of the eye to see clearly in the distance and at near
Near vision- the ability to see at inches (reading a book)
Intermediate vision- the ability to see at inches (computer distance)
Distance vision- the ability to see at 10 feet or more
20/20 indicates that you can see letters 3/8” high at 20 feet

10. Eye Health The absence of anomaly or disease
If not diagnosed or treated, eye disease can lead to vision loss or impaired vision
Ocular health is evaluated by external ocular examination with a biomicroscope, eye pressure evaluation, and a dilated fundus exam

11. Visual Integration
The ability to process and integrate visual information
Using our vision and other senses to understand what we see

12. Eye teaming The ability of the eyes to work properly together
The ability to coordinate and align both eyes to allow the brain to fuse a single image from the images it receives from each eye
The ability to judge relative distances of objects and have depth perception
The ability of the eyes to focus on something near by turning towards each other

13. Eye Motility Eye Focusing
The ability of the eyes to focus and shift focus to near and distant points easily and effortlessly
Eye Motility
The ability of the eyes to move from one point to another
The ability of the eyes to move across a page of print or to follow a ball, etc…

14. Prevalence of vision problems Age 6 months to 18 Years
Hyperopia (farsightedness) %
Astigmatism %
Accommodative & Binocular disorders 20%
Myopia (Nearsightedness) %
Strabismus (eye turn) %
Amblyopia %

15. Hyperopia (farsightedness)
The inability to see close-up things well
Eyeball is too short for normal focusing power of the eye
In children the lens can focus and accommodate through this error providing both clear distance and near vision, but much effort must be used. This can cause headaches, fatigue, and even crossed eyes.
Symptoms Include:
Rubs Eyes
Has watery eyes
Complains of blurred vision

16. Astigmatism
Results from an irregular shape of the front surface of the cornea.
The eye is more football shaped rather than round
Causes blurred vision for distant and close-up things
Symptoms include:
Rubs eyes
Has watery eyes
Complains of blurred vision

17. Myopia (Nearsightedness)
The inability to see distant things well
The eye is too long for the normal focusing power of the eye.
Symptoms include:
Squints
Gets close to the board

18. Strabismus Occurs when the eyes are not aligned when viewing an object
The eye may turn inward toward the nose (esotropia) or outward toward the side (exotropia)
This is usually caused by poor muscle control
Any eye turn can happen constantly or occasionally

19. Esotropia

20. Exotropia

21. Symptoms of Strabismus
Intermittent double vision
Closes or covers one eye
Says letters or words appear to move
Loses place
Is Inattentive
Rubs eyes
Has watery eyes
Complains of blurred vision
Has poor reading comprehension

22. Accommodative and Binocular Disorders
Accommodative- The eyes cannot focus well
The inability to contract and relax the eyes’ focusing muscles
Binocular – The eyes do not work well as a team; for example, the eyes cannot converge for up-close reading

23. Accommodative Symptoms
Headaches
Tired at the end of the day
Has blurred vision when looking from board to book or book to board
Holds things very close
Is Inattentive
Rubs eyes
Has watery eyes
Complains of blurred vision
Has poor reading comprehension

24. Binocular Disorder Symptoms
Headaches
Fatigue
Double vision
Blurriness
Watery eyes
Rubs Eyes
Is Inattentive
Loses place
Says Letters or words appear to move

25. Amblyopia Also known as a lazy eye
Reduced vision in an eye that was not stimulated in early childhood
Can result from strabismus or misaligned eyes or a difference in clearness between eyes. One eye is focusing better than the other one. One eye becomes stronger from its use and the other eye is suppressed and not worked hard enough

26. Vision Screenings
Designed to identify gross visual problems and to indicate the immediate need for an eye examination. Parents must follow through on the referral.
Most children who fail a vision screening will also fail a diagnostic professional examination

27. Components of Visual Screenings
Distance Visual Acuity
Purpose-To test for myopia, amblyopia, astigmatism, and high hyperopia
Equipment-Distance VA chart and Occluder
Visual Acuity Charts Include:
Snellen Chart
Tumbling E chart
Lea Symbols

28. Snellen Chart & Tumbling E
Photos Courtesy of POA

29. LEA Symbol Charts
Photos courtesy of POA

30. Criteria for Referral
If either eye is less than 20/40 or a two-line difference exists between the two eyes, retest the child
If the same results prevail, the student has failed and immediate referral is indicated

31. Near Visual Acuity
Purpose- To test for hyperopia, astigmatism, amblyopia, and focusing problems
Equipment- Near Acuity Cards and Occluder
Near Acuity Cards include:
Snellen
Lighthouse acuity
Lea Cards
Tumbling E

32. Near point cards
Photos courtesy of POA

33. Referral Criteria
If either eye is less than 20/40 or a two line difference exists between the two eyes, retest the child
If the same results prevail, the student has failed and immediate referral is indicated

34. Color Vision Test Detects difficulty in ability to recognize color
Children with color blindness are not actually blind to color, but simply have difficulty identifying and distinguishing between different colors
Color Deficiencies are usually hereditary and affect 1 in 12 boys but only 1 in 200 girls

35. Color Vision Tests
Photos courtesy of POA

36. Color Vision Test Equipment: Referral Criteria Occluder
Pseudo-Isochromatic Test Plates
Referral Criteria
Student fails if does not correctly identify the number on the card
Photos courtesy of POA

37. Convex Lens Test Detects hyperopia and binocular problems Equipment
Distance acuity chart
Occluder
Pair of Spherical Lens (ages 5-8)
Pair of Spherical Lens(>age 8)

38. Convex Lens Test Referral Criteria
If the student cannot read the 20/40 line while wearing the lenses then he/she has passed the test
If the student can read the 20/40 line while wearing the lenses then the student has failed and should be referred.

39. Stereo/Depth Test Tests for amblyopia, strabismus, and binocularity
Equipment
Random Dot E
Stereofly
Random Dot Stereotest

40. Stereotests
Photos courtesy of POA

41. Random Dot E & Polarized Glasses
Photos courtesy of POA

42. Cover Test
Tests for ocular alignment disorders, strabismus, and binocular problems
Done both at distance and near
Unilateral cover test
Movement on Unilateral cover test = strabismus
No movement on unilateral cover test = normal
Alternate Cover Test
Movement on Alternate cover test = Strabismus or binocular problem, depending on severity
No movement on alternate cover test = normal

43. Near Cover Test

44. Cover Test

45. Near Point of Convergence
Tests the ability of the eyes to converge for up-close tasks
If the eyes cannot effectively converge for near vision tasks, then the patient has convergence insufficiency
Equipment
Near Point fixation stick
Tape Measure
Photos courtesy of POA

46. Near Point of Convergence Referral Criteria
If the student reports double vision or either eye swings out at greater than 5 inches then he/she has failed
If the student does not regain alignment or report single vision at 7 inches or less, then he/she has failed

47. Vision Screenings vs. Comprehensive Eye Examinations
Screenings only detect gross visual problems and cannot substitute for regular professional eye examinations
Periodic eye health and vision examinations are essential for the prevention and diagnosis of conditions of the visual system
Parents MUST follow through on the referral

48. Definition of Optometrist
Optometrists are independent, primary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye and associated structures as well as diagnose related systemic conditions.
Courtesy of American Optometric Association

49. Ocular Emergencies
Red Eye
Chemical Burns
Foreign Body
Blunt Trauma

50. No Treatment Generally
“BLOODSHOT”
Painful and/or Vision Blurred
YES
See Doctor Now NO
“BLOODSHOT”
Discharge
Gritty Sensation
See Doctor Today
YES NO
YES
Blood Red Spot on
White of Eye
No Treatment Generally
Required
RED EYE NO
Lubricants
Warm Compresses
See Doctor if Worsens
No illness/trauma Hx
No Discharge
Slightly Red Eye
YES
Courtesy of AOA

51. Doctor immediately after
Is the Chemical a strong base?
Example: Drain Cleaner
Lime
Irrigate 30 Mins Lids
Forced open then see
Doctor immediately after
YES
Chemical Burns NO
Irrigate for 15 mins.
Then see Doctor.
Is it a strong acid?
Example: Battery Acid
YES NO
Irrigate 15 minutes.
See Doctor Today
A mild acid or alkali?
Example: Chlorine, bleach
Gasoline and Hairspray
YES NO
See
Doctor
Today
Mild Thermal Burn
Example: Singed eyelashes
UV Burn / Welding
YES
Courtesy of AOA

52. Burns Alkali- based chemicals Lime (cement, plaster, whitewash)
Drain cleaners
Lye
Metal polishes
Ammonia
Oven cleaners
Acid-based chemicals
Swimming pool acid (muriatic acid)
Battery (sulfuric) acid

53. Ocular Foreign Body See Doctor Now Call Doctor Today YES NO YES
Are any of the following true?
Can the foreign body be seen and
does it remain after gentle washing?
Could the injury have penetrated the globe
of the eye?
Can blood be seen in the eye?
Does it feel as though a foreign body might
be trapped behind the upper lid?
YES
Ocular Foreign Body
See Doctor Now NO
Is there any problem with vision?
YES
Foreign Body NO
Call
Doctor
Today
Is there any eye pain?
Courtesy of AOA

54. Blunt Trauma See Doctor Now See Doctor Today
Are any of the following true?
Is lid swollen shut?
Is blood in anterior chamber?
Is cornea white/hazy?
Is pupil irregularly shaped, fixed, dilated
or constricted?
YES
See Doctor Now NO
Is there any problem with vision?
-example: blur, visual field loss
Flashes, floaters, double vision
YES NO
Is there pain? NO
YES
See Doctor Today
Apply home treatment
example: ice pack first 2 hrs.
Then warm compresses
- If no overnight relief, see Doctor now
Courtesy of AOA

55. Other Examples of Blunt Trauma cases….

56. Case Studies John, 6 years old, kindergarten Screened in school
Screening findings:
Distance VA: 20/70 RE and 20/60 LE
Near VA: 20/30 OU
Could read the 20/40 line through the plus lens
All other findings within normal limits
John was referred for a comprehensive eye examination

57. John John was diagnosed with farsightedness (hyperopia)
He received a pair of glasses to correct his farsightedness
John’s corrected vision is now 20/20 at both distance and at near

58. Julie, 10 years old
Julie complains of occasionally seeing double, headaches, and blurry vision while reading for an extended period of time
Screening Results
Distance VA: 20/20 RE 20/20 LE
Near VA: 20/20 RE 20/20 LE
Stereovision: Normal
Color Vision: Normal
Plus Lens Test: Normal
Cover Test: Exophoria
NPC: Left eye swung out at 7 inches and patient could not regain alignment until 11 inches

59. Julie Julie was referred for a comprehensive eye examination
Julie was diagnosed with convergence insufficiency
Julie was enrolled into the vision training program to help improve her eye teaming

60. Megan, 13
Megan accidentally sprayed hairspray into her eye when she was styling her hair in the girls’ bathroom
Megan came in complaining that her eye was red and bothering her
What is the next course of action?

61. Megan, 13
Megan’s eye should be irrigated with saline or clean water for 15 minutes
Megan should see her eye doctor today

62. Healthy People 2010: National Health and Disease Prevention Program
Increase proportion of persons who have a dilated eye exam at appropriate intervals;
Increase the proportion of preschool children aged 5 years and under who receive vision screening;
Reduce uncorrected visual impairment due to refractive errors;

63. Healthy People 2010: National Health and Disease Prevention Program
Reduce blindness & visual impairment in children aged 17 & under;
Reduce visual impairment due to diabetic retinopathy;
Reduce visual impairment due to glaucoma;
Reduce visual impairment due to cataract;
Reduce occupational eye injury;

64. Healthy People 2010: National Health and Disease Prevention Program
Increase the use of protective eyewear in recreational activities & hazardous situations around the house; and
Increase the use of vision rehabilitation services & adaptive devices by people with visual impairments.

65. Good Vision = A+ Good Education
Questions??