DEVELOPMENT OF THE VISUAL SYSTEM

VISION
Process which allows us to understand the spatial layout of our environment
Developmental in nature (Duckman)
DEVELOPMENT OF VISUAL ACUITY
If VA is normal, the following assumptions can be made:
1. Little refractive error present
2. Macular area probably normal
3. No pathology present that may compromise VA
4 Types of Visual Acuity
Minimum
Being able to tell that a given visual stimulus is present/not
visible/
What is the smallest stimulus an individual can detect
detection
Not a good indicator of VA, as it depends on stimulus
acuity
Detection
Dark object on light BG seen DT light intensity difference
acuity
At least one retinal receptive unit should be stimulated (size is a
factor)
Visibility of white object on dark BG doesnt depend on size, but on
brightness
Minimum
separable
(resolution)

Resolution
acuity

Vernier
acuity

Localisation
acuity

Recognition
acuity

Measure of persons ability to detect separation of contours

Smaller the separation of acuity elements that patient can resolve,
the better the resolution acuity
EG: Teller acuity charts (forced preferential looking)
Expresses possibility to detect target having two or more parts
Consider width of point spread function of two separated objects

Hyperacuity/ Localisation acuity

Measure of eyes ability to perceive that misalignment exists
between elements of stimulus when compared with stimulus
without misalignment
Involve discriminating differences in spatial position of segments
of test object (such as break in contour)

Type of visual acuity that is normally measured specifically with

children that can report what they see
Starts at age 2 2.5 years
Involves being able to resolve detail in optotype and on cognitive
level to identify what stimulus is

Type of
acuity
Resolution

Definition

Example

Best performance

Minimum separation
to resolve two objects

Snellen VA, Tumbling E,

square wave gratings

Recognitio
n
Detection

Smallest object that

can be identified
Smallest object visible
(increment threshold
task)
Minimum detectable
misalignment

Snellen VA, paediatric

picture cards
Thin wire against sky

MAR = 0.75 to 0.5 arc

min
20/15 20/10
Same as Snellen

Vernier
(hyperacui
ty)

Slightly displaced lines

-1.0 arc second

2 10 arc seconds

OKN: (oldest measurement) Disadvantages

1. Difficult observing infants
2. Infants with considerable loss of vision or absence of visual cortex can still
demonstrate OKN
3. Child must attend to drum and accommodate on surface
4. Unable to draw definitive conclusions
Forced Preferential Looking:
Measureme
High spatial frequency = finer black and white lines
nt
Lower frequency = wider
30 cycles/degree = 20/20 resolution of Snellen
One cycle = one black and one white line
Inaccuracy
If infants become more interested in their environment, their
interest in black and white lines decreases
Function
More important to identify children with visual problems than to
measure accurate VA
VEP vs FPL
VEP
200% better than FPL when measuring
infants during first year of life
Responses easier to elicit during VEP
because attention doesnt need to be
maintained for as long as in FPL
Looks at wiring of visual system
Tells about integrity of visual pathways

FPL

More cognitive task where stimulus

information gets to cortex but child makes
cognitive decision about visual preference
Closely estimates what child can see

Development comparison of acuities

1. With all, VEP, FPL and OKN visual acuity improves over time
2. Development slower for FPL than VEP
3. VEP can measure 6/6 a 6 months
Can diagnose and treat earlier
4. Vernier acuity develops more rapidly

 At 9 weeks, measurement obtained was 40

Initial poor acuity obtained in infants can be usually attributed to:

1. Foveal cone immaturities:
At birth, cones are very short and stumpy with small optical apertures
At 15 months, cones are half the length of adult cone
Foveal cones reach adult length at 4 years
Cone density reaches adult levels only from 45 months
2. Cortical immaturities
3. Incomplete myelination of optic pathways
Takes more than2 years but most of it takes place in the first 24 months
Changes in VA with age: Graph

REFRACTIVE ERROR
Early detection:
Refractive development undergoes more complex and dynamic process than in any
other period of life
Important to be aware off these changes and should understand when it is
necessary to prescribe and when the refractive error is part of normal development

Refractive error in children

Can affect visual acuity and binocularity
Providing appropriate refraction may decrease incidence of amblyopia
If child cant see > less likely to develop normal fine and gross
motor/language/social skills
Prescription can provide visual comfort for near skills
Young children may often not be aware that they cant see > unable to
communicate blurry vision in sensible way
Signs and symptoms of uncorrected refractive error
1. Difficulty with depth perception
2. Eye-hand and coordination difficulties
3. Confuses likes and differences
4. Frequently rubs eyes
5. Blinks excessively
6. Complains of double vision
7. Cant maintain fixation on task
8. Frequently closes/covers one eye
9. Lack of interest in outdoor activities
10.
Sits close to TV or holds books close
11.
Squints
12.
Lack of interest in near tasks
Emmetropization
Definition

Clinically

Factors

Passive
process

Process producing greater frequency of occurrence of emmetropia

and near emmetropia than would be expected in chance
distribution
Thus a mechanisms exists that co-ordinates formation and
development of various components of human eye which
contribute to total refractive power
Duckman
Process by which refractive condition of eye, regardless of whether
initially hyperopia, myopia or astigmatism, centres on refractive
range around low hyperopia/emmetropia (+0.50 to +1.00)
Effectiveness of process depends on:
1. Healthy eye
2. Healthy environment
3. Operational refractive range
4. Intact emmetropization mechanism
Nature and genetics are key factors
Axial length:
Approximately 16.5mm at birth
Increases 3.8mm during first 2 years
Increases 1.2mm from 2-5 ears (growth takes place in vitreal
chamber)
Crystalline lens flattens
Anterior chamber deepens
Cornea flattens

Active
process

Refractive
error and
Emmetropiz
ation

Genetics:
42% chance of being myopic of both parents are myopic
22% chance if one parent is myopic
8% if neither is myopic
Emmetropization is mediated by retinal blur
Visual system can recognize existence of blur and responds by
compensating for it
Hyperopia > +4.00D at 6 months + resultant strab
Emmetropization compromised
Myopic in any meridian by > 2.50D at 1y
Tends to not emmetropize where those with lesser amount did
Children with hyperopia and poor accommodation skills tend to
become strabismic (> esotropia)
Use of lenses for hyperopia in infants do not impact on
emmetroopization but children that are corrected early tend to be
more hyperopic than normal children

Changes in refractive error

Premature
Gestational age < 37 weeks and less than 2.5kg
infants
Positive correlation between advanced stages of ROP, need for
surgical intervention and severity of myopia
Incidence of myopia, high myopia, anisometropia and astigmatism
increases with severity of ROP and conversely with increase of
birth weight
Infants
Most full-term infants born with mild to moderate degree
hyperopia
Power varies and averages out at 2.00D hyperopia
Most infants tend to be 2.00D with SD +/- 2.75D
Conforms to normal distribution resulting in bell-shape curve)
Black infants have higher prevalence of high myopia than whites,
but latter is more likely to develop school-aged myopia
Most findings of myopia occur in the first 2 months

Infancy to
school years

Toddlers and
preschool

School years

Expected outcome for infants

1. Reduction in manifests strabismus
2. Prevention of esotropic amblyopia secondary to abnormal
hyperopia
Amblyopia can develop from hyperopia > 2.00D
3. Optimize development of acuity
4. Improvement in binocular function
Bell-shaped distribution of refractive error changes to leptokurtic
distribution at school age
RE +0.50 to +1.00 with SD +/- 1.00
Emmetropization occurs mostly in first few years of life with
greatest in first 2 years
Refractive error reaches emmetropic plateau between 5-7 years
Hyperopia > 1.50D at 5y --- children tend to remain hyperopia
Hyperopia 0.50D 1.25D --- children tend to become emmetropic
Hyperopia < 0.50D or those with myopia --- Children tend to
become myopic during school ears
High prevalence of anisometropia present at birth decreases
rapidly so that prevalence is relatively low by the time child enters
school
80+% of children between 5-7 years are hyperopic between 0.50D
and 3.00D
Hyperopia > 5.00D present in only 5% of population
< 1% with myopia > 1.00D
Except with congenital or early onset high myopia
Gradual reduction of hyperopia of about 0.25D to 0.50D per year
Steady increase of myopia
School aged myopia increases
Astigmatism:
81% of 6 year olds have < 0.25DC
72% of 13 year olds have < 0.25DC

Increase from 3% ATR to 11% and associated with increase of

myopia
Extreme errors are congenital or inherited:
High ametropia most likely congenital
Congenital myopia 2x more prevalent than hyperopia
Development of myopia
Prevalence
Lowest prevalence at 5-7 years
Greatest prevalence in Jewish, Japanese and Chinese races and
ethnicities
Risk factors
Heredity most significant RF for juvenile myopia
Excessive near work and greater academic success are
contributory factors
Progression
Progression rate higher in children with esophoria
Classification
Low myopia: < 3.0D
Moderate myopia: 3.00D 5.75D
High myopia: > 6.00D
Congenital
Objective measurements
myopia
Retinoscopy
Measurement of corneal diameter
IOP
Management of high myopia (3.00 5.00D) in infants 12 months +
Correct myopia
Infant will start exploring its environment and identifying distance
objects
Prevalence:
Congenital myopia is 2-3x more prevalent than congenital
hyperopia
Astigmatism
Prevalence

Progression

Large amounts of astigmatism in children < 3y common

< 3.5 years: AR astig
3.5 years to 5.5 years: transition
> 5.5 years: WR astig
Magnitude declines over first few years
Especially common when ATR is present
High magnitude astigmatism (>3D) may not completely
disappear with age
Overall shift toward WR astigmatism

Anisometropia
Negatively correlated with age
Unusual developmental feature of flip-flopping
Children who had little anisometropia at 1 year and those with significant
amounts of anisometropia at 1 year found to have little anisometropia at 4
years

Consider stability before prescribing

VISION EFFICIENCY DEVELOPMENT

Fixation
Foveal immaturity and poor VA indicate that fixations may be poorer than adults
during first 2-3 months
Newborns will steadily fixate on object and infrequently shift fixation to another
object
Fixations of shorter duration than in adults
Colour vision
Newborns: can discriminate chromatic stimuli (rudimentary CV)
3-4 months: All three cone types exist > colour vision similar to adults but have
different thresholds
Takes several years to reach adult levels of CV
Eye movements: Saccades
Definition
High velocity eye movements that shift direction of gaze from one
location to the next
Function
Movements enable us to quickly bring fovea to new object so it can
be seen with maximal clarity
Magnitud
Every day circumstances = relatively large magnitude
e
Reading and stationary object (micro saccades) = small amplitude
saccades
Anatomy
Cortical component:
Responsible for perceptual information processing
Decision making ito where and when saccade should be made
Initiating sequence of events leading up to saccadic movement

Developm
ent

Voluntary
saccades
Saccadic
scan path

Brainstem component:
Structures that produce and shape actual motor signals that goes to
EOM
Pulse generator:
Creates pulse of neural activity
Pulse goes to integrator to produce step of neural activity
Resulting pulse-step goes to EOM
Generates saccadic movement
Neural integrator
Observed in newborns but infrequent
First 3 months: frequency of changing fixation to new visual objects
increases
1-2 months: infant has difficulty generating accurate saccade
Saccade is in the right direction but grossly hypometric
To look at object that seems to be of immediate interest
Occur reflexively in direction of something that happens suddenly
and without warning
Make repeated sequence of saccadics when entering room
Rapidly require information about physical characteristics and social
interaction

Eye movements: Pursuits

Definition
Eye movement to visually track a target moving at low to moderate
velocity
Stimuli
Perceived target velocity
Target offset from fovea
Target acceleration
Relative target-background motion
Anatomy
Cortical component resting on brainstem component
1.

Cortical:
Involved in perception of target velocity
Attention to target
Initiation of smooth pursuit movements
Maintenance of pursuit

2. Cortex: Sends velocity signal (step) to brainstem neural integrator

to produce an eye position signal (ramp)
3. Velocity and position signals: Add and generate pursuit
movement
Developm
ent

Would be susceptible to postnatal foveal development and

corresponding reduction in VA
< 8 weeks: do not show smooth pursuit eye movements when
tracking
Tracking responses: saccades which act to catch eye up to
moving target
2-3 months: smooth pursuits

Accommodation: development
Newborn infants dont utilize its capacity to accommodate because depth of focus
is too large
Large changes in target distance do not produce changes in perceived blur
3 months; Inaccuracies in accommodation disappear
6 months: accommodative responses to changes in dioptric power almost adultlike
Automatic digit naming ability may be a factor contributing to slower performance
observed in children with accommodative flexibility
Vergence
Definition
Developme
nt

Stereopsis

Has motor and sensory components

Responsible for maintaining ocular alignment
Birth: cosmetically acceptable alignment may be present, but it is
uncertain if bifoveal fixation exists
Vergence system goes through unstable period until 4-6 months
(stable bifixation established)
First 2 postnatal month: do not consistently change vergence
response with sufficient magnitude to maintain accurate bifoveal
fixation
Binocular sensory component of vergence system relies on retinal

Stimuli

image disparity for stereopsis

Stereopsis emerges from 4-6 months
Disparity between object images on two retinas
Blur of object mages
Proximity of object