Pediatric and Teen CL Care

Answering the Question “What Does My Baby See?”

By Christine W. Sindt, OD, FAAO

Parents are often curious about what their baby sees. They may be concerned with where their child is fixating or whether the eyes are tracking together. Discussing visual milestones with parents encourages implementation of any necessary treatments to avoid developmental delays. When it comes to infants and young children, the parents are the historians, so their impression should be noted in the chart.

From Birth to 12 Months

At birth, babies focus on objects that are 8 inches to 10 inches away and will wince and blink in response to bright light (Brown and Yamamoto, 1986). Newborns have an approximate visual acuity of 20/800. They will stare intently at high contrast images, such as the edges of faces (Brown and Lindsay, 2009). This may disturb some new parents, as they were hoping to look lovingly into the eyes of their newborn who instead always seems to be avoiding eye contact.

Practitioners can use a horizontal optokinetic nystagmus (OKN) with infants to address visual function. A positive OKN drum response indicates vision of at least counts fingers at three feet to five feet. The OKN response may be asymmetric between eyes until 6 months of age.

During the first several months after birth, vision improves significantly; babies will focus on their parents’ face and make eye contact. Two-month to 3-month-olds have an approximate visual acuity of 20/400, or 20/150 on visual evoked potential (VEP). By this age, babies will fix and follow as well as smile at objects. Saccades are developed, but pursuits do not reach adult levels until 6 months of age. Reaching for objects by around 3 months old is a positive assessment of vision development (American Orthoptic Council Syllabus, 2008).

Figure 1. Infants generally develop control of their eyes, and binocular vision, by 4 months of age. (Chloe Sindt at age 2 months)

Newborn eyes may intermittently seem to cross or wander independently of each other (Figure 1). Binocular vision is absent at birth but turns on by 4 months of age in both term and preterm infants (Jandó et al, 2012). A constant eye turn, however, is concerning and should be further evaluated.

By 4 months old, vision is about 20/200 (20/60 on VEP), and the infant will accommodate appropriately to a target. By 6 months old, vision has improved to 20/100, or 20/40 by VEP. A 6-month-old will be at adult levels for horizontal OKN. The child will readily fix and follow as well as be able to use preferential looking (teller acuity) to assess vision. A 6-month-old will open his mouth to a spoon and will recognize his own face in the mirror (American Orthoptic Council Syllabus, 2008).

One-year-olds have visual acuities of 20/60, or 20/20 by VEP. They will be able to judge distances fairly well, throw things with precision, and pick up small objects with the index finger and thumb. Snellen acuity will reach adult levels by 2 years of age. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #207.

Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is the past chair of the AOA Cornea and Contact Lens Council. She is a consultant or advisor to Alcon Vision Care and Vistakon and has received research funds from Alcon. You can reach her at christine-sindt@uiowa.edu.