|Year : 2015 | Volume
| Issue : 4 | Page : 149-153
The importance of detecting delays in the development of visual functioning and signs of disorders of the eyes during the 1 st year of life: An African perspective
Adedayo Omobolanle Adio1, Olubunmi Temitope Bodunde2, Lea Hyvärinen3
1 Department of Ophthalmology, University of Port Harcourt Teaching Hospital, Rivers State, Nigeria
2 Department of Ophthalmology, Olabisi Onabanjo University Teaching Hospital, Sagamu, Ogun State, Nigeria
3 Faculty of Rehabilitation Science, Technical University of Dortmund, Dortmund, Germany
|Date of Submission
|Date of Acceptance
|Date of Web Publication
Adedayo Omobolanle Adio
Department of Ophthalmology, University of Port Harcourt Teaching Hospital, Rivers State
Source of Support: None, Conflict of Interest: None
Normal visual functioning is related to cognitive, motor, and emotional development since typical children learn to use visual communication, to move, to talk, and to develop many activities they observe others using. Early detection of atypical visual functioning, particularly in the 1 st year of life can help avoid potentially life-threatening conditions and delays in development which may follow. This article discusses five visual developmental milestones during the 1 st year of life in a typical healthy infant. It also advocates using these milestones in a multidisciplinary approach to early intervention, which includes training of pediatricians and other stakeholders in contact with infants at every level. In addition to this, the development of a cadre of ophthalmic counselors to improve compliance and follow-up may be a cost-effective strategy for pediatric vision care in the developing countries today.
Keywords: Developmental emergency, early intervention, visual functions and functioning
|How to cite this article:
Adio AO, Bodunde OT, Hyvärinen L. The importance of detecting delays in the development of visual functioning and signs of disorders of the eyes during the 1 st year of life: An African perspective. Sub-Saharan Afr J Med 2015;2:149-53
|How to cite this URL:
Adio AO, Bodunde OT, Hyvärinen L. The importance of detecting delays in the development of visual functioning and signs of disorders of the eyes during the 1 st year of life: An African perspective. Sub-Saharan Afr J Med [serial online] 2015 [cited 2024 Mar 2];2:149-53. Available from: https://www.ssajm.org/text.asp?2015/2/4/149/172432
Vision plays an important role in early development of all infants and children. Impaired vision has ominous implications for education and future social, psychological, marital, and economic prospects. ,, Therefore, atypical features in the use of vision should lead to a thorough assessment of infants' eyes and vision by ophthalmologists experienced in examining infants and young children.
The need of well-structured early intervention has been discussed since the 1970s,  and the active role of vision in the development of motor functions based on the mirror neuron system is well-known. , However, early intervention is rarely included in clinical routines in Africa and even in Western countries where it may be "outsourced" to different organizations for the blind. Thus, residents do not learn assessment of visual functions for early intervention and rehabilitation and do not include early intervention in their work as ophthalmologists.
As an introduction to detection and assessment of vision problems, this article discusses visual milestones of healthy infants and infants with disorders in the 1 st year of life. ,,
| Newborn Period
Infants are visually active at birth looking at faces at close distances and can even copy facial movements, for example, protrusion of the tongue out of the mouth.
A newborn infant responds to light by turning its head and eyes toward light sources such as windows or large ceiling lights. At birth, the eyes should have normal structures, are symmetrical with equal motility, should respond to light and have clear red reflex from the retina. Healthcare workers engaged in infant care could be taught how to perform the red reflex test. This should be recorded in the child's immunization card. Subsequent vision development should be noted and recorded at each immunization visit.
The First Visual Milestone: Stable Eye Contact at 6 Weeks
At the age of 6 weeks, most typically developing infants have a stable eye contact with their parents; this facilitates the development of bonding. Therefore, in many countries, this is recorded in the immunization card.  If eye contact has not developed, no more than 2 weeks is the usual time to wait for the eye contact to begin. During this time, the parents are advised to hold their face close to the infant while talking. Holding the infant close to the naked body of the parent, the so-called "kangaroo care'' increases the infant's awareness of the parent and has been found beneficial for both the baby and the mother, especially in the care of prematurely born infants with failure to thrive. 
Patricia Sonksen, a developmental pediatrician, described the absence of eye contact at the age of 8 weeks as "developmental emergency."  This situation causes stress both in the baby and the parents who do not experience the feeling of "understanding each other" during normal eye contact.
Delayed eye contact could be as a result of:
- Hyperopia: High hyperopia is not corrected by accommodation. The infant sees everything double and blurred
- In mild hyperopia with poor development of accommodation, the infant may experience blurry vision leading to poor eye contact. This can be diagnosed with dynamic retinoscopy and confirmed by observing the infant's behavior when correct near vision correction is used [Figure 1]
|Figure 1: (a) Healthy 4-month-old infant apparently experienced the blurred image so disturbing that she turned eyes and face away from the face of the mother. (b) Refractive error of infant was +1.0 diopter in both eyes did not accommodate or converge during dynamic retinoscopy. Spectacles +4 gave the infant clear images on the retinas of objects at close distances. For a few seconds, the infant looked surprised. (c) Then, she converged and immediately smiled, copying the smile on the face of her mother. Published by permission from VISTEST. Originally, in What and How Does This Child see 2011
Click here to view
- High myopic astigmatism is a rare but possible cause of severe image distortion preventing the infant from seeing the parent's face clearly.
Treatment in these three conditions is near correction, i.e., reading glasses that give clear images on the infant's retinas at the important close distances used in communication and planning motor functions. 
If the eyes of the infant are found to be normal in structure and accommodation is effective, a rare cause of lack of eye contact may be a delay in the development of cortical recognition functions. In that case, the parents are taught how to communicate with the child using tactile and auditory information and close bodily contact. This may require the services of a therapist who is experienced in the early development of blind infants. This situation is rare but should be understood as a developmental emergency. It causes the same need of early intervention as severely impaired vision due to disorders in the eyes and visual pathways. Early detection of impaired vision in the children is important because blindness is closely linked to high infant mortality in developing countries. 
Detection and treatment of large refractive errors are not a part of recommendations of early vision care in most countries probably due to the cost of detection and treatment of cases. Therefore, it is possible to find school age children with high hyperopia who have not had glasses before they came to school and even at school have undercorrected glasses for near tasks. , Since they saw everything double and blurred, they did not adequately learn visual communication, did not learn copying goal-directed hand movements, and may have found the environment difficult to navigate. Poor vision may derail general development so that the children have been diagnosed as developmentally delayed with autistic behaviors. These originally normal but now severely impaired children are developmentally delayed due to failure in diagnosing the problems in early infancy. This should be avoided. Therefore, development of eye contact is important to observe, difficulties in near vision should be treated without delay, and families should have early intervention services. As facilities for pediatric eye care improve, early intervention services should become more widespread in Africa.
The Second Visual Milestone: Enjoyable Interaction and Social Smile at 12 Weeks
Communication and interaction skills develop during the 3 rd month at the same time as the ocular motor functions become better controlled. Their social smile makes adults and siblings happy and creates moments of warm emotional bonding. Infants begin to watch adults' lip movements, which makes them aware of speech. A typically developing 3-month-old infant is able to fixate and follow horizontal movements of the smiling face test with a diameter of 5 cm (Small Heidi Fixation Target, Good-Lite). Shifting gaze from one target to another with a quick eye movement, saccade, is not yet exact and improves during the next month. At the same time, infants learn to notice eye movements, gaze shifts of adults, and thus start to learn what adults are interested in. They learn to communicate with their smile and gaze.
The Third Visual Milestone: Becoming Aware of and Starting to Use Hands
When a normally sighted infant sees his/her hand and brings it into the mouth, the early asymmetric tonic neck reflex is counteracted. Bringing hands into the mouth is an effective way of learning about their structure. They watch their hands at different distances creating grating patterns with their fingers and thus train binocular vision for the development of stereopsis. Hand movements to hit pictures and toys hanging on mobiles are preceded by careful fixation, but the movement itself is based more on proprioception than vision. When hands meet in the midline, the infant becomes aware of his body as several parts that function together. Helping an infant to touch different parts of the body is an important part of the baby massage and motor activation supporting the development of body awareness. Infants with limited hand functions should be helped to explore their hands and different objects with the mouth. Today, many children with severe cerebral palsy explore their hands by bringing them into their mouth first in teenage when they come to a special school. 
Infants learn to use movements of both hands to hold objects given to them and bring them into their mouth for exploration. Infants observe their hands in all activities and learn about the planning of hand movements. At the same time, hands give concrete structure to visual objects, their size, surface quality, weight, temperature, and softness or hardness.
Follow-up visits to the health care worker/nurse are common in well-baby-clinics in many countries at the age of 14-16 weeks. Observations should again be made on visual communication between mother and the infant and response to smile on the tester's face. The structure of eyes should be recorded; size difference might be a sign of congenital glaucoma in the larger eye that should be noticed as early as possible. Following eye movements should be tested using the small smiling face target.
The Fourth Visual Milestone: Copying Goal-directed Reach
When eye-hand coordination has developed during the 5 th month so that smooth movements are possible, the infants keenly watch other infants' and children's hand movements in different activities and try to copy them, then train the movements numerous times. Visual learning has reached an important milestone: An infant has seen another infant doing something with his hands and can compare it with what the infant does with his or her own hands. Grasping becomes adjusted to the size of the objects. At the age of 6 months, many infants compulsively grasp everything within reach and do not let it go.
During the follow-up visits, fixation at the small accommodative targets of the smiling face test is a part of the direct cover test to detect the small angle of strabismus or a difference in the quality of vision. If the infant tolerates cover in front of one eye but not in front of the other eye, the cause for this difference needs to be investigated by an ophthalmologist. Hirschberg (or Bruckner test if available) may be used to detect strabismus, especially in infants who are difficult to test with cover test.  Shadows in the red reflex are to be noticed at all visits because cataracts or retinoblastoma may be detected at any age during the 1 st year. The tester's thumb is often the least frightening cover.
All infants should be given opportunity to observe different play situations many times and then try to copy them. An older sibling can be the teacher showing how he places blocks on top of each other, drops them through holes or places puzzle pieces in puzzles. These play situations prepare infants for understanding forms so that form perception and recognition can be used to measure visual acuity earlier than what has been usual. 
Picture perception develops, and pictures get names so that the child can be asked to point where in a picture an object is visible. The infant has learned that objects and their pictures have the same name; pictures represent objects.
The Fifth Visual Milestone: Recognition of Facial Features of Family Members
At the age of 7-9 months, children learn to recognize family members by their facial features before these say something so that the voice reveals who the person is. Healthy infants may have inherited atypical function in face recognition; they may not recognize eyes but may see the mouth better. , Children and adults with great difficulties in recognition of faces, face blindness or prosopagnosia, may be able to have normal perception of facial age and gender.  Hair becomes an important feature to recognize, as well as jewelry that is regularly worn and anything unusual in the face, for example, a large nevus, beard, or mustaches sometimes help recognition of a face. Biological motion is often an effective way to recognize people when face recognition does not work. Prosopagnosia can also be acquired and may occur in infants with different types of brain damage.
Infants with difficulties in face recognition look past the face at the structures they see well, and thus may be perceived as "avoiding-eye-contact," which is often wrongly interpreted as autistic behavior.
If an infant has prosopagnosia, face blindness, all persons in the care of the infant must be informed about its lack of facial recognition, and they should always say their name when approaching the infant. Each adult and child should wear something that is easy to recognize or have a name tag-like picture in the nursery school with the first letter of the name to facilitate recognition. Toddlers are sensitive to atypical behaviors and cannot understand explanations. In this situation, it has been helpful to prescribe for the infant with face blindness slightly darkened glasses and explain in a friendly manner that the child does not see well and needs help by everybody. If an infant does not seem to recognize people, it is also important to assess the anterior visual system so that poor image quality is not the cause of poor recognition.
It is important to be aware of these five developmental milestones and include observation of vision development as listed above in routine detection of diseases, i.e., cataract, glaucoma, strabismus, retinoblastoma, infections, and allergic reactions. This will help people in pediatric services to notice and take care of problems in visual functioning. Few special tests are needed for this part of vision screening, only awareness of the developmental steps.
Amblyopia, its risk factors, and treatment are the most common questions in eye doctors' offices. Further longitudinal studies of the development of vision, refraction, and ocular motor functions should be planned for the early development before clinically definable amblyopia can be diagnosed. ,
Creating a policy and possible legislation on infants' vision screening as has been done in developed countries can also be done by all stakeholders involved in child care.  This has been pioneered in one of the states in Nigeria and should be encouraged in all countries in Africa.  Advocacy for increased funding should be made also to take care of children with impaired vision and blindness. World Health Organization (WHO) recommends that there should be one pediatric ophthalmology service center per 10 million population.  In developing countries, however, these centers are not evenly spread or properly funded. In recent years, even though the WHO recommends a minimum of 5% of the budget to be used on health care, in 2010, the Nigerian government spent only 3.4% with a paltry 0.005% of This sum allocated to eyecare for the whole country.  Hardly any money is spent on children's eye care. A multidisciplinary approach including training of pediatricians and other stakeholders in the care and teaching of infants at state, regional, and national levels is necessary.
Training of pediatric ophthalmic counselors to inform and support the families and to improve compliance and follow-up of care would be a cost-effective strategy in pediatric vision care in the developing countries today. Improved funding will provide better pediatric ophthalmic services; this in turn directly impacts on social services and welfare which will help the pediatric ophthalmologists to improve treatment and follow-up.
The 1 st year of life is a very important period in the visual development of children. Screening of diseases and careful observations on the evolvement of visual skills at various milestones are cost-effective strategies to adopt in developing countries. Waiting beyond the 1 st year of life may lead to the development of severe visual problems which may be more expensive to treat and can lead to lifelong learning difficulties when discovered late.
Declaration of Patient Consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images, and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
Gogate P, Gilbert C, Zin A. Severe visual impairment and blindness in infants: Causes and opportunities for control. Middle East Afr J Ophthalmol 2011;18:109-14.
Adams GG, Sloper JJ. Update on squint and amblyopia. J R Soc Med 2003;96:3-6.
Days S. Normal and abnormal visual development. In: David T, editor. Pediatric Ophthalmology. Oxford, UK: Blackwell Science; 1997. p. 13-28.
Marshall WH. Foreword. Early Experience and Visual Information Processing in Perceptual and Reading Disorders: Role of gthe visual system: Optical and Oculomotor, Retinal and central neural factors. Committee on Brain Sciences, National Research Council. Edited; 1970.
di Pellegrino G, Fadiga L, Fogassi L, Gallese V, Rizzolatti G. Understanding motor events: A neurophysiological study. Exp Brain Res 1992;91:176-80.
Rizzolatti G, Cattaneo L, Fabbri-Destro M, Rozzi S. Cortical mechanisms underlying the organization of goal-directed actions and mirror neuron-based action understanding. Physiol Rev 2014;94:655-706.
Atkinson J, Braddick O, Robier B, Anker S, Ehrlich D, King J, et al.
Two infant vision screening programmes: Prediction and prevention of strabismus and amblyopia from photo- and videorefractive screening. Eye (Lond) 1996;10(Pt 2):189-98.
Feldman R, Rosenthal Z, Eidelman AI. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biol Psychiatry 2014;75:56-64.
Kristensen I, Aaby P, Jensen H. Routine vaccinations and child survival: Follow up study in Guinea-Bissau, West Africa. BMJ 2000;321:1435-8.
Sonksen PM. Developmental aspects of visual disorders. Curr Paediatr 1997;7:18-22.
Hyvärinen L, Jacob N. What and How Does this Child See? Assessment of Visual Functioning for Development and Learning. Finland: Vistest Ltd.; 2011.
Khandekar R, Kishore H, Mansu RM, Awan H. The status of childhood blindness and functional low vision in the Eastern Mediterranean region in 2012. Middle East Afr J Ophthalmol 2014;21:336-43.
Adio AO, Awoyesuku E, Alikor EA. Pattern of paediatric ophthalmic diagnoses in a teaching hospital in Nigeria. Niger J Med 2011;20:105-8.
Osunde EA, Raymond O, Adio AO. Refractive errors among a young population in an urban secondary school in South Southern Nigeria. Port Harcourt Med J 2010;4:228-36.
Tongue AC, Cibis GW. Brückner test. Ophthalmology 1981;88:1041-4.
DeGutis J, Cohan S, Mercado RJ, Wilmer J, Nakayama K. Holistic processing of the mouth but not the eyes in developmental prosopagnosia. Cogn Neuropsychol 2012;29:419-46.
Chatterjee G, Nakayama K. Normal facial age and gender perception in developmental prosopagnosia. Cogn Neuropsychol 2012;29:482-502.
Kwara State Childhood Sight Protection Law, Kwara State of Nigeria Gazette 2013;3:47.
Shrestha UD. Tertiary eye care centre model for development of paediatric cataract surgery services in developing countries. JNMA J Nepal Med Assoc 2011;51:154-6.
Adio AO. The pediatric ophthalmology service of the university of Port Harcourt teaching hospital - A reflection of a neglected area in health care delivery. Int J Trop Surg 2010;4:78-80.