Screen children with neurodevelopmental disabilities for vision problems
Sharon S.Lehman, M.D., FAAP and Kenneth W.Norwood Jr., M.D., FAAP
Focus on Subspecialties
Many children with neurodevelopmental disabilities such as cerebral palsy and spina
bifida have deficits in their senses, with vision impairment perhaps being the most
limiting to successful participation in life.
Several studies have found that vision care represents one of the greatest unmet needs
for children with special health care needs. In addition, infants and toddlers who
are socially at risk with functional vision difficulties make up one of the highest
subgroups of developmental vulnerability.
Examination of the eyes is a routine part of a well-child check. Thus, pediatricians
are in a unique position to detect vision impairment in children with neurodevelopmental
disabilities and ensure that appropriate referrals and intervention occur and classroom
accommodations are made.
In January 2016, the Academy published a clinical report and policy statement that
provide guidance on how to evaluate and when to refer children for full ophthalmologic
evaluation (see resources). The documents, issued along with the American Association
of Certified Orthoptists, the American Association for Pediatric Ophthalmology and
Strabismus, and the American Academy of Ophthalmology, emphasize that ocular problems
can be the initial manifestation of systemic or neurologic disease such as retinoblastoma
or neuroblastoma in addition to identifying vision-threatening ocular conditions.
Taking a history
Obtaining a history eliciting parental concerns and family history is essential. As
discussed in the policy, identification of a family history of serious eye disorders
such as retinoblastoma, childhood cataracts or glaucoma, strabismus and amblyopia
are indications for evaluation by an ophthalmologist experienced in the care of children.
Parental concerns about vision also are an indication for full ophthalmologic evaluation.
It is important to ask specifically about vision concerns when obtaining a history
about a child with complex medical problems. The family may be more focused on concerns
about respiratory or neurologic problems and forget to bring up vision issues, or
they may have a misconception that nothing can be done to help their child use his
or her vision more effectively.
Overcoming screening challenges
It is possible for pediatricians to screen children with neurodevelopmental disabilities
for vision problems, but it may be challenging due to cognitive impairment, processing
delays, inability to cooperate, multiple sensory deficits and expressive language
delay. The screening may need to be adjusted and may take more time, for instance
in children with cortical visual impairment who display latency due to a delayed response
because of extra time needed for processing and responding to the visual stimuli.
It is important to match the screening technique to the developmental age of the child
instead of chronologic age. Interesting toys and charts with pictures or symbols may
be used for acuity testing. The recommended charts for younger children are those
with Lea symbols or HOTV (limited number of symmetric letters). Providing the child
with matching cards can be helpful in obtaining cooperation when testing acuity. Using
critical line testing instead of threshold line testing as discussed in the 2016 clinical
report takes less time and may be particularly helpful in children with neurodevelopmental
Instrument-based screening which identifies refractive and structural risk factors
for amblyopia also can be used to screen a child who is nonverbal or cannot cooperate
for recognition acuity. This technique is quick, and noncontact and distraction techniques
can be used to obtain cooperation. It requires less sustained attention from the child.
The physical exam of the eye looking at the alignment, eyelid position and anterior
and posterior aspect (red reflex) also should be performed. If the recommended vision
screening cannot be performed or abnormalities are found on physical examination,
the child should be referred for full ophthalmologic evaluation.
Pediatricians should have a low threshold for sending a child with a neurodevelopmental
disability for full ophthalmologic evaluation if there are any concerns about vision
or if the child has a medical condition in which there is a significant risk of ocular
abnormalities or visual conditions.
Complex neurodevelopmental disability is among the conditions where evaluation by
a pediatric ophthalmologist or eye care specialist appropriately trained to treat
pediatric patients is necessary because of the risk of significant visual disability
affecting the child’s ability to learn and reach his or her potential.
Dr. Lehman is immediate past chair of the AAP Section on Ophthalmology Executive Committee.
Dr. Norwood is chair of the AAP Council on Children with Disabilities Executive Committee.