Children's Vision

Eye Examinations

Children’s consultations - there are four steps in our children’s comprehensive examinations.

The standard vision exam consists of:

  • A measure of your child’s sight for distance and at a close range
  • An assessment of your child’s prescription ie. long-sighted or short-sighted
  • Examination of the health of the eyes
  • The measurement of the behaviour and how robust your child’s vision system is:

Depth perception, colour vision, Eye tracking, teaming, convergence and focusing/accommodation

Visual Perceptual Skills:

Your child doesn’t see with their eyes; they see with their brain. Our Optometrist measures how well your child’s brain interprets signals, how many signals your child’s brain can take in at once, how well their brain can store visual information and retrieve it. Areas assessed include:

Questions About Your Child's Examination

Real frequently asked questions about children’s vision examinations.

Why do your optometrists need to test all that?

Simple tests such as how much of the chart your child can read is termed ‘sight’. Testing this is similar to testing how well your child can visually ‘sprint’. It’s a simple, quick skill required to function well in the classroom.

The subsequent areas test your child’s visual ‘marathon’ ability. There is so much more to your sight than simply ‘seeing clearly’.

When you cross a busy intersection, you will find yourself checking the different directions for cars several times. Again, this has very little to do with your sight, and much more to do with your ability to judge the speed of oncoming cars.

How you interpret the world around you will impact how you learn and react to the world. Our optometrist is passionate about how your child’s visual system is developing and reacting to the world of information available to them.

What about high needs children?

We can assess children with many of the spectrum diagnosis including ADHD, ADD, ASD, ODD, PDD, autism, Down’s syndrome, cerebral palsy and other special needs. If your child has any special needs such as physical or intellectual challenges, please let us know when you make your appointment. This way, we can be prepared to make your child as comfortable as possible.

How long will the examination take?

Allow 45 mins for your child’s detailed consultation. This creates time for all the areas to be assessed and to discuss the results with you. We’ll do our best to run to schedule. Please assist us by arriving for your child’s appointment on time.

Will my child end up with glasses they don’t need if they give the wrong answers?

Most certainly not. Our optometrist are specially trained and very experienced in assessing children’s vision. Many of the areas are tested in different ways and clinical decisions are not made based on one single test or answer.

My child isn’t sure of their letters yet. Can you still test them?

Our optometrists have a number of fun techniques for testing your child. These can include matching shapes or numbers, or recognizing pictures. There are many objective measures that our optometrists can use as well. This means that we can test children from birth.

When should I get my child’s eyes tested?

Most certainly book your child in to see our team if you have any concerns about turned eyes, lazy eyes or odd things your child does with their bodies or eyes during visual tasks like reading, writing or watching television. Otherwise, we advise to have your child’s first eye examination sometime before they start their first year of formal schooling.

If my child gets glasses, will they become dependent on them or will they need them ‘forever’?

The answer to this depends very much on the cause of the vision difficulty. In the majority of cases, children often need glasses for a few short years whilst their visual system develops.

However, in cases of long-sightedness, short-sightedness, strabismus (turned-eye) or amblyopia (lazy-eye) they are likely to need glasses for the foreseeable future. Our optometrists will discuss your child’s prognosis during the examination.

Convergence Excess

Convergence excess describes a condition where the eyes do not exactly aim together; rather, they aim too close or in front of the object. As a consequence, blur, confusion or fatigue may result. Convergence excess will effect near work tasks, especially reading and writing. Symptoms of convergence excess include eyestrain, headaches, blurred vision, double vision, sleepiness and (if reading) trouble remembering what was read.

Sometimes eyes it is associated with accommodative weakness as the eyes are aimed closer in than desired in an attempt to compensate for reduced focus stamina or focus ability. This leads to a mismatch between convergence and focus, thus affecting binocular vision accuracy.

Management of convergence excess requires therapeutic prescription lenses to enhance the focus efficiency thus reducing the need to pull the eyes closer in. The lenses are typically worn for close work tasks such as reading, writing, computer work and copying from the blackboard. This is a therapeutic treatment that requires monitoring over time to ensure the excessive demand is reduced to within a normal range of focus and convergence. In some cases, vision therapy may be required in addition to the glasses.

If vision therapy is required it usually consists of six in-office visits spaced one week apart, along with home based therapy between these visits. Treatment duration will depend on the particular patient’s condition.

Convergence Insufficiency

Convergence insufficiency is a condition in which the individual has difficulty keeping both eyes turned in to point in the same position when they are doing close work eg. reading, writing, computer work.

Convergence insufficiency is when both eyes are unable to turn inwards together, and sustain this posture. The problem can be congenital or occurs very early in life. Sometimes it is a fatigue problem caused by close work in susceptible individuals.

Individuals who have never refined the ability to maintain their eyes converged generally have very few visual symptoms. Children with this problem do tend, however, to have poorer fine eye-hand and visual motor skills and will tend to avoid near centered tasks like reading. Those children who have acquired the convergence insufficiency problem tend to have more symptoms, particularly when doing prolonged near centered tasks. These symptoms may include, but are not necessarily limited to the following:

  • Difficulty sustaining attention at visually demanding tasks
  • Visual fatigue or stress symptoms such as red eyes, sore eyes, frontal or temporal headaches, transient near and/or distance blur
  • Occasionally a child will also complain of double vision or the letters moving or running (swirling)
  • Abnormal postural adaptations when trying to center on near tasks, including head tilting or holding their work very close
  • General fatigue and pain around the eyes

 

The management of the case and the duration of the treatment will depend on why the child has the convergence insufficiency problem. If it is because the child has never refined this ability, then a broader optometric visual therapy program will be required, of which developing convergence skills is but one aspect. In these cases, training glasses are required.

Treatment of acquired convergence insufficiency will require the prescription of glasses. In some cases, because these lenses reduce the visual demands on the visual system this is all that is needed to be done. In other cases, however, visual therapy will also be needed to rebuild and develop the visual stamina and convergence skills. It is important that the glasses are worn in the classroom as well as for all homework, reading, computer, or any prolonged close work tasks.

In an uncomplicated acquired convergence insufficiency case, a unit of visual therapy comprising of six in-office visits spaced one week apart, may be all that is required. For the developmental convergence insufficiency case, a longer period may be required to develop and teach all the required visual skills.

Lazy or Turned Eyes

There may be concerns about the cosmetic appearance, vision, depth perception and difficulties with hand-eye co-ordination. Determining the best treatment plan such as the need for glasses, vision therapy or surgery can also be overwhelming.

Strabismus (turned eye)

When a turn is first developing, the child may experience moments of double or blurry vision, but their brain learns very quickly to turn one of the pictures off. This is called suppression and if it occurs long enough, then the eye that’s being turned off won’t see well at all.

Amblyopia (lazy eye)

When the eyesight becomes poor from prolonged suppression, this is now termed ‘Lazy eye’ (Amblyopia) and this will need treatment to teach the brain to pay attention to the eye. Even when the correct prescription is given, the brain may continue to ignore that eye due to the habits it has created.

Sometimes, amblyopia will develop without an eye turn. Again, the brain is trying not to pay attention to an eye because it is too blurry. In these cases, the treatment is very similar to the treatment for Strabismus.

It is possible that your child will not experience good depth perception, or 3-D vision until the brain has been taught to pay attention to both eyes at the same time.

In this case it is important to understand that there is not a problem with the muscles of the eyes, rather there is an adaptation being made in the brain. Therefore, treatment will need to address the eyeballs, as well as the brain adaptations.

Can my child grow out of it?

No.

What are our treatment options?

Glasses

Since the most common reason for a turned eye is the troubles focusing, it makes sense that if we reduce the focusing effort, then this will allow the eye to straighten. However, when removing the glasses, the eye may turn again, or may turn more as the brain attempt to ignore the eye again.

In many cases, glasses are required long-term for good binocular (or two-eyed) vision.

Often as the brain and child adapts to the prescription, it will need to be increased. Over the years, and with the correct therapy, the prescription may be able to be reduced in children with small amounts of turn and small amounts of prescription. Bifocals/multifocals are often prescribed for turned eyes. This is because the demand on the eyes for close tasks, such as reading, writing, drawing, playing, is much greater than the demand on the eyes for far tasks.  Once your child is old enough, contact lenses may become an option for them.

Vision Therapy

Customized programs including patching, eye tracking and eye control therapy are available at our practice. Often 6-9 months of therapy is required to treat turned and lazy eyes. 

What are Tracking Problems?

Accurate eye movement control, otherwise known as tracking, is required to follow a line of print, and is especially important in reading. Children with tracking problems tend to be slow readers. They will often lose their place, miss and skip words and lines, have poor fluency, have difficulty copying from the blackboard, will often report that words appear to move on the page when reading, and tend to have difficulty comprehending because of their difficulty moving their eyes accurately. Many are forced to use their fingers to follow the line because their eyes can’t.

When we read, our eyes don’t move smoothly across the line. Instead, our eyes make a series of jumps and pauses as we read. The small jumps between words or groups of words are called saccades. The brief pause we make while looking at the words is called a fixation. After a fixation, we move our eyes to the next word or group of words — another saccade.

This very precise coordination of jumps and pauses is controlled by our central and peripheral visual systems. Our central vision processes what we’re seeing in clear detail and defines what we’re looking at. Our peripheral, or side vision, simultaneously locates surrounding objects and lets us know where to look. (These two systems are sometimes referred to as the “Where is it?” and “What is it?” systems.) In reading, our central vision processes the word, while our side vision locates the following word and tells us where to aim our eyes next. The integration of these two systems is what allows us to efficiently move our eyes along a line of print without overshooting or undershooting, or mistakenly aiming our eyes at lines above or below.

Tracking control and reading skills?

Children with poor eye movement or tracking control tend to make a greater number of saccadic eye movements when reading. When we perform a saccade new information cannot be processed because the eyes are moving so quickly across the stable visual stimulus that only a blur would be perceived, this phenomenon is known as saccadic suppression. Therefore, if a child is forced to make more saccades than the average child their age when reading they will have greater periods where they are not processing new information, which results in a slower reading rate. Their reading rate will slow even further considering that it takes longer to initiate saccades in the first place and the fact that their saccades are also more inaccurate.

Poor tracking fixed? Yes!

Poor tracking can be remediated through vision therapy. If vision therapy is required it usually consists of six in-office visits spaced one week apart, along with home-based therapy between these visits. Treatment duration will depend on the particular patient’s condition.

What is Vision Development?

Children have healthy eyes internally and externally, no optical defects and have clear sight at six meters (100 per cent or 6/6 visual acuity), yet they are unable to effectively control and use their system to obtain ‘meaning’ from the environment. Self-generated movements play a critical role in the development of efficient visual skills. A normal healthy baby is born with the ability to see and move the eyes, though this is initially stimulus bound. That is, the infant is attracted to light and stimulated to turn towards bright objects or moving objects that stand out. The infant also looks as a reflex response to noise or touch. At first the infant tends to move his or her head to look, but later moves eyes alone to look and follow whatever has stimulated them.

The baby touches what he or she sees and learns to associate the feel and look of objects.  Similarly, the baby puts objects into the mouth or smells or listens; so that an association occurs with all sensory inputs and what he or she sees.

Experience of what is ‘far’ and what is ‘near’ comes from moving himself through space and seeing things from different points of view. Eventually judgments of distance, shape, size are refined and the infant learns that he can depend upon what he sees without the need to touch, mouth or taste.

As children develop, they learn to use their vision. Initially the conscious mind is significantly involved in both planning and managing appropriate visual responses. But later pre-programmed mechanisms for action and thinking ‘schemata’ free the conscious mind from the mechanics of the tasks. These schemata enable greater comprehension and assimilation of the available information. When a child is experiencing school difficulties, one of the factors which should be carefully checked is the adequacy of the ‘schemata’ that underpin efficiently visually directed behaviour and visual inspections.

Visual Skills

Expect your optometrist to give careful consideration to your child’s emerging visual abilities and to relate this information to the age expected and school demands. Some of the important visual skills that need to be considered are:

1. Visual problem solving style

Some children persistently demonstrate impulsive responses. Does your child show poor attention to visual detail; take little time to analyze available details and give rapid responses; and often need to ‘touch’ things that could be expected to be analyzed by visual inspection only?

2. Direction concepts

For optimal processing of visual information, directional responses should be completely accurate and automatic. This ability gradually comes as children relate to the ‘sidedness’ on their own body (right/left awareness), and project this understanding of direction onto the processing of direction – coded information such as “b, d”, “on, no”, “was, saw” and “31, 13”. Children develop an understanding of themselves as a point of reference for developing spatial concepts and making judgments of direction.

3. Visual analysis skills

The ability to make accurate visual discriminations, sometimes called form perception, gradually emerges. What is the child’s ability at making judgments of size, shape, position and distance? Can he or she remember what is seen and visualize objects in different spatial orientations?

4. Hand-eye coordination

The ability to team eyes and hands as ‘learning tools’ is obviously important to the child in the classroom.

5. Eye movement control

Can the child follow moving objects smoothly, accurately, effortlessly and automatically?

6. Eye-focus skills

Is it easy for the child to quickly focus from near to far etc. and get clear detail with each change?

7. Eye-training skills

How well do the two eyes work together on far seeing tasks; and near seeing tasks? 

Preventative care

Given the importance of efficient visual function it is recommended that ‘vision development’ not be left to chance. Ideally all children should be examined at the following stages:

  • At age six months
  • At age two and a half years
  • Before commencing school
  • Yearly thereafter

Your optometrist will be checking to ensure that your child’s visual abilities are appropriate for age.

An intermittent eye turn in a child over six months of age is not normal and early treatment is recommended. Optometric Visual Training is the treatment of choice for many visual dysfunctions.

 

Stress and Visual Problems

After the child has developed efficient visual skills, they are still ‘at risk’ if exposed to excessive near seeing demand and prolonged adverse stresses on the visual function.  Indeed, stress induced visual co-ordination difficulties can result at any age. Thus, a stress induced vision problem may result which will limit the person’s ability to visually perform with efficiency, comfort and accuracy for any sustained time. Avoiding close visual tasks eliminates symptoms, but otherwise, depending on the degree of deterioration of the visual function some or most of the following symptoms are usually produced.

Symptoms due to fatigue caused by extensive demand on the neuromuscular system:

  • Headaches or aching eyes; pain referred to the muscles of which an excessive effort is demanded
  • Such symptoms are often associated with excessive or prolonged use of eyes and will disappear or significantly reduce with withdrawal from, or avoidance of, visually demanding tasks
  • Difficulty changing focus from near to distant objects or vice versa. Inability to quickly make a distant object clear after sustained close reading without blinking or squinting
  • Glare discomfort, usually only partly relieved by sunglasses, but characteristically reduced by squinting one eye
  • Reading comprehension and efficiency drops after a short time on a task

Symptoms due to failure to maintain constant singular binocular vision:

  • Blurring of print (goes funny) or running together of words while reading
  • Intermittent double vision under conditions of fatigue
  • One eye turns without double vision (usually noted by family or friends)

Symptoms due to defective postural sensation:

  • Difficulty in judging distances and positions, especially of moving objects. Timing judgments for hitting and catching small balls are usually difficult
  • Bumping into objects or misjudgments of position of objects when involved in active visually directed movement and game play
  • Feeling of insecurity when dealing quickly with steps, escalators or parking the car

Treatment

Performance lenses: are ‘tools for the job’ of sustained near looking, and are used as a measure to prevent stress induced vision problems; and equally importantly, to enhance visual achievement on the printed page. They are usually low power lenses but may blur far seeing.

Multifocals may be considered, the upper portion with a compensatory power or no power, if lots of looking far and near is demanded.

Training lenses: Some visual function disorders can be treated by doing specific activities while wearing lenses that modify the focus teaming relationship. These lenses often initially disturb performance but become easier to tolerate as improved visual control is developed.

Compensatory lenses: Refractive compensation for such conditions as near sight, far sight and astigmatism, is usually achieved by either contact lenses or glasses.

With age, the lens inside the eye gradually loses elasticity. This normal age process commonly results in increasing near focus difficulty. After age 40 to 45 reading glasses are usually needed to compensate for the lost focus power of the presbyopic eye.

Progress reviews: Four to eight weeks after a patient has been wearing the new prescription directed at modifying performance, a progress review is recommended evaluation ensures that the expected performance changes have indeed occurred and identifies the patients needing Visual Training.

Optometric visual training: Many visual problems cannot be adequately treated by glasses or contact lenses alone. Visual training is prescribed to improve turned-eye and lazy eye problems, and to help patients learn, relearn or reinforce specific visual skills. For patients who are motivated, willing to practice and follow instructions, significant progress towards more efficient or comfortable visual performance usually results. There is no ‘typical’ program, since each patient will have individual needs. Usually patients are seen once per week for in-office treatment and are given procedures to practice daily at home. Appropriate lens support is always an essential component of visual training management.

Visual Information Processing

Visual Information Processing is the ability to give meaning to what is being seen. Good visual information processing means being able to quickly and accurately process and analyze what is being seen, and store it in visual memory for later recall. For example, in the classroom when reading and writing it is important to be able to quickly and accurately decode, comprehend and remember written material whilst still being able to listen to the teacher.

1. Visual Spatial Skills

Spatial awareness is an ability to make judgments about the world in relation to ‘me’. It is learned from infancy and depends on past experience. From an understanding of “where I am”, the position of objects and their sequences, there “where is it” takes on meaning.

Directional Responses gradually come as children relate to the “sidedness” on their own body (right/left awareness), and project this understanding of direction onto the processing of direction – coded information such as “b, d; on, no; was, saw; 31, 13; etc.”

Children with poor visual spatial skills will have poor knowledge of right and left, show reversals of letters, number and words, have difficulty setting out a page of writing, and have difficulty organizing themselves in space and time. Many also have poor eye movement skills.

2. Visual Analysis Skills

Visual analysis skills are a group of abilities used to recognize, recall, and manipulate visual information. The ability to make accurate visual discriminations gradually emerges. What is the child’s ability at making judgments of size, shape, position, and distance? Can he or she remember what is seen and visualize objects in different spatial orientations?

Visual analysis skills are used in learning to remember and recognize letters, numbers and words. Poor visual analysis skills leads to difficulty learning the alphabet, trouble with maths concepts, confusion of similar words, difficulty spelling, and forgetting words seen from one page to the next.

3. Visual Motor Skills

Visual motor integration, often referred to as eye-hand coordination, is the general ability to coordinate visual information processing skills with motor skills. Early visually directed motor skills develop into the fine eye-hand coordination skills required to catch a ball, tie shoelaces, build with blocks, and hold a pencil to colour and write.

Visual motor dysfunction can cause children to have difficulty copying written work accurately and efficiently, cutting, and drawing.

Can visual information processing skills be improved? Yes, with Visual Therapy.