Detecting Visual Concerns Early – A Story & 5 Red Flags

I met Sam when he was about 16 months old. He had been enrolled in early intervention since before his 1st birthday due to global developmental delays. He was making slow progress developmentally so I was asked to consult with this OT and his mother. After spending time watching Sam play and talking with his mother and his OT, I noticed that Sam liked to stand within inches of the TV screen to watch his cartoons. When he walked his gait was unsteady as if he was feeling his way with his feet. When he played with his toys, he tended to “overshoot” when required to use eye-hand coordination to aim (i.e., missing the ringstand when trying to place the ring).  When I offered Sam tiny sticks to pick up from my palm (from my handy assessment kit), his effort confirmed for me that his vision was a major concern. After looking very closely at my hand, Sam put his fingers on my palm, closed his eyes and turned his head. He knew that his vision wasn’t going to help him so he shut it off and relied on his sense of touch to pick up the sticks. I recommended that he see an ophthalmologist, and following his vision evaluation, I received an email from the physician thanking me for the referral. The doctor said that Sam had the most severe myopia (near-sightedness) that he’d ever seen in a child so young. Once Sam got his glasses, he asked for them every morning when he woke up and started making leaps in his development.

Detecting concerns with vision development in infants and toddlers can be a real challenge, especially when the visual concern is more subtle. In VA, a vision screening is conducted on all children entering the early intervention system, so it is important that service coordinators and service providers know subtle signs to look for that could indicate when a referral to a pediatric ophthalmologist is needed. Here are a few “red flags” to keep an eye out for:

Difficulty with locking gaze on and following a face or object

If an infant is not able to fixate or lock his gaze on a face or object after 3 months of age, this could be a red flag. When testing this, start with trying to get the baby to watch your face as you move slowly from side to side. Be sure that your face or an interesting toy is within 10-12 inches or so from the infant’s face. Be sure not to make noises while moving so that you know the child is following what he sees rather than what he hears.

Unusual head tilt or use of peripheral vision

If you see a child consistently tilting her head when she looks at things, this could indicate a concern with the child’s visual field. It could also just be the child playing with her vision so watch to see if she does this consistently over time. If you see a child who uses her peripheral vision alot, this could also be something to monitor. Children with sensory processing difficulties, such as those with autism spectrum disorders, may show unusual head tiling or use of peripheral vision too so monitoring is very important.

Difficulty focusing

If you notice that a child doesn’t seem to be focusing on your face or his toys, try placing your face or the toy at different distances from his face. Closely watch his eyes to see if he focuses better at a certain distance or at a certain point in his visual field.

Eyes that don’t move together

This can be typical in newborns, but when seen in older babies can be a cause for concern. Anytime you see a child with eyes turning inward or outward, talk to the child’s parents and pediatrician about a referral to an ophthalmologist.

Holding books or toys very close to the face

Like how Sam watched TV, you might also see toddlers holding toys or books very close to their faces to see. Again, this could just be playful, but if you notice a child doing this often, having his vision checked is probably a good idea.

Monitoring a child’s visual development is important throughout childhood, and even more so when you know the child is at risk for visual concerns, perhaps from being a preemie or having a diagnosed condition associated with visual impairment. Since vision has such a huge impact on development, make sure that you know what to look for and what to do when you spot a vision concern. There’s nothing like seeing a toddler’s world open up when he sees clearly for the first time!

Check out the NICHCY fact sheet on Visual Impairment, including Blindness for more information (available in English and Spanish).

What are other things YOU look for when doing a vision screening? Share your thoughts in the comments below.