Visual Impairment & Eye Health in Children Susan Cotter, OD, MS So CA College of Optometry Marshall B Ketchum University Fullerton, CA
Consequences of Childhood VI Social Emotional Physical Educational Economical Quality of Life
Consequences of Childhood VI Unilateral congenital cataract associated with delayed motor functioning at 4.5 years - may adversely affect social and academic functioning* If unilateral, risk of 5-year incident VI in betterseeing eye (RR = 2.7 X) *Celano et al. Dev Med Child Neurol in press (from Infant Aphakia Trial)
Leading Causes of Childhood Blindness in US Cortical visual impairment Optic nerve hypoplasia Retinopathy of prematurity (ROP) risk if minority, low SES, low birth weight Kong et al. J AAPOS 2012;16:501-507
Retinopathy of Prematurity: US Incidence Overall = 0.17% Premature infants in NICU = 7.35% If >28 days NICU = 15.5% Lad et al. Am J Ophthalmol 2009;148:451 458.
Leading Causes of Visual Impairment Infants, Toddlers, Preschoolers Amblyopia Refractive Error Strabismus The BIG THREE
Amblyopia Reduced best-corrected VA with amblyogenic factor in healthy eye(s) Abnormal visual experience interferes with normal development of visual pathways - impaired form vision Most common cause of vision loss in children
Strabismus
Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo 30-72 mo Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* MEPEDS. Ophthalmology 2008;115:1229-36 McKean-Cowdin et al. Ophthalmology 2013;120:2117-24
Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo 30-72 mo* Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% 2.5% 3.2% 3.6% Amblyopia* 2.6% 1.5% 1.8% 1.8% MEPEDS. Ophthalmology 2008;115:1229-36 McKean-Cowdin et al. Ophthalmology 2013;120:2117-24
Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence Age 6-72 mo 30-72 mo Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% 2.5% 3.2% 3.6% Amblyopia* 2.6% 1.5% 1.8% 1.8% MEPEDS. Ophthalmology 2008;115:1229-36 McKean-Cowdin et al. Ophthalmology 2013;120:2117-24
Risk Factors for Strabismus & Amblyopia Unilateral Amblyopia Hispanic ethnicity Esotropia Anisometropia Bilateral Amblyopia Lack of health insurance Lower primary caregiver education Astigmatism Hyperopia 4.00D SE Strabismus Prematurity Maternal smoking during pregnancy Hyperopia MEPEDS/BPEDS: 9970 Children 6-72 months; Ophthalmology 2011;118(11):2251-61 and 2262-73
Risk of Esotropia Associated with Bilateral Hyperopia MEPEDS/BPEDS: 9970 AA, Hispanic, White Children 6-72 months Bilateral SE Hyperopia Odds Ratio* 95% CI 0.0 to <+1.00 D reference ------ <0.00 (myopia) 2.5 0.9 6.9 +1.00 to <+2.00 D 1.8 0.7 4.6 +2.00 to <+3.00 D 6.4 2.6 15.9 +3.00 to <+4.00 D 23.1 9.7 55.6 +4.00 to <+5.00 D 59.1 23.6 151.5 +5.00 D 122.2 49.9 299.7 Based on multivariate stepwise logistic regression model; adjusted for age, anisometropia, maternal smoking, gestational age. Level of hyperopia defined by less hyperopic eye Cotter et al. Ophthalmology 2011;118(11):2251-61
Refractive Error
MEPEDS. Ophthalmology 2010;117:140-7;Fozailoff et al. Ophthalmology 2011;118:284-93; Wen et al. Ophthalmology 2013;120:2109-16 Refractive Error Prevalence MEPEDS: Children 6 to 72 Months of Age Refractive Error (SE*) Hisp n=3030 Afr Am n=2994 NHW n=1501 Asian n=1507 Myopia -1.00 D* 3.7% 6.6% 1.2% 4.0% Hyperopia 2.00 D* 26.9% 20.8% 25.7% 13.5% Astigmatism 1.50 D 16.8% 12.7% 6.3% 8.3%
WHO Visual Impairment Definition Presenting Visual Acuity
Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116:1990-20; Ophthalmology 2013;120:1220-6
Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116:1990-20; Ophthalmology 2013;120:1220-6
Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% 5.9% 2.6% 3.4% VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured Not RE 2.2% 1.8% 1.3% 1.2% *Refraction & retest Ophthalmology 2009;116:1990-20; Ophthalmology 2013;120:1220-6
Visual Impairment: Young Children MEPEDS: Children 6 to 72 months of Age Better Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 3.5% 3.9% 1.0% 0.9% With ophthalmic etiology (VI) 2.5% 2.8% 0.8% 0.8% VI: Resolving RE* 1.7% 1.9% 0.3% 0.5% VI: Best-Measured Not RE * Refraction & retest 0.7% 0.8% 0.3% 0.2%
Wearing Spectacle Correction? MEPEDS Hispanic & Afr-Am = 1.6% Asian & NHW = 2.2% BPEDS NHW & Afr-Am = 1.7%
VI is Not Always Present in Isolation
Children with Developmental Disabilities Increased risk of VI (10.5% vs. 0.16%)* - & other ocular disorders, including RE & strabismus Preterm Cerebral palsy Down syndrome Severe hearing impairment Learning difficulties Other neurodevelopmental disorders VI Not Always Recognized *Salt et al. Arch Dis Child 2014;99:1163 1168
Developmental Impact of VI Directly related to level of VI: Spatial awareness, posture, movement skills Use of hands & fine movement coordination Early concept development (e.g., object permanence) Locating sound in space Understanding meaning of words and thus speech / language development Social interaction and communication Self-care skills Salt et al. Arch Dis Child 2014;99:1163 1168
Refractive Error
Hyperopia: Other Concerns? Uncorrected hyperopic 4-& 5-yr old children with +3.00 to +6.00 D & no strabismus / amblyopia, vs. emmetropic controls? Visual acuity (distance & near) Stereoacuity Accommodative response (accuracy) Test of Preschool Early Literacy (TOPEL) Kulp et al. VIP-HIP ARVO May 2015; Ciner et al. ARVO May 2015
School-Age Children & VI
Refractive Error Prevalence School-aged Children CLEERE: Children 5-17 Years of Age (%) Refractive Error (both meridians)* Hisp (463) Af-Am (534) NHW (1035) Asian (491) Total (2523) Myopia -0.75 D* 13.2 6.6 4.4 18.5 9.2 Hyperopia +1.25D* 12.7 6.4 19.3 6.3 12.8 Astigmatism 1.00 D 36.9 20.0 26.4 33.6 28.4 Kleinstein et al. Arch Ophthalmol 2003:121:1141-7.
Are Decreased Vision & RE the Only Concerns for School-Age Children? Vergence Disorders Accommodative Disorders
Symptoms Associated with Reading in Children w/ Convergence Insufficiency Frequent loss of place Loss of concentration Double vision Blurred vision Headaches Reading slowly Eyestrain Tired eyes Sleepiness Trouble remembering was read Need to re-read same line of words what CITT Group. Arch Ophthalmol 2008;126:1336-49. Barnhardt et al. Optom Vis Sci 2012;89:1512-20.
Conclusion Childhood Visual Impairment ---------------------Definition dependent & age dependent Infants & Early Childhood Amblyopia Strabismus Refractive error Middle Childhood & Adolescence Refractive error Accommodative disorders Vergence disorders Ocular disease at all ages
Questions?scotter@ketchum.edu
Extra Slides Have 95% Confidence Intervals
Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence (95% CI) Aged 6 to <72 Months Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% (1.9-3.0) 2.5% (2.0-3.1) 3.2% (2.4-4.3) 3.6% (2.7-4.6) Amblyopia* 2.6% (1.8-3.4) 1.5% (0.9-2.1) 1.8% (1.1-2.9) 1.8% (1.1-2.9) MEPEDS. Ophthalmology 2008;115:1229-36 McKean-Cowdin et al. Ophthalmology 2013;120:2117-24
Strabismus & Amblyopia Prevalence Multi-ethnic Pediatric Eye Disease Study: MEPEDS Prevalence (95% CI) Aged 6 to <72 Months Hispanic n=3003 n=1687* Afr-Am n=3005 n=1663* NHW n=1502 n=937* Asian n=1522 n=938* Strabismus 2.4% (1.9-3.0) 2.5% (2.0-3.1) 3.2% (2.4-4.3) 3.6% (2.7-4.6) Amblyopia* 2.6% (1.8-3.4) 1.5% (0.9-2.1) 1.8% (1.1-2.9) 1.8% (1.1-2.9) MEPEDS. Ophthalmology 2008;115:1229-36 McKean-Cowdin et al. Ophthalmology 2013;120:2117-24
Visual Impairment: Young Children MEPEDS: Children 6 to 72 Months of Age Worse Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 10.5% 8.6% 3.6% 4.2% With ophthalmic etiology (VI) 7.1% (5.9-8.4) 5.9% (4.8-7.2) 2.6% (1.7-3.8) 3.4% (2.3-4.8) VI: Resolving RE* 5.3% 4.3% 1.4% 2.3% VI: Best-Measured 2.2% (1.5 3.0) 1.8% (1.2-2.6) 1.3% (0.7-2.2) 1.2% (0.6-2.1) *Refraction & retest. Ophthalmology 2009;116:1990-20; Ophthalmology 2013;120:1220-6
Visual Impairment: Young Children MEPEDS: Children 6 to 72 months of Age Better Eye Hisp (n=1615) Afr Am (n=1592) NHW (n=947) Asian (n=939) Presenting VA 3.5% 3.9% 1.0% 0.9% With ophthalmic etiology (VI) 2.5% (1.8-3.4) 2.8% (2.0-3.7) 0.8% (0.3-1.6) 0.8% (0.3-1.6) VI: Resolving RE* 1.7% 1.9% 0.3% 0.5% VI :Best-Measured 0.7% (0.4-1.2) 0.8% (0.4-1.3) 0.3% (0.1-0.9) 0.2% (0.0 0.8) * Refraction & retest
Refractive Error Prevalence School-aged Children CLEERE: Children 5-17 Years of Age Refractive Error (both meridians)* Hisp (463) Af-Am (534) NHW (1035) Asian (491) Total (2523) Myopia -0.75 D* 13.2 6.6 4.4 18.5 Hyperopia +1.25D* 12.7 6.4 19.3 6.3 Astigmatism 1.50 D 36.9 20.0 26.4 33.6 9.2 (8.1-10.3) 12.8 (11.5-4.1) 28.4 (26.6-30.2) Kleinstein et al. Arch Ophthalmol 2003:121:1141-7.