Vision in the neonate (full-term and premature): preliminary result of the application of some testing methods

Visual Acuity alterations in heavily impaired Congenital Zika Syndrome (CZS) children

Introduction

This study aimed to assess visual acuity (VA) in Congenital Zika Syndrome (CZS)-children to evaluate visual loss. To that end we evaluated 41 CZS - children, from Rio de Janeiro using Teller Acuity Cards.

Methods

To asses VA, we evaluated 41 CZS - children, from Rio de Janeiro using Teller Acuity Cards. The children had Zika virus-infection confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or clinical evaluation.

Results

In 39 out of 41 (95%) children, the VA scores were below normative values, while in 10 cases, VA was only marginally below normal; in the remaining 29 cases, VA was more than 0.15 logMAR below the lower limit. There was no correlation between VA and the cognitive domain tasks, although there was a correlation between VA and motor domain tasks. Thirty-seven children performed at least one task in the cognitive set, while fourteen children did not perform any task in the motor set. Children with VA above the lower limit performed better in the cognitive and motor tasks.

Discussion

We concluded that ZIKV- infected children with CZS were highly VA impaired which correlated with motor performance, but not with cognitive performance. Part of the children had VA within the normal limits and displayed better performance in the cognitive and motor sets. Therefore, even if heavily impaired, most children had some degree of VA and visual function.

Diagnosis and Evaluation of Visual Dysfunction in Premature Infants with Low Birth Weight

Visual impairment of many kinds is common in premature infants with low birth weight. The infant's visual system is quite plastic in the early stages, and early screening may help to discover treatable pathology. Clinical techniques are available that are not used in the routine examination given by the pediatrician. These include optokinetic nystagmus, preferential looking, and visually evoked potential. If such techniques were more widely employed where visual impairment is suspected, nonsurgical remedial intervention might be more successful.

Active Exploration of the Environment by Young Children with Low Vision: A Review of the Literature

Young children with low vision experience delays in cognitive development, motor development, and social skills because of the lack of motivation or insufficient opportunities to explore their environments actively. As a result, they have difficulty acquiring practical knowledge and spatial and environmental concepts. This review of the literature explores these problems, discusses current approaches to addressing them, and suggests areas for future research, including the use of optical aids.

Alterations in visual acuity and visual development in infants 1-24 months old either exposed to or infected by Zika virus during gestation, with and without microcephaly

PURPOSE

To evaluate visual acuity and visual acuity development in children from the state of São Paulo, Brazil, who were exposed to the Zika virus (ZIKV) gestationally.

METHODS

Children who had been exposed to ZIKV during gestation and age-matched control subjects received visual acuity and funduscopic examination. ZIKV exposure was confirmed by maternal quantitative polymerase chain reaction testing or serology assay. The ZIKV group was divided into two subgroups: exposed (ZE), with only the mother having confirmed ZIKV infection, and infected (ZI), with confirmed infection. Visual acuity development was compared with prior norms and quantified by measuring visual acuity correlation with age.

RESULTS

A total of 110 children were included: 47 who had been exposed to ZIKV (ZE, 23; ZI, 24) and 63 controls. Abnormal visual acuity was found in 5 of 24 ZI children. Of the 4 children with microcephaly, only 2 had visual acuity loss (only 1 also had abnormal funduscopic findings). There was significant correlation between age and visual acuity in both the control group (R² = 0.8; P < 0.0000) and the ZE subgroup (R² = 0.6; P < 0.0000). However, visual acuity did not correlate with age in the ZI subgroup (R² = 0.04; P = 0.38). Furthermore, the increment in octaves/month was much lower in the ZI subgroup.

CONCLUSIONS

Our data indicate that visual acuity losses only occur in infants who suffered gestational-infection, not simply exposure. Lack of correlation between age and visual acuity in the ZI subgroup suggests a slowing of visual development even in the absence of microcephaly. This result may have broad implications for the deleterious effects of ZIKV on the central nervous system.

The Human Fetus Preferentially Engages with Face-like Visual Stimuli

In the third trimester of pregnancy, the human fetus has the capacity to process perceptual information [1-3]. With advances in 4D ultrasound technology, detailed assessment of fetal behavior [4] is now possible. Furthermore, modeling of intrauterine conditions has indicated a substantially greater luminance within the uterus than previously thought [5]. Consequently, light conveying perceptual content could be projected through the uterine wall and perceived by the fetus, dependent on how light interfaces with maternal tissue. We do know that human infants at birth show a preference to engage with a top-heavy, face-like stimulus when contrasted with all other forms of stimuli [6, 7]. However, the viability of performing such an experiment based on visual stimuli projected through the uterine wall with fetal participants is not currently known. We examined fetal head turns to visually presented upright and inverted face-like stimuli. Here we show that the fetus in the third trimester of pregnancy is more likely to engage with upright configural stimuli when contrasted to inverted visual stimuli, in a manner similar to results with newborn participants. The current study suggests that postnatal experience is not required for this preference. In addition, we describe a new method whereby it is possible to deliver specific visual stimuli to the fetus. This new technique provides an important new pathway for the assessment of prenatal visual perceptual capacities.

Effects of prematurity on the development of contrast sensitivity: testing the visual experience hypothesis

In order to investigate the effects of visual experience on early visual development, the current study compared contrast sensitivity across infants born with different degrees of moderate-to-late prematurity. Here the logic is that at any given postterm age, the most premature infants will have the oldest postnatal age. Given that postnatal age is a proxy for visual experience, the visual experience hypothesis predicts that infants who are more premature, yet healthy, should have higher sensitivity. Luminance (light/dark) and chromatic (red/green) contrast sensitivities (CS) were measured in 236 healthy infants (born -10 to +2 weeks relative to due date) between 5 and 32 weeks postterm age from due date and 8-38 weeks postnatal from birth date. For chromatic CS, we found clear evidence that infants who were most premature within our sample had the highest sensitivity. Specifically, 4-10 additional weeks of visual experience, by virtue of being born early, enhanced chromatic CS. For luminance CS, similar but weaker results were seen. Here, only infants with an additional 6-10 weeks of visual experience, and only at later age points in development, showed enhanced sensitivity. However, CS in preterm infants was still below that of fullterm infants with equivalent postnatal age. In sum, these results suggest that chromatic CS is influenced more by prematurity (and possibly visual experience) than luminance CS, which has implications for differential development of parvocellular and magnocellular pathways.

Responses to a modified visual cliff by pre-walking infants born preterm and at term

The purpose of this study was to examine, using a modified visual cliff apparatus, possible perceptual differences at crawling age between infants born preterm and infants born at term without documented visual or motor impairments. Sixteen infants born at term and 16 born preterm were encouraged to crawl to their caregivers on a modified visual cliff. Successful trials, crossing time, duration of visual attention, duration of tactile exploration, motor strategies, and avoidance behaviors were analyzed. A significant surface effect was found, with longer crossing times and longer durations of visual attention and tactile exploration in the condition with the visual appearance of a deep cliff. Although the two groups of infants did not differ on any of the timed measures, infants born at term demonstrated a larger number of motor strategies and avoidance behaviors by simple tally. This study indicates that infants born at term and those born preterm can perceive a visual cliff and adapt their responses accordingly.

Contrast sensitivity threshold measured by sweep-visual evoked potential in term and preterm infants at 3 and 10 months of age

Although healthy preterm infants frequently seem to be more attentive to visual stimuli and to fix on them longer than full-term infants, no difference in visual acuity has been reported compared to term infants. We evaluated the contrast sensitivity (CS) function of term (N = 5) and healthy preterm (N = 11) infants at 3 and 10 months of life using sweep-visual evoked potentials. Two spatial frequencies were studied: low (0.2 cycles per degrees, cpd) and medium (4.0 cpd). The mean contrast sensitivity (expressed in percentage of contrast) of the preterm infants at 3 months was 55.4 for the low spatial frequency (0.2 cpd) and 43.4 for the medium spatial frequency (4.0 cpd). At 10 months the low spatial CS was 52.7 and the medium spatial CS was 9.9. The results for the term infants at 3 months were 55.1 for the low spatial frequency and 34.5 for the medium spatial frequency. At 10 months the equivalent values were 54.3 and 14.4, respectively. No difference was found using the Mann-Whitney rank sum T-test between term and preterm infants for the low frequency at 3 or 10 months or for the medium spatial frequency at 3 or 10 months. The development of CS for the medium spatial frequency was equally fast for term and preterm infants. As also observed for visual acuity, CS was equivalent among term and preterm infants, suggesting that visual experience does not modify the development of the primary visual pathway. An earlier development of synapses in higher cortical visual areas of preterm infants could explain the better use of visual information observed behaviorally in these infants.

Preterm birth and visual development

Visual impairment, oculomotor abnormalities, and refractive error are prevalent among children with a history of preterm birth. These conditions may result from exposure of the immature visual system to early visual stimulation, from nutritional deficits that occur following the abrupt loss of placental maternal-to-fetal transfer of essential nutrients, and as secondary effects of systemic disease or complications associated with preterm birth. This chapter provides an overview of the structural and functional maturation of the visual system of the healthy preterm infant and of several forms of visual impairment that are prevalent in the low birth weight population.

Visual field and grating acuity development in low-risk preterm infants during the first 2 1/2 years after term

The effect of early visual experience on visual field size and grating acuity development was studied longitudinally in 36 appropriate for gestational age (AGA) and 26 small for gestational age (SGA) low-risk preterm infants. These were selected out of 194 very low birth weight (VLBW) infants (birthweight less than 1500 g) born in 1985 and 1986. Criteria for inclusion as low-risk were the absence of neurological, respiratory, circulatory and alimentary problems in the neonatal period; no retinopathy of prematurity and no evidence of abnormality on the neonatal cranial ultrasound scans. Binocular field sizes were assessed using kinetic arc perimetry. Binocular grating acuity was tested by means of the prototype version of the acuity card procedure. Results were compared with norms obtained in control fullterms in earlier studies. Infants were tested at 6 weeks, 6, 6, 9 and 12 months of age from the expected term date. Twenty-two of these infants were retested at 2 1/2 years of corrected age. Visual field size and visual acuity estimates of (both AGA and SGA) low-risk, VLBW preterms and control fullterms overlapped at all test ages, except for a slight but significantly faster development of the upper and the lower visual field at 6 weeks corrected age in the preterm group. These results indicate that for clinical purposes visual experience before the expected term date has not only no measurable effect on the normal development of behavioural acuity, but also no accelerating effect on the development of peripheral vision.

Visual acuity of low- and high-risk neonates and acuity development during the first year

Binocular grating acuity of 65 neonates was measured using Teller acuity cards. At the time of testing, age corrected for prematurity ranged from -3 weeks to 2 weeks. On the basis of clinical data, serial ultrasound scans and EEG recording newborns were divided into 4 subgroups: fullterm low-risk (FLR, n = 22); preterm low-risk (PLR, n = 20); preterm medium-risk (PMR, n = 9) and preterm high-risk (PHR, n = 14). Mean visual acuity of PLR infants (0.86 cy/deg; S.D. 0.34 oct) was not significantly different from that of FLR newborns (0.80 cy/deg; S.D. 0.71 oct); the lower variability of the PLR infants might possibly be caused by their longer postnatal experience. Within the preterm groups, mean visual acuity of PLR newborns was found to be significantly higher than that of PMR (0.73 cy/deg; S.D. 0.26 oct) and PHR infants (0.73 cy/deg; S.D. 0.35 oct). This difference can not be explained by dissimilarities in postnatal or corrected age. Brain impairment, as documented by US scans and EEG recording could account for these findings. Longitudinal data are needed in order to substantiate these findings and correlate them with later neurological and neuro-imaging outcome. Preliminary results of an ongoing longitudinal study suggest acuity development of most, but not all, PHR infants, in whom a cystic-periventricular leukomalacia had been diagnosed, to be worse than that of low- and medium-risk infants.

Visual acuity in low birth weight (1500-2500 g) neonates

Binocular grating acuity was tested in 138 low birth weight (LBW) neonates (birth weights ranging from 1500 to 2500 g) by means of the prototype version of the Acuity Card Procedure. No surrounding screen was used. Mean visual acuity of 107 neonates successfully assessed at mean corrected ages of -1.9 weeks (+/- 1.9 weeks) amounted to 0.58 cycles/degree (S.D. 0.71 octaves). Success rate was 77.5%. Mean postnatal age was 2.3 weeks (+/- 1.6 weeks). Acuity values of various subgroups ranged between 0.68 cycles/degree (S.D. 1.3 octaves) in low-risk, small for gestational age (SGA) preterms (n = 7), to 0.56 cycles/degree (S.D. 0.7 octaves) in SGA fullterms (n = 34), independent whether at low-or at high-risk. These differences were not significant, although with multiple regression analysis with adjustment for corrected age of testing, mean acuity of low-risk preterms was slightly better than of low-risk fullterms (P = 0.055). No significant change of acuity over corrected age could be demonstrated, except for a slight progress (r = 0.57; P less than 0.05) in the subgroup of 13 low-risk fullterms. The high variability of acuity values in neonates and the slow acuity development at term age hamper assessment of differences between various subgroups of neonates.

Binocular visual acuity of neonates: the acuity card procedure

The acuity card procedure is a variant of the forced-choice preferential looking technique. In this study, four observers each tested 10 infants (all healthy fullterm neonates) with acuity cards containing either a one-aperture or a two-aperture stimulus configuration. For both card types the mean test time was eight minutes. No effect on acuity results was found between the two different configurations. The mean acuity values were within one octave of those reported in most previous behavioral studies of the acuity of neonates. The authors consider that the acuity card procedure provides a rapid, accurate technique for assessment of healthy newborn infants in a hospital setting.

Visual acuity in newborn and preterm infants measured with grating acuity cards

Binocular visual acuity of normal newborn infants, preterm newborn infants, and newborn, full-term infant patients with nonophthalmologic abnormalities was measured by means of grating acuity cards. Each test took about six minutes to complete, and 89% of the tests (154 of 174) were successful. Visual acuity of infants at 39 to 40 weeks of gestational age was about 0.023 stripes per minute of arc, or 0.69 cycles per degree (20/866). Between 34 and 44 weeks of gestational age, visual acuity improved at the rate of 0.46 octaves per month. This test is simple, fast, and reliable, and requires no apparatus except the cards themselves.

Objective techniques of visual acuity assessment in infancy

Three primary techniques for objective assessment of visual acuity in the preverbal infant are variations of optokinetic nystagmus, forced preferential looking and visual evoked potentials. Although these tests are useful, the clinician must be aware of their shortcomings. Failure to evoke optokinetic nystagmus may reflect the infant's lack of interest in the stimulus, an inherently uninteresting stimulus, or a defect in the motor system generating the nystagmus, other than failure to see the stimulus. Forced choice preferential looking has provided useful information about visual development in preverbal infants. The need for more complex stimuli to yield more precise estimates of acuity than the standard grafting stimuli, especially in cases of amblyopia, is discussed. Visual evoked potentials, like forced preferential looking, may grossly overestimate the acuity of the amblyopic patient. Of the techniques discussed, it holds the most promise.

The development of visual acuity in normal fullterm and preterm infants

The development of visual acuity during the first year of life was assessed in 91 normal fullterm infants and 36 preterm infants with minimal perinatal complications, using the forced-choice preferential looking technique. Acuity in the preterm infants lagged behind that of the fullterm infants up to the age of 6-8 months if age was calculated from birth, and then reached equal levels. When age was corrected for prematurity, acuities in the two groups were very similar at all ages, but mean preterm acuity was consistently slightly higher than in the fullterm infants. The results suggest that early visual experience of preterm infants in the period up to the expected date of term may lead to a slight acceleration of the development of behavioural visual acuity. This is discussed in relation to electrophysiological studies which report a greater effect of prematurity on acuity development.

Critical analysis of visual function evaluating techniques in newborn babies

The most widely-used techniques for testing visual function in babies are reviewed. Advantages and limitations of optokinetic nystagmus testing, visual evoked responses and preferential looking techniques are considered. The theoretical basis and the clinical applicability of those techniques are outlined. Other simple methods are considered as well, which allow practicing ophthalmologists to assess the presence or absence of vision in babies. The importance of early diagnosis for prevention and treatment of visual deficits in babies is stressed.

Spatial frequency sweep VEP: visual acuity during the first year of life

The grating acuity of 197 infants from 1 week to 53 weeks of age was measured using the visual evoked potential (VEP) in response to counterphase grating stimulation. The gratings were presented as a 10 sec spatial frequency sweep which spanned the acuity limit. The amplitude and phase of the second harmonic response were extracted by discrete Fourier analysis. The VEP amplitude versus spatial frequency function showed narrow spatial frequency tuning with amplitude peaks at one or more spatial frequencies. The phase of the response at medium to high spatial frequencies was generally constant at a spatial frequency peak, followed by a progressive phase lag with increasing spatial frequency. Grating acuity was estimated by linear extrapolation to zero microvolts of the highest spatial frequency peak in the VEP amplitude versus spatial frequency function. This visual acuity estimate increased from a mean of 4.5 c/deg during the first month to about 20 c/deg at 8-13 months of age. The VEP acuities at 1 month are a factor of three to five higher than previously reported for pattern reversal or pattern appearance stimuli. By 8 months VEP grating resolution was not reliably different from adult levels in the same apparatus.

Ophthalmological examination of the infant. Developmental aspects

In recent years, the ophthalmic examination of infants has been of increasing interest to both clinicians and vision researchers. Clinicians have documented a greater risk of retinopathy, strabismus and amblyopia in premature infants, especially those of low birthweight. In addition to the external and retinal examination of the infant eye, a number of clinical tests can help the ophthalmologist to detect visual dysfunction through the evaluation of pupillary responses and ocular motility. Recently, the development of objective techniques (optokinetic nystagmus, forced choice preferential looking, and visually evoked potentials) have not only aided in the detection of ophthalmic disorders in infants; they have contributed to useful definitions of "normal" vision at various ages and to the understanding of factors that influence the pre- and post-gestational development of visual function.