Learning to See: What you should know

How does your baby's vision develop in the first months and years? In conversation with orthoptist Lena Opderbeck, you'll learn what milestones are typical, what parents should look out for regarding possible abnormalities – and how an eye clinic examination works.

Read on for what you need to know to best support your child's visual development and to be able to act early if necessary.

Lena, what exactly does an orthoptist do? And how do they differ from an ophthalmologist?

Orthoptists primarily work in eye clinics. We treat adults, for example, for strabismus, acquired double vision, and asthenopic, i.e., non-specific, eye complaints. However, our main patients in eye clinics are children, mostly due to strabismus and/or amblyopia. Our focus is on diagnostics: Is there a need for glasses? Can we treat the strabismus or not? We also provide therapeutic treatment, for example, with patch therapy.

Can it be done without an ophthalmologist?

No, we always work with an ophthalmologist. Ophthalmologists issue spectacle prescriptions, rule out organic causes for strabismus or amblyopia, such as whether a cataract or an early childhood tumor is causing the symptoms. It is always important to check the fundus and rule out possible changes. If patients come to us for regular check-ups, the ophthalmologist usually checks the fundus once a year.

How does vision develop in babies during their first year of life?

Newborns primarily see contrasts and contours. They see best at a distance of 20 to 25 cm, otherwise rather vaguely. From birth, they recognize light sources and begin to track them. At 3 months, babies can slowly perceive depth. Their visual acuity increases, and with it, their visual range. They begin to make eye contact and perceive more colors. At about six months, they grasp objects purposefully, see all colors, and their reach becomes increasingly greater for grasping and exploring. It is assumed that by their first birthday, children have about 50% of adult visual acuity.

And what signs can indicate a visual impairment?

That depends entirely on the age. In newborns, it is noticeable if they do not react to light stimuli or do not track them, and if they do not maintain eye contact in the first 3 months of life and seem to look straight through their parents. At 6 months, parents should be concerned if "baby strabismus" does not decrease or even increases, if the child consistently misses when reaching or has no interest in grasping or objects at all. At 7 to 9 months, babies can usually distinguish between unfamiliar and familiar faces. If parents notice that their child relies more on voices and cannot distinguish their face from others, this is also an indication of a possible visual impairment.

And in toddlers?

Toddlers with vision problems often avoid or lack endurance for close-up activities. For example, they don't like to draw, craft, build towers, or do puzzles.

What are the most common vision problems in young children?

In our practice, we frequently see children with severe farsightedness, nearsightedness, astigmatism, or strabismus. These often occur in combination. And a large proportion already have what is known as amblyopia: where one eye is much weaker than the other. In that case, the well-known patch therapy is used: the stronger eye is covered with a patch to reactivate the weaker one.

When should parents have their child's vision checked?

In our practice, we recommend that parents bring their child to the eye clinic at ages 1, 3, and 6. Vision is simply so important for overall development: crawling, walking, grasping. If vision problems are overlooked here, development in other areas can suffer greatly. At 3 years old, children already cooperate well with the examination and can answer correctly. This makes it much easier, and we can perform a very reliable vision test for the first time. If something is detected now, intervention can still be made in time. At 6 years old, an examination is worthwhile so that a visual impairment does not jeopardize academic progress.

What are the consequences if a visual impairment is only detected late?

If children come to us only at school age, therapy is often much more difficult. Patch therapy is then often not as effective: they don't like to wear the patch at school, and if the good eye is covered, it is also very tiring for children to keep up in school. It would take a lot of energy to follow lessons with, for example, only 10% vision. You also need to know: Once children are 8 to 10 years old, visual development is pretty much complete, and therapy has little effect. The younger they are, the more responsive the brain is to therapy.

So, it's best to send them to the eye clinic at ages 1, 3, and 6?

That's what we recommend. Premature babies should definitely come to an eye clinic in their first year of life. Twins, preferably around their first birthday, because they also have an increased risk of visual impairments. If both parents have high refractive errors or there are strabismus conditions in the family, I would always recommend having the child's vision checked. And always: If parents are already coming with one child and we find an abnormal finding, then it's best to have the sibling checked as well.

Are there long waiting times?

That varies regionally. With us, you should expect about 4 to 5 months – unless it's an emergency, such as sudden, severe strabismus, in which case it needs to be examined immediately. However, the situation in Hamburg is generally better than in other federal states. We also have patients from Berlin and Brandenburg because it's almost impossible to get an appointment there.

So, it's better to come early than too late. Are there also cases where parents come to you unnecessarily?

Often, pediatricians send babies to us as a general rule if both parents wear glasses. However, this only makes sense if there is truly a high refractive error. If both parents, for example, have developed nearsightedness due to a lot of screen time, the child does not have an increased risk of a congenital visual impairment. In that case, it is sufficient for the children to come to us for a normal check-up at 1 year of age. Sometimes it only appears that babies are strabismic, when in fact they are not.

What does that mean: it only appears so?

Babies typically have a very flat nose and thus a slight epicanthus. This is a crescent-shaped skin fold at the inner corner of the eye. The strabismus is then only an optical illusion. Parents can even check this by shining, for example, their phone's flashlight into both eyes while looking straight ahead: You will then see a small light reflection, the corneal reflex. This is a small bright spot in the eye, which is the reflection of the light. It is not exactly in the middle of the pupil, but slightly nasally displaced in both eyes. Strabismus is present if the reflexes are not identically positioned.

And are routine check-ups with the pediatrician not sufficient for monitoring?

Pediatricians don't always perform vision tests. For babies, they do the so-called Brückner test. They shine a light on the back of the eye and check for any indication of strabismus, unilateral amblyopia, or an early childhood tumor in the eye. Later, they can roughly rule out or detect refractive errors with a screening device. The device measures the eye's values and compares whether they are age-appropriate or not. However, this examination often costs money with many doctors. Some pediatricians are willing to send children to eye clinics, others are more hesitant. Important for parents: You don't necessarily need a referral for an eye clinic. So, if parents have a persistent bad feeling and suspect a visual impairment, they should come to us even without a pediatrician's go-ahead.

What can parents expect during a visit to the eye clinic?

Especially with very young children, we usually work by exclusion. We check various things with small finger toys, lamps, or devices. This then comes together like a puzzle, and we can make a good diagnosis. The children usually cooperate well. We also have more time than ophthalmologists, about 15 minutes per appointment. So, we don't have to rush. If children don't want to cooperate at all, we can give them some time or arrange follow-up appointments so they can get used to us. Then the examination is often no longer a problem by the 2nd or 3rd appointment. However, this is not possible in all eye clinics.

Can parents also promote vision?

Actually, vision develops quite on its own if there are the right incentives. Babies enjoy contrast books or contrast cards and also bright colors. But bold colors are still important for toddlers too. I therefore always advise against buying everything in pastel shades or furnishing a nursery only in beige tones. I understand that parents may not like brightly colored plastic toys. But wooden toys are also available in really beautiful, bold colors. And these are exactly what children need for good visual development.

You can find even more scientifically sound information on early childhood development from 0–3 years, over 650 activities, and much more in the mo:mo app.