Optom Vis Sci

1040-5488/09/8606-0559/0 VOL. 86, NO. 6, PP. 559–560
OPTOMETRY AND VISION SCIENCE
Copyright © 2009 American Academy of Optometry
GUEST EDITORIAL
Infant and Child Vision Research: Present Status
and Future Directions
At the turn of the last century William James speculated that the
sensory world of an infant would be a “blooming, buzzing confusion.”
In fact, relatively little was known about visual development in infants
and young children until the 1950s and 1960s, just before Velma
embarked on her scientific career. With the advent of new techniques
to assess systematically the vision of non-verbal, seemingly uncooperative
subjects, a great deal has now been learned about vision in the
first months and years after birth.
Although specific information was being gathered from infants
and young children, neuroscientists were demonstrating that visual
experience could alter the neural circuitry of the developing brain.
These insights had implications for the management and treatment
of amblyopia. The demonstration of a sensitive period of
cortical plasticity was good news in that it held promise for success
in the treatment of experience-dependent conditions, but it was also
bad news in that it demonstrated that the window of opportunity for
aggressive treatment is early in childhood and relatively short.
Velma’s work and career exemplify the integration of two key
themes in understanding the development of vision in infants and
children. The first has been to ask fundamental questions about the
development of visual abilities in infants and how these skills integrate
with other aspects of their motor and cognitive development.
The second has been to ask how clinicians might be able to detect,
diagnose, treat, and potentially prevent permanent visual abnormality
during the first postnatal years.
These two approaches were apparent in a major review published
in the early 1990s. Chapters written by a group of scientists
and clinicians, including Velma, were compiled and edited by Kurt
Simons into the highly cited and referenced book, “Early Visual
Development, Normal and Abnormal.” This current feature issue
of OVS, 16 years on, has provided an excellent opportunity to
reflect on these themes in the context of additional knowledge. The
contributions to this issue illustrate the number of paths that have
been taken in the past two decades.
The development of the optics of the eye has attracted significant
attention for three clinically important reasons. First, retinal
image quality defines the information being presented to the developing
neural visual system and we need to ensure that this
information is appropriate for normal development during infancy
and early childhood. Thus, we need to understand normal refractive
development and the interaction between the developing optical
and neural visual systems, in the context of amblyopia in
particular. 1–5 Second, numerous studies have demonstrated the
potential for visual experience to influence the growth of the eye.
We need to understand the process of emmetropization, and de-
Optometry and Vision Science, Vol. 86, No. 6, June 2009
termine whether it can be encouraged through appropriate refractive
correction. 6,7 Finally, the realization that the incidence and
prevalence of myopia is increasing dramatically around the world
has revealed an urgent need for understanding the pathological
underpinnings of this condition. 8–11 We have been able to make
real progress in our understanding of refractive development with
the relatively recent development of autorefractors and photorefractors,
as well as more robust approaches to quantifying refractive
error. 12,13 However, significant elements of these core questions
still remain.
The clinical assessment of the status of the visual system has also
attracted attention, from both vision screening and full examination
perspectives. There are still significant challenges in obtaining
reliable data from “wriggly” children in a screening setting, and we
are still some way from reaching a consensus about how best to
provide the pediatric population with vision screenings. 14 In addition
to the impact of the sensitive period, these assessments also
need to occur at a young age before children enter school with its
additional visual demands. 15–17 The recognition that early treatment
is frequently beneficial for the developing visual system still
drives us to refine techniques for reliably diagnosing, assessing, and
monitoring visual status in the general clinical community. 18,19
Still, we have basic work to do to develop a clear understanding of
the mechanisms and natural history of a number of important and
relatively common clinical conditions. 4,20 Large-scale population
based studies using efficient techniques are still required to determine
the risk factors for these conditions and their natural history.
There have also been a number of interesting demonstrations in
the past 20 years that visual experience impacts developing neural
circuitry at higher stages of processing, and therefore that tools are
required to look at the more perceptual and cognitive aspects of
function. In this context, there have been a series of studies looking
at typical development of these functions and the impact of lower
level immaturities on them, 21–30 and also of complex and difficult
clinical conditions. 31–35
An area in which Velma has shown particular strength is the
transfer of new knowledge to clinical care. The most significant
contribution has likely been her work in two large clinical trials in
retinopathy of prematurity (ROP), the Cryotherapy for ROP
Study, and the Early Treatment for ROP Trial. By introducing
quantitative assessment of grating visual acuity in infants and
young children as a major outcome measure in these two studies,
an earlier determination of potential functional benefit could be
made rather than waiting until the child was able to provide more
“standard” measures of acuity. Such outcome measures allowed

560 Guest Editorial
intervention to be assessed in terms of functional outcome rather
than simply the appearance of the ocular structure. It would not be
an understatement to posit that introduction of quantitative functional
measures, including those of visual acuity and visual field,
revolutionized the design of clinical trials in pediatric ophthalmology
and optometry and this work will have lasting benefits for our
young patients. This laborious task was undertaken with intelligence,
honesty, and rigor by the individual to whom this feature
issue is dedicated.
As we honor Velma, our mentor, colleague and friend, we trust
that this compilation of research will inspire and challenge scientists
to further pursuits. In particular, there is still a real need and
obligation to help the families of young patients with as much
prognostic information as we can develop and gather. Advancing
our understanding of basic aspects of the development of extrastriate
cortex, visual perception and cognition is a particularly daunting
task, given the need for objective assessments in infants and
young children. Hopefully, new technologies including innovative
forms of brain imaging (e.g., near infrared spectroscopy, multielectrode
electroencephalogram, fMRI), will allow us to develop
norms and appropriate assessment tools to evaluate therapies for
these complex conditions and others.
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Velma Dobson
Tucson, Arizona
T. Rowan Candy
Bloomington, Indiana
E. Eugenie Hartmann
Birmingham, Alabama
D. Luisa Mayer
Boston, Massachusetts
Joseph M. Miller
Tucson, Arizona
Graham E. Quinn
Philadelphia, Pennsylvania