Refer to an ophthalmologist.

What Shouldn’t Be Missed

Learning disorders should not be missed.

Practically speaking, most parents will not bring their older children to their primary care provider specifically because of complaints of decreased or abnormal vision. Vision problems will usually come to attention either by your specific questions about vision during your regular well-child history, or if the child fails a vision screening test in the office.

There are several reasons older children may complain of decreased or abnormal vision:

• 1. Need for glasses. The most common reason children and young adults need glasses is myopia (nearsightedness). Patients with myopia can see things at near, but have difficulty seeing clearly in the distance. Myopia usually begins during grade school and typically worsens gradually. It is not uncommon for children with myopia to be unaware that they have a vision problem until it is specifically brought to their attention. This may occur either during a vision screening test or if the child is with someone who notes a distant object that the child cannot see (Table 4–1).
  
• 2. Learning disorders. Children with learning disabilities frequently complain that they are having trouble seeing. However, the problem for the vast majority of children with reading problems is not the eyes, but the processing of written information in the brain. It is important that these children be evaluated to verify that they do not have an underlying visual problem. If the eyes are fine, these children are best served with additional educational assistance (Table 4–2).
  
• 3. The child wants glasses. Some children, typically in early elementary school, may feign vision problems due to a desire to wear glasses. Most commonly, this occurs after someone in their class has received glasses that bring them positive attention (such as glasses with a cartoon character theme). Such children are often visibly disappointed when told they do not need to wear glasses.
  
• 4. Dry eyes. Problems with the tear film in children are not uncommon, and they are a frequently overlooked cause of blurred vision. A stable tear film is necessary to form crisp visual images. Children with dry eyes usually complain that things become blurry after they have been reading for a while. They may also complain of eye irritation (Table 4–3).
  
• 5. Colored spots. There are 2 common etiologies for children who describe colored spots. The first is physiological after-images. These are natural phenomena that occur after looking at lights. They can be demonstrated by looking at a bright light (such as a flashlight) in a dark room. When the light is turned off, persistent images can be appreciated. A striking example is illustrated in Figure 4–1. Physiological after-images occur in adults, but are usually ignored. Children may spontaneously report them, typically around age 5 or 6 years. The second common cause of seeing colored spots is migraine-associated phenomena. Classic migraines may be preceded by various visual symptoms, including colored spots, jagged streaks, sparkling lights, visual field loss, or a sensation similar to looking through jet flumes (Figure 4–2 ).