ODs may be first to spot autism risks

September 1, 2012

Because of autism's visual component, the optometrist may be the first to observe visual risk factors, said Glen T. Steele, OD, FCOVD, here at the annual meeting of the American Optometric Association (AOA).

Key Points

Chicago-Because of autism's visual component, the optometrist may be the first to observe visual risk factors, said Glen T. Steele, OD, FCOVD, here at the annual meeting of the American Optometric Association (AOA).

Autism is a complex developmental disorder marked by problems with social interaction and communication, which manifest very early in life. The disease ranges from mild to disabling in severity, and while it has a biological basis, early intervention is associated with better prognosis.

"You're not expected to diagnose autism, but you may be put in a position to do just that-initiate a process that may lead to eventual diagnosis of it," said Dr. Steele, a professor at the Southern College of Optometry in Memphis, TN. "We should be part of the team that recognizes risk factors."

The definition of autism was also broadened to include autism spectrum disorders, such as Asperger's syndrome. Autism spectrum disorder can be recognized as early as 14 months, according to the American Academy of Pediatrics (AAP). They suggest that all children be screened for the condition twice by age 2, which is where the OD comes in.

Developmental assessment begins with the baby's gaze. Healthy babies are engaged by looking into someone's eyes, and even this simple act causes a measurable increase in brain activity, he said.

"Mutual gaze is how kids later identify friendships. It starts at 2-to-3-minutes of age with the baby gazing into Mom's eyes," Dr. Steele said.

Even just looking at photographs, a baby will be engaged by an adult's direct gaze. Therefore, a lack of interest in making eye contact is an early sign of risk for a developmental disorder such as autism.

Early diagnosis is facilitated by InfantSEE, a public health program managed by the AOA Foundation and designed to ensure that eye and vision care are an integral part of infant wellness. Through this program, AOA–supported optometrists provide comprehensive eye and vision assessments for infants in the first year of life.

Assessments are recommended between the ages of 6 and 12 months, and are to include visual acuity, refractive status, ocular motility, alignment, and binocular potential; as well as assessments of overall eye health, including dilation.

"Early indicators of [autism] risk related to vision are pupillary reflex, blink reflex, gaze following, attention, oculomotor function, and choice of fixation object," Dr. Steele said.

He advised conducting routine exams with special attention to history. "Start with a careful history, and put particular emphasis on eye movement and control-including interest in the parent, staff and doctor, and in objects in the room as you test," he explained.

The areas of the optometric that should be most carefully scrutinized are ocular motility and fixation, binocular function, and pupillary response. Note where the infant looks, how long they look, and how well they track.

Dr. Steele also suggests lots of "tummy time" with the baby on its stomach, making active eye contact with the parent. Remind the parent that tummy time should be active, and should not be considered the parent's opportunity to read e-mails or send texts.

Retinoscopy is a significant resource for determining how the baby is really looking, he said.

"Look also at pupil size and change in this process," he said. "If binocular function is present, the chances improve for having a foundation for 'looking. The pupillary reflexes-speed and quantity of movement-are also linked to risk, as well as blink reflexes, which are linked with fixation."

Be conservative with 'diagnosis'

"If you suspect something is amiss, do you diagnose autism?" Dr. Steele asked. "Or do you refer as fast as you can?"

The response to this depends on many things, including the perceived severity, what the family suspects, and whether the findings change in the space of a month. He said that it is not necessary to make an immediate consideration of a diagnosis of autism. Rather, ODs should emphasize their concerns, and stress the need for and timing of a follow up visit.

"It's okay to monitor the patient for visual issues without alarming the parent," Dr. Steele said.

He suggested following the patient frequently, either alone or in concert with a pediatric optometrist. If problems persist, other professionals can be consulted.

"You've started a process that may lead to a diagnosis somewhere on the autism spectrum. If the diagnosis of autism is eventually made, the parents will feel as if a bombshell has been dropped on them, and they will need someone to talk to. Be that person. Tell them you will walk with them every step of the way."