Deaf children and vision

The eye, the optic nerve and the brain all need to work properly to allow us to see.

The eye focuses rays of light onto the retina at the back of the eye and the fovea within the retina enables us to see detail clearly. Cells in the retina change light rays into electrical signals and these signals are sent by the optic nerve to the brain, where information is decoded into pictures. 

Normal vision

With normal vision we can:

• see objects far away, such as a ship out at sea or a bird flying
• see small things close up, such as letters on a page, a speck of dust or a crumb on the floor
• notice objects at the edges of our visual field, such as an overhanging branch of a tree and moving objects that aren’t right in front of us
• judge the depth of a step as we walk downstairs
• see colours
• notice the difference between black, grey and white, to help us move around safely in dim light
• see at night when our eyes adapt to the dark.

The eyes also form an important part of our balance system.

Signs of poor vision

There are a range of things that you or your child may notice that could mean they have a vision problem:

• difficulty seeing the whiteboard or blackboard in the classroom
• more problems than usual seeing in poor light (for example, at night)
• difficulties reading a book or magazine
• problems seeing the scenery from the back of a car
• problems spotting a person in the crowd
• discomfort in bright light
• difficulty going from light to dark places, or from dark to light
• blinking or rubbing eyes more often than usual
• difficulty finding small items which have fallen onto the floor
• difficulty finding items against a busy or patterned background
• difficulty judging where things are in a space
• bumping into, or tripping over things more than usual.

If your child develops any of these problems or you have any concerns about your child’s vision you should let a professional know. Your concerns should be taken seriously and an appointment made with the ophthalmology service (eye clinic).

Children with permanent sensorineural deafness are at high risk of eye disorders and should be referred for a specialist eye examination by their local audiology service as soon as the deafness is confirmed, and then at regular times throughout their childhood.

In addition to the normal childhood vision screening, the Royal College of Ophthalmologists (eye doctors) guidance recommends that children with sensorineural deafness have further eye checks, including a full orthoptic examination, cycloplegic refraction and a fundus examination.

• An orthoptic examination measures how much the eye turns from various positions. It can provide information on lazy eye (amblyopia), double vision, your child being unable to use both eyes together, and other abnormal eye movements.
• Cycloplegic refraction is a procedure carried out to determine refractive error, which means that a child can’t properly focus their vision. Examples of this are near sightedness and far sightedness.
• A fundus examination looks for issues relating to the interior surface of the eye including the retina.

For some children, their deafness is a sign that they have a syndrome (syndrome is a medical term meaning a collection of signs or symptoms that appear together). Sometimes a syndrome has already been diagnosed, but if it hasn’t then an eye examination can help to diagnose a syndrome or confirm that hearing loss isn’t part of a syndrome.

The appointment letter from the ophthalmology service (eye clinic) will let you know if you need to make any special arrangements for the appointment.

Your audiology service should have told the ophthalmology service if you need a sign language or other language interpreter for the appointment. If your appointment letter doesn’t make it clear that one has been arranged, contact the ophthalmology department to make sure this will happen.

Eye care professionals

At the ophthalmology clinic you may meet different professionals, just as you would at the audiology department.

• An ophthalmologist is a doctor who specialises in detecting and treating eye disorders.
• An orthoptist is trained to assess vision, and assess and manage conditions related to the development and movement of the eye (for example, squints). They usually work with the ophthalmologist. Orthoptists often visit schools to check children known to have problems with their vision, or they may see them regularly in clinics.
• An optometrist examines eyes, recognises abnormal eye conditions, advises on eye care, and prescribes, fits and supplies glasses, contact lenses and other things to help correct vision (vision aids).
• Dispensing opticians are trained to fit, supply and sell glasses and vision aids, but don’t examine eyes.

Optometrists and opticians often have premises on the high street.

What happens at the eye appointment?

If your child uses lip-reading or sign language, you may need to remind the staff at the clinic. Ask professionals to make sure they keep light on their face and to face your child when speaking. Ask what will happen during the appointment before they turn the lights off so that your child knows what to expect.

You will be asked if you have any concerns about your child’s eyes and vision. The letter asking for the appointment should have given information about your child’s medical history, but it’s always helpful to take copies of any medical reports you have including your child’s ‘red book’ early health record if they are very young.

It’s most likely that your child will see both an orthoptist and an ophthalmologist during their appointment.

The orthoptist

Many children enjoy their eye test as the orthoptist uses a range of small toys to keep their interest in testing and often rewards children with stickers. The type of test used will depend upon the age and ability of an individual child.

During the appointment your child may be given eye drops. Eye drops can sting, but not for long – much like shampoo accidentally getting in your eyes. Your child should be reassured about this.

The eye drops will blur their vision slightly after about 10 minutes, especially when looking at things that are close to them. Let your child know about this and reassure them the effects will wear off but may take several hours to return to normal.

If your child signs it may be helpful to explain what tests will be needed later in the consultation before the blurring effect makes it harder for them to see your signing.

Eye drops can increase light sensitivity so take a peaked hat, sunglasses or make sure the baby carrier or pushchair has a shade or cover. Eye drops can raise a child’s temperature so make sure they have layers that can be removed if they look or feel hot.

A yellow eye drop may be used if eye pressure needs to be tested. This doesn’t sting but does numb the eye so be aware of your child rubbing their eye as they won’t know how hard they’re rubbing it.

The ophthalmologist

The ophthalmologist (eye doctor) will examine the back of your child’s eyes with various instruments that have bright lights including an instrument called an indirect ophthalmoscope.

They may ask for ocular electro-diagnostic tests including an electroretinogram (ERG). An ERG records the retina’s response to stimulation and is one of the tests used to test for Usher syndrome.

Ophthalmologists may suggest other tests such as visual evoked response (VER) or visual potential test (VPT) or an electro-oculogram (EOG). These are not routine tests and you will have to travel to a special centre if these tests are required.

Support for hospital appointments

If your child is worried or frightened about hospitals or is just very anxious, you can ask if the hospital has a play worker who can get in touch with you before your visit and work with your child to prepare them for the appointment.

You can also ask if your hospital has an eye clinic liaison officer or Family team. They can attend your appointment with you, give advice on your child’s diagnosis, tell you about what support and information is available in your local area regarding your child’s vision levels, offer emotional support, and give practical advice about benefits and equipment.

What help is available if my child has an eye condition?

Many of the common eye conditions can be treated easily and glasses aren’t always necessary. Most eye conditions aren’t serious but can cause educational difficulties if not treated.

Treatment varies depending on the eye condition. Sometimes treatment aims to prevent the condition from getting worse or becoming permanent, for example by using an eye patch for a lazy eye (amblyopia).

Sometimes glasses may be all that’s needed to help your child see properly. Occasionally surgery may be required, perhaps to help align the eyes or if there is a condition affecting the cornea.

Usually, the earlier the treatment, the better the outcome. Very occasionally the test results may show that although the eyes are functioning well now, they may deteriorate with time. This information could help your family prepare for and adjust to the future.

Low vision aids (LVA) such as magnifiers and telescopes can be helpful, and may be recommended if glasses, contact lenses or medical treatment can’t treat your child’s eye condition.

Your family doctor (GP), local optometrist, eye doctor, teacher, or professional from social services can refer your child for a low vision assessment. The assessment and any low vision aids prescribed are free of charge.

What if my child needs to wear a patch or glasses as well as hearing aids?

Having to wear hearing aids and glasses together may seem a bit daunting, especially for a small child. It’s very important that your child feels comfortable with them.

Your optometrist and audiologist need to work together to help get the best fit. Often the arm of the glasses can be adjusted by your optometrist to give a better fit next to the hearing aid.

Sometimes metal-framed glasses for children take up less space and wrap around the ear and so are a better fit than plastic framed glasses. Glasses with soft supports for the ear pieces may help.

If your child has lazy eye (amblyopia), they may have to wear a patch on the good eye to help the lazy eye come into line with the other one. If your child needs to see to lip-read and follow sign language, make this clear to the orthoptist if they recommend patching.

It may be helpful to get advice from a specialist teacher (for example, a Teacher of the Deaf or a teacher for children with visual impairments) to help with managing equipment and developing activities that will encourage a child to accept patching and glasses.

What happens if a severe visual condition is identified?

If your child is diagnosed with a syndrome that involves a severe visual condition, or a deteriorating visual condition, a referral should be made for specialist educational advice. This referral could be made by audiology professionals, eye professionals, or by your child’s school.

Depending on your child’s needs, a qualified teacher for visual impairment or multi-sensory impairment may become involved in providing advice and guidance to your child’s school.

A deaf child who later experiences visual difficulties may become quite worried and anxious. Organisations such as Sense, RNIB and Contact may be helpful in suggesting ways to help, social networks that you may find useful and online games for young people who have visual impairments.

Follow-up care

At an agreed age, young people won’t usually need to continue having routine eye tests at the hospital or clinic ophthalmology department. However, every child under 16 and every young person aged 19 or under and in full-time education is entitled to free NHS eye tests with an optometrist.

If you have concerns about your child’s vision, ask your audiology service or your GP to refer your child back to the ophthalmology department.

You should take older children for regular eye tests and help encourage good eye care in teenagers to prepare them for adulthood, particularly if there is a family history of eye problems or short-sightedness.