PePeadiatric eye adiatric eye assessmentassessment

Visual DevelopmentInfancy and early childhood is an important time in visual development

The eyes grow and emmetropise

Vision improves

Stereopsis matures

Accommodation develops

Visual problems

Visual disorders are the leading cause of childhood disability

Aside from congenital pathology common disorders include amblyopia, strabismus and refractive error

Early detection means prevention and better treatment

Visual milestonesVery soon after birth - can fix and follow a light source, face or large, colourful toy

1 month- Fixation is central, steady and maintained, can follow a slow target, and converge, preference of looking at face

3 months- Binocular vision and eye coordination, eyes follow a moving light or face, responsive smile

6 months - Reaches out accurately for toys

9 months- look for hidden toys

2 years - picture matching

3 years - letter matching of single letters

5 years - snellen chart by matching or naming

What are the challenges?

How to examine the children???

Be sensitive!!!You are a stranger to him, He feels safe only if the parents are comfortable with you.

Initially ignore the baby and act normal

Start by communicating with the parents

Slowly and be natural

While talking to the parents, introduce some toys at the same time

If he accepted the toy, you almost gained his trust.

Eye exam and Vision screening

Birth to 3 years

Ocular History

Vision assessment

External examination

Ocular motility/ alignment- corneal light reflex, alternate cover test, stereo acuity

Pupil examination

Red reflex

Ocular HistoryFor babies aged 0-3 years, history from parents are very important;

Asked questions like:

Does your child hold objects close to his or her face?

Does your child’s eyes appear straight or crossed?

Relevant family history regarding eye disorders

Birth history- full term, normal delivery?

Visual behaviour of child- clumsy, visually inattentive, close viewing distance

Visual Assessment

Mainly we want to see if baby can fix and follow

To determine whether each eye can fixate on an object, maintain fixation and follow the object into various gaze positions

The assessment should be performed binocularly and then monocularly.

External Examination

Consists of penlight evaluation of the lids, conjunctiva, sclera, cornea, and iris.

Persistent discharge or tearing may be attributed to ocular infection, allergy or glaucoma but the most common cause is lacrimal duct obstruction

Ocular motilityAlternate cover test

occlude one eye

move occluder to other eye

watch for shift of recently occluded eye

Corneal light reflex= Hirschberg’s test

reflexes symmetric= normal

reflex nasally= exotropia

reflex temporally= esotropia

Red ReflexReferral

dark spots in reflex

blunted/ dull reflex

lack of red reflex

white reflex

asymmetry color/ brightness/ size

Age 3 years and older

all previous and…

Age-appropriate visual acuity

attempt at ophthalmoscopy

Visual AcuityRecommended test

Snellen letters

Snellen numbers

Tumbling E

HOTV

Allen Figures or LEA

Preferential looking test of vision

Keeler/Teller cards for infants

Cardiff acuity cards for toddlers

Picture test of vision

Kay pictures

LEA symbols

Fundus examination

Important to examine the fundus to ensure no pathology

Abnormal findings could explain poorer than expected vision

Direct ophthalmoscopy can be difficult with young children due to the proximity required. They also have a tendency to keep looking at the ophthalmoscope light

Indirect methods can be more successful

Routine ReferralFailed visual screening

Amblyopia or amblyopia risk factor

Strabismus, horizontal nystagmus, torticollis

Eyelid abnormality

Nasolacrimal duct obstruction

refer at age 10-12months or sooner if problematic recurrent/resistant secondary infections

95% resolve by 12 months with conservative management: lacrimal massage and topical antibiotics

Urgent referralPreseptal cellulitis not responding to treatment

CN palsy/ acute onset strabismus

unusual nystagmus

red eye

severe conjunctivitis not responding to topical antibiotics

HSV keratitis

concern for acute uveitis

congenital glaucoma

Dacrocystocele

emergent referralophthalmia neonatorum

ocular trauma

concern for penetrating trauma

severe blunt trauma

leukocoria

Orbital cellulitis

sudden loss of vision

papilledema

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