PGH Basic Course 2016
Basic Pediatric Vision Exam
Alvina Pauline D. Santiago, MD Pediatric Ophthalmology & Strabismus
Visual milestones
• Birth Bright lights • 7 days vestibulo-ocular reflex • 3 mos transient fixation & following • 6 mos fixation & following
even for distance • 2-3 y 20/30 • 5-7 y 20/2
Vision Assessment
• Fixation pattern • 3 mos: transient fix and follow • 6 mos: fix and follow
– “CSM” : central, steady, maintained – cover one eye – start distance fixation
Fixation Preference & Visual Acuity
• Central, steady, maintained CSM 20/20-20/30
• CS, maintained briefly 20/40-20/60 • CS, not maintained (NM)20/70-20/80 • C, NS, NM 20/100-20/200 • Not C, Eccentric </= 20/300
Preferential Looking
• Modified optokinetic flag
• Teller acuity cards or its derivative
• Facial targets
School age child
• Not infants and toddlers • Preschool 3-6 years • Regular School 7-12 • Adolescent 13-18
Vision testing
• Quantifiable • Depends on patient discrimination • Depends on examiner ability to interpret
response • Standard: Snellen acuity: optotype • Psychophysical tests: test interpretation
subjective measured by patient’s ability to communicate recognition to examiner
Preschool
• Short attention span • Inability to sustain interest • Language and communication barriers • Cultural and social limitations
Preschool Tests
• Detection acuity tests – Stycar graded balls (Sheridan 1973) – Catford drum (Catford & Oliver 1973) – Dot visual acuity test
• Recognition acuity test – Direction oriented: Illiterate E, Landolt C – Picture charts – Letter charts
Vision Assessment: 3-6 years
• Allen pictures: cultural bias • Sheridan Gardner or HOTV/HOTEX • Illiterate E / tumbling E / E game • Landolt C • Snellen numbers, letters
– kids memorize! • Sloan Letters
Grating vs Snellen Acuity
• Grating acuity (cycles per degree)
• Snellen acuity (visual angle)
• Grating overestimates Snellen
Limitations of Optotype Test
• Snellen acuity unreliable before age 6-8 • Not all children will know alphabet &
numbers • Single optotypes may overestimate linear
acuity
Susceptible Period
• Most sensitive first 2-3 years
• Decreases until age 6-7 years (12? 18?) – complete visual
maturation – retinocortical pathways
and visual centers resistant to abnormal visual input
7-12 years
• Significant number still will not express poor vision
• Easy to perform Sloan linear acuity testing
Vision Assessment: Nystagmus
• Binocular near vision test – allow patient to assume own distance – test at standard near distance – check head posture – VA in forced primary
• Binocular distance vision • Monocular distance & near vision
Vision Assessment: Nystagmus
• Monocular occlusion – many will increase nystagmus
• Remote occlusion • Sufficient fogging: know refraction! • Neutral density filters • AO vectograph testing • Translucent occluder
Random dot stereograms
• 2 plates of randomly displayed dots, one plate to each eye
• Shape of figure displaced horizontally relative to other plate
• No monocular cues • Normal may fail
Sensory Tests & Visual Acuity
Circles Seconds of Arc VA 9 40 20/25 8 50 20/30 7 60 20/40 6 80 20/50 5 100 20/60 4 140 20/70 3 200 20/80 2 400 20/100 1 800 20/200 Donzis 1974