A Paula Grigorian, MDPediatric ophthalmologist

Associate Professor of Ophthalmology UAMS

No conflict of interests

Overview

Review vision screening methods

How to do it

What you may find

What it means

When to refer

Some things you may never

Visual development

At Birth - Poor vision 20/200-due to immature brain

Birth to 2 mos

Poor fixation, little visual attentiveness

Frequent exotropia

Jerky eye movements- saccades

No smooth pursuit

2 to 6 mos

Eyes should be straight

Crossing is abnormal!

Able to reaches for toys

Central fixation and smooth pursuit

8

After 3 years

A normally developing cooperative child should be able to read/match an eye chart

Screening

Is essential in preventing vision loss

It is a challenge

Nearly 4 mil newborns/yr

Preverbal, Non-verbal, Shy, Peeking, Uncooperative

Screening

External exam

Pre term infants: RED reflex

All neonates: + corneal light reflex, fixation

Preschool-aged: + cover test

School- age: + check VA

Anatomy

Valve of Rosenmüller

Valve of Hasner

-punctum to inferior meatus 20mm

Inferior turbinate

Dim room light

Direct ophthalmoscope

12-18in from the child

Dial the diopter control until the red reflex comes into focus

Check each eye at a time

Red reflex

Produced by the light reflected from the retina

Cataract, RB or retinal abnormalities dim RR = Leukocoria

Corneal light reflexes -test

Produced by a point source of light focused by the cornea

The position of the reflex is dependent on the alignment of the eyes

Diagnose strabismus

http://one.aao.org/Flash/VisionScreening/PediatricVisionScreening.html

Corneal light reflexes -test

Direct ophthalmoscope or penlight

A detailed near fixation target will help

Look at both eyes simultaneously

Corneal light reflexes -

Helps distinguish b/w strabismus and pseudostrabismus

Overcomes other misleading features: epicanthal folds or eyelid asymmetry

Hirschberg test

Combined, simultaneous corneal light reflex

red reflex

Direct ophthalmoscope

In addition it allows evaluation of the pupil for asymmetry

Red reflex

White reflex- media abnormalities

White reflex- media abnormalities

Strabismus

White reflex- media abnormalities

Strabismus

Detects refractive errors, anisometropia

White reflex- media abnormalities

Strabismus

Detects refractive errors, anisometropia

Rapidly compares pupil size

Guidelines for screening

AAP

RR screening by PCP w/in the first 2 mos :

Neonatal visit, 2 and 6 wks

Cover testing

Requires fixation in each eye

Can give information about vision

Cover testing

Preschool vision screening

Optotype-based vision

LEA symbols, HOTV, Allen cards, Snellen letter

Preschool vision screening

Test each eye at a time

Kids cheat!stick on patch for all children

Acuity Test: Age 6+

Sloan letters

Five letters every line

Inverted pyramid shape

Spacing proportional to the size of

the letter

More accurate vision assessment

then Snellen

Acuity Test Failure Criteria3 - 5 YO

Unable to read at least 20/40 with either eye.

REFER!

Acuity Test Failure Criteria>5 YO

Unable to read 20/30 either eye

OR

Two line difference between eyes (20/20 and 20/30)

REFER!

Depth perception (stereoacuity) testing?

Done in many schools and screening programs

Not recommended by AAPOS

Stereo Fly Test

Vision screening devices

Photoscreenersand Autorefractors

May detect amblyogenic factors, not amblyopia itself

Expensive

Autorefractors

Welch Allyn Suresight Nikon Retinomax

Monocular acuity screening -CPT 99173

Photoscreening99174

Photoscreeners

Photo of the eye's red reflex to estimate

refractive error

ocular alignment

other conditions degrading or blocking line of sight (cataract)

Things you probably will never see in

But you better not miss them if you do

Check red reflex of all neonates & children

Leukocoria = white pupil

Leukocoria = Retinoblastoma

www.occhioallaretina.it/Immagini/leucocoria.

JPG

Leukocoria= Retinoblastoma

Most common intraocular tumor of childhood

200/yr

No sex or race predilection

FH 25%

Leukocoria= Retinoblastoma

Almost always fatal w/o treatment

Survival rate >90% w/ treatment

Leukocoria= Retinoblastoma

Mortality is directly related to the extent of dz

Leukocoria Differential Diagnosis

Cataract

RETINOBLASTOMA

Persistent Fetal Vasculature

Coats disease

Infections- Toxocara

Retinal detachment

Conclusion

Pediatric eye exam is just a piece of cake!