Exam

Eye Examination in Children

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Eye Examination in Children, Pediatric Eye Exam, Pediatric Vision Screening

  • Epidemiology
  1. One quarter of children wear glasses in the U.S.
  2. Eye disease is identified in 7% of children under age 18 years old
    1. Yet only 20% of U.S. Children screened for eye disease in U.S.
  • Risk Factors
  • High risk children (may require eye specialist screening)
  1. Difficulty testing child on 2 separate attempts
    1. Age 3: Repeat attempt in 6 months
    2. Age 4 and older: Repeat attempt in 1 month
  2. Premature birth history
  3. Developmental Delay or neurologic disorder
    1. Down Syndrome
    2. Cerebral Palsy
  4. Systemic disease
  5. Family History of eye disorder
    1. Retinoblastoma
    2. Congenital Cataracts
    3. Metabolic disorder
    4. Strabismus
    5. Amblyopia
    6. Childhood Glaucoma
    7. First degree relatives requiring Vision correction as a child
  1. Has your child injured their eye at any time?
  2. Have you noticed your child having difficulty seeing close objects or far objects?
  3. Do your child's eyes appear straight, or do they appear to cross (esp. when tired)?
  4. Does your child tilt their head or squint with one eye when trying to see a distant object?
  • Exam
  • Well Child Exam Eye Screening
  1. Protocol
    1. AAP/AAOS recommend Vision Screening at ages 4, 5, 6, 8, 10 and 12 years
    2. Referral indications
      1. Visual Acuity worse than 20/40 (age <=6 years) or 20/30 (age >=6 years) OR
      2. Two-line difference between eyes
  2. Newborn Eye Exam
    1. Red Reflex (Pupillary Light Reflex, Bruckner Test)
    2. Pupil Response (observe for Anisocoria)
    3. Observe constant Eye Deviation
    4. Observe for Congenital Cataracts
  3. Infants at 6 months of age to 3 years
    1. Newborn Eye Exam (as above) AND
    2. Fixation and Following
    3. Ocular Alignment (Screen for Strabismus)
      1. Corneal Light Reflex (Hirschberg Test)
      2. Cover Test
  4. Children 3 to 5 years old
    1. Visual Acuity (Tumbling-E Test, Allen OR HOTV Chart)
      1. Consider Instrument-Based Vision Screening (Photoscreening, Autorefraction)
    2. Ocular Alignment (Screen for Strabismus)
      1. Corneal Light Reflex (Hirschberg Test)
      2. Cover Test
  5. Children 6 years and older
    1. Snellen Chart (Letters or Numbers)
  • Exam
  • Abnormal Vision testing
  1. Criteria for abnormal
    1. Age 3 to 4 years
      1. Either eye Vision <20/50
      2. Two-line difference between eyes
    2. Age 4 to 5 years
      1. Either eye Vision <10/20 or 20/40 (<3 of 5 correct)
      2. Two-line difference between eyes (e.g. 20/25 and 20/40)
    3. Age 6 and up
      1. Either eye Vision <10/15 or 20/30 (<3 of 5 correct)
      2. Two-line difference between eyes (e.g. 20/20 and 20/30)
  2. Additional testing: Pinhole Test
    1. Distinguishes Refractive Error from Amblyopia
    2. Indicated for failed Vision Screening
  • Differential Diagnosis
  • Childhood Eye Disease
  1. High risk diseases
    1. Amblyopia
    2. Strabismus
    3. Anisometropia
    4. Congenital Cataracts
    5. Leukocoria (Retinoblastoma)
    6. Congenital Glaucoma
    7. Nystagmus
  2. Common eye problems
    1. Refractive Error (Nearsighted, Farsighted)
    2. Conjunctivitis
    3. Uveitis and Iritis
    4. Eye Trauma
  • Resources
  1. Eye Exam Infant/Toddler
    1. https://www.youtube.com/watch?v=4hjONYSfjS8
  2. Eye Exam Preschool
    1. https://www.youtube.com/watch?v=WRqk5vqWMy0
  • References
  1. Bell (2013) Am Fam Physician 88(4): 241-8 [PubMed]
  2. Olitsky (1998) Pediatr Clin North Am 45:993-1012 [PubMed]
  3. Reedy-Cooper (2023) Am Fam Physician 108(1): 40-50 [PubMed]
  4. Simon (2001) Am Fam Physician 64(4):623-8 [PubMed]