Eye Examination in Children

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

1. Epidemiology
   1. Only 20% of U.S. Children screened for eye disease
2. 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 Infants
   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
3. Evaluation: Well Child Exam Eye screening
   1. Newborn Eye Exam
      1. Red Reflex (Pupillary Light Reflex, Bruckner Test)
      2. Pupil Response
      3. Observe constant Eye Deviation
      4. Observe for Congenital Cataracts
   2. 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
   3. Children 3 to 5 years old
      1. Visual Acuity (Tumbling-E Test, Allen OR HOTV Chart)
      2. Ocular Alignment (Screen for Strabismus)
         1. Corneal Light Reflex (Hirschberg Test)
         2. Cover Test
   4. Children 6 years and older
      1. Snellen Chart (Letters or Numbers)
4. Evaluation: Abnormal Vision testing
   1. Criteria for abnormal
      1. Age 3-5 years
         1. Either eye vision <10/20 or 20/40 (<4 of 6 correct)
         2. Two-line difference between eyes (20/25 and 20/40)
      2. Age 6 and up
         1. Either eye vision <10/15 or 20/30 (<4 of 6 correct)
         2. Two-line difference between eyes (20/20 and 20/30)
   2. Additional testing: Pinhole Test
      1. Distinguishes Refractive Error from Amblyopia
      2. Indicated for failed Vision Screening
5. 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. Conjunctivitis
      2. Uveitis and Iritis
      3. Eye Trauma
6. Resources
   1. AFP: Childhood Eye Exam
      1. http://www.aafp.org/afp/2013/0815/p241.html
7. References
   1. Bell (2013) Am Fam Physician 88(4): 241-8 [PubMed]
   2. Olitsky (1998) Pediatr Clin North Am 45:993-1012 [PubMed]
   3. Simon (2001) Am Fam Physician 64(4):623-8 [PubMed]