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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!