PEDIATRIC EYE EXAMINATION

OPHTHALMOLOGY

NEWBORNS - INFANTS

General ocular status Inspection of the eyesCorneal light reflex testingPupillary testingEvaluation of red reflexFundus examination

NEWBORNS - INFANTSYou can use visual reflexes to indirectly assess vision:

direct & consensual pupillary constriction in response to light

blinking in response to bright light (optic blink reflex)blinking in response to quick movement of an object

toward the eyes

NEWBORNS - INFANTS

Infants achieve the following visual milestones:

Birth - Blinks, may regard face1 month - Fixes on objects1½-2 months - Coordinated eye movements3 months - Eyes converge, baby reaches12 months - Acuity around 20/50

NEWBORNS - INFANTSInspection

Bright light causes infants to blink, so use subdued lighting If you awaken the baby gently, turn down the lights, & support

the baby in a sitting position Small colorful toys are useful as fixation devices in examining

the eyes Newborns may look at your face & follow a bright light if you

catch them during an alert period You can get some newborns to follow your face & turn their

heads 90° to each side

NEWBORNS - INFANTSExamine infants for eye movements

Hold the baby upright, supporting the head Rotate yourself with the baby slowly in one direction This usually causes the baby's eyes to open, allowing you to

examine the sclerae, pupils, irises, & EOM Baby's eyes gaze in the direction you are turning When the rotation stops, the eyes look in the opposite direction,

after a few nystagmoid movements

NEWBORNS - INFANTS

Look for abnormalities or congenital problems in the sclerae and pupils

Subconjunctival hemorrhages are common in newborns Observe pupillary reactions by response to light or by covering

each eye with your hand and then uncovering it Inspect the irises carefully for abnormalities. Examine the conjunctiva for swelling or redness

NEWBORNS - INFANTSOphthalmoscopic Examination Examine the red retinal (fundus) reflex by setting the ophthalmoscope at 0

diopters & viewing the pupil from about 10 inches Normally, a red or orange color is reflected from the fundus through the

pupil The cornea can ordinarily be seen at +20 diopters, the lens at +15

diopters, & fundus at 0 diopters In infants, the optic disc is lighter in color, with less macular pigmentation Foveal light reflection may not be visible Look carefully for retinal hemorrhages Papilledema is rare in infants because the fontanelles & open sutures

accommodate any increased intracranial pressure, sparing the optic discs

TODDLERS (1 – 2-YEAR-OLDS)

Inspection of the eyesConjugate or symmetric gazeCorneal light reflex test & cover-uncover test are

particularly useful in young childrenYou can perform the cover-uncover test as a game by

having the young child watch your nose or tell you if you are smiling or not, while you cover one of the child's eyes

CORNEAL LIGHT REFLEX TEST

Objective assessment of ocular alignment Patient is directed to look at a penlight held directly in front of the

eyes by the examiner at a distance of 2 ft The examiner aligns his eyes with the light source & compares

the position of the light as reflected by the cornea of each eye Normally, the light is reflected on each cornea symmetrically & in

the same position relative to the pupil & visual axis of each eye In a deviating eye, the light reflection will be eccentrically

positioned & in a direction opposite to that of the deviation

CORNEAL LIGHT REFLEX TEST

a) Normal alignmentb) Small esotropiac) Moderate esotropiad) Large left esotropia

COVER-UNCOVER TEST

Can be used on any patient over 6 months Have the patient look at a fixation point, such as a toy or

Snellen chart Note which eye seems to be the fixating eye Cover the fixating eye & observe the other eye If the uncovered eye moves to pick up the fixation, then it can

be reasoned that this eye was not directed toward the object of regard originally

Each eye must be tested separately

COVER-UNCOVER TEST If the eye moves inward to fixate, then originally it must have

been deviated outward & is exotropic If the eye moves outward to fixate, then originally it must have

been deviated inward & is esotropic If the eye moves up or down, then it is hypotropic or

hypertropic No shift in cover testing means there is no tropia but a phoria

could still occur A phoria is a latent tendency of the eye to deviate & detected

by alternate cover testing

COVER-UNCOVER TEST

When the Left eye is covered, the Right eye moves outward to pick up the fixation(Esotropia, OD)

PRE-SCHOOL (AGES 3 TO 5)

Inspection of the eyes Conjugate or symmetric gaze Visual acuity (If the child can follow directions & communicate

adequately) Picture card Tumbling E chart LEA Symbols Test

Visual fields

PRE-SCHOOL (AGES 3 TO 5)Tumbling E Chart A child who does not know letters or numbers reliably can be

tested using pictures, symbols, or the “E” chart Using the “E” chart, most children will cooperate by telling you in

which direction the “E” is pointing with his or her fingersVisual Fields Visual fields can be examined in young children with the child

sitting on the parent's lap Hold the child's head in the midline while bringing an object such

as a toy into the field of vision from behind the child

PRE-SCHOOL (AGES 3 TO 5)

For children younger than 3 years who cannot identify pictures on an eye chart, the simplest examination is to assess for fixation preference by alternately covering one eye

The child with normal vision will not object, but a child with poor vision in one eye will object to having the good eye covered

PRE-SCHOOL (AGES 3 TO 5)Visual Acuity

3 months - Eyes converge, baby reaches 12 months - 20/200 Less than 4 years - 20/40 4 years & older - 20/30

SCHOOL-AGED (6 YEARS & ABOVE)

Inspection of the eyesConjugate or symmetric gazeVisual acuity (If the child can follow directions,

communicate adequately & knows letters of the alphabet )Snellen Chart

Visual fields