2024 PGH Basic Pediatric Vision Examination.pdf

Lecture given at the 2024 Online Basic Course in Ophthalmology, Department of Ophthalmology and VIsual Sciences, University of the Philippines-Philippine General Hospital

1. Basic Pediatric Vision Exam
PGH Basic Course 2024
Alvina Pauline D. Santiago, MD
(c) APSantiago 2024 1#pediatriceyeexam

2. Vision Assessment
Preverbal Age Group
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3. Visual milestones
•Birth Bright lights
•7 days vestibulo-ocular reflex
•3 mos transient fixation & following
•6 mos fixation & following
even for distance
•2-3 y 20/30
•5-7 y 20/20
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4. Vision Assessment
•Fixation pattern
•3 mos: transient fix and follow
•6 mos: fix and follow
–“CSM” : central, steady, maintained
–cover one eye
–start distance fixation
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5. #pediatriceyeexam(c) APSantiago 2024 5
Figure from Wright’s Pediatric Ophthalmology & Strabismus 1995

6. #pediatriceyeexam(c) APSantiago 2024 6
Figure from Wright’s Pediatric Ophthalmology & Strabismus 1995

7. Fixation preference
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From Rosenbaum & Santiago. Clinical Strabismus Management 1999

8. Profound Amblyopia
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9. Fixation Preference & Visual Acuity
FIXATION PATTERN VA POTENTIAL
•Central, steady, maintained
CSM 20/20-20/30
•CS, maintained briefly 20/40-20/60
•CS, not maintained (NM) 20/70-20/80
•C, NS, NM 20/100-20/200
•Not C, Eccentric </= 20/300
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Actual Citation? From a Valbuena lecture
Figure From Rosenbaum &
Santiago. Clinical Strabismus
Management 1999

10. Optokinetic (Catford) drum
•Fast saccades
•May be calibrated
based on cycles per
degree
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11. Preferential Looking
•Modified optokinetic
flag
•Teller acuity cards or
its derivative
•Facial targets
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Figure From Rosenbaum & Santiago.
Clinical Strabismus Management 1999

12. Teller acuity cards
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Figure From Rosenbaum & Santiago. Clinical Strabismus Management 1999

13. Forced Choice
Preferential Looking Tests (FPLs)
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14. The “School Age” Child
•Not infants and toddlers
•Preschool 3-6 years
•Regular School 7-12
•Adolescent 13-18
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15. Vision testing
•Quantifiable
•Depends on patient discrimination
•Depends on examiner ability to interpret
response
•Standard: Sloan linear acuity: optotype
•Psychophysical tests: test interpretation
subjective measured by patient’s ability to
communicate recognition to examiner
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16. Sloan vs Snellen
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http://www.precision-vision.com
http://img.webmd.com

17. Preschool Child
•Short attention span
•Inability to sustain interest
•Language and communication barriers
•Cultural and social limitations
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18. Preschool Tests
•Detection acuity tests
–Stycar graded balls (Sheridan 1973)
–Catford drum (Catford & Oliver 1973)
–Dot visual acuity test
•Recognition acuity test
–Direction oriented: Illiterate E, Landolt C
–Picture charts: Allen, Lea® Symbols
–Letter charts: Snellen, Sloan
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19. Vision Assessment: 3-6 years
•Allen pictures: cultural bias
•Sheridan Gardiner or
HOTV/HOTEX
•Illiterate E / tumbling E / E
game
•Landolt C
•Lea® Symbols and
Numbers
•Snellen numbers, letters
–kids memorize!
•Sloan Letters
http://www.keeler.co.uk
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20. Illiterate/Preverbal Charts
Landolt CTumbling E
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http://www.precision-vision.com https://www.good-lite.com

21. Visual Acuity Testing
•Test Charts
–HOTV / HOTEX
–Tumbling “E” Game
–Landolt C
–Picture Charts
Lea® Symbols
Allen picture cards
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22. HOTV Charts
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https://www.good-lite.com

23. Lea® Charts
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https://www.good-lite.com

24. Lea® Charts
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www.good-lite.com

25. Grating vs Snellen Acuity
•Grating acuity (cycles
per degree)
•Snellen acuity (visual
angle)
•Grating overestimates
Snellen
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26. Limitations of Optotype Test
•Letter or number acuity
(e.g., Snellen or Sloan)
unreliable before age 6-8
•Not all children will know
alphabet & numbers
•Single optotypes may
overestimate linear acuity
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https://images-amazon.com

27. Sloan letters
#pediatriceyeexam
http://www.eyesfirst.eu/media/catalog/product/cache/1/image
/640x/040ec09b1e35df139433887a97daa66f/5/2/52098_etdr
s_tafel.jpg
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Sloan Letters

28. Sloan vs. Snellen Charts
https://www.schoolhealth.com/blog/selecting-an-eye-chart-sloan-letters-or-snellen/
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29. Normal Visual Development
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http://psych.ucalgary.ca

30. Development of Visual Acuity
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31. Susceptible Period
•Most sensitive first 2-3
years
•Decreases until age 6-
7 years (12? 18?)
–complete visual
maturation
–retinocortical pathways and visual centers
resistant to abnormal
visual input
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From Adler’s Physiology of the Eye

32. 7-12 years
•Significant number
still will not express
poor vision
•Easy to perform
Sloan linear acuity
testing
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http://www.precision-vision.com

33. 13-18 years
•Will verbalize a visual
problem
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http://c8.alamy.com

34. If the child cannot see 1st line
•Ask patient to come
closer until first line
can be read
•Hand movement
•Light Projection
•Light Perception
•Low vision charts
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http://www.precision-vision.com
https://images-amazon.com

35. Vision Assessment
Non/Pre Verbal
OKN DrumFPLOKN FlagTeller
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36. Vision Assessment
Picture ChartsHOTVSnellen / Sloan
http://www.uniroma2.it/otticafp/vafig1.gif
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37. Vision Assessment
in Special Situations
Nystagmus
Malingerers
Virtual Vision
LogMar Acuity
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38. Vision Assessment: Nystagmus
•Binocular near vision test
–allow patient to assume
own distance
–test at standard near
distance
–check head posture
–VA in preferred posture
and forced primary
•Binocular distance vision
–VA in preferred posture
and forced primary
•Monocular distance &
near vision
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39. Vision Assessment: Nystagmus
•Monocular occlusion
–many will increase
nystagmus
•Remote occlusion
•Sufficient fogging:
know refraction!
•Neutral density filters
•AO vectograph
testing
•Translucent occluder
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Figure from Rosenbaum & Santiago, Clinical
Strabismus Management, 1999

40. Random dot stereograms
•2 plates of randomly
displayed dots, one
plate to each eye
•Shape of figure
displaced horizontally
relative to other plate
•No monocular cues
•Normal may fail
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Figure from Rosenbaum & Santiago, Clinical
Strabismus Management, 1999

41. Sensory Tests & Visual Acuity
Circles Sec of Arc VA
9 40 20/25
8 50 20/30
7 60 20/40
6 80 20/50
5 100 20/60
4 140 20/70
3 200 20/80
2 400 20/100
1 800 20/200

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Donzis PB, Rappazzo JA, Burde RM, et al. Effect of binocular variations of Snellen’s visual acuity on
Titmus Stereoacuity. Arch Ophthalmol 1983; 101: 930-932.
http://www.snapily.com

42. Virtual Visual Acuity Testing
•Infant/Toddler•Check fixation and following
with a toy performed by
guardian
•Screen share age-
appropriate video
•Observe differences in
response to occlusion of
either eye
Bowe et al. Virtual visits in ophthalmology: timely advice for implementation during the COVID-19 Public Health Crisis.
Telemedicine and e-health 2020; https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0121. Accessed May 27, 2020
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43. Virtual Visual Acuity Testing
•Verbal Child
•Describe items around
the room with both eyes
or each eye individually
•Parents can download
chart usually for 10m
Bowe et al. Virtual visits in ophthalmology: timely advice for implementation during the COVID-19 Public Health Crisis. Telemedicine and e-
health 2020; https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0121. Accessed May 27, 2020
https://media.philstar.com/photos/2023/06/30/4_2023-
06-30_00-41-16.jpg
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44. Virtual Visual Acuity Testing
https://visionsource.com/patients/free-eye-chart-download/
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45. Virtual Visual Acuity Testing
•Older Child/Adult•Read items across the
room and give report of
relative visual acuity
•Screen share a vision
screening chart
•EHB (Eye Handbook) app
•AAO Recommends Verana
Vision Test (Free
Download)
Bowe et al. Virtual visits in ophthalmology: timely advice for implementation during the COVID-19 Public Health Crisis. Telemedicine and e-health 2020;
https://www.liebertpub.com/doi/pdf/10.1089/tmj.2020.0121. Accessed May 27, 2020
https://media.philstar.com/photos/2023/06/30/4_2023-
06-30_00-41-16.jpg
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46. LogMar Notation for Vision Tests
•Logarithm of Minimum Angle of
Resolution
•More accurate estimate of vision
•”Gold Standard”
•Research setting
•Notation of vision loss
•5 letters per line, same spacing
between letters and lines
•Each line 1.2589x bigger
•Able to resolve 1 min of visual
angle = LogMar 0 (20/20)
•ETDRS Sloan: square letters
•Bailey Lovey Chart: 5:4
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https://en.wikipedia.org/wiki/LogMAR_chart
https://youtu.be/fN8e8gazn2E?si=sEOlPqgjRT7pYdQ5
https://cdn.commercev3.net/cdn.bernell.com/image
s/uploads/6471_10994_popup.jpg

47. LogMar Notation for Vision Tests
•Each letter = 0.02 log units.
•5 letters per line = 0.02 x 5 = 0.1 log units per line
•Horizontal and vertical crowding
•Notation of Poor Vision / Low Vision
ØPositive LogMar poor vision
ØNegative LogMar better vision
•LogMar Vision
Ø0.1 + LogMAR value of the best line read − 0.02 ×
number of optotypes read
ØLogMAR value of the best line read + 0.02 × number
of optotypes missed
ØLogMar value of completed line – (0.02 x number of
optotypes read)
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https://en.wikipedia.org/wiki/LogMAR_chart
https://youtu.be/fN8e8gazn2E?si=sEOlPqgjRT7pYdQ5

48. LogMar Visual Acuity Charts
•4 meters
•35-40 cm for near
•Test chart luminance:
80cd/m2
•Room luminance 120
cd/m2
•Minimize ambient
light degradation of
chart
•Regular spacing
allows for use at
closer distances such
as 1m, 2m for low
vision patients
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49. LogMar Chart Example
•Vision is 0.3
•Snellen: 6/12
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https://en.wikipedia.org/wiki/LogMAR_chart
https://youtu.be/fN8e8gazn2E?si=sEOlPqgjRT7pYdQ5

50. •0.1 + 0.2
•2 x 0.02 = 0.04
•0.3 - 0.04 = 0.26
•0.2 + 0.02*3 = 0.26
•0.3 – 0.02*2 = 0.26
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https://en.wikipedia.org/wiki/LogMAR_chart
https://youtu.be/fN8e8gazn2E?si=sEOlPqgjRT7pYdQ5

51. •Completed line 0.3
•4 letters more
•4 x 0.02 = 0.08
•0.3-0.08 = 0.22
•0.1 + 0.02*6 = 0.22
•0.1 + 0.2 - 0.02*4 =
0.22
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https://en.wikipedia.org/wiki/LogMAR_chart
https://youtu.be/fN8e8gazn2E?si=sEOlPqgjRT7pYdQ5

52. Laser vision ;-)
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53. Thank You!
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