Pediatric Eye Examination

Taken from Vaughan & Asbury's General Ophthalmology

1. Pediatric Eye Examination Ophthalmology

2. Newborns - Infants General ocular status Inspection of the eyes Corneal light reflex testing Pupillary testing Evaluation of red reflex Fundus examination

3. Newborns - Infants You 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

4. Newborns - Infants Infants achieve the following visual milestones: Birth - Blinks, may regard face 1 month - Fixes on objects 1½-2 months - Coordinated eye movements 3 months - Eyes converge, baby reaches 12 months - Acuity around 20/50

5. Newborns - Infants Inspection 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

6. Newborns - Infants Examine 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

7. 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

8. Newborns - Infants Ophthalmoscopic Examination E xamine 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

9. Toddlers (1 – 2-Year-Olds) Inspection of the eyes Conjugate or symmetric gaze Corneal light reflex test & cover-uncover test are particularly useful in young children You 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

10. 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

11. Corneal Light Reflex Test Normal alignment Small esotropia Moderate esotropia Large left esotropia

12. 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

13. 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

14. Cover-Uncover Test When the Left eye is covered, the Right eye moves outward to pick up the fixation ( Esotropia , OD)

15. 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

16. 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 fingers Visual 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

17. 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 T he child with normal vision will not object, but a child with poor vision in one eye will object to having the good eye covered

18. 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

19. School-aged (6 years & above) Inspection of the eyes Conjugate or symmetric gaze Visual acuity (If the child can follow directions, communicate adequately & knows letters of the alphabet ) Snellen Chart Visual fields