PEDITRIC EYE AND

VISION EXAMINATION

Ayanaw Tsega , MSc

Assistant Professor of
Clinical Optometry

1 4/18/23 01:57 PM
 Learning Objectives

 By the end of this session, you will be able to:

 Describe the goals of the pediatric eye and vision examination
 Develop a full case history for an ideal tentative diagnosis
 Identify the appropriate vision assessment charts for the different age
groups

2
 Determine the examination components of pediatric patients
4/18/23 01:57 PM
 Introduction

 Pediatric age group: between birth and 18 years of age (Refer. AOA)

 Three subcategories of pediatric age group:

– Infants and toddlers (birth to 2 years, 11 months)

– Preschool children (3 years to 5 years, 11 months)

– School-age children (6 to 18 years)

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 Examination components
General considerations
Case history
Visual Acuity

 Binocular and ocular motility

 Refraction
Accommodation
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 Examination components
Ocular health assessment
Developmental tests
 Systemic health screening
Visual information processing
Diagnosis and management plan

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 General considerations
 Observation

 What ocular conditions can be picked up ?

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 1. Pediatric case history
 Brief courteous welcome
 Talk to the parent first to get cooperation from the kid
 Older children will answer their own questions
 External observation of the patient is important for gross
assessment
 Reschedule if child is exhausted
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 #01.Question

What are the components

of pediatric case history?
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 Pediatric case history

 Personal data  Family eye and medical histories

 Chief complaint  Developmental history of the child
 History of present illness (HPI)
 Immunization history
 Past visual and ocular history
 School performance history
 Medical history ( prenatal ,perinatal and
postnatal )
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 Pediatric medical history

 Prenatal – rule out toxic substances , infectious

agents ( Rubella,CMV,Toxo.etc) ,genetic or congenital
malformations ,metabolic disorders
 Perinatal –Birth history ( Birth wgt ,
prematurity ,Delivery hx) ,APGAR score ,
10 4/18/23 01:57 PM
 Question: Brainstorm
 What
ocular abnormalities are
associated with prematurity?

 What ocular findings can be

associated with delivery
11 complications ?
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 Medical history :

Postnatal---motor development ( gross ,

fine , language , personal and social life
etc) ,
Immunization History
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 Developmental History
 Gross motor development ---walking , crawling ,sitting
etc
 Fine motor skills ---Reaching to objects near by ,
holding pencils ,
 Language skills development
 Prematurity history

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 Educational history

 Problems with school work, reading, writing, behavior and

avoidance coping strategy

 Grade levels and related

 What type of visual problems can be found ?

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 Assignment
 Squint –3 years
 Tearing ---1 year
 White eye both eye @ 2
years
 Vision reduction ---7 years
 Nystagmus –5 years
 Raised orbital mass @ 8
years
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 Eye discharge -16years
 Ptosis @ 4 year
 Vitamin A deficiency 2
years
 Reading difficulty @ 12
years

 Examination of #Infants and # toddlers
 Exam components:  Ocular health assessment
• General considerations  Visual Acuity

• Case history  Developmental tests

• Binocular and ocular  Systemic health screening
motility  Diagnosis and management
• Refraction plan

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 Examination of #infants and #toddlers

3 months 6 months 16 months

- walking
- sleep - reaching
- constantly moving
- digestive - social
- anxious about strangers

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 2. Visual acuity assessment : Infants

 To establish whether there is vision or not use either of these :

CSM, F& F ,OKN , RTO, Stycar rolling balls test etc )

 Preferential looking tests : Teller ,keeler and

Cardiff acuity charts

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 Keller acuity cards

Optokinetic nystagmus
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 VA testing in Toddlers
 Pictures are less threatening to a young child than
the alphabet
– Teller acuity cards
– Cardiff Acuity Cards
– Bock Candy Bead test
– Bailey-Hall cereal test

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 Brainstorming Questions

 What are the advantages and disadvantages

of each VA chart ?
 How do we perform it ? Procedures

 How do we record VA results ?

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 Binocular vision and ocular motility
 Tips :
– Use an attractive target and maintain child's
attention
– Start with tests of normal , undisturbed (associated )
viewing conditions

– What are examples of such tests ?

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  What specific BV tests can be listed ?

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 Infants and toddlers
 What is the purpose of testing
infants fusion and stereopsis ?

 Easy-to-administer preferential looking

stereopsis test
– Uses polarized lenses.
– Test has no monocular cues
– 480 and 120 seconds of arc.
– 6 months to 5 years of age
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 Examination of preschoolers
 General considerations  Visual information processing
 Case history  Ocular health assessment
 Visual Acuity  Systemic health screening
 Binocular and ocular motility  Diagnosis and management plan
 Accommodation
 Refraction

25 4/18/23 01:57 PM
 General considerations
 Visual acuity
 Try to consider evaluation
 Visual fields
of visual efficiency  Colour vision
components , and visual  Ocular health
pathway integrity system
 Accommodation
 Vergence
 Eye movements

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 VA testing in preschoolers
 Allen cards
 Kay picture test
 Lea Symbols chart
 Broken Wheel acuity cards
 HOTV test
 Landolt C
 Tumbling
 Lighthouse charts Etc..

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 Binocular vision assessment
 Measurement of heterophoria /heterotropia
– Cover/uncover test
– Corneal reflex tests : Bruckner / Hirschberg/krimsky
 Measurement of amplitude of convergence
 With accommodative /with non-accommodative target
 Measuring of eye movements status
– Pursuits /star shaped/

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 Accommodation
 What is the importance of evaluating accommodation
 Accommodative deficiencies and efficiency
associated with poor academic performance
 Linked to reading and learning disabilities
 Associated with intraocular inflammations and
29 premature sclerosis
4/18/23 01:57 PM of lens ,neurological conditions
 Accommodation
 Amplitude
 Evaluate
– Minimum
– Amplitude
– Average
– Response
– Maximum
– Facility
– Relative
 Accuracy
– Use norms for age
– Lag
– Lead
 Facility : monocular /Binocular

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 Binocular vision sensory tests
 Suppression  Red green goggles
 Eccentric fixation  Visuoscopy
 Anomalous correspondence  Bagolini lenses

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 Binocular sensory tests

 Lang I and II
 Random dot E test
 Frisby
 Titmus fly test :

The most popular clinical test of

stereopsis for children
– 300 sec of arc for 3-year
– 90 sec of arc for 4-year
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– 40 sec of arc for 5-year
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 Examination of school children
 General considerations  Visual information processing
 Case history  Ocular health assessment
 Visual Acuity  Systemic health screening
 Binocularity and ocular  Diagnosis and management plan
motility
 Refraction

 Accommodation
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 VA testing in School children
 Can use numbers, as well as letters
 Sometimes use symbols (matching)
 E.g. Snellen chart


Sheridan Gardner →
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 Reading assignment

 => Discuss among yourself the charts

and techniques used to assess near
visual acuity of infants , preschoolers ,
and school going children ?

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 Binocular , ocular motility and
accommodation assessment

 These tests can be done like adult patients since

school children are verbally good for subjective
procedures and most visual functions can be
assessed including visual information processing
skills.
36  Consider 4/18/23
some exceptional cases
01:57 PM
 Ocular health assessment
 An evaluation of ocular health may include:
 Evaluation of the ocular anterior segment and adnexa
 Evaluation of the ocular posterior segment
 Assessment of pupillary responses
 Visual field screening (confrontation).

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 Ocular health assessment

 Infants and toddlers

– Slit lamp (hand held)
– Ophthalmoscopy
– Pupil examination
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  Preschoolers and school going children
– Slit lamp
– Confrontational visual field
– Ophthalmoscopy
– Colour vision

39
– Pupil examination
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 Summary : EXAMINATION
P
S Management Plan
Case History
Definitive diagnosis
Tentative diagnosis
A
O Interpretation &
Specific Tests Analysis of data
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 References
Dukman :
 American Optometric Association. Pediatric Eye And Vision Examination.
OPTOMETRIC CLINICAL PRACTICE GUIDELINE. 2002, 2nd Edition.
 Frank Eperjesi, BSc, MCOptom, FAAO. Examination of the pediatric patient.
Optometric educators. 1999.

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