PEDIATRIC EYE

EXAMINATION
 Unit outline
History and symptoms

Assessment of Visual acuity

Binocular status

Refractive status

Fundal examination
Unit objectives
 After completion of this session, the student will
be able to:
o Evaluate the functional status of the eyes and visual
system
o Assess ocular health and related systemic health
conditions
o Counsel and educate the parents and patient regarding
the status of the visual system and possible
associations with overall health and development.
Introduction

 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).
Introduction
Paediatric examinations are an important part of
optometry
They can be interesting, worthwhile and financially
viable, although sometimes challenging
Minimal additional equipment is required, and patience
and speed are important virtues
A Modified history and symptoms is required to elicit
parental concerns and any educational difficulties for
those of school age
 A range of visual acuity charts are needed in order to
use the most complex format that the child can cope with
Accurate binocular vision evaluation with emphasis on
the cover test and stereopsis is paramount, as is a detailed
fundal examination to rule out organic disease
Proper pediatric examination can result in early
detection of refractive, binocular vision and ocular
anomalies and treatment is more likely to have
successful outcome
 Research has shown that 4-11% of children
have a significant refractive error, 4-8%
have strabismus and 2-5% have amblyopia.

 All of these can have a detrimental effect on

the child’s ability to learn and, therefore, on
their future career prospects.

 Detection and proper management of these

ocular anomalies at the earliest possible age
allows for more successful remediation
Goals of the pediatric eye and vision examination

 Evaluate the functional status of the eyes and visual

system

 taking into account each child's level of development

 Establish a diagnosis and formulate a treatment

plan

 Counsel and educate parents/caregivers regarding

their child's conditions
History
 A comprehensive patient history may include:
 Nature of the presenting problem, including

chief complaint
 Visual and ocular history
 General health history, including prenatal,

perinatal, and postnatal

 history and review of systems

 Developmental history of the child.
History & Symptoms
 Family eye and medical histories
 Family history – of amblyopia, strabismus,

refractive errors, occlusion history?

 Birth history – full term, normal delivery?
 Visual behaviour of the child – clumsy?,

visually inattentive? Close viewing distance?

Cont…

 Information about the child's and parent's

general health can provide clues about the
potential risk for vision anomalies.
 If there is a strong history of a particular
vision problem that runs in the family, more
frequent examinations or special procedures
may be required.
 prenatal factors, such as maternal age,
maternal health, toxemia and post-natal
factors such as foetal distress/assisted
deliver prematurely and small-for-dates.
EXAMINATION TECHNIQUES
 After a brief courteous welcome, it is often best
to ignore the child at the beginning and talk
only to the parent.

 After the history and symptom taking, attention

can be turned to the child, who may now feel
comfortable with someone that ‘mummy’ or
‘daddy’ has been speaking with.
 Very young or small children will need to sit on a
parent’s lap, older children can sit in the main
examination chair, especially if it has a good
height adjustment range or a child support bench.
 Never speak down to the child; it is often useful to
establish communication by asking the child its age.
 How the child responds will let you know what level of
communication to expect during the rest of the
examination
Assessment of visual acuity
Visual performance and spatial sensitivity of
an infant or newborn baby is very poor due to
the following reasons :
o Poor visual acuity
o Poor control of eye movement
o Immature Optics
o Immature retinal anatomy and cortical
architecture
Types of visual acuity
 Methods used to measure acuity are diverse
and the principles that underlie them need to
be understood so that they can be used
appropriately and to maximal effect .
 The four basic types of acuity measure are:

 Detection
 Resolution
 Recognition
 Hyperaciuty
Detection
 The smallest test object that can just be
detected
 Under ideal conditions a dark line of width

0.5sec of arc can just detected

 Stycar balls are examples of traditionally used

tests
 However, detection tasks are less affected by

visual impairment than more complex tasks

 Therefore, OVER ESTIMATE VA in visually

impaired children
 Resolution
 Measures the smallest angular separation
between adjacent targets that can be resolved
 Probably limited by the optical limitations of

the eye and the retinal photoreceptor spacing

 Usually 30-60 sec of arc.

 PL and VEP tests are good examples

 A more useful and sensitive measure of VA
than detection
Recognition & identification
 The type of acuity measured with the snellen
chart and with other acuity tests that use
letters or other optotypes
 It refers to the ability to identify a form or its

orientation
 >2.5yrs of age can be tested successfully
 Recognition acuity tasks are affected by
contour interaction ,where as resolution
stimuli are not

 Overall, recognition acuities are more

sensitive to pathological and physiological
degradation than are resolution acuities
 Hyperacuity
 Describes the ability to determine differences
between two stimuli
 Relative size ,orientation and position can be

judged with an accuracy of 3-6 sec of arc

 Is less Limited by optical and retinal factors

than is resolution acuity

 Reflects cortical processing
 Stereoacuity and vernier acuities are

considered as a type of hyperaciuty

 VA tests
a. Preferential looking tests= designed
based on the principle that an infants looks
towards a pattern than a blank stimulus
- patterns are usually alternating black and
white lines of equal thickness and length and
of square –wave gratings
- the gratings are described in terms of spatial
frequency (the number of B-&-W pairs in each
degree of visual angle)
 Preferential looking tests of vision
 Keeler/Teller cards for infants

Cardiff acuity cards for

Toddlers at 1m distance.
But alter to 1/2 m if the
child unable to see 1st card.
 The higher the spatial frequency the finer the
gratings
 Commercially available PL test are teller and
keeler acuity system
 Vanishing optotypes are other examples –
use pictures =of B &W lines used to form the
pictures are made finer and finer to allow the
assessment of aciuty
b. Opto-type naming and matching

 Prior to a child knowing and being able to

relate accurately the letters of the snellen
acuity chart, recognition acuity can be
assessed using letter matching tests or picture
naming
 For matching the child has a key card that
displays the same elements as presented

The examiner presents the letter or picture

targets at a specified distance from the child
(3m or 6m)

>2.5-3yrs could be cope with matching

single optotypes
=>Kay pictures (for 2-3yrs)
- presents a series of isolated pictures at
3mor6m in a flip card format.
-Pictures can be either named or matched
-Use of pictures rather than letters
improves RA
=>Illiterate ,tumbling E and landot C
=>Sheridan- Gardiner= 2.5-3yrs child used at
3or6m. Test at 6m or 3m distance. The child
give a key card & he has to point the letter he
sees. V T H O X A U Letters used & shown one
at a time on flip chart.
= Most accurate for illiterate vision test.
= Does not provide crowded letter presentation
and over estimate acuity in amblyopic eyes
 ‘Picture’ tests of vision
Kay pictures Lea symbols

Both LogMAR scoring

Naming or matching can be done by the child.

Þ Cambridge crowding cards- letter matching
test contains counter interaction . Provide both
single letter and crowded letter presentation

Þ Disadvantage – acuity scale based on Snellen

chart and does not decrease in uniform steps
 log MAR acuity test
 Addresses problems of the majority of
children ‘s acuity tests by utilizing the
principle of the “gold standard” Bailey-lovie
acuity tests

- Presents letters such that the subject’s task

at each acuity level only varies with regard to
the level of acuity required to identify the
target .
 Letter tests of vision
 Letters – LogMAR acuity cards
 Snellen type chart

Again, child can match or name letters

 Near vision testing
 Children generally have ample accommodation
And Few near vision problems when distance
refractive errors are corrected
 However , those with neurological impairment

or low vision may have reduced amplitude of

accommodation .
 So it is important to assess near VA .

- Kay pictures and sherdin- Gardiner have near

vision charts consisting of letters or pictures
than words
Effects of Crowding
 Crowding phenomenon – process where
single letter acuity better than that measured
by ‘crowded’ letters.
 Crowding more sensitive measure
 Important to assess amblyopic children
 Expected norms for age
 With increasing maturity of visual system, we
expect to measure increasing levels of visual
acuity
 Therefore, it is wise for Optometrists to know

what level of acuity can be expected from a

child particular age when using a specific test
 BINOCULAR STATUS

 It may help to start with something simple, to

give the child (and yourself) confidence.

 Bruckner's test is a good start; its purpose is to

assess the symmetry of binocular fixation by
comparing the brightness of the red reflex in
each of the two eyes.
 The child should be instructed, and is then
examined with a direct ophthalmoscope in a dim
room with non-dilated pupils

 Direct the ophthalmoscope toward the child’s

eyes from a distance of 80-100cm using a large
round patch of light to illuminate both pupils
simultaneously.
 Instruct the child to look at the center of the light .
-If the two reflexes are equal bright, there is
binocular fixation.

-If the reflexes are not equally bright, the

darker red reflex indicates the fixation eye,
and the brighter, lighter, or whiter reflex
indicates the non-fixing eye(the deviated eye)
 This can be followed by the Hirschberg test
using a pen torch; watch
- for asymmetry of corneal reflexes.
 It is an insensitive test since 1mm
displacement = 20Æ but nevertheless useful
to differentiate between strabismus and
epicanthus.
During this test, the eyes should be
carefully examined for any signs of gross
external abnormalities
 While the pen torch is at hand, oculo-motility
can be attempted next.

 Hold the child’s head gently if necessary, or

ask the parent to do this if the child is sitting
on their lap.
The pen torch produces corneal reflexes which
are useful in determining if an under-acting
muscle is present, otherwise use anything that
will attract (but not frighten) the child.

Reading problems in school age children may

be caused by a IV nerve palsy(trocholea), so
particular attention needs to be paid to the
action of the superior obliques.
 At the end of the oculo-motility assessment, use
the target to test convergence by bringing the
target in slowly towards child’s nose.
 A 20 diopters prism can now be quickly placed

base out in front of each eye to test for fusion

ability.
 It should elicit fusional movement (adduction)

followed by abduction on removal.

 No movement equals poor fusion or inattention.
 The cover test can now be performed. Use the
smallest accommodative target the child will
attend to, but do not use a light or a pen.

 If the child allows you to, use a proper

occluder, if not, a hand or even a thumb can be
used; speed is essential and estimation vital.
Try for distance and near, but you must at
least have a result or near. This is the sole
reliable method of estimating oculo-motor
status and has

no substitute; it enables distinction

between heterophoria, heterotropia, and
orthophopia
Refractive examination
There are several ways of assessing refractive
error

 Distance static retinoscopy

 Dynamic retinoscopy
 Mohindra retinoscopy
 Cycloplegic retinoscopy
 Cont…
 It is imperative to obtain an accurate
measurement of any refractive error.

 Try first for a dry (non-cycloplegic) refraction

with distance fixation if co-operation allows,
or near fixation (Mohindra technique), if co-
operation is poor.
 Accurate refraction helps to
establish:

whether the child’s visual system is
developing normally
 offers an opportunity to correct any
ametropia
 allow the child to achieve a maximum
visual acuity
 highlights any irregularity in the
development of good binocular vision
In pediatric refractive examination, the
objective findings are critical in determining
the true refractive state

Even on older children, it is wise not to rely

too heavily on the replies

The most useful objective technique,

therefore, in determining refractive status of
a child is------------
Distance static retinoscopy
 Useful in older children.
 Relies on the child’s co-operation to fixate on a

distant target.
 Can be used in subsequent visits if child has a

stable prescription.
 Accommodation is relaxed
 It is worth to the Optometrist to keep talking

the child to hold attention , asking questions

about the target, parents etc.
Dynamic retinoscopy
 Performed whereby the child’s accommodation
kept in active state by encouraging the child to
fixate on an accommodative target at his/her
working distance
 The aim is to measure the effectiveness of

accommodation
 Theoretically ,if nothing hinders the child’s

accommodation and it is working accurately

,neutral should be found at its working distance
 Realistically, even with emmetropia and normal

accommodation, a small “with movement “is

seen
 A greater dynamic lag than the normal (+0.25
to +1.00D) indicate a level of uncorrected
hyperopia with which the child can’t cope

 A lag that appears different b/n the two eyes

=>anisohyperopia

 and if differ in two meridian’s =>astigmatism

Mohindra technique
 A modification of the near fixation retinoscopy
assumption= an infant may well be attracted
to the retinoscope light in a darkened room

 one eye should be occluded and if the

practitioner is not comfortable occluding one
eye while holding individual trail lenses in
front of the other eye ask the parents to do
that.
cont…
 Ret . Performed on one eye at a time and at
50cm
 Add -1.25D as a correction factor to the

sphere of the final result

 The theory is that in a totally darkened room,

the light will not act as an accommodative

target.
Cycloplegic refraction

 Often referred to as the ‘GOLD- STANDARD’

method.
 Paralyses accommodation – allows ‘full’

hypermetropia to be measured
 Some may argue all children should have a

cycloplegic refraction.
 Definitely indicated where unexplained

reduction in VA (in one or both eyes),

strabismus or large phoria, poor stereopsis,
first examination….
Cycloplegic (wet) refraction
 Indications ----
 Advantages and disadvantages ?
 Cycloplegic agents ?

Precautions :
Avoid over dosage (e.g., children with Down
syndrome, cerebral palsy and other central nervous
system disorders in whom there may be an increased
reaction to cycloplegic agents, 1% tropicamide may
be used).
Be aware of biologic variations in children (e.g., low
weight infants may require a modified dosage).
What is a significant refractive error?

It depends on:
 Age
 Binocular status
 Visions
 Anisometropia found
When and what to prescribe ?
 In considering whether or not to give a
spectacle correction and if so, what that
spectacle correction should be, the practitioner
needs to be aware of the expected refractive
errors in children.

 It is well known that the average refractive at

birth is one of hyperopia, in the region of
+2.50Ds
 We also know that this refractive error decreases
to +0.50DS as the child approaches to 5/6yrs
through -----------------

 Any child with refractive error that falls within

normal limits: providing that visual acuity
,motor status and sensory status are within
normal limits , no prescribing is necessary
 After 18 months Children are at risk for
strabismus and amblyopia IF:
 >+2.50D in the better eye
 >+1.00 D Anisometropia
 > 1.50DC astigmatism
 When deciding whether or not to prescribe
specs;

 remember that anisohypermetropia is more

likely to cause problems than anisomyopia,
and differences of 1.00D are clinically
significant in hypermetropia
Prescribing under the age of 6m

 During early developmental period, relatively

large refractive changes can be encountered
From 6m Onwards
Hypermetropia : if fully accommodative ET ,give
the full Cycloplegic correction
Hypermetropia

@. outside the normal range should be

monitored to look for any reduction in acuity
,stereopsis or a change in motor status.
@. should any of themselves present , a Rx
should be given and any resultant amblyopia
must be treated
- It is common to practice not to give the full
value of the prescription to allow some blur
to remain ,which encourages good
compliance and therefore acuity development
Myopia- prescribing guide lines
: less at risk for amblyopia and low Rx like
-1.00 can be monitored regularly

- any prescription > -3.00 should be given

to a child over the age of 1 yr
-at about 3yrs ,the child’s visual world
becomes larger and a myopic correction of
-1.00 may be beneficial
Astigmatism-prescribing guide lines

 As evidence suggests that astigmatism is

common in children under the age of 2yrs , a
moderate cyl of 2.00 to 2.50 can be monitored
Up until this age .
If the cyl over 2.50DC and stable for infants
>1yrs should be prescribed
Any cyl > 1.50Dcshould be given to a child over
1yr old if it causes reduction of acuity
 Anisometropia : a difference in RE of 1.00D or

more b/n the two eyes after 1yr accompanied

with difference in VA => very significant

What to prescribe ?

 Better to Compare Cycloplegic and non-

cycloplegic results
 If a difference in anisometropia is found . The
amount under cycloplegia should be used when
prescribing , as this will indicate the true
amount present under relaxed accommodation
Fundal examination
 This can be conducted with a hand held direct
ophthalmoscope, indirect head-mounted, and
modified monocular indirect ophthalmoscope.

 A thorough fundus examination is important

and required in all patients with strabismus or
amblyopia in order to rule out organic causes
prior to the initiation of treatment.
 Examination of very young children can be
difficult, especially when a detailed view of
the macula and optic nerve is required.
 The direct ophthalmoscope is often the best
available instrument for detailed retinal
examination in young patients
Fundus examination

 Important to examine the fundus

to ensure no pathology.
 Abnormal findings could explain poorer than
expected vision.
 Direct ophthalmoscopy can be difficult with
young children due to the proximity
required. They also have a tendency to keep
looking at the ophthalmoscope light.
 Indirect methods can be more successful!
Any ?

Thank you
so much!