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Vision

DRAFT:  This information in the Vision section is currently out for review by Pediatric Ophthalmology consultants.

Vision Screening: Birth to Three Years (or Non-Communicative Children)

See:

AAP Policy Statement (2003)
Eye Examination in Infants, Children, and Young Adults by Pediatricians)

American Academy of Ophthalmology Policy statement (2001)

Assessment Steps

For information on specific tests and procedures see: Vision Screening Tools and Tests section

1. History of eye problems, past medical history and family history (Ocular history)
2. Vision assessment
• Test the ability to fix on an object, maintain fixation,  and follow objects visually into various gaze positions. 
• Examine each eye independently and then both eyes together. 
• Children who have corrective lenses should have vision assessment performed while wearing the glasses.
3. External inspection of eyes and lids
   • Eyelids and orbits (incl. r/o ptosis)
   • External structure of the eyes
4. Ocular motility assessment
   • Eye motility (EOMs)
   • Eye muscle balance
5. Pupil exam /Pupil responses
6. Red Reflex - All infants should have a red reflex exam in the first 2 months of life by a pediatrician or primary care providerer trained in this technique. Assess individual red reflexes (one eye at a time) and simultaneous red reflex (Bruckner test)

Who to Refer for Ophthalmologic Assessment

• Any child who does not pass risk factor screening or observation. 
• Any alert, awake child who fails to fix and follow binocularly after 3 months of age.
• Any child with anatomic abnormality, poor visual fixation, eye misalignment, asymmetric or abnormal red reflexes, or nystagmus

Further Assessment - Visual Acuity

In infants and young children, visual acuity is most accurately determined by “preferential looking tests” (Teller Acuity Card test).  Testing in the child under three is challenging and usually requires specially trained personnel. 

Vision Screening: Preschoolers (Three to Five Years)

What to Assess

For information on specific tests and procedures see: Vision Screening Tools and Tests section

1. History — Review risk factors for visual impairment
2. External examination — Observe for ptosis and anatomic abnormality
3. Monocular distance visual acuity measurement (usually able to assess acuity around 3 years of age, depending on patient cooperation) —
   • Use Eye charts to assess for nearsightedness, farsightedness, astigmatism.  The Lea symbols, HOTV chart  and Tumbling E chart are recommended for preschoolers. Vision testing machines (similar to those at the driver’s licensing departments) can be difficult for younger children to use.  It is advisable to have wall charts and picture cards available. 
   • Eye patches are the only way to be absolutely sure there is no peeking with the other eye!
   • Children who wear corrective lenses, should have vision assessment performed while wearing the glasses.  If a child requires reading glasses only, remove them for distant visual acuity assessment. 
4. Eye alignment, motility and tracking — Examine for strabismus and risk for amblyopia (functionally defective development of central visual system), nystagmus (involuntary, rhythmic oscillation of the eyes)
   1. Unilateral Cover Test /Cover-Uncover Test
   2. Bruckner test (Red Reflexes from the retinas)
5. Pupil exam
6. Red Reflex Exam — Assess individual red reflexes and simultaneous red reflex (Bruckner test)
7. Stereopsis (binocular depth perception) — e.g. Random-Dot E stereo test 

Note: Stereopsis testing is recommended by the Preschool Vision Screening Task Force  (Preschool Vision Screening: Summary of a Task Force Report.  Pediatrics. 106(5):1105-1112, 2000.), but is not in the AAP guidelines  (Eye examination in infants, children and young adults by pediatricians.  Pediatrics. 2003.).

8. Retinal Exam — Attempt ophthalmoscopy. Success depends on patient cooperation and is possible in 3 to 4 year old children willing to fixate on a toy or other object while being examined with the ophthalmoscope. 

Other Potential Assessments

1. Color vision Screening to rule out color vision deficiency. Color vision deficits are not sight-threatening. 

A recommendation for color vision screening is included in recommendations of the American Optometric Association but is not in 2003 AAP Policy Statement (see Table 1 in ‘Preschool Vision Screening: Summary of a Task Force Report’.  Pediatrics. 106(5):1105-1112, 2000).

Who to Refer for Further Evaluation

• Children with anatomic abnormality, poor visual fixation, eye misalignment, asymmetric or abnormal red reflexes, nystagmus, visual acuity less than 20/40 in either eye are considered to have failed screening evaluation.

• Additional recommendations from Project Universal Preschool Vision Screening*– See  Preschool Vision Screening: Summary of a Task Force Report. Hartmann EE et al.  Pediatrics.  2000 Nov; 106(5):1105-1116. 
  • Children between 36-47 months who pass risk factors and observation but fail visual acuity or stereopsis screening.  If responses on visual acuity or stereopsis seem unreliable, re-screening within 6 months using the same tests is indicated.  If results on re-screening remain unreliable, referral is recommended.
  • Children 48-59 months who pass risk factors and observation, but do not pass visual acuity or stereopsis, must be referred or re-screened within one month.  If re-screening is unreliable or not passed, refer immediately.

*PUPVS — Project Universal Preschool Vision Screening is a cooperative agreement between the federal Maternal and Child Health Bureau (MCHB) and the American Academy of Pediatrics (AAP).  For more information go to: www.medicalhomeinfo.org/screening/Screen%20Materials/PUPVS_~2.DOC

Vision Screening: School Age Children (Six Years and Older)

What to Assess

For information on specific tests and procedures see: Vision Screening Tools and Tests section

1. History — review risk factors for visual impairment
2. All items in the Preschool exam –
   • External examination of orbit, eyelids, globe, cornea and iris
   • Pupil examination
   • Red reflex examination
   • Ocular motility assessment
3. Monocular visual acuity measurement — Assess every two years until age 10 and every three years thereafter
• Usually evaluated with Snellen Letter or Number Chart measuring visual responses at 10 feet from the eye chart with occlusion of the contralateral eye.
• Eye patches are the only way to be absolutely sure there is no peeking with the other eye! 
• Children who have corrective lenses, should have vision assesment performed while wearing the glasses.  If a child requires reading glasses only, remove them for distant visual acuity assessment. 
4. Binocular Alignment

1. Hirschberg corneal light reflex test
2. Bruckner test
3. Combination of cover-uncover test and alternating cover test (requires more cooperation but may elicit latent deviations) 

5.  Ophthalmoscopy/Retinal exam 

Who to Refer for Ophthalmologic Assessment

• Any child who does not pass risk factor screening or observation. 
• Any alert, awake child who fails to fix and follow binocularly after 3 months of age.
• Any child with anatomic abnormality, poor visual fixation, eye misalignment, asymmetric or abnormal red reflexes, or nystagmus

DRAFT:  This information in the Vision section is currently out for review by Pediatric Ophthalmology consultants.