2. OVERVIEW
•Infants and children and particularly
susceptible to permanent central visual loss,
opacities, refractive errors not associated with
amblyopia, strabismus, and other conditions
that interfere with visual acuity (Woo, 2020).
•Early detection and correction of these
conditions may prevent permanent loss in the
mature central visual system of the older child
or adult (Woo, 2020).
•When care for children with eye problems,
priorities include promoting optimizing growth
and development of the ocular structures and
maximizing visual acuity (Woo, 2020).
•Nurse practitioners should seek to promote
good vision and health, detect abnormalities,
and treat conditions that fall within their scope
of practice (Woo, 2020).
•Nurse practitioners should also refer patients
with conditions requiring an ophthalmologist’s
attention, as well as provide education and
3. HISTORY AND CLINICAL
FINDINGS
•The U.S. Department of Health and
Human Services (HHS) Healthy
People 2020 propose to:
• Increase the proportion of
preschool children (<5 years of
age)
• Reduce blindness and visual
impairment in children and
adolescents (<17 years of age)
• Reduce uncorrected visual
impairment due to refractive
errors
• Increase the use of personal
protective eyewear in
recreational activities and
hazardous situations around the
home
•The U.S. Preventive Services Task
Force (USPSTF) recommends vision
screening for children 6 months to
5 years of age (Woo, 2020).
4. RECOMMENDED AGES AND
METHODS FOR PEDIATRIC EYE
EVALUATION SCREENING
Recommended Age Method for Evaluation
Newborn to 3 months old Ocular history
Red reflex
Inspection
3-6 months old Ocular history
Fix and follow
Red reflex
Inspection
6-12 months old and until child is able to cooperate for verbal visual
acuity
Ocular history
Fix and follow with each eye
Alternate occlusion
Corneal light reflex
Red reflex
Inspection
Photoscreening
3 years of age and older and every 1-2 years after 5 years of age Ocular history
Visual acuity
Corneal light reflex/cover-uncover reflex
Red reflex
Inspection
Photoscreening or autorefraction
Attempt ophthalmoscopy
5. PHYSICAL
EXAMINATION
• With a penlight, gross inspection should be made of the
external structures including the lids, bulbar and
palpebral conjunctiva, cornea, lacrimal structures, the
size, symmetry, and reactivity of the pupils, orbits, eye
muscle balance, and mobility (Woo, 2020).
• The red reflex is tested in all ages. It must be assessed
for color, intensity, and clarity (opacities or white spots)
(Woo, 2020). A rule a thumb is that if the examiner
cannot see into the eye, the patient cannot see out (Woo,
2020).
• In children beginning at age 5 years, funduscopic
examination may allow for visualization of the retina,
choroid, fovea, macula, optic disc and cup, and entry and
exit or the vessels and nerves (Woo, 2020).
• Examination of the conjunctiva and sclera is sometimes
facilitated by using a cotton-tipped applicator the evert
the eyelid (Woo, 2020).
• Growth parameters (especially head growth and shape)
and the head and neck or other structures should be
examined if a systemic condition is suspected (Woo,
2020).
6. PHYSICAL
EXAMINATION:
RED REFLEX
• The red reflex should be
tested at every well
examination, including the
initial newborn examination.
• The red reflex test is also
called the Bruckner test and
allows the clinician to detect
the presence of asymmetric
refractive errors, strabismic
deviations, and abnormalities
in the ocular media such as
cataracts, corneal
abnormalities, and
retinoblastoma (Woo, 2020).
• Disease processes involving
the cornea, lens, vitreous, or
retina block the light from
entering or exiting the pupil
and result in an abnormal red
reflex (Woo, 2020).
7. COLOR VISION
TESTING
•The human retina contains
6 million red and green
cones and approximately 1
million blue cones (Woo,
2020).
•Alterations in color vision
occur when the normal
photopigments in the
photoreceptor cones are
replaced by different ones
(Woo, 2020).
•Color ranges are then
interpreted or perceived
differently (Woo, 2020).
• Red-green color
deficiency
• Blue-yellow deficiency
8. ASSESSMENT OF
VISUAL LOSS
If significant visual disturbance is suspected, the
following functional vision assessments should be
performed, and the child referred immediately to an
ophthalmologist:
Shine a penlight into the eye from a lateral
position and turn the light off and on several times
to assess light perception. If the child can identify
when the light is on or off, vision is described as
“LP” (light perception) (Woo, 2020).
Move a hand back and forth with periodic
cessation 12 inches from the child’s face.
Indication of search and recognition is
documented as “H/M at 1 ft” (hand motion) (Woo,
2020).
Ask the child to count the number of fingers (C/F)
seen when one, two, or three fingers are held up
12 inches from the child’s face. If the child is
correct, document the vision as “C/F at 1 ft” (Woo,
This Photo by Unknown Author is licensed under CC BY-NC
This Photo by Unknown Author is licensed under CC BY-NC
9. INDICATIONS FOR A COMPREHENSIVE PEDIATRIC
EYE EVALUATION
TABLE 35.4
PAGE 621
Risk Factors
Prematurity, Retinopathy of prematurity,
Intrauterine growth retardation, Neurologic
disorders, Thyroid disease, Cleft palate, Suspected
child abuse
Family History of eye problems
Retinoblastoma, Childhood cataract, Childhood
glaucoma, Retinal degeneration, Strabismus,
Amblyopia, Eyeglasses in early childhood, Sickle
cell anemia
Signs or Symptoms of eye problems
Defective ocular fixation, Abnormal light reflex,
Irregular pupils, Drooping eyelids, Lumps/Swelling
around eyes, Nystagmus, Squinting, Persistent
head tilt This Photo by Unknown Author is licensed under CC BY-NC-ND
10. SPECIAL
CONSIDERATIONS
FOR EYE
EXAMINATIONS
Infants and Toddlers (newborn-2 years
of age)
Better to preform examination early in
the morning or after an infant nap.
Preschool Children (3 years-5 years of
age)
At this age children have expressive
language skills, but testing
modifications are often needed to
gather information. Begin exam with
procedures that appear less
threatening.
School-Age Children (6-18 years of
age) This Photo by Unknown Author is licensed under CC BY-SA
11. DIAGNOSTIC STUDIES
•PHOTOSCREENING AND
AUTOREFRACTORS
• Used to screen for optical
and physical abnormalities
of the eyes and at
preventive visits in the
pediatric office.
•LABORATORY AND
IMAGING STUDIES
• Cultures and gram staining
of eye discharge
• Ultrasound
• CT
• MRI
•FLUORESCEIN STAINING
This Photo by Unknown Author is licensed under CC BY-NC
12. PATIENT AND
FAMILY
EDUCATION AND
PREVENTION
•Prevent Blindness 2018
recommends specific prevention
steps which include the following:
• Using safety gates and
cushions/pads at sharp corners,
storing sharp utensils/tools out
of reach of children, and storing
chemicals securely
• Restraining children properly in
the car, not allowing children
under 12 years of age to sit in
the front seat
• Limiting/supervising the use of
laser pointers, BB guns, air
rifles, paintball devices, darts
and fireworks
13. MANAGEMENT/REFERRAL/
FOLLOW-UP
Eye pathology is referred to an ophthalmologist or
optometrists depending on the severity of the eye
disorder.
Management includes:
Occlusion - by patching, optical or pharmacologic
penalization, or occlusive contact lens.
Corrective lens – contact lenses or eyeglasses.
The American Academy of Ophthalmology (AAO)
discourages LASIK surgery in children younger than
18 years of age and provides strict guidelines for
candidates for the procedure.
This Photo by Unknown Author is licensed under CC BY-SA-NC
14. REFERENCES
Woo, T. M. (2020). Eye disorders. Burns’ Pediatric
Primary Care.
American Optometric Association. (2017).
Comprehensive pediatric eye and vision examination.
Retrieved from https://www.aoa.org/news/clinical-
eye-care/health-and-wellness/aoa-releases-new-
evidence-based-guideline-for-pediatric-eye-
care?sso=y
Editor's Notes
Hello, today ms KeScharnae Drakeford and myself, Melissa collins will be presenting eye disorders in the pediatric population.
The recommended technique follow: darken the examination room, as it is easier to detect more subtle asymmetries between the red reflexes. Stand an arm’s length away from the infant or child with the ophthalmoscope’s light set at 0 or +1 to illuminate the face. NOTE: In children with fair skin pigmentation, the red reflex is bright red-orange; in those with darker pigmentation, the red reflex is dark-brown or pale yellow. The red reflexes should be symmetric; any asymmetry, dark or white spots, opacities, or leukocoria (white pupillary reflex) requires prompt referral to an ophthalmologist.
Red-green color deficiency is an X-linked inherited disorder or may indicate optic nerve disease. Inherited (X-linked) color deficiencies are more common in males, affecting less than 5% of females. Color vision deficiency may also be acquired. A patient with acquired color deficiency may have had normal color vision and then experienced color changes and losses. Diabetes, infections, optic neuritis, and toxins are systemic conditions that can lead to such losses. Blue-yellow deficiency is the most common type of acquired color deficiency. A significant color vision deficiency can affect school performance, have safety implications if the child is unable to distinguish traffic or vehicle brake lights, and affect career choices. Color vision is tested by using the Richmond pseudoisochromatic plates or Ishihara plates. Children 3 to 4 years of age are usually able to comply with testing directions, but the test is not routinely administered. Parents may request testing when their child is young and makes errors when asked to identify colors.
Photoscreeners assess the red light reflex and high refractive error and screen for amblyopia and strabismus. Autorefractors may be used to determine the refractive error of each eye. Medial opacities and refractive errors can be discerned using instrument-based screening in preverbal or developmentally delayed children. Instrument-based vision screening is a valid and reliable alternative method for visual screening in children under 5 years of age or who are not able to use vision charts.
Cultures and gram staining of eye discharge are done if identification of infection or particular organisms would be helpful in guiding managements. Ultrasound (not to be used in cases of suspected ruptured globe), computed tomography (CT), or magnetic resonance imaging (MRI) is sometimes useful in determining a diagnosis of orbital cellulitis, trauma, or tumor or in substantiating a concern about the central nervous system (CNS). An MRI should not be used in the case of a suspected intraocular metal foreign body.
Fluorescein staining may be used to determine the extent of damage the corneal or conjunctival epithelium as a result of trauma, infection, or exposure to a foreign body. After applying the fluorescein, examine the cornea with a cobalt blue filter light in a darkened room; any injury will take up the fluorescein stain and appear as a greenish area. Too much of the stain will cloud the entire cornea.
