Vision disorders are common in children and can negatively impact development if left untreated. A comprehensive eye exam evaluates vision, eye alignment and tracking, focusing ability, and screens for conditions like nearsightedness and lazy eye. Exams are important because many issues have no obvious symptoms. Screenings miss up to 1/3 of problems and may lead to misdiagnoses. Comprehensive exams are recommended at ages 6 months, 3 years, before school, and every 2 years thereafter to catch issues early for best outcomes. Bringing an infant for an exam requires preparing them to be well-rested and not distressed.

1. Importance of a
Comprehensive Pediatric
Vision and Eye
Evaluation
Tamara Petrosyan, O.D.

2. Why have a comprehensive vision exam?
● Vision disorders are the 4th most common disability in the
U.S. and the most prevalent handicapping condition
during childhood
● 2006 analysis of 1,051 infants (0-12mo) checked for
'visual risk factors'
– ocular or visual complication requiring careful follow
up or treatment
● 17% had a positive risk factor
● 25% if premature, minority, or family income below
$41K

3. Why have a comprehensive vision exam?
● Risk factors for many eye conditions have no signs or
symptoms
● Estimated 1 in 10 children (age 6 and below) is at risk for
an undiagnosed eye or vision problem
● Only 13% of parents make sure their child receives a
comprehensive eye assessment

4. Why have a comprehensive vision exam?
● If left untreated, eye and vision problems can lead to
difficulties in development, education, and potential
permanent vision loss
– Majority of learning in school is done through reading,
especially after 3rd grade
● Distance vision tests only catch myopes (nearsighted),
high hyperopes (farsighted) and high astigmatism.
– Vision screenings miss many potentially problematic issues

5. Why have a comprehensive vision exam?
●
● Good vision involves the ability to take incoming visual information, process that information, and obtain
meaning from it
– Simply having 20/20 vision is not enough
● For good incoming visual information you must have
○ Clear distance vision
○ Clear near vision - through use of the focusing system
○ Good eye teaming - so you do not see double
○ Good eye tracking - so you can follow an object or jump
from one object to another

6. Why have a comprehensive vision exam?
● For fluent reading, a person must
– focus on the page to make it clear
– comfortably keep that focus for a long period of time
– coordinate eye teaming so both eyes point at the same place at the same time
– accurately and quickly jump from one word to another or from the end of one line to the start of another
– interpret and accurately process and decode what is read to give it meaning

7. Essential Health Benefit
● Starting January 1st 2014, yearly comprehensive pediatric eye and vision evaluations are considered one
of the ten essential health benefits under the ACA
● Pediatric eye health care is defined as an annual comprehensive eye exam and treatment, including
medical eye care
● All new health plans - both inside and outside of state exchanges – are required to provide fully integrated
coverage for pediatric eye health care and must recognize optometrists as providers of medical eye care

8. What we are trying to catch during a vision exam?
● Amblyopia (lazy eye)
● Strabismus (cross eye)
● Significant Refractive Error
– farsighted, nearsighted, or astigmatism
– accommodative problems
● Eye Disease

9. What is tested during a comprehensive vision exam?
● Amblyopia (lazy eye)
– The loss or lack of development of central, detailed
vision in an otherwise healthy eye
– Vision not correctable to 20/20 with glasses or
contacts
– Due to a lack of proper visual nerve pathway
connection between the eye and the brain
● high or asymmetric refractive error
● strabismus
– Occurs in 2.5 – 6.5 % of the population
– Can happen in one or both eyes
– Treatable: early intervention of glasses and/or therapy

10. ● Convergence Insufficiency / Strabismus (cross eye)
– When the two eyes do not point at the same place at
the same time causing either diplopia or binocular
vision suppression
– Strabismus can cause amblyopia
– Occurs in 4 – 6% of the population
– Can be
● one or both eyes
● constant or intermittent
– Treated with glasses, therapy, and/or surgery
What is tested during a comprehensive vision exam?

11. ● Oculomotor and Pursuit Dysfunction (eye tracking)
– Inability to accurately jump from one target to another
– Inability to smoothly and properly follow a moving object
– Treated with therapy
What is tested during a comprehensive vision exam?

12. ● Significant Refractive Error
– Myopia / Nearsighted
● Rays from a distant object focus in front of fovea
– Hyperopia / Farsighted
● Rays from a distant object focus behind the fovea, eye must accommodate to make image clear
– Astigmatism
● Rays from an object at any distance will focus in different areas on the retina giving a blurred
image
What is tested during a comprehensive vision exam?

13. ● Significant Refractive Error
– Accommodative Insufficiency and In-facility
● Inability of the eyes focusing / accommodative
system to properly focus images falling behind the
fovea
● Inability to sustain the focus of the eye or inability to
quickly and accurately change focus on objects at
different distances
What is tested during a comprehensive vision exam?

14. ● Ocular Disease (less than 2% in pedes)
– Eyelid or eyeball infections
– Entropion / Ectropion
– Ptosis
– Nasolacrimal Duct Obstruction
– Nystagmus
– Cataract
– Glaucoma
– Color Vision Deficiency
– Retinopathy of prematurity
– Retinoblastoma
What is tested during a comprehensive vision exam?

15. ● If the above mentioned problems are not caught early, they can impede development
● A comprehensive eye and vision evaluation tests for all of these problems
– The sooner the problem is caught, the easier and more successful the treatment will be
What is tested during a comprehensive vision exam?

16. Children at increased risk for eye problems
● Difficult or assisted labor, associated with fetal
distress or low APGAR scores
● Premature birth, low birth weight, or oxygen use
following birth
● Drug or alcohol use during pregnancy
● Sexually transmitted disease, CMV, HIV

17. Children at increased risk for eye problems
● Developmental delay, Downs syndrome, Fragile X
syndrome, Fetal alcohol syndrome, Autism
spectrum, Cerebral Palsy, Spina Bifida
● Family history of eye disease such as
retinoblastoma, congenital cataract, congenital
glaucoma, metabolic or genetic disease
● Family history of high refractive error, cross eye
or lazy eye

18. Symptoms requiring a comprehensive eye exam
Symptoms commonly associated with refractive error,
focusing, eye teaming, or eye tracking dysfunctions
blurred vision difficulty reading
blurry vision after reading blurry vision at end of the day
headache with reading ocular
discomfort
‘pulling’ sensation around eyes eye tiredness or fatigue
double vision rubbing eyes when
reading
avoidance of reading sleepiness when reading
squinting, rubbing, closing eye motion sickness
loss of concentration skipping words / lines
problems understanding what is read problems remembering what is read
problems copying from the board difficulty with math
difficulty with sports seeing words move on a
page
burning or tearing of the eyes poor eye-hand coordination

19. Normal Visual Development
By 6 months of age, many portions of visual function are on their way to being fully developed
Newborn 1
month
2
month
4
month
6 month 9
mont
h
12
mont
h
18
mont
h
24
mont
h
3
years
OCULOMOTOR
Fixate to face
H Saccades
V Saccades
Pursuits
Visually Directed Reaching
Face Regard
OKN
+
+
+
+
+
+
+
ACUITY
Preferential Looking OU
Visually Evoked Response
OU
20/400-
20/1200
20/100
20/300-
20/1200
20/200
20/150
-
20/600
20/80
20/50-20/200
20/40
20/40-
20/10
0
20/30
-
20/80
20/20
BINOCULARITY
Alignment
Convergence Near Point
Fixation of Moving Target
10^ Response
Stereopsis
To 10”
+
+
To nose
70%
+
ACCOMMODATION
Accuracy
Lag
@30cm
(+)0.75
@75-150cm
PUPIL RESPONSE Sluggish +
COLOR VISION Developing +
BLINK RESPONSE TO
VISUAL THREAT
+
CONTRAST SENSITIVITY 3-5yo

20. Normal Visual Development
● 0 – 2 months
– Prefers large high contrast targets and faces
– Eyes do not always align or track together
● Concern if eyes are never aligned or if alignment
does not gradually improve
– Tear drainage ducts not fully developed and may
cause excess tearing
● 2 – 4 months
– Eyes start to track together
– Shifts gaze between objects with minimal head
movement

21. Normal Visual Development
● 4 – 6 months
– Begins to track and reach for objects
– Depth perception (3D) begins to develop
● 6 – 8 months
– Nasolacrimal duct open in most
– Color vision improved
– Visual acuity potential 20/25
– Eye teaming, tracking, and focusing improved
● 8 – 12 months
– Eye teaming, tracking, and focusing close to adult
level

22. Limitations of vision screening
● No full, comprehensive ocular history and symptomatology
● No quantification of the problem
– vision
– refractive error / asymmetry
– accommodative function / facility
– binocular or eye teaming function
● No assessment of stamina of the visual system
– accommodative system
– binocular system
– oculomotor system

23. Comprehensive Eye Exam vs. Screening
●
●Only comprehensive eye exams fully identify eye
problems, provide diagnosis, and ensure a linkage
to treatment for all of the vision and eye health
issues that can impact a child’s ability to meet
important developmental and educational
milestones
● Even the most highly-trained vision screeners using
the top-of-the-line screening equipment will miss
one-third of all learning-related eye and vision
problems in children

24. Comprehensive Eye Exam vs. Screening
●
●Once missed by vision screening, children may be
misdirected toward Individualized Education Plans
(IEPs) and/or treatment for disorders like Attention
Deficit Hyperactivity Disorder (ADHD) without ever
receiving the vision care they need to help them
succeed

25. What is done during an infant and pediatric
comprehensive eye and vision evaluation
●Comprehensive medical and family history
●Measure visual performance / function at various
distances both objectively and subjectively
●Evaluate refractive error, eye teaming, eye tracking,
and eye focusing of the eyes both individually and
together
●Evaluate for any eye disease, including dilated fundus

26. What is done during an infant and pediatric
comprehensive eye and vision evaluation
●
●Manage any abnormality found by either close
monitoring, treatment, or referral
●American Optometric Association recommends a
child be seen for a comprehensive ocular and vision
evaluation at 6 months, at age 3, before school,
and every two years after that

27. When bringing a patient for a pediatric exam
● The baby should be
– Well fed
– Changed
– Has had a normal nights sleep
– Is not getting ready for a nap
– Is not sick
– Try to avoid siblings in the exam room
– Bring snacks and one or two of the baby’s favorite
toys to use as distractors or part of the exam.

28. For more information or to find a
pediatric optometric physician
near you visit
eyecare.org or njsop.org