This document provides guidelines for pediatric eye examinations across different age groups. It divides children into infants/toddlers (birth to 2 years 11 months), preschool (3 to 5 years 11 months) and school-age (6 to 18 years). Examination procedures are described for each age group, including visual acuity testing, refraction, binocular vision evaluation, ocular health assessment and more. The document emphasizes using age-appropriate techniques and establishing expected levels of visual function for pediatric patients. Key examination procedures are defined, such as cycloplegic retinoscopy, cover tests, stereopsis tests and others. Recommended examination frequencies are provided based on a patient's age and risk factors.

1. 1

2. Pediatric Eye And Vision
Examination
‫شکرا شفائی کارشناس ارشد‬
‫اپتومتری‬
2

3. Pediatric population can be divided into three
(subcategories: (Press LJ, Moore BD.1993
(Infants
and toddlers (birth to 2 years, 11 months ■
(Preschool
children (3 years to 5 years, 11 months ■
(.School-age
3
children (6 to 18 years ■

4. 4

5. Recommended Eye Examination Frequency for the
Pediatric Patient (OPTOMETRIC CLINICAL PRACTICE GUIDELINE ; Mitchell M.
(Scheiman, 2002
Patient Age Asymptomatic/ At-risk
At-risk
Patient Age risk-free
Birth to 24
months
At 6 months of age
At 6 months of age or as
recommended
.to 5 yrs 2
At 3 years of age
At 3 years of age
or as recommended
.to 18 yrs 6
Before first grade
and every 2 years
thereafter
Annually or as
recommended
5

6. A. Examination of Infants and Toddlers
General Considerations. 1
time of examination; morning visit types of examination; objective fast but exact; age appropriate -
Early Detection and Prevention. 2
Examination Sequence. 3
a. Patient History
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
Family eye and medical histories■
.Developmental history of the child■
6
■

7. b. Visual Acuity
Assessment of visual acuity for infants and
:toddlers may include these procedures
Gross estimate of visual function at near•
Fixation maintenance & preference tests•
prism diopter (PD) lens 10-
OKN•
Preferential looking visual acuity test•
VEP•
7

8. (.pincer grasp to pick up cake decoration ( or raisin
(Candy
beads at 8 cm = 20/285 ( Frenkel & Evans, 1980
40

9. .lights on
lights turned down
Note marked retraction of the upper lids. indicating some
9
.visual function

10. Fixation maintenance test
To test central & steady fixation■
Shine a light at uncovered eye■
Estimate the position of the light reflexes (or angle Kappa(;
displaced +0.5 mm nasally
Any deviation = eccentric fixation■
10
■

11. Fixation preference test
can be judged when obvious strabismus is present■
cover and uncover the fixing eye to force fixation to the
nonpreferred eye
observe the fixation pattern ■
good vision in case of alternate fixation 11
■

12. Teller cards
pack of 16 cardsfrom 38.0 to 0.32 cycles/cmtest dist. 38 cm for infants , 55 cmfor toddlers
12

13. Spatial frequency paddles
)calibrated for a specific distance( 1 m-
.paddles and 6 different sp. fr 4. hold the gray over one of sp. frseparate the paddles and notice the fixation 13

14. Preferential looking tests of vision
Keeler/Teller cards for infants
14

15. 15

16. Normal levels of vision
(Preferential
looking tests
(Mayer et al, 1995
month
24/400 – 20/1600 1
month
20/100 – 20/400 4
month
20/80 – 20/300 12
16

17. Vertical optokinetic nystagmus testing using an OKN
drum. If a vertical nystagmus can be elicited, vision is
.20/400 or better
17

18. vestibular-ocular reflex, which stimulates the semicircular
.canals, causing the eyes to deviate in the direction of rotation
18

19. The early decreased visual acuity in the infant is due
:to
foveal cone immaturities; small and stumpy- 1
at 4 years, the length of an adult cone at 3.5 – 4 years, adult level of cone density cortical immaturities- 2
incomplete myelination of the optic pathways- 3
19

20. Cardiff acuity cards for toddlers; vanishing optotype
in children from 1 to 3 years of age■
sets of cards are available ; 20/400 to 20/20 11 ■
test dis. 0.5 m and 1.0 m ■
present one set of cards and notice the fixation ■
(better done binocularly first( Adoh and Woodhouse,1994 ■
20

21. (
Cardiff acuity test (Monocular; Adoh & Woodhouse 1994
+0.4 to +0.8 L.MAR
months(20/50-20/120) 12-18
+0.1 to +0.7 L.MAR
months( 20/25- 20/100) 24- 18
+0.1 to +0.5
L.MAR
months( 20/25-20/60) 24-30
+0.0 to +0.3
LMAR
months(20/20-20/40) 30-36
21

22. c. Refraction
Traditional subjective procedures , ineffective with infants or
toddlers because of short attention span and poor fixation. (Ciner EB,
(1990
:The two most commonly used procedures are
Cycloplegic retinoscopy■
Near retinoscopy ■
22

23. (Take
several precautions: (Gray L. 1979
Select the cycloplegic agent carefully (e.g., an increased •
response to drugs in fair-skinned children with blue eyes and more frequent or
(.stronger dosages in darkly pigmented children
Avoid overdosage (e.g., children with Down syndrome, cerebral palsy,
•
trisomy 13 and 18, 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 •
23
(.infants may require a modified dosage

24. Cyclopentolate hydrochloride , the cycloplegic
agent of choice
, One drop , twice, 5 minutes apart, in each eye
for children from birth to 1 year 0.5% (for older children. (Amos JF, 2001 1% Spray administration of the drug , a viable alternative.
(Amos JF,
)2001
The child has less of an avoidance response) 1(
A single application can achieve both cycloplegia and pupillary dilation ) 2(
.a mixture of 0.5% cyclopentolate, 0.5% tropicamide, and 2.5% phenylephrine is used) 3(
Retinoscopy may be performed 20-30 minutes after instillation.
((Bartlett JD, 1993
24

25. Near retinoscopy
:May have some clinical value in the following situations
When frequent followup is necessary •
When the child is extremely anxious about instillation
of cycloplegic agents
When the child has had or is at risk for an adverse
25
. reaction to cyclopentolate or tropicamide
•
•

26. Near retinoscopy , an alternative to cycloplegic refraction in ■
(. children
and infants (Mohindra 1977
A dim retinoscope light is used as a fixation target and seen in
complete darkness and perform retinoscopy using a lens rack or
. individual trial case lenses
■
Working at 50 cm, -1.25 DS rather than the standard -2.00 DS is
(.
added to the final retinoscopy result .(Mohindra 1977
■
The test is comparable to cycloplegic retinoscopy (e.g. Saunders &
■
(.
Westall1992
Add - 0.75 DS for infants (2 years( ; -1.00 DS for children (over 2
( years( rather than the original 1.25 DS. (Saunders & Westall (1992
26
■

27. REFLEX SCANING
,To get a quick idea of the prescription in both eyes
(Lynne Speedwell, 2007(
hold a pair of +2.00DS trial lensesin front of the child’s eyes in a
.darkened room
With the child fixing on the,retinoscope light at 50 cm
quickly move the retinoscope
horizontally and then vertically
.across both eyes
27

28. Refractive Error
Green line – cycloplegic
refraction on infants (0)6mths
80
70
Frequency (%)
60
Blue line – non-cycloplegic
refraction on infants (0)6mths
50
40
30
Red line – Refraction in older
children
20
10
0
-6
-4
-2
0
2
4
6
Spherical Equivalent (Dioptres)
28
8
Adapted from
Gwiazda et al 1993

29. d. Binocular Vision and Ocular Motility
Observation•
Hirschberg test•
Krimsky test•
Brückner test•
Cover test•
29

30. 30

31. General observation- 1
size of head■
IPD ■
nose bridge ■
lid asymmetries ■
pupil or orbit position ■
epicanthal folds ■
31
lid asymmetries

32. Hirschberg test- 2
fixate your penlight at 50 cm ■
(mm ( nasal displacement of reflex 0.5+
note any asymmetric displacement ■
(
1mm = 22 pd( Eskridge et al, 1988 ■
32
■

33. Krimsky test- 3
A( The light reflection in the(
deviated right eye is
temporal to the pupillary
. center
B( Using a prism, the(
Krimsky test measures the
amplitude of the esotropia
by centering the light
.reflection in the right pupil
33

34. Brückner test- 4
fixate an ophthalmoscope light at one meter ■
illuminate both eyes at the same time ■
observe the relative whiteness & brightness of ■
each pupillary reflex
strabismus in case of whiter & brighter reflex ■
it can help in the diagnosis of small angle
) strabismus (Miller et al. 1995
34
■

35. Cover test- 5
Targets; brightly colored with sound & fine detail Use your thumb to avoiddistraction
For distance, moving targets-
35

36. Binocular vision testing
intermittent esotropia should stop by the age of two months ■
(.■ exotropia by six months (Sondhi et al, 1988
There are three types of prism test that are useful on young
:children
The 20Δ base out prism test- 1
A 20Δ base in lens- 2
A 10Δ base down- 3
36

37. The 20Δ base OUT prism test- 1
Assesses motor fusion and gross binocular function , not ideal ■
. for amblyopia assessment
The child fixes a toy and a 20Δ base OUT lens is placed in front ■
. of one eye
Both eyes should move in the direction of the prism apex and ■
then the eye not being covered by the prism should be seen to
. refixate to the centre
If no refixation movement is seen with one eye, it is likely that
there is only weak fusion, suggesting one eye has poorer
. vision
37
■

38. A
B
.The 20 Δ base out test
A- fixation toy is used as a target and corrective eye
B - movements are observed in response to a 20
. diopters base out prism challenge
38

39. A 20Δ base IN lens. 2
will assess fixation preference and will therefore ■
.demonstrate amblyopia
The prism is held in front of first one eye then the
. other, whilst the child fixes a light
■
The eye underneath the prism should move
(. outwards (in the direction of the prism apex
■
If the eye under the prism is amblyopic, it will ■
. not move when the prism is placed in front of it
39

40. A
A 20Δ base IN lens test
40
B

41. 10Δ base DOWN. 3
In front of each eye in turnThe upward vertical movement is easy for the .observer to see
41

42. e. Ocular Health Assessment and Systemic Health
Screening
: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•
42

43. Testing visual fields
in a young child.
Begin by attracting
the child’s attention
(. straight ahead (top
Then move an object
in from the side. A
head movement to the
side of the target
(bottom( indicates
.intact peripheral field
43

44. B. Examination of Preschool
Children
44

45. b. Visual Acuity
Lea Symbols chart•
Broken Wheel acuity cards•
.HOTV test•
Allen chart•
45

46. The LH or Lea Cards
make use of a logMAR scoring
system and produce accurate
results
available in linear and single■
optotype formats and use shapes
instead of letters
at a dist. of 10 ft to 20 ft■
■
Lea optotypes
46
'A Lea symbol presented in a 'crowded box

47. Broken Wheel acuity cards
(best
for testing 3 year olds( McDonald and Chaudry, 1989a set of 7 matched pairs of cards.to 20/100, held at 10 ft 20/20should point to the car with broken wheelsif the child gets47 of 4, go to the smaller sets4

48. Kay picture cards
Having vision checked using
the crowded 3 meter LogMAR
48

49. HOTV test
.for children , 21/2 to 5 yrs. of ageno verbal responsejust point to the appropriate letter .at a dist. of 3 m-
49

50. The Allen Preschool Vision Test
ALLEN CARDS
optotypes for 2.5 to 5 yrs. of age 720/200 ,20/100 ,20/50,20/70 ,20/40 , 20/30 ask the child50 call off the name of the pictures he seeto

51. Expected levels of vision
Age
Vision
Neonate
6/300
month
6/200 – 6/90 1
months
6/60 – 6/36 3
months
6/60 – 6/36 6
months
6/36 – 6/24 9
year
6/24 – 6/12 1
years
6/12 – 6/9 2
years
51
6/9 – 6/6 3

52. c. Refraction
Static retinoscopy•
.Cycloplegic retinoscopy•
52

53. Cyclopentolate (1%( is the cycloplegic agent of choice. Two drops
should be instilled, one at a time, 5 minutes apart, in each eye .
((Bartlett JD , 2001
The use of a spray bottle to administer the drug is also effective
.for this age group
Retinoscopy may be performed with a lens rack or loose lenses
(20-30 minutes after instillation.(Bartlett JD, 1993
53

54. d. Binocular Vision, Accommodation and Ocular
Motility
Cover test•
Positive and negative fusional vergences (prism
( bar/step vergence testing
(Near point of convergence (NPC•
(Stereopsis (Lang stereotest , Frisby tests•
Monocular estimation method (MEM( retinoscopy •
.Versions•
54
•

55. e. Ocular Health Assessment and Systemic Health
Screening
Evaluation of the ocular anterior segment and adnexa •
Evaluation of the ocular posterior segment •
Color vision testing•
Assessment of pupillary responses•
(.Visual field screening (confrontation•
55

56. C. Examination of School-Age
Children
56

57. b. Visual Acuity
LogMAR chart
57

58. c. Refraction
Static (distance( retinoscopy•
Cycloplegic retinoscopy•
.Subjective refraction•
58

59. , d. Binocular Vision, Accommodation
and Ocular Motility
Cover test•
(Near point of convergence (NPC•
Positive and negative fusional vergences, AC/A•
Accommodative amplitude and facility,NRA,NPA•
Monocular estimation method (MEM( retinoscopy•
(Stereopsis (random dot stereopsis test•
Versions•
assessment of stability of fixation , saccadic function pursuit function 59
BV equipment

60. Cover-uncover test
60

61. Alternate cover test
61

62. NPC assessment
The near point of convergence (NPC(
is performed with a 6/9 target on a
fixation stick
62
Fusional reserves assessment

63. The negative/positive relative accommodation
NVA/PRA( is done in the phoropter with a 6/9 target (
at 40cm 63

64. Measuring the fusional reserves with a prism bar
64

65. The monocular/binocular accommodative flippers
(MAF/BAF(65 performed with ±2D flippers and a 6/9
is
target on a fixation stick held at 40cm

66. e. Ocular Health Assessment and Systemic Health
Screening
Evaluation of the ocular anterior segment and
adnexa
Evaluation of the ocular posterior segment •
Measurement of intraocular pressure•
Color vision testing•
Assessment of pupillary responses•
(.Visual field screening (confrontation•
66
•

67. Peripheral visual field assessment by confrontation
67

68. Finger mimicking visual fields. The child is asked to
show the same number of fingers as the examiner. These
68
.should be displayed quickly to avoid fixation artifact

69. Thank you
69