Eye examination in infants,
children and young adults by
pediatricians
Ronit Friling
Pediatric Ophthalmology Unit,
Schneiders Childrens Medical Center
of Israel, Petah Tikva, Sackler
Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel
1
Eye evaluation in the physician’s
office
Birth to three years
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Ocular history
Vision Assessment
External inspection of the eyes and lids
Ocular motility assessment
Pupil examination
Red reflex examination
2
Ocular history
• Does your child hold objects close to his or
her face?
• Does your child’s eyes appear straight or
crossed?
• Relevant family history regarding eye
disorders
3
Vision Assessment
Age 0-3 years
To determine whether each eye can fixate on
an object, maintain fixation and follow the
object into various gaze positions.
The assessment should be performed
binocularly and then monocularly.
4
Visual Acuity Measurement
Older than 3 years
Picture tests such as (LEA symbols) and
Allen cards can be used for children 24 years of age
5
External Examination
Consists of penlight evaluation of the
lids, conjunctiva, sclera, cornea and iris.
Persistent discharge or tearing may be
attributed to ocular infection, allergy
or glaucoma but the most common cause
is lacrimal duct obstruction.
6
Ocular Motility
The most common cause of pseudostrabismus
is prominent epicentral lid folds that cover
the medial portion of the sclera on both eyes
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Pupils
The pupils should be equal, round, and
reactive to light in both eyes
8
Red Reflex Test
The red reflex can be used to detect
opacities in the visual axis such as cataract
or corneal abnormality and abnormalities of
the back of the eye such as retinoblastoma
or retinal detachment
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Visual Acuity Test
Snellen Acuity Cards
HOTV Test
The test consists of a wall chart composed of H,O,T,V
The child is provided a board containing a large H,O,T,V
Allen Cards
Consists of 4 cards containing 7 schematic figures
LEA Symbols
The LH Symbol test is made of
house, apple, circle, square
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Amblyopia
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Amblyopia
The most common cause of
monocular visual impairment in
children
A substandard correct visual acuity
without evidence of organic eye
disease Prevalence 2-2.5% in
general population
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Causes
• Strabismus
• Anisometropia
• Visual deprivation
14
Compliance
• 49% - 87%
• Skin imitation
• Social reasons
15
Pharmocologic Penalization
• Instillation of a long acting topic
cycloplegic agent (atropine) into
the sound eye
• Prevents accommodation
• Blurring the sound eye at near
fixation
16
• Penalization has been advocated only for
mild and moderate amblyopia 6/18 or
better
• Because the blurring effect on the sound
eye may be insufficient when visual acuity
in the amblyopic eye is worse that 6/18
17
419 Patients
215 - Patching group
204 - Atropine group
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Patching Group
• 6 hours 43% of
patients 8 hours
30% of patients
• 10 hours 7% of
patients
• 12 hours 20% of
patients
Atropine Group
• A drop of atropine
per day
19
Results on VA in the amblyopic eye
• Improvement in VA from base line in
both patching and atropine groups
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Results (cont)
• Mean change in V.a. from baseline
• 3.16 lines - patching group
• 2.84 lines - atropine group
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VA in the sound eye
• At six-month examination
• VA in the sound eye was
decreased from baseline by 1 line
• 7% - patching group
• 15% atropine group
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Side effects
• Patch - skin irritation
• Atropine - light sensitivity 18%
• Lid - irritation 4%
23
Treatment
• Encouragement of visual
development making the patient
use the amblyopic eye by
reducing the visual stimulation of
the fellow eye
24
Success rates of penalization
therapy
Optical
Atropine
65% - 93%
74% - 89%
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Criteria for combined optical atropine
penalization treatment (COAT)
• Lack of compliance with conventional
full-time total occlusion
• Failed to show an expected
improvement (doubling in VA) after
apparent compliance
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Criteria for COAT
• A hypermetropic refractive error of at
least 1,75D in the fellow eye (the eye to be
penalized)
• The prescription for the fellow eye was
replaced with a plano lens
27
Follow-up
• Treatment was continued until
the VA in the amblyopic
eye was either equal to that of
the fellow eye or had not
improved
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Pharmacologic penalization
• Ease of administration
• Reliable assessment of compliance
• Relative cheapness
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Disadvantage
• Potential toxicity
• Duration of effect if reverse
amblyopia is detected
30
Results
• The mean VA in the fellow eye at the
end of treatment was not
significantly different from that of
the commencement of treatment
• The change in VA after COAT was
much higher than after occlusion
31
Results (cont)
• COAT for previously foiled FTO
produced a success rate of 76%
success is defined as doubling of VA
of the amblyopic eye
32