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Chapter 1 Index
A. General Information
about the well child examination B. Nutrition Issues
C. Sleep Issues
D. Dental Issues
E. Anticipatory Guidance
F. Screening Tests
--Hearing Screening in
Children |
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Vision Screening in Children
Steven E. Brooks, MD
Introduction: Screening should occur in the first newborn
exam and continue throughout childhood. The red reflex should be looked for
at every well child exam; amblyopia occurs in 1-6% of the population and
needs to be diagnosed before 3-4 years of age to have optimal hope of
-saving vision. (Much greater incidence of amblyopia if positive family
history, prematurity, developmental delay). Most often associated with
strabismus or refractive errors.
Equipment needed to successfully screen vision in private practice:
-
Penlight: Hirschberg or corneal reflex test, pupil
reaction, congenital abnormalities of eye.
-
Small toys: test tracking, each eye tested
separately.
-
Ophthalmoscope: keep lights in room down, and use a
strong light in scope. Tests red reflex.
-
Optotype acuity tests: Allen pictures, E-game, letter
chart for 3 yrs. of age and above. Need to have eye patches to be sure you
are testing only one eye. Also near vision card.
-
Probably do not need Titmus machine ($2500) or other
machines similar to it.
-
Some offices and schools are now using Polaroid
photoscreening (MTI) for amblyogenic risks.
What to look for on eye examination:
- Abnormal Red Reflex (causes: retinoblastoma, cataract, small pupils,
persistent pupillary membrane, and dark pigmentation, VH). Always look
for symmetry between the two eyes.
- Structural abnormalities: such as eyelid anomalies (coloboma,
entropion, ptosis), epibulbar dermoids (Goldenhar’s syndrome), iris
abnormalities (aniridia, coloboma, heterochromia, anisocoria); lens
abnormalities (cataract); leukocoria (Retinoblastoma, RD, cataract, ROP,
PHPV); corneal abnormalities (glaucoma, dystrophy)
- Fixation and tracking of small toy or at short distances-look for
objection to eye being covered.
- Eye alignment: Hirschberg test, Cover test (movement of eye occurs in
uncovered eye showing weak eye muscles on that side) to determine
strabismus (after 3 mos of age).
- Eye movements: is there symmetry, is range normal, is there nystagmus?
- Head posturing: face turn, head tilt: if persistent may be due to
decreased sight in one eye.
| Screening
Method |
Birth |
6 mo-12 mo |
3 yrs. |
5-6 yrs |
|
Inspection |
x |
x |
x |
x |
|
External exam penlight |
x |
x |
x |
x |
|
Vision: fixation and tracking |
|
x |
x |
x |
|
Eye Movements |
|
x |
x |
x |
|
Eye Alignment: Hirschberg, Cover |
|
x |
x |
x |
|
Optotype (Allen pictures, E-game, letter chart) |
|
|
x |
x |
|
Visual Acuity test with wall chart (see Optotype) |
|
|
x |
x |
|
Titmus |
|
|
No |
no |
|
Polaroid Photoscreening |
|
|
+/- |
+/- |
When to refer
for eye problems:
Abnormalities of screens above plus:
1. Vision abnormalities: marked fixation preference
- two line difference or more in visual acuity on eye chart
- age 3: visual acuity of worse than 20/50
- age 5: visual acuity of worse than 20/30
2. Eye movements:
- asymmetry present at any age;
- nystagmus over 1 month of age
3. Eye Alignment:
- strabismus over 6 months of age (others state refer after 3 mos of
age)
- abnormal head posturing over 6 months of age
4. Red Reflex: abnormal or asymmetric at any age.
5. Medical conditions: rheumatoid arthritis, steroid therapy,
neurodegenerative disease
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