Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Screening
Age-appropriate eye and vision evaluations should be performed in the newborn period and at all subsequent health supervision visits, [A:III] because different childhood eye problems may be detected at each visit and new problems can arise during childhood.
At a child's first examination by a new primary care provider, a history of risk factors for eye and vision abnormalities should be elicited. [A:III] At each scheduled well-child examination, the primary care provider should ask the parent/caregiver about the baby's visual interactions and possible eye or vision problems. [A:III]
The screening examination should include examination of the red reflex to detect abnormalities of the ocular media; external inspection to detect ocular abnormalities; pupil examination; visual acuity on an age-appropriate basis; and, after 6 months of age, the corneal light reflection test (Hirschberg reflex) and cover testing for ocular alignment as well as motility testing. [A:III]
Children who fail a screening should be referred for a comprehensive pediatric ophthalmic evaluation after the first screening failure. [A:III]
If a child is unable to cooperate for vision testing at 3 years of age, a second attempt should be made within 6 months. [A:III] If the child is 4 years old, a second attempt should be made within the month (American Academy of Pediatrics, 2003). [A:III] Although the child may be re-screened if screening is inconclusive or unsatisfactory, undue delays should be avoided; if retesting is inconclusive, referral for a comprehensive ophthalmic evaluation is indicated (Maguire & Vision in Preschoolers Study Group, 2007). [A:III]
Referral Plan
If eye and vision abnormalities or their risk factors are suspected or identified at a screening examination, an appropriate referral plan should be initiated and recorded. [A:III] The tables below list specific examples of indications for a referral for a comprehensive pediatric ophthalmic evaluation.
Comprehensive Ophthalmic Evaluation
History
Although a thorough history generally includes the following items, the exact composition varies with the patient's particular problems and needs:
- Demographic data, including identification of parent/caregiver, and patient's gender and date of birth [A:III]
- Documentation of identity and relationship of historian [B:III]
- The identity of other pertinent health care providers [A:III]
- The chief complaint and reason for the eye evaluation [A:III]
- Current eye problems [A:III]
- Ocular history, including other eye problems, diseases, diagnoses, and treatments [A:III]
- Systemic history; birth weight; prenatal and perinatal history that may be pertinent (e.g., alcohol, drug, and tobacco use during pregnancy); past hospitalizations and operations; general health and development [A:III]
- Current medications and allergies. [A:III]
- Family history of eye conditions and relevant systemic diseases. [A:III] A social history, including racial or ethnic heritage, is germane for certain diagnostic considerations such as sickle cell anemia or Tay-Sachs disease.
- Review of systems. [B:III]
Examination
Documentation of the child's level of cooperation with the examination can be useful in interpreting the results and in making comparisons among the examinations over time. In general, the examination may include the following elements:
- Assessment of visual acuity and fixation pattern [A:III]
- Ocular alignment and motility [A:III]
- Red reflex or binocular red reflex (Brückner) test [A:III]
- Pupil examination [A:III]
- External examination [A:III]
- Anterior segment examination [A:III]
- Cycloplegic retinoscopy/refraction [A:III]
- Funduscopic examination [A:III]
Other tests that may be indicated in selected patients:
- Binocularity/stereoacuity testing
- Sensorimotor evaluation (e.g., strabismus, suspected neurological disease)
Diagnosis and Management
Category I: Low Risk
When the evaluation is normal, the ophthalmologist reassures the patient and the parent/caregiver and advises as to the appropriate interval for re-examination. Although this group of patients is considered low risk, periodic eye screening by the primary care provider should be continued. [A:III] Patients should undergo a comprehensive pediatric ophthalmic evaluation if new ocular symptoms, signs, or risk factors for ocular disease develop. [A:III]
Category II: High Risk
When the evaluation reveals risk factors for developing ocular disease or signs that are suggestive of an abnormal condition, the patient is considered to be at high risk. The ophthalmologist should determine an appropriate follow-up interval for each patient based on the findings. [A:III]
Category III: Requiring Intervention
Most patients with abnormal signs and symptoms can be diagnosed and treated solely on the basis of a comprehensive pediatric eye evaluation. Recommendations for appropriate treatment and follow-up will vary with the patient. The Amblyopia Preferred Practice Patterns (PPP) and Esotropia and Exotropia PPP contain specific recommendations for management of these conditions (see the National Guideline Clearinghouse [NGC] summaries of the American Academy of Ophthalmology PPPs Amblyopia and Esotropia and exotropia.
Optical correction should be considered if the visual acuity can be improved, if ocular alignment can be improved, to prevent or treat amblyopia, to treat strabismus, or if the patient has asthenopia. [A:III] The goals when prescribing eyeglasses for young children are to achieve good vision, straight eyes, normal binocular vision, and acceptance of the eyeglasses.
Table: Indications for Referral for a Comprehensive Pediatric Ophthalmic Evaluation
| Indication |
Specific Examples |
| Risk factors (general health problems, systemic disease, or use of medications that are known to be associated with eye disease and visual abnormalities) |
- Prematurity (birth weight less than 1500 grams or gestational age 30 weeks or less)
- Retinopathy of prematurity
- Intrauterine growth retardation
- Perinatal complications (evaluation at birth and at 6 months)
- Neurological disorders or neurodevelopmental delay (upon diagnosis)
- Juvenile rheumatoid arthritis (upon diagnosis)
- Thyroid disease
- Cleft palate or other craniofacial abnormalities
- Diabetes mellitus (5 years after onset)
- Systemic syndromes with known ocular manifestations (at 6 months or upon diagnosis)
- Chronic systemic steroid therapy or other medications known to cause eye disease
- Suspected child abuse
|
| A family history of conditions that cause or are associated with eye or vision problems |
- Retinoblastoma
- Childhood cataract
- Childhood glaucoma
- Retinal dystrophy/degeneration
- Strabismus
- Amblyopia
- Eyeglasses in early childhood
- Sickle cell disease
- Systemic syndromes with ocular manifestations
- Any history of childhood blindness not due to trauma in a parent or sibling
|
| Signs or symptoms of eye problems by history or observations by family members* |
- Defective ocular fixation or visual interactions
- Abnormal light reflex (including both the corneal light reflections and the red fundus reflection)
- Abnormal or irregular pupils
- Large and/or cloudy eyes
- Drooping eyelid
- Lumps or swelling around the eyes
- Ocular alignment or movement abnormality
- Nystagmus (shaking of eyes)
- Persistent tearing, ocular discharge
- Persistent or recurrent redness
- Persistent light sensitivity
- Squinting/eye closure
- Persistent head tilt
- Learning disabilities or dyslexia
|
Note: These recommendations are based on panel consensus.
*"Headache" is not included since it is rarely caused by eye problems in children. This complaint should first be evaluated by the primary care physician.
Table. Recommended Ages and Methods for Pediatric Eye Evaluation Screening
| Recommended Age |
Method |
Indications for Referral to an
Ophthalmologist |
| Newborn to 3 months |
Red reflex |
Absent, white, dull, opacity, or asymptomatic |
| External inspection |
Structural abnormality |
| Pupil examination |
Irregular shape, unequal size, poor or unequal reaction |
| 3 to 6 months (approximately) |
Fix and follow |
Failure to fix and follow in a cooperative infant |
| Red reflex |
Absent, white, dull, opacity, or asymptomatic |
| External inspection |
Structural abnormality |
| Pupil examination |
Irregular shape, unequal size, poor or unequal reaction |
| 6 to 12 months and until child is able to cooperate for verbal visual acuity |
Fix and follow with each eye |
Failure to fix and follow |
| Alternate occlusion |
Failure to object equally to covering each eye |
| Corneal light reflex |
Asymmetric or displaced |
| Red reflex |
Absent, white, dull, opacity, or asymptomatic |
| External inspection |
Structural abnormality |
| Pupil examination |
Irregular shape, unequal size, poor or unequal reaction |
| 3 years and 4 years (approximately) |
Visual acuity* (monocular) |
20/50 or worse, or 2 lines of difference between the eyes |
| Corneal light reflection/cover-uncover |
Asymmetric/ocular refixation movements |
| Red reflex |
Absent, white, dull, opacity, or asymptomatic |
| External inspection |
Structural abnormality |
| Pupil examination |
Irregular shape, unequal size, poor or unequal reaction |
| 5 years (approximately) |
Visual acuity* (monocular) |
20/40 or worse, or 2 lines of difference between the eyes |
| All other tests and referral indications are as in age 3 and 4 years. |
|
| Every 1 to 2 years after age 5 |
Visual acuity* (monocular) |
20/30 or worse, or 2 lines of difference between the eyes |
| All other tests and referral indications are as in age 3 and 4 years |
|
Note: These recommendations are based on panel consensus. Although the child may be retested if screening is inconclusive or unsatisfactory, undue delays should be avoided; if inconclusive on retesting, referral for a comprehensive pediatric ophthalmic evaluation is indicated. [A:III]
*Figures, letters, "tumbling E" or optotypes, LEA symbols (Precision Vision, Inc., La Salle, IL), vision testing machines.
Table: Consensus Guidelines for Prescribing Eyeglasses for Young Children [A:III]
| Condition |
Diopters |
| Age 0-1 year |
Age 1-2 years |
Age 2-3 years |
| Isometropia (similar refractive error in both eyes) |
Myopia |
>–5.00 |
>–4.00 |
>–3.00 |
Hyperopia (no manifest deviation)* |
>+6.00 |
>+5.00 |
>+4.50 |
Hyperopia with esotropia** |
>+3.00 |
>+2.00 |
>+1.50 |
Astigmatism |
>3.00 |
>2.50 |
>2.00 |
| Anisometropia |
Myopia |
>–2.50 |
>–2.50 |
>–2.00 |
Hyperopia |
>+2.50 |
>+2.00 |
>+1.50 |
Astigmatism |
>2.50 |
>2.00 |
>2.00 |
| Additional Factors |
- History of previous amblyopia or strabismus surgery
- Visual acuity
- Acceptance of eyeglass wear
- Possible accommodative esotropia/monofixation syndrome
- Medical comorbidities
- Developmental delay
|
Note: These values were generated by consensus and are based solely on professional experience and clinical impressions, because there are no scientifically rigorous published data for guidance. The exact values are unknown and may differ among age groups; they are presented as general guidelines that must be tailored to the individual patient.
*May reduce the correction by up to 50% (but no more than 3.00 diopters) depending on the clinical situation.
**In higher hyperopes, reduction of the cycloplegic refraction may be necessary to achieve eyeglass acceptance.
Definitions:
Ratings of Importance to the Care Process
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
Ratings of Strength of Evidence
Level I: Includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
Level II: Includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
Level III: Includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] Panel consensus with external peer review)
