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

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