Practical Vision Screening in the Pediatric Office

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Practical Vision Screening in the Pediatric Office

• Jerry E. Berland, MD, FAAP
• Pediatric EyeCare of Atlanta

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Pediatric EyeCare of Atlanta

• Stephen B. Levine, MD, FACS, FAAP
• Jeri S. Salit, MD, FAAO
• Jerry E. Berland, MD, FAAP, FAAO
• Stephen N. Lipsky, MD, FAAO

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GA
I 575
400
I 85
Woodstock
Lilburn
Atlanta
I 75
I 285
I 85
I 75
Fayetteville
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Vision Screening

• Detect abnormal visual functioning or conditions
  that may lead to abnormal visual functioning.

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Amblyopia- Lazy Eye

• A reduction in visual acuity that is due to
  abnormal visual experience in early life.
• Affects 4 of the population

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Causes of Amblyopia

• Strabismus
• Anisometropia
• Visual obstructions such as cataracts and eyelid
  conditions

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Strabismus

• Eye misalignment
• Greek to squint or look obliquely at

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• Esotropia Crossed eyes
• Exotropia Out-turned eyes
• Hypertropia An eye turned upward
• Hypotropia An eye turned downward

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Glasses in Children

• Farsightedness (Hyperopia)
• Nearsightedness (Myopia)
• Astigmatism
• Reading glasses (bifocals)

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Rationale for Vision Screening

• Very early treatment of congenital abnormalities
  can prevent severe vision loss.
• 2 of American children ages 1 to 3 years old
  have a manifest strabismus. (An additional 3
  have latent strabismus.)

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Rationale for Vision Screening

• 1 of 4 school-age children has a vision problem
  that requires professional care
• Refractive errors (82)
• Amblyopia (10)
• Strabismus (5)
• Cataracts and other conditions (3)

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Rationale for Vision Screening

• Early identification and treatment of children
  with strabismus could have prevented amblyopia in
  approximately 5 million Americans.
• Prevent Blindness Crossed Eyes, A Needless
  Handicap 1981

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Vision Screening -- Ages

• Birth
• 4-6 months
• Toddler
• Pre-school
• School age

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Vision Screening Equipment

• 10 ft. visual acuity cards
• Direct ophthalmoscope
• Transilluminator light
• Finger puppet
• Cover paddle
• Color test plates

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Vision Screening Sequence

• Observation
• Corneal light reflex testing
• Bruchner red reflex test
• Cover test for alignment
• Cover test for amblyopia or organic vision loss
• Distance visual acuity
• Other optional tests

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Observation and Inspection

• Use light with toy
• Judge visual interest
• Is fixation steady? (Nystagmus)
• Pupil reactivity
• Examine external eye
• Simultaneous with corneal reflection test

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Corneal Light Reflection Testing

• Use light with toy
• Blink light for increased interest
• Look for asymmetry
• Nasal displacement exotropia
• Temporal displacement esotropia

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Bruchner Red Reflex Test

• Use ophthalmoscope at arms length
• Compare light reflection from each pupil
• Detects
• strabismus
• asymmetric refractive error
• cataracts
• Underutilized but valuable

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Cover Test for Alignment

• Use detailed target
• Look for shift in either eye
• Can detect manifest (cover test) and latent
  (alternate cover test) strabismus

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Cover Test for Amblyopia or Organic Vision Loss

• Objects to covering
• Is visual interest and tracking, reaching, etc.,
  equal with each eye?

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Distance Visual Acuity

• Screening for distance visual acuity is the
  single most important test of visual ability

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Standardized Technique

• Standard charts
• Adequate lighting
• Standard distance 10 feet or 20 feet
• Re-screen children who fail within 2 weeks

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Recommended Tests and Methods

• Snellen ABCs
• E game
• HOTV matching
• Allen Pictures
• Linear vs. isolated

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Criteria for Referral

• Age 3 to 5 20/50 or poorer
• Age 5 to 8 20/40 or poorer
• Age 8 and older 20/30 or poorer
• Two lines difference
• Symptoms or observable conditions

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Other Tests

• Stereopsis
• Color vision
• Photo screening

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Color Vision Testing

• Ishihara color plates
• Males 8 deficient
• Females 0.5 deficient
• Test in 3rd to 7th grade

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Vision Screening

• Birth
• Observation and inspection
• Red reflex testing

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Vision Screening

• 4-6 months of age
• Observation and inspection
• Corneal light reflex testing
• Bruchner red reflex testing

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Vision Screening

• Toddler
• Observation and inspection
• Corneal light reflex testing
• Bruchner red reflex testing
• Cover test for alignment
• Cover test for amblyopia or organic vision loss

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Vision Screening

• Pre-school
• Observation and inspection
• Corneal light reflex testing
• Bruchner red reflex testing
• Cover test for alignment
• Cover test for amblyopia or organic vision loss
• Distance visual acuity

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Vision Screening

• School-age
• Observation and inspection
• Corneal light reflex testing
• Bruchner red reflex testing
• Cover test for alignment
• Cover test for amblyopia or organic vision loss
• Distance visual acuity
• Other optional tests

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Vision Screening Pearls

• Infants and Toddlers
• Toy over light allows easier and more accurate
  corneal light reflex testing
• Bruchner red reflex testing underutilized but
  valuable
• Objects to cover may equal Amblyopia

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Vision Screening Pearls

• Pre-school and School-age
• Make testing fun
• Beware of the professional peeker
• Testing at 10 feet may be better