Eye and Vision Exams in the Outpatient Clinic

Erika Beard-Irvine MD

LCDR MC (FS) USN

Objective

AAP practice parameters for red reflex and vision screening

Techniques for red reflex and vision screening

Disease processes Referral criteria

Terminology

Myopia

http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html

http://www.ophthobook.com/chapters/pediatrics

Terminology

Myopia Hyperopia

http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html

Terminology

Myopia Hyperopia Astigmatism

http://www.childrenshospital.org/az/Site1517/mainpageS1517P0.html

Terminology

Myopia Hyperopia Astigmatism Amblyopia Anisometropia

http://www.ohioamblyoperegistry.com/

Red Reflex Examination

Newborn examination All routine health supervision visits

http://www.bartsandthelondon.nhs.uk/forgps/checking_for_the_red_reflex_in_children.asp

http://seeweimer.com/eye-anatomy/

Technique

Ophthalmoscope power to 0 Lights off Simultaneously at 2-3 feet away Separately at 12-18 inches away

http://www.ophthobook.com/chapters/pediatrics

Leukocoria

http://www.daisyseyecancerfund.org/rb/eye/index.html http://www.orphancancer.org/ORbIT/leukocoria.html

http://www.nature.com/onc/journal/v25/n38/fig_tab/1209622f1.html

Differential of Leukocoria

Retinoblastoma Congenital cataract ROP PFV Coloboma

• Uveitis• Toxocariasis• Coats’ disease• Vitreous hemorrhage• Retinal dysplasia

Absent Red Reflex

http://www.peds.ufl.edu/peds2/research/debusk/pages/page7_61.html

Absent Red Reflex

http://www.bartsandthelondon.nhs.uk/forgps/checking_for_the_red_reflex_in_children.asp

Asymmetric Red Reflex

http://www.abcd-vision.org/vision-screening/red-reflex.html

Asymmetric Red Reflex

http://www.abcd-vision.org/vision-screening/bruckner.html

Asymmetric Red Reflex

Mills, MD. “The eye in childhood,” Am Fam Physician. 1999 Sep 1;60(3):907-916.

Eye Evaluation

Ocular history Vision assessment External inspection of the eye and lids Ocular motility assessment Pupil examination Red reflex examination Attempt at opthalmoscopy (>3 yo)

Ocular History

Does you child seem to see well? Does your child hold objects close to his/her face when

trying to focus? Do your child’s eyes seem to cross or drift? Do your child’s eyes appear unusual? Do your child’s eyelids droop or does 1 eyelid tend to

close? Have your child’s eyes ever been injured? Family history of eye disorders or early eyeglass wear.

Vision Assessment

Fix and follow Visual acuity measurement (>3 yo) Photoscreening

Photoscreening

Screening for amblyogenic factors: Strabismus Media opacities Significant refractive errors

Evaluate photo of red reflex and pupillary light reflex

AAP says it could be helpful but recommends more study

External Examination

Tearing or discharge Corneal clouding

http://www.mps1disease.com/en/patients/about/signs-and-symptoms/corneal-clouding.aspx

External Examination

Tearing or discharge Corneal clouding Ptosis

http://www.cosmeticeyesandface.com/Pediatrics.html

External Examination

Tearing or discharge Corneal clouding Ptosis Iris abnormalities

http://www.glaucomaconsultantsnorthwest.com/glaucoma%20in%20children.html

http://www.med.umn.edu/ophthalmology/faculty/schimmenti/home.html

Ocular Motility

Corneal reflex test Extra-ocular movements Cover-uncover test Random dot E stereo test

Corneal Light Reflex

http://health.utah.gov/cshcn/HSVS/photo.html

Mills, MD. “The eye in childhood,” Am Fam Physician. 1999 Sep 1;60(3):907-916.

Mills, MD. “The eye in childhood,” Am Fam Physician. 1999 Sep 1;60(3):907-916.

http://www.wahajr.com/hajrvb/showthread.php?t=402925749&page=4

Ocular Motility

Corneal reflex test Extra-ocular movements Cover-uncover test Random dot E stereo test

Ocular Motility

Corneal reflex test Extra-ocular movements Cover-uncover test Random dot E stereo test

Random Dot E

http://health.minnesota.gov/divs/fh/mch/webcourse/vision/mod7a.cfm

Pseudostrabismus

http://www.sarawakeyecare.com/Atlasofophthalmology/paediatric/paediatricophthalmologytpicture4.htm

Pupil Exam

http://www.atlasophthalmology.com/atlas/photo.jsf?node=5832&locale=en

Referral Criteria

Leukocoria or absent red reflex Any abnormality on exam Persistent torticollis or head tilt FHx of retinoblastoma FHx corrective lenses in preschool or “lazy

eye” Parent concern