A Brief Synopsis or AFPs "Childhood Eye Examination"

Childhood Eye Examination
AMANDA L. BELL, MD; MARY ELIZABETH RODES, MD, MEd; and LISA COLLIER KELLAR, MD, MSCE  Wright State University Boonshoft School of Medicine, Dayton, Ohio
Am Fam Physician. 2013 Aug 15;88(4):241-248.
http://www.aafp.org/afp/2013/0815/p241.pdf

     Eye examinations should begin at the first well child visit. The purpose is to identify treatable conditions and refer them to the proper specialist. As with all exams, a past medical and family history can reveal important risk factors. The first part of the eye exam is the visual acuity test. It should be done within three years of age. There are charts of pictures instead of letters if the child cannot read. Eyes should be covered individually and tested separately. 20/20 vision may not evolve until the child is six years old, but the vision should at least be equal. The eyes should not be more than two lines apart on the eye chart. The child should not get more than three wrong on the 20/30 line.
     External examination of the eye includes the eyelids, orbits, sclera, conjunctiva, cornea, and iris. The lacrimal sac should be evaluated if there is persistent discharge. Excessive tearing (accompanied with redness and corneal edema) is a sign of childhood glaucoma.
    Pupillary response is another part of the test. Anisocoria is a difference in pupil size greater than 1 mm, which may be a normal finding. Horner syndrome or third nerve palsy may be seen with this test.
     The child should respond to the presence or the physician's face within six weeks, and should be able to follow and track an object within two months. Ocular alignment may deviate as a normal variant for the first four months, but beyond that will require a referral. The corneal light reflex should be equal and symmetrical by six months of age.
     There are three other tests to check for alignment. The cover test is done by covering one eye while watching for the other eye deviate. The cover-uncover test is done by rapidly covering and uncovering the same eye and watching for it to deviate. The alternate cover test is done by alternating which eye you are covering in rapid succession (left right left right...), while watching for deviation. These tests are performed while having the patient focus on a fixed object, one time far and one time near. Strabismus is a cause for referral. Amblyopia is caused from any alteration in vision that affects the image that the brain receives. A child may tilts his or her head to compensate for the abnormality.
     The red light reflex is used to detect ocular alignment, cataracts, refractive, or retinal problems. It is a two part test (which is news to me!) Each eye is checked individually from 12-18" and checked together from 2-3'. The color should be orange/red. Asymmetry of color between the two eyes or presence of a dark or white spot could be leukocoria, retinoblastoma, cataract, or a refractive error A referral is needed.