Pediatric ophthalmology offers particular challenges to the ophthalmologist, pediatrician, and family physician. Symptoms are often nonspecific, and the usual examination techniques require modification. Development of the visual system is still occurring during the first decade of life, with the potential for amblyopia even in response to relatively mild ocular disease. Because the development of the eye often reflects organ and tissue development of the body as a whole, many congenital somatic defects are mirrored in the eye. Collaboration with pediatricians, neurologists, and other health workers is essential in managing these conditions. Similar collaboration is required in assessing the educational needs of any child with poor vision.
Details of the embryology and the normal postnatal growth and development of the eye are discussed in Chapter 1.
Every newborn’s physical examination should include assessment for normal symmetrical external ocular anatomy and normal red reflex in each eye (Table 17–1). If any abnormality is identified, full ophthalmological assessment is required, for which the necessary instruments are hand light, loupe, direct and indirect ophthalmoscopes, and occasionally a portable slitlamp. Any congenital abnormality may be associated with nonocular abnormalities requiring further investigations.
Table 17–1.Pediatric Eye Examination Schedule |Favorite Table|Download (.pdf) Table 17–1. Pediatric Eye Examination Schedule
External ocular anatomy and red reflex.
In infants requiring examination for retinopathy of prematurity (ROP) or with abnormal red reflex, dilate the pupils with phenylephrine 2.5% and cyclopentolate 1% or tropicamide 1% instilled 1 hour prior to examination. (Cyclopentolate 0.2% and phenylephrine 1% combination [Cyclomydril] is used in babies with lightly pigmented eyes and premature neonates.) Special attention should be paid to the optic disks and maculas; detailed examination of the peripheral retinas is not necessary unless the baby is at risk for ROP.
|Age 6 months Ocular fixation, alignment (looking for strabismus), and movements. |
|Age 4 years Visual acuity with Snellen letters, HOTV matching optotypes, or Lea symbols. Visual acuity should be normal (20/20–20/30). |
|Age 5–16 years Visual acuity at age 5. If normal, test visual acuity with the Snellen chart every 2 years until age 16. Color vision should be tested at ages 8–12. No other routine eye examination (eg, ophthalmoscopy) is necessary if visual acuity is normal and the eyes appear normal upon inspection. |
Assessment of vision of the neonate is limited to observing the following response to a visual target, the most effective being a human face. Visual fixation and following movements can be demonstrated in most neonates; however, during the first 2 months of life, some do not demonstrate consistent fixation behavior and following (smooth pursuit) eye movements may be coarse and jerky.
The eyelids are inspected for growths, deformities, lid notches, and symmetric movement ...