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Chapter 17. Special Subjects of Pediatric Interest

Douglas R. Fredrick, MD

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.

All infants should have their eyes examined as a part of the newborn physical examination, and the practitioner should look for the presence of a normal red reflex in both eyes, normal external ocular anatomy, and symmetry between the eyes. A careful eye examination soon after birth may reveal congenital abnormalities that suggest the presence of abnormalities elsewhere in the body and the need for further investigations. A pediatric examination table is presented in Table 17–1.

Table 17–1. Pediatric Eye Examination Schedule
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Table 17–1. Pediatric Eye Examination Schedule
Neonatal Examination
External eye examination and confirmation of presence of red reflex. In infants requiring examination for retinopathy of prematurity (ROP) or with abnormal red reflex, dilate eyes with phenylephrine 2.5% and cyclopentolate 1% or tropicamide 1% in each eye 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
Test ocular fixation and ocular movements. Look for strabismus.
Age 4 years
Test visual acuity with Snellen letters, HOTV matching optotypes, or Lea symbols. Visual acuity should be normal (20/20–20/30).
Age 5-16 years
Test 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.

The instruments required for the ocular examination of the newborn are a good hand light, direct and indirect ophthalmoscopes, a loupe for magnification, and occasionally a portable slitlamp. Phenylephrine 2.5% and cyclopentolate 1% or tropicamide 1% are generally safe for pupillary dilation in full-term neonates, although even these concentrations may have adverse effects on blood pressure and gastrointestinal function in premature neonates and those with lightly pigmented eyes; in these instances the combination of cyclopentolate 0.2% and phenylephrine 1% (Cyclomydril) should be ...

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