2 - Pediatric Eye Exam Techniques for Infants and Young Children

Question 1

what are some challenges of a pediatric eye exam?

Answer 1

requires skill, speed and enthusiasm and requires variety of VA tests and binocular function tests

Question 2

what is the basic purpose of the pediatric eye exam?

Answer 2

to identify and initiate management of: amblyopia, strabismus, refractive error, ocular/visual pathology and significant functional vision issues

Question 3

what are you concerned about specifically for infants (birth to 18 months)?

Answer 3

amblyopia, strabismus (congenital or pseudo-ET), high refractive error, congenital malformations, neurologic disorders, pathology, development delays

Question 4

what are you concerned about specifically for toddlers (18 months - 3 years)?

Answer 4

amblyopia, strabismus (accommodative-ET), moderate refractive error, congenital malformations, pathology, development delays

Question 5

what are you concerned about specifically for preschoolers (3-5 years)?

Answer 5

amblyopia, significant phorias/tropias, mild-moderate refractive error, ocular or visual pathway pathologies

Question 6

what are you concerned about specifically for school-aged children (6-18 years)?

Answer 6

amblyopia, significant phorias/tropias, mild-moderate refractive error, functional BV/accommodaitve anomalies, oculomotor dysfunction, learning difficulties, color vision anomalies, ocular/visual pathway pathology

Question 7

what do you look for when you are observing the child?

Answer 7

general appearance, developmental milestones, behavior/energy level, use of glasses, level of independence, head/body posture

Question 8

what parts are different for a child’s history than adults?

Answer 8

birth history, delays in reaching milestones, social/educational history

Question 9

what are 4 types of VA tests for infants?

Answer 9

preferential looking, M/B fixation pattern (avoid), OKN and VEP

Question 10

what are 2 types of VA tests for toddlers/preschool children?

Answer 10

preferential looking (cardiff) and subjective (lea symbols, patti pics, HOTV, tumbling E, brocken wheel)

Question 11

what type of VA test can you use for school-age children?

Answer 11

recognition

Question 12

what is the monocular/binocular fixation pattern (fix, follow, maintain) VA method?

Answer 12

gross assessment of acuity and relative difference in acuity between eyes

Question 13

why should you avoid the monocular/binocular fixation pattern (fix, follow, maintain) VA method?

Answer 13

not quantitative (or reliable), may show fixation preference without amblyopia when strabismus is present

Question 14

what are the general advantages of the VEP?

Answer 14

most objective test - doesn’t require perceptual recognition, communication, coordinated motor responses

Question 15

what are the general limitations of the VEP?

Answer 15

expensive, time consuming (set up), and rarely used in clinic

Question 16

what is preferential looking (PL)?

Answer 16

child will fixate on a pattern rather than a plain stimulus - no preference observed when the pattern cannot be resolved

Question 17

what are the advantages of PL?

Answer 17

objective, doesn’t require perceptual recognition, communication, coordinated motor responses

Question 18

what are the limitations of PL?

Answer 18

tests near VA only, underestimates VA loss due to amblyopia, refractive error and macular/foveal pathology, difficult to judge pattern with strabismus/nystagmus, time-consuming, expensive

Question 19

when does FPL reach adult levels?

Answer 19

increases rapidly in the first 6 months and reaches adult levels at 3-5 years

Question 20

what is the VA using FPL for a 1 month old? 3 month? 6 month? 12 month?

Answer 20

FPL = 1 cycle/degree (20/600)
FPL = 3 cycles/degree (20/200)
FPL = 6 cycles/degree (20/100)
FPL = 12 cycles/degree (20/50)

Question 21

what are tellar acuity cards? advantages/disadvantages?

Answer 21

measure VA in infants
advantage = monocular and binocular norms, peep-hole
disadvantage = large and difficult to transport

Question 22

what are the lea grating paddles?

Answer 22

same grating pattern as tellar cards = more portable but examiners face can be distracting

Question 23

what are the cardiff cards?

Answer 23

alternative preferential looking test for toddlers or individuals with disabilities (6 familiar pictures = fish, house, apple, train, boat, duck)
vanishing optotypes

Question 24

what are the advantages/disadvantages for cardiff cards?

Answer 24

advantage = pictures maintain interest
disadvantage = poor at detecting refractive error

Question 25

what is the expected cardiff acuity (monocular) for a 12-18 month old?

Answer 25

+0.4 to +0.8 LogMAR (20/50 - 20/120)

Question 26

what is the expected cardiff acuity (monocular) for a 18-24 month old?

Answer 26

+0.1 to +0.7 LogMAR (20/25 - 20/100)

Question 27

what is the expected cardiff acuity (monocular) for a 24-30 month old?

Answer 27

+0.1 to +0.5 LogMAR (20/25 - 20/60)

Question 28

what is the expected cardiff acuity (monocular) for a 30-36 month old?

Answer 28

+0.0 to +0.3 LogMAR (20/20 - 20/40)

Question 29

what is required from the child to perform subjective VA’s?

Answer 29

receptive and expressive communication skills (verbal or coordinated motor responses)
usually tested at 10ft

Question 30

what are the advantages for the lea symbols, patti pics and HOTV?

Answer 30

both can be used at distance and near, well standardized and available in LogMAR form with crowding bars

Question 31

when can you use the tumbling E?

Answer 31

it is a resolution acuity task = required understanding of laterality and directionality

Question 32

when can you use the broken wheel for VA?

Answer 32

it is a resolution acuity/two-forced choice = doesn’t require understanding of laterality or directionality

Question 33

when do you use the allen figures?

Answer 33

avoid - they are not well standardized and no consistent critical detail

Question 34

what is the expected LogMAR monocular acuity for a 3 year old?

Answer 34

+0.450 to -0.025 (20/50-20/20)

Question 35

what is the expected LogMAR monocular acuity for a 4 year old?

Answer 35

+0.250 to -0.100 (20/40 - 20/15)

Question 36

what is the expected LogMAR monocular acuity for a 5 year old?

Answer 36

+0.175 to -0.150 (20/30 - 20/15)

Question 37

what is the expected LogMAR monocular acuity for a 6 year old?

Answer 37

+0.175 to -0.200 (20/30 - 20/15)

Question 38

what is the expected LogMAR monocular acuity for a 7 year old?

Answer 38

+0.175 to -0.225 (20/30 - 20/10)

Question 39

what is a significant difference between eyes or visits for the keeler cards, cardiff cards, snellen, or LogMAR?

Answer 39

keeler = 2 cards 
cardiff = 2 cards
snellen = 3 lines 
LogMAR = 4 letterns

Question 40

why should you make of note of the child’s co-operation?

Answer 40

often you get good co-operation for one eye and then the child gets bored and the other eye doesn’t look as good
need to compare to other visits/future tests

Question 41

how should you measure a child’s subjective refractive error?

Answer 41

use a trial frame instead of phoropter (pay close attention to child’s behavior, quality of responses)

Question 42

what are 4 ways to determine a childs eye alignment (motor evaluation)?

Answer 42

hirschberg, krimsky, bruckner and cover test

Question 43

what are 4 things that a bruckner test can tell you?

Answer 43

presence of: strabismus, anisometropia, media opacities, pupil size asymmetries
and insight into likelihood of amblyopia

Question 44

which eye will have the brighter reflex during the bruckner test if the patient has strabismus?

Answer 44

the turned eye = brighter reflex

Question 45

what sensory test can you use with infants and toddlers?

Answer 45

stereo smile

Question 46

what sensory tests can you use with preschoolers?

Answer 46

worth 4 dot, random dot E, randot sterofly

Question 47

when performing ocular motilities on children, what are you looking for?

Answer 47

comitancy, nystagmus, potential VF defects

Question 48

what are the 6 categories of ocular motilities?

Answer 48

position maintenance (fixation), versions (EOMs), smooth pursuits, saccades, NPC (vergences), VOR and OKN

Question 49

when is the accommodative status the most relevant?

Answer 49

at school age

Question 50

what is the monocular estimation method (MEM) assessing?

Answer 50

the accuracy of the accommodative system

Question 51

when is color vision a concern?

Answer 51

when children are 3-4 years old (1/12 males and 1/200 females)

Question 52

what are the 3 tests for color vision?

Answer 52

waggoner HRR, ishihara, and PV-16

Question 53

what are you looking for specifically in the orbit, lids/lashes and lacrimal system?

Answer 53

size/position of orbit
lid position (entropion, ectropion), trichiasis, hordeolum/chalazion and if lacrimal system is obstructed

Question 54

what are you looking for on the iris? lens?

Answer 54

lisch nodules

opacities and red reflex

Question 55

what size pupils for infants usually have?

Answer 55

usually miotic and are larger when startled

Question 56

what are the signs of congenital glaucoma?

Answer 56

increased corneal diameter, corneal clouding, Haab’s striae, large/asymmetric cupping, optic atrophy, associated systemic or ocular abnormalities (iris, angle)

Question 57

when should you perform a DFE on a child?

Answer 57

all children especially at first eye exam

Question 58

why is DO difficult on young children?

Answer 58

due to proximity - have a tendency to keep looking at the light
indirect methods are more successful