The pediatric population should be a primary concern to all optometrists, as one in five preschool-aged children have vision problems.1-7 Knowing this, it is shocking to learn that according to the American Optometric Association's Think About Your Eyes campaign, nearly 50% of parents with children under the age of 6 have never taken their child to an eye doctor.”
The value of early pediatric eye consultations
As a family’s eyecare provider, the conversation around children’s eye health should occur before the baby arrives for parents/patients to understand the vital role that optometrists play. The following is a recommended exam protocol.
With the increasing use of screens in personal and academic settings, it is encouraged to have children seen yearly for their eye exams after they begin school. This ensures that their visual systems are healthy and equipped for the visual demands of learning.
Table 1 highlights recommended eye exam protocols by age according to the InfantSEE program.
| Exam | Age | Protocol |
|---|---|---|
| 1st | Between 6 to 12 months under the InfantSEE program | The InfantSEE program is a public service that provides a no-cost exam (regardless of insurance status) to infants between 6 to 12 months of age by participating providers. This program has identified 13,700+ causes for concern in kids’ eye health since the start of the program. |
| 2nd | 3 years | If there is no cause for concern at the initial visit, it is recommended that the child return for an exam at age 3. |
| 3rd | 5 years | If there is no cause for concern, an exam at age 5 before starting kindergarten is recommended. Recommendations will vary for follow-up depending on the child and the case. |
Table 1: Courtesy of the American Optometric Association
To become an InfantSEE program provider, click here.
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Early Pediatric Eye Exam Guidelines Cheat Sheet
This cheat sheet provides refractive error guidelines to keep in mind during pediatric eye exams and information about the InfantSEE program.
Eye exam protocols for infants and preschoolers
Infant and preschool exams should have all the components of a typical eye examination for an adult. It is essential to explore all the pieces of the visual system of a developing child to ensure proper visual development. It is encouraged to discuss with the parents prior to the exam that you may not be able to attain all of the information on the first visit depending on the temperament of the child.
Set the stage for success by explaining to the parent/caregiver what the expectation is for the exam and that it is okay if they have to return for additional testing. Below will detail all of the parts of a pediatric exam.
Patient history
For this patient population, the pregnancy, birth history, and discussion of developmental milestones are imperative to understand any potential issues.
Visual acuity
Assessing the visual acuity in an infant/child will be dependent on their age and ability to match/identify shapes, letters, and numbers. Visual acuity should be tested monocularly and binocularly to rule out anisometropia or amblyopia. If there is any resistance to occlusion of one side, this may be indicative of an underlying issue.
Types of visual acuity
- Forced preferential looking (FPL).
- FPL is a technique that can be used for younger/non-verbal patients that helps to get a baseline of what their visual acuity is. Grating acuity cards, such as Teller Acuity Cards or Lea Paddles, can also be used.
Optotype testing
The target here may be symbols (i.e., Lea Symbols), letters, or numbers. This presentation can be done with either the child matching or identifying the target. The recommendation for presentation in young kids should be done as a single optotype initially, and then depending on the child’s ability, whole-line acuity can be attempted.
It is essential to properly record how the target was presented in your charting so you can accurately track any improvements or decreases in their acuity. For example, “Single Picture-Matching Acuity 20/30” or “Single Letter Acuity OU: 20/40.”
Retinoscopy
Retinoscopy is single-handedly one of the most useful skills you can have as an optometrist when dealing with the pediatric population. Often babies and young kids do not stay still long enough to obtain an accurate auto-refraction, leaving you and your retinoscopy at the helm of discovering their refractive error.
If you are just getting started with the pediatric population, I recommend that you hone your retinoscopy skills with your adult population first. Practice retinoscopy on all of your patients before you refract them; it takes just a minute or so but can give you an incredible amount of information about the patient and their visual system, not just their refractive error.
Tips for performing retinoscopy on pediatric patients
Retinoscopy with children is often done with your lens rack so you can move with the patient and quickly scope and change lenses. Occasionally you may have to scope with trial lenses, but this is often reserved for kids that do not like the lens bars in front of their faces.
Additionally, retinoscopy should be performed both dry and wet (see below for recommendations of cycloplegic agent) as both provide you with information about your patient’s vision. In addition, dynamic retinoscopy can be performed for additional information on the patient’s accommodative system.
Binocular vision/motility
The extent of binocular testing will be dependent on the age of the child. However, at the very least, the following four tests should be attempted at any age.
1. Ocular alignment at distance and near
This should be done with both unilateral and alternate cover tests. For young patients with poor visual attention, Hirschberg testing is recommended.
2. Ocular motility
For young kids, testing for eye tracking and version is often done with a toy or a penlight. A tip for testing this is to make it a game and have them ‘push’ the penlight once they follow where it went. This keeps them engaged and often breaks the ice with the child.
3. Near point of convergence (NPC)
This should be done on the patient’s midline and watch for any break in fusion, which often looks like the child looking away. Sometimes the recovery here is hard to record. If you only get the break that still gives you a lot of information!
It is recommended that this test be done with an accommodative target and a non-accommodative target and then repeated. Repeat testing can reveal any fatigue in the system, and the potential for intermittent eye turns to appear.
4. Stereopsis
In this population, global RDS testing is sufficient in identifying if the patient is binocular. The Randot Preschool Stereotest or even the Stereo Fly is useful. With young or non-verbal children, you can place the glasses on them and watch for a response of them reaching out to ‘touch’ the image that they see floating.
This can be recorded as “+ response,” and as the child ages, there can be more accurate measures of the level of stereopsis present.
5. Color vision
A family history of color vision deficiencies will be identified during case history, but this should be tested on each pediatric patient. It should be noted that this testing is often unreliable before the age of 58.
However, the Waggoner Diagnostics Color Vision Testing Made Easy test is designed to screen kids as young as 3. This test has circles, stars, and squares. It is important to identify any issue with color identification early to ensure proper educational intervention. There are a wide array of color vision tests available on the market.
6. Overall ocular health
A full assessment of the eye’s ocular health can be done on patients of all ages. Pupil testing and the evaluation of the anterior segment are done easily in this age demographic. More challenging tests would be gross confrontation visual field testing and measurement of intraocular pressure.
From experience, visual field testing is best done with a toy that is presented from the side vs. fingers. Intraocular pressure should be attempted. The advent of the iCare Tonometer has been an incredibly useful and accurate tool,9 but at the very least, palpate closed lids to identify that the eyes are equally soft.
Assessing the posterior segment in pediatric patients
Evaluation of the posterior segment is recommended and achieved with a cycloplegic agent, typically cyclopentolate (0.50% for infants 12 and under, 1% for older).10 This can be achieved by the traditional methodology of drop insertion or by spraying the lids/lashes with the drug.
Sometimes kids may be reluctant to cooperate during the instillation of eye drops. Having parents accompany their children, either by holding their hands, or offering the child to sit on their laps, can facilitate this process. Children who are unable to cooperate in-office may need to be rescheduled for a follow-up visit.
I’ve had great success with giving parents cyclopentolate drops to take home. I instruct them to instill the drops in their child’s eyes prior to them waking for their morning follow-up visit with me.
Reasons for visual testing on infants and toddlers
There are many visual conditions that may occur during childhood that can negatively impact visual development. Early intervention in the following listed areas is key to a successful visual outcome.
Refractive errors
The easiest to treat, but sometimes the hardest to tell, is when a child has an underlying refractive error. Oftentimes, kids cannot verbalize that they are not seeing well, and for them, this is their only visual experience so it is "normal."
Sometimes kids will show signs of underlying refractive errors by being sensitive to the sun, squinting/rubbing an eye, turning/tilting their head, complaining of headaches, holding things abnormally close, or having difficulty with eye-hand coordination.
Provided by the American Optometric Association, Table 2 lists the prevalence of refractive errors at 6 months to 72 months of age.
| Condition | Error | White/Non-Hispanic | Hispanic | African American | Asian |
|---|---|---|---|---|---|
| Myopia | ≤1.000 spherical equivalent (SE) | 1.2% | 3.7% | 6.6% | 4.0% |
| Myopia | ≥ 1.000 SE | 0.7% | 5.5% | ||
| Hyperopia | ≥2.000 SE | 25.7% | 26.9% | 20.8% | 13.5% |
| Hyperopia | ≥3.000 SE | 8.9% | 4.4% | ||
| Astigmatism | ≥1.500 cylindrical refractive error | 6.3% | 16.8% | 12.7% | 8.3% |
| Astigmatism | ≥3.000 cylindrical refractive error | 2.9% | 1.0% | ||
| Anisometropia | ≥1.000 SE | 4.3% | 4.2% |
Table 2: Courtesy of the Multi-Ethnic Pediatric Eye Disease Study Group and the Baltimore Pediatric Eye Disease Study
Dr. Suzanne Leat from the School of Optometry Waterloo published a guideline for spectacle prescribing in infants and children. It is important to note that your prescription in your pediatric population can have large effects on their visual development and future refractive error.
It is recommended to prescribe the least amount of power to have the most impact on the visual system, while considering other factors like binocularity, accommodation, the natural course of emmetropization, and the visual goals for your patient.
Strabismus
This is often obvious, and parents will bring the child in because they see an eye turn. Just like an adult, a child can suffer from any type of strabismus, whether it be exotropia, esotropia, or hyper/hypotropia.
One of the most common strabismus types in this age demographic is accommodative esotropia, estimated at 1 to 2% of the population with no sex or race predilection.12 Parents often start to notice the eye turning inward while the child is playing or reading, and it may come on suddenly, slowly, or after the child is sick.
Treatment for strabismus is dependent on the frequency, size, and consistency of the turn. The first line of treatment is always the assessment of refractive error and how lenses can shift a patient’s visual posture. From there, the determination of the need for surgery or vision therapy (or both!) is made.
Amblyopia
The etiology of the amblyopia (refractive vs. strabismus vs. deprivation), will determine the course of treatment. I like to refer to amblyopia as a "monocular manifestation of a binocular disorder," and the research is catching up with what optometry has known for years. The best approach to treating amblyopia is a binocular treatment plan with things like monocular fixation in a binocular field (MFBF) and other red/green-type activities.13
Other ocular health concerns to assess in pediatric patients
The list of potential ocular health concerns in this population is extensive, but I would like to highlight two.
Congenital cataracts
Congenital cataracts are estimated to be present in 3 to 4 infants per 10,000 live births.14 These are often caught early by the pediatrician or the parent, but early intervention is key to the best visual outcome.
As an optometrist, they may come to you for specialty contact lens fitting (i.e., aphakia) or to treat any amblyopia that may have developed.
Retinoblastoma
Retinoblastoma is a cancer of the retina and most commonly affects children under the age of 5 with approximately 300 children in the United States affected.15 The two classic signs of retinoblastoma are leukocoria or a "white pupil" (often seen in photos) or strabismus.
This cancer can be genetic or idiopathic and may be unilateral or bilateral. Prognosis is dependent on a multitude of factors, but early detection and quick assessment are key in the management of this disease.16
Pediatric patients and screen time
If you are seeing the pediatric population, it is imperative to discuss screen time recommendations with parents.
The American Psychological Association recommends the following:
- Under 2: Zero screen time with the exception of video chatting with family and friends
- 2- to 5-year-olds: No more than one hour per day of high-quality (interactive, learning-based) programming that is viewed with a parent or sibling.
- 5- to 17-year-olds: No more than 2 hours a day, excluding time spent on digital devices for school/work.
Similarly, the American Academy of Pediatrics recommends setting up a family media plan to help set healthy boundaries for everyone. It is recommended that you approach this conversation with parents from a place of understanding rather than judgment because most parents are aware their children have too much screen time. Discuss with them the potential visual effects screens can have on their child and give them resources and tools to support them.
5 tips to recommend for developing good visual skills
Lastly, at the conclusion of each pediatric exam, I speak to the parents about things they can do to help develop healthy vision. These are some of the recommendations.
- Play: Doing things like rolling, catching, tossing a ball/balloon, building blocks, and completing puzzles with your child are great activities that help engage a lot of different parts of their visual systems.
- Read: Reading should start as early as possible! Interact with your child as you are reading- point to words and pictures, and as they grow, have them identify things that they see.
- Get messy: Let your child get messy! Play with finger paints, color, cut, and do things like beading and other arts/crafts. All of these experiences lay the groundwork for good visual motor and fine motor skills that lead to school readiness.
- Get outside: Moving their bodies and exploring their visual world is imperative to visual development. If there is a family history of myopia (nearsightedness) I discuss benefits here as well.
- Reduce screen time: Kids are not meant to be on screens; they are meant to learn and interact with the world. I always tell parents to be the example and tell them to put their phones down and see what fun they can get into together!
At the end of the day, the pediatric population is a unique demographic that optometrists are very well equipped to treat. Opening your doors (and hearts!) to this population is extremely fulfilling as a practitioner and is a family practice builder!
It should be highlighted that the AOA created a Comprehensive Pediatric Eye and Vision Examination Guideline that is much more extensive than what is able to be covered here.
