To those who have never submerged themselves in it, a pediatric eye clinic feels like a whole new world. From different history questions to unique exam techniques, it is easy to get lost in how to make an exam go smoothly and make sure all of the right data is collected.
Often, pediatric eye clinics have pediatric ophthalmologists and pediatric optometrists working side by side. With that, you now have to adapt to plus cylinder form and different strabismus notations.
This clinic guide is designed to help optometry students and residents get up to speed on how to be proficient in pediatric clinics.
Taking pediatric patient history
Taking a thorough history will always be vital to the diagnosis, no matter what exam room setting. This is especially true in pediatrics. Many eye conditions in pediatrics present in specific age groups, so it is important to know what those may be.
First, review the patient’s systemic history, as there are many ocular manifestations that can occur with systemic conditions. Second, ask about the birth and developmental history, including therapies.
To learn more about how to take a birth and developmental history, check out Obtaining Developmental History for Pediatric Exams with Downloadable Checklist!
Screening for retinopathy of prematurity (ROP)
Screen for retinopathy of prematurity (ROP) by asking questions regarding birth history. Determining how many weeks the patient was born can identify premature babies and whether or not they were at risk for ROP. Also, it gives information about adjusting visual milestones based on age.
Below are the current ROP screening guidelines from the American Academy of Pediatrics (AAP), American Academy of Ophthalmology (AAO), and American Association of Pediatric Ophthalmology and Strabismus (AAPOS):1,2
- Birth Weight (BW): Infants with a BW of ≤1,500 grams (approximately 3.3 pounds)
- Gestational age (GA): Infants born at ≤30 weeks gestation
If ROP is suspected, and or confirmed, ask these follow-up questions:
- Is it one eye or both eyes?
- What was the staging?
- What treatment was utilized (laser vs. anti-VEGF)? Observation?
It is important to note that patients with ROP can have secondary complications from prematurity, the disease itself, and or treatment. Some of those are cataracts, glaucoma, retinal detachment, high refractive error, and strabismus.1
Getting the ocular history and chief complaint
This is going to look a little different depending on what the family states they are here for. Be sure to FOLDARQ (frequency, onset, laterality, duration, associated symptoms, relieving factors, quality) all complaints.
Below is a review of questions that should be asked in addition to the chief complaint. Keep in mind that with pediatric patients, you must dig deeper, as they often don't articulate their concerns the way adults do.
Carefully observing their behavior is also crucial, as it may reveal an additional or underlying chief complaint. For example, frequent rubbing of eyes may indicate allergic conjunctivitis or vision problems.
Questions to ask about pediatric patients alongside the chief complaint:
- Ocular disease
- Are they suffering from redness, tearing, or discharge?
- Do they complain of itchy eyes?
- Do they rub their eyes often?
- Do they complain of eye pain?
- Do they often have headaches?
- Pediatric patients may not explicitly say they have headaches. Ask these questions instead:
- Do they hold their head often? Or rub their temples?
- Do they act uncomfortable for extended periods of time that can’t otherwise be explained?
- Pediatric patients may not explicitly say they have headaches. Ask these questions instead:
- Binocular vision
- Do you ever see two of something instead of one? (i.e., Do you ever see two Mommys instead of one?)
Download the Guide to Pediatric Eye Exams for Optometry Students here
📄
Guide to Pediatric Eye Exams for Optometry Students
Download this cheat sheet developed for optometry students and residents to practice and confidently perform pediatric eye exams.
Special considerations for strabismus and amblyopia
Strabismus (crossed eyes) and amblyopia (“lazy eye”) are two conditions that are considered to be the “bread and butter” when it comes to pediatric patients. Asking the right questions can help identify what kind of strabismus they have, and in turn, determine the appropriate level of concern.
Questions to establish whether either exists and their severity include:
- Do you ever see the eyes misaligned?
- If so, does the eye move in toward the nose or out towards the side? (Establishes type)
- When did you first notice this? (Establishes age of onset and duration)
- Does it happen when the patient looks off into the distance or when they are looking at something up close? (Establishes pattern)
- Do you notice it more or less than 50% of the day? (Establishes frequency)
- When it does happen, does the patient correct it quickly? Or does it stay that way for a while? (Establishes control)
Examining pediatric patients with glasses and/or patching
Determine if the patient has ever been prescribed glasses, and then follow up by establishing the age at which they started wearing spectacles and their subsequent compliance with glasses. If their results have been poor, do not assume the glasses Rx is wrong.
It could be a sensory issue, cosmetic issue, or even a poor frame fit. If the parent/patient reports they have not been compliant in wearing their glasses, ask why. It is also important to find out if the patient has ever been patched.
If so, ask the following questions to understand what methods have been successful or unsuccessful, why that was, and what to try next:
- What age did they begin patching?
- How many hours/day?
- How many days/week?
- For how long did they patch for?
- What type of patch did they use?
- Compliance with patching?
- Was there any improvement in alignment or visual acuity noted?
Remember, there are different methods to treat amblyopia beyond a physical patch, which include:
- Atropine eye drops
- Vision therapy
- Virtual reality (VR) devices
Surgical history
To establish surgical ocular history, ask if the patient has undergone any eye surgeries in the past.
If so, determine the:
- Purpose
- Age
- Type of operation that occurred
- Eye that was corrected
- Office/hospital where it occurred
- Were there any subsequent surgeries or regression in alignment
- Parent's feelings on whether or not the surgery was successful
Family history
Additionally, take a thorough family ocular history. Begin by finding out who in their immediate family wears glasses and for what purpose. Due to the genetic component of myopia, this is an especially important inquiry.
Next, probe for other eye conditions, with a special emphasis on hereditary ones, including congenital cataracts, glaucoma, corneal dystrophies (i.e., keratoconus), strabismus, amblyopia, and retinal dystrophies (i.e., retinitis pigmentosa).
Social and educational history
Finally, social and educational history are vital components of a pediatric eye exam because they provide context for a child's visual demands and daily functioning.
Understanding their academic performance, behavior in school, and home environment can reveal vision-related challenges that may not surface during standard testing. This information helps tailor management plans to support both visual development and learning needs.
Ask the patient/parent the following questions:
- How is school going for the patient?
- What subjects are most difficult for the patient?
- This can allude to a binocular vision disorder if the patient struggles with subjects like reading, math, and writing.
- Does the patient have an individualized education program (IEP)?
- A child with an IEP and mild/moderate hyperopia may benefit more from a low reading Rx compared to a child who does not have an IEP and loves to read.
- What activities does the patient like to do?
- This can give you information about environmental factors that can impact the risk of myopia (i.e., increased reading and screen time).
Testing visual acuity in children
When taking visual acuity in pediatric patients, it is important to use the most challenging method as well as to take a visual acuity at both distance and near.
Don’t skip near vision
Near vision can reveal a lot about the refractive error and whether or not the patient will need glasses. It can identify myopia almost immediately (vision worse at distance compared to near), it can identify a hyperope who is struggling (vision worse at near compared to distance), and it can also identify amblyopia (decreased vision at both distance and near).
Another reason to complete a near visual acuity is that some patients lose attention at distance. This may be the only visual acuity available. The hierarchy of visual acuity testing is: Snellen > LEA Symbols > Allen Pictures.
Table 1: Comparison chart of visual acuity testing methods.3,4,5
| Method | Description | Target Population | Pro | Cons | Ideal Use Case |
|---|---|---|---|---|---|
| Snellen acuity | Chart with the alphabet | School-aged children; literate patients | Widely available, inexpensive, well established | Requires literacy/letter recognition, not suitable for young children | Standard acuity testing for literate children and adults |
| LEA symbols | Chart with four simple symbols (circle, square, house, apple) | Toddlers, preschooler; nonverbal patients | Standardized, validated, culturally neutral, easy to understand, can match | Limited symbol option may become boring | Screening and clinical testing for toddlers and preschoolers |
| Allen pictures | Chart with familiar images (e.g., house, hand) | Young children | Recognizable, engaging for kids from variety of images, can match | Poor standardization, outdated images, high variability, difficult to see beyond 20/40 | Use when LEA Symbols are not available or unable |
Alternative acuity testing for pediatric patients
Besides the traditional way, there are other ways to test visual acuity in pediatric patients, specifically for those who are preverbal or nonverbal, such as:3,4,5
- Fix and follow (F&F)
- Fixation preference testing (FP)
- Resistance to occlusion
- Central, steady, maintained with induced tropia test
- Teller acuity cards
Fix and follow (F&F)
“Fix" refers to the patient's ability to maintain steady fixation on a target, while "follow" assesses the ability to visually track a moving target. This test is typically performed binocularly and then monocularly to detect any intraocular differences.3,4,5
It is important to document the type of target used, as some patients—particularly young children—may demonstrate visual preferences for specific shapes, colors, or features (e.g., motion or sound). Be sure to note whether the target included sound, but try to avoid sound if possible, as this may influence the child’s response.
Fixation preference testing (FP)
Fixation preference testing is commonly used to screen for potential amblyopia, particularly in preverbal or nonverbal children. While it provides valuable clinical insight, the test is highly subjective and is only capable of detecting moderate to severe amblyopia.3,4,5
It is considered a more advanced assessment than fix-and-follow (F&F) but lacks the sensitivity to quantify visual acuity differences or detect mild amblyopia.6 For pediatric patients, there are two options. The most basic vision assessment in pediatrics is to check for unilateral resistance to occlusion.
Induced tropia test
A more advanced test is to assess central, steady, maintained (CSM) with the induced tropia test:
- Central (monocular): Central vs. Eccentric fixation
- Steady (monocular): Nystagmus or not
- Maintained (binocular): Fixation preference or not
To begin the test, first have the patient look at a distance target. Then, observe if the patient is directly looking at the object to suggest central or eccentric fixation. Next, observe for any nystagmus or roving eye movements. Lastly, assess for fixation preference depending on if the patient has strabismus or not.
For strabismic patients, perform FP by covering and uncovering each eye monocularly while observing the response. A fixation preference would be if the patient consistently shifts to fixating unilaterally after uncovering the fixating eye.
For non-strabismic patients, perform FP with the induced tropia test. The induced tropia can be used with a 10 to 12pd BD or 16pd BI single prism. Place the prism in front of one eye and observe the response. An oscillation of the eyes indicates no fixation preference.
A one-directional movement of the eyes, or no movement, suggests a fixation preference. The eye that moves towards the apex of the prism is the preferred eye OR the eye that shows movement when the other eye does not. Repeat the induced tropia test on both eyes to confirm the response and minimize observer bias.
Examples of notation are as follows:
- CSM = Central, Steady, Maintained
- CSNM = Central, Steady, Not Maintained
- CNSM = Central, Not Steady, Maintained
- NCSM = Not Central, Steady, Maintained
Teller acuity cards (TAC)
TAC consists of high-contrast black-and-white stripes of varying spatial frequencies presented on a gray background. It is mainly used for young children and nonverbal patients.7,8
- Pros
- Can be used on anyone
- Easy to administer
- Does not require explanation–patients naturally look towards the black and white stripes
- Cons
- Can take a long time
- Subjective interpretation variability
- Patients can get bored or distracted
- Underestimates visual acuity
- Expensive
Want a condensed version of the article? Download the Guide to Pediatric Eye Exams for Optometry Students!
3 other integral eye tests for pediatric patients
Along with a thorough assessment of visual acuity, children should undergo visual field, extraocular muscle, and a cover testing.
Visual fields
For patients who can confidently count, confrontation visual field testing can be a fun game. For those who are shy or nonverbal, toys can be used as engaging visual stimuli.
One approach is to have the child fixate on your face, or a central toy, while presenting another toy in the periphery. A full visual field is suggested if the child consistently looks toward the peripheral stimulus, indicating awareness and detection.
Extraocular muscles
Extraocular motility testing is typically straightforward in pediatric patients and generally well-tolerated. During assessment, be sure to observe for overaction or underaction of the extraocular muscles, as well as limitations in abduction or adduction.
Key conditions to consider include Duane syndrome, Brown syndrome, congenital cranial nerve palsies, and other forms of restrictive or paretic strabismus.
Cover test
The goal of cover testing is to identify ocular deviations, including both phorias and tropias. There are several techniques to perform cover testing, and in pediatric settings, the examiner’s hand is often the occluder.
Unilateral cover test is used to differentiate between a phoria and a tropia, while the alternate cover test helps determine the direction (eso, exo, hyper, or hypo), magnitude, and control of the deviation. The alternate prism cover test (APCT) is considered the gold standard when checking for a deviation.9,10
Other ways to measure cover testing include the Hirschberg and modified Krimsky test.
Hirschberg test
The Hirschberg test delivers an estimation of deviation based on the pupillary light reflex. This is the simplest method to estimate deviation and should only be used if the clinician is unable to perform other methods.
Note: 1mm of deviation from the center of the pupil corresponds to 15pd in corrective prism.
To perform the Hirschberg test:
- Shine the light at the patient from ~2 feet (60cm)
- Observe the reflex in both eyes
Light displacement:
- Temporally = Esotropia
- Nasally = Exotropia
- Superiorly = Hypotropia
- Inferiorly = Hypertropia
Figure 1: How to interpret results from the Hirschberg test.
Estimation of light displacement (mm) with corresponding corrective prism:
- 2mm (edge of pupil) = 30pd
- 4mm (mid iris) = 60pd
- 6mm (limbus) = 90pd
Figure 2: Illustration of light displacement with corresponding corrective prism.
Modified Krimsky test
A modified Krimsky test provides an estimation of deviation utilizing the Hirschberg reflex along with prism. The modified Krimsky test is used to estimate the deviation when the APCT cannot be reliably performed. It is frequently utilized for measuring deviations in various positions of gaze.
The modified Krimsky test is considered more accurate than the original Krimsky test because it places the prism in front of the fixating eye, rather than the deviating eye, giving a more reliable estimate.
To perform:
- Shine a light at ~2 feet (60cm)
- Observe the the reflex in both eyes
- Place the correcting prism in front of the FIXATING eye until the Hirschberg reflex appears equal.
Correcting prism:
- Esotropia: Base OUT
- Exotropia: Base IN
- Hypertropia: Base DOWN
- Hypotropia: Base UP
Figure 3: Illustration of how to interpret the modified Krimsky test.
Remember, some deviation estimation is better than none, but it is important to try and perform the gold standard as much as possible. Practice makes perfect.
Target size is another important detail in testing. Asking a pediatric patient to stare at a single letter is an invitation for distraction. Instead, try hitting the “cycle” button on the M&S system and have them say which letter they see—it keeps things moving and holds their attention.
Alternatively, use an object as your target and ask engaging questions about it to keep them focused (e.g., “What color is the hat?” or “How many legs does the animal have?”).
Exam pearl: Cover testing should be performed at both distance and near, with and without correction. Additionally, it should also be completed in at least five positions of gaze—primary, right, left, up, and down.
This is essential for detecting pattern deviations, such as A, V, X, or Y patterns, which are critical in the classification and diagnosis of strabismus.
Focus in on binocular vision
Base level binocular vision testing should include alignment, stereopsis, Worth 4 Dot, and near point of convergence (NPC). Depending on the patient’s concerns and these findings, further workup could include vergences and accommodative testing.9,11,12
Vergences are best done in free space with a prism bar, also known as step vergences, for pediatric patients. Doing so allows the clinician to control the environment and also objectively ensure that the patient is accurately performing the test.
Pediatric patients are not always the best responders. For example, if the patient does not report diplopia but their eyes oscillate between the two images, record that number as the break.9,11,12
Accommodative testing usually begins with monocular amplitudes. This is a great method for a patient who is old enough to participate. Even so, pulling away instead of pushing up may be more accurate.
Another accommodative test that works well, especially for nonverbal patients, is monocular estimation method (MEM). This test is an objective measure instead of subjective, which is heavily relied upon in pediatrics.9,11,12
Below are testing recommendations for binocular vision:9,11,12
- Alignment
- Expected norms:
- Near: Ortho – 6XP
- Distance: 1EP – 3XP
- Notes:
- Binocular, taken sc and cc
- Expected norms:
- Stereopsis (Randot 3)
- Expected norms:
- 3 years old: 100 to 400"
- 4 to 5 years old: 60 to 200"
- 7 years old and up: >40-60"
- Notes:
- Binocular
- Minimums based on age groups
- Expected norms:
- Worth 4 Dot
- Expected norms:
- Normal:
- 4 dots = fusion at D & N
- Abnormal:
- 2 red dots = OS suppression
- 3 green dots = OD suppression
- 5 dots = Diplopia
- Uncrossed = red on right, green on left
- Crossed = red on left, green on right
- Normal:
- Notes:
- Binocular
- Distance = central fusion/suppression
- Near = peripheral fusion/suppression
- Expected norms:
- Accommodative amplitude:
- Expected norms:
- Hofstetter’s minimum: 15 - (0.25 x age)
- Notes:
- Monocular
- Pull away vs. push up
- Expected norms:
- Monocular estimation method (MEM):
- Expected norms:
- +0.25D to +0.75D (lag)
- Notes:
- Binocular
- Expected norms:
- AC/A ratio
- Expected norms:
- 3:1 to 5:1
- Notes:
- Binocular
- High AC/A is associated with accommodative ET
- Expected norms:
- Near point of convergence (NPC):
- Expected norms:
- <5cm (break) / <10cm (recovery)
- Notes:
- Binocular
- Expected norms:
- Divergence (BI, negative fusional vergence):
- Expected norms:
- Distance: 7/4
- Near: 13/10
- Notes:
- Binocular
- Expected norms:
- Convergence (BO, positive fusional vergence):
- Expected norms:
- Distance: 11/7
- Near: 19/14
- Notes:
- Binocular
- Expected norms:
Note: All testing above should be performed with correction unless otherwise specified.
Don't forget to check out the Guide to Pediatric Eye Exams for Optometry Students!
Measuring intraocular pressure in peds
Intraocular pressure should be measured on every patient, but realistically, it is not always possible in pediatrics. The challenges with taking intraocular pressure in peds include staying calm and alleviating nervousness.13 When necessary, or needed, iCare is preferred. Another option is Tonopen.
Below is a comparison of iCare and Tonopen:
- iCare: Rebound tonometry
- No anesthetic and/or fluorescein needed
- Incredibly well-tolerated and quick
- Easy to administer
- Can be inaccurate at low/high pressures
- Tonopen: Applanation tonometry
- Needs anesthetic
- Patients may “feel” it more and be more scared
- Takes longer to complete
- Concern for examiner variability
- More reliable for a wider range of pressures
Pro tip: When using the iCare, describe it as a tickle and test it on their cheek or eyelid first to alleviate anxiety.
Retinoscopy and refraction for children
Retinoscopy is arguably the most important skill to have in pediatrics. It will not only evaluate the refractive error, but also evaluate accommodative function, whether or not there are media opacities, if there are corneal irregularities, and more. Practice this skill as much as possible.
Retinoscopy under cycloplegia is widely considered the gold standard for assessing refractive error in pediatric patients. Cycloplegia fully relaxes accommodation, allowing for the most accurate, objective measurement. Especially in patients too young to provide reliable subjective feedback, cycloplegic retinoscopy offers the clearest insight into true refractive error and is essential in guiding appropriate spectacle correction.14
Retinoscopy should be in free space with this population. Similar to vergence testing, retinoscopy in free space allows the examiner to control their environment. Pediatric patients are likely to move when placed behind a phoropter, which can lead to inaccurate retinoscopy findings. Instead, focus on using retinoscopy racks/paddles or loose lenses.
How to perform retinoscopy on pediatric patients
When beginning retinoscopy, ensure that the child is seated all the way back in the exam chair or comfortably against the parent, to minimize movement and stabilize the head. Instruct the patient to fixate on a distant target to help relax accommodation without blocking their view.
When scoping the right eye, align your right eye with the patient’s right eye, and then your left eye with their left. This helps preserve proper working distance. In cases of strabismus, consider patching or covering one eye at a time to stay on axis. Position the lenses as close to the patient’s eyes as possible—ideally at the plane where eyeglasses would be—to maintain consistency.
It can be helpful to rest the retinoscopy rack/paddle on the child’s forehead. Maintaining lens position is especially important in high refractive errors, where even slight variations can significantly affect measurements. Finally, always maintain your working distance, adjusting it only as a last resort.
Plus cylinder form is typically used instead of minus cylinder form in pediatrics because of the crossover with pediatric ophthalmology. The first meridian to neutralize in minus cylinder form is the LEAST MINUS or MOST PLUS. When working in plus cylinder form, aim to neutralize the MOST MINUS or LEAST PLUS meridian first.
The astigmatism axis can be tricky to nail down without a phoropter. Even though the patient is not behind the phoropter, the examiner can still utilize it. When the retinoscopy beam is aligned in the presumed astigmatism axis, without rotating the beam, move the retinoscope to the phoropter and read the axis.
Another option is to put the retinoscopy findings in a trial frame and perform an over-retinoscopy. The two meridians should be 90° and 180° if the axis is correct. If they are not, the axis is incorrect, and the examiner can rotate the astigmatism axis in the trial frame until it is. This is now the astigmatism axis.
Retinoscopy exam pearls: If plus cylinder retinoscopy still seems confusing, pick up a +3D lens and start in the 90° meridian, or the retinoscopy beam horizontally. Remember, the retinoscope beam direction is perpendicular to the meridian being evaluated.
Change the lenses based on the motion seen until neutral, record this lens. Switch the beam to the other meridian and observe the motion.
Chances are that the other meridian will be WITH motion because of with-the-rule astigmatism (axis 90°). If it is not, repeat the same process while starting in the 180° meridian, or the retinoscopy beam vertically. The axis is now 180°.
Subtract your working distance from the first neutralized lens for the sphere. The difference between the two neutralized lenses is the cylinder. Record the axis.
Performing refraction on pediatric patients
Subjective refractions should be used selectively with pediatric patients, as reliability can vary widely based on age and cooperation. This is why retinoscopy remains essential—it may be the most accurate, or even the only, way to assess refractive error in younger children.
As a general rule, consider attempting subjective refraction with patients around reading age (6 to 7 years old) who show good cooperation and maturity through initial testing.15 Keep in mind, younger patients often struggle with consistency during testing, limiting the usefulness of subjective findings.
Equally important is to consider the impact of a failed refraction on families. If the refraction is challenging, families may question the need for glasses—especially if the patient did not achieve 20/20. This can potentially undermine their confidence in the treatment plan and their provider.
In such cases, a trial frame refraction following cycloplegic retinoscopy may be a better option in younger patients to quantify visual acuity improvement with correction and support clinical decision-making. Phoropters in a pediatric eye clinic will typically be in plus cylinder form as well.
The only difference in refracting with these phoropters is the Jackson Crossed Cylinder (JCC). In plus cylinder phoropters— chase the WHITE dot for axis, ADD cylinder on WHITE, REMOVE cylinder on RED.
Fun with the fundus exam
For your fundus exam, the most important structures, like the optic nerve and macula, should be your main focus. This does not mean skip the peripheral exam, but rather, beyond the posterior pole, evaluate as many quadrants and as far out to the periphery as possible. Be sure to make a note describing what was able to be assessed.
To help get out to the periphery, use an interesting object, like a toy, to maintain fixation. Again, ask questions about that object to keep the patient engaged. Switch to something else when needed.
When considering a 90D lens exam, stick with a 20D lens exam instead. A 20D exam is sufficient unless there is a particular concern. If a more peripheral view is desired, use a 28D lens. A 28D lens gives a larger field of view but with less magnification. Most pediatric eye clinics have them for ROP exams.
3 pediatric exam pearls
- In pediatric eye exams, focus on objective findings more than subjective findings, but do not discredit the patient just because they are young.
- Retinoscopy is arguably the most important skill to master in pediatrics. It goes beyond refractive error.
- Cycloplegic retinoscopy is the gold standard for assessing refractive error in children.
- In plus cylinder retinoscopy, neutralize the MOST MINUS (LEAST PLUS) meridian first. In plus cylinder refraction, chase the WHITE dot for axis and ADD CYL on WHITE on JCC.
Components of a comprehensive pediatric eye exam
The following 14 exam components should be included at a minimum in a pediatric comprehensive eye exam. These tests are crucial to assessing the whole patient, not just their refractive error.
- Lensometry: Check to see if the correct Rx was made
- Visual acuity at distance and near: Always record the method used
- Pupils
- Visual fields
- Extraocular muscles: Check for underaction, overaction, deficits
- Cover test at distance and near (sc and cc): Check for patterns
- Color vision
- Binocular vision testing: Stereopsis, Worth 4 Dot, NPC, and vergences
- Over-retinoscopy: On CURRENT glasses
- Slit lamp exam: Prior to dilation
- Intraocular pressure
- Cycloplegic retinoscopy
- Refraction
- Fundus exam
Follow-up pediatric exam
During the follow-up exam with the child, the following testing should be performed.
- Lensometry
- Visual acuity at distance and near: Stay consistent with the last VA and use the highest level possible
- Pupils
- Visual fields
- Extraocular muscles: Check for underaction, overaction, deficits
- Cover Test: At distance and near (sc and cc): Check for patterns
- Over-retinoscopy: On CURRENT glasses
- Slit lamp exam
- Binocular vision testing: Stereopsis, Worth 4 Dot, NPC, accommodative testing, and vergences
Conclusion
Pediatric eye exams are dynamic and require a little bit of creative thinking—no pediatric eye exam goes the same way twice, know when to pivot. The pediatric eye examination requires a nuanced and adaptable approach that integrates knowledge of visual development, child behavior, and ocular pathology.
Mastery of age-appropriate examination techniques—paired with detailed history-taking and careful clinical observation—enables the early detection of conditions with lifelong visual and developmental implications.
Caring for pediatric patients is both a privilege and a profoundly rewarding experience, offering clinicians the opportunity to make a lasting impact on a child’s visual development.
