An unequal objection to occlusion may reveal an eye preference. Notice if the child cries or objects to having one eye covered. If they have an abnormal head position, allow them to assume their preferred position. For children with nystagmus, do not patch rather, use a frosted or fogged lens. To check for CSM vision in a child with misalignment, start by occluding one eye with an adhesive patch or a parent's hand. Centrality and steadiness are measured monocularly, while maintenance is measured binocularly. Older infants should fixate on and follow a visual target with each eye independently.įor children under two years of age or in nonverbal children, vision is measured by describing whether it is central, steady, and maintained, or CSM. In babies up to three months old, blinking or wincing to light is an appropriate response. At all ages, assessing for symmetry of vision or preference for one eye is critical. Normal visual responses vary depending on the age of the child. While having the child fixate on your nose, slowly move the object towards fixation and observe for a saccade. Cover one eye and hold an interesting object in one hand outside of the visual field. Confrontation Visual FieldsĬonfrontation visual fields can be tested in a similar manner. Keep the head still if possible and make sure to check the extremes of gaze. Toys and flashing lights can be helpful for tracking. Extraocular MotilityĬheck motility by having the child look in the 6 cardinal directions of gaze. If the child sees four dots at near but suppresses at distance this may indicate that peripheral fusion is present. That is, they will only see three green dots, because the green lens filters out red dots.Ī shortcut to remembering these patterns is that the color of the dots the patient sees corresponds to the non-suppressed eye. If the child is suppressing the right eye, they will only see the dots through the green filter. That is, they will only see two red dots, because the red lens filters out green dots. If the child is suppressing the left eye, they will only see the dots through a red filter. They may also see two red and three green dots as the white dot will appear red or green depending on which eye is being used. If there is no suppression present, they will see four dots: one red, two green, and one that alternates between red and green. Record their response and repeat for distance testing. If they are shy, ask them to touch all the dots they see. Starting with near using a Worth four dot flashlight, ask the child how many dots they see and what color they are. Perform the test at near and at distance. Display the four dots of the Worth four dot test: 1 red dot, 2 green dots and 1 white dot. To start, have the child wear red-green glasses, with the red lens over the right eye. A full review of the applications of this test is beyond the scope of this video. In pediatrics, the Worth four dot test is mainly used to assess for suppression. If a child is uncooperative or refuses to wear glasses, the Lang test, which tests stereopsis without stereo glasses, may be a good alternative. Finer depth discrimination can be assessed with further testing, shown here using circles and animals. When asked to pinch the wings, their fingers should remain above the page as shown here. The child should see the wings of the fly elevated above the page. A traditional test is the Titmus fly test. Test stereo in young children using stereo glasses. Stereopsis testing should always be performed prior to cover testing as cover testing disrupts fusion and thus can affect stereopsis. This is always performed first because it depends on intact fusion. The first step in the pediatric eye exam is measuring stereopsis, or depth perception. Remember, parents can also assist you during the exam. This may involve using visually interesting toys and lights, asking silly questions, or examining a favorite stuffed toy. Making the exam feel like a game is often very effective. However, with patience, creativity, and flexibility, the exam can be performed successfully. General ApproachĮxamination of a child involves a unique set of challenges. We will not discuss cover testing or retinoscopy for these maneuvers, please see the EyeRounds tutorials at the following links. We will discuss the general approach to examining children, stereopsis, the Worth four dot test, extraocular motility, confrontation visual fields, visual acuity, intraocular pressure, pupils, and the anterior segment and funduscopic exams. In this video, we will provide an overview of basic pediatric ophthalmic examination techniques for medical students, interns and early ophthalmology residents. This is Salma Dawoud and David Ramirez from the University of Iowa.
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