Taken from Vaughan & Asbury's General Ophthalmology

1. PEDIATRIC EYE EXAMINATION
OPHTHALMOLOGY

2. NEWBORNS - INFANTS
General ocular status
Inspection of the eyes
Corneal light reflex testing
Pupillary testing
Evaluation of red reflex
Fundus examination

3. NEWBORNS - INFANTS
You can use visual reflexes to indirectly assess vision:
direct & consensual pupillary constriction in response to light
blinking in response to bright light (optic blink reflex)
blinking in response to quick movement of an object toward the
eyes

4. NEWBORNS - INFANTS
 Infants achieve the following visual milestones:
Birth - Blinks, may regard face
1 month - Fixes on objects
1½-2 months - Coordinated eye movements
3 months - Eyes converge, baby reaches
12 months - Acuity around 20/50

5. NEWBORNS - INFANTS
Inspection
 Bright light causes infants to blink, so use subdued lighting
 If you awaken the baby gently, turn down the lights, & support the baby
in a sitting position
 Small colorful toys are useful as fixation devices in examining the eyes
 Newborns may look at your face & follow a bright light if you catch them
during an alert period
 You can get some newborns to follow your face & turn their heads 90° to
each side

6. NEWBORNS - INFANTS
Examine infants for eye movements
 Hold the baby upright, supporting the head
 Rotate yourself with the baby slowly in one direction
 This usually causes the baby's eyes to open, allowing you to examine the
sclerae, pupils, irises, & EOM
 Baby's eyes gaze in the direction you are turning
 When the rotation stops, the eyes look in the opposite direction, after a
few nystagmoid movements

7. NEWBORNS - INFANTS
 Look for abnormalities or congenital problems in the sclerae and pupils
 Subconjunctival hemorrhages are common in newborns
 Observe pupillary reactions by response to light or by covering each
eye with your hand and then uncovering it
 Inspect the irises carefully for abnormalities.
 Examine the conjunctiva for swelling or redness

8. NEWBORNS - INFANTS
Ophthalmoscopic Examination
 Examine the red retinal (fundus) reflex by setting the ophthalmoscope at 0 diopters
& viewing the pupil from about 10 inches
 Normally, a red or orange color is reflected from the fundus through the pupil
 The cornea can ordinarily be seen at +20 diopters, the lens at +15 diopters, & fundus
at 0 diopters
 In infants, the optic disc is lighter in color, with less macular pigmentation
 Foveal light reflection may not be visible
 Look carefully for retinal hemorrhages
 Papilledema is rare in infants because the fontanelles & open sutures accommodate
any increased intracranial pressure, sparing the optic discs

9. TODDLERS (1 – 2-YEAR-OLDS)
 Inspection of the eyes
 Conjugate or symmetric gaze
 Corneal light reflex test & cover-uncover test are particularly useful
in young children
 You can perform the cover-uncover test as a game by having the
young child watch your nose or tell you if you are smiling or not,
while you cover one of the child's eyes

10. CORNEAL LIGHT REFLEX TEST
 Objective assessment of ocular alignment
 Patient is directed to look at a penlight held directly in front of the eyes by
the examiner at a distance of 2 ft
 The examiner aligns his eyes with the light source & compares the position
of the light as reflected by the cornea of each eye
 Normally, the light is reflected on each cornea symmetrically & in the same
position relative to the pupil & visual axis of each eye
 In a deviating eye, the light reflection will be eccentrically positioned & in a
direction opposite to that of the deviation

11. CORNEAL LIGHT REFLEX TEST
a) Normal alignment
b) Small esotropia
c) Moderate esotropia
d) Large left esotropia

12. COVER-UNCOVER TEST
 Can be used on any patient over 6 months
 Have the patient look at a fixation point, such as a toy or Snellen chart
 Note which eye seems to be the fixating eye
 Cover the fixating eye & observe the other eye
 If the uncovered eye moves to pick up the fixation, then it can be
reasoned that this eye was not directed toward the object of regard
originally
 Each eye must be tested separately

13. COVER-UNCOVER TEST
 If the eye moves inward to fixate, then originally it must have been
deviated outward & is exotropic
 If the eye moves outward to fixate, then originally it must have been
deviated inward & is esotropic
 If the eye moves up or down, then it is hypotropic or hypertropic
 No shift in cover testing means there is no tropia but a phoria could still
occur
 A phoria is a latent tendency of the eye to deviate & detected by
alternate cover testing

14. COVER-UNCOVER TEST
When the Left eye is
covered, the Right eye
moves outward to pick up
the fixation
(Esotropia, OD)

15. PRE-SCHOOL (AGES 3 TO 5)
 Inspection of the eyes
 Conjugate or symmetric gaze
 Visual acuity (If the child can follow directions & communicate
adequately)
 Picture card
 Tumbling E chart
 LEA Symbols Test
 Visual fields

16. PRE-SCHOOL (AGES 3 TO 5)
Tumbling E Chart
 A child who does not know letters or numbers reliably can be tested using
pictures, symbols, or the “E” chart
 Using the “E” chart, most children will cooperate by telling you in which
direction the “E” is pointing with his or her fingers
Visual Fields
 Visual fields can be examined in young children with the child sitting on
the parent's lap
 Hold the child's head in the midline while bringing an object such as a toy
into the field of vision from behind the child

17. PRE-SCHOOL (AGES 3 TO 5)
 For children younger than 3 years who cannot identify pictures on
an eye chart, the simplest examination is to assess for fixation
preference by alternately covering one eye
 The child with normal vision will not object, but a child with poor
vision in one eye will object to having the good eye covered

18. PRE-SCHOOL (AGES 3 TO 5)
 Visual Acuity
 3 months - Eyes converge, baby reaches
 12 months - 20/200
 Less than 4 years - 20/40
 4 years & older - 20/30

19. SCHOOL-AGED (6 YEARS & ABOVE)
 Inspection of the eyes
 Conjugate or symmetric gaze
 Visual acuity (If the child can follow directions, communicate
adequately & knows letters of the alphabet )
Snellen Chart
 Visual fields