Visual System Assessment in Infants, Children, and Young Adults by Pediatricians

Timing of Examinations And Screening

Preterm infants should initially be evaluated under the guidance of the American Academy of Pediatrics policy statement “Retinopathy of Prematurity Screening”⁶ and referred for a specialized eye examination by an ophthalmologist experienced in evaluating and treating infants, if required. Similar referral to a specialist should be made for newborn infants with family histories of congenital cataracts, retinoblastoma, or metabolic disease or in whom systemic disease associated with serious ocular abnormalities is suspected. Because family history is an important risk factor for amblyopia and strabismus, pediatric clinicians should consider referring children who have first-degree relatives with these conditions; referral should take place promptly if symptoms or signs are present and, if not, once a child is of sufficient age to cooperate for examinations.⁷ Otherwise healthy children should be screened in the primary care setting at the intervals provided in Table 1. Because ocular problems can be the initial manifestation of neurologic or systemic disease, pediatricians should be aware of subtle but important findings that can be detected through screening or careful examination of the ocular system. A history of epiphora associated with photophobia or the presence of cloudy or enlarged corneas should prompt timely referral to rule out glaucoma. Ptosis, when associated with anisocoria, can be the harbinger of neuro-ophthalmologic disease and should also warrant referral. A bright or yellow red reflex or, conversely, a dull or absent red reflex, can be an indication of a significant abnormality that necessitates further evaluation by a pediatric eye care specialist. Details of the history and examination procedures are provided in the accompanying clinical report.

Instrument-based screening devices for vision screening are available commercially and have had extensive validation, both in field studies^8–11 and, more recently, in the pediatrician’s offices.^12,13 Screening instruments detect amblyopia, high refractive error, and strabismus, which are the most common conditions producing visual impairment in children.^14,15 If available, they can be used at any age but have better success after 18 months of age.^9,16 Instrument-based screening can be repeated at each annual preventive medicine encounter through 5 years of age or until visual acuity can be assessed reliably using optotypes. Using these techniques in children younger than 6 years can enhance detection of conditions that may lead to amblyopia and/or strabismus compared with traditional methods of assessment.¹² The recent US Preventive Services Task Force statement supporting the use of these technologies for preschool vision screening¹⁷ should prove useful in ensuring adequate payment for these services.

The use of optotype-based (traditional) acuity algorithms remains current practice for children aged 4 years and older. Acuity screening becomes more reliable and efficient in children aged 6 years and older. Details regarding the techniques for evaluating visual acuity with optotype-based screening are provided in the accompanying clinical report.¹ Instrument-based screening may be a helpful alternative in screening developmentally delayed children of any age.¹⁸

Summary

Evaluation of the visual system should begin in infancy and continue at regular intervals throughout childhood and adolescence. Serial visual system screenings in the medical home, using validated techniques, provide an effective mechanism for the detection and subsequent referral of potentially treatable visual system disorders.

Lead Authors

Sean P. Donahue, MD, PhD, FAAP

Cynthia N Baker, MD, FAAP

AAP Committee on Practice and Ambulatory Medicine, 2014-2015

Geoffrey R. Simon, MD, FAAP, Chairperson

Cynthia N Baker, MD, FAAP

Graham Arthur Barden, III, MD, FAAP

Oscar W. “Skip” Brown, MD, FAAP

Jesse M. Hackell, MD, FAAP

Amy Peykoff Hardin, MD, FAAP

Kelley E. Meade, MD, FAAP

Scot B. Moore, MD, FAAP

Julia Richerson, MD, FAAP

Staff

Elizabeth Sobczyk, MPH, MSW

AAP Section on Ophthalmology Executive Committee, 2014-2015

Sharon S. Lehman, MD, FAAP, Chairperson

Daniel J. Karr, MD, FAAP, Chairperson-Elect

Geoffrey E. Bradford, MD, FAAP

Steven E. Rubin, MD, FAAP

R. Michael Siatkowski, MD, FAAP

Donny Won Suh, MD, FAAP

David B. Granet, MD, FAAP, Immediate Past Chairperson

Liaisons

Shelley Klein, CO – American Association of Certified Orthoptists

Christie Morse, MD, FAAP – American Association of Pediatric Ophthalmology and Strabismus

Pamela E. Williams, MD, FAAP – American Academy of Ophthalmology

Gregg T. Lueder, MD, FAAP – American Academy of Ophthalmology Council

C. Gail Summers, MD – American Academy of Ophthalmology

George S. Ellis, Jr, MD, FAAP – Section Historian

Staff

Jennifer G. Riefe, MEd