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MattiSeppänen

Examination of Vision at Child Welfare Clinics

Essentials

  • Visual and eye changes may occur at any stage of development.
  • The earlier any abnormal development is noticed, the more effective its treatment will be.
    • A delay in the development of visual communication is a sign of a disturbance of cerebral function. Because it affects both the child's development and the family dynamics, the infant should be referred promptly for further investigations and the whole family should be provided early rehabilitation.
  • The first 3 months after birth are important for the development of the visual system. If deficient visual perception is left untreated, it will quickly lead to permanent visual handicap.
  • The primary aim of examining vision at child welfare clinics is to screen for, and refer sufficiently early for further treatment, children with:
    • strabismus
    • reduced visual acuity
    • suspected eye disease.
  • Recent-onset strabismus is always an indication for referral to an ophthalmologist. For Referral criteria, see here.

Examinations by age Preschool Vision Screening

  • See table T1.

Examination of vision at child welfare clinics. Source (available in Finnish only): Hyvärinen L. Näön ja silmien tutkiminen [Examination of vision and eyes]. In: Mäki P et al (eds.). Terveystarkastukset lastenneuvolassa ja kouluterveydenhuollossa [Periodic health check-ups in child welfare clinics and school health services]. National Institute for Health and Welfare (THL), Finland 2017. http://urn.fi/URN:ISBN:978-952-302-964-4

AgeExaminationsIndications for referral
Newborn
Appearance of the eyes
Abnormal structure of the eyes or eyelids, abnormal shape of the pupil or its reaction to light, constant unilateral strabismus
Red reflex
Dim or missing red reflex
4-6 weeks
Eye contact
Missing or abnormal eye contact
Parent-child interaction has not started.
Appearance of the eyes
Abnormal structure of the eyes or eyelids, abnormal shape of pupil or its reaction to light, constant unilateral strabismus
Red reflex
Dim or missing red reflex
Record any eye and vision problems in the immediate family (amblyopia, refractive errors, strabismus, tumours)
Eye examinations indicated in Down's syndrome
Hypotonic infants
4 months
Eye contact, smile response
Missing or abnormal eye contact
Problems with early interaction: vision (accommodation, problems with fixation) and hearing should be examined
Appearance of the eyes
Abnormal structure of the eyes or eyelids, e.g. difference in the size of the eyes (glaucoma)
Red reflex
Dim or missing red reflex
Fixation and convergence
Inaccurate eye tracking
Hirschberg's test
Manifest, constant or frequently recurring strabismus
8 months and 18 months
As at 4 months
As at 4 months + problems with lacrimal passages
Cover test
Even intermittent strabismus (may not be present during the examination); refer without delay if the eyes were previously correctly aligned and strabismus is of acute onset
Examination of pinch grip
Employment of vision does not correspond to age, the child looks at things close up, is not interested in pictures, hand-eye coordination is inaccurate.
Does the child recognize family members before they say anything?
Does not recognize faces but recognizes a person by the voice.
3 years
Near vision acuity (if the child co-operates)
Binocular visual acuity is less than 0.5
OR
A difference of 2 rows or more between the eyes in the near visual acuity, provided that the near visual acuity of both eyes can be measured

Abnormal head posture, e.g. tilting
Hirschberg's test
Manifest strabismus
Cover test
Manifest strabismus or asymmetric reaction to covering of the eye
4 years
Near and distance visual acuity
Near vision: binocular acuity less than 0.5
Distance vision: binocular acuity less than 0.5, unless near visual acuity is 0.5 or better (= myopia)
OR
A difference of 2 rows or more between the eyes in the near and distance visual acuity

Binocular near visual acuity more than 2 rows worse than far visual acuity (possible causes are impaired accommodation or hyperopia)
Hirschberg's test
Manifest strabismus
Cover test
Manifest strabismus or asymmetric reaction to covering of the eye
5 or 6 years
Examine as at 4 years, as necessary. Examine especially if
- the child is about to be investigated by a psychologist
- the child has disorders of visual perception
Near vision: binocular acuity less than 0.63
Distance vision: binocular acuity less than 0.63, unless near visual acuity is 0.63 or better (= myopia)
OR
A difference of 2 rows or more between the eyes in the near and distance visual acuity

Binocular near visual acuity more than 2 rows worse than far visual acuity (possible causes are impaired accommodation or hyperopia)
Manifest strabismus, abnormal head posture

Workup

Red reflex

  • Should be examined by the age of 6 weeks and re-examined in association with the routine health checks at ages 4, 8 and 18 months.
  • Congenital cataract, structural abnormalities of the eyes, and abnormal pupillary reaction to light are indications for further investigation.

Hirschberg's test

  • Perform the test at each visit to the child welfare clinic from the age of 4 months.
  • The test will only reveal manifest strabismus.
  • Examination procedure
    • Shine a light (a penlight or the lamp of an otoscope without the ear speculum) in the child's eyes directly in front of the child at a distance of about 50 cm from the child's face.
    • Observe the location of the light spot in the eyes.
    • Normally, the light reflex is seen slightly medial to the centre of the pupil, symmetrically in both eyes.
    • If there is inward strabismus, the reflex is displaced outward from the centre of the cornea.
    • The workup should be continued with the cover test.

Cover test

  • In small children, the cover test to detect manifest strabismus should be performed with the target at a close distance (30 cm).
  • When visual acuity and cooperative ability have developed sufficiently to allow reliable fixation at 4 metres, the test can be performed at both far and close distances.
  • Examination procedure
    • Ask the child to look at a 5 cm fixation target at a distance of 30 cm from the eyes.
    • Move your hand from above first to cover the left eye of the child.
    • Observe whether the right eye moves.
    • The cover test should be performed for each eye separately.
    • Let the eyes return to a free position for a moment before moving on to examine the other eye.
  • Interpretation of the result
    • Any corrective movement will occur in the opposite direction to the strabismus: for example, when you cover the left eye and the right eye performs a corrective movement inward towards the nose, the patient has outward strabismus of the right eye.
    • There is no manifest strabismus if covering the eye causes no corrective movement in the uncovered eye.
    • If covering one eye causes corrective movements in both eyes, the patient has alternating manifest strabismus.
  • If the infant/child reacts asymmetrically to the covering of each eye in turn, i.e. if he/she accepts the covering of one eye but avoids the covering of the other, the vision may be abnormal in the eye that could be covered without problem. Further investigation is indicated even if no strabismus is detected.

Pinch grip test

  • Examination procedure
    • Scatter a few dark nonpareils (hundreds and thousands, sprinkles) on an examination table behind the child who is in sitting position.
    • Turn the child around to lie in prone position leaning on his/her arms.
    • See whether the child observes the candies and in what way he/she grabs them.
  • Interpretation of the result
    • If the child picks up a very small object, tries to grab it using the pinch grip and puts his/her weight well on the supporting arm, eye-hand coordination and identification of small objects can be interpreted as normal.

Criteria for referral

Urgent referral to an ophthalmologist

  • Suspected eye disease
    • Missing red reflex (congenital cataract, for example)
    • White pupillary reflex (leukocoria: suspected retinoblastoma Retinoblastoma)
    • Drooping eyelid partly or completely covering the visual field (if left untreated in newborn babies and infants, it will lead to visual handicap)
  • Strabismus
    • New strabismus in previously correctly aligned eyes
    • Suddenly developed strabismus may also be a sign of retinoblastoma.
  • Other findings
    • Consult an ophthalmologist (further treatment within a maximum of 1 month).

Referral to an ophthalmologist ≤ 1 month

  • Abnormal visual acuity
    • Reduced visual acuity compared to previous examination (difference of more than one row)
    • Visual acuity worse than expected for age (see Table T1).
    • Significant difference between near and distance visual acuity
  • Risk groups
    • Particularly infants and children with lower visual acuity than expected for their age belong to a risk group if
      • a sibling or at least one of the parents has been diagnosed with strabismus or
      • they have some other diagnosed impairment, delayed motor or cognitive development, muscular hypotonia, hearing impairment, or a diagnosed condition or disease that is often associated with visual impairment or severe refractive errors (Down's syndrome Down's Syndrome).
    • Examination of the eyes and of refractory error should be done during early development for children with delayed visual development who belong to a risk group, and measures should be taken to plan early rehabilitation.
    • If a child belongs to a risk group and suspicion of delayed visual or other neurological development arises, examination by an ophthalmologist should be considered even if no reduced visual acuity or abnormal eye position has been detected.
      • Left untreated, particularly inward strabismus beginning at the age of 6 months to 3 years may lead to permanently impaired vision in the eye with strabismus.

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