section name header

Information

Editors

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.
  • Check also local (national/regional) guidelines.

Examinations by age Preschool Vision Screening

  • See table T1.

Examination of vision at child welfare clinics.

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, smile response
Problems with early interaction: vision (accommodation, problems with fixation) and hearing should be examined
Bright light is directed at the eyes
No reaction to glare
Appearance of the eyes
Abnormality in the 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
4 months
Hirschberg's test
Constantly visible strabismus
Eye contact, smile response
Poor eye contact or smile response
Gaze fixation and tracking
Poor visual tracking or abnormal eye movements
Appearance of the eyes
Abnormal structure of the eyes or eyelids, e.g. haemangioma or flame naevus
Red reflex
Dim or missing red reflex
8 months
Hirschberg's test
Constantly or periodically visible strabismus (preferably documented in a photograph)
The referral should also include the result of the red reflex examination.
Inspection
Abnormal head position
Ptosis where the eyelid droops over the middle of the pupil
Constant tearing
Alternate cover test
Resisting the covering of either eye
Examination of pinch grip
Hand and eye coordination is inaccurate.
Red reflex
Abnormal red reflex
18 months
Hirschberg's test
Constantly or periodically visible strabismus (preferably documented in a photograph)
The referral should also include the result of the red reflex examination.
Inspection
Abnormal head position
Alternate cover test
Resisting the covering of either eye
Examination of pinch grip
Hand and eye coordination is inaccurate.
Red reflex
Abnormal red reflex
3 years
Hirschberg's test
Constantly or periodically visible strabismus
The referral should also include the result of the red reflex examination.
Direct cover test
A corrective movement in the eye that remains gazing
Poor gaze fixation in the uncovered eye (interpretation: see here)
Inspection
Abnormal head position
Near visual acuity with an LH chart (binocular if cannot be examined separately) http://www.lea-test.fi/index.html?start=en/vistests/instruct/instruct.html or with another appropriate test
Binocular visual acuity is less than 0.4 or the child has poor fixation with one eye.
If asymmetry is suspected, the referral should also include the result of the red reflex examination.
Red reflex, if vision is abnormal or cannot be examined
Suspicion of abnormal vision
4 years
Hirschberg's test
Constantly or periodically visible strabismus
Direct cover test
A corrective movement in the eye that remains gazing
Inspection
Abnormal head position
Near and distance visual acuity with an LH chart and eyes examined separately (binocular if cannot be examined separately) http://www.lea-test.fi/index.html?start=en/vistests/instruct/instruct.html or with another appropriate test
Separately examined near or distance visual acuity less than 0.5 in both eyes

OR
A difference of 2 rows or more between the eyes in the near and distance visual acuity

OR
Binocular visual acuity less than 0.5 if vision cannot be examined separately
5-6 years
Hirschberg's test
Constantly or periodically visible strabismus
Direct cover test
A corrective movement in the eye that remains gazing
Near and distance visual acuity with an LH chart and eyes examined separately (binocular if cannot be examined separately) http://www.lea-test.fi/index.html?start=en/vistests/instruct/instruct.html or with another appropriate test
Separately examined near or distance visual acuity less than 0.63 in both eyes

OR
A difference of 2 rows or more between the eyes' visual acuities (near and distance vision)
Modified from: Lindahl P, Majander A, Vasara K, et al. [Examination of vision and the eyes]. NEUKO Database. Finnish Institute for Health and Welfare (THL). Available in Finnish at http://www.terveysportti.fi/apps/dtk/ltk/article/nla00117 (subscription required).

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 (and at age 3 years if necessary).
  • Examination of red reflex: see Eye Examination.
  • 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 in relation to the pupillary aperture of both 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 on the outer edge of the pupillary aperture (on the side of the temple).
    • If there is outward strabismus, the reflex is displaced on the inner edge of the pupillary aperture.
    • The workup should be continued with the cover test.

Direct cover test

  • Performed at (8 months, 18 months) 3 years, 4 years and, if necessary, 5-6 years of age.
  • At 8 months and 18 months of age, Hirschberg's test is the most important examination method for detecting manifest strabismus. In older children, strabismus is examined with cover test, but it is also useful in children aged 8 months and 18 months because it may suggest abnormal vision in one eye.
    • 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.
  • Examination procedure
    • Ask the child to look at e.g. a small toy or approximately a 5 cm-size 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.

Pinch grip test

  • Examination procedure
    • Scatter e.g. a few dark nonpareils (sprinkles) or rice cereals 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): emergency referral and/or telephone contact with an eye clinic
    • 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.

Non-urgent referral to an ophthalmologist

  • If the other referral criteria mentioned in table T1 are met

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 disease or syndrome that is often associated with visual impairment or severe refractive errors (e.g. Down's syndrome Down Syndrome).
  • In children who have been diagnosed with delayed visual development and who belong to a risk group, it should be ensured that eye examinations and refractive error detection are carried out within the planned schedule and that early rehabilitation is planned.
  • 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.