Practice Gap
Incorporating vision screening and a basic eye examination in the primary care
setting can be challenging. Determining which screening examination to perform and
when to refer a patient to a pediatric eye care provider is critical.
Objectives
After completing this article, readers should be able to:
Understand the importance of vision screening and know what conditions
can be detected by periodic eye examinations.
Describe the components of a vision screening examination at different
ages and plan an appropriate evaluation of vision.
Recognize the indications for referral to pediatric ophthalmology.
Introduction
Vision screening is crucial for early detection and
prevention of vision loss in young children. Vision screening can be performed by
primary care providers, trained laypersons (eg, school-based screenings), and eye
care providers. Vision screening techniques are either provider-based (eg,
traditional acuity testing, inspection, red reflex testing) or instrument-based.
Instrument-based screening can often be performed at an earlier age than
provider-based acuity testing and allows earlier screening for risk factors that are
likely to lead to amblyopia and poor vision. The American Academy of Pediatrics
(AAP) and the American Association for Pediatric Ophthalmology and Strabismus have
developed guidelines to help practitioners screen for vision problems at different
ages (Table 1).
Table 1.
Age-Appropriate Methods for Pediatric Vision Screening and Criteria for
Referral
METHOD
INDICATIONS FOR REFERRAL
RECOMMENDED AGE
Newborn–6 mo
6 mo until cooperative for vision testing
3–4 y
4–5 y
Every 1–2 y after age 5 y
Red reflex test
Absent, white, dull, asymmetrical
Evaluate at all ages
External inspection
Structural anomaly (eg, ptosis, hemangioma)
Evaluate at all ages
Pupil examination
Unequal size, poor reaction to light, irregular
shape
Evaluate at all ages
Corneal light reflex
Asymmetrical or displaced
*
*
*
*
Instrument-based screening
Failed to meet screening criteria
*
*
*
*
Cover test
Refixation movement
*
*
*
Visual acuity (distance, monocular)
Failure to fixate and follow
Failure to fixate and follow
20/50 or worse in either eye
20/40 or worse in either eye
20/30 or worse or 2-line difference between eyes
Asterisks indicate the method of vision screening that should be
performed in that age column.
The Importance of Vision Screening
Vision screening allows the early detection of preventable
vision-threatening or life-threatening conditions. Amblyopia, colloquially called
“lazy eye,” is a reduction of best-corrected visual acuity that is not
directly caused by any structural abnormality of the eye. It is caused by an
abnormal visual experience resulting from strabismus, refractive error, or stimulus
deprivation. Amblyopia occurs in 1% to 4% of children (1) and can be caused by visual
deprivation (eg, cataract,
ptosis, corneal opacity), strabismus (any form of eye misalignment, such as
esotropia or exotropia), high refractive error (eg, hyperopia or myopia), or
anisometropia (asymmetry of refractive error between the eyes). Amblyopia is more
easily and successfully treated the earlier it is detected, and it becomes
impossible to treat after 7 to 9 years of age. Patients and caregivers may be
unaware of the consequences of delayed evaluation and treatment. (2) The short window
of opportunity to save
vision underscores the importance of vision screening to detect amblyopia or its
risk factors while treatment is still effective. Vision screening assessments in
early childhood reduce the risk of vision loss at age 7 years by more than 50%.
(3)
Vision screening and eye examinations within the medical home create frequent and
early opportunities to diagnose a myriad of conditions. In the first year of life,
causes of deprivation amblyopia are more frequent and result in the most profound
vision loss. Conditions affecting infants include corneal opacities, cataracts,
ptosis, glaucoma, and retinoblastoma. Deprivation amblyopia in infancy can develop
very rapidly. A few weeks of deprivation of visual stimulus in 1 eye from a dense
cataract or complete ptosis can result in profound amblyopia that often requires
years of numerous hours of patching treatment. Early detection of retinoblastoma can
save the child’s vision and life. Ocular abnormalities may be the first
recognized sign of a systemic disease. For example, blurred vision and bilateral
cataracts in a child can be the first presentation of a neurodegenerative disease,
cerebrotendinous xanthomatosis, that if unrecognized causes irreversible cognitive
impairment. Early recognition and treatment with an oral medication can prevent
lifelong disability. In addition, a crossed eye may be the first sign of vision loss
in a baby with optic nerve hypoplasia as part of septo-optic dysplasia. Effective
screening by the pediatrician can lead to earlier diagnosis of systemic
problems.
The etiologies of amblyopia vary with age. Form deprivation amblyopia is more
frequent and profound in infants. A unilateral cataract in a newborn will cause
substantial amblyopia if untreated and should be removed within weeks; in contrast,
a traumatic cataract in a 6-year-old with previously good vision is much less likely
to cause amblyopia, and in the absence of other damage from the trauma, the cataract
can be removed nonurgently. In children younger than 3 years, strabismus is the most
common cause of amblyopia; in children 3 to 6 years old, strabismus and
anisometropia contribute equally. (4) In
younger children (eg, up to age 3 years), the examination is more challenging and
the disorders can be subtle, but early detection can have a profound effect on the
child’s vision and future if treatment is initiated quickly. To detect these
abnormalities, vision screening should be performed by primary care providers or
trained laypersons (eg, school-based screenings) throughout childhood. The combined
sensitivity of a series of screening evaluations is higher than a single evaluation,
especially if different methods are used for each screening evaluation. (5) Unfortunately,
children present to the
ophthalmologist at age 6 to 8 years for their first eye examination with significant
amblyopia (frequently, anisometropic amblyopia) whose vision loss would have been
preventable if they had been detected earlier and been prescribed glasses at a
younger age. The routine assessment of vision in all children cannot be
overemphasized; special attention should also be given to children with
disabilities. Children with developmental delay can experience a delay in
identification of their ocular disease that further impedes successful
treatment.
Some children should be referred directly for a comprehensive examination. For
example, poor eye contact by a term infant with the caretaker after 8 weeks of age
warrants further assessment (8 weeks' adjusted age for premature children).
Table 2 lists red flag signs and symptoms
for possible eye problems. Special attention should be given to children with a
history of a known medical risk factor for vision problems, including prematurity,
cerebral palsy, craniofacial abnormalities, Down syndrome, Marfan syndrome,
congenital cytomegalovirus, eyelid hemangiomas, Sturge-Weber syndrome, sickle cell
disease, and nevus of Ota. Children with medical conditions such as diabetes or
juvenile idiopathic arthritis should receive a comprehensive evaluation soon after
diagnosis.
Table 2.
Signs and Symptoms of Potential Vision Loss
SIGN/SYMPTOM
POTENTIAL EYE PROBLEM
PEDIATRIC PROVIDER ACTION
No eye contact in an infant >8 wk old corrected age
Decreased vision, delayed vision maturation
Vision screen and refer to ophthalmologist
Head tilt or face turn
Strabismus, nystagmus, high astigmatism
Vision screen and refer to ophthalmologist
Unable to comply with vision screening
Decreased vision
Refer to ophthalmologist
Tearing
Congenital nasolacrimal duct obstruction, glaucoma
Age <1 y without other signs of glaucoma (enlarged corneas,
photophobia, blepharospasm), vision screen
Age >1 y refer to ophthalmology
Photophobia
Congenital glaucoma, inflammation
Vision screen and consider referral
Squinting
Refractive error, strabismus
Vision screen and consider referral
Provider-Based Vision Screening
Red Reflex Testing
The red reflex test is the most important screening test
for infants and young children. Red reflex testing requires no patient
participation and can be performed shortly after birth. A direct ophthalmoscope
is used to view both eyes simultaneously from 2 to 3 ft away from the patient
(Fig 1).
Figure 1.
A. A provider performing red reflex testing approximately 2 to 3 ft from
the infant. B. The provider's view of bilateral red reflex viewing
both eyes simultaneously.
The red reflex represents reflection of the retina through a clear pupillary
axis. Distortion in the red reflex can be caused by an abnormality anywhere in
the visual axis (eg, in the retina [retinoblastoma], vitreous [vitreous
hemorrhage], lens [cataract], or cornea [scar or infection]). A difference in
the red reflex can also be caused by asymmetry in the refractive power of the
eye, which can cause amblyopia and be vision threatening. The AAP recommends
routine screening for structural abnormalities using red reflex testing. (6) Figure
2 represents examples of normal and abnormal red reflex testing.
Figure 2.
Red reflex examination. A. Normal: Child looks at light. Both red
reflections are equal. B. Unequal refraction: One red reflection is
brighter than the other. C. No reflex (cataract): The presence of lens
or other media opacities blocks the red reflection or diminishes it. D.
Foreign body/abrasion (left cornea): The red reflection from the pupil
will backlight corneal defects or foreign bodies. Movement of the
examiner’s head in 1 direction will appear to move the corneal
defects in the opposite direction. E. Strabismus: The corneal light
reflex is temporally displaced in the misaligned right eye, indicating
esotropia. (Reprinted with permission from American Academy of
Pediatrics; Section on Ophthalmology; American Association for Pediatric
Ophthalmology and Strabismus; American Academy of Ophthalmology;
American Association of Certified Orthoptists. Red reflex examination in
neonates, infants, and children. Pediatrics.
2008;122(6):1402. Image courtesy of Alfred G. Smith, MD ©
1991.)
Red reflex testing allows for the prompt diagnosis of and referral for leukocoria
(white pupil), which occurs when there is an opacity preventing a clear view of
the retina. The most concerning cause of leukocoria is retinoblastoma, a
life-threatening tumor in children. All patients with abnormal red reflex tests
should be referred to pediatric ophthalmology, and concern for leukocoria should
be urgently referred.
External Examination
The external examination of the eyes, eyelids, and face
is an important part of the visual system screening in a primary care office. A
simple penlight examination of the eyelids can reveal ptosis, capillary
hemangiomas, and port wine stains, which are risk factors for amblyopia and
systemic diseases. Careful inspection of the globe size is important in
screening for pediatric glaucoma, which can cause either unilateral or bilateral
ocular enlargement. Ptosis requires prompt identification because it can cause
amblyogenic astigmatism even if the lid itself does not block the visual axis.
Substantial ptosis obstructing the visual axis requires urgent referral in any
child. For subtler ptosis, referral to an ophthalmologist is appropriate for
children too young to assess vision using either optotypes (figures or letters
of different sizes used to test vision acuity) or instrument-based screening. In
older children who pass a vision screening with subtle ptosis, referral to
ophthalmology is not required. Ptosis combined with miosis, which is an
asymmetrically constricted pupil, may represent Horner syndrome and would
require an ophthalmology evaluation for neuroblastoma in children. In addition,
an enlarged globe (buphthalmos) is caused by elevated eye pressure. Any enlarged
eye, especially with a history of tearing and photophobia, should be referred
immediately for concern of pediatric glaucoma. Careful inspection by an astute
primary care provider is crucial to the early identification of
vision-threatening and potentially life-threatening problems.
Visual Acuity Testing
What is normal visual acuity? Normal acuity changes with
age because visual acuity improves as children grow. Infants, 0 to 2 months of
age, should blink in response to bright light and have equal pupillary
responses. Additional signs of normal vision in infants include the
“eye-popping reflex.” For the first year of life, children with
normal vision manifest an eye-popping reflex where the eyelids retract on
turning off the lights. It can be clinically helpful to determine that an infant
has at least light perception vision when parents are concerned that their baby
cannot see. The eyelid retraction disappears when ambient light is turned on,
and the phenomenon is thought to be a form of primitive startle reflex. (7) Fixation
and tracking should improve and
become reliable around 6 to 8 weeks of life. Premature children may have some
delay in their visual development and may not fix and follow until their
adjusted age reaches 8 weeks. Newborns may have intermittent strabismus (either
eye turning outward or inward), but this should resolve by 2 to 4 months of age.
Any constant strabismus is considered abnormal at any age, and intermittent
strabismus after 4 months warrants referral. From age 6 months to 2 years,
children should be able to fix and follow an object monocularly and have normal
alignment. After age 3 to 5 years, subjective vision can usually be measured
using eye charts. Video 1 demonstrates a
technician checking vision in a 2.5-year-old girl using matching LEA
SYMBOLS® (Good-Lite Co, Elgin, IL) optotypes (standard symbols such as
letters or pictures). A practical tip for checking vision in very young children
is to begin the “matching game” before covering each eye to
confirm understanding and to encourage participation before introducing the eye
patch.
Video 1. Video of a technician checking
vision monocularly in a 2.5-year-old girl using matching LEA
SYMBOLS® optotypes and an eye patch.
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Children 3 years or older typically can participate in provider-based subjective
visual acuity testing. Children who cannot participate in subjective visual
acuity testing are considered untestable, and untestable children have been
shown to have vision problems more often than testable children. (8) Repeated examination
in 6 months is
recommended, and inability to assess vision in a 3- to 5-year-old merits
referral to an eye care provider. (5)
Recommendations for referral based on visual acuity are presented in Table 1.
Recognition visual acuity testing is the gold standard in vision screening and
the preferred method for assessing vision to detect amblyopia, especially in
older children. Vision is routinely tested at 2 standard distances (10–20
ft for distance vision and 14–16 in for near vision). Vision should be
measured monocularly, which involves sufficiently occluding 1 eye with an
adhesive patch or occlusive tape. Vision should be checked while the child is
wearing any necessary corrective lenses. Young children improve performance if
allowed to match optotypes presented on the chart to a handheld card (eg, Video 1).
The choice and presentation of
optotypes on an eye chart affect the visual acuity obtained. The current
recommendations by the American Academy of Ophthalmology are for LEA
SYMBOLS® (Fig 3) or HOTV letters to be
used as the preferred optotypes for preliterate children. The goal is for the
optotypes to be standardized, clear, and without cultural bias. Allen figures,
tumbling E charts, and Lighthouse symbols are not standardized and are no longer
recommended as preferred optotypes.
Figure 3.
LEA SYMBOLS®. (Reprinted with permission from Good-Lite Co, Elgin,
IL.)
Cover and Hirschberg Testing for Strabismus Evaluation
A common concern among parents is for strabismus
(misalignment of the eyes). An esodeviation refers to a convergent misalignment
of the visual axis. Esophoria is a latent esodeviation that under normal
binocular conditions the eyes remain properly aligned. Esotropia is an
esodeviation that is not controlled by fusional mechanisms, so the deviation is
constantly manifest. Exodeviation is a divergent strabismus that can be latent
(exophoria) or manifest (exotropia). Most people have some latent strabismus
(esophoria and exophoria) that can be revealed by extensive cover testing and is
not amblyogenic, but manifest strabismus is a frequent cause of amblyopia.
Examination techniques such as cover testing and Hirschberg testing are crucial
for evaluating concern for strabismus. For example, parents can report esotropia
but may in fact be appreciating pseudoesotropia. Children with large epicanthal
folds or a flat nasal bridge often have pseudoesotropia (appearance of crossed
eyes when the eyes are in fact straight), which may be diagnosed by symmetry of
the pupillary light reflex when shining a penlight toward the patient or by
cover testing (Fig 4). If the primary care
provider is confident in the diagnosis of pseudoesotropia, these patients do not
require referral to ophthalmology.
Figure 4.
Pseudoesotropia with wide epicanthal folds. Despite the left eye
appearing crossed because there is less white sclera visible nasally,
the well-centered light reflexes confirm pseudoesotropia.
The cover-uncover test and the Hirschberg test are used to determine whether
there is a manifest misalignment of the eyes. The Hirschberg test is a simple
test where a penlight is directed at the patient while he or she is looking
straight ahead. The light reflex should be reflected in the center of each pupil
if the patient’s eyes are straight. If there is a manifest exotropia, the
light reflex will be nasal to the pupil. If there is a manifest esotropia, the
light reflex will be temporal to the pupil (Fig
5). The Hirschberg test, along with the cover test, can be very
helpful in distinguishing a benign pseudoesotropia from a true manifest
strabismus requiring ophthalmology referral.
Figure 5.
Esotropia of the left eye.
The cover test requires the child to fixate either at near (eg, a sticker on an
examiner’s nose or a toy held up close) or distance (eg, a television or
parent at the end of the room). If the patient is watching your nose and there
is a manifest exodeviation of the right eye (ie, the right eye is turning out),
the left eye is straight and fixating. The cover test involves covering the
fixating eye and watching the deviated eye shift toward central fixation. If the
misaligned eye is drifted out, the eye will shift inward when the fixating eye
is covered. If the deviated eye is turned in, the eye will shift outward when
the fixating eye is covered. Video 2
demonstrates a child with esotropia whose inward-turned eye refixates outward
when his opposite eye is covered.
Video 2. Video of a provider evaluating for
strabismus. This is a 7-year-old boy with esotropia whose inward-turned
eye refixates outward when his opposite eye is covered.
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Ocular Motility and Nystagmus
In addition to alignment, ocular motility is an
important part of the eye examination. Parents who observe “funny eye
movements” may be the first observers of a complex strabismus syndrome,
such as congenital fourth nerve palsy, Brown syndrome, or Duane syndrome.
Congenital fourth nerve palsy is characterized by a vertical misalignment of the
eyes caused by weakness of the ipsilateral superior oblique muscle. Children
typically have a head tilt toward the side of the palsy. Brown syndrome is also
characterized by vertical misalignment of the eyes caused by a deficit of the
superior oblique muscle where the affected eye cannot elevate in adduction.
Duane syndrome is characterized by anomalous innervation of the lateral rectus
by the sixth cranial nerve causing limitation in horizontal eye movements as
well as retraction of the globe on attempted adduction. If a patient has an
esotropia, evaluating motility is important for determining the urgency of the
referral. The most common forms of esotropia, including congenital esotropia and
accommodative esotropia, typically have normal ocular motility. Limitation of
abduction (eye movement away from the nose) can be a sign of a sixth nerve palsy
in contrast to congenital or accommodative esotropia with full ductions and no
abduction limitation. In addition, the presence of nystagmus or unusual eye
movements in an infant or young child can indicate decreased vision or
neurologic dysfunction and warrants further evaluation by either an
ophthalmologist or a neurologist.
Pupil Examination
The pupils should be equal in size and reactive to light
from birth. A dim room and using a bright light elicits the best pupil response,
especially in newborns. The pupils normally will decrease in diameter with
accommodation and if the child is looking at the examiner at near; the pupil
response may be less marked if the pupils are small already during
accommodation. Any evidence of anisocoria or pupils of different shapes should
be referred to an ophthalmologist.
Instrument-Based Vision Screening
Provider-based visual acuity assessment depends on child
participation and screener experience. With practice, instrument-based vision
screening can be fast and require less participation from the child. (Video 3) Instrument-based
screening can be very
helpful in screening children before reliable subjective visual acuity can be
obtained. (9) Recent guidelines released by
the AAP in January 2016 recommend instrument-based screening starting at 1 year old
and continuing until the child can reliably read the eye chart. (10)
Video 3. Video of a technician using a vision
screener with a 6-year-old boy.
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There are 2 types of instrument-based vision screening: photoscreeners and
autorefractors. Neither type measures visual acuity itself but rather measures risk
factors for vision loss, including myopia, hyperopia, astigmatism, and strabismus.
Children with retinal disease or structural causes for amblyopia may have
false-negative screening tests. Amblyopia risk factors were identified in 5% of
preschool children participating in 16 photoscreening programs of more than 400,000
children. (11) Approximately 4% of children
younger than 6 years have myopia, 5% to 10% have astigmatism, and up to 20% have
hyperopia. (12)(13)(14) Photoscreeners
are binocular devices that estimate refractive error, media clarity, ocular
alignment, and eyelid position. Photoscreeners have been shown to have high
sensitivity and specificity when used in community and office settings. (15)(16)(17)
Autorefractors
monocularly estimate refractive error and are useful for screening for high
refractive error and anisometropia. Once a child is old enough to reliably read an
eye chart, direct visual acuity should supplement vision screening. Instrument-based
vision screening would not detect structural abnormalities causing decreased vision
(eg, retinal dystrophies or optic nerve hypoplasia) even if vision was poor because
visual acuity is not directly measured. Table
3 compares common commercially available instrument-based vision
screening devices.
Table 3.
Instrument-Based Vision Screening Devices (18)
DEVICE
iScreen (14)
Plusoptix S09, S12c (19)
Spot screener (12)
Righton Retinomax (4)
SureSight (20)
Type
Photoscreener
Hybrid
Hybrid
Autorefractor
Autorefractor
Monocular/binocular
Binocular
Binocular
Binocular
Monocular
Monocular
Image interpretation
Vendor
Automated
Automated
Automated
Automated
Conditions screened
Refractive error, strabismus, anisometropia, anisocoria,
cataracts
Refractive error, strabismus, anisometropia, anisocoria
Refractive error, strabismus, anisometropia, anisocoria
Refractive error
Refractive error
Cost per machine, $
4,200
7,595
7,490
12,495
3,999
Cost per test
∼$10
None
None
None
Time per test, seconds
7
1
1
1
1
Time for results
<1 h
Instant
Instant
Instant
Instant
Data from Colburn J. Comparison of instrument-based vision
screening devices. American Academy of Ophthalmology
website.
https://www.aao.org/pediatric-center-detail/vision-screening-performance-data-resource-2
.
Published 2014. Accessed August 1, 2017
Vision Screening Coding
Last, Current Procedural Terminology codes
99173 and 99174 are specific for provider-based visual acuity screening and
instrument-based photoscreening, respectively. The AAP recommends that vision
screening not be bundled into the global code of well-child care. Adequate
reimbursement for photoscreening must be encouraged to promote widespread adoption
of vision screening. Unfortunately, some insurance plans may not cover vision
services. The National Eye Institute has information regarding vision services
available to uninsured and underinsured children (https://nei.nih.gov/health/financialaid).
Summary
On the basis of expert consensus as well as prospective cohort research,
routine vision screening decreases the incidence of vision loss in early
childhood. (3)
Based on consensus, the most important aspects of a provider-based vision
screening are red reflex testing, external examination of lids and
adnexa, ocular motility, and visual acuity testing.
Based on some research evidence as well as consensus, instrument-based
vision screening can be used to reliably evaluate vision in children.
(10)
Referral to an eye care provider is indicated if a patient does not pass
a component of the vision screen or when further diagnostic and
management recommendations are required.