Childhood Eye Examination in Primary Care

Alexis Reedy-Cooper; Christina Scartozzi; Theresa Yurkonis

ALEXIS REEDY-COOPER, MD, MPH, CHRISTINA SCARTOZZI, DO, AND THERESA YURKONIS, DO, MHSA

Am Fam Physician. 2023;108(1):40-50

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wears glasses. Routine eye examinations during childhood can identify abnormalities necessitating referral to ophthalmology, which optimizes children's vision through the early diagnosis and treatment of abnormalities. The U.S. Preventive Services Task Force recommends vision screening at least once in children three to five years of age to detect amblyopia or its risk factors to improve visual acuity. The American Academy of Family Physicians supports this recommendation. The American Academy of Pediatrics recommends screening starting at three years of age and at regular intervals in childhood, and that instrument-based screening (e.g., photoscreening, autorefraction) is an alternative to vision charts for testing visual acuity in patients three to five years of age. Eye examinations include visual acuity testing, external examinations, assessing ocular alignment and pupillary response, and assessing for opacities with the red reflex examination. Common abnormalities include refractive errors, amblyopia (reduction in visual acuity in one eye not attributable to structural abnormality), and strabismus (misalignment of the eye). Rare diagnoses include retinoblastoma (often detectable through loss of red reflex), cataracts (detectable by an abnormal red reflex), and glaucoma (often manifests as light sensitivity with corneal cloudiness and enlargement).

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wear glasses.^1,2 Routine eye examinations and vision screening during well-child examinations can identify risk factors and abnormalities consistent with those eye disorders and lead to a referral to ophthalmology. Subsequent diagnosis and treatment can optimize a child's eye health and vision, thereby minimizing or avoiding developmental delays, impaired school performance, and problems with social interactions and self-esteem.³

Clinical recommendation	Evidence rating	Comments
The USPSTF recommends vision screening at least once in all children three to five years of age to detect amblyopia or its risk factors to improve visual acuity.⁴ This recommendation is supported by the American Academy of Family Physicians.⁵	B	USPSTF grade B recommendation
The benefits of vision screening to detect amblyopia or its risk factors in children younger than three years are uncertain according to the USPSTF, and the balance of benefits and harms cannot be determined.⁴	C	USPSTF grade I recommendation
The American Academy of Ophthalmology recommends referral for children five years and older who cannot read three or more letters or figures on the 20/30 line or a two-line difference between eyes because this may indicate amblyopia (i.e., one eye has worse visual acuity than the other).⁶	C	Expert opinion
The American Academy of Pediatrics recommends instrument-based vision screening as an alternative to a vison chart in patients three to five years of age for annual screening.^8,10,11	C	Expert opinion

Recommendation	Sponsoring organization
Annual comprehensive eye examinations are unnecessary for children who pass routine vision screening assessments.	American Association for Pediatric Ophthalmology and Strabismus

The U.S. Preventive Services Task Force (USPSTF) recommends vision screening at least once in all children three to five years of age (grade B recommendation) to detect amblyopia or its risk factors to improve visual acuity.⁴ The benefits of vision screening to detect amblyopia or its risk factors in children younger than three years are uncertain according to the USPSTF, and the balance of benefits and harms cannot be determined (grade C recommendation).⁴ The American Academy of Family Physicians supports this recommendation.⁵ The American Academy of Ophthalmology recommends that components of the visual screening occur at every well-child examination⁶ (Table 1^6–8). The American Academy of Pediatrics recommends beginning vision screening at four to five years of age and as early as three years of age in cooperative children.⁹ Instrument-based screening (e.g., photoscreening) is recommended starting at 12 months of age.^10,11

Method	Indications for referral	Implication	Recommended age
Method	Indications for referral	Implication	Newborn to six months	Six months and until the child is able to cooperate for subjective visual acuity measurement	Three to four years	Four to five years	Every one to two years after five years of age
External inspection	Structural abnormality (e.g., ptosis)		X	X	X	X	X
Fix and follow test	Failure to fix and follow	Strabismus	Cooperative infant older than three months	X
Pupillary examination	Irregular shape, unequal size, poor or unequal reaction to light	Horner syndrome, retinoblastoma	X	X	X	X	X
Red reflex examination	Absent, white, dull, opacified, or asymmetric	Retinoblastoma, cataract, glaucoma, retinal abnormality	X	X	X	X	X
Corneal light reflex test	Asymmetric or displaced	Strabismus		X	X	X	X
Cover test	Covered eye moves back to alignment when uncovered	Strabismus		X	X	X	X
Instrument-based screening*	Failure to meet screening criteria based on instrument guidelines	Amblyopia, refractive errors, strabismus		Can be used to assess risk when available	X	X	X
Distance visual acuity† (monocular)	20/50 or worse in either eye	Amblyopia, vision impairment			X	X	X
	20/40 or worse in either eye					X	X
	Worse than three out of five characters on 20/30 line, or two lines of difference between the eyes						X

History

Comprehensive personal and family histories, including parental observations, are important components of visual and eye screening examinations (Table 2).^11,12 A personal history that warrants a referral to ophthalmology includes premature birth, Down syndrome, and cerebral palsy.

Eye Examination

The eye examination should include an external examination, pupillary response, corneal light reflex, red reflex, fixation and alignment, cover and cover-uncover, and visual acuity testing. American Family Physician provides videos demonstrating eye examinations in infants/toddlers (https://www.youtube.com/watch?v=4hjONYSfjS8) and preschoolers (https://www.youtube.com/watch?v=WRqk5vqWMy0).

PUPILLARY RESPONSE

Pupillary response should be assessed in light and darkness using a light source to illuminate the pupil while the child's attention is directed toward a remote target of interest (e.g., a toy). Pupils should be compared for size and symmetry. A difference in pupil size greater than 1 mm can be a sign of underlying pathology.

CORNEAL LIGHT REFLEX

To test the corneal reflex, the clinician should center light on the pupils to assess if there is an equal light reflex. This can be accomplished most naturally during the external inspection and assessment of pupillary response. A toy in front of the child can help keep the child's gaze still, making the assessment easier.

Light reflex should be symmetric by four to six months of age. Light reflex helps differentiate pseudostrabismus from strabismus (i.e., a misalignment of the eyes). A light reflex in patients with pseudostrabismus is normal despite a wide nasal bridge or epicanthal fold that may initially make the eyes appear to be misaligned (Figure 1 and Figure 2¹²).

RED REFLEX

Red reflex testing is recommended starting in the neonatal period and continuing through subsequent well-child examinations. This test is critical for detecting vision and serious abnormalities such as cataracts, glaucoma, retinoblastoma, retinal disorders, systemic diseases with ocular manifestations, and high refractive errors.⁶

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History

Eye Examination

PUPILLARY RESPONSE

CORNEAL LIGHT REFLEX

RED REFLEX

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Eye Examination

PUPILLARY RESPONSE

CORNEAL LIGHT REFLEX

RED REFLEX

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