directed to pediatricians and GP

3. Vision.
Red reflex.
Ocular alignment.
Detect external eyes problems.
Children with systemic medical conditions.
Red eye.

6. There are many ways to assess even if the child is 6 months old.
In childhood at the stage of vision development, If eyes cannot send clear images to the brain, the
eyes will be Lazy permanently (can’t be corrected later in life); Amblyopia but if detected early ,we can
treat efficiently.
Early detection of poor vision ,enable us to avoid permanent visual disability.
Good vision is important for baby's physical development, later success in school and
overall well-being. Poor vision will lead to inability to cope with the mates , bullying, poor academic
performance, and reduced quality of life.
Vision screening is important in early ages:
Photo refraction
Vision screening can be done in an uncooperative child:

8. Amblyopia (lazy eye)
Amblyopia definition:
poor vision in an otherwise normal eye-occurs when vision in one or both eyes does
not develop properly during childhood.
It can be caused by:
1. Significant refractive error or significant difference in the errors of refraction in
both eyes.
2. Misalignment of the eyes (squint).
3. Media opacity (vision stimulus deprivation).
anything that blocks a clear image from reaching the retina such as visually
significant ptosis (droopy eyelid) , cataract or corneal opacities ,...
Why it is important to detect amblyopia? What if not treated?
Amblyopia is reversible with treatment in childhood as the child will develop normal vision in
this age. (six to eight years of age )
The cause must be identified and treated by this age otherwise, permanent reduction in vision
in one or both eyes.

10. Preschool (3 years).
First grade (5 years).
Second grade (7 years).
Fifth grade (10 years).
Eighth grade (13 years).
Tenth grade (15 years).
Red reflex test by pediatrician (a basic indicator that the eyes are normal).
Newborn:
Birth to 24 months:
At 6 months of age.
An ophthalmologist should perform a comprehensive exam if the baby is premature or at high risk
for medical problems for other reasons.
Preferential looking – Teller test – Cardiff test.
Snellen test.
Above Ages:
Fixation pattern.
(Pen torch- monocular test).
Guidelines for screening school-age children:
(Prevent Blindness America Organization)

11. Preferential looking
Cardiff test
Snellen test for distance vision

13. • If reduced visual acuity.
• If abnormal vision behavior.
• If uncooperative to vision screening.
When to refer:

14.  Birth:
 First two months:
 At 3 months old:
 At around 5:6 months old:
Fixation pattern:
transient fixation and follow
= 20/40 – 20/60 (6/12 - 6/18).
Fixation pattern:
Fix and follow Central ,Steady ,Maintained
= 20/20 – 20/30 (6/6 - 6/9).
Light perception.
babies' eyes often do not work together very well.
baby's eyes should work together to focus and track objects. fixates and follow
interesting bright colored objects.
A baby's ability to see how far an object is from them (called depth perception) has
developed more fully.

15.  Age 3-5 years:
 All ages:
 Age 6 years and older:
A child must correctly identify more half of the symbols on 20/40 line(6/12 or 0.50).
A child must correctly identify more half of the symbols on 20/30 line (6/9 or 0.6).
A visual acuity of 20/20 (6/6 or 1.0) for all ages is considered excellent.
(Snellen test)
Visual acuity scale

16. 1- Vision in either eye of 20/50 (6/15 or 0.4) or poorer.
Vision in either eye of 20/40 (6/12 or 0.5) or poorer. (Anisometropic amblyopia)
3-year-olds: According to Prevent Blindness America Organization:
All other ages/grades: According to Prevent Blindness America Organization:
2- A two-line difference in visual acuity between the eyes in the passing range
(i.e. 20/20 in one eye, and 20/40 in the other. (Anisometropic amblyopia)
6 months: 24 months
Central steady, maintain briefly 20/40 -20/60 (6/12 or 0.5)
Cs, not maintained 20/70-20/80
Not central, Eccentric fixation </= 20/300

17. . Rubs eyes frequently.
· Blinks excessively.
· Holds book too far or too close to face.
· Makes frequent change in distance at which book is held.
· Is inattentive during lesson or Stops after brief period.
· Shuts or covers one eye.
· Tilts head or face in attempt to see distant things clearly.
· Tends to reverse words or confuses words or letters.
· Tends to lose place on page.
. Eye strain following excessive use of electronic devices. (computer vision syndrome)
Children observed to have any of the these signs
should be referred for a vision exam regardless
of age or grade placement.

18. Red Reflex

19. 19
 Direct ophthalmoscope, darkened room.
 View eyes separately at 12-18 inches.
Red Reflex
Normal: The light is reddish-orange, reflecting the color of normal retina.
Interpretation:
Abnormal Finding:
The red reflex is either absent or white (leukocoria)
(abnormal reflection of light coming out of the eye.)
Technique:
When light enters the eye through the pupil, the retina absorbs most of the light. A
small amount of light is reflected by the retina back out of the eye through the pupil.

20. Retinitis of prematurity (ROP)
Coloboma
(chorioretinal – optic nerve)
Congenital Cataract
Retinal detachment
White pupil DD:

21. Retinoblastoma
Ocular Toxocariasis
Coats disease
Persistent Foetal Vasculature

22. Ocular
Alignment

23. 23
Ocular Alignment
Simultaneous red reflex test (Bruckner)
Performed using direct ophthalmoscope
to obtain red reflex simultaneously in both eyes help in diagnosis of

25. Detect external eyes problems
Eye lids dropping.
Corneal clouding.
Large cornea.

27. Children with systemic medical conditions:
Learning disability.
Developmental delay.
Neuropsychological condition or behavioral issue.
Metabolic diseases.
Refer children with systemic diseases like:

29. Red eye:
Treat conjunctivitis (bacterial / Allergic)
Patients with the following features should be referred to eye clinic:
 Severe eye pain.
 Severe photophobia.
 Marked redness of one eye.
Corneal Foreign body
Corneal abrasions
Conjunctival Foreign body
Be aware that some serious conditions present as red eyes:

30. Retinoblastoma
Congenital glaucoma
Rhabdomyosarcoma

32. Comprehensive ophthalmology exam

33. Assessment of visual acuity in eye clinic
Subjective visual acuity testing:
For infants and toddlers :
-Fixation preference tests.
-Preferential looking visual acuity test.
-Visual acuity charts should be tested as soon as the child is
old enough to cooperate.

34. Assessment of visual acuity in eye clinic
For infants and toddlers :
Objective visual acuity testing:
-Visual Evoked Potential/Response (VEP/VER).
-Retinoscopy.
-Photo-screening is another way to check refraction that
does not require a young child to cooperate with the test.
-Auto-refraction.

35. Refraction
Objective Cycloplegic refraction(wet):
cycloplegic drops to paralyze their
accommodation
using a retinoscopy to measure a patient’s refraction.
Subjective (manifest, dry):
Using a refractor (also known as a phoroptor) to allow a
patient to provide their subjective response about their
prescription.
Refraction is the measurement of the eye’s power. Spectacles correct errors
of refraction.
There are also different types of refraction:

36. •Reduced vision - abnormal vision behavior.
•children who are uncooperative to test the vision.
Vision screening:
•White pupil.
Red reflex .
•Inward- outward- upward- downward deviations.
•Abnormal eyes movements.
Ocular alignment .
•eye lids dropping - Corneal clouding- large cornea.
Detect external eyes problems
•learning disability, developmental delay, neuropsychological condition or behavioral issue.
Children with systemic medical conditions
•treat conjunctivitis but be aware that some serious conditions present as red eyes e.g.
congenital glaucoma, retinoblastoma , rhabdomyosarcoma,…
Red eye

37. Index
1. Vision screening…………………………….…………... slide 5
2. Red reflex testing. ……………………………………..... slide 19
3. Ocular alignment evaluation……………..….…………. slide 23
4. Detect external eyes problems…… ……………..….…. slide 25
5. Systemic medical conditions……… ……………..…..…. slide 27
6. Red eyes. ……………..….………………………………. slide 29
1. Comprehensive ophthalmology exam………………………………… slide 33.
2. Assessment of visual acuity in eye clinic…………….…….………… slide 34.