Procedures for the Evaluation of the Visual System by ... · CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Procedures for the Evaluation of the Visual System

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Procedures for the Evaluation of theVisual System by PediatriciansSean P. Donahue, MD, PhD, FAAP, Cynthia N Baker, MD, FAAP, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE,SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS,AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AMERICAN ACADEMY OF OPHTHALMOLOGY

abstractVision screening is crucial for the detection of visual and systemic disorders. Itshould begin in the newborn nursery and continue throughout childhood. Thisclinical report provides details regarding methods for pediatricians to use forscreening.

This clinical report supplements the combined policy statement from theAmerican Academy of Pediatrics (AAP), American Association for PediatricOphthalmology and Strabismus, American Academy of Ophthalmology, andAmerican Association of Certified Orthoptists titled “Visual SystemAssessment in Infants, Children, and Young Adults by Pediatricians.”1 Theclinical report and accompanying policy statement supplant the 2012policy statement “Instrument-Based Pediatric Vision Screening,”2 the 2003policy statement “Eye Examination in Infants, Children, and Young Adultsby Pediatricians,”3 and the 2008 AAP policy statement “Red ReflexExamination in Neonates Infants and Children.”4 The policy statementarticulates the screening criteria and screening methods, and the clinicalreport explains the various evaluation procedures that are available foruse by the pediatrician or primary care physician.

VISUAL SYSTEM HISTORY ASSESSMENT

Relevant family history regarding eye disorders (cataracts, strabismus,amblyopia, and refractive error), eye surgery, and the use of glasses duringchildhood in parents or siblings should be explored. Parents’ observationsare also valuable in the history and review of systems. Questions that canbe asked include:

1. Do your child’s eyes appear unusual?

2. Does your child seem to see well?

3. Does your child exhibit difficulty with near or distance vision?

4. Do your child’s eyes appear straight or do they seem to cross?

5. Do your child’s eyelids droop or does one eyelid tend to close?

6. Has your child ever had an eye injury?

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit fromexpertise and resources of liaisons and internal (AAP) and externalreviewers. However, clinical reports from the American Academy ofPediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course oftreatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

www.pediatrics.org/cgi/doi/10.1542/peds.2015-3597

DOI: 10.1542/peds.2015-3597

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

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OCULAR EXAMINATION

The ocular examination consists ofthe external examination, pupilexamination, red reflex testing toassess ocular media, the examinationof the ocular fundus by usingophthalmoscopy, and an assessmentof visual function.

EXTERNAL EXAMINATION (LIDS/ORBIT/CONJUNCTIVA/CORNEA/IRIS)

External examination of the ocularstructures consists of a penlightevaluation of the eyelids, conjunctiva,sclera, cornea, and iris. Detection ofabnormalities, such as ptosis,nonresolving conjunctivitis, or thepresence of cloudy or enlargedcorneas and/or photophobia,necessitates timely referral to an eyecare specialist appropriately trainedto treat children. Nasolacrimal ductobstruction that has not resolved by1 year of age also should lead toreferral. Thyroid disease can manifestby increased visibility of the superiorcornea caused by eyelid retraction.

RED REFLEX TESTING

Red reflexes from the retinas can beused by the physician to greatadvantage. The red reflex test, orBruckner test if performedbinocularly, is used to detect opacitiesin the visual axis, such as a cataract orcorneal abnormality, as well asabnormalities in the posteriorsegment, such as retinoblastoma orretinal detachment. The examineralso may detect subtle differences inthe red reflex between the eyes,consistent with the presence ofstrabismus or refractive errors. Theinequality of the red reflection or theinterference with the red reflectioncan be noted in various conditions(Fig 1).

Red reflex testing should beperformed in a darkened room (tomaximize pupil dilation). Eye dropsto further dilate the pupils are notnecessary. The direct ophthalmoscopeis set on “0,” and while viewing

FIGURE 1Red reflex examination. A, NORMAL: Child looks at light. Both red reflections are equal. B, UNEQUALREFRACTION: One red reflection is brighter than the other. C, NO REFLEX (CATARACT): The presenceof 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 back-light corneal defects orforeign bodies. Movement of the examiner’s head in one direction will appear to move the cornealdefects in the opposite direction. E, STRABISMUS: The corneal light reflex is temporally displaced inthe misaligned right eye, indicating esotropia. (Used with permission of Alfred G. Smith, MD, ©1991.)

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through it at a distance ofapproximately arm’s length from thechild, both pupils are evaluatedsimultaneously as the child looks atthe light. To view more detail, theexaminer can move closer to the childto assess each eye individually. Theobserved red reflexes can becompared and should be a lightorange-yellow in color in lightlypigmented eyes or a dark red indarkly pigmented brown eyes. Ifnormal, the 2 red reflexes should beidentical in color, brightness, and size.A bright white or yellow reflex or,conversely, a dull or absent red reflexcan be an indication of a significantabnormality that necessitates furtherevaluation by a pediatricophthalmologist, or if unavailable, acomprehensive ophthalmologist oroptometrist with specialized interestin the treatment of children, and whouses cycloplegia (dilating drops) aspart of his or her routine evaluation.Because there is often considerablevariation in the qualitative nature ofthe red reflex among patients withouteye abnormalities, the frequent,routine assessment of the red reflexwill help the primary care physicianbetter distinguish an abnormality ofthe reflex from a normal one.

PUPIL EXAMINATION

Both pupils should be equal, round,and equally reactive when light isdirected toward either eye.Asymmetric responses to light mayindicate visual system dysfunction.Moreover, asymmetry of pupil shapeor difference in diameter greater than1 mm can often be attributable to anocular injury or disease or to aneurologic disorder. Differences inpupil size less than 1 mm can occurnormally and are generally benignunless associated with ptosis or anocular motility deficit.

OCULAR ALIGNMENT AND MOTILITYASSESSMENT

The assessment of ocular alignmentin the preschool- and early school-

aged child is also important. Thedevelopment of strabismus inchildren may occur at any age and,although often isolated, may alsorepresent serious orbital, intraocular,or intracranial disease.

The corneal light reflex test and thecover test are each useful inidentifying the presence ofstrabismus as well as indifferentiating true strabismus frompseudostrabismus.

The corneal light reflex test (ie,Hirschberg test) is performed with apenlight directed onto the child’s facefrom arm’s length away and byobserving the symmetrical location ofthe white pinpoint light reflexes whilethe child gazes at the light. Normally,these reflexes fall symmetrically in ornear the center of the pupils. Anabnormal response occurs when thereflex in one eye is centered in thepupil while the reflex in the oppositeeye is displaced nasally, temporally, orvertically away from the pupil center(Fig 1). This asymmetry of thereflexes typically indicates thepresence of strabismus.

The cover test should be performedwhile the child fixates on a small,interesting target, such as a small toyor sticker on a tongue depressor. Thebright beam of a penlight does notprovide a comfortable target anddoes not adequately stimulateaccommodation (focusing). As thechild attends to the target, each eye isalternately covered. A shift in an eye’salignment as it assumes fixation ontothe target is a possible indication ofstrabismus.

Strabismus in the neonatal period isnot unusual, and intermittentstrabismus is often a normal findingin early infancy. However, constanthorizontal strabismus that persistsafter 4 months of age does not resolvespontaneously.5 Thus, any child olderthan 4 months with strabismusshould be referred for evaluation.

Pseudostrabismus is the appearanceof crossed eyes (esotropia)

attributable to the presence ofprominent epicanthal skin folds thatcover the medial portion of the scleraon 1 or both eyes, giving the falseimpression of esotropia. The inabilityto differentiate strabismus frompseudostrabismus also necessitatesreferral.

Finally, the presence of unusual eyemovements in an infant or young childmay indicate nystagmus or a similardisorder and often indicates decreasedvision or neurologic dysfunction.Nystagmus does not resolvespontaneously and often indicatesafferent visual system dysfunction orneurologic disease and necessitatesfurther evaluation by either anophthalmologist or neurologist.

OPHTHALMOSCOPY

Use of the direct ophthalmoscope inolder, cooperative children serves tovisualize structures in the back of theeye, such as the optic nerve, retinalblood vessels, and central retina(fovea). To properly visualize thesestructures, the child looks into thedistance at a target of interest. Theophthalmoscope is dialed to a +10 lensand the examiner focuses on the pupilfrom ∼3 inches away. The examinerthen gradually moves as close to theeye as possible while sequentiallydialing less lens power until retinalvessels come into focus. These vesselscan be followed to identify and viewthe optic nerve. The normal opticnerve has a yellow-pink color and isgenerally flat. To view the foveal reflex,the child is asked to look directly atthe light of the ophthalmoscope. Thenormal foveal reflex should appearbright and sharp. Retinal hemorrhagescan be observed after a normal vaginaldelivery but are also the harbinger ofsevere child abuse; a swollen opticnerve may be an indicator of increasedintracranial pressure.

ASSESSMENT OF VISUAL ACUITY INPREVERBAL CHILDREN

The assessment of visual function inthis very young age group is best

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accomplished by evaluating thechild’s ability to fixate on and followan object held before the child. Astandard assessment strategy is todetermine whether each eye canindependently fixate on the object,maintain fixation on it for a shortperiod of time, and then follow it asit is moved in various directions. Thechild should be awake and alert forthis testing, and the targeted objectshould be a toy or something ofinterest to the child. Disinterest orpoor cooperation can mimic a poorvision response. This assessmentshould first be performedbinocularly and then repeated witheach eye alternately covered. If poorbinocular fixation and followingbehavior is noted after 3 months ofage, an ocular or neurologicabnormality may be present.Similarly, asymmetry in responsesbetween the 2 eyes in children ofany age necessitates furtherevaluation.

ASSESSMENT OF VISUAL ACUITY INOLDER CHILDREN

Children who are old enough todelineate objects on a wall-mountedor handheld eye chart can provide adirect measurement of visual acuity.For some children, this may beaccomplished as young as 3 years,but for the typical healthy child, anaccurate visual acuity can beachieved with a high degree ofsuccess at 4 years and older. Eyesshould be tested monocularly,ensuring that the child does not peekwith the fellow eye.

With traditional visual acuityscreening, the selection of age-appropriate shapes or letters andspecific testing methods is crucial inobtaining the most accurate screeningresults. Many children can identifyoptotypes (figures or a selection ofdistinct letters formatted on chartlines or presented singly onindividual cards) by 4 years of age.Eye charts using lines of optotypes ormatching cards with lines (crowding

bars) around each optotype providethe most accurate assessments ofvisual acuity (Fig 2). Using cards withsingle optotypes but withoutcrowding bars can overestimatevisual acuity. Crowding barssurround an optotype and makeindividual letters more difficult torecognize by an amblyopic eye, thusincreasing the sensitivity to detectamblyopia (Fig 2). Accurateassessment of visual acuity, therefore,is best accomplished by using a lineof symbols or symbols with crowdingbars around them.

The currently preferred optotypes arethe LEA or HOTV symbols, althoughother new picture optotype acuitytests are under development.6,7 Allenfigures, Lighthouse characters, and theSail Boat Chart are not standardizedand are no longer recommended foruse, nor are the Tumbling E or LandoltC charts, because a child of preschoolage may not yet have developed theability to express the orientation ofthese optotypes. HOTV symbols are

easier for the young child tounderstand, as they are symmetricand not subject to letter reversal. Withthe examiner pointing to a symbolwith a finger under it, a timid child canpoint to the optotypes that he or sherecognizes on a card with similarsymbols; this allows the child toeffectively offer nonverbal responsesduring testing. Once a child candistinguish letters, a chart with letteroptotypes should be used. Althoughthe traditional Snellen chart remainsin wide usage, Sloan letter chartspresent letters in a standardizedfashion and should be used for acuitytesting if they are available.

Screening Process

Large optotypes at the top of an eyechart or on handheld cards are firstreviewed with the child with both eyesopen to help the child understand thetest. After this review, 1 eye isoccluded (preferably by an occlusivepatch or tape) and lines of optotypesor cards with single crowdedoptotypes (ie, the figure is surroundedby bars on all 4 sides) are presented toeach eye separately. Effectiveocclusion, such as with tape or anocclusive patch of the eye not beingtested, is important to eliminate thepossibility of peeking.

Threshold Line Evaluation

The time-honored method of testingvisual acuity has been to ask the childto start at the top of an eye chart andcontinue reading down each line untilhe or she recites the smallest line ofoptotypes discernable with each eyetested separately. This method iscalled “threshold” acuity testing andremains a common method of acuitytesting. It enables one to identify thebest level of visual acuity in each eye.Thus, children with near-normalacuity who still have a mild differencein acuity between each eye can bedetected. However, threshold lineevaluation can be sufficiently time-consuming to result in loss ofattention from a young subject.

FIGURE 2A, Five 20/50 letters presented in a row. B,Crowding bars isolate a single letter on thesame 20/50 line, making it easier for a child toidentify the letter, but are less subject to the“crowding phenomenon” (see text).

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Critical Line Evaluation

Young children, even those withnormal vision, are frequently unableto attend sufficiently to smalloptotypes and identify them. “Criticalline” screening is an effectivealternative to threshold testing foridentifying children with potentiallyserious vision concerns and can bemore quickly administered than canscreening by using threshold testing.The “critical line” is the age-dependent line a child is expected tosee normally and pass. For screeningpurposes, it is unnecessary tomeasure acuity below the age-specificcritical line to pass the test. Thecritical line to pass screeningbecomes smaller as age increases.Most eye charts present 4 to 6optotypes per line, and passing thescreening requires the child to correctlyanswer a simple majority of theoptotypes present on the critical lineappropriate for his or her age as follows:

• Ages 36 through 47 months: Ifattempted at this age, the critical lineto pass screening is the 20/50 line

• Ages 48 through 59 months: Thecritical line to pass screening is the20/40 line

• Ages 60 months and older: Thecritical line to pass screening is the20/30 line (or the 20/32 line onsome charts)

Establishing an Effective ScreeningEnvironment and Methodology

It is important that the screening areabe conducive for assessing visualacuity and that proper technique isused to promote accurate screening.It is important that screeningpersonnel be trained to recognize andavoid pitfalls that reduce the accuracyof visual acuity screening. Accuratescreening of visual acuity requiresdedicated and skilled staff members.

1. A well-illuminated area free fromdistraction is important. A quietexamination room or hallway isgenerally sufficient for thispurpose.

2. An appropriate testing distancemust be used. For children up to5 years of age, especially whenpictorial optotypes are used, thisdistance should be set at 10 feetrather than 20 feet as a standard.This shorter distance helps to en-hance interaction between thechild and the individual adminis-tering the screening without de-creasing the accuracy of screeningresults. Indeed, current standard-ized preschool eye charts aretypically calibrated for use at10 feet. For children 6 years andolder for whom a letter chart isused, the test distance may beappropriately set at either 10 feetor at the common standard of20 feet, as long as the chart isproperly calibrated for use atthat distance.

Increasingly, screening methods usingshort testing distances are becomingavailable in the form of handheldoptotypes used at a testing distance of5 feet8 or as computer, tablet, or smartphone–based models with testingdistances within 1 to 2 feet. Althoughthe accuracy of screening visual acuityat these shorter distances has not yetbeen validated in large population-based studies, the use of thesemethods can fit well into small clinicalwork areas. One computer-basedapplication, available from the JaebCenter for Health Research, isspecifically for use by nonophthalmichealth care professionals. The JaebVisual Acuity Screener incorporates allcurrent screening guidelines and isavailable free of charge for downloadand unlimited use at http://pedig.jaeb.org/JVAS.aspx.

3. It is important to recognize thatchildren with visual impairmentmay inaccurately pass a visionscreening if they peek around anincompletely covered eye or if theyare able to correctly guess whenonly 2 or 3 optotype choices arepresented. Use of an adhesivepatch over the nontested eyeis recommended. Visuallyimpaired children may become

uncooperative during an examina-tion; such behavior should beconsidered a possible indicator ofpoor visual function.

4. The use of validated and stan-dardized optotypes and acuitycharts is important for an accurateassessment of vision. For thisreason, only the LEA symbolsand HOTV characters are recom-mended for preschool visionscreening at this time. Otheroptotypes are not well validated inthe screening environment.

5. Every effort should be made not toisolate shapes or letters in-advertently on a line with a fingeror cover to “help” a strugglingchild. If performed in this manner,the visual acuity result may bemade falsely elevated by blockingout the natural crowding inherentin open lines of letters. If singleoptotypes are presented, theyshould include “crowding bars.”

6. Screening visual acuity to thechild’s threshold (ie, best possibleacuity) may provide a less accurateresult than testing to the age-appropriate critical line for thatchild. Critical line testing is an ap-propriate alternative to thresholdtesting, requires less time to ad-minister, and may provide a moreaccurate screening assessment of achild’s visual function.

Incorporating these concepts intoclinical practice offers a quick andreliable assessment of visual acuityin young children. To assistpediatricians and primary carephysicians, the AmericanAssociation for PediatricOphthalmology and Strabismus hasdeveloped a Vision Screening Kitdesigned specifically for youngchildren that incorporates theseimportant concepts. It is availablecommercially and can be purchasedfrom the AAP.

For healthy children 6 years andolder, testing of visual acuity usingoptotype-based vision charts at 10 or

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20 feet remains the preferred methodfor screening and should be repeatedevery 1 to 2 years (Table 1).

Although barriers to its use exist, alevel-1 Current Procedural

Terminology (CPT) code, 99173, hasbeen established for visual acuityscreening and is available to primary

care physicians to seek payment forthis testing.

INSTRUMENT-BASED SCREENINGTECHNIQUES

Instrument-based screening isendorsed by the AAP2 and by the US

Preventive Services Task Force as a

TABLE 1 Eye Examination Guidelines

Function Recommended Tests Referral Criteria Comments

Newborn to 6 moVision assessment Fixation and follow

responseInconsistent or no response by 3 mo

Ocular media clarity Red reflex White, pupil, dark spots, absent or asymmetricreflex

External inspection Direct observation Any ocular abnormality of concern

6 to 12 mo

Pupil examination Flashlight As above for ages newborn to 6 mo, plus

Ages 1–3 y

As above for ages 6 mo to 12 mo, plusInstrument-based vision

screening when available(CPT 99174)

Photoscreening Failed screening as indicated by the deviceAutorefraction

Distance visual acuitymay be attemptedat age 3 y

HOTV or LEA Symbols Fewer than a simple majority of optotypescorrect on the 10/25 (20/50) line with eithereye tested monocularly at 10 ft

Ages 4–5 y

Distance visual acuity orinstrument-basedscreening whenavailable (CPT 99173)

HOTV or LEA symbols A simple majority of figures correct on the age-appropriate critical line with either eyetested monocularly at 10 ft

1. Use a well-illuminated area free from distraction.2. Either critical line testing or threshold testing maybe used (see text for details).

3. Testing distance of 10 ft is recommended for allvisual acuity tests.

4. A line of figures is preferred over single figures,unless the single figures are “crowded” (see text).

5. The fellow eye should be covered by an occluderheld by the examiner or by an adhesive occluderpatch applied to the eye; the examiner shoulddetermine that it is not possible to peek with thenontested eye.

Ages:

48–59 mo: 10/20 (=20/40)60+ mo: 10/15 (=20/30)

or

For threshold testing only: a 2-line differencebetween eyes, even with the passing range;eg, 20/15 (20/30) and 10/10 (20/20) for a 60-mo-old

Ocular alignment Cross cover test Any eye movement Child must be fixing on a target while cross cover testis performed.

Any asymmetry ofpupil color, size,brightness

Direct ophthalmoscope used to view both red reflexessimultaneously in a darkened room from 2–3 feetaway; detects asymmetric refractive errors as well.

Ocular media clarity Red reflex White pupil, dark spots in pupil, absent redreflex

Direct ophthalmoscope, darkened room. View eachred reflex separately at 12–18 inches; white reflexindicates possible retinoblastoma. Dark or absentreflex indicates possible cataract.

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valid method for screening veryyoung children.9 A recentrandomized, controlled,multicentered crossover studydemonstrated photoscreening to besuperior to direct testing of visualacuity for screening well childrenages 3 to 6 years in the pediatricoffice.10 If available, instrument-based screening can be attemptedbeginning at age 12 months,11 and aprevious study has demonstratedbetter eventual outcomes for childrenundergoing their first photoscreeningbefore 2 years of age.12

Instrument-based screening can berelatively quick and requires lessattention from the child comparedwith traditional visual acuityscreening. Screening instrumentsidentify optical and physicalcharacteristics that indicate thepresence of ocular conditions knownto cause amblyopia. Similar to thecode for visual acuity screening, alevel-1 CPT code, 99174, has beenassigned to photoscreening and

enables the primary care physician toseek payment for its use. CPT codes99173 and 99174 are specific forvisual acuity screening andphotoscreening, respectively.

Two types of instrument-based visionscreening are now available for use inambulatory care settings. Althoughneither type provides a directassessment of visual acuity, bothidentify ocular risk factors that canlead to early vision loss in children.Once children can read an eye charteasily, optotype-based acuity should

supplement instrument-based testing.The actual age for this is not yet wellestablished and likely variesdepending on the child.

The most common ocularabnormalities seen during the earlychildhood years are strabismus,anisometropia, and a high magnitudeof uncorrected refractive errors:hypermetropia, myopia, andastigmatism. The AmericanAssociation for PediatricOphthalmology and Strabismus hasdeveloped refractive criteria to help

TABLE 1 Continued

Function Recommended Tests Referral Criteria Comments

Ages ‡6 y

Distance visual acuity;instrument-basedscreening whenavailable for childrenunable to perform acuity

Sloan letters orSnellen letters

Fewer than a simple majority of optotypescorrect on the 10/15 (20/30) line with eithereye tested monocularly at 10 ft

1. Tests are listed in decreasing order of cognitivedifficulty; the highest test that the child is capableof performing should be used.

HOTV or LEA symbols 2. Use a well-illuminated area free from distraction.3. Either critical line testing or threshold testing maybe used (see text for details).

4. Testing distance of 10 ft is recommended for allvisual acuity tests.

5. A line of figures is preferred over single figuresunless the single figures are “crowded” (see text).

6. The fellow eye should be covered by an occluderheld by the examiner or by an adhesive occluderpatch applied to the eye; the examiner shoulddetermine that it is not possible to peek out of thecovered eye.

or

For threshold testing: only: a 2-line differencebetween eyes, even within the passingrange; eg, 10/10 (20/20) and 10/15 (20/30)

Any eye movement Simultaneous red reflex test (Bruckner test).Child must be fixing on a target while cross cover testis performed.

Ocular media clarity Red reflex White pupil, dark spots, absent reflex Direct ophthalmoscope, darkened room. View eachred reflex separately at 12–18 inches; white reflexindicates possible retinoblastoma. Dark or absentreflex indicates possible cataract.

TABLE 2 Amblyopia Risk Factor Targets Recommended by the American Association for PediatricOphthalmology and Strabismus

Refractive Risk Factor Targets

Age, mo Astigmatism, D Hyperopia, D Anisometropia, D Myopia, D

12–30 .2.0 .4.5 .2.5 .23.531–48 .2.0 .4.5 .2.0 .23.0.48 .1.5 .3.0 .1.5 .21.5

Nonrefractive Risk Factor TargetsAll ages Media opacity .1 mm

Manifest strabismus .8 prism D in primary position

D, dioptersFrom Donahue et al.13

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primary care physicians appreciatethe levels of refractive error known toincrease risk of amblyopia(Table 2).13 Referral criteria that bestdetect these amblyopia risk factorsmay vary depending on the screeninginstrument used and the desiredlevels of sensitivity and specificity.

Photoscreening devices identifyoptical characteristics of the eyes toestimate refractive error, mediaclarity, ocular alignment, and eyelidposition. Abnormalities in thesecharacteristics constitute risk factorsfor the presence or development ofamblyopia. Photoscreening has beenshown to have high sensitivity andspecificity in community and officesettings.14–20 Photoscreeninginstruments assess both eyessimultaneously and the images can beinterpreted by trained operators, by acentral reading center, or withcomputer software.

Autorefraction instruments, likephotoscreeners, also are useful forscreening young children.21,22

Handheld autorefractors use opticalmethods to estimate the refractiveerror of each eye, 1 eye at a time, andas such, are limited in their ability todetect strabismus in the absence ofan abnormal refractive error.However, autorefractors remainuseful in detecting anisometropia inthe absence of strabismus, which isthe most common cause of amblyopiaundetected at an early age.

Instrument-based devices usingtechnology based on visual evokedpotentials23 and retinalbirefringence24 are currently indevelopment and may provideadditional means to assess visualacuity and ocular health in youngchildren.

For all instrument-based devices, thesensitivity and specificity to detect anocular abnormality has been carefullyconsidered by their manufacturers.Typically, when a high sensitivity(ie, high rate of detection of at-riskchildren) is chosen, an increase in

overreferrals (ie, low specificity)results. Conversely, when a highspecificity is set, there is often a lowsensitivity (ie, reduced detection ofat-risk children). Given these factors,the referral criteria can be adjustedfor many instruments on the basis ofthe child’s age and desired levels ofsensitivity and specificity.

LEAD AUTHORS

Sean P. Donahue, MD, PhD, FAAPCynthia N Baker, MD, FAAP

AAP COMMITTEE ON PRACTICE ANDAMBULATORY MEDICINE, 2014–2015

Geoffrey R. Simon, MD, FAAP, ChairpersonCynthia N Baker, MD, FAAPGraham Arthur Barden, III, MD, FAAPOscar W. “Skip” Brown, MD, FAAPJesse M. Hackell, MD, FAAPAmy Peykoff Hardin, MD, FAAPKelley E. Meade, MD, FAAPScot B. Moore, MD, FAAPJulia Richerson, MD, FAAP

STAFF

Elizabeth Sobczyk, MPH, MSW

AAP SECTION ON OPHTHALMOLOGYEXECUTIVE COMMITTEE, 2014–2015

Sharon S. Lehman, MD, FAAP, ChairpersonDaniel J. Karr, MD, FAAP, Chairperson-ElectGeoffrey E. Bradford, MD, FAAPSteven E. Rubin, MD, FAAPR. Michael Siatkowski, MD, FAAPDonny Won Suh, MD, FAAPDavid B. Granet, MD, FAAP, Immediate PastChairperson

LIAISONS

Shelley Klein, CO – American Association of Certified

Orthoptists

Christie Morse, MD, FAAP – American Association of

Pediatric Ophthalmology and StrabismusPamela E. Williams, MD, FAAP – American Academy of

Ophthalmology

Gregg T. Lueder, MD, FAAP – American Academy of

Ophthalmology Council

C. Gail Summers, MD – American Academy of

Ophthalmology

George S. Ellis, Jr, MD, FAAP – Section Historian

STAFF

Jennifer G. Riefe, MEdAmerican Academy of OphthalmologyAmerican Association for Pediatric Ophthalmologyand StrabismusAmerican Association of Certified Orthoptists

ACKNOWLEDGMENTS

The writing committee and leadauthor thank Drs James B. Ruben, MD,FAAP, and Geoffrey E. Bradford, MD,FAAP, for assistance with drafting andediting this document.

ABBREVIATIONS

AAP: American Academy ofPediatrics

CPT: Current ProceduralTerminology

REFERENCES

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2. Miller JM, Lessin HR; American Academyof Pediatrics Section on Ophthalmology;Committee on Practice and AmbulatoryMedicine; American Academy ofOphthalmology; American Association forPediatric Ophthalmology andStrabismus; American Association ofCertified Orthoptists. Instrument-basedpediatric vision screening policystatement. Pediatrics. 2012;130(5):983–986

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