Guideline:
Eye examination in infants, children and young adults by pediatricians
Bibliographic Source(s)
- American Academy of Pediatrics. Eye examination in infants children and young adults by pediatricians. Pediatrics 2003 Apr;111(4 Pt 1):902-7. [8 references] PubMed
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Academy of Pediatrics (AAP). Eye examination and vision screening in infants children and young adults. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine Section on Ophthalmology. Pediatrics 1996 Jul;98(1):153-7.
American Academy of Pediatrics (AAP) clinical reports automatically expire 5 years after publication unless reaffirmed revised or retired at or before that time.
Guideline Category
Evaluation
Prevention
Screening
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)
To provide recommendations for eye examinations in infants children and young adults
Target Population
Newborns infants children and young adults
Interventions and Practices Considered
Evaluation/Screening
Eye evaluation in the physician’s office including:
Birth to 3 years of age
- Ocular history including parent’s observations and relevant family histories
- Vision assessment including
- Ability to fix and follow objects (age 0 to 3 years)
- Visual acuity measurement of vision screening using LH/LEA symbols and Allen cards (children 2-4); Snellen letters and numbers tumbling E test and the HOTV test (children older than 4)
- Photoscreening
- External examination of the lids orbit cornea and iris
- Ocular motility assessment
- Corneal reflex test
- Cross cover test
- Random dot E stereo test
- Examination of pupils for symmetry and light reflectivity
- Red reflex test (monocular and binocular Bruckner test)
Additional testing in children 3 years and older
- Age-appropriate visual acuity measurement
- Ophthalmoscopy
Major Outcomes Considered
Not stated
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not stated
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
Not stated
Major Recommendations
- All pediatricians and other providers of health care to children should be familiar with the joint eye examination guidelines of the American Association for Pediatric Ophthalmology and Strabismus the American Academy of Ophthalmology and the American Academy of Pediatrics (see table below).
- Every effort should be made to ensure that eye examinations are performed using appropriate testing conditions instruments and techniques.
- Newborns should be evaluated for ocular structural abnormalities such as cataract corneal opacities and ptosis which are known to result in vision problems and all children should have their eyes examined on a regular basis.
- The results of vision assessments visual acuity measurements and eye evaluations along with instructions for follow-up care should be clearly communicated to parents.
- All children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.
Table. Eye Examination Guidelines*
Ages 3-5 Years
Function: Distance visual acuity
Recommended Tests: Snellen letters; Snellen numbers; Tumbling E; HOTV; Picture tests (Allen figures LEA symbols)
Referral Criteria: (1) Fewer than 4 of 6 correct on 20-ft line with either eye tested at 10 ft monocularly (i.e. less than 10/20 or 20/40) or (2) Two-line difference between eyes even within the passing range (i.e. 10/12.5 and 10/20 or 20/25 and 20/40)
Comments: (1) Tests are listed in decreasing order of cognitive difficulty; the highest test that the child is capable of performing should be used; in general the tumbling E or the HOTV test should be used for children 3-5 years of age and Snellen letters or numbers for children 6 years and older. (2) Testing distance of 10 ft is recommended for all visual acuity tests. (3) A line of figures is preferred over single figures. (4) The nontested eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to eye; the examiner must ensure that it is not possible to peek with the nontested eye.
Function: Ocular alignment
Recommended Test: Cross cover test at 10 ft (3 m)
Referral Criteria: Any eye movement
Comments: Child must be fixing on a target while cross cover test is performed.
Recommended Test: Random dot E stereo test at 40 cm
Referral Criteria: Fewer than 4 of 6 correct
Comments: None
Recommended Test: Simultaneous red reflex test (Bruckner test)
Referral Criteria: Any asymmetry of pupil color size brightness
Comments: Direct ophthalmoscope used to view both red reflexes simultaneously in a darkened room from 2 to 3 feet away; detects asymmetric refractive errors as well.
Function: Ocular media clarity (cataracts tumors etc.)
Recommended Test: Red reflex
Referral Criteria: White pupil dark spots absent reflex
Comments: Direct ophthalmoscope darkened room. View eyes separately at 12 to 18 inches; white reflex indicates possible retinoblastoma.
Ages 6 Years and Older
Function: Distance visual acuity
Recommended Tests: Snellen letters; Snellen numbers; Tumbling E; HOTV; Picture tests (Allen figures LEA symbols)
Referral Criteria: (1) Fewer than 4 of 6 correct on 15-ft line with either eye tested at 10 ft monocularly (i.e. less than 10/15 or 20/30) or (2) Two-line difference between eyes even within the passing range (i.e. 10/10 and 10/15 or 20/20 and 20/30)
Comments: (1) Tests are listed in decreasing order of cognitive difficulty; the highest test that the child is capable of performing should be used; in general the tumbling E or the HOTV test should be used for children 3-5 years of age and Snellen letters or numbers for children 6 years and older. (2) Testing distance of 10 ft is recommended for all visual acuity tests. (3) A line of figures is preferred over single figures. (4) The nontested eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to eye; the examiner must ensure that it is not possible to peek with the nontested eye.
Function: Ocular alignment
Recommended Test: Cross cover test at 10 ft (3 m)
Referral Criteria: Any eye movement
Comments: Child must be fixing on a target while cross cover test is performed.
Recommended Test: Random dot E stereo test at 40 cm
Referral Criteria: Fewer than 4 of 6 correct
Comments: None
Recommended Test: Simultaneous red reflex test (Bruckner test)
Referral Criteria: Any asymmetry of pupil color size brightness
Comments: Direct ophthalmoscope used to view both red reflexes simultaneously in a darkened room from 2 to 3 feet away; detects asymmetric refractive errors as well.
Function: Ocular media clarity (cataracts tumors etc.)
Recommended Test: Red reflex
Referral Criteria: White pupil dark spots absent reflex
Comments: Direct ophthalmoscope darkened room. View eyes separately at 12 to 18 inches; white reflex indicates possible retinoblastoma.
* Assessing visual acuity (vision screening) represents one of the most sensitive techniques for the detection of eye abnormalities in children. The American Academy of Pediatrics Section on Ophthalmology in cooperation with the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology has developed these guidelines to be used by physicians nurses educational institutions public health departments and other professionals who perform vision evaluation services.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
- Early detection and prompt treatment of ocular disorders in children is important to avoid lifelong visual impairment.
- Through careful evaluation of the ocular system retinal abnormalities cataracts glaucoma retinoblastoma strabismus and neurological disorders can be identified and prompt treatment of these conditions can save a child’s vision or even life.
Potential Harms
Not stated
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Timeliness
Bibliographic Source(s)
- American Academy of Pediatrics. Eye examination in infants children and young adults by pediatricians. Pediatrics 2003 Apr;111(4 Pt 1):902-7. [8 references] PubMed
Source(s) of Funding
American Academy of Ophthalmology
American Academy of Pediatrics
American Association for Pediatric Ophthalmology and Strabismus (AAPOS)
American Association of Certified Orthoptists
Guideline Committee
Committee on Practice and Ambulatory Medicine and Section on Ophthalmology
Composition of Group that Authored the Guideline
Primary Authors: Jack Swenson MD (Chairperson); Edward G. Buckley MD
Committee on Practice and Ambulatory Medicine 2001-2002: *Jack Swanson MD (Chairperson); Kyle Yasuda MD (Chairperson-Elect); F. Lane France MD; Katherine Teets Grimm MD; Norman Harbaugh MD; Thomas Herr MD; Philip Itkin MD; P. John Jakubec MD; Allan Lieberthal MD
Staff: Robert H. Sebring PhD; Junelle Speller
Liaison Representatives: Adrienne A. Bien; Todd Davis MD; Winston S. Price MD
Section on Ophthalmology 2001-2002: Gary T. Denslow MD MPH (Chairperson); Steven J. Lichtenstein MD (Chairperson-Elect); Jay Bernstein MD; *Edward G. Buckley MD; George S. Ellis Jr MD; Gregg T. Lueder MD; James B. Ruben MD
Consultants: Allan M. Eisenbaum MD; Walter M. Fierson MD; Howard L. Freedman MD; Harold P. Koller MD (Immediate Past Chairperson)
Staff: Stephanie Mucha MPH
American Association of Certified Orthoptists: Kyle Arnoldi CO (Liaison to the AAP Section on Ophthalmology)
American Association for Pediatric Ophthalmology and Strabismus: Joseph Calhoun MD (Liaison to the AAP Section on Ophthalmology); Jane D. Kivlin MD (Past Liaison to the AAP Section on Ophthalmology)
American Academy of Ophthalmology: Michael R. Redmond MD
*Lead authors
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Academy of Pediatrics (AAP). Eye examination and vision screening in infants children and young adults. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine Section on Ophthalmology. Pediatrics 1996 Jul;98(1):153-7.
American Academy of Pediatrics (AAP) clinical reports automatically expire 5 years after publication unless reaffirmed revised or retired at or before that time.
Guideline Availability
Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site.
Print copies: Available from American Academy of Pediatrics 141 Northwest Point Blvd. P.O. Box 927 Elk Grove Village IL 60009-0927.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on August 18 2003. The information was verified by the guideline developer on September 8 2003.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor American Academy of Pediatrics (AAP) 141 Northwest Point Blvd Elk Grove Village IL 60007.
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