One of the concerning outcomes of an abnormal red reflex examination is the identification of a retinoblastoma. If there is any concern for childhood glaucoma, prompt referral is indicated to prevent blindness. 5, 9 Childhood glaucoma can also present with corneal clouding, photosensitivity, and enlarged eyes. 5 Close follow-up for symptom resolution is recommended because childhood glaucoma has a similar presentation (although tearing in childhood glaucoma is usually accompanied by redness and corneal edema). 5, 9 It can be treated with lacrimal duct massage and, if there are signs of infection, with topical antibiotics. This is recognized when pressure over the lacrimal sac produces mucus in an eye that otherwise has constant clear tearing. Lacrimal duct obstruction is the most common cause of persistent eye discharge in infants. Using a light, the examiner should inspect for excessive tearing, watery or purulent discharge, photosensitivity, conjunctival injection, and gross structural abnormalities. Vision screening continues with examination of the external portion of the eye, including the eyelids, orbits, conjunctiva, sclera, cornea, and iris. The American Academy of Ophthalmology recommends referral for children five years or older who have monocular vision worse than three of five optotypes (letters, numbers, symbols) on the 20/30 line, or two lines of difference between the eyes, because this may be an indicator of amblyopia (decreased vision in one eye compared with the other). 7 Most children do not have 20/20 vision until after six years of age, 7 but at any age, visual acuity should be approximately equal between the eyes. The Multi-Ethnic Pediatric Eye Disease Study provided updated norms for visual acuity in children two and a half to six years of age ( Table 2). Each eye should be tested independently and the opposite eye occluded to discourage peeking. 1 Picture charts (Lea or Allen) or matching charts (HOTV) can be used in preliterate children, and letter charts (Snellen) can be used in literate children ( Figure 1 6). The American Academy of Ophthalmology recommends the use of an eye chart by three years of age. Assessing visual acuity in infants and toddlers involves evaluation of fix and follow behavior (discussed later). The eye examination begins with a measurement of visual acuity. Red reflex examination is used to diagnose retinoblastoma, childhood cataracts, and other ocular abnormalities. Evaluation of fixation and alignment can identify amblyopia or strabismus. Visual acuity measurement and external ocular examination are performed to recognize refractive error, childhood glaucoma, and various ocular conditions. Vision screening begins with a review of family and personal vision history to identify risk factors requiring referral, including premature birth, Down syndrome, cerebral palsy, and a family history of strabismus, amblyopia, retinoblastoma, childhood glaucoma, childhood cataracts, or ocular or genetic systemic disease. Screening can reveal conditions commonly treated in primary care and can aid in discussion of visual concerns with parents or caregivers. The purpose is to detect risk factors and visual abnormalities that necessitate treatment and to identify those patients who require referral to an ophthalmologist skilled in examining children. Vision screening in children is an ongoing process, with components that should occur at each well-child visit.
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