LESSON ~ PUTTING IT ALL TOGETHER!
ASSESSMENT COMPETENCIES FOR HEALTH CARE PROVIDERS
As mentioned at the onset of this program, eye examinations are recommended
at birth, six-months, three years and five years of age. If the child
is at risk for vision problems due to prenatal, perinatal, or postnatal
history (pre-term, low-birth weight); family visual or medical history
(retinoblastoma, congenital cataracts), and other genetic disorders associated
with general health or visual disorders (e.g. Cerebral Palsy, Down Syndrome,
Tuberous Sclerosis, seizures, hydrocephaly); a vision health provider
may recommend more frequent examinations. Additional information about
these genetic disorders is available at http://www.nlm.nih.gov/medlineplus/healthtopics_t.html.
Visit this website now. It contains critical disease specific information
including diagnosis/symptoms, clinical trials, disease management, patient/family
information and more.
Competency Set One:
Assessing and Examining
the Infant and Toddler
Evaluating a newborn’s vision is primarily to detect congenital
anomalies such as cataracts. The primary care provider performs the eye
exam in the newborn nursery and then again during the first office visit.
As a care provider, obtaining information about the newborn’s history
from the parent requires skill and patience, coupled by direct observation
of the infant. The history might include key information about the prenatal,
perinatal, and postnatal course and the family’s medical history
(include questions about visual and ocular conditions).
Beyond the history, an assessment for the corneal light reflex and the
red reflex (see Tools for Testing, below) is the primary means of checking
for congenital anomalies of the eye. As children grow older additional
tests to assess for eye pathologies can be added to your repertoire. In
infant to toddler years, assess for retinoblastoma, cataracts, refractive
errors, and strabismus.
When examining a child for visual disturbances, the child’s developmental
stage will determine the equipment/test to be performed. Keep in mind
that the presence of a visual disturbance may deter eye and/or vision
development and thereby alter the tools necessary. Observe the child and
interview the caregiver to determine the child’s performance of
age-appropriate behaviors. When performing assessments always note the
child’s chronological age but always assess to the child’s
1. Tools for Testing the Infant and Toddler: Head Tilt
Watch the infant/toddler at play. Observe the eyes for
abnormalities and the child’s head positioning to determine if the
infant or toddler tips, tilts, or turns the head.
In this video clip notice the gentleness of Dr. Lozada’s
voice and how he uses his hand to move the child’s head.
Did you note the child’s chin as it turned to the
right and left, and as it tipped down and tilted up. If you did not, review
the video again.
Interview the caregiver about the infant’s ability to pick up,
grasp and follow toys with his/her eyes. Ask the care provider if they
Wandering eyes or eyes not moving together in synchrony, especially
when the child is tired.
Play preferences that center on auditory to the exclusion of visual
stimulation – indicating a possible visual problem.
Any change in the child’s behavior.
If any of the above noted, the child should be referred for further assessment
by a vision health professional.
2. Tools for Testing the Infant and Toddler: Hirschberg Test / Corneal Light Reflex
The Hirschberg Test is used to assess eye alignment by noting the location
of reflected light on the cornea.
Before clicking on this video notice the light dots on this child’s
eyes as Dr. Hemphill shines the light on them.
Did you see the light reflex? Notice that the light is at the same place
on each pupil.
Notice the corneal light reflex on the photo below. Is it your judgment
that it reflects a normal light reflex?
Reprinted from the Atlas of Strabismus,
G. K. Von Noorden, Page 29, figure 20
(1983), with permission from Elsevier.
3. Tools for Testing the Infant and Toddler: Cover Test
The cover test is the most commonly used test by healthcare
providers to assess for amblyopia and binocular vision (the ability of
the child to use both eyes together). It is used because it is easy to
administer and requires little time. Its utility is enhanced because it
does not require the child to speak the language of the provider and can
be used before the child has acquired language skills. The cover test
is demonstrated in the next video clip.
Notice in this video how Dr. Burlingame is using an age appropriate toy
in her left hand to keep the child’s eyes fixated for the purpose
of the exam and her right hand to cover the child’s eye.
Did you note the position of Dr. Burlingame’s thumb to cover the
child’s eye? This technique can be used by a parent of caregiver.
Reprinted from the Atlas of Strabismus, G. K. Von Noorden,
Page 65, figure 44 (1983), with permission from Elsevier
For the answer, click on the question above.
4. Tools for Testing the Infant and Toddler: Extraocular Movements & Near Point Convergence
To assess the extraocular movements of an infant or toddler, use a penlight
or a finger puppet. Engage the infant to follow the penlight with his/her
eyes. The corneal light reflex should be assessed in each of the six cardinal
fields of gaze. If the child is unable to maintain attention to the
penlight, try using a brightly colored toy and move it in the six cardinal
fields of gaze, attending to the child’s capacity to follow with
When assessing for near point convergence
(NPC) bring the penlight or finger puppet (target) toward the child’s
face in midline. As the target slowly approaches the child’s eyes,
lower the angle to ease convergence and determine if both eyes do, indeed,
converge. Children who have (a) uncorrected refractive
error, (b) a difference in refractive error between the two eyes,
or (c) who already have developed amblyopia will not be able to maintain
convergence. The affected eye will either turn in, (esotropia) or turn
out (exotropia), depending on the condition. For some children it might
help to use either your hand or a colorful appealing occluder, such as
one shaped like an animal.
Dr. Hemphill will demonstrate the Hirschberg test, extraocular movements,
and near point convergence on this infant.
Were you able to see the child’s eye movements and
the position of the light reflex on the pupils? If not, watch again.
5. Tools for Testing the Infant and Toddler: Fixation Preference Test / Preferential Looking Test
The preferential looking visual acuity test is another important screening
tool for determining infant and toddler visual disorders. Most often an
infant or toddler will look at patterns with higher contrast and detail
over a solid color or an object with decreased contrast.
In the clip that follows Dr. Burlingame manipulates the
preferential looking drum to discern the infant’s capacity to show
preference for changes in light.
During this test notice the infant’s capacity to stay focused.
If a deviation from normal is found in any screenings tests, a referral
to a pediatric eye specialist should be made.
Competency Set Two:
Assessing and Examining
the 3-year old
Just as with the infant and toddler, begin the assessment of the three
year-old child with a comprehensive history that includes visual health
and ocular history, prenatal, perinatal, and postnatal history, family
eye and medical history, developmental history, and general health.
Nothing can replace an astute clinical observation of the child to determine
developmental and visual challenges. If the child does not participate
in age-appropriate activities, such as coloring, cutting pictures, or
kicking a ball, it may be a visual problem that is deterring this activity.
Notice the child’s head position while playing with toys or looking
at a book. Does the child have a preferential head position, i.e. does
the child tip the head down, tilt the head up or turn the head to the
left or the right? If so, this may be the only indication that the child
is having difficulty seeing!
1. Tools for Testing the 3-Year Old: Head Tilt
In the picture below, note the head position of these older children.
Reprinted from the Atlas of Strabismus, G. K. Von Noorden,
Page 133, figure 86 (1983), with permission from Elsevier.
Use the ophthalmoscope to assess the structures of the child’s
eyes, particularly the retina
and lens. With the ophthalmoscope, determine the pupilliary response,
the red reflex, corneal
reflex, near point convergence (NPC) and, using the ophthalmoscope
as a target, observe the child’s extraocular movements. Near point
convergence (NPC) and extraocular movements can be checked using the ophthalmoscope
or substitute a brightly colored toy that the child can follow with his/her
2. Tools for Testing the 3-Year Old: Extraocular Movements & Near Point Convergence
In the following video, note how Dr. Hemphill uses a toy
to assess the child’s extraocular movements as well as the light
Did you notice the technique Dr. Hemphill used when the
child was unable to hold his head still when moving his eyes? If not,
view the video again.
3. Tools for Testing the 3-Year Old: Cover Test
Strabismus, or crossed-eyes, is another common problem that
can be detected through observation. The eye crossing may be subtle or
very prominent, but if detected, needs further evaluation.
A simple test to assess for strabismus is the cover test.
Note the use of an occluder.
For the answer, click on the question above.
4. Tools for Testing the 3-Year Old: Stereopsis Test
If capable, the child may be assessed for problems with
binocular vision and depth perception by testing stereopsis. A stereopsis
test can also be used to assess for strabismus and provides objective
measurements of the child’s ability to match appropriate figures.
Note that the stereopsis test will assess for the eyes working
together, depth perception, and equal vision in both eyes.
Distance visual acuity is the single most important test
of visual acuity and may detect problems with amblyopia, refractive
errors, or cataracts (Kansas Department of Health and Environment,
2004). There are a variety of tools to assess for visual acuity, but it
is important to use the one that is age and developmentally appropriate
for the child.
5. Tools for Testing the 3-Year Old: Tumbling E & Broken Wheel
Using your knowledge of growth and development, which visual
acuity screening test would you recommend for this three year-old boy?
If you guessed the Broken Wheel test was the appropriate test for a three
year old boy, you are CORRECT! The boy in the previous examples does not
yet have the skill set to understand the directions for the Tumbling E
task. Given that he probably has a car or two in his toy box, he could
easily relate to and identify the car with the ‘broken wheel.’
Look at video again. Note the child’s lack of interest in the tumbling
E and then interested focus on the broken wheel. Children will not always
do what you want them to do. Very astute observation is imperative.
6. Tools for Testing the 3-Year Old: Lea Symbols
A more difficult and specific test may be done if the child is older.
Did you notice how Dr. Hemphill used the cardboard window to isolate
Competency Set Three:
Assessing and Examining the 4-5
An exam for a pre-school age child is similar to that of a younger one.
As the child enters school, the importance of vision becomes even more
critical. Also at this age children expand their independence with activities
that provide added safety risks. It is important to determine the child’s
developmental age when choosing a visual acuity screening test. For example,
if a child is not familiar with letters but is more comfortable with shapes,
the Lea Symbols test is most appropriate.
1. Tools for Testing the 4-5 Year Old: Lea Symbols
Do you recall that this is a matching exercise for the child?
2. Tools for Testing the 4-5 Year Old: Snellen Chart
If the child knows letters, the Snellen chart may be appropriate.
3. Tools for Testing the 4-5 Year Old: Tumbling E
The tumbling E chart may also be appropriate.
Compare the older child here with the 3-year old child in the Competency
Set Two video clip for age appropriate testing using the Tumbling E.
In this comparison, it is apparent that the older child has the cognitive
skills to make the Tumbling E test an effective screening tool.
4. Tools for Testing the 4-5 Year Old: Assessment for Language Barriers
Assess for language barriers when determining which visual acuity test
Do you see how an examiner could not only misinterpret visual but also
cognitive skills and ability of this child due to a language barrier?
If a language barrier is present, the Lea Symbols may be appropriate.
This tool for testing could also be used for adults with language barriers.
5. Tools for Testing the 4-5 Year Old: Stereopsis Test
The child should be assessed for strabismus. This may be done with the
cover test as well as a stereopsis test.
Which of the following may indicate a problem with depth perception or
binocular vision for this child?
If you answered the second video clip, you are correct!
In the second clip, the child actually touches the page as he is pinching
the wings of the fly.
In vision screening, an element that is often overlooked is assessing
a child for problems with near vision.
Which of the following pictures is least likely to make you suspect a
Roll your mouse over the pictures to reveal the answer.
A child who doesn’t like to read or has difficulty reading
may indicate a vision problem. Frequent rubbing of the eyes may also be
6. Tools for Testing the 4-5 Year Old: Kindergarten Test
Near vision may be easily tested with a Snellen chart or a Kindergarten
In order for this tool to be effective, it is important
that the child is familiar with shapes.
7. Tools for Testing the 4-5 Year Old: Color Deficiency Screening
Observation and screening may detect a child who has problems with color
vision. Have you observed a child having difficulty matching colors or
understanding directions involving colors? This difficulty may be due
to the child’s problems with color vision.
Sometimes referred to as color blindness, children with color vision
deficiency are not truly ‘blind’ to color; they simply have
difficulty distinguishing some colors and shades. Statistics from the
American Optometric Association show color vision deficiency in 8% of
males and 1% of females. Children with color deficiency should be referred
for a complete professional eye examination.
There are many types of color vision deficiency; however the inability
to distinguish certain shades of red and green is by far the most common.
As you might imagine, this can present challenges when selecting clothing
or responding to the way a traffic signal lights up! As children are developing
interests in job careers it is important for them to know if they have
a color deficiency as it may impact their choice of careers.
Color deficiency is not a treatable condition; but if known, can decrease
frustration among the child, parent, and teachers with projects that involve
color. Screening for color deficiencies is simple and easy to perform.
Screening for color deficiencies is simple and easy to perform. In the
following video clip, a young boy is asked to point to shapes embedded
in a book of ‘pictures.’
Color screening does require attention to detail and may
not be age-appropriate for a younger child. In the next video clip, the
child needs additional prompting from the optometrist before he can successfully
complete the task.
Did you notice the different instructions given to the children of different
ages? A younger child can sometimes be successful if the task is appropriately
modeled along with the instructions.
Statisticsshow that 15-25% of preschool children have vision problems,
but fewer than 15% receive eye examinations. Early detection of a visual
problem increases the chance of effective treatment and may prevent irreparable
damage. Visual problems that are left untreated may lead to developmental
delays and even behavioral problems. As a health care provider, you may
be the first responder in detecting visual problems and decrease the incidence
of future issues by referring a child for a complete ophthalmic examination.
Take a moment to ponder the key points of the lesson!
1. What information about eye examinations was new to you?
2. What have you learned in your practice that makes the children
you examine more comfortable during the exam?
3. What communication skills have you found useful to put the child
and parent at ease?
4. Do you find it helps to wait to do parts of the exam that the child
might find scary until the end of exam?
5. How would you adjust the tools and techniques used in an examination
for a child whose chronological age differs from developmental age?