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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.
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Competency Set One:

Assessing and Examining the Infant and Toddler

History Taking

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 developmental age.

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 have observed:

  • 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.

Next, assess the child’s eyes using an ophthalmoscope, noting pupilliary responses, red reflex, and any abnormalities that prevent light from entering the eye. Additional information on examination of the red reflex in infants is available in the Policy Statement by the American Academy of Pediatrics at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/5/980.

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 his/her eyes.

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 eyes.

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 reflex.

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?

Tumbling E

Or ...

Broken Wheel

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.

Lea Symbols


Did you notice how Dr. Hemphill used the cardboard window to isolate the figures?


Competency Set Three:

Assessing and Examining the 4-5 Year Old

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 to use.

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 vision problem?
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 of concern.

6. Tools for Testing the 4-5 Year Old:
    Kindergarten Test

Near vision may be easily tested with a Snellen chart or a Kindergarten test.

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.

show 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?

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