INTRODUCTION AND REVISION

PEDIATRIC VISION EXAMINATION

Goal
1. Evaluation of refractive error of eyes and visual system
NB: childs level of development
2. Assess ocular health and related systemic health conditions
3. Establish diagnosis and formulate treatment plan
4. Council and educate parents regarding childs visual, ocular and related health
care status
Also recommend treatment, management and preventative care
Minimum battery of tests
1. Eye movements
2. Convergence
3. Cover test (distance and near)
4. VA
5. Refraction (objective and subjective)
6. Accommodative ability
7. Colour vision
8. Depth perception
9. Binocular function
10.
DEM
11.
Wold digit symbol test/ Wold sentence copy test
12.
One other perceptual test
Visual disorders

Models of decision making

Input for decision making process

1. Work quickly and efficiently to keep child from fatiguing
2. If child fatigues during one part of exam, try to regain attention and cooperation by
moving to another procedure
3. Use brightly coloured interesting targets to hold childs attention
4. Become an expert in using special testing procedures that are effective in
gathering clinical findings in children
5. Remember that separation anxiety occurs because child wants to be close to
parent/caregiver
6. Develop caring trusting relationship with child
7. Dont schedule exam during childs normal nap or meal time
8. Use both verbal and nonverbal communication appropriately to build trust
9. If youre not able to get all info, consider having patient return to complete exam
Emphasis of case history
1. Chief concern of parents and patient
2. Obtain clear understanding of childs academic performance
3. Evaluate possible contributions that visual system may have on childs
success/failure
4. Determine whether there is a visual component to learning problem:
Visual efficiency problem
Visual information processing problem
What to ask:
1. Chief complaint
2. History of present
illness

3. Ocular history
4. Medical history

5. Medications
6. Allergies
7. Family medical
history
8. Family ocular history
9. Developmental Hx of
child
10.
School Hx

Write in patients own words

Onset
When did it start
Anything triggering symptom
Frequency
How often?
Location
Of symptoms
Duration
Since onset
Does it change?
Associating factors
Other symptoms accompany
Modifying factors
What makes it better/worse
Severity
How intensive/extensive?
Ask questions pertaining to the eye
Information concerning patients general health
Prenatal, perinatal, postnatal for infants and young
children
Dosage, how often
Food, medication, environment

Example: Complaint of headaches

1. When was it first noticed?
2. Describe some of the associated signs and symptoms
3. How often does it occur?
4. How severe is it?
5. Is it changing? Getting better/worse?
6. Have you sought other opinions or remedies?
7. What happened?
Format for a child with learning related vision problems
1. Chief complaint/concern
Frequently reported chief complaints:
a. Not performing up to potential
b. Frequent reversal errors
c. Poor reading performance
d. Frequent loss of place when reading
e. Unable to finish written work in time allotted
f. Distractibility or short attention span
g. Difficulty in copying from the board
2. Educational history
3. Medical history:
At risk: Medicobiological:
a. Hereditary and genetic conditions
b. Prenatal factors
- Maternal drug use
- Prematurity
- Low birth weight
- Complications during birth
c. Postnatal medical events
d. Nutrition
Environmental psychosocial
a. Socioeconomic status
b. Parental education
c. Intelligence
d. Mother and child interactive behaviour

4.
5.

6.
7.

Childhood medical history:

a. Long periods of hospitalization/illness during important
developmental periods in young childs life may account for
developmental delays
b. Low level lead exposure correlated with:
- Lower IQ scores
- Decreased speech and language processing
- Impaired attention
c. Otitis media
- Substantial auditory processing problems
- Disturbance in auditory visual integration
- Speech and language delays
- Reading disorders
- Poor spelling
- Decline in verbal IQ
- Be slower in developing word combinations
- Chronic otitis media associated with hyperactivity and
inattentiveness independent of learning disability
d. Malnutrition
- At risk for lowered IQ
- Developmental lags in:
1. Hearing
2. Speech
3. Eye-hand coordination
4. Categorization skills
5. Language acquisition
Developmental history
Previous assessments and treatment
Visual
Psychoeducational
Audiology, speech and language
Occupational and physical therapy
Neurological evaluation
Behaviour and attention
Family history

Investigation of signs and symptoms

1. Onset (when)
2. Nature (How)
3. Manifestations (what)
4. Severity (mild, moderate, severe)
5. Duration
6. Perception of getting worse/better
7. What has been done
Signs and symptoms
1. Representativ
e behavioural
signs
2. Accommodati
ve

3. Vergence
deficiencies

4. Ocular
motility
deficiencies

Visual efficiency

1.
2.
3.
4.
5.

Blur/fluctuating vision at near

Eyes hurt, burn or tire when reading
Astenopia, headaches or ocular fatigue with near work
Excessive rubbing, blinking or tearing of eyes
Intermittent blur of distance vision after near point
activities
Astenopia
Intermittent diplopia
Rereading the same line of words
Closing or covering one eye
Difficulty aligning columns of numbers
Letters/words appear to jump, float or move around when
reading
Headaches or ovular fatigue with near work
Excessive head movement when reading
Frequent loss of place when reading
Omission of words/skipping lines when reading
Use of a finer or a marker when reading
Lack of comprehension when reading

1.
2.
3.
4.
5.
6.
7.
1.
2.
3.
4.
5.

Problem orientated approach

Subjectivw
Information provided by patient about:
1. Course of signs and symptoms
2. Compliance with management plan
3. Understanding of patient education
4. New concerns
Objective
Practitioners examination findings
Assessment
Practitioners interpretation of status of problems following
initial management
Plan
Any modification of initial plan

NORMAL PREGNANCY AND THE BIRTH PROCESS

Ovum
Ovum unites with sperm > zygote
stage
Germinal period: rapid cell division that lasts a week
Embryo
Second prenatal period
stage
End of week 1 to end of second month of conception
Differentiation:
a. Ectoderm: skin, nervous system, sensory cells
b. Mesoderm: muscles, blood, excretory system
c. Endoderm: lungs, digestive systems, thyroid glands
Foetal
Final period of prenatal development
stage
Beginning of third month after conception until birth
Birth process
APGAR
Layers related to each ocular structure
Surface
Conjunctival and corneal epithelium
ectoderm
Lacrimal gland and drainage system
Vitreous
Lens
Neural
Muscular layer of ocular and orbital BV
crest
Ciliary muscles
TM
Corneal stroma and endothelium
Meningeal sheaths of ON
Uveal and epithelial melanocysts
Choroidal stroma
Neuroectod
ON, axons and ganglia
erm
Non-pig and pigmented ciliary epithelium
Iris musculature
RPE and neural ret
Mesoderm
Endothelial lining of ocular and orbital BV
EOM

GROWTH AND DEVELOPMENT

Psychomotor development
Continuing through first years of life, physical growth predominates
During first year:
Increases length by 50%
Weight by 200%
Physical control:
Head to foot
Trunk to extremities
Large to small muscle
Normal motor development
Weight
2x in first 5 months
3x at end of first year
X in first 30 months
Height
20% at 3 months
50% in first year
Major
Roll over
4 months
accomplishm
Coordinating head, shoulder, trunk and leg teamwork
ents
Sitting
Must acquire sufficient strength in muscles of back
up
and neck to maintain head control
Creeping
7 months
Develop into crawling
Crawling
Simultaneous and contralateral
Pulling
Into standing position
up
Walking
12 months
To explore environment
18m
Dangerous
2y
For objects on counters etc
Warning signs 9m
Unable to sit
Hand preference
Fisting
Squint
Persistence of primitive reflexes
12
Unable to sit or bear weight
months
Abnormal grasp
Failure to respond to sound
18
Failure to walk
months
No pincer grip
Inability to understand simple commands
No spontaneous vocalization
Mouthing
drooling
24
unable to understand simple commands
months
tremor

 in coordination
Normal cognitive development
About the thinking process and how one acquires knowledge
Piagets concepts of cognitive development: (SELF STUDY)
1. Sensorimotor
2. Preoperational
3. Concrete operational
4. Formal operational
PERINATAL STAGE
STORCH
1. Syphilis
2. Toxoplasmosis
3. Other
4. Rubella
5. Cytomegalovirus
6. Herpes Simplex
MODEL OF VISION
What does vision include?
1. Development
2. Visual perceptual motor skills
3. Ability to integrate vision with other sensory motor skills
Three categories
Visual acuity

Visual skills efficiency

Visual information
processing

Largely dependent on eye health, refractive status and

normal development of visual system
Composed of oculomotor, accommodative and binocular
skills
Represents ability to recognize and discriminate visual
stimuli and interpret them correctly in light of previous
experience