THE INSTITUTE OF OPTOMETRY

THE OPTOMETRISTS GUIDE TO

PROVIDING EYECARE FOR YOUNG
CHILDREN
Prof Bruce Evans
BSc (Hons) PhD FCOptom DipCLP DipOrth FAAO FBCLA
Director of Research
Visiting Professor
Visiting Professor
Private practice

The Institute of Optometry is unique in being an independent self-financing charity dedicated to

the promotion of clinical excellence, research, and education in optometry.
Roberson (1989)

PLAN

Institute of Optometry
City University
London South Bank University
Brentwood, Essex

References
Pickwells Binocular Vision Anomalies, 5th Edition, Elsevier, 2007
Vision & Reading Difficulties, www.optometry.co.uk/otbookshop

Paediatrics: general approach

small, inexperienced adults

INTRODUCTION
OCULAR HEALTH
VISUAL ACUITY
REFRACTION
ORTHOPTIC FUNCTION
CONCLUSIONS

put child at ease; have fun; praise

may need to be quick
do what you can
can, where you can
can, when
you can
dim lights slowly
explain, in appropriate language
train them and give prizes

Full handout from: www.bruce-evans.co.uk

Paediatrics: when to refer

Non-accidental injury (NAI)

Ocular signs

active & some old pathology

Fundus photography useful from age 3-4y

Peripheral retinal haemorrhages

Periocular bruising
Subconjunctival haemorrhages

visual conversion reactions can mask

pathology
non-accidental injury

Hyphaema
Dislocated lens
Retinal detachment

Systemic signs
Surface bruises
Multiple fractures & injuries
Scalds & burns

Development of binocular vision

Child protection

Occasional (<15% of the time) neonatal

misalignments are common and OK in the first
month of life and only require referral if

Avoid unnecessary physical contact

To protect yourself against unfounded
allegations you may:

they worsen after 2 months or

Ensure presence of parent/carer at all times

there is an intermittent deviation at 4 months

Door ajar so parent/carer can hear

Open access policy: staff knock & enter any time

But preserve confidentiality

C. Optom guidelines (2012)

For most infants, motor fusion and sensory

fusion develop at about 3-4 months
By 6 months children should converge to a 20
base out prism and, if cooperative, should be
able to fixate coarse stereoscopic targets.

Symptoms, history, family history

PLAN
Symptoms:
Do you ever see an eye turning?
Distance vision (birds, planes)

INTRODUCTION

Near vision (detail in pictures)

OCULAR HEALTH

History:

VISUAL ACUITY

Birth on time

REFRACTION

Birth weight

ORTHOPTIC FUNCTION

Birth complications

CONCLUSIONS

Family history
Esotropia, amblyopia, Rx
Full handout from: www.bruce-evans.co.uk

Ocular health

PLAN

First time with pre-school, dont expect to see too much

Pupil reactions. Indirect can be useful

INTRODUCTION

Slit lamp possible

OCULAR HEALTH

Retinoscope with plus lenses

VISUAL ACUITY

If in doubt, dilate. Photos if possible

If still in doubt,
refer
Colour vision
Ishihara
TCU (1 & 2)

REFRACTION

OCULAR HEALTH
mm L:
PUPILS:
HVID: R:
MEDIA:
FUNDUS: red reflex / some fundus seen and normal / most fundus seen and normal/ all fundus seen &

ORTHOPTIC FUNCTION
CONCLUSIONS

normal

DISCS: R: seen / not seen:

MACS: R: seen / not seen:
OTHER OBSERVATIONS:

L: seen / not seen:

L: seen / not seen:

Full handout from: www.bruce-evans.co.uk

Visual acuity: goals

SYMPTOMS & HISTORY
PARENTAL REPORTS:
BIRTH:
VISUAL ACUITY
METHOD 1:
METHOD 2:
Reaction to occlusion:

R.E.
R.E.

Visual acuity: overview

Macular is poorly developed at birth

FH:

L.E.
L.E.

Large variation in rate of development

B.E.
B.E.

good/modera
good/modera

tolerant / equally intolerant to R or L occlusion / particularly intolerant of occlusion of RE /

Results vary with different test methods

VEPs are an option

LE

We need to detect strabismic amblyopia

REFRACTION
STATIC METHOD:
R.E.
L.E.
response:

good/moderate/poor

DYNAMIC METHOD:
R.E.
L.E.
response: good/moderate/poor

Visual acuity: grating preferential looking

Teller or Keeler or Lea
Suitable from birth
Two out of three

So, do crowded tests as soon as you can

Visual acuity: Cardiff cards

Vanishing optotypes suitable
from 6 months
Binocular readings possible for
96% aged 12-36 months
Adoh and Woodhouse (1994)

Easier to do than you think!

No peeping!
Not good at detecting strabismic
amblyopia
Vernier is the future

A game that children enjoy

Encourage them (noises etc.)
Poor at detecting strabismic
amblyopia

(Drover et al., 2010)

Visual acuity: shapes and pictures

Visual acuity: letter matching

Manageable by many 2 year olds

Worst:

Avoid isolated uncrowded

optoypes

Better

Sheridan Gardiner

Poor at detecting strabismic amblyopia

Lea & Kay have LogMAR design

Test Chart 2000 is ideal

Sonksen Silver
Cambridge cards
Glasgow Acuity Test

Best: Test Chart 2000

Possible from c. 2.5 years

Most children who can do these

can match crowded letters

Visual acuity: near charts

Visual acuity: better than nothing

Thomas the tank engine

Reaction to occlusion

IOONTC

10 up one eye

Many others

Should alternate freely

minimum normal acuity for age (months)

1
method
vertical prism test
grating preferential looking (Teller, 1990) 6/180
Cardiff cards (binoc.; Adoh & Woodhouse, 1994)
Cardiff cards (monoc.; Adoh & Woodhouse, 1994)
Tumbling E
Snellen chart letter matching

3
6/90

6
12
24
36
48
with 10 up one eye, should alternate freely
6/30
6/24
6/12
6/6
6/5
6/48
6/15
6/12
6/6
6/38
6/19
6/12
6/42
6/15
6/15
6/12
6/12
6/9

Refraction: Basic minimum

PLAN
Are the retinoscopy reflexes
symmetrical and no large refractive
errors?

INTRODUCTION
OCULAR HEALTH

Be adaptable about working distance

VISUAL ACUITY

Hold trial lenses with infants

REFRACTION
ORTHOPTIC FUNCTION

Fixation target is anything that will

attract their attention, ideally Test
Chart 2000

CONCLUSIONS

Full handout from: www.bruce-evans.co.uk

Refraction: Mohindra retinoscopy

Refraction: accommodative lag

Working distance = 55cm

measured by MEM retinoscopy

Totally darkened room

px binocularly fixes target on

retinoscope at normal reading distance

practitioner monocularly rapidly

interposes lenses to neutralise reflex

mean +/- 1 SD quoted as plano to

+0.75

Occlude one eye

Fixate retinoscope light
-1.00 to -1.25D allowance
High correlation with cycloplegic
retinoscopy for over 2 yr-olds

Refraction: cycloplegic

Refraction: normal development

Indications for cycloplegic:

At birth +2.00 DS (SD = 2.00 DS)

Symptom of intermittent SOT

very variable in first year

Sign of SOP or SOT

On average, hypermetropia decreases

rapidly during the first year to a mean
level of about +1.50
+1 50 D at age one year

Unexplained poor VA
Unexplained symptoms

High astigmatism in first year often

reduces

Variable or suspicious Rx

Refer if under 3 months

Under 12 months use 0.5% cyclo
Dark pigmentation leave for longer

Refraction: norms
PLAN
Nearly 75% of children with esotropia &/or amblyopia have a
significant Rx
myopia, hypermetropia (2.00), anisometropia (1.00), astigmatism (1.50)

INTRODUCTION

No concrete guidelines, below are suggestions only

(Evans, 2007, Pickwells Binocular Vision Anomalies, 5th edition)

OCULAR HEALTH
VISUAL ACUITY
REFRACTION

refractive errors probably require correction if stable and:

age
(months)

N.B.., better prognosis if Rx is reducing and non-cyclo ret<< cyclo ret. If Rx more than half the values below then monitor

1-6 (refer)
6-9
9-18
18-36
36-48

> +6.00 DS
> +4.00 DS
> +3.50 DS
> +2.50 DS
> +2.25 DS

> -5.00 DS
> -5.00 DS
> -4.00 DS
> -2.00 DS
> -1.00 DS

> 6.00 DC
> 4.50 DC
> 2.50 DC
> 1.50 DC
> 1.25 DC

ORTHOPTIC FUNCTION

hypermetropic anisometropia > 2.50 DS/DC

hypermetropic anisometropia > 2.00 DS/DC
hypermetropic anisometropia > 1.25 DS/DC
hypermetropic anisometropia > 1.00 DS/DC
hypermetropic anisometropia > 1.00 DS/DC

CONCLUSIONS

Full handout from: www.bruce-evans.co.uk

Orthoptics: development

Orthoptics: tests of alignment

VOR present at full term birth

Cover test: the gold standard

Saccades improve over first 2 months

Hirschberg: inaccurate

Pursuit improves over the first 3 months

Krimsky:

Bifoveal fixation occurs at about 2-3 months

Bruckner

Sensory & motor fusion & stereopsis at 3-4 months

Accommodation relatively inaccurate, in line with
sensory abilities until about 3 months

1mm = 15-20

14

Symmetry of red reflexes, direct ophthalmoscope at 80-100cm, dial in

correction for clear view. Darker reflex in strabismic eye
Detects strabismus, anisometropia, anisocoria or pathology

Orthoptics: motility

Orthoptics: motor fusion

Infants dont like having head held

Base out prism test

Move around

Have child fix a detailed picture

Or parent can rotate the child

Can measure in older children with prism

bar

age (months)
0-3
by 6

test
20 out
20 out

response
unlikely to make any response
should be overcome

Evans (2007) Pickwells Binocular Vision Anomalies, 5th edition

Orthoptics: sensory fusion & stereo

Orthoptics: stereotest norms

Lang works well with infants: look at eye movements

Generally, different tests give different results

Frisby makes a good game with squeaky toy

But Titmus circles similar to Randot circles

Recommended from age 2y is Randot

age
0-3 mo.
6-18 mo
mo.
18-24 mo.
> 24 mo.
24 mo.
24 mo.
3-5 yrs.
> 5 yrs.
3.5 yrs.
5
yrs.
6
yrs.
7
yrs.
9
yrs.
3-5 yrs.
3-5 yrs.

Random dot
Contoured

Mallett polarised
letters test

test
any
Lang 1
Lang 1 or 2
Lang 1 or 2
Randot (shapes)
Randot (animals)
Randot (circles)
Randot (circles)
Titmus
Titmus
Titmus
Titmus
Titmus
Frisby
TNO

response
unlikely to make any response
observe patient
patientss eyes: may see fixations indicating sees pictures
should fixate and may point at pictures
should be able to point and name pictures
if sees shapes on random dot background indicates no strabismus
should be able to see all animals
70"
40" or better
3000
(Romano et al., 1975)
140
(Romano et al., 1975)
80
(Romano et al., 1975)
60
(Romano et al., 1975)
40
(Romano et al., 1975)
250"
120"

KEY SIGNS OF DECOMP. PHORIA

Orthoptics: summary

Symptoms

Poor cover test recovery

Aligning prism (FD test)

Low fusional reserve opposing phoria

Sheards criterion
Particularly useful for exophorias

For esophorias, size and imbalanced fusional reserves

are relevant

For hyperphorias, size matters

Try to do more than one method

Record quality of response
OCULAR ALIGNMENT (Methods: cover test; Hirschenberg, Krimsky, Bruckner)
D: METHOD 1:
RESULT:
N METHOD 1:
N:
1
RESULT
RESULT:
N: METHOD 2:
RESULT:
NPC:

cm

Validity:

good/modera
good/modera

good/moderate/poor

MOTILITY:

good/modera

FUSIONAL RESERVE
METHOD:
eye movements:
base out
Estimated validity of result: good/moderate/poor
STEREO-ACUITY
METHOD:

good/modera

RESULT:

brisk / moderate / slow / none

seconds

good/modera

Strabismus: the bottom line for the busy optometrist

ALIGNING PRISM: Mallett Unit

is it new or changing?

aligning prisms/spheres to eliminate FD

good foveal and peripheral fusion lock

yes

no

do I know the cause?

any treatment needed?

(probably not)

question set is important

ask if a line ever moves
Karania & Evans (2006)

B
yes
e.g., hypermetropia

1.0

1+

for symptomatic phoria:

1+

.8

sensitivity 75%

no
REFER

can I correct it?

O
P

.4

3+

2+

aged 40 years
and over

.2

Jenkins, Pickwell,
& Yekta (1989)

yes
e.g., Rx

no
REFER

under the age

of 40 years

3+

0.0
0.0

.2

L
Y

2+

.6

specificity 78%

.4

.6

.8

1.0

sorted!

1-SPECIFICITY

Strabismus: the bottom line for the busy optometrist

Profound learning difficulties

is it new or changing?

yes

no

A
do I know the cause?

yes
e.g., hypermetropia

any treatment needed?

(probably not)

no
REFER

can I correct it?

yes
e.g., Rx

no
REFER

sorted!

Common visual
problems in dyslexia
Meares-Irlen Syndrome/ Visual
(
)
Stress (MISViS)

e.g., Downs syndrome

often associated with:

refractive error

strabismus

poor accommodation

O
P
I

reduced VA

paediatric techniques may work; be quick

need eyecare, often need Rx (bifocals)

PLAN
INTRODUCTION
OCULAR HEALTH
VISUAL ACUITY

Binocular instability

REFRACTION
ORTHOPTIC FUNCTION
CONCLUSIONS

Accommodative insufficiency
Full handout from: www.bruce-evans.co.uk

Conclusions: they need us

Conclusions: we need them

Young children need and deserve more

than once only vision screening on school
entry

c. 10% of population is under 16 yrs

Many subtle orthoptic anomalies can be

best managed in primary optometric care

some orthoptic patients prefer exercises

in primary care

Accept that you wont get perfect results

specialist care for SpLD

children need regular brief exams

Record the quality of the response

A personal perspective: Dr Optometry

In 2008 the Institute of Optometry
launched a Doctor of Optometry
degree in collaboration with London
South Bank University
5 year part time professional doctorate
Year 1 has 13 taught days & 2
assignments
Year 2 has 8 taught days & 2 assignments
Years 3-5 are supervised doctoral
research
Research

most likely to be clinical, in practice

the ultimate HQ for UK optometrists