Examination of the Infant and Toddler PDF 2025

Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS EXAMINATION OF THE INFANT AND TODDLER Study Questions From this lecture, you should be able to answer the following questions: 1. At what age should a child have his or her first vision examin...

Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS EXAMINATION OF THE INFANT AND TODDLER Study Questions From this lecture, you should be able to answer the following questions: 1. At what age should a child have his or her first vision examination? 2. What visual behaviors should the examiner note in a newborn, one-month old, two- month old, three-month old, and six-month old infant? 3. Name eight prenatal risk factors. Name four perinatal risk factors. 4. What is the APGAR test? 5. Identify key characteristics of Grating Acuity Tests and the Cardiff Acuity Test: What is used as a target? How is the test administered? What are the advantages/limitations of each test? 6. Be able to interpret results of the Fixation Preference Test. 7. What is the preferred method to assess refractive error in infants and toddlers? 8. For infants with significant hyperopia, list three potential adverse consequences of not wearing refractive correction. 9. Be able to interpret findings of the unilateral and alternating cover test, as well as the Hirschberg Test, Krimsky Test, and Brückner Test. 10. What is the Preschool Assessment of Stereopsis with a Smile (PASS)? 11. Describe assessment of fixation and ocular motility. 12. What is the expected corneal diameter of a one-year old? 13. What is the likelihood that an infant with pseudostrabismus ultimately has strabismus? When should the first vision examination occur? Between six to twelve months o Rapid change occurs during first six months of life. o By age six months, typical infants should have reached multiple critical developmental milestones. o Key developments should have occurred in VA, accommodation, and binocular vision. Goals of the Infant Eye and Vision Examination § Confirm critical developmental milestones met § Test vision o Rapid development of VA, accommodation, and binocular vision is expected o Monitor visual function; identify any visual problems § Early diagnosis and treatment targets any visual problems and minimizes vision loss and adverse impact on development. o Detect amblyopia and amblyopic risk factors to lower prevalence and severity of amblyopia Preparation for the Infant Eye Examination 1  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS Infants perform best if the examination is early in the morning or after a nap. Age-appropriate examination strategies should be used. Often need to rely on objective examination procedures and perform tests more rapidly than with older children Observation of visual behavior Observations of the infant and toddler provide important clues to what the infant can see. Assessment of visual behavior begins by observing the child's reaction when you enter the room. Child's behaviors including looking at the examiner, visually tracking the examiner as he or she walks across the room, and responding to the examiner's smile should be noted. Visual behavior varies with the child’s age: Newborn: infants demonstrate visual fixation when an appropriate target (such as their parents’ face) is used One-month-old infants: make eye contact and begin to look at objects that are close to their faces. They appear serious as they fixate. Two-month-old infants: begin to display facial expression as they fixate. Three-month-old infants: begin to observe their hands while holding them close to their faces; start to track objects Three- to four-month-old infants: begin to watch activity that occurs around them. Six-month-old infants: visually attentive; observe their surroundings and recognize favorite people, toys, or foods at a distance. Nine-month-old infant: Picking up objects, tracking well, should look at objects across room Intake Parent or caregiver may complete questionnaire What are we looking for? Is there a specific concern? Can the baby see well? Are the eyes straight? Are the eyes healthy? Is treatment necessary? History Chief complaint Nature and history of the presenting problem Visual and ocular history General health history, including prenatal, perinatal and postnatal history; review of systems, surgical and/or head or ocular trauma history; any vision or ocular 2  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS treatment o Preterm infants High prevalence of vision and ocular health problems Hx of retinopathy of prematurity (RoP) associated with higher prevalence of high myopia, astigmatism, anisometropia, strabismus, and optic atrophy-> should be closely monitored o Other risk factors – brain damage, epilepsy Medications taken, including prescription and nonprescription drugs (e.g., over the counter medications, supplements, herbal remedies) Documentation of medication allergies; other allergies Family ocular and medical history. Developmental history – Prenatal/Natal-Gestational age, birth weight, type of delivery, delivery complications, forceps, problems or exposures during the pregnancy -Labor -Milestones –When did child start to talk? walk? If child is not biological offspring- Ask child’s age at adoption or when foster care/guardianship began Names of, and contact information for, the patient’s other health care providers. Prenatal History Risk Factors prenatal exposure to prescription or illicit drugs, smoking; alcohol use toxins (including radiation exposure) infections and acute maternal illness rubella, venereal diseases, AIDS maternal diabetes, hypertension, heart, lung and kidney problems bleeding or trauma; put on bedrest prenatal care- including nutrition, prenatal vitamins problems with placenta reducing flow of blood and nutrients Perinatal History Possible Risk Factors Delivery Complications (difficult or assisted labor) Trauma (forceps/vacuum extractor) gestational age (ie, degree of prematurity) presentation of the child and delivery type birth weight Apgar score < 6 indicates increased risk Includes five areas; each area is scored 0 to 2; total possible score =10 Pulse/Heart rate Respiration/Breathing Muscle tone/Activity 3  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS Reflex response Color/Appearance Prematurity and associated factors Low Birth weight < 5 lb 8 oz; about 1 in every 12 babies in the United States /Fetal growth restriction Gestation - Premature if should be closely monitored Postnatal period o Complications in the neonatal period (e.g., intracranial hemorrhage feeding difficulties, apnea, bradycardia, infection, and hyperbilirubinemia) External Observation LOOK at your patient Look for – Strabismus (Eye Turn) – Head tilt or turn – Preferred gaze pattern – very close working distance, looking out the corner of one eye – Anatomical Hyperdeviation Visual Acuity Visual acuity estimation helps to confirm or exclude diagnoses and hypotheses regarding visual development, including binocularity. o Preferential looking Methods – can provide estimates of resolution visual acuity o Grating cards o Vanishing Optotypes - Cardiff Acuity o Fixation Preference Test o Electrodiagnostic testing – VEPs provide objective estimates of visual acuity Acuity measured by Grating Cards Teller Acuity Cards, Patti Square, Lea Patti Square Wave Test o Handles labeled- cycles per centimeter and cycles per degree for test distances of 25, 50, and 100 cm (10, 20 and 40 in) Lea - multiples of 57 cm 4  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS o Contrast sensitivity tested by placing the gray paddle in front, grated paddle behind o Grated paddle then slides out o If child can see grating level, they follow paddle o Includes six gratings, three with gratings on both sides and one with a solid gray side for presentation o Reported as “responded to ___ cpcm grating at a distance of ___ cm/inches” Cardiff Acuity Test o Used for pts aged 1-3 yrs or with cognitive delays o Preferential Looking o Forced choice testing procedure o Picture on top half or in the bottom half of the card o Examiner watches eye movements to judge if pt sees target o Vanishing optotype target o pictures are white band bordered by two black bands on neutral grey background o Avg brightness equals that of the grey background o If child can resolve the white and black bands, sees picture, looks towards it o When target is beyond acuity limit (bands too narrow), picture merges with grey background, becomes invisible. Child cannot see picture, sees blank grey card Auxiliary Testing Methods for Visual Acuity Fixation Preference Test Indirect measure of visual acuity – must be interpreted in context of other findings such as the amount of anisometropia present or cover test findings o Disadvantage - Poor sensitivity for amblyopia esp in young children o Technique o Place 10Δ base down prism in front of OD to dissociate patient; Patient fixates on target. o Under normal binocular conditions, patient sees double; Image seen by the OD above the image seen by OS. o Examiner occludes one eye to force fixation with unoccluded eye. o If patient responds negatively when eye is occluded, acuity in unoccluded eye may not be as good as that of other eye. To test that hypothesis-> occlude other eye and observe any differences in behavior. o When uncovering occluded eye, observe fixation pattern. Did patient maintain fixation with the previously unoccluded eye? Or did patient immediately re-fixate with the eye that was previously occluded? o Repeat with the other eye. o Testing Results and Interpretation o Normal - Alternates fixation equally with non-dominant eye through smooth pursuit or blink o Red Flag - Holds briefly (3 sec or less) but one eye dominates Resistance to Occlusion 5  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS Refraction Objective measures of refraction with a lens bar or loose lenses should be used, because of short attention span and poor fixation of infants Should analyze measures of refraction with other findings obtained during exam o Net analysis determines if, and how much optical correction is needed Techniques o Cycloplegic retinoscopy – preferred method § Cyclopentolate – preferred agent Dosage - Infants and toddlers are small; use lowest concentration possible o 0.5% cyclopentolate hydrochloride for most infants 1 year Combination drops 0.2% cyclopentolate hydrochloride and 1% phenylephrine) may be used to maximize dilation Nasolacrimal occlusion may be used to decrease ris of systemic side effects Spray administration to open or closed eyes o acceptable alternative to eye drops o may be better tolerated and less distressing o use of cyclopentolate spray in children with dark irides may not achieve adequate cycloplegia o Spray caps available for use on bottles of cyclopentolate, eliminating need to have the spray compounded by a pharmacy Tropicamide An option, if cyclopentolate not available or contraindicated 1 % tropicamide effective for non-strabismic infants o Drop Instillation Tip o If patient is lying in parent’s lap, instill drops in eye closer to parent’s body; o After instillation, patient’s reflex will be to turn towards parent, thus exposing the other eye o Non-cycloplegic retinoscopy – performed at near substitutes for cycloplegic retinoscopy, but not as good Mohindra Technique o Controls for accommodation o Dark room o Monocular o 50 cm working distance o Fixates on retinoscopy light o Subtract 1.25 DS from sphere power for net findings may be useful when: o child/parent is extremely anxious about instillation of 6  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS cycloplegic agents o if child has had, or is at risk for, adverse reaction to cycloplegic agents Video refraction without cycloplegia may be used to detect infants with significant ametropia, particularly hyperopia Significance of detecting and managing infant refractive error Refractive error linked not only to vision problems, but also developmental difficulties Infants with hyperopia – considerations for refractive correction o may show deficits in many visuocognitive, spatial, visuomotor, and attention tests o at increased risk for early development of strabismus and amblyopia age 4 years o wearing partial correction for significant hyperopia and anisometropia throughout infancy reduces the incidence of poorer than average visual acuity in 3 to 5 1/2 year olds. o Spectacle correction in infancy improves the chances having normal vision at age 4 and beyond Binocular Vision and Ocular Motility Test selection at this age depends on patient’s cooperation, visual signs, and symptoms. Possible tests: Unilateral cover test at distance and near - usually can be completed o Pseudostrabismus § Associated with prominent epicanthus § Estimated to be 1% of infants § Some patients with diagnosis of pseudostrabismus later found to have true eye misalignment § Incidence of manifest strabismus following pseudostrabismus- 4.9% to 9.6% among infants Hirschberg test – An option, if cover test results are unreliable o Test distance ~50cm o Penlight aligned with patient’s midline o Estimate any displacement of corneal light reflex in each eye from center of the pupil. o (+) = nasal displacement o (-) = temporal displacement § 15 pd edge of pupil § 30 pd mid iris § 45 pd edge of iris Krimsky Test – Use prisms with Hirschberg to align corneal reflex and estimate 7  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS magnitude of any deviation. Brückner test Whiter, brighter pupil is suspicious eye useful when cover test result can’t be done or results unclear May be useful in detecting strabismus (including small angle) May be useful in detecting anisometropia o Increasing distance from one meter to four meters improves detection of anisometropia Stereopsis o May be attempted after age 6 months to provide a sensitive measure o Preschool Assessment of Stereopsis with a Smile (PASS) -uses preferential looking paradigm Near point of convergence (NPC) o assessed objectively o use a penlight or interesting targets, that have sounds or blinking lights. Ocular motility assessment o Versions and eye tracking abilities may be assessed using a penlight, small toy, or other object. o Doll’s Head Maneuver § Detects limitations in motility § Elicited by quickly turning the patient's head horizontally from side to side or vertically up and down § Eyes should stay fixated as head turns § May need to hold lids open Binocular Fixation Preference - may be used to assess fixation child’s attention directed to near target observe which eye was strabismic and which eye was fixating, note if alternating between the 2 eyes or if 1 eye seemed to be preferred for fixation. If alternation between eyes seen, estimate the proportion of time each eye used for fixation If 1 eye seemed to be preferred for fixation, occlude that eye with a occluder, forcing nonpreferred eye to fixate. ->remove occluder and observe how well and how long nonpreferred eye maintain fixations before the preferred eye refixated. Confrontation Visual Fields examiner obtains patient’s attention centrally and places target at edge of periphery Can detect gross peripheral defects and areas of constricted visual fields. Ocular Health Assessment Procedures may need to be modified 8  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS Anterior Segment Evaluation Equipment o Bluminator o Clear High Plus Lens and Transilluminator o Portable Slit Lamp Evaluate external eye and adnexa, ocular surface, anterior chamber, and crystalline lens. Lids/Lid Margin o Observe for shape, irregularity o Discharge on lashes/lid margin Cornea/Iris/Lens o Corneal Horizontal Diameter Norms § Neonate: 9-10 mm § 1 yr old: 11 mm § 3-4 years old to Adult: 11.5-12.0 mm Pupils – Assess for size, shape, symmetry, direct and consensual response to light and relative afferent pupillary defect. o Constricted - 1.2 - 2 mm o Fully dilated - 7.5 – 8 mm o Resting – 2.5 - 4 mm o In infancy pupillary rxn to light less than in childhood o Often absent in very premature infants (1st response at 28-32 wks) Intraocular Pressure Non-contact and handheld applanation tonometers approximate measurements close to Goldmann Applanation tonometry Rebound tonometry is portable, easy to use, and better tolerated Posterior Segment Evaluation Requires pupil dilation Often requires a mix of strategies and equipment Equipment o Direct ophthalmoscope § Not as bright to patient § Image is upright/real § Magnification 13x § Image isn’t stereoscopic § Visible =small area of posterior pole; approx. 5 degrees o Panoptic § Field of view 25 degrees § Held slightly further from patient than direct o Binocular indirect ophthalmoscope § Magnification 2-5 x § Field of view approx. 45 degrees § Image – inverted, reversed Optic Nerve Head – color, size, symmetry 9  Pediatric Optometry /Learning Related Vision Problems – Rachel A. “Stacey” Coulter, OD, MS Macula – integrity, reflex Vessels – tortuosity/attenuation Rarely examinations under anesthesia may be required References Blaikie Andrew J, Dutton Gordon N. How to assess eyes and vision in infants and preschool children BMJ 2015; 350 :h1716 Cotter SA, Tarczy-Hornoch K, Song E, et al. Fixation preference and visual acuity testing in a population-based cohort of preschool children with amblyopia risk factors. Ophthalmology 2009;116:145-53. doi:10.1016/j.ophtha.2008.08.031. Fern KD, Manny RE, Burghart C. Resistance to occlusion: sensitivity to induced blur in 6- to 12-month-old infants. J Am Optom Assoc 1994;65:651-9. Silbert AL, Matta NS, Silbert DI. Incidence of strabismus and amblyopia in preverbal children previously diagnosed with pseudoesotropia. J AAPOS. 2012 Apr;16(2):118-9. doi: 10.1016/j.jaapos.2011.12.146. PMID: 22525164 Wright KW, Walonker F, Edelman P. 10-Diopter Fixation Test for amblyopia. Arch Ophthalmol 1981;99:1242-46. 10