The two most important aspects of the eye examination for young children are to test visual acuity in each eye and to determine whether the gaze is conjugate or symmetric.
Use the methods described in Chapter 7 for adults to assess conjugate gaze, or the position and alignment of the eyes, and the function of the extraocular muscles. The corneal light reflex test and the cover-uncover test are particularly useful in young children.
You can perform the cover-uncover test as a game by having the young child watch your nose or tell you if you are smiling or not while you cover one of the child's eyes.
Both ocular strabismus and anisometropia (eyes with significantly different refractive errors) can result in amblyopia, or reduced vision in an otherwise normal eye. Amblyopia can lead to a "lazy eye," with permanently reduced visual acuity if not corrected early (generally by 6 years).
It may not be possible to measure the visual acuity of children under 3 years of age who cannot identify pictures on an eye chart. For these children, the simplest examination is to assess for fixation preference by alternately covering one eye; the child with normal vision will not object, but a child with poor vision in one eye will object to having the good eye covered. In all tests of visual acuity, it is important that both eyes show the same result.
Eyes converge, baby reaches
12 months -20/200
Less than 4 years 20/40 4 years and older 20/30
As shown on the next page, visual acuity in children 3 years and older can usually be formally tested using an eye chart with one of a variety of optotypes (characters or symbols). A child who does not know letters or numbers reliably can be tested using pictures, symbols, or the "E" chart. Using the "E" chart, most children will cooperate by telling you in which direction the "E" is pointing.
The visual fields can be examined in infants and young children with the child sitting on the parent's lap. One eye should be tested at a time with the other eye covered. Hold the child's head in the midline while bringing an object such as a toy into the field of vision from behind the child. The overall method is the same as that for adults, except that you will have to make this into a game for your patient.
Any difference in visual acuity between the eyes (e.g., 20/20 on the left and 20/30 on the right) is abnormal, and the patient should be referred to an ophthalmologist.
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