Screen for vision concerns at every well-child visit. I recommend a consistent method of screening so you and your staff develop a skill set and yield consistent results. The screening method varies by the age and cooperation of the child, so it is useful to establish protocols for the preverbal child and for an older child who can actively participate in visual acuity testing.
The American Academy of Pediatrics has a wonderful publication with vision screening recommendations for pediatricians. The AAP’s policy statement on "Eye Examination and Vision Screening in Infants, Children, and Young Adults" contains consensus-driven information of high value to pediatricians.
By Dr. David Coats
Importantly, keep in mind that many children old enough to participate in vision testing often perform poorly initially. There is a large learning curve, and a child who performs poorly the first time will often do very well on the second test. So it’s a good idea to retest before referring a child to a specialist for poor vision.
If the child is cooperative, you can retest during the same visit and save the patient a return trip to your office. If the child fails visual acuity testing twice, that is when I would refer to an eye specialist.
Pediatricians are essentially looking for reduced vision, misalignment of the eye, and any anatomic abnormalities. More specifically, you are screening for amblyopia, which can occur in up to 4% of the population; strabismus or eye misalignment; and anatomic concerns including ptosis, abnormal size of the eye, or a white pupil that suggests a cataract or a retinoblastoma.
A positive finding on almost every aspect of screening indicates need for referral of the patient to a specialist.
In contrast, acute abnormalities such as redness of the eye, minor injuries, and allergic conjunctivitis can be managed well in your office.
Keep in mind that failure to respond to initial treatment is an indication for referral. If you treat a child for red eye, for example, and the eye does not improve quickly, referral is warranted. Importantly, it is not usually an indication to change their antibiotic drop or switch them to another treatment. Although most of the time a simple problem may be the culprit, a red eye also can signal a more serious condition.
Referral of any child who screens positive for an eye concern or fails to initially respond to treatment generally requires no additional evaluation in the primary care setting. Just send the child along with a note explaining your concern and outlining any special circumstances that might not emerge on routine history-taking with the parents. We’ll take it from there.
Two Eye Evaluation Mnemonics for Primary Care Physicians
In addition to the AAP guidelines, I recommend two mnemonics to assist primary care physicians during eye evaluation. A stretched version of MVP, the MVPea mnemonic can guide assessment and ensure that a quick examination is complete:
– M stands for motility. Are the eyes straight and do they move normally?
– V is vision assessment.
– P is pupil assessment. Are the pupils equal, round, and reactive? Do you see an afferent defect (decreased pupillary response to light in the affected eye), or an abnormality such as a white pupil or pupillary asymmetry?
– e is external exam. Assess surrounding structures, including the eyelids and eyelashes, for any abnormality.
– a is for the anterior segment. Evaluate the cornea, the lens, and other structures.
These are the critical components of a pediatrician’s regular eye examination. These steps should take you a very short amount of time.
If you have a particular interest in eye disorders and some practice and skill at ocular examinations, you can consider adding three supplementary components to your assessment. I call these the ophthalmic version of CPR for the pediatrician:
– C is for confrontational visual field testing.
– P is for pressure.
– R is for retina.
This column, "Subspecialist Consult," regularly appears in Pediatric News, a publication of Elsevier. Dr. Coats is chief of ophthalmology at Texas Children’s Hospital and professor of ophthalmology and pediatrics at Baylor College of Medicine, both in Houston. He said he had no relevant financial disclosures.