Screening for early identification and management of vision abnormalities should begin from birth and continue throughout childhood and adolescence, according to a new policy statement released by the American Academy of Pediatrics.
“Through careful evaluation of the visual system, retinal abnormalities, cataracts, glaucoma, retinoblastoma, strabismus, and neurologic disorders, including amblyopia, can be identified,” Dr. Sean P. Donahue and Dr. Cynthia N. Baker wrote on behalf of five committees and organizations involved in the statement. “Timely treatment of these conditions is critical, as is the education of parents with respect to the importance of timely follow-up and documentation in the medical record that the education occurred” (Pediatrics 2015 Dec. 7. doi: 10.1542/peds.2015-3596 and doi:10.1542/peds.2015-3597).
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The most common conditions in children that can result in visual impairment include amblyopia, high refractive error, and strabismus. Instrument-based screening devices can detect all of these at any age, but particularly after 18 months of age. The policy recommends annual screenings through 5 years or until clinicians can use optotypes to assess visual acuity, recommended from age 4 years on.
“Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten the child’s life,” the statement noted.
In the clinical report, the authors recommend that clinicians take relevant family history regarding parent or sibling cataracts, strabismus, amblyopia, refractive error, other eye disorders, eye surgery, or use of glasses during childhood. Doctors also should ask parents about the child’s eyes and vision, such as whether the child’s eyes appear normal and functional or whether any eye injuries have occurred or the parents have noticed anything unusual.
An ocular examination in newborns and children up to 6 months old should include a general vision assessment using the fixation and follow response, use of the red reflex to test ocular media clarity, and direct observation for any other apparent abnormalities. Children with inconsistent or lack of response to the fixation and follow response by 3 months of age should be referred, as should children with any concerning abnormalities or with a white pupil, dark spots in the iris, or an absent or asymmetric (strabismus) red reflex. After 6 months of age, these tests should continue, along with pupil examination with a flashlight.
Starting at age 1 and through age 3 years, clinicians should add autorefraction tests, such as photoscreening, to annual exams, which can “estimate refractive error, media clarity, ocular alignment, and eyelid position,” the statement noted. “Abnormalities in these characteristics constitute risk factors for the presence or development of amblyopia.” They can also add HOTV or LEA SYMBOLS tests to assess distance visual acuity at these ages.
Guidelines for ages 4-5 years include distance visual acuity assessment with HOTV or LEA SYMBOLS, assessing ocular alignment with a cross cover test, and testing red reflex. Clinicians can begin using Sloan letters or Snellen letters at age 6 years, to be continued annually, and should continue to test red reflex.
The groups contributing to the statement include the AAP Committee on Practice and Ambulatory Medicine, the AAP Section on Ophthalmology Executive Committee, the American Association of Certified Orthoptists, the American Association of Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. The statement updates and replaces three previous policy statements: “Eye Examination in Infants, Children, and Young Adults by Pediatricians” in 2003, “Red Reflex Examination in Neonates, Infants, and Children” in 2008, and “Instrument-Based Pediatric Vision Screening” in 2012.
The statement did not require external funding. The authors did not report disclosures.