The Keeler PSL Classic is useful for young children who cannot be propped into a mounted biomicroscope.
The Spot Vision Screener from Welch Allyn
can screen for and detect amblyopic risk factors in children as young as six months.
PlusoptiX can take binocular readings from
1 m (3.3 ft.) away in less than one second.
The Grand Seiko WAM-5500 Advanced from AIT Industries can dynamically measure
accommodation at a rate of six measurements per second.

These insights into examining pediatrics will help grow your practice. 

Kids are more than miniature adults, and your ability to obtain clinical information rests on being prepared ahead of time. Although the data you’re seeking is similar to adult patients regarding visual acuity, refraction, accommodation, binocular vision, motility and eye health, the way in which you’ll gather it is unique””whether you’re using handheld instrumentation, devices or targets.

Visual Acuity
Teller cards are the gold standard of infant acuity testing, relying on forced-choice preferential looking (PL). This can be time consuming, so other PL procedures tend to be favored in busy clinical practices. Lea Paddles use the same idea of grating patterns, though my preference in paddles is the Richman Face Dot Test because infants and toddlers enjoy looking at faces. The Cardiff Acuity Test and similar tests of vanishing optotypes present outlines of figures such as a house that is preferentially viewed over a blank field on either the top or bottom half of the card.
For preschoolers who are non-verbal, consider the Broken Wheel Test, a form of PL well suited to pointing or matching responses. The Sweep Visual Evoked Potential (sVEP) is useful in nonverbally  detecting amblyopia. For verbal children, Lea Symbols (apple, house, square and circle) are generally preferable to Allen Symbols. Most automated projectors and computerized chart systems are available with a variety of pediatric optotypes.

Although retinoscopy is the mainstay of objective refraction, a number of photo and autorefractors are available. These include the plusoptiX pediatric autorefractor and the new Spot Vision Screener from Welch Allyn. The Grand Seiko WAM-5500 Advanced from AIT Industries is an excellent open view device that objectively records accommodative responses to near targets. We have used this successfully with children as young as three years of age.

Binocular Vision
Hirschberg corneal light reflexes in conjunction with the cover test aid documentation of motor alignment of the eyes. Convergence nearpoint testing is accomplished with finger puppets or similar targets of high interest. Sensory responses to anaglyphic tests can usually be elicited in preschool years with the Berens Three Character Flashlight, a variant of the Worth 4 Dot. Red/Green Press Lites can be used as an anaglyphic PL procedure. Stereopsis is an index of binocular vision, and Random Dot Stereopsis (RDS) tests are generally preferred. The Randot Stereo Smile Test can be used as a PL procedure with infants and toddlers. The Random Dot E (RDE) is a PL test used for preschoolers that can be achieved with matching a model template. RDS test booklets are used with school-aged children.

Ocular Motility
Spinning light targets are very effective in capturing attention for visual tracking with children of all ages. Pediatric drums with animals are used for OKN testing. The DEM and King-Devick Tests are used to measure saccades of school-aged children. Infrared sensors are used with goggles to measure eye movement patterns when children read. Remote eye-tracking technology that can be used in conjunction with a tablet or computer monitor is on the horizon but not yet clinically reliable for young children.

Ocular Health
A direct ophthalmoscope is useful not only to conduct the Bruckner Test in screening for strabismic misalignment and asymmetric refraction, but it can also be used for eye health screening for abnormal red reflexes indicating media opacities or retinal abnormalities. The Welch Allyn PanOptic direct ophthalmoscope is useful with small undilated pupils in providing both a larger image size and a more panoramic view. The PanOptic can be paired with the new iExaminer 6 for digital fundus photography  (works for iPhone 6, iPhone 6S, iPhone 6 Plus).

Binocular Indirect Ophthalmoscopy (BIO) is used for children of all ages. The Keeler PSL Classic is an excellent portable slit lamp useful for young children who cannot be propped into a mounted biomicroscope. A useful alternative for inspection of the anterior segment with magnification and UV light is the Burton Lamp or Bluminator.

Examining infants and young children can be challenging yet fun and rewarding.

Keep alternatives close at hand to improvise when things aren’t going as smoothly as planned, and learn to develop your powers of observation with this population. Contributing through early assessment and intervention is a gift you give to the child and family that lasts a lifetime.

Leonard J. Press, OD, FCOVD, FAAO, is optometric director of The Vision & Learning Center, Fair Lawn, NJ.


AIT Industries
800-729-1959 |

Keeler Instruments, Inc.
800-523-5620 |

Plusoptix Inc.
800.488.6436 |

Welch Allyn
800-535-6663 |


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