Procedures for the Evaluation of the Visual System by Pediatricians Sean P

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Procedures for the Evaluation of the Visual System by Pediatricians Sean P. Donahue, MD, PhD, FAAP, Cynthia N Baker, MD, FAAP, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS, AMERICAN ACADEMY OF OPHTHALMOLOGY

Vision screening is crucial for the detection of visual and systemic disorders. It abstract should begin in the newborn nursery and continue throughout childhood. This clinical report provides details regarding methods for pediatricians to use for screening.

This clinical report supplements the combined policy statement from the American Academy of Pediatrics (AAP), American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, and American Association of Certified Orthoptists titled “Visual System Assessment in Infants, Children, and Young Adults by Pediatricians.”1 The clinical report and accompanying policy statement supplant the 2012 policy statement “Instrument-Based Pediatric Vision Screening,”2 the 2003 policy statement “Eye Examination in Infants, Children, and Young Adults by Pediatricians,”3 and the 2008 AAP policy statement “Red Reflex Examination in Neonates Infants and Children.”4 The policy statement This document is copyrighted and is property of the American articulates the screening criteria and screening methods, and the clinical Academy of Pediatrics and its Board of Directors. All authors have filed report explains the various evaluation procedures that are available for conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process use by the pediatrician or primary care physician. approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

VISUAL SYSTEM HISTORY ASSESSMENT Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external Relevant family history regarding eye disorders (cataracts, strabismus, reviewers. However, clinical reports from the American Academy of amblyopia, and refractive error), eye surgery, and the use of glasses during Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent. childhood in parents or siblings should be explored. Parents’ observations The guidance in this report does not indicate an exclusive course of are also valuable in the history and review of systems. Questions that can treatment or serve as a standard of medical care. Variations, taking be asked include: into account individual circumstances, may be appropriate. 1. Do your child’s eyes appear unusual? All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, 2. Does your child seem to see well? revised, or retired at or before that time. 3. Does your child exhibit difficulty with near or distance vision? www.pediatrics.org/cgi/doi/10.1542/peds.2015-3597 4. Do your child’s eyes appear straight or do they seem to cross? DOI: 10.1542/peds.2015-3597 5. Do your child’s eyelids droop or does one eyelid tend to close? PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). 6. Has your child ever had an eye injury? Copyright © 2016 by the American Academy of Pediatrics

Downloaded from by guest on December 8, 2015 PEDIATRICS Volume 137, number 1, January 2016 FROM THE AMERICAN ACADEMY OF PEDIATRICS OCULAR EXAMINATION The ocular examination consists of the external examination, pupil examination, red reﬂex testing to assess ocular media, the examination of the ocular fundus by using ophthalmoscopy, and an assessment of visual function.

EXTERNAL EXAMINATION (LIDS/ORBIT/ CONJUNCTIVA/CORNEA/IRIS) External examination of the ocular structures consists of a penlight evaluation of the eyelids, conjunctiva, sclera, cornea, and iris. Detection of abnormalities, such as ptosis, nonresolving conjunctivitis, or the presence of cloudy or enlarged corneas and/or photophobia, necessitates timely referral to an eye care specialist appropriately trained to treat children. Nasolacrimal duct obstruction that has not resolved by 1 year of age also should lead to referral. Thyroid disease can manifest by increased visibility of the superior cornea caused by eyelid retraction.

RED REFLEX TESTING Red reflexes from the retinas can be used by the physician to great advantage. The red reflex test, or Bruckner test if performed binocularly, is used to detect opacities in the visual axis, such as a cataract or corneal abnormality, as well as abnormalities in the posterior segment, such as retinoblastoma or retinal detachment. The examiner also may detect subtle differences in the red reflex between the eyes, consistent with the presence of strabismus or refractive errors. The inequality of the red reflection or the interference with the red reflection can be noted in various conditions (Fig 1). FIGURE 1 fl Red re ex testing should be Red reflex examination. A, NORMAL: Child looks at light. Both red reflections are equal. B, UNEQUAL performed in a darkened room (to REFRACTION: One red reflection is brighter than the other. C, NO REFLEX (CATARACT): The presence maximize pupil dilation). Eye drops of lens or other media opacities blocks the red reflection or diminishes it. D, FOREIGN BODY/ fl to further dilate the pupils are not ABRASION (LEFT CORNEA): The red re ection from the pupil will back-light corneal defects or foreign bodies. Movement of the examiner’s head in one direction will appear to move the corneal necessary. The direct ophthalmoscope defects in the opposite direction. E, STRABISMUS: The corneal light reflex is temporally displaced in is set on “0,” and while viewing the misaligned right eye, indicating esotropia. (Used with permission of Alfred G. Smith, MD, ©1991.)

Downloaded from by guest on December 8, 2015 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS through it at a distance of aged child is also important. The attributable to the presence of approximately arm’s length from the development of strabismus in prominent epicanthal skin folds that child, both pupils are evaluated children may occur at any age and, cover the medial portion of the sclera simultaneously as the child looks at although often isolated, may also on 1 or both eyes, giving the false the light. To view more detail, the represent serious orbital, intraocular, impression of esotropia. The inability examiner can move closer to the child or intracranial disease. to differentiate strabismus from to assess each eye individually. The pseudostrabismus also necessitates The corneal light reflex test and the observed red reflexes can be referral. cover test are each useful in compared and should be a light identifying the presence of Finally, the presence of unusual eye orange-yellow in color in lightly strabismus as well as in movements in an infant or young child pigmented eyes or a dark red in differentiating true strabismus from may indicate nystagmus or a similar darkly pigmented brown eyes. If pseudostrabismus. disorder and often indicates decreased fl normal, the 2 red re exes should be vision or neurologic dysfunction. The corneal light reflex test (ie, identical in color, brightness, and size. Nystagmus does not resolve fl Hirschberg test) is performed with a A bright white or yellow re ex or, spontaneously and often indicates fl penlight directed onto the child’s face conversely, a dull or absent red re ex afferent visual system dysfunction or fi from arm’s length away and by can be an indication of a signi cant neurologic disease and necessitates observing the symmetrical location of abnormality that necessitates further further evaluation by either an the white pinpoint light reflexes while evaluation by a pediatric ophthalmologist or neurologist. ophthalmologist, or if unavailable, a the child gazes at the light. Normally, comprehensive ophthalmologist or these reflexes fall symmetrically in or OPHTHALMOSCOPY optometrist with specialized interest near the center of the pupils. An in the treatment of children, and who abnormal response occurs when the Use of the direct ophthalmoscope in uses cycloplegia (dilating drops) as reflex in one eye is centered in the older, cooperative children serves to part of his or her routine evaluation. pupil while the reflex in the opposite visualize structures in the back of the Because there is often considerable eye is displaced nasally, temporally, or eye, such as the optic nerve, retinal variation in the qualitative nature of vertically away from the pupil center blood vessels, and central retina the red reflex among patients without (Fig 1). This asymmetry of the (fovea). To properly visualize these eye abnormalities, the frequent, reflexes typically indicates the structures, the child looks into the routine assessment of the red reflex presence of strabismus. distance at a target of interest. The ophthalmoscope is dialed to a +10 lens will help the primary care physician The cover test should be performed and the examiner focuses on the pupil better distinguish an abnormality of while the child fixates on a small, fl from ∼3 inches away. The examiner the re ex from a normal one. interesting target, such as a small toy then gradually moves as close to the or sticker on a tongue depressor. The eye as possible while sequentially PUPIL EXAMINATION bright beam of a penlight does not dialing less lens power until retinal provide a comfortable target and Both pupils should be equal, round, vessels come into focus. These vessels does not adequately stimulate and equally reactive when light is canbefollowedtoidentifyandview accommodation (focusing). As the directed toward either eye. the optic nerve. The normal optic child attends to the target, each eye is Asymmetric responses to light may nerve has a yellow-pink color and is alternately covered. A shift in an eye’s indicate visual system dysfunction. generally flat. To view the foveal reflex, alignment as it assumes fixation onto Moreover, asymmetry of pupil shape the child is asked to look directly at the target is a possible indication of or difference in diameter greater than the light of the ophthalmoscope. The strabismus. 1 mm can often be attributable to an normal foveal reflex should appear ocular injury or disease or to a Strabismus in the neonatal period is bright and sharp. Retinal hemorrhages neurologic disorder. Differences in not unusual, and intermittent can be observed after a normal vaginal pupil size less than 1 mm can occur strabismus is often a normal finding delivery but are also the harbinger of normally and are generally benign in early infancy. However, constant severe child abuse; a swollen optic unless associated with ptosis or an horizontal strabismus that persists nerve may be an indicator of increased fi ocular motility de cit. after 4 months of age does not resolve intracranial pressure. spontaneously.5 Thus, any child older OCULAR ALIGNMENT AND MOTILITY than 4 months with strabismus ASSESSMENT OF VISUAL ACUITY IN ASSESSMENT should be referred for evaluation. PREVERBAL CHILDREN The assessment of ocular alignment Pseudostrabismus is the appearance The assessment of visual function in in the preschool- and early school- of crossed eyes (esotropia) this very young age group is best

Downloaded from by guest on December 8, 2015 PEDIATRICS Volume 137, number 1, January 2016 3 accomplished by evaluating the bars) around each optotype provide easier for the young child to child’s ability to fixate on and follow the most accurate assessments of understand, as they are symmetric an object held before the child. A visual acuity (Fig 2). Using cards with and not subject to letter reversal. With standard assessment strategy is to single optotypes but without the examiner pointing to a symbol determine whether each eye can crowding bars can overestimate with a finger under it, a timid child can independently fixate on the object, visual acuity. Crowding bars point to the optotypes that he or she maintain fixationonitforashort surround an optotype and make recognizes on a card with similar period of time, and then follow it as individual letters more difficult to symbols; this allows the child to it is moved in various directions. The recognize by an amblyopic eye, thus effectively offer nonverbal responses childshouldbeawakeandalertfor increasing the sensitivity to detect during testing. Once a child can this testing, and the targeted object amblyopia (Fig 2). Accurate distinguish letters, a chart with letter should be a toy or something of assessment of visual acuity, therefore, optotypes should be used. Although interest to the child. Disinterest or is best accomplished by using a line the traditional Snellen chart remains poor cooperation can mimic a poor of symbols or symbols with crowding in wide usage, Sloan letter charts vision response. This assessment bars around them. present letters in a standardized fi should rst be performed The currently preferred optotypes are fashion and should be used for acuity binocularly and then repeated with the LEA or HOTV symbols, although testing if they are available. each eye alternately covered. If poor other new picture optotype acuity fi binocular xation and following tests are under development.6,7 Allen Screening Process behavior is noted after 3 months of figures, Lighthouse characters, and the age, an ocular or neurologic Large optotypes at the top of an eye Sail Boat Chart are not standardized fi abnormality may be present. chart or on handheld cards are rst and are no longer recommended for reviewed with the child with both eyes Similarly, asymmetry in responses use, nor are the Tumbling E or Landolt betweenthe2eyesinchildrenof open to help the child understand the C charts, because a child of preschool test. After this review, 1 eye is any age necessitates further age may not yet have developed the evaluation. occluded (preferably by an occlusive ability to express the orientation of patch or tape) and lines of optotypes these optotypes. HOTV symbols are or cards with single crowded ASSESSMENT OF VISUAL ACUITY IN optotypes (ie, the figure is surrounded OLDER CHILDREN by bars on all 4 sides) are presented to Children who are old enough to each eye separately. Effective delineate objects on a wall-mounted occlusion, such as with tape or an or handheld eye chart can provide a occlusive patch of the eye not being direct measurement of visual acuity. tested, is important to eliminate the For some children, this may be possibility of peeking. accomplished as young as 3 years, but for the typical healthy child, an Threshold Line Evaluation accurate visual acuity can be The time-honored method of testing achieved with a high degree of visual acuity has been to ask the child success at 4 years and older. Eyes to start at the top of an eye chart and should be tested monocularly, continue reading down each line until ensuring that the child does not peek he or she recites the smallest line of with the fellow eye. optotypes discernable with each eye With traditional visual acuity tested separately. This method is screening, the selection of age- called “threshold” acuity testing and appropriate shapes or letters and remains a common method of acuity specific testing methods is crucial in testing. It enables one to identify the obtaining the most accurate screening best level of visual acuity in each eye. results. Many children can identify Thus, children with near-normal optotypes (figures or a selection of acuity who still have a mild difference distinct letters formatted on chart FIGURE 2 in acuity between each eye can be lines or presented singly on A, Five 20/50 letters presented in a row. B, detected. However, threshold line individual cards) by 4 years of age. Crowding bars isolate a single letter on the evaluation can be sufficiently time- same 20/50 line, making it easier for a child to Eye charts using lines of optotypes or identify the letter, but are less subject to the consuming to result in loss of matching cards with lines (crowding “crowding phenomenon” (see text). attention from a young subject.

Downloaded from by guest on December 8, 2015 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS Critical Line Evaluation 2. An appropriate testing distance uncooperative during an examina- Young children, even those with must be used. For children up to tion; such behavior should be normal vision, are frequently unable 5 years of age, especially when considered a possible indicator of to attend sufficiently to small pictorial optotypes are used, this poor visual function. optotypes and identify them. “Critical distance should be set at 10 feet 4. The use of validated and stan- line” screening is an effective rather than 20 feet as a standard. dardized optotypes and acuity alternative to threshold testing for This shorter distance helps to en- charts is important for an accurate identifying children with potentially hance interaction between the assessment of vision. For this serious vision concerns and can be child and the individual adminis- reason, only the LEA symbols more quickly administered than can tering the screening without de- and HOTV characters are recom- screening by using threshold testing. creasing the accuracy of screening mended for preschool vision The “critical line” is the age- results. Indeed, current standard- screening at this time. Other dependent line a child is expected to ized preschool eye charts are optotypes are not well validated in see normally and pass. For screening typically calibrated for use at the screening environment. 10 feet. For children 6 years and purposes, it is unnecessary to 5. Every effort should be made not to older for whom a letter chart is measure acuity below the age-specific isolate shapes or letters in- used, the test distance may be critical line to pass the test. The advertently on a line with a finger appropriately set at either 10 feet critical line to pass screening or cover to “help” a struggling or at the common standard of becomes smaller as age increases. child. If performed in this manner, 20 feet, as long as the chart is Most eye charts present 4 to 6 the visual acuity result may be properly calibrated for use at optotypes per line, and passing the made falsely elevated by blocking that distance. screening requires the child to correctly out the natural crowding inherent answer a simple majority of the in open lines of letters. If single optotypes present on the critical line optotypes are presented, they appropriate for his or her age as follows: Increasingly, screening methods using “ ” short testing distances are becoming should include crowding bars. • Ages 36 through 47 months: If available in the form of handheld 6. Screening visual acuity to the attempted at this age, the critical line optotypes used at a testing distance of child’s threshold (ie, best possible 5 feet8 or as computer, tablet, or smart to pass screening is the 20/50 line acuity) may provide a less accurate phone–based models with testing • Ages 48 through 59 months: The distances within 1 to 2 feet. Although result than testing to the age- critical line to pass screening is the the accuracy of screening visual acuity appropriate critical line for that 20/40 line at these shorter distances has not yet child. Critical line testing is an ap- • been validated in large population- propriate alternative to threshold Ages 60 months and older: The based studies, the use of these critical line to pass screening is the methods can fit well into small clinical testing, requires less time to ad- 20/30 line (or the 20/32 line on work areas. One computer-based minister, and may provide a more some charts) application, available from the Jaeb accurate screening assessment of a Center for Health Research, is child’s visual function. specifically for use by nonophthalmic Establishing an Effective Screening health care professionals. The Jaeb Incorporating these concepts into Environment and Methodology Visual Acuity Screener incorporates all clinical practice offers a quick and current screening guidelines and is reliable assessment of visual acuity It is important that the screening area availablefreeofchargefordownload be conducive for assessing visual and unlimited use at http://pedig.jaeb. in young children. To assist acuity and that proper technique is org/JVAS.aspx. pediatricians and primary care used to promote accurate screening. physicians, the American It is important that screening 3. It is important to recognize that Association for Pediatric personnel be trained to recognize and children with visual impairment Ophthalmology and Strabismus has avoid pitfalls that reduce the accuracy may inaccurately pass a vision developed a Vision Screening Kit fi of visual acuity screening. Accurate screening if they peek around an designed speci cally for young screening of visual acuity requires incompletely covered eye or if they children that incorporates these dedicated and skilled staff members. are able to correctly guess when important concepts. It is available commercially and can be purchased 1. A well-illuminated area free from only 2 or 3 optotype choices are distraction is important. A quiet presented. Use of an adhesive from the AAP. examination room or hallway is patch over the nontested eye For healthy children 6 years and generally sufficient for this is recommended. Visually older, testing of visual acuity using purpose. impaired children may become optotype-based vision charts at 10 or

Downloaded from by guest on December 8, 2015 PEDIATRICS Volume 137, number 1, January 2016 5 20 feet remains the preferred method Terminology (CPT) code, 99173, has INSTRUMENT-BASED SCREENING for screening and should be repeated been established for visual acuity TECHNIQUES every 1 to 2 years (Table 1). screening and is available to primary Instrument-based screening is Although barriers to its use exist, a care physicians to seek payment for endorsed by the AAP2 and by the US level-1 Current Procedural this testing. Preventive Services Task Force as a

TABLE 1 Eye Examination Guidelines Function Recommended Tests Referral Criteria Comments Newborn to 6 mo Vision assessment Fixation and follow Inconsistent or no response by 3 mo response Ocular media clarity Red reflex White, pupil, dark spots, absent or asymmetric reflex External inspection Direct observation Any ocular abnormality of concern 6to12mo Pupil examination Flashlight As above for ages newborn to 6 mo, plus Ages 1–3y As above for ages 6 mo to 12 mo, plus Instrument-based vision Photoscreening Failed screening as indicated by the device screening when available Autorefraction (CPT 99174) Distance visual acuity HOTV or LEA Symbols Fewer than a simple majority of optotypes may be attempted correct on the 10/25 (20/50) line with either at age 3 y eye tested monocularly at 10 ft Ages 4–5y Distance visual acuity or HOTV or LEA symbols A simple majority of figures correct on the age- 1. Use a well-illuminated area free from distraction. instrument-based appropriate critical line with either eye 2. Either critical line testing or threshold testing may screening when tested monocularly at 10 ft be used (see text for details). available (CPT 99173) 3. Testing distance of 10 ft is recommended for all visual acuity tests. 4. A line of figures is preferred over single figures, unless the single figures are “crowded” (see text). 5. The fellow eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to the eye; the examiner should determine that it is not possible to peek with the nontested eye. Ages: 48–59 mo: 10/20 (=20/40) 60+ mo: 10/15 (=20/30) or For threshold testing only: a 2-line difference between eyes, even with the passing range; eg, 20/15 (20/30) and 10/10 (20/20) for a 60- mo-old Ocular alignment Cross cover test Any eye movement Child must be fixing on a target while cross cover test is performed. Any asymmetry of Direct ophthalmoscope used to view both red reflexes pupil color, size, simultaneously in a darkened room from 2–3 feet brightness away; detects asymmetric refractive errors as well. Ocular media clarity Red reflex White pupil, dark spots in pupil, absent red Direct ophthalmoscope, darkened room. View each reflex red reflex separately at 12–18 inches; white reflex indicates possible retinoblastoma. Dark or absent reflex indicates possible cataract.

Downloaded from by guest on December 8, 2015 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Continued Function Recommended Tests Referral Criteria Comments Ages ‡6y Distance visual acuity; Sloan letters or Fewer than a simple majority of optotypes 1. Tests are listed in decreasing order of cognitive instrument-based Snellen letters correct on the 10/15 (20/30) line with either difficulty; the highest test that the child is capable screening when eye tested monocularly at 10 ft of performing should be used. available for children HOTV or LEA symbols 2. Use a well-illuminated area free from distraction. unable to perform acuity 3. Either critical line testing or threshold testing may be used (see text for details). 4. Testing distance of 10 ft is recommended for all visual acuity tests. 5. A line of figures is preferred over single figures unless the single figures are “crowded” (see text). 6. The fellow eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to the eye; the examiner should determine that it is not possible to peek out of the covered eye.

or For threshold testing: only: a 2-line difference between eyes, even within the passing range; eg, 10/10 (20/20) and 10/15 (20/30) Any eye movement Simultaneous red reflex test (Bruckner test). Child must be fixing on a target while cross cover test is performed. Ocular media clarity Red reflex White pupil, dark spots, absent reflex Direct ophthalmoscope, darkened room. View each red reflex separately at 12–18 inches; white reflex indicates possible retinoblastoma. Dark or absent reflex indicates possible cataract. valid method for screening very enables the primary care physician to supplement instrument-based testing. young children.9 A recent seek payment for its use. CPT codes The actual age for this is not yet well randomized, controlled, 99173 and 99174 are specific for established and likely varies multicentered crossover study visual acuity screening and depending on the child. demonstrated photoscreening to be photoscreening, respectively. The most common ocular superior to direct testing of visual Two types of instrument-based vision abnormalities seen during the early acuity for screening well children screening are now available for use in childhood years are strabismus, ages 3 to 6 years in the pediatric ambulatory care settings. Although anisometropia, and a high magnitude fi 10 of ce. If available, instrument- neither type provides a direct of uncorrected refractive errors: based screening can be attempted assessment of visual acuity, both hypermetropia, myopia, and beginning at age 12 months,11 and a identify ocular risk factors that can astigmatism. The American previous study has demonstrated lead to early vision loss in children. Association for Pediatric better eventual outcomes for children Once children can read an eye chart Ophthalmology and Strabismus has undergoing their first photoscreening easily, optotype-based acuity should developed refractive criteria to help before 2 years of age.12 Instrument-based screening can be relatively quick and requires less TABLE 2 Amblyopia Risk Factor Targets Recommended by the American Association for Pediatric Ophthalmology and Strabismus attention from the child compared Refractive Risk Factor Targets with traditional visual acuity screening. Screening instruments Age, mo Astigmatism, D Hyperopia, D Anisometropia, D Myopia, D identify optical and physical 12–30 .2.0 .4.5 .2.5 .23.5 characteristics that indicate the 31–48 .2.0 .4.5 .2.0 .23.0 presence of ocular conditions known .48 .1.5 .3.0 .1.5 .21.5 Nonrefractive Risk Factor Targets to cause amblyopia. Similar to the All ages Media opacity .1mm code for visual acuity screening, a Manifest strabismus .8 prism D in primary position level-1 CPT code, 99174, has been D, diopters assigned to photoscreening and From Donahue et al.13

Downloaded from by guest on December 8, 2015 PEDIATRICS Volume 137, number 1, January 2016 7 primary care physicians appreciate overreferrals (ie, low specificity) ACKNOWLEDGMENTS the levels of refractive error known to results. Conversely, when a high The writing committee and lead fi increase risk of amblyopia speci city is set, there is often a low author thank Drs James B. Ruben, MD, 13 (Table 2). Referral criteria that best sensitivity (ie, reduced detection of FAAP, and Geoffrey E. Bradford, MD, detect these amblyopia risk factors at-risk children). Given these factors, FAAP, for assistance with drafting and may vary depending on the screening the referral criteria can be adjusted editing this document. instrument used and the desired for many instruments on the basis of levels of sensitivity and specificity. the child’s age and desired levels of sensitivity and specificity. Photoscreening devices identify ABBREVIATIONS optical characteristics of the eyes to LEAD AUTHORS AAP: American Academy of estimate refractive error, media Pediatrics clarity, ocular alignment, and eyelid Sean P. Donahue, MD, PhD, FAAP Cynthia N Baker, MD, FAAP CPT: Current Procedural position. Abnormalities in these Terminology characteristics constitute risk factors AAP COMMITTEE ON PRACTICE AND for the presence or development of AMBULATORY MEDICINE, 2014–2015 amblyopia. Photoscreening has been shown to have high sensitivity and Geoffrey R. Simon, MD, FAAP, Chairperson Cynthia N Baker, MD, FAAP fi fi REFERENCES speci city in community and of ce Graham Arthur Barden, III, MD, FAAP – settings.14 20 Photoscreening Oscar W. “Skip” Brown, MD, FAAP 1. American Academy of Pediatrics. Section instruments assess both eyes Jesse M. Hackell, MD, FAAP on Ophthalmology; American Association simultaneously and the images can be Amy Peykoff Hardin, MD, FAAP for Pediatric Ophthalmology and Kelley E. Meade, MD, FAAP Strabismus; American Academy of interpreted by trained operators, by a Scot B. Moore, MD, FAAP Ophthalmology; American Association of central reading center, or with Julia Richerson, MD, FAAP Certified Orthoptists. Visual system computer software. assessment in infants, children, and Autorefraction instruments, like STAFF young adults by pediatricians. photoscreeners, also are useful for Elizabeth Sobczyk, MPH, MSW Pediatrics. 2015, In press screening young children.21,22 2. Miller JM, Lessin HR; American Academy Handheld autorefractors use optical AAP SECTION ON OPHTHALMOLOGY of Pediatrics Section on Ophthalmology; methods to estimate the refractive EXECUTIVE COMMITTEE, 2014–2015 Committee on Practice and Ambulatory Medicine; American Academy of error of each eye, 1 eye at a time, and Sharon S. Lehman, MD, FAAP, Chairperson Ophthalmology; American Association for as such, are limited in their ability to David B. Granet, MD, FAAP Pediatric Ophthalmology and detect strabismus in the absence of Geoffrey E. Bradford, MD, FAAP Steven E. Rubin, MD, FAAP Strabismus; American Association of an abnormal refractive error. R. Michael Siatkowski, MD, FAAP Certified Orthoptists. Instrument-based However, autorefractors remain Donny Won Suh, MD, FAAP pediatric vision screening policy useful in detecting anisometropia in David B. Granet, MD, FAAP, Immediate Past statement. Pediatrics. 2012;130(5): the absence of strabismus, which is Chairperson 983–986 the most common cause of amblyopia 3. Committee on Practice and Ambulatory undetected at an early age. LIAISONS Medicine, Section on Ophthalmology. – American Association of Certified Instrument-based devices using Noelle S. 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Procedures for the Evaluation of the Visual System by Pediatricians Sean P. Donahue, Cynthia N Baker, COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, AMERICAN ASSOCIATION FOR PEDIATRIC OPHTHALMOLOGY AND STRABISMUS and AMERICAN ACADEMY OF OPHTHALMOLOGY Pediatrics; originally published online December 7, 2015; DOI: 10.1542/peds.2015-3597 Updated Information & including high resolution figures, can be found at: Services /content/early/2015/12/07/peds.2015-3597.full.html References This article cites 23 articles, 6 of which can be accessed free at: /content/early/2015/12/07/peds.2015-3597.full.html#ref-list-1

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