The appropriate ocular history will vary depending on the reason the child has come for evaluation. If a child presents for a routine well-child examination, the ocular history will be included in the review of systems. The caregiver should be asked about any specific eye complaints. In infants and younger children, the examiner’s questions should include whether the child appears to see normally, if there are any abnormal eye movements, or if there are any visible abnormalities of the eyes or periocular structures. Older children may be questioned directly regarding subjective symptoms, including blurred vision (difficulty seeing the blackboard at school or objects that friends or family members can see easily), double vision, or other concerns regarding vision or the appearance of the eyes.
If a child presents for evaluation of an ocular problem, the appropriate history will depend on the specific complaint. As with any medical concern, questions should include the onset and duration of symptoms, aggravating and alleviating factors, history of similar problems, and previous treatment.
General medical and family histories are also important elements to explore during history taking. Children who are born prematurely or who had perinatal difficulties have an increased risk of developing vision problems. Preterm infants are at highest risk for retinopathy of prematurity; they also have higher rates of amblyopia, strabismus, refractive error, and cortical visual impairment depending on their comorbidities.
Many systemic disorders, such as trisomy 21 and Marfan syndrome, are associated with specific ocular problems. Children with juvenile idiopathic arthritis are at increased risk for asymptomatic intraocular inflammation (uveitis) and therefore require longitudinal screening. Children with neurofibromatosis type 1 require annual examinations to identify signs of optic pathway glioma. A family history of an ocular condition or systemic disease that affects the eye may also alert the examiner to look for specific problems. If family members have been affected by serious eye disorders that may be inherited, such as infantile cataracts, pediatric glaucoma, or retinoblastoma, screening by an ophthalmologist may be indicated, even if the screening office evaluation appears normal. More common familial problems include strabismus, myopia, and astigmatism.
When obtaining an ocular history, it is important to recognize that children may be unaware that they have a vision problem, even with significant visual impairment. Young children in particular typically adapt very well to decreased vision and often do not voice complaints, even when vision is below the level of legal blindness (worse than 20/200 in the better eye or severe visual field constriction). The visual demands of infants and toddlers are relatively minor—they only need to see well enough to find their food and toys and identify family members, and they do not need to read fine print. Therefore, they may appear to function quite well, often until grade 1 or 2, when visual demands begin to increase. In addition, children whose vision loss is confined to 1 eye ...