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  • • All newborn infants and all children at subsequent well-child health supervision visits.

    • All premature infants.

    • Children with significant developmental delay or neurologic disorders.

    • Children with systemic disease associated with eye abnormalities.

    • All children with a family history of congenital cataracts, retinoblastoma, and metabolic or genetic diseases.


  • • Costs associated with the further evaluation of children with false-positive screening results.

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• Depends on age and what is being assessed.

Vision Assessment (Newborn to Age 3 Years)

  • • Any object to assess ability to fix and follow.

Visual Acuity (Age 3 Years and Older)

  • • Picture tests, such as Allen cards or LEA symbols (flash cards with figures or symbols), are suggested for children 3–4 years of age.

    • Tumbling E test (which involves matching the orientation of the legs of the letter E with the child’s fingers) or HOTV test (which involves matching the letters H, O, T, V on a wall chart with the correct letter on a testing board) is suggested for children ages 3–5 years.

    • Snellen acuity chart (using Snellen letters or numbers) is suggested for children 6 years of age and older.

    • Occluders are used to obtain complete coverage of the untested eye.

External Inspection of the Eyes and Lids

  • • Penlight.

Ocular Alignment

  • • Cross cover test uses any object to focus on and an occluder.

    • Random dot E stereo test uses raised and recessed E cards.

    • Titmus test uses objects printed on material polarized at 90 degrees and polarized filter spectacles.

    • Simultaneous red reflex test (Bruckner test) uses direct ophthalmoscope.

Ocular Media Clarity

  • • Red reflex uses direct ophthalmoscope.

  • • When testing visual acuity, the test requiring the highest level of cognitive function that the child is capable of performing should be used.

    • Children who wear eyeglasses should have their visual acuity tested while wearing the eyeglasses.

    • It is recommended that visual acuity be tested using commercially available occluders that provide complete occlusion rather than cardboard or paddle occluders, which can allow for peeking.

    • When testing visual acuity, tests that use a line of figures are preferred over tests using single figures.

  • • The child should be examined while in good health.

    • The child should be comfortable; for younger children this may require that the child be sitting on a parent’s or guardian’s lap.

    • Keep distractions to a minimum.

  • • The child should be visually fixing on an object, particularly when assessing ocular alignment.

    • When measuring visual acuity, it is imperative that the child be 10 feet away from the testing equipment.

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