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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.
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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.
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General medical and family histories are also important in evaluating the
eyes. Children who are born prematurely or who had perinatal difficulties
have an increased risk of developing vision problems. 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.1 Children
with neurofibromatosis type 1 require annual examinations at least
during the first 7 years of life 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 office evaluation appears normal. More common familial
problems include strabismus, myopia, and astigmatism.
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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 one eye also frequently do not voice complaints,
even if specifically questioned. They function well with the vision
in the normal eye and usually ignore the eye with the problem. This
ability ...