Four Stages of Screening

The AAO and AAPOS recommend that children be examined for eye problems in the following four stages (Table 41-4):

1. In the newborn nursery, physicians should examine all infants. Ophthalmologists should be consulted to examine patients at high risk for conditions such as retinopa-thy of prematurity (ROP), cataracts, congenital defects, and other ocular pathology.

2. At 6 months

4. At 5 years and older

The AAO statement recommends that family physicians establish a close working relationship with a local ophthalmologist who is familiar with children's eye problems. The collaboration can help clarify questions about vision screening and the need for referral. (See online content for specific information on different stages of vision screening.)

Also, special groups may need additional vision screening. The following children should also be screened, even if they are not due to be examined by their age: all children

Table 41-4 Recommended Vision Screening by Family Physicians



Referral Criteria


Penlight examination of cornea

Rule out nystagmus Red reflexes

Any ocular pathology Nystagmus

Abnormal red reflexes or white reflex

6 months

Fixation to light and small toys

Penlight examination Corneal light reflex test, cover test Red reflexes

Object to occlusion Nystagmus; any ocular pathology Strabismus

Abnormal red reflexes or white reflex

3 years

Visual acuity: Snellen letters, tumbling E, or HOTV wall chart

Corneal light reflex test, cover test

Fundus examination

Acuity of 20/40 or less in one or both eyes Strabismus Any ocular pathology

25 years

Visual acuity: Snellen letter, tumbling E, or HOTV (see online text) Corneal light reflex test, cover test

Fundus examination

Acuity of 20/30 or less in one or both eyes Strabismus Any ocular pathology

at high risk of having vision disorders, including those who are mentally retarded or who have trisomy 21 or cerebral palsy; and all children who show signs or symptoms of visual problems, experience school failure, or have reading difficulties or other learning problems (e.g., dyslexia). It is important to note that children with learning disabilities such as dyslexia have the same incidence of ocular abnormalities (strabismus, refractive error) as children without such disabilities. Dyslexia involves interpretation by cortical processing centers and does not generally indicate any ocular pathology. Eye defects do not cause letter, number, or word reversal.

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