Visual acuity in children aged 1 to 3 years is assessed by their ability to identify brightly colored objects and to circumnavigate the examining room. Routine visual acuity testing should begin when the child is about 4 years of age, with an appropriate Snellen eye chart. Pediatric eye charts use pictures or the ''illiterate E.'' Average visual acuity for a 3-year-old child is 20/40;at age 4 to 5 years, it is 20/30.

Confrontation visual field testing is performed only in children older than 4 years of age in whom there is a suspicion of decreased acuity or an intracranial mass. The test is conducted as in adults, except that a small toy is used instead of finger counting. The toy is brought in from the periphery of the child's vision, and the child is instructed to tell the examiner when he or she sees it.

Check ocular motility. Are the eyes straight? Be aware that a child with large epicanthal folds that partially cover the globe may be thought to have strabismus. The eyes should be parallel in all fields of gaze. Shine a light from 2 feet (61 cm) away, and have the child look at it. The light should fall in the center of both pupils. Hold the patient's head, and turn it to the right and then to the left while the position of the light is maintained. Is the corneal reflection symmetric in both eyes as the head is turned? If there is asymmetry, perform the cover test as described in Chapter 10, The Eye.

Is the conjunctiva red? One of the most common eye problems in this age group is red eye. The causes are numerous and include conjunctivitis, obstruction of the nasolacrimal duct, chalazion, local trauma, allergy, and toxin exposure.

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