PEDIATRIK

OPTOMETRY

TOPIC 3: VISUAL ACUITY

MEASUREMENT IN
PEDIATRIC POPULATION

Ms Prema Muthiah
BOptom (Hons), MHSc (Clinical Optom)
ukrida.ac.id
TOPIC 3: VISUAL ACUITY MEASUREMENT IN PEDIATRIC
POPULATION

LEARNING OUTCOMES:
1. To be able to understand different types of test
chart for different age groups
2. Able to rule out the advantages and
disadvantages of each chart
TOPIC 3: VISUAL ACUITY MEASUREMENT IN PEDIATRIC
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Visual Acuity

• It is the resolving power of the eye.

• it is an ability to see two separate objects separately.
• It is determined by the smallest retinal image which can be
appreciated at certain distance.
• Standardized chart distance for VA for Adult is 6m/20 feet but it
may varied in case for children.
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Visual acuity in infant

• Visual acuity, in preverbal infants(who cannot speak) is

defined as
a motor or sensory responses to a threshold stimulus of known
size at known distance.

• In preliterate but verbal children , VA is defined as

the smallest target of known size at known testing distance
correctly verbally identified by a child
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Why to record visual acuity in

children?
1. To know if the visual development is normal.
2. Most of the eye problems can be treated if detected early.
3. Helps to decide eligibility for low vision and rehabilitation
services
4. Useful in decision making.
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Factors to be consider while assessing VA

in infants
1. A child should be aware & responsive to the surroundings & situations.
2. In both normal and visually at-risk infants, improvement in vision on time
depends on both the assessment technique used and the aspect of vision that
is being assessed.
3. Visual development during infancy is highly plastic and can be interrupted
or modified by either external or internal environmental
factors(physiological factors).
4. Examination early in the morning or after an infant's nap is usually most
effective.
5. Infants are more cooperative and alert when feeding, it is also helpful to
suggest that the parent bring a bottle for the child.
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PEDIATRIC POPULATION: AGE GROUP

CATEGORIES
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How Actually a baby sees a real world?

1. New born Can Fix a light source

2. 1 Months = able to focus on objects 3 feet away & face in front.
3. 2 Months = eyes become more coordinated
4. 3 months = start to reach for objects
5. 5- 6 months= can perceive color spectrum
6. 11- 12 months = fully develop VA like adults
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Remember:

• In infants we use resolution acuity rather than recognition

acuity.
• Resolution acuity underestimate some visual deficits like
amblyopia although it is still the best method for assessing an
infant child’s visual capabilities.
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Different types of VA Assessments in infants

1. Opto kinetic nystagmus test

2. Preferential looking test
3. Cardiff acuity card test
4. Visually evoked response
5. Catford drum test
6. Indirect assessment of visual acuity
7. Hundred & thousand sweet test.
8. Lea paddle
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1. Optokinetic Nystagmus Test

• OKN drum has been proposed as a method of measuring visual acuity in pediatric
population
• In this test, nystagmus is elicited by passing a succession of black & white stripes through
the patient’s field of vision.
• Procedure:
1. Striped patterns are presented on a rotating drum at 40cm.
2. The drum is moved in one direction in front of the patient.
3. The drum should be rotated 1 revolution per 2-3 sec.
4. If the striped pattern is visible, the patients eyes will make ‘Rail road Nystagmus’ eye
movements as they follow the movement of the stripes.
5. This gives the evidence of vision in child.
6. Rotating OKN drum Induced pendular nystagmus
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2. Preferential Looking Test

• Used to assess VA in infants & young children who are unable to identify pictures or
letters.
• The child is presented with two stimulus field.
• One with stripes and the other with a homogenous gray area of the same average
luminance as stripes randomly alternated
• Typically, infants and children will look at the more interesting stripes
• A small peephole is centered between the two fields, for observer.
• Observer judges the location of the strips based on the child’s head & eye movements.
• If the child can see the stripes, he/she will prefer to look them.
• If the child can’t see them, the child will not show a preference.
• Visual acuity determined with this method
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Cardiff Acuity Test

1. Good for slightly older children
2. They are held in front of the child
3. Each card has a picture in the upper or the lower
part of the card
4. The examiner simply observes the children’s
fixation.
5. The target are pictures drawn with a white band
bordered by two black bands , all on a neutral
grey background.
6. The average brightness of the picture is equal to
that of the grey background
7. If the child's vision is good enough to resolve the
white and black bands, the picture will be visible
8. If the child vision is poor, then, the bands are too
narrow for child to resolve them, the picture
merges with the grey background, and simply
becomes invisible. ( Like vanishing optotypes)
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4. Visually Evoked Potential

1. It is a electro-encephalo graphic recording made from the
occipital lobe in response to visual acuity.
2. It is the only clinically objective technique available to assess
the functional state of the visual system beyond the retinal
ganglion cells.
3. It is quite useful in assessing visual function in infants.
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5. Indirect assessment of visual acuity

1. Blink reflex in response to sound.

2. Menace reflex i.e; closure of the eyes on the approach

of an object if vision is normal.

3. Cry when the room light switched off suddenly

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5. Indirect assessment of visual acuity

4. Binocular fixation preference
• Behaviour evidence of decreased vision in right eye.
• The examiner covers the right eye to monitor fixation of the left eye.
• The child fixates on the toy without objecting.
• When the left eye is covered, the child objects & tries to move the
examiner’s hand.
• When the right eye is covered, the child does not object & tracks the object
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5. Indirect assessment of visual acuity

6. CSM Method
• ‘C’ refers to the location of corneal light reflex fixates the examiner light
at monocular conditions.
• ‘S’ refers to the Steadiness of fixation at examiners light and also as it
slowly moved about.
• ‘M’ refers to the ability of the patient to Maintain alignment first with
one eye then the other as the opposite eye is uncovered.

• Procedure:
1. Done with one eye fixating on an accommodative target held at 40 cm
2. Normally reflected light from cornea in near the centre of cornea and it
should be positioned symmetrically in both eyes.
3. If fixation target is viewed eccentrically, fixation is termed uncentral.
4. Record as:
• CSM :– 6/9 – 6/6
• CSNM: – 6/36 – 6/60
• Unsteady central fixation < 6/60.
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6. Hundred & Thousand

Beads Test
1. If child able to pick up small sweets at 33 cm, visual acuity is
at least 6/24 or 20/80.
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VISUAL ACUITY ASSESSMENT IN TODDLERS & PRESCHOOLERS

1. Cardiff acuity card

2. Lea symbols
3. Kay Pictures
4. Allen Cards
5. Sheridan Gardiner
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1. Cardiff Acuity card

• The test combines the principles of preferential looking and
vanishing optotypes.
• designed to measure acuity in toddlers aged 1-3 years and in
individuals with intellectual impairment.
• uses pictures that will interest a child (house, car, duck etc.)
positioned either at the top or at the bottom of an otherwise
grey card.
• There are eleven VA levels, with three cards at each level.
• Performed at 50 cm & 1m.
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2. Lea symbols
• For screening children ages 2 1/2 to 4
• Advantages of optotypes and pictures and standardised
• Use three symbols, a house, an apple, and a square, differing in few
critical details from the fourth symbol, which is a circle.
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3. Kay Pictures
• 18 months, and commonly by 24 months.
• Quick, easy and accurate
• All the acuity sizes are together in one book and there is a
choice of three or four pictures at each acuity size.
• This variety keeps a child interested during the test and
allows a different selection to be shown when testing each
eye in turn.
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4. Allen Cards
• The Allen card test consists of 4 flash cards
containing 7 schematic figures: a truck,
house, birthday cake, bear, telephone,
horse, and tree.
• When viewed at 20 feet, these figures
represent 20/30 vision.
• It is important that a child identify verbally
or by matching all 7 pictures before actual
visual testing.
• Testing should only be performed with the
figures that the child readily identified.
• Perform testing with viewing the cards at
2 to 3 feet away.
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5. Sheridan-Gardiner test
• Suitable for children aged 2 to 7 years.
• Consists of a set of cards with range of sizes of letters in the set
• Each marked with a single letter of specific size
• Cards are shown one-at-a-time to the child who is located a
specific distance away (50cm,1m & 3m)
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6. HOTV Chart
• Preschool to 1st grade (6 years old).
• VA is screened at a distance of 10 feet using the symbols
HOTV.
• The child need not know these symbols, but must be able to
match the indicated symbols on a wall chart with those on
the response card.

OPTOZC 231 26
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VISUAL ACUITY ASSESSMENT IN SCHOOL CHILDREN

1. Snellan Chart
• Recognition and resolution acuity
• Testing distance : 3/6 meters
• Subjective method
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2. Illiterate E chart/ Tumbling

• E chart
Useful for testing patients that are illiterate or mute.
• Tumbling "e" charts are considered highly reliable and are second
only to landolt "c" tests.
• Use only one optotype positioned differently and are useful for
testing several types of patients.
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3. Landolt "C" test

• Useful for testing patients that are illiterate or mute
• Use only one optotype positioned differently and are useful for testing
several types of patients
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THINGS TO REMEMBER DURING PEDIATRIC VISUAL ACUITY ASSESSMENT

1. Environment must be child friendly.

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THINGS TO REMEMBER DURING PEDIATRIC VISUAL ACUITY ASSESSMENT

2. It is best to access VA with child in lap of

parents.
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THINGS TO REMEMBER DURING PEDIATRIC VISUAL ACUITY ASSESSMENT

3. Examiner must always try to gain child's attention either

by singing rhymes, whistling or with toys etc.
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THINGS TO REMEMBER DURING PEDIATRIC VISUAL ACUITY ASSESSMENT

4. Child may peep through finger may press

eye with palm
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THINGS TO REMEMBER DURING PEDIATRIC VISUAL ACUITY ASSESSMENT

5. It is best to encourage the child during the procedure by

saying good ,excellent or with certain rewards like
candy.
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Challenges in paediatric VA
assessment
1. Uncooperative child
2. Child with syndromes or with delayed developmental
milestones
3. Child who is dumb/deaf/blind/communication barrier
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Summary
1. Any task with pediatric population is always challenging &
critical.
2. Examiner must have enough calmness and patience
3. Must choose appropriate method for each age group.
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References:
1. Jerome Rosner & Joy Rosner. Pediatric Optometry (1990)
2. Leonard J Press, Bruce D. Moore (1993) Clinical Pediatric Optometry.
3. Harvey W. & Gilmartin B. Pediatric Optometry (2004)
4. Theodore P. Grosvenor. Primary Care Optometry (2007).
5. Optometry: Science, Techniques and Clinical Management by Mark
Rosenfield & Nicola Logan
6. Primary Care Optometry by Theodore Grosvenor
7. Clinical Procedures in Primary Eye Care by David B. Elliott
Thank You
ukrida.ac.id