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College of Optometry Theses, Dissertations and Capstone Projects

5-1998

A manual of pediatric optometry presented in English and French

Jacquelyn M. Delplanche
Pacific University

Recommended Citation
Delplanche, Jacquelyn M., "A manual of pediatric optometry presented in English and French" (1998).
College of Optometry. 104.
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A manual of pediatric optometry presented in English and French

Abstract
This project consists of a manual of pediatric optometry presented in both English and French. This
manual originated as a course outline in Pediatric Optometry taught at l'University d'Optometrie. It was
written for both instructor and student to serve as a general outline for performing examinations on the
pediatric population. This manual was written with the assumption that the reader already knows how to
perform these optometric tests on the adult population, and is now interested in applying this knowledge
to the pediatric population of five years old and under. This manual addresses the additional questions
involved with a pediatric case history. It gives variations on entrance skills testing including age-
appropriate binocular tests. The examination section describes a wide range of visual acuity tests,
refraction and the ocular health check. Finally, flow charts address treatment suggestions for various
diagnoses. This manual is presented in both English and French to serve a multicultural population.

Degree Type
Thesis

Degree Name
Master of Science in Vision Science

Committee Chair
Willard Bleything

Subject Categories
Optometry

This thesis is available at CommonKnowledge: https://commons.pacificu.edu/opt/104

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 A Manual Of Pediatric Optometry
Presented In
English And French

PRESENTED BY:

Jacquelyn M. Delplanche, O.D.

In partial fulfillment for the Master of Education

Visual Function in Learning
at Pacific University

May 1998

TTEE MEMBERS:
J

. r. · ·fllard Bleythjng
J
Pr6f.e · sor of Optometry

l iC~cd:C l if:nC:k'.,__,_;_,
Dr. . ta McClain
Coordinator, M.Ed.VFL Program
j ~~.;ClHG UN\VERSn~ .UBRAu~'
,·-1 q~,: ~T GROVE, OREGON
JJ ~ ~ ~~" U l -

1
 TABLE OF CONTENTS

Page

ABSTRACT ........ .................... .......................................................................... 1

INTRODUCTION ................ .. ...................................................... ........ ............ 2
CASE HIS'I'ORY ........ ...................................................................................... 3
Family History ...... ... ... ... .. ...... .......... ..................................................... 3
Du1·ing Pregnancy ........................ ... ...... ....................... .... ... .......... ........ 3
During Delive1·y ..................................................................................... 3
Development of the Child ..................................................................... 4
Visual Problems ...... ............... ....... ............................ .. ...... .................... 4
ENTRANCE TESTS ........ ~ ............................................................................... 5
Tracking ...... ........... .... ·:· .................................................. .... .................. 5
Nearpoint of Conve1·gence ...... .. .... ...... ........ .. ........................................ 5
Reaction To Sound ............................... ...... ..................... ............ .. ........ 6
Cover Test .. .......... ..... ............................... .............................................. 6
IIirscl1bei·g .. .. .................... ....................... .............................................. 7
Stereopsis 'I,ests ..... ... .................. .......... ................................. .. .............. 7
1. The Lang Stereotest ............................................................... 7
2. Titmus Stereotest ............ ...................................... .. ............... 8
3. Ran dot Stereotest .................................. ........ ...... ...... ............. 9
4. F1'isby Stereotest ... ........... ............ .......................................... 9
Visual Field .. ... .... ..................... ... ... ....... ....... .. ...... ........... ... ................ ... 10
EXAlVIINATION ........ .. .. ............................................................ ....................... 11
Visual Acuity ................................... .. .................................................... 11
1. Newborn Babies ...................................................................... 12
A. Preferential Looking .................................................. 12
B. Pendular Eye Movements .......................................... 13
C. Bock Candy Bead Test ............................................... 14
2. Children Age Three ... .................... ................... ........ .............. 15
A. Ffooks Symbol Test .... ............ ........ ........... ............. .... 15
B. Allen Picture Card Test ............................................ . 16
C. New York Lighthouse Flashcard Test.. ..................... 17
3.Chilill·en Ages Four to Five ..................................................... 17
J A. Sjogren Hand Test.. .................................................... 18
B. Tumbling E Test.. ...... ..................... :........................... 19
C. Landolt C Test ................ ............................................ 19
D. Broken Wheel Test ..................................................... 19
Refraction ................................ .............................................................. 20
1. l{eratometry ............... .. ........................................................... 23
1
2. Retinoscopy ............. ........... .................. .............. ..... ................ 24
3. Monocular Estimate Method Retinoscopy ............................. 24
1 Ocular Health Examination ................................. ......... .......... ............. 26
I
l 1. IJupils ............ .. ....... .... .............................. .. ............ ..... ... ... .... .. 26
2. Direct Ophthalmoscopy .......................................................... 26
3. Intraocular Pressure ..................... ..... ......... ... .... .. ..... ............. 28
TREA'fMENT .. ... ................ ..... ... ......................... .............................. ... . 28
1. Myopia .... ................... ...... .. .. ......... ... ....... .... .... .. ... .... .. ....... .. .... 30
2. llyp eropia ...... .......... .............................. .. .................... ... ........ 31
3. Astigmatism ....... ...... ............. ..................................... ............. 32
. A.n isometropia ... .. .. ..... .......... .... .................. .... ............ .. .. .......... 33
REFERENCES ....... ... ........... .. ........... .... ......... .. .... ..... .... .. ...... ..... .. ... ...... 34
 ABSTRACT

This project consists of a manual of pediatric optometry presented in both

English and French. This manual originated as a course outline in Pediatric

Optometry taught at !'University d'Optometrie. It was written for both

instructor and student to serve as a general outline for performing

examinations on the pediatric population.

This manual was written with the assumption that the reader already knows

how to perform these optometric tests on the adult population, and is now

interested in applying this knowledge to the pediatric population of five years

old and under. This manual addresses the additional questions involved with

a pediatric case history. It gives variations on entrance skills testing

including age-appropriate binocular tests. The examination section describes

a wide range of visual acuity tests, refraction and the ocular health check.

Finally, flow charts address treatment suggestions for various diagnoses.

This manual is presented in both English and French to serve a

multicultural population.

1
 INTRODUCTION

This is a manual for a course in Pediatric Optometry. The idea to write this

manual came from my good friend Jean-Paul Roosen who is the Dean of

l'Universite d'Optometrie in Bures-Sur-Yvette, France. Several years ago I

was fortunate enough to work at l'Universite d'Optometrie teaching Pediatric

Optometry. This course was not a part of their normal curriculum. This

manual was written after the course was over to serve as a guideline for next

year's class. (I was unable to return to the school the following year.)

This manual was written to serve as a general outline for performing

examinations on the pediatric population. I chose specific tests to write about

based mainly on the availability of the testing materials at l'Universite

d'Optometrie. It is by no means a complete explanation of all tests, but a

practical version of a selected few. It was an incredible opportunity to work at

l'Universite d'Optometrie, but it was an even greater challenge to put my

words down on paper in the form of this manual. As I wrote it in French first,

translating it into English has been a wonderful learning experience.

2
 PEDIATRIC OPTOMETRY

CASE HISTORY

During this first part of the examination, ask the parents if they have noticed

any visual problems the child may have exhibited. Also, take a family

history. Inquire about the prenatal history, birth and the development of the

child.

Family History

- Are there any hereditary health problems in the family of both parents?

- Are there any hereditary visual problems in the family of both parents?

During Pregnancy

- Inquire about the age of the mother at the time of the birth.

- Did the mother use any medications?

- Was the mother exposed to any radiation during pregnancy?

During Delivery

- Was the baby premature?

-Was there a problem with a lack of oxygen at the time of birth?

-Was there a Cesarean section?

- Did the doctor use forceps?

3
- What was the duration of the labor?

Development of the Child

-How much did the baby weigh at birth?

- Has the development of the baby been on schedule?

- Have there been problems with multiple ear infections or other illnesses?

- Does the baby have any allergies?

- Have there been any injuries to the eyes or head?

Visual Problems

- Does the baby rub her eyes?

- Have the parents noticed an eye turning?

- If so, is there a pattern as to the time of day?

- Which direction does the eye turn?

- How does the demeanor of the child change when the eye is turned?

Strabismus, an eye that turns, is the most common reason for parents to

bring their baby to an Optometrist. However, the epicanthal fold can create

the illusion that an eye is crossing and parents may mistake this for an

actual strabismus. As a general rule, most newborns will achieve alignment

of the eyes by about four weeks after birth.

4
 ENTRANCE TESTS

Usually visual acuities are the first part of the examination after the history.

However, for babies, this is not the case. In attempting to cover an eye during

visual acuity testing the baby may very well cry, thereby making the rest of

the examination very difficult. Therefore, it is better to wait until after

binocular testing to check visual acuity.

I. TRACKING

Tracking should be done with an eye-catching toy presented between 12-16".

-Perform the "H" test: move the toy slowly tracing an "H" in front of the

child.

- Complete rotations should be done both clockwise and counter-clockwise.

During the test, it is normal for the infant to move her head. Therefore, it is

necessary to hold the baby's head still.

II. NEARPOINT OF CONVERGENCE (NPC)

Perform the NPC on a baby the same as you would on an adult, using a small

toy or penlight instead. Starting at 16", slowly approach the baby's nose and

watch for a break in binocularity noted by an eye deviating out. If using a

penlight the corneal reflex will be a good indicator of the deviating eye. There

5
are two thresholds with NPC: objective and subjective.l Threshold is recorded

as the distance between the fixation target and the patient. Subjective is

represented by the child's response to a "doubling'' of the target. Objective

means the examiner observes an eye that deviates out at some point during

the test.

III. REACTION TO SOUND

Try to test whether the infant will react visually to sound. Use a small bell in

the nine positions of gaze. Ring the bell and watch the baby turn her eyes to

find the bell. This test is also helpful in assessing r·ange of motilities.

IV. COVER TEST

In general, the unilateral cover test is used to detect strabismus. An

alternate cover test is used to discover a heterophoria and to measure the

magnitude of a strabismus after one is detected.2

Use a penlight or a small toy. With infants less than two years old, the cover

test may be challenging, as it is difficult to keep the baby fixated long enough

to perform the test. Generally, infants do not like to have their eyes covered

completely. With that in mind it is better to do cover test with your thumb

instead of an occluder. 3 As the baby is looking at the light, cover the right eye

watching for a movement of the left eye. Repeat the unilateral cover test with

6
 the left eye as well. Next, alternately cover each eye watching for large

esophoric or exophoric deviations

V. HIRSCHBERG

It is necessary to be seated directly in front of the baby. Hold a pen light so

that it is shining centrally on the baby's face. Observe the corneal reflections

to see if they are equal and symmetrically positioned fairly close to the center

of each pupil. If one of the reflexes is displaced laterally, a misalignment of

the eyes may be noted. Each millimeter of decentration corresponds to 14-22

prism diopters of strabismus. 4

VI. STEREOPSIS TESTS

1. The Lang Stereotest: (6 months)

The Lang Stereotest 5 is a good test for infants because it is one of the only

Stereotest that does not require Polaroid glasses or redlgreen filters. Place

the card directly in front of the baby at 16 inches. If the baby has stereopsis

she will be able to recognize the cat, the star and the car and look at their

respective positions on the card. The examiner may even ask the baby to

touch each object. If the baby reaches for a target in the correct position, that
I
is a confirmed positive test. However, if the baby fails to reach for the targets,

1 you may watch for fixation of gaze on the target as well. To further verify if

1
7
 indeed the baby has seen the objects, turn the card vertically. The baby

should then lose fixation of the objects.

2. Titmus Stereotest: (2 years)

Figure 1

The Titmus Stereotest consists of a stereogram and Polaroid glasses. If the

child sees a large fly that "floats" off the page she has at least gross

binocularity. Ask her to pinch the fly's wings. A child with the capacity for at

least gross stereopsis will grasp for the fly's wings about an inch from the
I book.s It is possible to repeat the test turning the book up side down. In this

I case the wings will appear to sink into the page and the child will push on

the page in an attempt to touch the wings. At 16 inches, the fly represents a
I disparity of 3,000 seconds of arc. As this test demands good motor control, a

1 negative result should be determined after careful consideration as bifoveal

I fixation is not necessary. With the Titmus Stereotest, it is possible to check

8
fine ste1·eopsis as well: the animals and the circles are a good test for children

at approximately 4 years of age. The animals represent 400 to 100 arc

seconds. The circles represent 800 to 40 arc seconds. 7

3. Randot Stereotest: (3 years)

The Randot8 test resembles the Titmus test except that instead of a fly it

utilizes geometric shapes randomly placed on the card. It is a contourless

design, meaning that the target is not outlined. It has been reported that this

test design is more difficult for some individuals. 9 The shape is represented

on a random dot background. Ask the child to identify the shape seen and

then point to it. This is also a gross test of stereopsis.

4. Frisby Stereotest: (3 years)

Like the Lang Stereotest, the Frisby Test does not require any spectacle

filters. 10• 11 The Frisby TestJ 2 consists of three cards. Each card must be

divided into quarters. In each quarter there is a circular form which will not

be seen if binocular vision is not present. The stereo acuity will depend on the

thickness of the card and the distance at which the test is performed.

Considering these two variables it is possible to have disparities ranging

from 15 to 600 arc seconds.

9
 Testing Thickness of the Card

Distance

Cm 6mm 3mm lrnm

Disparity
30 600 300 100
In
40 340 170 55

Arc 50 215 110 35

60 150 75 25
Seconds
70 110 55 20

80 85 40 15

Table 1

Begin the test with the 6-mm card at 40 em. Position the card to minimize

reflections on the card. Place a blank piece of white paper behind the card to

decrease confusion with objects behind the card. It is necessary to present

two cards, one that has the disparate circle in it and one that does not. Ask

the child to find which box has the ball in it.

Three positive responses are necessary for a successful test. If this occurs,

continue with the 3-mm card at 40 em. If this is again successful, test the

same card at 60 em. If the child is able to identify the circles continue on with

the 1-mm card at 40 em.

VISUAL FIELD

It is very difficult to test visual fieldS on children. You may need to use the

motor response of the child as a positive sign. If a stimulus is moved from a

10
zone out of the peripheral vision of the child into the zone of potential

peripheral vision, the child will have a tendency to turn her eyes or head to

look at the stimulus. It is necessary to perform multiple trials to obtain a

valid measurement.

If one is unable to find an object that will grab the child's interest when seen

in the periphery, use the movement of your fingers back and forth quickly.

When the child first sees the movement they will turn their eyes to see it.

It may be necessary to enlist the aid of a parent or a sibling to keep the

fixation of the child straight-ahead during the test. At that moment present

the stimulus in the periphery.

EXAMINATION

VISUAL ACUITY

It is often very difficult to obtain a precise and consistent visual acuity with

infants. In newborns, forced choice resolution tests such as Teller

''Preferential Looking" are most amenable. Is Infants prefer to look at a

stimulus that is more interesting, such as black lines on a gray background,

as opposed to an empty gray field. It is prudent to try to obtain a visual

acuity with both eyes first. Attempting to cover or patch an eye will often

11
upset the child and may lead to crying. Refer to the table below taken from

Rosner 14 to reference visual acuity as a function of age when using

Preferential Looking.

Table 2. Changes in visual acuity as a function of age and measurement

method.

Age Tumbling Pendular OKN PL VEP

(Months) E Eye Movement s

1 20/300 20/400 20/300

2 20/150 20/300 20/200

3 20/150 20/200 20/60

4 20/150 20/200 20/50

5 20/60 20/150 20/40

6 20/400 20/20

12 20/140 20/200 20/40

24 20/48 20/100 20/30

36 20/46 20/50 20/20

48 20/40

60 20/33

1. Newborn Babies

A. Preferential Looking

The clinical method of choice for evaluating visual acuity in babies is Forced

Choice Preferential Looking.15 One reliable example, the Teller Acuity Cards

has published normative values for use in the clinical setting. 16 • 17 Preferential

Looking should be presented as a game to the baby. On one side of each

12
rectangular Teller Acuity Card is an imprint of a network of black lines on a

gray background. Each card has a different resolution of lines corresponding

to a given visual acuity. The cards have a small hole in the center where an

observer can peer through to watch the infant's response. This test is

performed at 16 inches. Begin by presenting to the infant the card with the

largest resolution of lines. Looking through the hole, the Optometrist

watches to see on which side of the card the baby prefers to look. If the baby

looks at the lines, the Optometrist should turn the card and 1·epeat the trial.

If the infant is successful on two or three rotations of the card, continue on to

a card with a smaller resolution of lines until no response is seen. The

infant's visual acuity is then noted by the last correct response.

B. Pendular Eye Movements

1. Catford Vision Testing Apparatus

2. Optokinetic Nystagmus (OKN)

Goldmann 1s proposed that it would be possible to measure visual acuity by

presenting oscillating stimuli of different sizes and watching the eye

movements of the infant. These movements a1·e a physiological ocular

nystagmus which is induced by attempting to fixate on the lines that are

quickly traversing the visual field.I9

As long as the infant is able to see the lines, a pendular movement of the

baby's eyes would be seen. Begin with the rotating drum about 15 inches

13
from the infant. When pendular movements of the infant's eyes are noticed,

the testing distance of the drum should be gradually increased. Determine

the distance at which the pendular eye movements cease. Continue the test

using smaller and smaller stimuli until no pendular movements are seen.

The size of the stripe width combined with the furthest distance the response

was present is used to calculate the visual angle. This may then be converted

to standard Snellen acuity.2o

C. Bock Candy Bead Test

Figure 2

The Bock Candy Bead Test2 1 is appropriate for children as young as one year

old. Give the child a taste of the candy by guiding her hand to a bead and

allowing her to eat it. Start with the 1-mm stimulus in the palm of the

14
examiner's hand. If the child sees the bead she will be able to repeat the trial

successfully. Do the test with both eyes initially, and then continue by

attempting a monocular trial. Unfortunately, some studies show that actual

visual acuity equivalent is only about 20/200. Other studies report that it is

inappropriate to view test outcomes as analogous to Snellen letter test

responses. 22

2. Children Age Three

A. Ffooks Symbol Test

The Ffooks Symbol Test23 is easier for children to comprehend than the

Snellen and Directional E tests. This test utilizes cards with figures of

familiar geometric shapes of differing sizes.

To administer the test, show the three-year-old child a Ffooks card at the

standardized testing distance of 30 feet and ask her to name the picture.

If she correctly names the picture her Ffooks acuity is noted as 30/30.

Record visual acuities in fractions using 30 as the denominator. Using

simple ratios this can be translated to a Snellen visual acuity of 20/20.

If she does not respond verbally, give her one picture of each shape. Next,

ask her to choose the same picture that you are holding. If she still does

not respond, move closer to decrease the visual demand. However, in this

case one must recalculate the visual acuity based on the distance that the

15
card was last shown. If the child was able to identify the pictures at 15

feet, her Ffooks visual acuity is 15/30. This translates to a Snellen visual

acuity of 20/40.

B. Allen Picture Card Test

~· l·
o. r
I
1
-- ~· ~-~

Figure 3

The Allen Picture Card Test 24 consists of seven pictures of the familiar

objects shown on the previous page. This test closely resembles the Ffooks

Test, but it is slightly more difficult. Administration of the test is done in

the same manner as that of the Ffooks Test.

16
 C. New York Lighthouse Flashcard Test

Figure 4

Originally, this test was designed for children with low vision. 25. 26 It is

easier than the Allen Picture Card Test. Administration of this test is also

the same as the Ffooks Test except that the New York Lighthouse

Flashcards are designed to be performed at a fixed distance.

3. Children Ages Four to Five

A. Sjogren Hand Test

Figure 5

17
The Sjogren Hand Test27 is similar to the more familiar Tumbling E Test

except that it uses a picture of a hand instead of an E. The child need only

to copy the direction that the fingers of the hand are pointing (for

example: up, down, left or right). The main problem with this test is that

the palm of the hand is larger and helps the patient identify the direction

more easily. For this reason, the Tumbling E Test is preferred.

B. Tumbling E Test

This is the most commonly used test for preschool children. 2s The letter E

is presented in the four positions. The child must identify if the E is

pointing up, down, left or right. The final acuity measurement is

equivalent to the Snellen Acuity.

To begin the test, give the child a card with an E printed on it, or even

better a plastic E. Ask the child to hold it the same way as the shown on

the test chart. Continue to present smaller E's in varying positions until

the child is no longer able to answer correctly. Begin this test

monocularily for each eye, then repeat it with both eyes.

Unfortunately the Tumbling E Test requires a more sophisticated

understanding of spatial orientation. A child who hasn't fully developed

spatial orientation may be especially confused on right and left

18
presentations of the E. If this is the case, an inaccurate result may occur

and it would be better to use the Broken Wheel test.

C. Landolt C Test

The Landolt C Test29 is very similar to the Tumbling E Test. Instead of an

E the letter C is used. The Landolt C Test is more difficult for children to

understand. The results are very similar to the Tumbling E Test.

D. Broken Wheel Test

~
~
Figure 6

The Broken Wheel Acuity Test consists of seven pairs of 5x7-inch cards.

Each card has a picture of a car. In each pair of cards, one car has "broken

wheels" as shown above. Both cards are presented to the child at 10 feet.

If the child chooses the ''broken wheel" card four times in a row, continue

the trial by presenting another pair of cards with a smaller stimuli. so The

Broken Wheel cards range in size from 20/100 to 20/20.

19
 REFRACTION

The technique used to perform a refraction on a child is very different than

that of an adult. The technique varies depending on the age of the child.

Between the ages of 0 and 2 years it is very difficult to obtain a visual acuity.

The prescription is based solely on retinoscopy. Virtually all reports indicate

that infants, born full term and in good health are usually hyperopic. Banks 31

combined information from 11 reports using data obtained from 3057

children. He calculated a range of mean from +0.60D to +2.60D. Therefore,

any amount between plano and +3.00 diopters would be considered in the

normal range. Banks also noted that an infant weighing less than 5.5 pounds

at birth, or born prematurely will usually have less hyperopia. In fact, it is

very likely that these infants will become myopic. Howland observed that

astigmatism is common in children one year old or less but it tends to

diminish with age. s2

Between the ages of two and five it is possible to obtain a more reliable visual

acuity but it is still difficult to do a subjective refraction so a prescription for

glasses would still be based predominantly on retinoscopy. Ingram and Barr

report that a child of this age would still present as a low hyperope,

approximately +0.50 diopters.ss

20
 Mter five years of age, cooperation on the part of the child is generally

sufficient to measure visual acuity and obtain a subjective refraction in the

same fashion as you would with an adult.

Grosvenor and Hirsch,34 in summarizing data from several studies concluded:

If a child is myopic between ages five and six, the myopia is most likely

permanent and will almost certainly increase.

If a child has greater than + 1.50 diopters of hyperopia between the

ages of five and six, it is likely that she will remain hyperopic at least

until age of 13-14. Then the hyperopia is likely to decrease.

If a child is refracted between + 1.25 and +0.50 at the ages of five and
j
I six, the chances are very good that she will become an emmetrope at
I
the age of 13-14.
I
I If a child is refracted between plano and +0.50 diopters at the ages of

!II five and six, there is a great chance that she will become myopic by the

I age of 13-14. The probability is even greater ifther·e is an against the

I
! rule astigmatism present.
II

I Rosnera5 discusses a classic case of significant hyperopia (greater than 3D)

and acquired accommodative esotropia. The case illustrates the effects of

uncorrected hyperopia and how it can lead to an accommodative esotropia

by about age two. At this age, the child has been introduced to an

increased amount of nearpoint activities and therefore an accommodative

21
esotropia is manifested.36 .In this case the optometrist should perform a

cycloplegic refraction and prescribe lenses, usually with a bifocal, to

attempt to establish clarity and binocular alignment both far and near.

Vision therapy may also be introduced as soon as the child is old enough

to cooperate.

There is some debate as to the methodology of prescribing the best Rx.

The classical school of thought favors full plus power and continues to

monitor the child for any increase in plus.s7 However, the theory of

emmetropization plays a role in modifying the lens power prescribed. 38 As

the hyperopic child seeks less hyperopia over time the final prescription

should be a compromise between a lens power· that allows alignment and

still permits the emmetropization process to continue. If this is not

possible, the more classic strategy should be adopted. s9

Bifocal power may vary depending on the amount of plus needed to

achieve binocularity at near. Ideally, the bifocal power should be the

maximum amount of plus tolerable to achieve alignment and clarity. It is

not uncommon to go beyond the traditional +2.50 maximum and prescribe

even as high as +3.00 for the child's bifocal power.

22
A. Keratometry

Figure 7

Some optometrist use keratometry to evaluate corneal astigmatism. The

examiner simply studies the reflection of the rings on the cornea to

determine if the child has a significant amount of astigmatism. Neatly

circular ring indicate a spherical cornea while distorted or oval rings

signal corneal toricity. 4o The advantage is that the keratoscope is hand

held, though less accurate, thus the patient does not need to maintain the

posture required by the instrument. This is ideal when testing the infant

population.

The keratoscope can indicate increasing corneal astigmatism or serve to

detect any irregularities in the cornea. It may be useful in children ages

three and greater.

23
B. Retinoscopy

With children it is necessary to perform retinoscopy rapidly, as the child's

attention is limited. 41 In addition, there is the problem of the child's

accommodative system rapidly changing during retinoscopy. It is difficult

to perform retinoscopy with very young children. It may be necessary to

enlist the aid of the mother, another child or some other person who is

able to attract the child's attention far away with a large toy or puppet.

Retinoscopy is more easily performed on pre-school age children. It is wise

to give the patient an interesting fixation target that is large enough for

her to see easily. This target should be something that she can easily

recognize and name. It is ideal if the examiner is able to ask the child

simple questions about the target to insure fixation. The target should be

at 20 feet.

C. Monocular Estimate Method (MEM) Retinoscopy

Figure 8

24
The purpose of :MEM is to discover whether the accommodative response is

equal to the accommodative stimulus. The goal is to observe the spontaneous

accommodative response of the child looking at a target presented at the

child's habitual working distance.42

The fixation target is a white card with a hole in the center. Around the hole

are letters, or symbols, depending on the age of the patient. This card is

attached to the front of the retinoscope. Position the child, as they would be

sitting during a near task. The child should be wearing their habitual

glasses. The examiner should be slightly lower than the patient's normal

downward gaze. Ask the child to call out the letters/symbols around the hole.

At this time the examiner, shining the retinoscope beam through the hole,

estimates the state of accommodation by judging the amount of "with" or

"against" motion seen from the reflex. The examiner then estimates the other

eye. Choose the lens that would neutralize each estimation. Quickly place

that respective lens before the child's eye and check for a neutral response.

The estimation should be done quickly so as not to alter the child's

accommodation.

The normal result is a lag of accommodation between +0.50 and +0. 75

diopters. Reading glasses, roughly equal in power to the actual MEM

measurement, should be considered if the MEM demonstrates a lag larger

25
than+ 1.00 diopter. However, it is important to rule out latent hyperopia as

well as accommodative spasm.

OCULAR HEALTH EXAMINATION

I. PUPILS

The pupils of a neonate are normally small, equally round and reactive to

direct and indirect light. Slight variation in the size of the two pupils may be

considered normal if they constrict and dilate equally_ 43, 44

Observation of the pupillary reflexes is very important. Pupillary contraction

should not be less than 2-mm. Pupillary dilation should not be greater than

5-mm.

Shine the transilluminator at the pupil of the right eye and observe the

direct reflex of the right eye. Repeat this three times observing the

consensual reflex of the left eye as well. Repeat the same procedure with the

left eye.

2. DIRECT OPHTHALMOSCOPY

Ophthalmoscopy is an objective method to detect pathology of the eyes. This

procedure allows the examiner to observe the interior structures of the eyes.

To examine the right eye of the patient, the examiner should use her right

26
eye and right hand. To observe the left eye of the patient, the examiner

should use her left eye and her left hand.

In attempting ophthalmoscopy on newborn babies, the mother may hold the

baby in a horizontal position in her arms. Alternatively, it is best to have the

mother hold the baby over her shoulder. In this case the examiner should

position herself behind the mother. The infant may be more relaxed with a

bottle.

It is best to avoid touching the baby's face. Enlist the help of an assistant to

capture the infant's attention across the room. Do not hesitate to use age

appropriate toys in this endeavor.

Begin ophthalmoscopy at about 16 inches. Setting the ophthalmoscope at

zero, use the white filter at the smallest aperture setting. Compare the red

reflexes of the eyes. Approach the baby slowly at a slightly oblique angle (15

degrees) shining the light into the pupil. Ophthalmoscopy is very difficult to

perform on infants. Frequently infants may not want to cooperate with this

test. It is sufficient to note that the media is clear and the reflexes are red.

27
3. INTRAOCULAR PRESSURE (lOP)

The Goldman45 and Perkins methods of measuring lOP are very precise. One

other method is nearly as precise: the Ton open. 46 The advantage of the

Tonopen is that, like the Perkins method, it is portable. Pneumatic

tonometers are becoming more reliable for pressures less than 30 mmHg and

function better with pre-school children if the clinician works quickly.

lOP is very difficult to obtain with infants. Another method that is easier for

infants is the KEELER pulse-air. This portable tonometer does not touch the

eye of the baby. Finally, if one is still unable to obtain an lOP with these

more conventional methods, it is acceptable to do digital lOP. Ask the child to

close his eyes. Gently feel the eyes to check that they are not too firm and

that they are equal.

TREATMENT

It is important to clearly express to the patient (and their parents) the goal of

the treatment, and the improvements that you hope to achieve.

Many of the recommendations for the treatment of refractive errors reflect

the clinical experience and philosophy of the vision care professional rather

28
than the research. The most important questions to ask are why, when and

how much to prescribe.

The following pages are the recommendations for the treatment of refractive

errors such as myopia, hyperopia, astigmatism and anisometropia. 47

29
 THE TREATMENT OF MYOPIA

Ciirrec:
•d D, Correct at
>3D ar 1 year
n.o P.X any age
>1 0 at 3 years
..
i T
Amblyopia. Evaluate
nor a and treat
concern ;amblyopia
~

'
· Exo : :VII RX
Esc : consider
undercouecting

I
·C-iJ'I re<no'l'Q
3 1ne<ar

~
Full- orne
W'f!¥

l
Presc.-ibe Consieer
glasses CQOt3C[
un~l olC~r lenses
T
,.I
ln•rial
follow-up
at 1 month
I
T

Amblyopia or
Normal VA an<:
decreased
binoCJ\.a rit·t
binoa.:lari:y

Ahe r •n•lial ...I

ex.am. evalua:e Fie -eva lua;~
E.,.alua:e
at 2-J yea~s ba~d en
yearly
and at 5 years c;,itd·s .a<;;e

30
 THE TREAT!'vJENT OF HYPEROPIA

Minimal el1ect
cn behavior or
Observe
interest and
G .
Correc: ii
st.able
accommodation , per1orrnance
with near
activi;ies

Amblyopia Evalua:e
Nota and treat
con~ rn amblyo;:>ia

Sinoeulat
dydu~

Es.o: full RX
Exo: consiee--
undercorrecting

N gf\X;
FuU-time
(".On:inu~ to
wear
mQoitor

<5 D. prescribe
>5 D . consiC<;r
!;lasses only
=ntacl lenses
until older

IO. ItJUl
lollcw-u;>
at 1 rncn:..-.

.~ -- ··

Ar.er
l 1r.iii~l
exam. ev.Jll;L!:e
Ii
Normal VA af1C
binocul:>ri:y

I
Ar.>!:llyop<a o r
cecrease-c
binoOJ iar ny
I
..
.~: 2·· 3 )"t...' i.H:.i I Re -e valur..:e-
o: a~e one ~; ~.; b.ascc cr.
:rt?a:;s. ol a-;c ..J ch :J~·s a~~

31
 THE TREATMENT OF ASTIGMATISM

<1 .25 0 >1.25!)

prescribing
b<~sed on
c:-.ild" s a,;e

Yo..:r.~er than aoer lt\ao .age

o-;:e 1 ye:;;;(, 1 year. observe
:t:i"\.C.:ian net interest and
a conc:e cn pertormance

I
...
Amblyo;:>;'! .
no ~ a

~nc.ern·

<5o : >5o.
presc:-ibe consicer
slasses contact
until oleer lenses

1
FuH-tirne
wear. initial
1 oHow~p al
1 n1an[.'l

r__ _L _i
I "ocr,-..;1 v;.. I Ar.-.=:·.' op ia

AI:er "";;'-' I
y
am. ev<lh..;a:e

[
1 2-3 yo:us
old and ar 5
r··· E·-w:~.;:e I
year s o :d L_::_~·~---·-· --~

32
 THE TREATMENT OF ANISOMETROPIA

~ns : .:1~ : c 1--·------- .[_s....,:..,.-bl_e_ _..J

l
l
>l 0.
...
I <1

- - - ~---- - ~
0
I consider
=rrec1~

L
...--H-y-p;;op4~]
1-tyop4c or or
:an;imetropic
:astigmatic ,

r-
~
Younger th~n Older than
[ _ ' "" o• 4 years of ao;e 4 ye:ars. of .:11:;e

- T=-- =--
Moni10r and
evaluale
rifle -motor
coorCination

EvaiUdte
and uea t
amblyop<a and
binoc.luac
dysfunction
T

r .----__!+__--.
<50. >5 D.
prescr it.e consider
glasses contact
until older lenses
--~

'L--------~--------~ I

~--- ·
WI?Ut' . ir.i-:..:31
lollo·-·u::: .>1
1 mcnl"l

.
Amblyopi;, or
Normal VA and
c'e<rea~C'C
binocuf.;;11:y

------1
Af:t;"r in~:Jal
exam. ev~_dua:e
b.noculan!y

C
Ol 2-.J ·,e;Jn,
old unc:' .Jl ~
Eva lua :e 'e·evalu;:~:J
b..3~'-~ en
yea :1y
__?'~:! ' \ o ld cholc! "s a o;e
- -- -

33
 REFERENCES

1. Rosner, J, Rosner J. Pediatric Optometry. Stoneham, MA: Butterworth

Publishers, 1990 p.263.

2. Rosner, J, Rosner J. Pediatric Optometry. Stoneham, MA: Butterworth

Publishers, 1990 p.218.

3. Krumholtz I. Optometric examination & management of the infant-the

basics. J Behav Optom 1995; 6(2):39.

4. Griffin J. Binocular anomalies--procedures for vision therapy. Chicago:

Professional Press Inc., 1976: 14-16.

5. Lang J. A new stereotest. J Ped Ophthal & Strab 1983; 20(2):72.

6. Ciner EB. Examination procedures for infants and young childTen. J

Optom Vision Dev 1996; 27:61.

7. Hatch SW, Richman JE. Stereopsis testing without polaroid glasses: a

comparison study on five new stereoacuity tests. JAm Optom Assoc

1994; 65(9):639.

8. SuperS, Cronje S, Grobler D, Naude R. Stereoscopic vision testing. J

Behav Optom 1991; 2(4):94-95.

9. Simons K. A comparison of the Frisby, Random-DotE, TNO & Randot

Circles stereotests in screening and office use. Arch Ophthalmol1981;

99:446-452.

34
10.Hatch SW, Richman JE. Stereopsis testing without polaroid glasses: a

comparison study on five new stereoacuity tests. JAm Optom Assoc

1994; 65(9):638.

11.Manny RE, Martinez AT, Fern KD. Testing stereopsis in the preschool

child: is it clinically useful? J Pediatr Ophthalmol Strabismus 1991;

28:223-1.

12.Frisby P, Mein J, Saye A, Stanworth A. Use of random-dot stereograms in

the clinical assessment of strabismic patients. Br J Ophthal 1975; 59:545.

13.Fulton ABet al. A behavioral method for efficient screening of visual

acuity in young infants. II: clinical application. Inv Ophthal 1978;

17(12): 1151.

14.Rosner, J, Rosner J. Pediatric Optometry. Stoneham, MA: Butterworth

Publishers, 1990, p. 72.

15. Ciner EB. Examination procedures for infants and young children. J

Optom Vision Dev 1996; 27:55.

16.Salomao SR, Ventura DF. Large sample population age norms for visual

acuities obtained with Vistech-Teller Acuity Cards. Invest Ophthalmol

Visual Sci 1995; 36:657-670.

17.Mayer DL, Beiser AS, Warner AF, Pratt EM, Raye KN, Lang JM.

Monocular acuity norms for the Teller Acuity Cards between one month

and four years. Invest Ophthalmol Visual Sci 1995; 36:671-685.

35
18. Goldmann H. Objektive sehscharfenbestimming. Ophthalmologica 1943;

105:240.

19. Cline, Hofstetter H. Griffith J. Dictionary of visual science. Clinton

Publishing, 1989.

20.Krumholtz I. Optometric examination & management of the infant-the

basics. J Behav Optom 1995; 6(2):38-39.

21. Bock RH. Amblyopia detection in the practice of pediatrics. Arch Pediatr

1960; 17:335.

22.Richman JE, Garzia RP. The bead test: a critical appraisal. Am J Optom

& Phy Optics 1983; 60(3): 199-203.

23.Ffooks 0. Vision test for children. Br J Ophthal1965; 49:312.

24.Allen HF. A new picture series for preschool testing. Am J Ophthal1957;

44(1):38.

25.A flash card vision test for children. New York: Low Vision Lens Service,

N.Y. Assn. For the Blind, 1966.

26.Faye EE. A new visual acuity test for partially sighted non-readers. J Ped

Ophthal 1968; 5(4):210-212.

27. Sjogren H. A new series of test cards for determining visual acuity in

children. Acta Ophthal1939; 17:67.

28. Hatfield EM. Methods and standards for screening preschool children.

Sightsaving Rev Summer 1979:74.

29. Landolt A. Bull Soc Franc Ophthal 1888; 6:213.

36
I I
30.Richman JE, Petito GT, Cron MT. Broken wheel acuity test: a new and

valid test for preschool and exceptional children. JAm Optom Assoc 1984;

55(8):561-65.

31. Banks M. Infant refraction and accommodation. In: International

Ophthal. Clinics. Electrophysiology and psychophysics: the use in

ophthalmic diagnosis. Spring 1980; vol. 20, no. 1

32.Atkinson J, Braddock 0, French J. Infant astigmatism: its disappearance

with age. Vis Res 1980; 20:891.

33.Ingram RM, Barr A. Changes in refraction between the ages of 1 and 3 %

years. Br J Ophthal1979; 63:339.

34. Grosvenor TP. Primary care optometry: a clinical manual. Chicago:

Professional Press, 1982.

35.Rosner, J, Rosner J. Pediatric Optometry_,_ Stoneham, MA: Butterworth

Publishers, 1990, p.494-496.

36.Fitzgerald DE, Grunning CF. Vision Therapy for a preschool child with

acquired accommodative esotropia. J Behav Optom 1997; 8(3):59-61.

37.Parks :.Ml\:1. Management of acquired esotropia. Brit J Ophthal

1974;58:240-246.

38.Ingram RM, Arnold PE, Dally S, Lucas J. Emmetropization, squint, and

reduced visual acuity after treatment. Brit J Ophthal1991;75:414-416.

39.Fitzgerald DE , Grunning CF. Vision Therapy for a preschool child with

acquired accommodative esotropia. J Behav Optom 1997; 8(3):59-61.

37
 40.Krumholtz I. Optometric examination & management of the infant-the

basics. J Behav Optom 1995; 6(2):39.

41.Rosner, J, Rosner J. Pediatric Optometry. Stoneham, MA: Butterworth

Publishers, 1990 p.145.

42.Harmon DB. Notes on a dynamic theory of vision. 3rd. ed. Published

privately, 1958.

43 .Duke-Elder S . Systems of ophthalmology. Vol. III. St. Louis: Mosby, 1970.

44.Spooner JD. Ocular anatomy. London: Butterworth, 1957.

45 .Krumholtz I. Optometric examination & management of the infant-the

basics. J Behav Optom 1995; 6(2):40.

46. Ciner EB. Examination procedures for infants and young childl·en. J

Optom Vision Dev 1996; 27:65.

47. Turnbull DK. A Student's Introduction to Visual Science and Optometry.

38
j
 OPTOMETR!E PEDIATRIOUE

HISTOIRE DE CAS

Au cours de cette premi~re partie de l " examen on

interroge Jes parents sur le probl~me visuel qu'i Is pensent
avoir decel~ chez ! 'e nfant.
On interroge les parents sur les antecedents famil iaux.
sur Je d~roulement de la grossesse et de ]"accouchement
ainsi que sur la croiss a nce de ! ·· enfant.

Ant~c~dents famil iaux

- probl~me de sant~ h~r~ditaire dans la fami l le de l ' un ou
de ! 'aut re des parents
- probl~me visuel h~r~ditaire dans la fami lIe de l ' un ou de
! / autre des parents

D~roulement de Ia grossesse
- aoe de la m~re ~ Ia naissance
uti I isation de medicaments par la m~re
-exposition de Ia mere a des radiations

Deroulement de ] / accouchement
- ! / enfan t ~tait pr~matur~?
un probl~me d / oxyg~ne pendant ] / accouchement?
une c~sarienne?
Je medcin uti 1 ise des forceps?
la duree de ] ' accouchement?

Croissance de ! ·· enfant
combien ! ' enfant pesait-il ~ Ia naissance?
- le d~ v eloppement est normal?
aucun maiadies ou infections g~n~ral?
]'enfant a des allergies?
-des biessures a I 'oeil ou ~ Ia tete?

Probl~mes visu els

l " enf~nt se frotte les yeux?
- signes de strabisme?
- si oui. est-ce que les signes apparaissent a une heure
regu 1 i ~re?
- sens du strabisme
- 3ttitude de ! ' enfant qu6nd les signes apparaissent
 La strabisme est une raison frequente pour laquel le les
parents ammenent le ur enfant chez l . ·optometriste. Le pli
epicanthaire present chez !'enfant en bas age a tendance ~
tramper les parents qui l .. assimilent ~ un strablsme. En
r~gle g~nerale Ia plupart des nourrissons obti enne nt
l'a li gneme~t quatre semaines apr~s la na issance.

ETAT BINOCULAIRE

o ·· habitude: pour un examen, on dolt faire les acuites

immediatement apr~s J·"histoire de cas. En fait. chez
! ' enfant. on ne les fait qui apr~s les autres tests. parce
que . quand on essa i e de cacher un oe i 1 . 1e b~be peu t deven i r
malheureux. Dans ce cas l ' examen est fini! Done. i 1 vaut
mieux attendre I a fin des tests binoculaire. --

I MOTRICITE

Les tests de motricite se font avec un Jouet:

- le "H" test
- les rotations
Pendant les test. II est normal que l ' enfant bouge Ia
tete. Parfois il est necessaire de tenir la tete de ! - enfant
legerement.

II PUNCTUM PROXIMUM DE CONVERGENCE CPPC)

On fait le PPC pour les enfants comme pour les adultes.

Avec les enfants on peut uti l lser un tres petit joue t au
lieu d ' un stylo lampe.

III REACTION AUX SONS

On essaie de voir si ]'enfant reagit visuel lement au x

sons. On util lse une petite clochette dans les neufs
positions de regard.

IV LE I'1ASQUAGE

Pour le masquage on utilise un sty lo lampe ou un petit

.louet. Avec les enfants qui ant mois de 2 ans le masquage
est tres difficile ~ realiser parce que I 'e nfant ne fixe pas
bien au loin.
En general. les enfants n-'aiment pas d ' avoir les yeux
cach~s. Done. on dolt faire le masquage avec le pouce.

V LE TEST DE HIRSCHBERG

I , est necessaire d'etre assis directement en face de

·· enfant. Ensuite. on met un stylo lampe exactement dans le
plan median. On observe les r~flets corneens. s· ils sont
egaux et dans Ia m~ m e pos i tion pour chaque oeil:
l
VI DES TEST STEREOSCOPIOUES

1. Test Stereoscopioue de Lang: <6 mois)

LANG STEREOTEST Dist ance: 40 em

STAR
Di ~ parit y : 600"

CAT CAR
Disparity : 1200·· 'i:ri s parity : 550"

/\ It rig hts rc ::~rvcd Prof. Ot J oseph L8 ng

Fre ie5tr. 4 7
CH-80 32 Zlll ich
·--- ---·- -- - ·- - - - - - -- - - - -- ----'
C ' est un bon test car on n 'a pas besoin d~ filtres
polarises ni de fl ltres rouge / verts. II comprend un chat.
une etoi I le et une v oiture qui se proJeteront hors du plan
de Ia page si Ia vision blnoculaire e x iste. Ce test est tr~s
simple d'utll isation. On montre Ia carte~ !'enfant~ 40cm
et on lui demande de toucher les obJets. Chaque objet a une
disparite differente. Le but est que ! ' enfant attrape taus
les chases. Si !'enfant n / essaye pas de toucher des images.
on regarde bien si ! ' enfant les fixes. Si oui. on repete le
test en le tournant du haut v ers le bas. A ce moment lA.
! ' enfant devrait perdre la fi xat ion des obJets.

2. Titmus Stereotest: <2 ans)

FJGIJRE G.S . Tilrnu s stcreo test

Ce test consiste en des stereogrammes de contour. et

des fi ltres polarises. Il comprend une mouche geante qui se
1
proJetera hors du plan de Ia page ~i la vision binoculalre
exlste. Il sera demande a ! ' enfant de pincer les ailes de la
mouche. L / enfant normal pincera a environ deux-trois
centimetres de la page. II est possfble de repeter le test
en le tournant du haut vers le bas. Dans ce cgs les ailes
se~ont enfoncees. A 40 em, la mouche presente une disparite
de 3000 secondes d / arc. Comme le test demande un assez bon
controle moteur. une reponse negative devra etre interpretee
prudemment, de plus une fixation bifoveolalre n / est pas
necessaire. Le meme test comprend aussl des dessins de
disparite beaucoup plus fins: les animaux et Jes cercles aux
guels les enfants de guatre ans repondent bien.
Les animaux represent 400 a 100 secondes d/arc. Les
cercles represent 800 a 40 seconds d ' arc.

3. Randot Stereotest: <3 ans)

Ce test ressenble au Titmus exception faite de Ia

mouche. En effet. Ia mouche est remplacee par des formes
geometrigues en points disperses au hasard. Il suffit de
demander a !/enfant. soit de nommer ce gu/il voit. soit de
pointer une figure en partlcul ier. La aussi c / est de Ia
stereoscopie grossiere.

4. Frisbv Stereotest: <3 ans)

•:•.' i" .. . • .,

ce test consiste en trois plaques comprenant quatre

patrons au hasard. et dans un de ces p~tro~s on retrouve une
forme clrculalre. qui ne sera v ue qui si Ia vision
binocuiaire est presente. L ' acuite stereoscopique va
dependre de 1/epaisseur de Ia plaque et de Ia distance a
laquel le est effectue Je t est. Selon ces deux variables. on
pourra avolr une disparite de 15 a 600 secondes d'arc. II
 faut pr~senter une plaque et lu) demander de trouver ou se
cache le cerlce.

Distance Epaisseur de la plaque

l du test

em 6mm 3mm 1 mm

30 600 300 100

40 340 170 55
50 215 110 35 -- Dispari te en
60 150 75 25 : secondes
70 11 0 55 20 d'arc
80 85 40 15

Il faut commencer ce test avec Ia plaque de 6 mm et a

40 em. Faire attention ace qu-'1 l n 1 y ait pas de reflexions
de lumiere sur les plaques et mettre un papier blanc
derriere les plaques afln qu i 1 n / y ait pas de confusion
1

avec 1 arriere plan.

1

Pour que le test soit reussi, 3 bonnes reposes sont

n~cessaires. Si Ia plaque est reussie. il taut continuer
avec celle de 3 mm . tourJours a 40 em. Si c·· est encore
reussi, tester Ia meme plaque a 60 em. En cas de reussite
prendre Ia plaque 1 mm et Ia tester a 40 em.
VII CHAMP VISUEL

II est tres dlffici le de faire des champs visuels chez

les enfants. Mais au besoin on utilisera Jes reponses
matrices de !/enfant. Si un stimulus va d'une zone vue vers
une zone non vue. 1 / oeil aura tendance a tourner. Mais il
faudra s ' assurer par plusieurs essals de Ia val idlte de Ia
mesure.
Si l / on ne possede pas d -' ob.Jet qui lui plaise. on peut
faire bouger nos doigts d / un cote puis de l 1 autre. Si
1
l enfant volt un mouvement en peripherie. 11 tour-nera les
yeux pour le r-egarder de face.
Pours / assurer de Ia fi x ation de l 1 enfant. on pourr-a
s ' assurer Ia collabo r ation d ' un fr~re / soeur- ou d'un parent
qui lui monopol iser-a I /attention. A ce moment nous pouvons
lntervenlr en p~ripherie.
 AGUITE VISUELLE
1 1 est souvent difficile d'obtenir des valeurs d'acuite
visuel le precis~s et simll~ires en ~as d'ex~mens multiples
pour les enfants. Chez les nouveaux-nes, des tests de
resolution. comme Le "Reaarde Prefer-ential" de Tellar. sont
parfaitement adaptes.' II~ preferent regar-der les stimuli
interressants. s'ils peuvent les voir et s / ils ne sont pas
distraits par autre chose. En premier. on fait L'acuite
vlsuel le binoculalre. parce que c ' est possible que ! ' enfant
pleure quand on essaie mettre un pansement A l'oiel.
Acuite visuelle Methode d"examen
Age
approximative

Naissa nce -. I moi s 2/ 10 <i 5/10 Nyst. optocinetique

PEV CORTIC AUX
2 a 10 moi s ~ 5/ 10 Exa men cl ini que :
• renexc de fixation
• ri:nexc de poursui te de Ia
lumii:re
I an a 2 a ns 1/ 2 5/ IO aSI IO Possibilit i: de voir o u de re-
connaitre des objets familier s
2 an s I /2 ;i ~ ~ns I /2 8/ 10 Opt o types :
• ROSSANO ou ROS-
SANO- WEISS
• SHERIDAN
3 an s 1/2 a 5 a ns 1/ 2 8/ IO a I O/to Ech e lles de SNELLEN
ROSSANO
/\pres 5 ans 10/ 10 Echelle s de MONOYER
Test de PARIN/\UD
L __ _ __ _ __ __ - · · ' - -- - -- - - -- - - - ' - -- -- - -- - --

TAnU:: 3.1 C hanges in visual acuity as a fun ction of age a nd

measurement me thod

Pendu lorb
Age Tumblin~· e)'e
(rn o nth s ) E m ovements OKN< f'L ~ VEP·

20/30 0 201400 20/3 00

20/ 150 20/:100 21J/ 20U
201150 2!l/200 20/()0
·I 201150 20/200 20/ 50
5 20/GO 20/1 5 0 20 /4 0
6 2 0 /400 20/2 0
12 2 01140 2012 00 20140
24 201·10 20/ JOU 20130
3G 20146 20/50 20/20
40 20/40
60 20/33

·Slatapcr.
~_ S c hwarting.

· :\ 11 <~ 11 : Cal (or d .

·Suknl; M ~ q~ ; H a rlcr .

Echell es d c :
--
Ouverture angulaire
SN ELLEN MONOYER en minutes d ' arc
- ----- - -- -- -~ --- ·.

Picd s l\1ctres
10/ 10 (
20/ 20 616
20125 617 .9 - 1,2 5
20/ 30 6/ 9 8/ 10 1,50
20/40 6/12 5/10 2
20/50 6/ 15 4/ 10 2,50
20/60 6/ 18 0,3~ 3
20170 (, /2 1 0.29 3.50
20/ RII 6124 0.25 4
20 / 911 6/27 4,50
20/ 100 6/J O 2/ 10 5
20/200 6/61) 1/ 10 10
20/ 400 6/ 120 1120 20
------- - -- - - - - -·-··- ··- ·-··-- ___ . ---·-·-
-
1. Pour les nouveaux-n~s

A. Regard Preferential:

VUE DE DESSUS

-------'-~-·_ _ _ _ OPTOI•JETRISTE
/ --~\
I CQ\ _________ L " ENFANT
A ~ LE PARENT
L----------------------~

VUE DE FACE DU TEST

'' . . .~ l'
; r--~ ---:- - - ---' -1

Ce test est compose d ' un Jeu de cartes rectangulaires.

D/ un cote de chaque carte est imprime un reseau des I ignes
noires sur fond blanc. Chaque carte possede un reseau de
l ignes de tal I le different correspondant a une acuite
donnee. Chaque carte est percee en son centre d~un tres
petit trou permettant a un observateur plac~ derriere la
carte d " observer les reactions de ] ' enfant. Ce test
s ' effectue ~ 40 ems. On commence par presenter a ! ' enfant la
carte possedant le reseau le plus gros. A travers le trou
i ·· optometriste sur vei lle si ] ·' enfant regarde le reseau de
1 ignes. Si ! " enfant ! ' observe on effectue une rotation de Ia
carte. de fa9on a modifier ]'emplacement du reseau. Si
! ' enfant parvient toujours a observer le reseau apres 2 ou 3
rotations de la carte . on lui presente une carte poss~dant
un reseau plus petit, et ainsi de suite jusqu ' a ce que
! / enfant ne soit plus attire par le test.
 B. Mouvement Pendulaire Des Yeux

- Catford Vision Testing Apparatus

- Optokinetic Nystagmus

i ! ............

I /
1--ig 3.24 The opr()hnetic drum .

De ce fait Goldman a propose de mesurer 1/acuite

visuel Je en presentant un stimulus asci l Jatoire de tail Jes
differentes et i I suffit de determiner Ia plus petite tai I le
qui donne un mouvement des yeux.

C. Candy Bead Test ·

F1C:llltl-: ~Ui. Vi~u:JI acu-
ity lf!sfinK with candy
!wad s

1 Mesure 20/60 = 6/ 18. Faire gouter des bonbons de

d i f f e c e n t e s co u J e u c s a 1 " e n f an t cd i am e t r e 1mm ) p u i s I u i
faire prendre dans la main de J · examinateur. Faire le test
en binoculaice d " abocd et ensuite en monoculaire et touJours
comparer les deux yeux.
l
I Malheureusement. les etudes montrent que Ia veritable
acuite visuel le equival Iente est de 20/200 = 6/60 = 1/10.

2. Enfant de 3 ans

A. Test De Ffooks

Ce test se veut mains diffici le que celui de Snellen et

du E directionnel. Pour cela i J utilise des figures
geometrlques fami 1 ieres de tai 1 les differentes.
Pour cela. on montre les figures A ! / enfant et on lui
demande de nous les nommer. L' important n'est pas qu/11
donne Ia bonne reponse mais qu ' i l soit conslstant dans ses
reponses. Si !/enfant a du mal a repondre oralement, lui
donner une copie des differentes figures geometr4.:-ques et lui
demander de nous montrer Ia meme figure. Si l ' ~nfant repond
mal, on avance vers lui ce qui aura pour effet· de diminuer
1 / acuite visuelle demandee . Dans le cas contraire el faut
augmenter la distance.

B. Cartes D' Al len

Le test se compose de sept cartes de dessins d ' objets

selectionnes. Le test ressemble beaucoup au test de Ffooks.
mais plus difficile. Vadministration du test se fait de Ia
meme maniece.
1 C. New York Lighthouse Fl~sh~ard Test

FIGURE 3.4. New York

Lighthouse Flashcard Test

o~habitude pour le basse vision de les enfants. ces

cartes son plus faci Je que les Cartes d/Allen. ·
L/adminlstration du test se fait de Ia meme maniere sauf
avec ce test. on ne puet pas augmenter Ia distance.

3. Enfant de 4-5 ans

A. Main De SJogren

FIGURE 3.2. Sjogren Hand Test

Similaire au E directionnel. mafs dans ce cas c'est une

main qui est repr~sent~e. L/enfant doit identifier Ia
direction dans laquel le les doigts de Ia main pointent. <a
drolte. a gauche. en haut. en bas)
Le grand probleme de ce test est que Ia paume de Ia
main es large et aide beaucoup a identifier Ia direction. De
ce fait on prefere leE directionnel.

B. E Directionnel

C'est le test le plus employ~ pour les enfants d'age

prescolaire. Il consiste en la lettre E qui est tournee dans
quatre positions. L'acuite obtenue est ~quivalente a
1/ acuite Snellen.
l
I Pour faire ~ le te'~t.- ~ on donne a ! ' enfant une carte avec
un E ou bien un E en plastique. On demande a ! ' enfant
d / indiquer avec Ia main Ia direction duE. On commence le
test en lui presentant de grands E puis succesivement avec
des E de plus petite tal lie. On commence d'abord avec
l ' aculte vlsuelle monuculaire et ensuite binoculaire.

C. C De Landolt
Simi laire au E directionnel. La partie ouverte du
cercle est montree dans Jes quatres directions. Par rapport
au E directionnel. le C de Landolt est plus diffici Je a
comprendre pour ! ' enfant et ses resultats sont similaires
aux E directionnels.

LA REFRACTION DE L'ENFANT
Les techniques d ' examen de Ia refraction et leur
correction chez l'enfant different de eel les adultes. et
dependent surtout de ! ' age de !'enfant.

II exlste en effet un age I imite. de 0 a 2 ans. ou i I

est difficile. voire impossible. de chiffrer l ' aculte
visuel le. La prescription repose alors sur les resultats de
la sklascopie qu ' il faudra Interpreter en fonction de J ' age
de ! ' enfant. Le nouveau-ne. ne a terme et en bonne sante est
hypermetrope, Ia valeur normale est comprise entre plan et
+3.00 dp. Un enfant pesant mains de 2500 g a Ia naissance.
ou ne prematurement possede un valeur d'hypermetropie
inferieure a cette fourchette. II peut meme etre myope.
L'astigmatisme est retrouve assez souvent chez !'enfant de
mois d'un an, mais i I tendrait a diminuer avec l'age.

Entre 2 et 5 ans, en periode pre-scolaire, l'acuite

visuel le peut etre chiffree en s ' aidant d'optotypes, mais Ia
prescription de verres de lunettes depend Ia encore de Ia
skiascopie. D' habitude. ! ' enfant dans cette periode d,age
aurait une hypermetropie approximativement de +0.50 dp.

Apres 5 ans. Ia cooperation est en general suffisante

et Ia mesure de l ' acuite visuel le. Ia refraction subjective.
sont menees de Ia meme facon que chez l'adulte.

Grosvenor et Hirsch ont conclu en resume des

differentes etudes qui ant ete faites. que:
- Si un enfant est my ope a 5 - 6 ans, Ia myopie est
sure de rester et augmentera probablement.
- Si un enfant a pius de +1.50 dp d ' hypermetropie a 5-6
ans. il restera hypermetrope a 13-14 ans, mais de valeur
mo i ndre.
- Si un enfant a une refraction entre +1.25 et +0.50 a
!"age de 5 - 6 ans. il aura de grandes chances de devenir
emmetrope a 13 a 14 ans.
 - Un enfant ayanf "une· refraction entre plan et +0.50 dp
a ) / age de 5 - 6 ans, a des tres grandes chances de devenir
myope vers 13- 14 ans. La probabi I ite est plus grande si un
asti~natisme inverse est present.

A. Keratoscope
FIGUI!E 5 2. Th e p lacido
di ~ c

._

C/est un disque de placida avec une lumiere. II permet

d / evaluer un astigmatisme superieur a 1.00 dp.

B. Keratometrie
fiG Uil f. S.) . Th e kcral o·
scope

Indique le mo ntan t d ~ astigmatisme corneen ou sert a

! detecter t oute irregularite corneenne. Peut etre uti 1 ise
chez les enfants de 3 ans.
l
C. Sklascople Statlque

Chez ! ' enfant il faudra proc~der rapldement, car son

attention est limitee. Ainsi plus on mettra de temps. plus
!'enfant aura de chance d·accommoder. I! est tr~s difficl le
de faire cette technique chez les tr~s Jeunes enfants. On a
besoin d ' avoir ! ' assistance de la m~re qui tiend !'enfant et
une autre personne qui attire !'attention de l ' enfant au
loin avec un grand Jouet.

El le pourra etre executee plus facilement . chez Jes

enfants d ' age pre-scholaire. II faudra donner une cible de
fixation qui l'interresse. done grosse. facile A voir et
l ·" enfant dolt pouvoir Ia reconnaitre et la nomm~. II est
bon de poser des questions faciles et simples : ~ propos des
symboles pour s ' assurer de Ia fixation. La cible etant A
6 m.

D. Sklascople "l'1onocuiar Estimate Method" (MEM>

-·
B.I

I
FIL /" 1:1 -, I \ I !: \ 1 •··li n " ' ' •q n

- ------------------------------
 Cette skiascopie. ne pourra etre effectuee que chez les
enfants cooperatifs et attentifs. On recherche ici a savoir
si Ia reponse accommodative est ega! au stimulus
accomrnodatif. Le but est done d'observer Ia reponse
accomrnodatif spontanee de )·'enfant a une cible presentee a
sa distance habituelle de travail.

La cible de fixation est une carte blanche percee d'un

trou au centre avec tout autour. des lettres ou des dessins
differents selon 1/age du sujet. L' examinateur est assis un
peu plus bas, que le patient, pour que Ia direction de
regard soit semblable a eel le adoptee pendant Ia lecture.
Puis avec Ia prescription en place. on demande a l'enfant de
1 ire Jes lettres. ou de decrire les dessins a haute voix. A
ce moment l ' examinateur place le reflet dans Ia pupil le et
note si le mouvement est direct ou inverse. On · fait !'autre
oeil ensuite. II faut ensuite neutral lser le r~flet avec des
verres d ' essais. L'estimation du mouvement dolt toujours
s'effectuer rapidement pour ne pas deranger Ia reponse
accommodative du patient <Ja reponse accommodative commence
apres 0.36 secondes>. Le resultat normal est un lag de +0.50
a +0.75 dp. Si le MEM demontre un lag superieur a +1.00 dp.
n pourra condiderer une addition de pres. de Ja valeur du
lag. Mais auparavant. il faudra s ' assurer qu'il n ' y a plus
d··hypermetropie Jatente ou de spasme accommodatif avec Ja
prescription en VL.

L ' EX~MEN OCULAIRE

A. PUPILLES

Les pupil Jes du nouveau-ne sont generalement rondes,

d'egale grandeur. et reactives a l'i l lumination directe et
indirecte. Une variation dans leur grandeur peut etre
consideree comme nbrmale si la constriction et Ia di Jatation
sont egales des deux cotes.

L' observation des reflexes pupl !!aires est tres

important. La pupil les contractee ne doi~ pas etre
infet- ieure a 2 mm. Ja pupi lle di latee pas superieure a 5 mm.

On place le faisceau lumineux de l'opthalmoscope sur Ia

f pupil le de l ' oei J droit et on observe Je reflexe direct de
l '00. On recommence 3 fois en observant le reflexe
consensuel de J · oei l OG. On repete Ia meme observation avec
J L·OG.

B. L OPTHALMOSCOPIE DIRECT

L· opthalmoscopie est une methode objective pour

detecter les pathologies oculaires. On peut observer des
structures oculaires internes. Pour observer l ' oeil droit du
patient. l'observateur dolt uti! iser son oeil droit et sa
main droite. Pour observer l ' o~il gauche du patient.
l ' observateur dolt utll iser son oeil gauche et sa main
gauche.

Pour Jes nouveau - ne. Ia mere peut tenir \ .. enfant dans

les bras en posit : on al longee. ou bien sur J ' epaule. Dans sa
cas. l ' examinateur se place deri~re I a m~re. L' enfant peut
etre plus calme avec son biberon.

Il est preferable de ne pas toucher la visage de

]'enfant. Pour maintenir ] ' attention de ] ' enfant au loin. II
ne faut pas hesiter A uti I iser des Jouets <appropries ~son
age). Done. on a besoin de ! ' assistance d .. une autre
personne.

On commence a une distance d ' envlron 40 ~:·50 em. On

uti 1 ise le verre plan. 1e fitre blanc et le petit cercle. On
volt et compare les reflet rouge dans les yeux. Une approche
horizontale et leg~rement oblique <15") permet de tomber
directement sur Ia papi lie. I 1 est tr~s diffici 1e d ' uti 1 iser
]'ophthalmoscope chez les nouveau-ne. Si ] ' enfant ne se
montre pas cooperant. Il suffit de voir si les mi J ieux .est
clair et Jes reflets bien rouge .

C. PRESSION INTRA OCULAIRE

La PIO par Ia methode de Goldman et Perkins est plus

precises. mais i l existe une autre methode qui semble tres
precise: le Tonopen. L' advantage du Tonopen est que comme le
Perkins i 1 est portable. Les tonometres pneumatiques sont
devenus fiables pour des PIO inferieures a 30 mmHg et
fonctionnent bien avec les enfants pre-scolaires si le
clinicien travaille vite.

Pour les nouveau - ne. la PIO est tr~s diffici Je a

obtenir. II exlste une autre methode qui est plus facile
pour les enfants: KEELER pulse-air. C .. est un tonometre qui
ne touche pas l ' oel 1 de ! ' enfant. II est egalement portable.
Finalement. si on ne peut pas obtenir Ia PIO. on peut faire
I a pression digltale. On demande a ! ' enfant de fermer les
yeu x . Ace moment. J · examinateur touche legerement les yeux
pour sentir s .. ils ne sont pas trap durs.
 LE TRAitEMENT DE LA MYOPIE

E +
~
>50

<1 0, coo~• ~
>3 0 at 1 ye<Jr
Cocrect at
no RX .• any age
> 1 0 at 3 years

L
Amblyo pia. Evaluate
nota and treat
concern amblyopia

~ i
~
Exo : :ull RX
Eso: c:::nsid€ r
undercorrecting

Can remoV€ Full-time

at near wear

~
Presc:-ibe Consid€r
glasses contact
until olcer lenses

"T
' -·
Initial
follow-up
at 1 month
I
T

Amb lyopia cr
Normal VA ane
decreased
binoCJlarity
binoo;l;:;rity

Mter rniual
eY::;n_ eval uat e Re-evalua:e
Evalu :J:e
a! 2-..3 years based en
ye a.r1y
and at 5 years c~11id·s a<;e
 LE TRAITEMENT DE L' HYPERMETROPIE

Min imal et1ect Observe

Correct ii
on behavior or interest and
stable
a c eommoeation perlormance
with near
:activities ·-
-·
I .
_ _.,____

c
f
mblyopia Evalu:a:e
Nota -, and tre at
conce rn :amhlyo;Jia

t {
No }--- Binocular
bi·nocul:ar
dysfuncion
cy ~;[unc:i on

~
Esc: lull RX
Exo: c:ons~er
undercorrecting

i
No RX:
FuU -time
co ntinue to
wear
monitor

i
I. l
<5 D. p<"escribe
>50 consid-?r
~lasses only
contact lenses
until older

I 1
-~

Initia l
lollow-u;:::
at 1 men~':
I

..-- - - i l
Ar<1~lyopia or
N orm al VA and
ceoeas ee
bin ocula ri:y
binoOJ I:arirv
At:er 1niti<J I ~-
e ~ a rn. e v;;lu a :e T

at 2 - J )' ~ d rS Re -evalua:e
E:valu a :e
o f ;;;~c vn d J ~ S b.osc c en
year:] [
ve 3' S ol a;:c ch :lc·s ac e
l LE TRAITEMENT DE L'ASTIGMATISME

r I
S;;;!:J!€ over
Uns;a~l e
3 visits
---
~
..-
C onsider
prescribing
b.; sed on
6ilos a<;e

1
! ll
YOl.:r.s;er than Oder than age
c.;e 1 year. 1 year. obsefVe
!\;;1c:ion net interest and
a CJncern performance

!
Ar.~blyopi<j
at near
T
Amblyopia
I
Mo n it or nota evaluate
ccncern and treat
~

l_
c r l.
<5 0 . >5o.
presc: ibe ccnsicer
<_;la sses contact
until oleer lenses
I I
·~

Full -time
wear. initial
follow-up at
1 m o nL'1
~
I !
~l o r~ a l VA Ar.::::lfopia
A f:er ini :i;;l
exam. e va lu a:e ,.I
a t 2 -..J y ears Re-evaluate
old and at 5
t.a sed on
yc:Jr s ofd ch ilc ·s ac.;e
 BIBLIOGRAPHIE

1. Pediatric Ootometrv - Jerome Rosner

2. A Student/s Introduction to Visual Sc ien c e and

.Dot om_~_t rv- D. K. Turnbu I I

3. Pedo - Optometrie - Phi I ippe AI I ieri. 0.0. et Pascale

AI I ieri-Thepenier. O.D.

"
I