Section 2 - Child health checks

1. Procedure

• Ask the parent or child the age appropriate questions according to Table 1.
• Determine if the child requires any visual assessments
• Determine if the child requires a referral and place on a follow-up and recall register

2. Assessing eye appearance ^2,3

• Sit child on chair. For security and compliance infants can sit on parent’s lap
• Ask the parent to hold the child’s forehead if needed
• With an ophthalmoscope visualise external and anterior eye for:
  • symmetry of pupils
  • abnormal movements (nystagmus)
  • lift each eyelid with thumb and check for:
    • scarring
    • cysts
    • styes
    • droopy eyelids (ptosis)
  • conjunctiva and cornea for redness, swelling, discharge (conjunctivitis), scarring or membranes (pterygium)
  • sclera for jaundice (Hepatitis B, page 337), bloodshot or haemorrhage (trauma)

3. Assessing visual acuity (VA) ^2,3

• Test children while wearing their prescribed glasses or contact lenses
• Place a Snellen eye chart (or Tumbling E eye chart for younger children) 6 metres away in a well lit area at eye level
• Note the numbers next to each line on the chart:
  • the first number represents metres the child is standing from the chart i.e. 6
  • the second number on each successive line increases, mimicking increased distance in metres, with smaller lettering e.g. 9m, 12m, 18m, 24m, 36m or 60m
• Tell the child to state the letter you point to, or if using the Tumbling E chart, show how 3 fingers makes an ‘E’ and to hold these fingers left, right, up or down to indicate what they see
• Cover one of their eye’s with an occluder and begin test
• Start at the top line and point clearly to each letter
• Allow the child adequate time to respond

• Progress along each line until the child can no longer identify letters
• If they get > 3 letters incorrect on a line, stop, go up a line and repeat
• Allow 2 attempts
• Record the last line the child can read without making any mistakes
• Cover the other eye and repeat process

3. Fixates and follows an object assessment ^2,3
   • Hold a pen or toy 30 cm away and slowly move it up, down, left and right in an ‘H’ pattern
   • Encourage child to look at the object without moving their head
   • Note the child’s eyes track the object
4. Assessing corneal light reflex ^2,3
   • Generally the child can be looking anywhere for this test
   • Shine a pencil torch between the child’s eyes at a distance of 30 cm
   • Observe the light reflecting in both eyes
5. Assessing red reflex ^2,3
   • Ask the child to look at a distant point e.g. your ear, the wall
   • Direct the ophthalmoscope light at the pupil from 30 cm away
   • Look through the scope slowly moving back and forth, up and down until you see a red reflex (the blood at the rear of the retina)
6. Performing cover test ^2,3
   • Performed to identify a squint (strabismus) or lazy eye (amblyopia)
   • Ask the child to focus on a distant target (picture) without moving their eyes still
   • Cover their right eye with an occluder and observe the left eye for movement
   • Slowly and smoothly remove the card and observe the right eye
   • Repeat these steps for the left eye
   • If needed repeat until satisfied that the test has been performed adequately
   • Movements of the cover should be slow and smooth so the eye has time to fixate
   • Repeat all of the above steps for a near target e.g. your ear or a pencil

2. Results

1. Eye appearance results
   • The eyes should appear:
     • conjunctiva white clear, clean, free of redness, swelling and pus
     • pupils symmetrical
     • eye movements equal and intentional
2. Visual acuity results ¹
   • Normal VA is 6/9 for < 7 years olds and 6/6 for > 7 year olds
3. Fixates and follows an object results
   • Both eyes follow the target easily and smoothly
   • Refer if eyes do not follow in unison or movements are jerky, uneven, child uses head movements or eyes cross
4. Corneal light reflex results
   • A reflection in the same place on both corneas means each eye is fixing on an object equally; reflections in different places of the corneas indicates the opposite
   • This test is a preliminary step to the cover test which will tell you which eye is affected
5. Red reflex results
   • No red reflex can indicate an obstruction between the pupil and retina e.g. a tumour, congenital cataract or haemorrhage
6. Cover test results
   • A squint is indicated if eye movement is noted to:
     • establish fixation on an abject while it is being covered or
     • re-establish fixation on an object while slowly being uncovered

3. Brief intervention

• Provide parents with Resources 1–5. as required

4. Referral ^1–4

• Refer to the Primary Clinical Care Manual if signs of conjunctivitis:
  • itchy or irritated ± red eye(s)
  • watery, pus or mucous discharge
  • crusting of eyelids or eye lashes
• Refer to the MO/NP, ophthalmologist or optometrist if:
  • child’s visual acuity in one or both eyes is:
    • > 6/9 for < 7 year olds (i.e. 6/12, 6/18, etc)
    • > 6/6 for > 7 year olds (i.e. 6/9, 6/12, 6/18, etc)
  • abnormal eye appearance or eye movement
  • reported blurriness
  • squinting to see
  • failure of a child to fixate or follow an object
  • uneven eye movement
  • no red reflex
  • eye movements during cover test
  • other concerns

5. Follow-up

• Place the child on a recall register if required
• Ensure all referrals are actioned
• Provide the parent with details for the next scheduled follow-up appointment

6. References

• All Chronic Conditions Manual references are available via the downloadable References PDF

7. Resources

1. Queensland Health Eye Health
2. Health Direct Eye Health
3. AIHW: Eye health in Aboriginal and Torres Strait Islander people
4. Vision Australia
5. Indigenous Eye Health Unit