Infant to Six (ITS) and Pediatric Eye Care Clinic Guidelines

Goals

Vision develops rapidly during the first year of life and most aspects of vision are adult like by one year of age. It is important to detect and correct amblyogenic factors such as strabismus, anisometropia , high refractive errors and media opacities before they have an adverse effect on visual development. A comprehensive vision examination is recommended for infants at nine months of age followed by an examination at both three and five years of age (California Optometric Associations, American Optometric Association). In the Infant To Six (ITS) clinic, a comprehensive vision assessment is provided for infants, toddlers and children up to six years of age. The Pediatric Primary Care clinic (Peds) serves school age children (7 to 10 years) providing primary care exams and serving as a referral base to other specialty clinics (the Binocular Vision clinic or Myopia Control clinic, for example). These pediatric clinics are direct patient care clinics. The one hour examination is conducted by the clinical instructor working side by side with optometric student clinicians. Students gain experience in providing eye examination to pediatric patients of different ethnic and socioeconomic backgrounds with varied eye and vision disorders and varied levels of cooperation.

Assessment of Refractive Error

Retinoscopy under cycloplegic and non-cycloplegic conditions with lens bars or trial lenses and trial frame techniques. Refraction with phoropters is not used. Effective and safe eye drop instillation. Demonstration of commercially available pediatric autorefractors as appropriate. Case driven discussion of what and when to prescribe, lens design (single vision, bifocals or progressives, prism).

Assessment of Visual Function

Pediatric tests for visual acuity (Lea symbols chart, Lea single symbols with crowding bars, Cardiff picture acuity test, UCBSO Preferential Looking grating acuity and the Sweep Visual Evoked Potential. Pediatric tests for contrast sensitivity (Mr. Happy contrast test and the Cambridge grating contrast test). Pediatric tests for color vision (Berkeley variant of the Berson test, saturated and desaturated Portnoy plates, and the F2 square and face color vision tests). Confrontation visual field testing with a flashing diode wand. The student clinician will gain experience in the use of operant forced-choice testing procedures for the behavioral based assessment of vision capabilities in this young population. The student clinician may observe and assist in the sweep VEP testing of visual acuity, Vernier acuity and contrast sensitivity. Case driven discussion of normal values for age.

Assessment of Ocular Health and Treatment/Management of Ocular Disease/Disorders

Hand-held slit lamp biomicroscopy, direct and indirect ophthalmoscopy (including small pupil BIO), hand-held intraocular pressure assessment with the Icare tonometer, and pupillary testing. Instruction is given about safe and proper instillation of diagnostic medications and examination techniques for non-cooperative children. Case driven discussion of treatment/management either under the optometrist scope of practice or appropriate referral to pediatric ophthalmologist or other professionals.

Patient Management Skills

Acquisition of effective strategies for working with this mostly non-verbal, often difficult-to-examine, but mostly delightful population.

Fees for Service

The direct patient care exam fee is $148. The exam fee may be covered by Medi-Cal, VSP, Kaiser, private insurance or other sponsors such as school districts, Sight-for-Students vouchers, Lions club pre-authorization is required prior to the exam. A VEP measure of vision function, at an additional cost of $175, may be needed if a vision impairment is suspected and behavioral based measures are not possible.