Amblyopia

Amblyopia meets the World Health Organization criteria for a disease that benefits from screening.[32]Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70. https://www.aaojournal.org/article/S0161-6420(22)00866-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36543602?tool=bestpractice.com

UK screening programme

The UK National Screening Committee (NSC) provides the following general recommendations for vision screening:[33]UK National screening Committee. Child screening programme: vision defects. 2019 [internet publication]. https://view-health-screening-recommendations.service.gov.uk/vision-defects [39]The Royal College of Ophthalmologists. Diagnostic pathway following child vision screening. May 2023 [internet publication]. https://www.rcophth.ac.uk/resources-listing/diagnostic-pathway-following-child-vision-screening ​​[49]McCullough S, Saunders K. Visual profile of children who passed or failed the UK school vision screening protocol. Br Ir Orthopt J. 2019 Mar 26;15(1):36-46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7510406 http://www.ncbi.nlm.nih.gov/pubmed/32999973?tool=bestpractice.com ​​

• Screen all children aged 4-5 years in an orthoptic-led screening service.

• Perform monocular visual acuity assessment using a computerised Keeler crowded LogMAR acuity chart at 3 metres (standardised to background luminance at different testing locations).

• Refer children with a visual acuity less than 0.20 logMAR on the Keeler crowded logMAR test in one or both eyes to specialist services for further assessment of ocular motility and binocular function, cycloplegic refraction, and examination of optical media and retina/fundus.

• Attempt a second screening test or refer directly to community or hospital eye services if screening cannot be completed (e.g., due to lack of cooperation).

US screening programme

The US Preventive Services Task Force (USPSTF) recommends screening in children aged between 3 and 5 years.[34]US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children ages 6 months to 5 years: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Sep 5;318(9):836-44. https://jamanetwork.com/journals/jama/fullarticle/2652657 http://www.ncbi.nlm.nih.gov/pubmed/28873168?tool=bestpractice.com

The following screening tests can be performed by paediatricians or primary care providers during routine health maintenance visits from birth.[32]Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70. https://www.aaojournal.org/article/S0161-6420(22)00866-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/36543602?tool=bestpractice.com [34]US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children ages 6 months to 5 years: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Sep 5;318(9):836-44. https://jamanetwork.com/journals/jama/fullarticle/2652657 http://www.ncbi.nlm.nih.gov/pubmed/28873168?tool=bestpractice.com [41]​American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Joint policy statement: vision screening for infants and children. 2022 [internet publication]. https://www.aao.org/education/clinical-statement/vision-screening-infants-children-2022

Aged newborn to 6 months

• Red reflex test with a direct ophthalmoscope. Refer if absent, white, dull, opacified, or asymmetric.

• External inspection of the eyes to assess for any structural abnormalities (penlight examination is sufficient). Refer structural abnormalities (e.g., ptosis).

• Pupillary examination. Refer if irregular shape, unequal size, and poor or unequal reaction to light.

• In a cooperative infant ≥3 months perform the ‘fix and follow’ test and corneal light reflex. Refer if failure to fix and follow or if the corneal light reflex is asymmetric or displaced.

Aged 6 months to 3 years

• Repeat tests for the previous age group.

• Photoscreening and handheld autorefraction may be performed electively in children aged 1-3 years, allowing earlier detection of conditions that may lead to amblyopia (e.g., media opacities, strabismus, or high refractive errors).

Aged 3-4 years

• Repeat tests for the previous age group.

• Cover/uncover test to assess for re-fixation movements in the fellow eye. Refer if re-fixation is present.

• Distance visual acuity testing, independently for each eye. Visual acuity of 20/50 or worse in either eye, or a ≥2-line difference between the two eyes, should be referred. Photoscreening and handheld automated refraction are an alternative in children who are unable or unwilling to cooperate.

Aged 4-5 years (then every 1-2 years)

• Repeat tests for the previous age group

• Distance visual acuity testing, independently for each eye. Visual acuity of 20/40 or worse in either eye, or a ≥2-line difference between the two eyes, should be referred. Photoscreening and handheld automated refraction are an alternative in children who are unable or unwilling to cooperate.

If screening is inconclusive or unsatisfactory at any point, retest the child within 6 months; if this is not possible or testing remains inconclusive, refer for a comprehensive eye evaluation.