The Cribsiders podcast

#38: Ophthalmology in Pediatrics – A “Global” Phenomenon

November 10, 2021 | By


Is the pediatric eye exam a bit fuzzy to you? Are you having trouble seeing what to learn? Join us as we talk through all things “kids eyes” with pediatric ophthalmologist Dr. Roni Levin! She teaches us what we are actually looking at when we see the red reflex, the 4 aspects that should be a part of every eye exam, and what ophtho findings should worry us. Dr. Levin also discusses her advocacy work and some of the health inequities in pediatric ophthalmology. Tune in and we promise: you will begin to see these concepts clearly.


  • Writer and Producer: Edward Corty, MD
  • Executive Producer: Maximilian Cruz, MD
  • Infographic: Edward Corty, MD
  • Cover Art: Chris Chiu, MD
  • Hosts: Justin Berk, MD; Chris Chiu, MD
  • Editor:Justin Berk MD; Clair Morgan of
  • Guest(s): Roni Levin, MD

Ophthalmology in Pediatrics Pearls

  1. The red reflex (or fundal reflex) should be examined in both eyes simultaneously from 2-3 feet away at every pediatric visit.
  2. The most emergent cause of an abnormal red reflex is retinoblastoma or another tumor, but any abnormality in the visual axis can cause a distortion in the red reflex. 
  3. Remember VPEP for the “vital signs of the eye”: Visual acuity, Pupils, Extraocular movements, Pressure. 
  4. A randomized control trial in Baltimore City showed that vision screening with follow-up in children in grades 3-7 improved reading scores after one year.
  5. Amblyopia is decreased visual acuity due to abnormal visual development; it can be caused by strabismus, refractive error, or structural issues (deprivation amblyopia).
  6. Pseudoesotropia is extremely common. You can tell the difference between pseudoesotropia and true esotropia because the cover-uncover test and corneal light reflex testing will be normal in pseudoesotropia.


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Ophthalmology in Pediatrics Notes


The Red Reflex (or Fundal Reflex) 

What is the red reflex? 

The red reflex represents the reflection of the retina through a clear pupillary axis. It is the most important screening tool in ophthalmology for infants and children. This should be checked at every visit (Peds in Review 2018). The red reflex is sometimes called the “fundal reflex” because it is not always red, particularly in children with darkly pigmented skin. A yellow fundal reflex can be completely normal- the important thing is symmetry

Proper technique

Use a direct ophthalmoscope to look at both eyes simultaneously about 2-3 feet away from the patient. Ensure that they are symmetric. The reflex may be dull in one eye or completely white (not present at all). If it is not present at all, it is called “leukocoria.”

The abnormal (or dull) red reflex

An abnormal red reflex can represent many abnormalities, including: 

  • Retinoblastoma: the most common ocular tumor in children and can be fatal
  • Congenital cataract (or any corneal opacity) 
  • Retinopathy of prematurity 
  • TORCH infections (Toxoplasma, Other, Rubella, CMV, HSV)
  • Strabismus (i.e. misalignment of the eyes)  
  • Anisometropia: each eye having different refraction power

Next steps with an abnormal red reflex

  • If you definitely see leukocoria, refer urgently (within days) to peds ophtho.
  • If the red reflex is a bit dull (perhaps due to refractive error) patient should be seen by peds ophtho within weeks to months.
  • When in doubt, refer to pediatric ophthalmology.
  • The pediatric ophthalmologist will examine the vital signs of the eye (below) and then use the slit lamp to look at all the parts of the eye: (anterior to posterior) lids and lashes, conjunctiva and sclera, cornea, iris, lens (with direct ophthalmoscope)

The Pediatric Eye Exam

Tips for a successful pediatric eye exam 

  • Start with developing rapport—don’t go straight for the eyes or else they will cry.
  • Prioritize the important parts of the exam.
  • Use distractions! Toys, flashing lights, videos, sing, whatever works.
  • If it is becoming very difficult, think “how can we change this?”—Different time of the day? Split into a few visits? 

Vital signs of the eye

Remember “VPE” for routine screening: Visual acuity, Pupils, Extraocular movement.

Remember “VPEP” for vital signs of the eye: Visual acuity, Pupils, Extraocular movement, Pressure.

Visual acuity

  • Blinks to light in a newborn infant, check in each eye separately.
  • Objection to occlusion: cover one eye and the child is fine, cover the other one and they start crying. This is a sign of poor vision.


  • Are they equal, round, and reactive to light? 

Extraocular movement

  • Use toys to check how babies are tracking! 


  • Use two thumbs to softly palpate over the closed eyelid, the eye should feel like a soft grape.


Check out a video of Dr. Levin’s pediatric eye exam! 

Health inequities

  • Children in low-income communities are less likely than those in high-income communities to receive a diagnosis of strabismus (Ophthalmology).
  • A recent randomized study in Baltimore City public schools with children in grades 3-7 found children that received glasses through the school vision program had better reading scores after one year (JAMA Ophthalmology)


A misalignment of the eyes that can lead to amblyopia if not treated appropriately.

Types of strabismus: 

  • Esotropia—eyes turn in. 
  • Exotropia—eyes turn out.
  • Hypertropia—eyes turn up.
  • Hypotropia—eyes turn down.

Tests for strabismus

Cover-uncover test: forcing the affected eye to “work.” The affected eye will shift to fixate on an object when the unaffected eye is covered. For example, if a child has esotropia in their right eye (eye turned in), when their left eye is covered, their right eye will refixate outward.

Hirschberg test (corneal light reflex): a penlight is directed at the patient while they are looking straight ahead. The reflection should be in the center of each pupil if the eyes are straight,  and will not be symmetrical in strabismus. For example, in exotropia, the light reflex will be nasal to the pupil. 

Downstream effects

Children do not develop double vision because their brain “suppresses” the vision in one eye. Over time, this leads to amblyopia (see below) due to actual brain atrophy of the visual system. 

Treatment for strabismus

  • For refractive error it’s possible the child will just need glasses to fix the crossing. 
  • For strabismic amblyopia, patch the good eye for specific time intervals based on vision. We are covering the good eye to force the weaker eye to work. 
  • Eye muscle surgery may be necessary to 1) improve eye contact, 2) prevent double vision, and 3) to help with depth perception. 


Decreased vision due to abnormal visual development. There are 3 kinds of amblyopia: 

  1. Strabismic amblyopia (described above)
  2. Refractive amblyopia: one eye has a refractive error, which leads to abnormal visual development.
  3. Deprivation amblyopia: a structural issue depriving the patient of vision (e.g. ptosis, congenital cataract, retinoblastoma) leading to abnormal visual development.

Rapid Fire (“At First Glance”) 

  • Blue light is not harmful to the vision, but it does affect circadian rhythms. Don’t use it before bed. Try the 20-20-20 rule: Every 20 minutes, look away from the screen for 20 seconds, at a spot 20 feet away. 
  • Tearing and blinking can be a red flag sign of glaucoma. You should do an immediate pressure exam by palpation of the closed eye.
  • Pseudoesotropia is extremely common. You can tell the difference between pseudoesotropia and true esotropia because the cover-uncover test and corneal light reflex testing will be normal.

Other Stuff


  1. Dr. Levin’s pediatric eye exam
  2. Ophthalmology resources for medical students


  1. Allison R. Loh, Michael F. Chiang. Pediatrics in Review May 2018, 39 (5) 225-234; DOI: 10.1542/pir.2016-0191
  2. Ehrlich JR, Anthopolos R, Tootoo J, Andrews CA, Miranda ML, Lee PP, Musch DC, Stein JD. Assessing Geographic Variation in Strabismus Diagnosis among Children Enrolled in Medicaid. Ophthalmology. 2016 Sep;123(9):2013-22. doi: 10.1016/j.ophtha.2016.05.023. Epub 2016 Jun 24. PMID: 27349955.
  3. Neitzel AJ, Wolf B, Guo X, et al. Effect of a Randomized Interventional School-Based Vision Program on Academic Performance of Students in Grades 3 to 7: A Cluster Randomized Clinical Trial. JAMA Ophthalmol. 2021;139(10):1104–1114. doi:10.1001/jamaophthalmol.2021.3544


Listeners will learn about the aspects of routine pediatric eye screening, findings to “not miss,” and the pathophysiology of common pediatric ophthalmology issues like an abnormal red reflex, strabismus, and amblyopia.

Learning objectives

After listening to this episode listeners will be able to…  

  1. Recall the utility, technique, and relevant findings of the red reflex exam. 
  2. List three concerning pathologies that can cause an abnormal red reflex exam. 
  3. List the vital signs of a pediatric eye exam. 
  4. Describe health inequities related to pediatric ophthalmology. 
  5. Discuss the importance of adequately assessing and treating strabismus in pediatric populations. 
  6. List the three major causes of amblyopia in pediatric patients.


Dr. Levin reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 


Corty EW, Levin R, Cruz M, Masur S, Chiu C, Berk J. “#38: Ophthalmology in Pediatrics – A “Global” Phenomenon”. The Cribsiders Pediatric Podcast. https:/ November 10, 2021.


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The Cribsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit and search for this episode to claim credit.

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