1.

PIGASSOU TEST
The Pigassou Test is one of the favorites of pediatric ophthalmologists. What is
Get with this ocular exam to measure the visual acuity of children. It can
to occur at a very young age and the guarantees of success in the diagnosis are
elevated.
This eye examination follows a very simple process. The specialist shows you the
less a series of drawings that the little one will easily recognize. First of all, it
they show the images in a large size, to find out if the child identifies them all and
subsequently, each drawing is shown in smaller sizes.

Pigassou test with recognizable drawings for the child in different sizes.

The patient must describe what they see in each of the images and the
The ophthalmologist will be analyzing your expression and the gestures you are making. Obviously, the
difficulty increases considerably during each round, which will offer the specialist
some keys about children's visual acuity.
The exam will be conducted about 4 or 5 meters away from the images and takes place
First with one eye and then with the other. It can be established that there is some problem.
Visualize if the child does not correctly identify any of the images.

2.TEST AND SNELLEN

It is known as Snellen's E, another visual test, especially indicated for the
child population. The procedure of the eye examination is similar to the one that is performed
with the Pigassou Test, but in this case, instead of several different figures,
Only the letter 'E' is shown to the child.
Something curious is that it is not necessary for the child to know how to identify the letter nor that
understand what the drawings show. The ophthalmologist will show the letter 'E' in various
positions and the child will have to indicate the orientation of it.

Snellen Test E where the child must indicate the direction of the "legs" of the E.
figure.

If the eye examination is being conducted on a very young child, they may be asked
that indicates with their thumb which way the little feet of the letter are pointing. As in the
In the previous case, this eye test is performed first for one eye and then for the other.

3.VISUAL PREFERENCE TEST

The latest visual test for children is designed for very young patients. It is usually carried out in
end in children between 6 months and 2 years of age. Therefore, it is very likely that it will
It was carried out during the first children's vision check, which is recommended to take to
cabo at a very young age.
The exam consists of showing the child some sheets that have white and black stripes.
on a gray background. The stripes are getting thinner and thinner, so there comes a moment when
the one that the child stops following them with his gaze. The specialist observes the child through
through a hole, to check that he still follows the sequence of images with his gaze.
When the patient stops turning their head, the visual acuity can be determined.
small.
It is important to perform this visual test quickly to prevent the child from losing the
concentration during the process.

Newborn examination

When examining a newborn, we must focus on the correct

formation of the eyeballs and the orbit, as the capacity of
The visual fixation of the newborn is limited. It has been estimated that their acuity
visual oscillates between 20/400 and 20/800, although the conjugate gaze
horizontal and the optokinetic nystagmus are clearly present
since the moment of birth. At birth, most children
they are ortotropic or exotropic, but at 3 or 4 weeks of age the
the majority of them have their eyes properly aligned
(orthotropic)

The cornea in a newborn measures between 9 and 10.5mm in diameter and

grows until it reaches its final size, which ranges between 11.5 and
12mm, at the age of one year. Both the cornea and the lens.
normals should always be transparent; the color of the iris changes
during the first 6 months after birth, and the retina
the peripheral is well developed at birth, but the macula is immature
and continues its development until the age of 4.

Visual acuity increases with the development of the visual system.

and by 4 months it is estimated at 20/200 and by 4 years, between 20/40 and
20/20, but some children may not reach normal vision (20/20)
up to 7 years of age.

Leukocoria

Leukocoria is defined as the whitish pupillary reflex that is

it is obtained by illuminating the pupil with a flashlight or in a photograph, in
place of the normal orange reflection of the retina (fig. 1). Its absence
must be assessed in every healthy child examination and its presence is mandatory
an urgent evaluation by an ophthalmologist.

Figure 1.

Leukocoria of the right eye due to cataract.

(0.04MB).

The lack of fixation from 3 months of age, nystagmus, the

leukocoria and strabismus are the main warning signs due to
constitute the way of presenting eye diseases that
they require immediate therapeutic intervention such as cataracts
congenitals, retinoblastoma, Coats' disease, persistence
of primary vitreous or retinal detachment. 1-3

Obstruction of the tear duct

A common problem in newborns (5%) is tearing, due to

to congenital obstruction (or imperforation) of the tear duct, with
frequent infections or recurring conjunctivitis associated. Others
possible complications include the development of a mucocele and even
cutaneous fistulas. Until 6 months of age, the management is
conservative, through daily massages on the tear sac, washes
with saline solution and topical antibiotics when necessary. The
massage involves applying pressure to the tear sac in a way
repeated, so that in this way the secretions do not accumulate and
It may open the lacrimal-nasal meatus. For it to be effective, it is important
Keep in mind that the tear sac is not located in front, but
behind the lower nasal orbital rim. When these measures
they are not effective, it is necessary to permeabilize the distal tear duct
by introducing a metal probe, a technique known as
like a survey. The effectiveness between 80 and 90% is maintained throughout
from the first 3 years of life, it decreases from then on and is of
65% at the age of 5. 4.5

The obstruction of the tear duct is the most common cause of tearing.
but we cannot forget that it is also one of the symptoms
presentation of congenital glaucoma (in this last case along with the
photophobia and irritability associated with corneal edema, which is observed
due to the lack of transparency of the cornea). When it occurs before the
At 3 years, the eye and cornea acquire a size larger than normal.
referred to as buftalmos and megalocoria, respectively. The
The treatment for this condition should be surgical and early.

Refractive defects and amblyopia

Refractive errors and amblyopia are the main causes.

frequent visual deficits in childhood. In the United States,
between 1 and 4% of preschool children exhibit amblyopia and
between 5-7% present significant refractive defects. The child, 6

on average, tends to be hyperopic when born and to become myopic in

the following years. At the age of 5, the refractive state is
predictive with respect to the final one at the end of the development; thus, if the
the child presents some degree of myopia or a defect less than +0.50
diopters, it will tend towards myopia or if it already exists, it will increase; if it is
hyperopic of more than 1.5 diopters, will tend to be hyperopic, and if
its refraction fluctuates between +0.50 and +1.25 diopters, it is likely that
llegue a ser emétrope.

Refractive errors not associated with amblyopia include the

myopia and hyperopia which, when corrected with correction
appropriate optics achieve a normal level of vision,
regardless of the age at which they are detected. 6

Amblyopia is defined as a decrease in visual acuity without

identifiable organic causes in the eye and is associated with factors of
amblyogenic risks that interfere with normal binocular vision
like strabismus, anisometropia (difference in the defect of
refraction of both eyes) and palpebral ptosis. Strabismus is a
oculomotor parallelism disorder that occurs in up to 4% of children
(fig. 2). Eye alignment is achieved in most of the
7

infants at 3–4 weeks of life.

Figure 2.

Hirschberg reflex in a patient with exotropia. This simple test is based on the
observation of the reflection on the cornea and is measured by the distance that separates the reflection

corneal center of the pupil. If the reflection is symmetrical and is in the center of the cornea,
orthotropism exists.

(0.05MB).

Small angle and intermittent deviations are usually resolved in

the first months, but if a convergent strabismus (or esotropia,
(inward deviation) persists at the third month or strabismus.
divergent (or exotropia, outward deviation) at the fifth month, it
they are considered abnormal and must be evaluated by the specialist.
Large angle deviations and constants require an assessment.
early, because strabismus constitutes a warning sign. 7

Visual defects due to refractive errors and amblyopia are

they are mainly treated through optical correction and therapies of
penalización visual. La medida inicial más habitual es la prescripción
of optical correction. This is necessary in myopes with visions
lower than 20/30, in hyperopes over 5 diopters, patients
with astigmatism of at least 1.5 diopters and when it is detected
amblyopia due to anisometropia, which usually occurs when the difference
between the two eyes is greater than one diopter. The prescription in
milder defects will depend on age and visual symptoms of the
child. When assessing a child's graduation, refraction is important.
8

under cycloplegia to avoid overestimating myopic defects. Only with

7

Wearing glasses or contact lenses with the correct prescription is possible.

resolve up to 30-50% of amblyopias due to anisometropia and up to
75-90% can improve. 9,10

In children under 7 years old with amblyopia, when the carrier

Continuation of glasses is not enough, other measures are necessary.
to stimulate the vision of the eye with lower vision.

The patch occlusion for 2 to 6 hours a day of the dominant eye has
proven to be effective in the treatment of moderate amblyopias and
severe. 11–16

Another effective therapy for the treatment of moderate amblyopia consists of

in applying atropine to the fixing eye, especially in patients
farsighted 8,13,17,18

The effectiveness of these therapies is related to the age of onset.

Well, the visual results are inferior in children over 7.
years. Treated with time closures or atropine, they improve at least
17

two lines, 50% of children between 7 and 12 years old, although only in 1 of
for every 5 children, vision will achieve unity.
19,20

Despite advances in the detection and treatment of the causes

most common visual deficits, there are still cases of low vision,
below 6/18 in both eyes, in childhood. In countries
developed countries, the annual average incidence of low vision is
3/100,000 children born at term and the prevalence of 38/100,000. 21

The most common causes in term-born children are atrophies.

of the optic nerve, congenital cataracts, visual impairment of
central origin, Leber's congenital amaurosis and retinoschisis
youth linked to X. It is important to detect them as soon as possible to
21
 integrate these visually impaired children into the programs of
rehabilitation that promotes their autonomy and personal development.

In newborns, we must pay attention to the fact that the eyeballs and the
orbits have been formed correctly. At any age, the detection
of nystagmus, leukocoria, strabismus or corneal opacity are
Reasons for preferred ophthalmological evaluation. But, how
we detect the most common problems such as defects of
refraction or amblyopia? The simplest test included in
the monitoring programs for healthy children is the evaluation of the
visual acuity with each eye separately. For this, you can use
multiple optotypes of which there are versions for younger children
small (fig. 3). But this alone is insufficient,
especially when the children are not very cooperative.

What is a Pinhole Camera?

View larger image

The Pinhole is an instrument used in ophthalmology and
optometry to assess the patient's visual acuity. This tool consists of
one or several holes of 1 mm in diameter. With the other eye covered, what
we must look through the little hole to perform the test of
visual acuity.

Visual acuity with pinhole

If the result of the visual acuity test with a pinhole is positive, it is
to say that the patient sees better through the pinhole is clear
that has a refractive defect. If the test is negative, even if not
a refractive defect is ruled out, it is likely that there is some functional lesion
of the visual system (for example in the retina or the optic nerve).

It is a quick and simple test in which we evaluate distance vision. Looking

through the hole the patient must read the optotypes down to the smallest size
small that can. When using optical correction, whether glasses or
contact lenses, you should see at least as well as with the help of the pinhole.
pinhole

The pinhole aperture is capable of improving visual acuity in patients.

with regular ametropias (myopia, hyperopia, astigmatism). Just as in
those with irregular astigmatism,keratoconusaccommodation paralysis or
Opacities of the lens (cataract). But how is it possible?, next
we explain the pinhole effect.

pinhole

The pinhole is used in visual assessment by all specialists, already

an ophthalmologist or optometrist provides us with a lot of information about visual capacity
each patient. The purpose of the pinhole is to increase the depth
patient's focus, and reduce retinal blurriness. This test should be applied to those
patients who can see up to 20/200 or less, on the 'nellen' scale. This tool helps us
will help during the visual acuity exam. This test consists of making someone see
patient for an opaque disk with several holes or perhaps it could only have one hole, that
they allow to quickly test the loss of visual acuity of a person is due to
refractive defect 'such as myopia or hyperopia (or if, on the contrary, there may be
any eye disease that should worry us. "The functioning is quite simple, if
We start from the basis that to see correctly we need light rays.

Part of the regular ametropias also helps in the paralysis of accommodation.

keratoconus, irregular astigmatism, lens opacities. Now we will go
explaining how the effect of the pinhole hole is. The rays of light are like
Arrows that go in several directions, now to obtain a clean image,
The rays of light that reach Sudiana, that is, all the rays of light must concentrate in
a single point of the retina, now to convert those rays that come out divergent from the
illuminated point in convergents within the eye, we have the optical system * a series of
lenses. + when the optical system is not perfect, we talk about errors or defects of
refraction, that means that the eye lenses cannot focus the image correctly
That is to say, the arrows do not reach the same point. Now explaining how the metaphor of the arrows works.
if we use an additional trick to improve the situation when the lenses were not working well,
we eliminate part of the deflected arrows using a panel that acts as a screen, with a
opening in the middle. The goalkeeper, the hole, of the panel and a target must be aligned, and
As it is not a perfect system, because some arrows can still get stuck by it.
hole that they do not give in the control of the target serves quite well. So to this
The property is called pinhole effect, so we see that the system consists of
block the peripheral rays with something opaque. )s% with the pinhole.
we can block the rays we don't need, and thus improve the
visual aid. )well in the next image we will be able to see how it works here
we can see a screen in front of the eye with a hole in the center, now the central rays
they are represented by solid lines and enter through the hole, the dashed lines
They represent the peripheral rays that will project far from the point they need to go to.
however, we see that they do not pass through the hole, so they ultimately do not reach the retina and
the nodes focus the image.

Thanks to this set of instruments, we know or realize that this

the mechanism is the same that shortsighted people use to see when they squint their eyes, and it is that when
By partially closing the eyelids, we also eliminate those annoying peripheral rays.