Case History

• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• Time spent outdoors, on near work and screen viewing
• Names of, contact information for, patient’s other health care providers

Visual System Health Status Evaluation

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Binocularity – ocular alignment (cover test, Hirschberg, Krimsky, Bruckner, Stereopsis, near point of convergence) Any of test is sufficient
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Tonometry (Tactile) – If child is cooperative
• Screening visual fields/confrontations at doctor’s discretion

*Note: Fundus photos and optomap^® retinal exams are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

Entering and Best Corrected Visual Acuity
Suggested measure of acuity assessment, not limited to the following (recorded monocularly):

• Fixation preference tests
• Bruckner’s test
• Preferential looking visual acuity test
• Fix and follow and Visual evoked potential

Refraction or Autorefraction

• Cycloplegic retinoscopy
• Static retinoscopy

Case History

• Identification and description of the chief complaint
• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history and review of systems
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• Time spent outdoors, on sports activities, on near work and screen viewing
• Names of, and contact information for, the patient’s other health care providers

Visual System Health Status Evaluation

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Binocularity – ocular alignment at distance and near (cover test, Hirschberg, Krimsky, Stereopsis,near point of convergence, Positive and Negative Fusional Vergence, Accomodative convergence) Any one test is sufficient
• Screening visual fields/confrontations at doctor’s discretion
• Color Vision Testing – Once in lifetime
• Tonometry – if child is cooperative

*Note: Fundus photos and optomap^® are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

Entering and Best Corrected Visual Acuity

Suggested measure of quantitative acuity, not limited to the following (recorded monocularly):

• Broken wheel acuity cards
• Lighthouse cards with matching blocks
• HOTV test
• Tumbling E chart
• Snellen acuity chart
• Lea symbols and Sloan letters

Refraction or Autorefraction

At least one, with corrected visual acuity as stated at left:

• Static retinoscopy
• Cycloplegic retinoscopy

Accommodation

Accomodative Function is a guideline based on the doctor’s professional judgment and not an exam requirement. Any near point accommodation testing is performed when clinically indicated.

Case History

• Identification and description of the chief complaint
• Visual and ocular history
• Prenatal, perinatal, and postnatal general health history
• Current medications and medication allergies
• Family eye and medical histories
• Child’s developmental history
• School performance history
• Time spent outdoors, on sports activities, on near work and screen viewing
• Names of, and contact information for, the patient’s other health care providers

Visual System Health Status Evaluation

• External exam
• Biomicroscopy (anterior segment photos are separate procedures. They’re not acceptable in place of biomicroscopy without separate documentation of anterior segment findings)
• Internal/Fundus exam including direct and/or indirect ophthalmoscopy with or without pupillary dilation and at minimum, a numerical notation of cup-to-disc ratio documented for each eye*
• Pupillary reflexes
• Ocular motility/Versions (must be recorded separately from binocular function testing)
• Binocularity – ocular alignment at distance and near (cover test, Hirschberg, Krimsky, Stereopsis,near point of convergence, Positive and Negative Fusional Vergence, Accomodative convergence) Any one test is sufficient
• Screening visual fields/confrontations at doctor’s discretion
• Color Vision Testing – Once in lifetime
• Tonometry Guideline: Attempt either applanation or noncontact at the earliest age that a child is cooperative. Tactile estimations acceptable if documentation supports the reason why numerical tonometry wasn’t performed.

*Note: Fundus photos and optomap^® retinal exams are separate procedures. They’re not acceptable in place of performing direct or indirect ophthalmoscopy.

Entering and Best Corrected Visual Acuity

Suggested measure of acuity assessment, any one test is sufficient. (Must be recorded monocularly):

• Bruckner’s test
•  Snellen acuity chart
• ETDRS Visual Acuity

Refraction

• Static retinoscopy or Auto refractor results- acceptable in non-verbal patients
• Determination of refractive state with best corrected visual acuities (recorded monocularly). Testing may be delegated to qualified staff under the supervision of a licensed VSP Network Doctor (as permitted by state regulation) and may be done with or without DPA's (diagnostic pharmaceutical agents)
• Cycloplegic retinoscopy

Accommodation

• Accommodative Function is a guideline based on the doctor's professional judgment and not an exam requirement. Any near point accommodation testing is performed when clinically indicated.