Vision Screening Online Training Program - External Inspection

Vision Screening Online Training Program

Module 3: External Inspection and Observation
(C&TC: Often performed by the health care provider)

External inspection means simply looking at the eyes with your own eyes. Look at the sclera (the clear covering of the visible eye) and note if there is any redness or unusual spots or markings. Look at the whites of the eyes. Notice if they are reddened, yellowed, have exudate or any brown spots. Look at the iris (the colored portion of the eye) to make sure that the eyes are the same color and that there are not any unusual markings.

Look at the pupils to make sure that they are round and the same size. They should also be black and not cloudy or white. If they are white (leukocoria) then an immediate referral to an ophthalmologist is required. Also, look at the lids and lashes for any abnormalities.

Refer to the illustration below to view what a normal eye should look like. Click on the links below to see what kind of abnormalities (e.g., Whites, Iris, Pupil, and Lids/Lashes) would require referral.

Normal eye showing the upper eyelid, sclera, pupil, iris, lacrimal papilla, lacrimal caruncle, and the pilca semilunaris

W - Whites: The sclera covering the whites should be clear. There should be no discoloration or growths.

Picture of abnormal whites

I - Iris: The iris should be a complete circle. Both should be the same color.

Picture of abnormal iris

P - Pupil: The pupils should be clear and dark. There should be no cloudiness or white discoloration. The pupils should be of equal size and circular shape.

Picture of abnormal pupils

Lids and Lashes: The lids in their natural, open position should give a full view of the pupil. The lids should be free of lumps (chalazia). There should not be redness or signs of discharge along the margin or signs of a sty. The margin of the lid should be flush against the surface of the eye. The child should show normal blinking during observation period. Lashes should be present on the top and bottom lids of both eyes. Lashes should not turn in, causing them to come in contact with the eye.

Pictures of abnormal lids and lashes


Observation involves looking at the position of the child’s eyes and head for an indication of strabismus (crossed eyes)

Eyes may cross or turn for various reasons, the goal of screening is to note if an eye crosses and if so, refer to an eye professional. The screener may observe either one or both eyes turning or crossing. The eyes may always turn/cross or may only turn occasionally (i.e. when tired or under stress).

If any eye is always turned or crossed, it is termed a -tropia. If any eye only occasionally turns, it is called a -phoria. In addition, the direction of the way the eye turns should also be noted. For example, if an eye turns in towards the nose, it is called 'eso-', if the eye turns out towards the temple, it is called 'exo' If the eye turns upward, it is called 'hyper' and if the eye turns down, it is called 'hypo-'.

If the eye is always turned IN towards the nose, it is called esotropia. If it only occasionally turns IN, it is called intermittent esotropia.

If the eye is always turned OUT towards the ears, it is called exotropia. If it only occasionally turns OUT, it is called intermittent exotropia.

If the eye is always turned UP towards the eyebrows, it is called hypertropia. If it only occasionally turns UP, it is called intermittent hypertropia.

You may note an eye turning DOWN. This is called hypotropia, or intermittent hypotropia if it is occasional. This is very rare.

examples of Esotropia, Exotropia, Hypertropia, and Hypotropia as described above

Procedure for External Inspection and Observation

Post newborn through 20 years.

To check for signs of external eye disease or abnormalities.

A systematic inspection of observable parts of the eye and surrounding tissue.


Screener qualifications
In school and community settings this procedure can be performed by screeners who have received the Minnesota Department of Health recommended training or equivalent.

Well-lit room without distractions.


  1. The area around the eyes should be checked for swelling and/or discoloration, excessive tearing, or discharge.
  2. Observe the child’s eyes to see if one eye appears to turn in, out, up, or down in relation to the other. The eyes should hold steady, without excessive movement (nystagmus), while gazing straight ahead. The position of a persistent head tilt should also be noted. When performing this procedure on a child with glasses, leave their glasses on. Rationale for wearing glasses during observation.
  3. The eyes themselves should be checked in the order suggested by the acronym "WIPL."

Normal appearance of all parts of the eye.

Any noted abnormality:

  • If a white pupil (leukocoria) is noted, an immediate referral to an ophthalmologist or optometrist is necessary.
  • If one eye appears to turn in (eyes cross), out, up, or down in relation to the other, there is excessive movement (nystagmus), or a persistent abnormal head position, the child should be referred to an ophthalmologist or optometrist.
  • Signs of excessive redness and/or discharge indicate the screening should be stopped and the child referred to their primary health care provider, ophthalmologist or optometrist to reduce the risk of spreading a possible infection and/or falsely failing the screening.
  • Screening should be rescheduled for the next available time.


If a child appears to have conjunctivitis, the screener should refer the child?
After the rest of the vision screening has been completed
Not at all. It is not needed to refer a child for conjunctivitis.

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