Teaching case. A child has been referred "for patching" after failing the chart at kindergarten. The referral contains no refraction, no mention of the fundus, no strabismus. Prescribing a patch on such a referral means treating a number, not a child. The PPP requires that the initial evaluation of suspected amblyopia be a comprehensive ophthalmic examination focused on risk factors: strabismus, anisometropia, family history, ptosis, media opacity, structural defects.
A history that cannot be reduced to "complaint about an eye". The PPP lists: who is giving the history and in what language; who else is caring for the child; perinatal history (gestational age, birth weight, smoking/alcohol/drugs during pregnancy — as risk facts, not as blame); developmental delay; family history of strabismus, amblyopia, childhood cataract, glaucoma. Prematurity <30 weeks, weight <1500 g, cerebral palsy, syndromes with ocular involvement (the PPP names Down syndrome), uveitis and ptosis are reasons for at least one full examination once the factor is identified.
The examination as a sequence, not a menu. The key elements of the Amblyopia PPP:
- binocular red reflex (Brückner) before dilation — otherwise subtle asymmetry is lost;
- binocularity / stereopsis — before patching and the cover test;
- acuity and/or fixation pattern;
- alignment and motility;
- pupils;
- external examination;
- anterior segment;
- cycloplegic retinoscopy / refraction with subjective refinement when possible;
- fundus examination.
Brückner from 45–75 cm, ophthalmoscope lens at "0", darkened room, both eyes at once. Normal is a symmetrical red reflex. Abnormal is an opacity in the reflex, a markedly diminished, white or yellow reflex, or asymmetry. The PPP reminds us: the appearance of the reflex depends on fundus pigmentation, that is, on race and ethnicity; significant hyperopia gives a brighter inferior crescent, myopia a superior one. It is a screening manoeuvre, not a substitute for refraction.
Why stereopsis so early. Because dissociation (patching, cover) itself breaks what you want to see. High-grade stereopsis supports the hypothesis of normal alignment; its absence does not prove amblyopia.
Document the child's cooperation. The PPP asks for the level of cooperation to be recorded: otherwise "0.3 today and 0.7 in a month" is read as treatment, when it was a different level of engagement. In amblyopia, measurement noise is part of the working environment of the disease, not a "whim".
When this set is not enough. Colour vision, visual fields and examination of the periphery with a lid speculum — according to the task, not for everyone. The periphery in a young child often requires sedation; this decision is not "about amblyopia" but about excluding organic disease if the central fundus does not explain the picture.
The risk factors for which the PPP wants at least one full examination, once more as a list, because they are missed in outpatient clinics: uveitis; ptosis; gestation <30 weeks; weight <1500 g; delayed visual or neurological maturation of unclear nature; cerebral palsy; syndromes with ocular involvement; family history of amblyopia, strabismus, childhood cataract, childhood glaucoma.
The lesson's boundary. This plan is not kindergarten screening. Screening catches a suspicion. The diagnosis of amblyopia is made by an examination that has found both an acuity deficit and a factor. Without a factor the PPP requires a search for an alternative, not a label.