Pediatric Eye Evaluations

Publication Date: December 19, 2022
Last Updated: January 2, 2023


  • Amblyopia meets the World Health Organization criteria for a disease that benefits from screening because it is an important health problem for which there is an accepted treatment, it has a recognizable latent or early symptomatic stage, and a suitable test or examination is available to diagnose it before permanent vision loss occurs. The U.S. Preventive Services Task Force (USPSTF) recommends vision screening at least once for all children aged 3 to 5 years to detect amblyopia or its risk factors.
  • Vision testing with single optotypes is likely to overestimate visual acuity in a patient who has amblyopia. A more accurate assessment of monocular visual acuity is obtained by presenting a line of optotypes or a single optotype with crowding bars that surround (or crowd) the optotype being identified.
  • The choice and arrangement of optotypes (letters, numbers, symbols) on an eye chart can significantly affect the visual acuity score obtained. The preferred optotypes are LEA symbols, HOTV, and Sloan letters because they are standardized and validated.
  • Instrument-based screening techniques, such as photoscreening and autorefraction, are useful for assessing amblyopia and reduced-vision risk factors for children ages 1 to 5 years, as this is a critical time for visual development. Instrument-based screening can also be used for older children who are unable to participate in optotype-based screening. This type of screening has been shown to be useful in detecting amblyopia risk factors in children with developmental disabilities.
  • Vision screening should be performed at an early age and at regular intervals throughout childhood to detect amblyopia risk factors and refractive errors. The elements of vision screening vary depending on the age and level of cooperation of the child, as shown in Table 1.


Having trouble viewing table?


Indications for Referral

Recommended Age

Newborn– 6 mos

6–12 mos

1–3 yrs

3–4 yrs

4–5 yrs

Every 1–2 yrs after age 5 yrs

Red reflex test

Absent, white, dull, opacified, or asymmetric

External inspection

Structural abnormality (e.g., ptosis)

Pupillary examination

Irregular shape, unequal size, poor or unequal reaction to light

Fix and follow

Failure to fix and follow

Cooperative infant ≥3 mos

Corneal light reflection

Asymmetric or displaced

Cooperative infant ≥3 mos

Instrument- based screening*

Failure to meet screening criteria

Cooperative infant ≥6 mos

Cover test

Refixation movement

Worse than 20/50 either eye or 2 lines of differences between the eyes

Distance visual acuity† (monocular)

Worse than 20/40 either eye

Worse than 3 of 5 optotypes on 20/30 line, or 2 lines of difference between the eyes

SOURCE: Hagan JF, Shaw JS, Duncan PM, eds. 2017, Bright Futures: Guidelines for Health Supervision of Infants,
Children and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
NOTE: These recommendations are based on panel consensus. If screening is inconclusive or unsatisfactory, the child
should be retested within 6 months; if inconclusive on retesting, or if retesting cannot be performed, referral for a
comprehensive eye evaluation is indicated.9
* Subjective visual acuity testing is preferred to instrument-based screening in children who are able to participate
reliably. Instrument-based screening is useful for some young children and those with developmental delays.
† LEA Symbols10 (Good-Lite Co., Elgin, IL), HOTV, and Sloan Letters11 are preferred optotypes.

Recommendation Grading



Pediatric Eye Evaluations

Authoring Organization

Publication Month/Year

December 19, 2022

Last Updated Month/Year

February 13, 2024

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Document Objectives

Identify risk factors for ocular disease. Identify systemic disease based on associated ocular findings. Identify factors that may predispose to visual loss early in a child's life. Determine the health status of the eye and related structures and of the visual system and assess refractive errors. Discuss the nature of the findings of the examination and their implications with the parent/caregiver, primary care provider and, when appropriate, the patient. Initiate an appropriate management plan. 

Inclusion Criteria

Male, Female, Adolescent, Child, Infant

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, optician, optometrist, physician, physician assistant


Diagnosis, Assessment and screening, Prevention

Diseases/Conditions (MeSH)

D005128 - Eye Diseases


eye exam, blurred vision, pediatrics, vision loss

Source Citation

Hutchinson AK, Morse CL, Hercinovic A, Cruz OA, Sprunger DT, Repka MX, Lambert SR, Wallace DK; American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern. Ophthalmology. 2022 Dec 19:S0161-6420(22)00866-1. doi: 10.1016/j.ophtha.2022.10.030. Epub ahead of print. PMID: 36543602.

Supplemental Methodology Resources

Data Supplement, Data Supplement, Data Supplement


Number of Source Documents
Literature Search Start Date
July 1, 2021
Literature Search End Date
May 31, 2022