Pediatric Eye Evaluations
HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE
- 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.
AGE-APPROPRIATE METHODS FOR PEDIATRIC VISION SCREENING AND CRITERIA FOR REFERRAL
| Method |
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
Overview
Title
Pediatric Eye Evaluations
Authoring Organization
American Academy of Ophthalmology
Publication Month/Year
December 19, 2022
Last Updated Month/Year
February 13, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
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
Scope
Diagnosis, Assessment and screening, Prevention
Diseases/Conditions (MeSH)
D005128 - Eye Diseases
Keywords
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.