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Risk Factors for Eye Problems

  • Born very premature (gestational age of 30 weeks or less), less than 1500 grams at birth, or history of retinopathy of prematurity (ROP) or unstable clinical course.
    • Increased risk of strabismus, amblyopia, decreased visual acuity
    • If history of ROP, esp. if higher severity – increased risk of the above and retinal detachment, visual field loss
  • History of maternal “TORCH” infection during pregnancy    (Toxoplasmosis,Other,  Rubella, Cytomegalovirus, Herpes Simplex Virus)
  • Family history of
    • high refractive errors,
    • congenital or juvenile cataract,
    • aniridia,
    • glaucoma,
    • strabismus,
    • amblyopia,
    • retinoblastoma,
    • congenital retinal dysplasia,
    • other congenital retinal and lenticular disorders,
    • metabolic or genetic diseases,
    • color vision deficiency,
  • Neurological and developmental disorders
  • Presence of systemic disease associated with eye abnormalities, e.g. juvenile rheumatoid arthritis
  • Use of medications associated with eye or vision abnormalities

Symptoms and Signs of Eye Problems

  • Delay in acquiring visual developmental milestones
  • Habitual head tilt
  • Structural defects
  • Misaligned eyes or poor visual fixation
  • Light sensitivity, itchiness, pain or discomfort
  • Ocular discharge, crusting
  • Persistent redness or swelling
  • Recurring eyelid infections
  • Persistent tearing
  • Nystagmus
  • White pupil
  • Excessive eye rubbing
  • Covers or closes one eye
  • Inability to see things in the distance
  • Holds items excessively close to see or squints

Referral to Ophthalmologist:

  • Any child with risk factors listed above
  • Any child with trauma to the eye
  • Parental concern about vision
  • Newborns and Infants
    • Abnormal red reflex
    • Structural abnormalities of the eye
    • Poor visual tracking after three months of age (corrected)
    • Strabismus
    • Nystagmus
    • Chronic tearing or discharge
  • Toddlers and Preschool Children
    • Strabismus
    • Nystagmus
    • Chronic tearing or discharge
    • Persistent ptosis, eyelid mass or red eye
    • Asymmetric pupil size (>1mm)
    • Fail photoscreening
    • Unable to read at least 20/40 with either eye on acuity chart
    • Difference between right and left eye of two or more lines on visual acuity chart evaluation
  • Kindergarten and school age
    • Strabismus
    • Cannot read at least 20/30 with one or both eyes, or a two-line difference between eyes
    • Fail photoscreening
    • Not reading at grade level

Guidelines for Referral to a Pediatric Ophthalmologist -in Referral to Pediatric Surgical Subspecialists, Policy Statement by AAP Surgical Advisory Panel (2014)

A pediatric ophthalmologist has completed a residency in ophthalmology, is certified by the American Board of Ophthalmological Surgery, and has completed additional training of at least one year in pediatric ophthalmology. For purposes of developing these guidelines, the following age group definitions are used: infant (0–1 year), child (2–12 years), and adolescent (13–18 years).

Pediatric patients with the following conditions should be referred to a pediatric ophthalmologist:

  • Children 7 years or younger who are nonverbal or unable to read letters and in whom there is reason to suspect eye disease.
  • Infants or children with retinoblastoma or other tumors of the eye and orbital area.
  • Infants or children with known or suspected cataracts, glaucoma, or blindness.
  • Infants or children diagnosed with, or at risk of, retinopathy of prematurity.
  • Infants or children with congenital or genetic ocular anomalies or infections (eg, aniridia, toxoplasmosis).
  • Infants or children with systemic syndromes, metabolic disorders, or chromosomal abnormalities with possible ocular involvement (eg, juvenile rheumatoid arthritis, galactosemia, diabetes mellitus, Marfan syndrome, Down syndrome).
  • Infants or children suspected of being abused and in whom there is a possibility of eye injury.

Pediatric patients with the following conditions are preferably managed by a pediatric ophthalmologist:

  • Infants with congenital nystagmus and children with early onset nystagmus.
  • Children with strabismus or amblyopia (ie, dimness of vision without detectable organic lesion of the eye) or risk factors for strabismus or amblyopia (eg, family history of amblyopia, orbital or eyelid hemangioma).
  • Children with a family history of congenital or genetic ocular anomalies (eg, aniridia), infections (eg, toxoplasmosis), tumors (eg, retinoblastoma), or a family history of systemic or metabolic syndromes (eg, juvenile rheumatoid arthritis, galactosemia, diabetes mellitus), chromosomal abnormalities (eg, Down syndrome), or other disorders with possible ocular involvement.
  • Infants or children with exposure during gestation to drugs or other substances (including alcohol) that may cause anomalies of the eyes.
  • Infants or children with poor vision or delayed attainment of vision-related developmental milestones and infants and children with severe refractive errors or a strong family history of severe refractive errors.
  • Infants or children with ocular or periocular inflammation not responding to initial topical and/or systemic antibiotic therapy or not clearing within 3 weeks of treatment and children with suspected herpes simplex or zoster infections involving the eye or a history of these infections involving the eye.


  1. Screening examination of premature infants for retinopathy of prematurity.  American Academy of Pediatrics Section on Ophthalmology, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists. Pediatrics. 2013. 131:189-195.
  2. Policy Statement: Vision Screening for Infants and Children: A Joint Statement of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and the American Academy of Ophthalmology (AAO).  Issued March 2007.  Approved by the AAPOS Board of Directors July 2011.
  3. Clinical Statements: Eye Examination in Infants, Children, and Young Adults by Pediatricians – 2003: reaffirmed May 2007. American Academy of Ophthalmology.
  4. Instrument-Based Pediatric Vision Screening Policy Statement. Joint policy statement of the American Academy of Pediatrics, AAO, AAPOS and American Association of Certified Orthoptists. Pediatrics 2012; 130:983-986.