See:

  • 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.
  • Clinical Statements: Eye Examination in Infants, Children, and Young Adults by Pediatricians – 2003: reaffirmed May 2007. American Academy of Ophthalmology.
  • 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.
  • Vision Screening for Children 1 to 5 years of Age: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2011; 127:340-346.

Assessment Steps

For information on specific tests and procedures see: Vision Screening Tools and Tests section

  1. History of eye problems, past medical history and family history (Ocular history)
  2. Vision assessment
    • Test the ability to fix on an object, maintain fixation,  and follow objects visually into various gaze positions.
    • Examine each eye independently and then both eyes together.
    • Children who have corrective lenses should have vision assessment performed while wearing the glasses.
  3. External inspection of eyes and lids
    • Eyelids and orbits (incl. r/o ptosis)
    • External structure of the eyes
  4. Ocular motility assessment
    • Eye motility (EOMs)
    • Eye muscle balance
  5. Pupil exam /Pupil responses
  6. Red Reflex – All infants should have a red reflex exam in the first 2 months of life by a pediatrician or primary care providerer trained in this technique. Assess individual red reflexes (one eye at a time) and simultaneous red reflex (Bruckner test)

Instrument-Based Vision Screnning (Photoscreening and Autorefraction): An Option – Children 6 months to 5 years can benefit from this automated vision screening technology which does not depend on behavioral responses of the child. The evaluator must know how to properly apply the technology. It is especially useful in the preverbal, preliterate or developmentally delayed child.  Instrument-based screening dies not measure acuity, but assesses for the presence of amblyopia risk factors.

Who to Refer for Ophthalmologic Assessment

  • Any child who does not pass risk factor screening or observation.
  • Any alert, awake child who fails to fix and follow binocularly after 3 months of age.
  • Any child with anatomic abnormality, poor visual fixation, eye misalignment, asymmetric or abnormal red reflexes, or nystagmus
  • Traumatic injury to the eye

Further Assessment – Visual Acuity

In infants and young children, visual acuity is most accurately determined by “preferential looking tests” (Teller Acuity Card test).  Testing in the child under three is challenging and usually requires specially trained personnel.

Results of vision assessments, visual acuity measurements (if performed), eye evaluations and recommendations for follow-up care should be clearly communicated to parents.