This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics (AAP). Eye examination and vision screening in infants, children, and young adults. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. Pediatrics 1996 Jul;98(1):153-7.

American Academy of Pediatrics (AAP) clinical reports automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

1. All pediatricians and other providers of health care to children should be familiar with the joint eye examination guidelines of the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, and the American Academy of Pediatrics (see table below).
2. Every effort should be made to ensure that eye examinations are performed using appropriate testing conditions, instruments, and techniques.
3. Newborns should be evaluated for ocular structural abnormalities, such as cataract, corneal opacities, and ptosis, which are known to result in vision problems, and all children should have their eyes examined on a regular basis.
4. The results of vision assessments, visual acuity measurements, and eye evaluations, along with instructions for follow-up care, should be clearly communicated to parents.
5. All children who are found to have an ocular abnormality or who fail vision screening should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.

Table. Eye Examination Guidelines*

Recommended Tests: Snellen letters; Snellen numbers; Tumbling E; HOTV; Picture tests (Allen figures, LEA symbols)

Referral Criteria: (1) Fewer than 4 of 6 correct on 20-ft line with either eye tested at 10 ft monocularly (i.e., less than 10/20 or 20/40) or (2) Two-line difference between eyes, even within the passing range (i.e., 10/12.5 and 10/20 or 20/25 and 20/40)

Comments: (1) Tests are listed in decreasing order of cognitive difficulty; the highest test that the child is capable of performing should be used; in general, the tumbling E or the HOTV test should be used for children 3-5 years of age and Snellen letters or numbers for children 6 years and older. (2) Testing distance of 10 ft is recommended for all visual acuity tests. (3) A line of figures is preferred over single figures. (4) The nontested eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to eye; the examiner must ensure that it is not possible to peek with the nontested eye.

Function: Ocular alignment

Recommended Test: Cross cover test at 10 ft (3 m)

Referral Criteria: Any eye movement

Comments: Child must be fixing on a target while cross cover test is performed.

Recommended Test: Random dot E stereo test at 40 cm

Referral Criteria: Fewer than 4 of 6 correct

Comments: None

Recommended Test: Simultaneous red reflex test (Bruckner test)

Referral Criteria: Any asymmetry of pupil color, size, brightness

Comments: Direct ophthalmoscope used to view both red reflexes simultaneously in a darkened room from 2 to 3 feet away; detects asymmetric refractive errors as well.

Function: Ocular media clarity (cataracts, tumors, etc.)

Recommended Test: Red reflex

Referral Criteria: White pupil, dark spots, absent reflex

Comments: Direct ophthalmoscope, darkened room. View eyes separately at 12 to 18 inches; white reflex indicates possible retinoblastoma.

Ages 6 Years and Older

Recommended Tests: Snellen letters; Snellen numbers; Tumbling E; HOTV; Picture tests (Allen figures, LEA symbols)

Referral Criteria: (1) Fewer than 4 of 6 correct on 15-ft line with either eye tested at 10 ft monocularly (i.e., less than 10/15 or 20/30) or (2) Two-line difference between eyes, even within the passing range (i.e., 10/10 and 10/15 or 20/20 and 20/30)

Comments: (1) Tests are listed in decreasing order of cognitive difficulty; the highest test that the child is capable of performing should be used; in general, the tumbling E or the HOTV test should be used for children 3-5 years of age and Snellen letters or numbers for children 6 years and older. (2) Testing distance of 10 ft is recommended for all visual acuity tests. (3) A line of figures is preferred over single figures. (4) The nontested eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to eye; the examiner must ensure that it is not possible to peek with the nontested eye.

Function: Ocular alignment

Recommended Test: Cross cover test at 10 ft (3 m)

Referral Criteria: Any eye movement

Comments: Child must be fixing on a target while cross cover test is performed.

Recommended Test: Random dot E stereo test at 40 cm

Referral Criteria: Fewer than 4 of 6 correct

Comments: None

Recommended Test: Simultaneous red reflex test (Bruckner test)

Referral Criteria: Any asymmetry of pupil color, size, brightness

Comments: Direct ophthalmoscope used to view both red reflexes simultaneously in a darkened room from 2 to 3 feet away; detects asymmetric refractive errors as well.

Function: Ocular media clarity (cataracts, tumors, etc.)

Recommended Test: Red reflex

Referral Criteria: White pupil, dark spots, absent reflex

Comments: Direct ophthalmoscope, darkened room. View eyes separately at 12 to 18 inches; white reflex indicates possible retinoblastoma.

* Assessing visual acuity (vision screening) represents one of the most sensitive techniques for the detection of eye abnormalities in children. The American Academy of Pediatrics Section on Ophthalmology, in cooperation with the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Ophthalmology, has developed these guidelines to be used by physicians, nurses, educational institutions, public health departments, and other professionals who perform vision evaluation services.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

2003 Apr

American Academy of Pediatrics - Medical Specialty Society

American Academy of Ophthalmology
American Academy of Pediatrics
American Association for Pediatric Ophthalmology and Strabismus (AAPOS)
American Association of Certified Orthoptists

Committee on Practice and Ambulatory Medicine and Section on Ophthalmology

Primary Authors: Jack Swenson, MD (Chairperson); Edward G. Buckley, MD

Committee on Practice and Ambulatory Medicine, 2001-2002: *Jack Swanson, MD (Chairperson); Kyle Yasuda, MD (Chairperson-Elect); F. Lane France, MD; Katherine Teets Grimm, MD; Norman Harbaugh, MD; Thomas Herr, MD; Philip Itkin, MD; P. John Jakubec, MD; Allan Lieberthal, MD

Staff: Robert H. Sebring, PhD; Junelle Speller

Liaison Representatives: Adrienne A. Bien; Todd Davis, MD; Winston S. Price, MD

Section on Ophthalmology, 2001-2002: Gary T. Denslow, MD, MPH (Chairperson); Steven J. Lichtenstein, MD (Chairperson-Elect); Jay Bernstein, MD; *Edward G. Buckley, MD; George S. Ellis, Jr, MD; Gregg T. Lueder, MD; James B. Ruben, MD

Consultants: Allan M. Eisenbaum, MD; Walter M. Fierson, MD; Howard L. Freedman, MD; Harold P. Koller, MD (Immediate Past Chairperson)

Staff: Stephanie Mucha, MPH

American Association of Certified Orthoptists: Kyle Arnoldi, CO (Liaison to the AAP Section on Ophthalmology)

American Association for Pediatric Ophthalmology and Strabismus: Joseph Calhoun, MD (Liaison to the AAP Section on Ophthalmology); Jane D. Kivlin, MD (Past Liaison to the AAP Section on Ophthalmology)

American Academy of Ophthalmology: Michael R. Redmond, MD

*Lead authors

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatrics (AAP). Eye examination and vision screening in infants, children, and young adults. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. Pediatrics 1996 Jul;98(1):153-7.

American Academy of Pediatrics (AAP) clinical reports automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

None available

None available

This NGC summary was completed by ECRI on August 18, 2003. The information was verified by the guideline developer on September 8, 2003.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest Point Blvd, Elk Grove Village, IL 60007.