- 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).
- Every effort should be made to ensure that eye examinations are performed using appropriate testing conditions, instruments, and techniques.
- 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.
- The results of vision assessments, visual acuity measurements, and eye evaluations, along with instructions for follow-up care, should be clearly communicated to parents.
- 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*
Ages 3-5 Years
Function: Distance visual acuity
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
Function: Distance visual acuity
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.