Assessment of the visual system in infants and children

Age	Important aspects of history	Examination	Ophthalmology referral indications
Newborn to 6 months	Birth weight <1500 grams or gestational age <30 weeks Family history of: Congenital cataracts Retinoblastoma Metabolic or genetic disease	Vision assessment (fixate and follow response) External eye examination (lids, orbit, conjunctiva, cornea, iris) Pupillary response Simultaneous red reflex	Positive history Abnormal examination (eg, abnormal red reflex, pupillary asymmetry of ≥1 mm, unilateral ptosis, unable to fix and follow by age 3 months)
6 to 12 months	Neurologic abnormality Systemic disease associated with eye abnormalities Does the infant recognize faces and objects? Does the infant fix and follow? Do the parents notice: Eye deviation? Tearing?	Vision assessment (fixate and follow response) External eye examination (lids, orbit, conjunctiva, cornea, iris) Ocular motility Pupillary response Simultaneous red reflex	Positive history Abnormal examination (eg, abnormal red reflex, pupillary asymmetry of ≥1 mm, unilateral ptosis, unable to fix and follow)
1 to 3 years	Neurologic abnormality Systemic disease associated with eye abnormalities Does the child recognize faces and objects? Does the child fix and follow? Do the parents notice: Eye deviation? Tearing?	Age-appropriate visual assessment: Infants and young toddlers: Fixate and follow response Cooperative older toddlers: Monocular visual acuity with HOTV* or LEA^¶ optotypes Instrument-based vision screening (eg, photoscreening, autorefraction) if available External eye examination (lids, orbit, conjunctiva, cornea, iris) Ocular motility Pupillary response Simultaneous red reflex Ophthalmoscopy if possible	Positive history Abnormal examination (eg, abnormal red reflex, pupillary asymmetry of ≥1 mm, unilateral ptosis) Eye preference or unable to fix and follow Ocular alignment abnormalities Visual acuity worse than 20/50 in 1 or both eyes Visual acuity difference of 2 or more lines between eyes Failed instrument-based screening as indicated by the device
4 to 5 years	Neurologic abnormality Systematic disease associated with eye abnormalities Does the child recognize faces and objects? Do the parents notice: Abnormal head posturing? Squinting or blepharospasm? Eye deviation? Tearing?	External eye examination (lids, orbit, conjunctiva, cornea, iris) Ocular motility Pupillary response Simultaneous red reflex Corneal light reflex Ocular alignment (cover-uncover test) Monocular visual acuity^Δ◊: Snellen letters or numbers Surrounded HOTV* or LEA^¶ optotypes Instrument-based vision screening (eg, photoscreening, autorefraction) if available Ophthalmoscopy if possible	Positive history Abnormal examination (eg, abnormal red reflex, pupillary asymmetry of ≥1 mm, unilateral ptosis) Eye preference Ocular alignment abnormalities Visual acuity worse than 20/40 for children 48 through 59 months or worse than 20/30 for children ≥60 months in 1 or both eyes Visual acuity difference of 2 or more lines between eyes Failed instrument-based screening as indicated by the device
>6 years	Neurologic abnormality Systematic disease associated with eye abnormalities Does the child recognize faces and objects? Do the parents notice: Abnormal head posturing? Squinting or blepharospasm? Eye deviation? Tearing?	External eye examination (lids, orbit, conjunctiva, cornea, iris) Ocular motility Pupillary response Simultaneous red reflex Monocular visual acuity^◊: Sloan or Snellen letters or numbers Surrounded HOTV* LEA symbols^¶ Ophthalmoscopy if possible	Positive history Abnormal examination (eg, abnormal red reflex, pupillary asymmetry of ≥1 mm, unilateral ptosis) Eye preference Ocular alignment abnormalities Visual acuity worse than 20/30 in 1 or both eyes Visual acuity difference of 2 or more lines between eyes

* HOTV is an optotype vision chart using only the letters H, O, T, and V. "Surrounded" HOTV refers to the use of crowding bars around the letters. Crowding bars improve detection of amblyopia and should be used when single optotypes rather than a row of figures are presented.
¶ LEA is an optotype vision chart using 4 simple shapes (an apple, a pentagon, a square, and a circle).
Δ Testing distance of 10 feet is recommended; testing with line of figures rather than single figures is preferred.
◊ Instrument-based vision screening (eg, photoscreening, autorefraction) is suggested if visual acuity testing cannot be performed with age-appropriate optotypes.

Adapted from:

Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, et al. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics 2015.
Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, et al. Procedures for the evaluation of the visual system by pediatricians. Pediatrics 2015.
Essman SW, Essman TF. Screening for pediatric eye disease. Am Fam Phys 1992; 46:1243.

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Assessment of the visual system in infants and children