Eye Examinations in Children

Eye and vision examinations are important and need to be included in newborn and subsequent well child health supervision visits. If an infant or child is at high risk for a problem they need to be seen by a pediatric ophthalmologist or an ophthalmologist experienced in the care of children. At risk children include those who were very premature or have a family history of congenital cataracts, retinoblastomas or genetic/metabolic disease. Children with neurodevelopmental problems or physical conditions that affect the eye also require referral.
Most children do not complain of vision difficulty and cooperation for testing can be difficult. Screening for vision should be initiated at 3 years of age and any child with concerns needs to be referred for further evaluation.
The eye assessment in infants and children includes the following: a thorough history including family history, external inspection of eyes and lids, eye movement assessment, pupil examination and red reflex examination. Children starting at age 3 years need a visual acuity measurement and ophthalmoscopy if cooperation allows. If cooperation limits testing at age 3 then repeat screening is done 4-6 months later and referral can be pursued if testing concerns or if cooperation is not possible. For children age 4 years and older the same routine is followed with earlier repeat testing and referral as needed.
The assessment of ocular alignment is very important in the pre-school age child. Strabismus may occur at any age and can be a sign of serious underlying medical conditions. Some children will appear to have strabismus on observation due to prominent inner epicanthal lid folds that cover the inner portion of the eye. This is normal and does not require treatment. A referral to a pediatric ophthalmologist at the earliest age possible is necessary for children with eye muscle imbalances since this can lead to a loss of visual acuity that cannot be reversed.