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Paediatr Child Health. 1998 Jul-Aug; 3(4): 261–262.
PMCID: PMC2851347

Vision screening in infants and children

Periodic visual screening in paediatrics has been traditionally directed at preschoolers for the early detection of amblyopia (a reduction in the quality of central corrected vision resulting from a disturbance in retinal image formation) (1). The two most common causes of this visual loss are strabismus and unequal refractive error. Amblyopia has a prevalence of approximately 1% to 5% and is the leading cause of unilateral vision loss in the 20- to-70-year-old age group.

While it appears that the burden of this condition is sufficient to justify universal screening, recent and extensive reviews of the evidence-based literature identified significant concerns about the validity and reliability of current screening tests (2,3). Moreover, questions still remain about the impact of early detection of amblyopia on treatment outcome.

The emergence of photoscreening by photographic or computer and video methods represents a major innovation in screening techniques. The potential of this manoeuvre in screening for strabismus, refractive error and amblyopia is both exciting and very encouraging. However, an insufficient database of well-designed cohort studies or randomized controlled trials prevent the endorsement of photoscreening as the modality of choice for visual screening at this time.

Despite these limitations, all children should be screened in their preschool years for amblyopia or its risk factors, as well as for ocular diseases that may have serious consequences, such as retinoblastoma and cataracts. While the paediatrician has a unique opportunity to examine a child’s eyes for pathology periodically, and is instrumental in case-finding based on perinatal risk factors or genetics, the responsibility for screening of visual acuity is currently shared by a variety of individuals in both the private and public health sectors. To maximize the sensitivity and specificity of the existing visual charts used for screening tests, it is essential that a screener is trained to administer a given test effectively. It remains the responsibility of the child’s paediatrician to ensure that these tests are performed by the most qualified personnel.

Recommendations can be made based on the current understanding of paediatric developmental ophthalmology (46) and the existing epidemiological data (2,3,7,8). The frequency of visual screening in these guidelines underscores the critical period for amblyopia detection and is intended to enhance the opportunities for a child to be screened.


A. Newborn to three months

  • A complete examination of the skin and external eye structures as well as the conjunctiva, cornea, iris and pupils is an integral part of the physical examination of all newborns, infants and children.
  • The red reflex should be inspected for lenticular opacities (cataracts) and signs of posterior eye disease (retinoblastoma).
  • Failure of visualization or abnormalities of the red reflex are indications for referral to an opthalmologist.
  • Corneal light reflex should be tested to detect ocular misalignment.

B. Six to 12 months

  • Conduct examination as above.
  • Ocular alignment should again be observed to detect strabismus. The corneal light reflex should be central and the cover-uncover test normal.
  • Fixation and following are observed.

C. Three to four years

  • Conduct examination as above.
  • Visual acuity testing with an optotype test (eg, E acuity card or Allen chart) should be completed.
  • A child with visual acuity less than 20/30 should be referred to an ophthalmologist.

D. Five years

  • Conduct examination as above.

E. Six to 18 years

  • Visual acuity should be assessed every two years until age 10 years, then every three years thereafter (eg, Snellen chart).


*Adapted from the American Academy of Ophthalmology Preschool Vision Screening Program recommendations, 1992.


Members: Drs Fabian P Gorodzinsky, London, Ontario; Nasirmohamed Jetha, Vancouver, British Columbia; Denis Leduc, Montreal, Quebec (chair, principal author); Paul Munk, Toronto, Ontario (director responsible); Peter G Noonan, Charlottetown, Prince Edward Island; Sandra Woods, Val-d’Or, Québec

The recommendations in this Clinical Practice Guideline do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.


1. Friendly DS. Amblyopia: Definition, classification, diagnosis, and management considerations for pediatricians, family physicians, and general practitioners. Pediatr Clin North Am. 1987;34:1389–401. [PubMed]
2. Simons K. Preschool vision screening: Rationale, methodology and outcome. Surv Ophthalmol. 1996;41:3–30. [PubMed]
3. Feightner JW. The Canadian Task Force on the Periodic Health Examination. Ottawa: Public Works and Government Services Canada; 1994. Routine preschool screening for visual and hearing problems. Canadian guide to clinical preventive health care.
4. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screening in pediatric practice: A study from the Pediatric Research in Office Settings (PROS) Network. Pediatrics. 1992;89:834–8. [PubMed]
5. Reinecke RD. Ophthalmic examination of infants and children by the pediatrician. Pediatr Clin North Am. 1983;30:995–1002. [PubMed]
6. Friendly DS. Development of vision in infants and young children. Pediatr Clin North Am. 1993;40:693–703. [PubMed]
7. Fulton A. Screening preschool children to detect visual and ocular disorders. Arch Ophthalmol. 1992;110:1553–4. (Edit) [PubMed]
8. Catalano RA, Nelson LB. A Text Atlas. Norwalk: Appleton and Lange; 1994. Pediatric Ophthalmology.

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