Comprehensive Pediatric Eye and Vision Examination

Evidence-Based Clinical Practice Guideline

Comprehensive

Pediatric Eye and

Vision Examination

The American Optometric Association represents approximately 39,000 doctors of optometry, optometry students

and paraoptometric assistants and technicians. Optometrists serve individuals in nearly 6,500 communities across

the country, and in 3,500 of those communities are the only eye doctors. Doctors of optometry provide two-thirds of

all primary eye care in the United States.

Doctors of optometry are on the frontline of eye and vision care. They examine, diagnose, treat, and manage

diseases and disorders of the eye. In addition to providing eye and vision care, optometrists play a major

role in an individual’s overall health and well-being by detecting systemic diseases such as diabetes and

hypertension.

The mission of the profession of optometry is to fulﬁll the vision and eye care needs of the public through

clinical care, research, and education, all of which enhance the quality of life.

Disclosure Statement

This Clinical Practice Guideline was funded by the American Optometric Association (AOA) without ﬁnancial support

from any commercial sources. The Evidence-Based Optometry Guideline Development Group and other guideline

participants provided full written disclosure of conﬂicts of interest prior to each meeting and prior to voting on the

quality of evidence or strength of clinical recommendations contained within this guideline.

Disclaimer

Recommendations made in this guideline do not represent a standard of care. Instead, the recommendations are

intended to assist the clinician in the decision-making process. Patient care and treatment should always be based

on a clinician’s independent professional judgment, given the patient’s circumstances, and in compliance with state

laws and regulations.

The information in this guideline is current to the extent possible at the time of publication.

OPTOMETRY: THE PRIMARY EYE CARE PROFESSION

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE

COMPREHENSIVE PEDIATRIC EYE

AND VISION EXAMINATION

Developed by the AOA Evidence-Based Optometry Guideline Development Group

Approved by the AOA Board of Trustees February 12, 2017

©American Optometric Association 1995, 2002, 2015

243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

TABLE OF CONTENTS

EVIDENCE-BASED CLINICAL GUIDELINE

A. What is the Evidence-Based Process? .................5

B. How to Use This Guideline ....................................7

I. INTRODUCTION .......................................................10

A. Guideline Objectives ............................................10

II. BACKGROUND .........................................................10

A. Visual Development ..............................................10

B. Epidemiology of Eye and Vision Disorders in

Children .................................................................11

C. Access to Care .....................................................15

D. Costs of Eye and Vision Disorders in Children .. 16

E. Early Detection and Prevention of Eye and Vision

Disorders ..............................................................16

III. CARE PROCESS ..................................................... 17

A. Comprehensive Pediatric Eye and Vision

Examination ..........................................................17

1. General Considerations ....................................... 17

a. Infants and Toddlers .....................................18

b. Preschool Children ....................................... 18

c. School-age Children ..................................... 18

2. Examination Procedures .....................................18

3. Patient History.....................................................19

4. Testing ................................................................19

4.1 Testing of Infants and Toddlers .......................... 19

a. Visual Acuity ................................................. 19

b. Refraction ....................................................19

c. Binocular Vision and Ocular Motility .............. 20

4.2 Testing of Preschool Children ............................21

a. Visual Acuity ................................................. 21

b. Refraction ....................................................21

c. Binocular Vision, Ocular Motility, and

Accommodation..........................................22

d. Color Vision ..................................................22

4.3 Testing of School-age Children ..........................22

a. Visual Acuity ................................................. 22

b. Refraction ....................................................23

c. Binocular Vision, Ocular Motility, and

Accommodation..........................................23

d. Color Vision ..................................................24

5. Ocular and Systemic Health Assessment ...........24

a. Assessment of Pupillary Responses .............25

b. Visual Field Evaluation ..................................25

c. Evaluation of the Ocular Anterior Segment and

Adnexa .......................................................25

d. Evaluation of the Ocular Posterior Segment ..25

e. Measurement of Intraocular Pressure ...........25

6. Supplemental Testing .......................................... 25

a. Electrodiagnostic Testing .............................. 25

b. Imaging ........................................................ 25

c. Testing for Learning-related Vision Problems 26

7. Children with Special Needs ................................26

a. At-risk Children .............................................26

b. Developmental Disabilities ............................27

8. Trauma and Ocular Manifestations of Child Abuse/

Neglect ............................................................27

a. Trauma (Accidental) ...................................... 27

b. Ocular Manifestations of Child Abuse and

Neglect (Non-accidental) ............................. 27

9. Potential Beneﬁts and Harms of Testing ..............29

B. Assessment and Diagnosis .................................29

C. Management ........................................................ 29

1. Prescription for Correction...................................29

2. Additional Treatment Services .............................29

3. Counseling and Education ..................................29

a. Eye Safety and Protection ............................31

b. Ultraviolet Radiation and Blue Light

Protection ...................................................32

c. Impact of Near Work and Reduced Time

Outdoors on Vision .....................................32

d. Myopia Control .............................................33

4. Coordination and Frequency of Care ................... 33

a. Coordination of Care ....................................33

b. Frequency of Care ........................................34

c. At-risk Children .............................................39

D. Conclusion ............................................................39

IV. REFERENCES ..........................................................41

V. APPENDIX .................................................................55

A. Appendix Figure 1: Comprehensive Pediatric Eye

and Vision Examination: A Flowchart ................55

B. Appendix Table 1: Potential Components of the

Comprehensive Eye and Vision Examination for

Infants and Toddlers ............................................56

C. Appendix Table 2: Potential Components of the

Comprehensive Eye and Vision Examination for

Preschool Children ..............................................57

D. Appendix Table 3: Potential Components of the

Comprehensive Eye and Vision Examination for

School-age Children ............................................58

E. Appendix Table 4: Partial Listing of Ocular

Manifestations of Neurodevelopmental Disorders

and Other Syndromes ..........................................59

F. Abbreviations/Acronyms ......................................61

G. Summary of Action Statements .......................... 62

H. Gaps in Research Evidence .................................64

VI. METHODOLOGY FOR GUIDELINE

DEVELOPMENT .......................................................64

VII. EVIDENCE-BASED OPTOMETRY GUIDELINE

DEVELOPMENT GROUP ......................................... 66

EVIDENCE-BASED CLINICAL GUIDELINES

A. WHAT IS THE EVIDENCE-BASED PROCESS?

As a result of the Medicare Improvement for Patients and Providers Act of 2008, Congress commissioned the

Secretary of Health and Human Services to create a public-private program to develop and promote a common

set of standards for the development of clinical practice guidelines (CPGs). These standards address the structure,

process, reporting, and ﬁnal products of systematic reviews of comparative effectiveness research and evidence-

based clinical practice guidelines.

The Institute of Medicine (IOM), now the Health and Medicine Division of the National Academies of Sciences,

Engineering, and Medicine (NASEM), in response to a request from the Agency for Healthcare Research and Quality

(AHRQ), issued two reports in March 2011: Clinical Practice Guidelines We Can Trust and Finding What Works in

Health Care: Standards for Systematic Reviews.

In Clinical Practice Guidelines We Can Trust,

the IOM redeﬁned CPGs as follows

“Clinical practice guidelines are statements that include recommendations intended to optimize patient care that

are informed by a systematic review of the evidence and an assessment of the beneﬁts and harms of alternative

care options.”

The report states that to be trustworthy, guidelines should:

• Be based on a systematic review of existing evidence

• Be developed by a knowledgeable, multidisciplinary panel of experts and key stakeholders

• Consider important patient subgroups and preferences, as appropriate

• Be based on a transparent process that minimizes conﬂicts of interest and biases

• Provide a clear explanation of the logical relationships between alternative care options and health outcomes

• Provide a grading of both the quality of evidence and the strength of the clinical recommendation

• Be revised as appropriate when new evidence warrants modiﬁcations of recommendations.

Based on the IOM/NASEM reports, the American Optometric Association (AOA) Evidence-Based Optometry (EBO)

Committee developed a 14-step process to meet the new evidence-based recommendations for trustworthy

guidelines.

AOA’s 14 Steps to Evidence-Based Clinical Practice Guideline Development

1. Guideline Development Group: Evidence-Based Optometry (EBO) Committee selects a multidisciplinary panel of

experts, including patient and public representatives, for the Guideline Development Group (GDG).

2. Transparency and COI: GDG manages all conﬂict of interest (COI), which is documented by AOA staff.

3. Clinical Questions*: GDG explores and deﬁnes all clinical questions through a Question Formulation Meeting and

deﬁnes search criteria.

4. Search for Evidence: AOA Staff sends clinical questions for query (outside researchers) and provides all papers to

the Guideline Development Reading Group (GDRG). There should be no inclusion of Systematic Review (SR) writers in

the GDRG.

5. Grade Evidence and Clinical Recommendations: Two clinicians from the GDRG read and grade papers,

randomly selected according to the pre-designed evidence search criteria. They state clinical recommendation(s) from

each paper and grade the strength of each.

6. Articulate Clinical Recommendations*: GDRG reviews all clinical recommendations and articulates each for

inclusion in the guideline during an “Articulation of Recommendations” meeting and identiﬁed gaps in medical research

are documented.

7. Write Draft: AOA Staff sends the Articulation results to the writer for development of draft 1.

8. Draft Review and Edits*: GDG reads draft 1, discusses and edits.

9. Rewrite/Final Drafts: AOA Staff sends the draft results to the writer for writing/revisions for draft 2, then sends to

medical editor for copy editing, then a ﬁnal review is completed as necessary.

10. Approval for Peer Review: AOA Staff or EBO Committee Chair sends the Peer Review draft to AOA Board of

Trustees for approval to post for peer and public review. This draft is posted on the AOA website, the review period is

announced, and comments are solicited.

11. Final Document Produced: GDG reviews all peer review comments and revises the ﬁnal document (includes peer

review comments, documents why a peer review comment was not included, or identiﬁes further gaps for review when

preparing the next edition).

12. Final Draft Approval and Legal Review: AOA Staff or EBO Committee Chair sends to the AOA Board of

Trustees and AOA Legal Counsel for approval that the GDG followed the evidence-based process as outlined by the

IOM and AOA EBO Committee (same management of COI).

13. Post Guidelines: AOA Staff posts the evidence-based guideline to AOA website and submits it to the National

Guideline Clearinghouse for public use, accompanied by AOA’s written process and documents.

14. Schedule Reviews: GDG reviews all previously identiﬁed gaps in medical research and any new evidence, and

revises the evidence-based guideline every 2 to 5 years.

**Denotes face-to-face meeting

B. HOW TO USE THIS GUIDELINE

The following table provides the grading system used in this guideline for rating evidence-based clinical statements.

Grades are provided for both quality of the evidence and strength of clinical recommendations.

Key to Quality of Evidence and Strength of Clinical Recommendation Grading

Grade Quality of Evidence Levels

Data derived from well-designed, randomized clinical trials (RCTs); systematic reviews; meta-analyses; or

diagnostic studies (Grade A) of relevant populations with a validated reference standard. Grade A diagnostic

studies do not have a narrow population or use a poor reference standard and are not case control studies of

diseases or conditions.

Randomized clinical trials (RCTs) with weaker designs; cohort studies (retrospective or prospective); or

diagnostic studies (Grade B). Grade B diagnostic studies have only one of the following: a narrow population,

or the sample used does not reﬂect the population to whom the test would apply, or uses a poor reference

standard, or the comparison between the test and reference standard is not blinded, or are case control studies

of diseases or conditions.

Studies of strong design, but with substantial uncertainty about conclusions or serious doubts about

generalizations, bias, research design, or sample size. Nonrandomized trials; case control studies (retrospective

or prospective); or diagnostic studies (Grade C). Grade C diagnostic studies have at least 2 or more of the

following: a narrow population, or the sample used does not reﬂect the population to whom the test would

apply, or uses a poor reference standard, or the comparison between the test and reference standard is not

blinded, or are case control studies of diseases or conditions.

Cross sectional studies; case reports/series; reviews; position papers; expert opinion; or reasoning from

principal.

Strength of Clinical Recommendation Levels

Strong Recommendation: The beneﬁts of the recommendation clearly exceed the harms (or the harms clearly exceed

the beneﬁts in the case of a negative recommendation) and the quality of evidence is excellent (Grade A or B). In some

clearly identiﬁed circumstances, a strong recommendation may be made on lesser evidence when high-quality evidence

is impossible to obtain and the anticipated beneﬁts strongly outweigh the harms.

This recommendation should be followed unless clear and compelling rationale for an alternative approach

is present.

Recommendation: The beneﬁts of the recommendation exceed the harms (or the harms exceed the beneﬁts in the

case of a negative recommendation) but the quality of evidence is not as strong (Grade B or C). In some clearly identiﬁed

circumstances, a recommendation may be made on lesser evidence when high-quality evidence is impossible to obtain

and the anticipated beneﬁts strongly outweigh the harms.

This recommendation should generally be followed, but remain alert for new information.

Option: The beneﬁts of the recommendation exceed the harms (or the harms exceed the beneﬁts in the case of a

negative recommendation) but the quality of evidence is low (Grade D) or well-done studies (Grade A, B, or C) show little

clear advantage of one approach versus another. In some clearly identiﬁed circumstances, an option may be elevated

to a recommendation even with lesser evidence when high-quality evidence is impossible to obtain and the anticipated

beneﬁts strongly outweigh the harms.

There should be an awareness of this recommendation, but a ﬂexibility in clinical decision-making, as well as

remaining alert for new information.

Clinical Notes and Statements

Quality of evidence grades (A, B, C, or D) are shown throughout the guideline for clinical notes and statements. For

example, a clinical note or statement with a quality of evidence grade of “B” is shown as “(Evidence Grade: B)”.

Evidence-Based Action Statements will be highlighted in an “Action” box, with the quality of evidence, level of

conﬁdence, and clinical recommendation grading information listed. For example:

EVIDENCE-BASED ACTION STATEMENT: Parents/caregivers and children should be educated about

potential risks for eye injuries at home, at school, and during sports and recreational activities and advised

about safety precautions to decrease the risk of ocular injury.

193,199

Prevention of eye injuries in children should

focus on the use of protective eyewear, parental supervision, and on education about both the risks of eye

injury and the beneﬁts of protective eyewear.

194

Evidence Quality: Grade B: Retrospective cohort studies

Level of Conﬁdence: Medium

Clinical Recommendation Strength: Strong Recommendation. This recommendation should be followed

unless clear and compelling rationale for an alternative approach is present.

Evidence Statements: It is important to discuss eye safety issues with children/ parents/caregivers.

193

(Evidence Grade: B),

199

(Evidence Grade: B)

Prevention strategies should focus on the use of protective eyewear, parental supervision, and on childhood

education about both the risks of eye injury and the utility of protective eyewear.

194

(Evidence Grade: B)

Potential Beneﬁts: Reduction in eye injuries in

children

Potential Risks/Harms: None

Beneﬁt and Harm Assessment: Beneﬁts signiﬁcantly outweigh harms

Potential Costs: Direct cost of counseling as part of a pediatric eye and vision examination

Value Judgments: None

Role of Patient Preferences: None

Intentional Vagueness: Speciﬁc type/form of counseling is not stated, as it is patient speciﬁc

Gaps in Evidence: None identiﬁed

The Action Statement proﬁle provides additional information related to the development and implementation of the

clinical recommendation. The following is an explanation of the categories listed in the proﬁle:

Evidence Quality – The quality of evidence grade (A, B, C, or D) or the aggregate quality of evidence grade (if

multiple studies were available for review) and the type/method of research study or studies reviewed.

Level of Conﬁdence – The consistency of the evidence and the extent to which it can be trusted speciﬁed as

high, medium, or low.

Clinical Recommendation Strength – The grade (Strong Recommendation, Recommendation, or Option)

assigned to the implementation of the clinical recommendation made in the Action Statement.

Evidence Statements – The clinical statements derived from research studies reviewed that support the Action

Statement.

Potential Beneﬁts – Favorable changes which would likely occur if the Action Statement was followed.

Potential Risks/Harms – Adverse effects or unfavorable outcomes that may occur if the Action Statement was

followed.

Beneﬁt and Harm Assessment – A comparison of the relationship of beneﬁts to harms speciﬁed as “beneﬁts

signiﬁcantly outweigh harms” (or vice versa) or a “balance of beneﬁts and harms.”

Potential Costs – Direct and indirect costs refer to the costs of the procedure, test, or medication; time spent

counseling the patient; administrative time; parent/caregiver time off from work, etc.

Value Judgments – Determinations made by the Guideline Development Group in the development of the

Action Statement relating to guiding principles, ethical considerations, or other priorities.

Role of Patient Preference – The role the patient has in shared decision making regarding implementation of

the Action Statement speciﬁed as large, moderate, small, or none.

Intentional Vagueness – Speciﬁc aspects of the Action Statement that are left vague due to factors such as the

role of clinical judgment, patient variability, concerns over setting legal precedent, etc.

Gaps in Evidence – Areas identiﬁed during searches and evaluations of the research that show gaps in available

evidence.

Consensus-Based Action Statements, based on consensus by the Guideline Development Reading Group, are

also highlighted in an “Action” box, but without any quality of evidence or strength of clinical recommendation grading

information listed. For example:

CONSENSUS-BASED ACTION STATEMENT: At the conclusion of a comprehensive pediatric eye and vision

examination, the diagnosis should be explained to the patient/parent/caregiver and related to the patient’s

symptoms, and treatment plans and prognosis discussed.

Evidence Quality: There is a lack of published research to support or refute the use of this recommendation.

Beneﬁt and Harm Assessment: Implementation of this recommendation is likely to increase patient/

parent/caregiver understanding of any diagnosed eye or vision problems and improve compliance with any

recommended treatment. The beneﬁts of this recommendation were established by expert consensus opinion.

I. INTRODUCTION

Eye and vision problems in children are a signiﬁcant

public health concern. An estimated one in ﬁve

preschool children have vision problems.

2-8

In the United

States, about one in four school-age children wear

corrective lenses.

Since eye and vision problems can

become worse over time, early diagnosis and treatment

are essential to optimize children’s eye health and vision

and to prevent future vision loss.

Eye and vision disorders can lead to problems in a child’s

normal development,

10,11

school performance,

12-16

social

interactions,

and self-esteem.

17-19

Vision disorders that

occur in childhood may manifest as problems well into

adulthood, affecting an individual’s level of education,

employment opportunities, and social interactions.

Early recognition of visual disorders is especially

important in children with developmental and intellectual

disabilities.

21,22

Children with disabilities are reported to

have signiﬁcantly more eye and vision problems (e.g.,

strabismus, refractive errors, and nystagmus) than

children without these disabilities.

22-27

The increasing

severity of the disability may be related to a higher

prevalence of vision problems.

This Evidence-Based Clinical Practice Guideline for the

Comprehensive Pediatric Eye and Vision Examination

describes procedures for evaluation of the eye health

and vision status of infants and children. It contains

recommendations for timely diagnosis and, when

necessary, referral for consultation with, or treatment

by, another health care provider. Other guidelines

developed to address treatment of speciﬁc eye and

vision conditions can be found at AOA Clinical Practice

Guidelines web page.

The recommendations in this guideline were developed

to assist doctors of optometry and ophthalmologists

involved in providing eye and vision examinations for

infants and children. Others who assist in providing

coordinated patient care for speciﬁc services, as well as

patients, parents, and caregivers, may also gain insight

from this document.

A. GUIDELINE OBJECTIVES

This Guideline can help achieve the following objectives:

• Recommend an optimal timetable for comprehensive

eye and vision examinations for infants and children

(newborn through 18 years of age)

• Suggest appropriate procedures to effectively

examine the eye health, vision status, and ocular

manifestations of systemic disease of infants and

children

• Reduce the risks and adverse effects of eye and

vision problems in infants and children through

prevention, education, early diagnosis, treatment,

and management

• Inform and educate patients, parents/caregivers, and

other health care providers about the importance of

eye health and good vision, and the need for and

frequency of pediatric eye and vision examinations.

II. BACKGROUND

A. VISUAL DEVELOPMENT

Development of the visual system begins prenatally and

continues after birth.

Basic visual functions develop

rapidly during the ﬁrst year of life. By 6 months of age,

vision has become the dominant sense and forms the

basis for perceptual, cognitive, and social development;

however, maturation of the visual system continues for

several years. From birth to about 6 years of age, the

visual system is susceptible to vision conditions that

cause either blurred visual input or abnormal binocular

interaction such as interference from amblyogenic

bilateral refractive error, amblyogenic anisometropia,

constant unilateral strabismus, congenital cataracts,

hemangioma, corneal scarring, and any other condition

that obstructs vision. This interference can lead to

amblyopia, which, if left untreated, can cause serious

vision loss.

Objective testing (visual evoked response) demonstrates

that the visual cortex is capable of achieving 20/20

visual acuity by 6 months of age;

however, the ability

of a child to respond to subjective visual acuity tests is

inﬂuenced by verbal and cognitive development. For

some children, it may not be possible to elicit 20/20

visual acuity until after 5 years of age; therefore, it is

critical to select age appropriate tests. Stereopsis ﬁrst

appears at 3 to 4 months of age and continues to

develop through the ﬁrst two years of life.

31, 32

Mature

accommodative behavior is present at 5 to 24 months of

age.

Development of accommodative facility, vergence

ability, and eye movements continues in the preschool

and school-age years.

34-37

B. EPIDEMIOLOGY OF EYE AND VISION

DISORDERS IN CHILDREN

There are many visual conditions and ocular or systemic

diseases, which may occur in childhood that can

affect visual development. Eye and vision disorders

experienced by infants and children may include:

• Refractive errors

Refractive errors (hyperopia, myopia, astigmatism,

and anisometropia) are the most common causes of

correctable reduced vision in children.

38, 39

Estimates of

refractive errors in children 6 months to 72 months (6

years) of age are shown in Table 1.

Hyperopia has a high prevalence among young children

up to 5 years old, with over 20% estimated to have

≥2.00 diopters (D).

2,3

Hyperopia (≥2.00D) is found to be a

signiﬁcant risk factor for the development of strabismus

and amblyopia

up to 5 years of age.

Myopia generally develops in children during their early

school years and increases in magnitude, as they get

older. The age at onset typically ranges from 7 to 16

years. In the Collaborative Longitudinal Evaluation of

Ethnicity and Refractive Error Study (CLEERE), one in six

children ages 5 to 16 (Asian, Hispanic, African American,

Native American and White) developed myopia during

their school-age years. More than 75% of the new cases

of myopia occurred between the ages of 9 and 13.

Among school-age children, the prevalence of myopia

has been increasing in recent years and developing at

a younger age.

42,43

The National Health and Nutrition

Examination Survey results for 12 to 17 year olds show

the prevalence of myopia increased from 24% in 1971-

1972 to 33.9% in 1999-2004

and it continues to rise.

High levels of myopia can contribute to the development

of lattice degeneration, retinal holes, tears, or

detachment, cataracts, glaucoma, and myopic macular

degeneration.

45,46

Astigmatism up to 2.00D is common in children under

3 years of age. Studies show that 30 to 50% of infants

less than 12 months of age have astigmatism (≥1.00D),

which declines over the ﬁrst few years of life, and

becomes stable by approximately 2 1/2 to 3 years of

age.

47, 48

Anisometropia of 1.00D or more is considered

clinically signiﬁcant. There is a low prevalence (4%) of

anisometropia before 6 years of age;

however, it has

been shown to increase to nearly 6% at 12 to 15 years

of age. Infantile anisometropia can be transient and

may decrease; however, severe anisometropia (≥3.00D)

may persist and is likely to lead to the development of

amblyopia during the preschool years.

50, 51

Table 1: Prevalence of Refractive Errors in Children

6 Months to 72 Months (6 Years) of Age

Condition

White

Non-

Hispanic

African

American

Asian

Myopia

≤1.00D spherical

equivalent (SE)

1.2% 3.7% 6.6% 4.0%

≥1.00D SE 0.7% 5.5%

Hyperopia

≥2.00D SE 25.7% 26.9% 20.8% 13.5%

≥3.00D SE 8.9% 4.4%

Astigmatism

≥1.50D cylindrical

refractive error

6.3% 16.8% 12.7% 8.3%

≥3.00D cylindrical

refractive error

2.9% 1.0%

Anisometropia

≥1.00D SE 4.3% 4.2%

Source: Multi-Ethnic Pediatric Eye Disease

Study

2-4,49

and the Baltimore Pediatric Eye Disease

Study

(Note: The ethnicity of children reported in Tables 1, 2, 3

and 4 is based on the categorization used in the studies

cited.)

Table 2: Prevalence of Refractive Errors in Children

5 to 17 Years of Age

Condition

White

Non-

Hispanic

African

American

Asian

Myopia

≥0.75D in each

principal meridian

4.4% 13.2% 6.6% 18.5%

Hyperopia

≥1.25D in each

principal meridian

19.3% 12.7% 6.4% 6.3%

Astigmatism

≥1.00D difference

between two

principal meridians

26.4% 36.9% 20.8% 33.6%

Source: Collaborative Longitudinal Evaluation of

Ethnicity and Refractive Error Study

In the school-based CLEERE study of children 5 to 17

years of age, overall 9.2% of the children were myopic,

12.8% were hyperopic, and 28.4% had astigmatism

(Table 2).

Click to view the (AOA Clinical Practice Guidelines web

page)

• Amblyopia

Amblyopia is the leading cause of monocular vision loss

in children. It is generally attributable to strabismus,

anisometropia, combined strabismus and anisometropia,

or form deprivation (e.g., media opacity). Unilateral

amblyopia is commonly associated with constant

unilateral strabismus and/or amblyogenic anisometropia,

while bilateral amblyopia usually results from high bilateral

refractive error

or bilateral form deprivation.

Although amblyopia is a treatable condition in both

children and adults,

the end result is better when

diagnosed and treated early.

55-60

The prevalence of

amblyopia in the general population is believed to be

between 2% and 2.5%.

Estimates of the prevalence of

amblyopia in young children in an urban population are

shown in Table 3.

Click to view the (AOA Clinical Practice Guidelines web

page)

• Strabismus

The estimated prevalence of strabismus in the general

population varies from 2.5% to 4.6% based on various

studies.

The prevalence of strabismus in young children

in an urban population is shown in Table 3.

Although strabismus can develop at any age, it usually

develops during childhood. Infantile esotropia has

an onset prior to 6 months of age; accommodative

esotropia typically has an onset between 2 to 3 years

of age, but can develop before 6 months of age. Young

children with constant unilateral strabismus often develop

amblyopia and impaired stereopsis. Early identiﬁcation

and treatment of children with strabismus may prevent

amblyopia and preserve stereopsis.

Table 3: Prevalence of Amblyopia and Strabismus

in Children 6 Months to 72 Months (6 Years) of Age

Condition

White Non-

Hispanic

African

American

Asian

Amblyopia 1.8% 2.6% 0.8% - 1.5% 1.8%

Strabismus 3.2% - 3.3% 2.4% 2.1% - 2.5% 3.6%

Source: Multi-Ethnic Pediatric Eye Disease Study

6, 8

and the Baltimore Pediatric Eye Disease Study

Click to view the (AOA Clinical Practice Guidelines web

page)

• Non-strabismic binocular vision problems and

accommodative disorders

Other than refractive errors, the most prevalent

vision conditions in children fall into the category of

accommodative and binocular vision anomalies, as

reported in a large-scale prospective study of the

prevalence of vision disorders and ocular disease in a

clinical population of children between the ages of 6

months and 18 years.

Oculomotor conditions

Oculomotor conditions include a variety of eye

movement disorders, which can affect saccadic,

ﬁxation, and vergence eye movements.

Convergence insufﬁciency (CI) is a binocular vision

disorder that affects up to 8.3% of school-age

children

and is associated with symptoms such

as eyestrain, headaches, blurred vision, diplopia,

sleepiness, difﬁculty concentrating, movement

of print while reading, loss of place, and loss of

comprehension after short periods of reading.

65-67

The Convergence Insufﬁciency and Reading Study

Group investigators found that 13% of ﬁfth and

sixth grade children (deﬁnite and high suspect)

had clinically signiﬁcant CI (insufﬁcient fusional

convergence, receded nearpoint of convergence,

and/or exophoria at near ≥4 prism diopters at far).

Convergence excess (CE) has been reported

to occur in 7.1% of children in one clinical

pediatric population.

It may be due to a high

accommodative convergence/accommodation

(AC/A) ratio. Symptoms can include blurred vision,

diplopia, headaches, and difﬁculty concentrating on

near tasks.

Accommodative disorders

Children with accommodative dysfunctions may

have difﬁculty focusing on near objects, maintaining

focus for long periods, or easily changing focus

from near to far and back again. Studies in clinic

populations have been conducted to determine

the prevalence of accommodative dysfunction.

A study of over 2,000 children found that 5% of

children between the ages of 6 and 18 years had

accommodative disorders.

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web page)

• Color vision deﬁciency

Children with color vision deﬁciency, either inherited or

acquired, may have difﬁculty precisely matching colors

or discriminating ﬁne color differences. Inherited (X

chromosome) color vision deﬁciency is estimated to

occur in nearly 8% of white males and less than 0.4% of

white females, with lower prevalence in other ethnicities

(Table 4). The severity of color vision deﬁciency can

range from mild to severe. The most common form of

color vision deﬁciency is red-green. Less common is

blue-yellow color vision deﬁciency.

Table 4: Prevalence of Inherited Color Vision

Deﬁciency in Children 61 Months (5 years) to 72

Months (6 Years) of Age

Color Vision

Deﬁciency

White Non-

Hispanic

African

American

Asian

Boys 7.8% 2.9% 2.1% 3.5%

Girls <0.4% <0.4% <0.4% <0.4%

Source: Multi-Ethnic Pediatric Eye Disease Study

• Ocular Diseases

Ocular inﬂammatory disease

Ocular inﬂammation in children involves an array of

conditions, including but not limited to conjunctivitis,

keratitis, scleritis, and uveitis. It may occur due

to infection, trauma, malignancy, or autoimmune

response. Inﬂammations can range from benign and

self-limiting to chronic and sight-threatening.

70, 71

Systemic autoimmune diseases in children can have

ocular manifestations that are vision-threatening.

Juvenile idiopathic arthritis is associated with the

development of chronic anterior uveitis. Other

diseases with ocular inﬂammatory manifestations

include sarcoidosis, juvenile rheumatoid arthritis,

Behçet’s disease, and Sjögren’s syndrome.

71, 72

Ocular conditions of prematurity

Children born prematurely are at risk for the

development of severe visual impairment and

blindness. Preterm infants have higher rates of

amblyopia, strabismus, optic atrophy, and refractive

errors.

73-76

Sixty percent of infants born at 28 to 31 weeks have

been reported to develop retinopathy of prematurity

(ROP) and over 80% of infants born before 28

weeks developed ROP.

ROP is also common in

children with birth weight of less than 1,251 grams

(g). Oxygenation of infants in the hours and days

after birth may also be a contributing factor.

The

frequency and severity of ROP is inversely related to

gestational age and birth weight of the baby.

The

incidence of ROP is 47% in infants with birth weights

between 1,000 and 1,251 g and 81.6% in infants

weighing <1,000 g at birth.

Cataract

Childhood cataracts can be classiﬁed as congenital

or developmental. They may be idiopathic, due

to infection (e.g., rubella), genetics (e.g., Down

syndrome), or the result of secondary causes such

as trauma or metabolic etiology. The prevalence of

visually signiﬁcant congenital cataracts is estimated

to be three to four infants per 10,000 live births.

If not treated early, visually signiﬁcant congenital

cataracts may cause vision impairment.

Glaucoma

Childhood glaucoma is an uncommon disease

characterized by increased intraocular pressure

leading to optic neuropathy and visual ﬁeld changes,

and is often associated with signiﬁcant vision loss.

It may be inherited or associated with other eye

disorders.

Glaucoma in children may be classiﬁed as congenital

(present at birth), infantile (occurring between 1 to

2 years of age), or juvenile (developing after age 3).

Most cases develop during the ﬁrst year of life. A

review of records of pediatric patients seen in one

county in the United States over a 40-year period

found an incidence of glaucoma of 2.29 per 100,000

persons younger than 20 years of age.

Retinitis pigmentosa

Retinitis pigmentosa (RP) is a group of hereditary

retinal diseases characterized by progressive loss

of peripheral vision and the development of night

blindness. RP is caused by the degeneration of

photoreceptor cells resulting in severe damage to

the retina. While RP is usually limited to the eye, it

may also occur as part of a syndrome (e.g., Usher

syndrome, Bardet-Biedl syndrome).

Retinitis pigmentosa is the most frequent cause

of inherited visual impairment.

It is estimated to

affect 1 in 3,000 to 1 in 4,000 people in the United

States.

Retinoblastoma

Retinoblastoma, a cancer of the retina, usually

affects children under age 5. The most common

signs of retinoblastoma are leukocoria (white

pupillary reﬂex) and strabismus. Retinoblastoma

accounts for approximately 11% of cancers

occurring in the ﬁrst year of life, with 95% diagnosed

before 5 years of age.

It is the most common

intraocular cancer of childhood and affects

approximately 300 children in the United States each

year. More than 90% of children with retinoblastoma

could be treated with early diagnosis;

however,

signiﬁcant disparities exist in the care and outcomes

of children with retinoblastoma.

Retinoblastoma is associated with a mutation

of the RB1 gene. The tumor may be unilateral

or bilateral and can be inherited. Prognosis for

survival, saving the eye, and preservation of vision

are largely dependent on the stage of disease at

presentation. Early diagnosis, multidisciplinary

treatment, and genetic counseling are all priorities in

the management of this tumor.

Diabetic retinopathy

Diabetes is the third most common chronic disease

among children and a leading cause of vision

impairment among young adults. Type 1 diabetes

mellitus has historically been the most common

type in children, affecting approximately 2 per 1,000

school-age children in the United States; however,

Type 2 diabetes mellitus now accounts for about

45% of new cases of the disease.

88, 89

Diabetic retinal disease, primarily manifesting as

diabetic retinopathy (DR) and/or diabetic macular

edema, is the most common microvascular

complication of diabetes. Among pediatric patients,

the average duration of diabetes before the

development of DR is 5.7 to 9.1 years; however, the

risk for developing DR is greater in patients who are

diagnosed with diabetes during or after puberty.

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web page)

Optic nerve hypoplasia

Optic nerve hypoplasia is one of the most prevalent

causes of visual impairment among young children.

Although the speciﬁc prevalence is unknown,

the Babies Count Registry reported optic nerve

hypoplasia as the third most prevalent cause of

vision impairment in children age 3 years or younger

in the United States.

The exact cause of optic nerve hypoplasia in not

known, but it may be associated with prenatal

exposure to alcohol, smoking, recreational drugs,

antidepressants and anticonvulsants, and with

prenatal complications including gestational

diabetes, toxemia, viral infection, and maternal

anemia. Seventy percent of the cases identiﬁed have

no known risk factors. More recent studies have

indicated the mother’s young age (≤ 20 years) and

primiparity (that is, the affected child is the mother’s

ﬁrst child, regardless of the mother’s age) are the

predominant characteristics in the background of

children with optic nerve hypoplasia.

Optic nerve hypoplasia was believed to occur

either as an isolated anomaly or accompanying

the syndrome of septo-optic dysplasia or de

Morsier syndrome

that includes midline brain

malformations and hypopituitarism. Evidence now

suggests that optic nerve hypoplasia infrequently

occurs in isolation and is more appropriately

designated as the syndrome of optic nerve

hypoplasia.

In the syndrome, most children

with optic nerve hypoplasia have hypothalamic

dysfunction and/or neurodevelopmental impairment,

such as cerebral palsy or growth problems.

Cortical (cerebral) visual impairment

Cortical visual impairment (CVI) is deﬁned as a

reduction or complete loss of visual acuity and

optokinetic nystagmus due to injury to the visual

cortex, with preservation of pupillary response,

normal eye motility, and normal retina.

In addition

to cortical visual impairment, the term cerebral visual

impairment is also used to describe not only visual

impairment associated with the visual cortex, but

also regions outside the cortex that can affect other

visual pathway structures.

In children experiencing perinatal or postnatal

hypoxia/ischemia, CVI, ROP, and optic nerve

hypoplasia were commonly identiﬁed conditions.

Of the three, CVI was the most prevalent visual

condition identiﬁed and was often the last to be

diagnosed.

Vision loss associated with brain damage is reported

to be a signiﬁcant cause of visual impairment

in young children. Identiﬁcation of children with

suspected CVI requires neuroimaging to ascertain

the extent of the injury to speciﬁc regions in the

brain. Failure to do so will underestimate the level of

visual dysfunction and systemic disability.

C. ACCESS TO CARE

Although comprehensive pediatric eye and vision

examinations are essential for timely diagnosis and

treatment of eye disease and maintenance of good

vision, many children do not receive comprehensive

eye care. An estimated one in ﬁve preschool children

and one in four school-age children in the United States

has a vision problem; however, the Centers for Disease

Control and Prevention report that less than 15% of

preschoolers receive an eye examination by an eye care

professional and less than 22% receive some type of

vision screening.

A factor that may limit access to comprehensive eye and

vision examinations and treatment services is the false

sense of security that school screenings mistakenly give

to parents (false negative results). Other factors that limit

access include the absence of signs, symptoms, or a

family history of eye and vision problems,

or the inability

of parents/caregivers to afford needed services due to

lack of insurance coverage or limited family income.

Limited access may now be partially resolved because

comprehensive eye and vision examinations have

received increased attention from the Affordable Care

Act and other insurance programs reviewing essential

health beneﬁts necessary for children.

D. COST OF EYE AND VISION DISORDERS

IN CHILDREN

Eye and vision disorders can impose a signiﬁcant burden

on patients, parents, and the public. The total economic

cost of vision loss and eye disorders among children

younger than 18 years of age in 2012 was estimated

to be $5.9 billion.

100

This includes the direct medical

costs for eye examinations, eyeglasses, and low vision

aids. Also, the debilitating nature of vision loss results in

major indirect and nonmedical costs including special

education services, federal assistance programs, and

decreased quality of life.

The above estimate does not include the costs of

educational services for children with undiagnosed

and untreated vision conditions. Learning-related

vision problems have been reported to be signiﬁcant

contributors to reading difﬁculties and ultimately to the

need for special education services.

14, 15, 65, 101, 102

Vision

problems can increase educational costs in the form of

Individualized Education Programs (IEPs) and special

education services, which would otherwise not be

necessary, if the vision problems were treated. A study

of students (ages 6-16) with IEPs found that they have

high rates of undiagnosed and untreated vision problems

affecting reading speed and comprehension.

103

In addition to the current costs of care, future costs for

undiagnosed and untreated vision problems may include

the loss of a child’s full potential, and limitations on his

or her occupational choices and future earnings. The

cost of treating any visual impairment later in life could

potentially be more expensive than treatment of the initial

problem.

E. EARLY DETECTION AND PREVENTION

OF EYE AND VISION DISORDERS

Many vision conditions are asymptomatic or not readily

recognized, and will not prompt a patient, caregiver,

or parent to seek a comprehensive eye and vision

examination.

104

Undiagnosed or uncorrected refractive

errors and other visual disorders in children can lead

to developmental, academic, and social challenges

and in some cases permanent vision loss, which has

lifelong complications.

105

In the preschool population, the

concern is for early diagnosis and treatment of signiﬁcant

refractive error, amblyopia, strabismus, and ocular

disease. For the school-age population, the concern

is the negative impact that untreated vision disorders

(accommodation, binocular vision, ocular motility,

and vision information processing) have on academic

performance.

A comprehensive eye examination by a doctor of

optometry or ophthalmologist is the reference standard

of eye care.

105

Not all children receive professional eye

examinations for various reasons including education

and language barriers, health literacy, cost, geographic

access, immigration status, and transportation

challenges.

106

The role of vision screenings in addressing the current

gaps in children’s eye care remains unclear. The U.S.

Preventive Services Task Force (USPSTF) has concluded

that the current evidence is insufﬁcient to assess the

balance of beneﬁts and harms of vision screening

for children 3 years of age and younger.

107

While the

USPSTF concluded with moderate certainty that vision

screening for children 3 to 5 years of age has moderate

net beneﬁt compared with no screening, they did not

compare the beneﬁt of screening to a comprehensive

eye examination.

108

Vision screening procedures lack the evidence needed,

with proven high sensitivity and speciﬁcity, for identifying

the targeted vision problems present in the population

of children being screened.

104,109

The sensitivity of a

wide variety of screening techniques was evaluated

by the Vision in Preschoolers (VIP) study, which unlike

standard screenings used licensed eye doctors who had

completed VIP study speciﬁc training and certiﬁcation.

104

In the study, the sensitivity of 11 vision screening

techniques used for detecting clinically signiﬁcant vision

problems in children 3 to 5 years of age varied from 16%

to 64%, with speciﬁcities ranging from 62% to 98%.

These tests were compared again with a speciﬁcity of

94%, and the sensitivity dropped even further.

109

When

these same tests were performed by trained nurses or

lay screeners (except for non-cycloplegic retinoscopy,

which was deemed too technically challenging), the

sensitivity was similar or lower.

110

Even with the use of

trained examiners, these vision screening techniques

were unable to provide high levels of both sensitivity and

speciﬁcity for detecting many vision problems in children.

Currently, widespread application of vision screenings

do not utilize licensed eye care professionals or the

techniques found to be most sensitive.

When Snellen visual acuity alone was used as a

screening tool, it was 100% speciﬁc for identifying

reduced acuity, but missed 75.5% of the children found

to have binocular and oculomotor vision problems when

given a complete visual examination.

111

Additionally, a

study of 1,992 school-age children found that 41% of

children who failed the State University of New York

screening battery would not have been identiﬁed if the

screening was based on visual acuity alone.

112

Many children who fail a screening do not receive the

necessary treatment of their conditions. A study of public

school children reported only 38.7% who failed the vision

screening received follow-up care after screenings.

113

Due to a lack of follow-through, screenings alone may

not lead to the earlier diagnosis and treatment of eye

and vision problems. While screenings may identify some

children at risk for vision problems, a comprehensive

eye exam is necessary for deﬁnitive diagnosis and

appropriate treatment.

114

III. CARE PROCESS

A. COMPREHENSIVE PEDIATRIC EYE AND

VISION EXAMINATION

The comprehensive pediatric eye and vision examination

provides the means to evaluate the structure, function,

and health of the eyes and visual system. It is preferable

in most cases for the parent/caregiver to accompany

the child into the examination room. The in-person

interaction between patient/parent/caregiver and doctor

is a dynamic process. It involves collecting subjective

data from the patient/parent/caregiver and obtaining

objective data by observation, examination, and testing.

During the examination, information is obtained to

explain symptoms reported by the patient and/or parent/

caregiver and diagnose their cause. It also provides

the means to identify the presence of other ocular or

systemic conditions that may exist with or without

symptoms. (See Appendix Figure 1.)

The goals of the comprehensive pediatric eye and vision

examination are to:

• Evaluate the refractive, binocular, and

accommodative status of the eyes and visual

system, taking into account special vision demands

and needs

• Assess ocular health and related systemic health

conditions

• Establish a diagnosis (or diagnoses)

• Formulate a treatment and management plan

• Counsel and educate the patient/parent/caregiver

regarding visual, ocular, and related systemic

health care status, including recommendations for

prevention, treatment, management, and future care.

1. General Considerations

Since the capabilities and needs of children vary

signiﬁcantly by age, the potential components of the

comprehensive pediatric eye and vision examination

have been divided into three age groups. This

subdivision of the pediatric population is based on the

developmental changes that occur from birth through

childhood. The following age groups were also chosen

to be compatible with those used by other medical and

governmental groups involved with children’s health.

Because an individual child’s development can vary

signiﬁcantly from expected age norms, it is important

not to rely solely upon chronological age when choosing

testing procedures. Appropriate test procedures need to

be based on the child’s developmental age and speciﬁc

capability.

a. Infants and Toddlers (newborn through 2 years of

age)

Children in this age group may perform best if the

examination is early in the morning or after an infant’s

nap. Age-appropriate examination strategies should be

used. It is necessary to rely on objective examination

procedures and to perform tests more rapidly than with

older children.

b. Preschool Children (3 years through 5 years of

age)

At about 3 years of age, children have achieved

adequate receptive and expressive language skills

to begin to cooperate for some of the traditional eye

and vision tests; however, testing modiﬁcations are

often needed to gather useful information. Beginning

the examination with procedures that appear less

threatening may help to put the child at ease. The use of

subjective tests requiring verbal interaction may need to

be modiﬁed.

c. School-age Children (6 through 18 years of age)

Most of the examination procedures used on

adults apply to this age group; however, for some

patients, modiﬁcations should be made to improve

understanding and cooperation. Utilization of tests

designed for younger age groups may be appropriate.

Tests of accommodation, oculomotor skills, and

binocular function should be included as part of the

comprehensive examination.

2. Examination Procedures**

The examination procedures described are not intended

to be all-inclusive. Professional judgment and individual

patient symptoms and ﬁndings may signiﬁcantly inﬂuence

the nature and course of the examination. It is important

to remain alert for new and emerging technologies,

instruments, and procedures and incorporate them into

the clinical examination, as appropriate.

CONSENSUS-BASED ACTION STATEMENT:

A comprehensive pediatric eye and vision

examination should include, but is not limited to:

• Review of the nature and history of the presenting

problem, patient and family eye and medical

histories, including visual, ocular, general health,

leisure and sports activities, and developmental

and school performance history of the child

• Measurement of visual acuity

• Determination of refractive status

• Assessment of binocular vision, ocular motility, and

accommodation

• Evaluation of color vision (baseline or periodic, if

needed, for qualiﬁcation purposes or if disease

related)

• Assessment of ocular and systemic health,

including evaluation of pupillary responses,

anterior and posterior segment, peripheral retina,

evaluation/measurement of intraocular pressure,

and visual ﬁeld testing.

Refer to section III. Care Process, A. 9 for a listing of

potential beneﬁts and harms of testing.

Evidence Quality: There is a lack of published

research to support or refute the use of all of

the tests and/or assessments included in this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to result in the

enhanced ability to diagnose any eye or vision

problems in infants and children. The beneﬁts of

this recommendation were established by expert

consensus opinion.

** See Appendix Tables 1, 2, and 3 for a listing of

speciﬁc tests by age group.

3. Patient History

The patient history is an initial and ongoing component

of the examination. The objective is to obtain speciﬁc

information about the patient and/or parent’s/caregiver’s

perception of the child’s eye and vision status and

important background information on related medical

issues. It helps to identify and assess problems, and it

provides an opportunity to become acquainted with the

patient and/or his/her parents or caregivers, establishing

a relationship of conﬁdence and trust.

The collection of demographic data generally precedes

the taking of the patient history. Having the parent

or caregiver ﬁll out a questionnaire may facilitate

obtaining the patient and family history, if known. Major

components of the patient history include, but are not

limited to:

• Nature and history of the presenting problem,

including chief complaint

• Visual and ocular history

• General health history, including prenatal,

perinatal and postnatal history, and review of

systems, surgical and/or head or ocular trauma

history, and any vision or ocular treatment

• Medication reconciliation, including prescription

and nonprescription drugs (e.g., over the

counter medications, supplements, herbal

remedies) and documentation of medication

allergies

• Family ocular and medical history

• Clinical note: It is recommended that the

patient history should also include the refractive

status of both parents,

115, 116

(Evidence Grade:

B) because it is a possible risk factor for the

progression of myopia in school-age children.

• Developmental history of the child

• School performance history of school-age

children

• Time spent outdoors, on sports activities, and

on near work and screen viewing

• Names of, and contact information for, the

patient’s other health care providers.

4. Testing

4.1 Testing of Infants and Toddlers (newborn

through 2 years of age)

a. Visual Acuity

Estimation of visual acuity in an infant or toddler can help

to conﬁrm or reject certain hypotheses about the level of

visual system development, including binocularity, and

provide direction for the remainder of the eye and vision

examination. Assessment of visual acuity for infants and

toddlers may include these procedures:

• Preferential looking visual acuity

Preferential looking methods are useful for the

assessment of visual acuity in infants and toddlers.

Grating acuity targets (e.g., Teller acuity cards) and

vanishing optotypes (e.g., Cardiff acuity test) can

provide estimates of resolution visual acuity.

117

• Fixation preference test

Fixation preference testing results need to be

interpreted in the context of all other available

information (e.g., degree and type of anisometropia,

frequency and type of strabismus). Results of

ﬁxation preference testing may be unreliable for

diagnosing amblyopia,

118, 119

particularly secondary

to anisometropia; therefore, monocular visual acuity

measurements should be obtained, if possible.

120

• Visual evoked potential

Electrodiagnostic testing, such as visual evoked

potentials, is an objective method that can be used

to provide an estimate of visual acuity in infants.

121

b. Refraction

Objective measures of refraction with a lens bar or loose

lenses should be used in this age group because of the

short attention span and poor ﬁxation of infants. The

refractive error measurement should be analyzed with

other testing data obtained during the examination. This

information is used to determine if, and in what amount,

an optical correction is needed. Procedures may include:

• Cycloplegic retinoscopy

When performing cycloplegic retinoscopy in an infant

or toddler, the appropriate cycloplegic agent should

be selected carefully.

122

The lowest concentration

of drug that yields the desired cycloplegia should

be used. A concentration of 0.5% cyclopentolate

hydrochloride can be used in most infants under

12 months of age and a 1% concentration for

older children.

123

Combination drops (0.2%

cyclopentolate hydrochloride and 1% phenylephrine)

are also available for use with infants. The potential

for systemic absorption may be reduced with

nasolacrimal occlusion. The cycloplegic of choice

is cyclopentolate hydrochloride; however, when it

is not available or is contraindicated, tropicamide

1% has also been shown to be effective for the

measurement of refractive error in non-strabismic

infants.

124

Spray administration of cyclopentolate to the open

or closed eyes of young children is an acceptable

alternative, if necessary, to using eye drops and is

often better tolerated and less distressing than other

methods of drug administration;

125-128

however, the

use of cyclopentolate spray in children with dark

irides may not achieve adequate cycloplegia.

129

Spray caps are available for use on bottles of

cyclopentolate, eliminating the need to have the

spray compounded by a pharmacy.

• Non-cycloplegic retinoscopy

Non-cycloplegic retinoscopy performed at near is

an objective means of estimating refractive error

in infants and toddlers,

130

but should be used with

caution as a substitute for cycloplegic retinoscopy.

131

It may be useful when a child/parent is extremely

anxious about instillation of cycloplegic agents,

or the child has had, or is at risk for, an adverse

reaction to cycloplegic agents.

132

Video refraction without cycloplegia can also be

used to detect infants with signiﬁcant ametropia,

particularly hyperopia or other accommodative

problems.

133

c. Binocular Vision and Ocular Motility

Depending on the patient’s age, level of cooperation,

and visual signs and symptoms, appropriate tests

of binocular vision and ocular motility should be

incorporated into the examination. Testing in this age

group may include:

• Ocular alignment assessment

The unilateral cover test at distance and near can

generally be used with very young children. If cover

test results are unreliable because of the child’s

resistance to testing, use of the Hirschberg test

may be successful. Prisms can be used with the

Hirschberg test to align the corneal reﬂex (Krimsky

test) and estimate the magnitude of any deviation.

• Brückner test

If cover test results are equivocal, particularly in

young or uncooperative patients, the Brückner test

may be helpful in detecting strabismus, including

small angle strabismus. It may also be useful in

the clinical evaluation of anisometropia in infants

and young children.

134

Increasing the examination

distance from one meter to four meters can improve

its sensitivity for detecting anisometropia.

135

• Stereopsis

Testing of stereopsis, after 6 months of age, can

provide a sensitive measure of visual development in

infants.

136

In this population, tests like the Preschool

Assessment of Stereopsis with a Smile (PASS) 3,

which uses a preferential looking paradigm, should

be used.

• Near point of convergence (NPC)

Assessment of convergence ability may be

determined objectively in infants using a penlight or

other interesting targets, which include sounds or

blinking lights.

• Ocular motility assessment

Versions and eye tracking abilities may be assessed

using a penlight, small toy, or other object.

4.2 Testing of Preschool Children (3 through 5 years

of age)

a. Visual Acuity

The accurate measurement of visual acuity in children

allows for the early detection of amblyopia and

signiﬁcant/high refractive errors. While some children in

this age group may respond verbally, acuity testing may

require the use of a matching or a forced-choice task. An

assessment of visual acuity may include the use of:

• Symbol optotype or letter matching visual acuity

measurement

Symbol optotype or letter optotype testing (e.g., Lea

symbols) and letter matching testing (e.g., HOTV)

can be used to measure the visual acuity of most

children aged 3 through 5 years.

137-140

b. Refraction

A refraction should include objective and, as appropriate,

subjective assessment of the child’s refractive status;

however, the results of a refraction do not provide

all the information needed to determine an optical

prescription. The refractive error measurement should be

analyzed with other testing data and the patient’s visual

needs obtained during the in-person examination. This

information is used to determine if, and in what amount,

an optical correction is needed to provide optimal vision

and comfort for all viewing distances. Testing in this age

group may include:

• Static (distance) retinoscopy

Use of a lens rack or loose lenses with appropriate

control of accommodation, rather than a phoropter,

enables the child’s eyes to be seen and allows for

observation if the child loses ﬁxation. Viewing a video

may assist in capturing a child’s attention in order to

sustain distance ﬁxation.

• Cycloplegic retinoscopy

Spray administration of cyclopentolate to the open

or closed eyes of young children is an acceptable

alternative, if necessary, to using eye drops and is

often better tolerated and less distressing than other

methods of drug administration;

125-128

however, the

use of cyclopentolate spray in children with dark

irides may not achieve adequate cyclopelgia.

129

Spray caps are available for use on bottles of

cyclopentolate, eliminating the need to have the

spray compounded by a pharmacy.

CONSENSUS-BASED ACTION STATEMENT:

Cycloplegic retinoscopy is the preferred procedure

for the ﬁrst evaluation of preschoolers. It is

necessary to quantify signiﬁcant refractive error

in the presence of visual conditions such as

strabismus, amblyopia, and anisometropia.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to enhance the

ability to evaluate and diagnose eye and vision

problems in preschool children. The beneﬁts of

this recommendation were established by expert

consensus opinion.

• Autorefraction

The use of a hand-held autorefractor is preferable in

this age group since it may be less intimidating than

a table mounted instrument.

Autorefractors can provide an objective measure

of refractive error, but may underestimate the level

of hyperopia and overestimate the level of myopia

under non-cycloplegic conditions,

141, 142

and their

usefulness in testing children less than 3 years of

age may be limited.

143

c. Binocular Vision, Ocular Motility, and

Accommodation

• Ocular alignment assessment (distance and

near)

Testing should include use of the unilateral cover

test and alternating cover test. If cover test results

are unreliable because of the child’s resistance

to testing, use of the Hirschberg test may be

successful. Prisms can be used with the Hirschberg

test to align the corneal reﬂex (Krimsky test) and

estimate the magnitude of any deviation.

• Ocular motility assessment

Examination of eye movements in this age group

involves an assessment of comitancy.

• Near point of convergence (NPC)

Assessment of maximum convergence ability may

be determined objectively or subjectively.

• Stereopsis

In the preschool population, stereopsis testing can

provide useful information about development of

binocular vision and eye alignment. Testability in this

age group has been reported to be close to 90%

using age appropriate techniques.

136, 144, 145

The

presence of global stereopsis is an indication that

the patient is bifoveally ﬁxating and evidence that a

constant strabismus is less likely to be present.

146,

147

This information is valuable when the cover test

results are equivocal and the clinician suspects a

small angle, constant strabismus may be present.

To accomplish this objective, a stereopsis test that

assesses global, rather than local stereopsis, should

be used. The PASS 3 and the Randot Preschool

tests are examples of global stereopsis tests that

can be used for this purpose. Stereopsis tests that

have monocular cues (local stereopsis e.g., Titmus

Test) may lead to false-positive results.

147

• Positive and negative fusional vergence ranges

Assessment of positive and negative fusional

vergence ranges can be done using a step vergence

procedure with a hand-held prism bar.

37, 148

• Accommodative testing

Clinical note: Dynamic retinoscopy has been

shown to be a reliable method for assessing

accommodation in young children.

149,150

(Evidence

Grade: B)

d. Color Vision

Children with color vision deﬁciency, either congenital or

acquired, may have difﬁculty precisely matching colors

or discriminating ﬁne color differences.

151

The severity

of color vision deﬁciency can range from mild to severe

depending on the cause. Most children can be reliably

evaluated for color vision deﬁciency after 60 months (5

years) of age.

It is helpful to know whether a color vision deﬁciency

exists, because severe color vision deﬁciency may

cause a child to be misidentiﬁed as learning disabled.

152

Identiﬁcation of abnormal color vision prior to school

age is also important, since part of the early educational

process generally involves the use of color identiﬁcation

and discrimination. The presence of a color vision

deﬁciency may also indicate an ocular health problem;

therefore, color vision testing may need to be repeated, if

an acquired color vision deﬁciency is suspected.

Although effective when used with standard illuminant,

some pseudoisochromatic plate tests only detect protan

and deutan color vision deﬁciency,

153

while other color

vision tests provide the added advantage of detection

of tritan defects and the ability to categorize defects as

mild, moderate, or severe.

154

4.3 Testing of School-age Children (6 through 18

years of age)

a. Visual Acuity

Visual acuity may be measured monocularly and

binocularly, at distance and near, with and without the

child’s most recent spectacle or contact lens correction.

An assessment of visual acuity in children age 6 years or

older may include:

• Snellen visual acuity

For some children, Snellen visual acuity testing may

need to be modiﬁed by isolating one line, or even

one-half line of letters. If amblyopia is suspected,

single letters with surround bars should be used.

• Early Treatment of Diabetic Retinopathy Study

(ETDRS) visual acuity chart

The ETDRS chart may be used to measure visual

acuity in school-age children

155

and can be especially

useful in diagnosing and monitoring children with

amblyopia.

b. Refraction

A refraction may include objective and subjective

assessment of a child’s refractive status; however, the

results of a refraction do not provide all the information

needed to determine an optical prescription. The

refractive error measurement should be analyzed with

other testing data and the patient’s visual needs obtained

during the in-person examination. This information is

used to determine if, and in what amount, an optical

correction is needed to provide optimal vision and

comfort for all viewing distances.

Both objective and subjective testing for refractive error

can generally be used in this age group. It may include:

• Static (distance) retinoscopy

Retinoscopy may be performed with a phoropter, or

without a phoropter using a lens rack or loose lenses

and fogging glasses.

• Cycloplegic retinoscopy

CONSENSUS-BASED ACTION STATEMENT:

Cycloplegic retinoscopy is the preferred procedure

for the ﬁrst evaluation of school-age children.

It is necessary to quantify signiﬁcant refractive

error in the presence of visual conditions such as

strabismus, amblyopia, and anisometropia.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to enhance the

ability to evaluate and diagnose eye and vision

problems in school-age children. The beneﬁts of

this recommendation were established by expert

consensus opinion.

Clinical note: In school-age children, cycloplegic

refraction results in a more positive spherical

power measurement than that obtained

using optical fogging techniques to relax

accommodation.

156

(Evidence Grade: B) The

difference in spherical equivalent refractive errors

measured in pre- and post-cycloplegic refractions

is signiﬁcant up until age 20.

157

(Evidence Grade:

• Subjective refraction

Typical examination procedures used to measure

refractive error in adults can generally be used for

school-age children.

• Autorefraction

Autorefraction may be used as a starting point

for subjective refraction, but not as a substitute

for it; however, retinoscopy, when performed by

an experienced clinician, is more accurate than

automated refraction for determining a starting point

for non-cycloplegic refraction.

158

(Evidence Grade: C)

c. Binocular Vision, Ocular Motility, and

Accommodation

In analyzing the results of these tests, it is important

to examine all the data and group ﬁndings rather than

depend on a single ﬁnding to arrive at a diagnosis.

Testing in this age group is similar to that for adults and

may include:

• Ocular alignment assessment (distance and

near)

Testing may use the unilateral cover test and

alternating cover test. If cover test results are

unreliable because of the child’s resistance

to testing, use of the Hirschberg test may be

successful. Prisms can be used with the Hirschberg

test to align the corneal reﬂex (Krimsky test) and

estimate the magnitude of any deviation. Other tests

include the Von Graefe phoria, Modiﬁed Thorington,

and Maddox Rod.

• Ocular motility assessment

Examination of eye movements in this age group

involves an assessment of comitancy of ﬁxation,

saccadic, and pursuit functions. Versions may also

be performed to rule out a noncomitant deviation.

• Near point of convergence (NPC)

Determination of maximum convergence ability may

be obtained objectively or subjectively.

• Stereopsis

School-age children should be able to complete

any of the available random dot stereopsis

tests. If random dot (global) stereopsis is not

present, testing should continue to evaluate local

stereopsis, potential for ﬂat fusion, and potential for

simultaneous perception.

• Positive and negative fusional vergence ranges

Evaluation should be made of both the amplitude

and facility of fusional vergence ranges.

• Accommodative testing

Assessment of accommodation may include

accommodative amplitude, facility, and

response.

149,159

Testing of negative relative

accommodation (NRA) and positive relative

accommodation (PRA) may provide useful

information on both accommodative and binocular

status.

149

d. Color Vision

If not done previously, school-age children should be

tested for color vision deﬁciency. Color vision deﬁciency

can interfere with daily activities involving colors and

prohibit some occupational choices.

160

One-third

of individuals with abnormal color vision reported

their career choice had been affected by color vision

deﬁciency and one-quarter had been precluded from an

occupation because of it or had problems in their current

job.

161

CONSENSUS-BASED ACTION STATEMENT:

Abnormal color vision can affect daily performance

of activities involving color discrimination and

may interfere with or prevent some occupational

choices later in life. Children should be tested as

soon as possible for color vision deﬁciency and the

parents/caregivers of children identiﬁed with color

vision deﬁciency should be counseled.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to increase early

detection of color vision deﬁciency and alert

parents/caregivers to any potential effects on a

child’s education or occupational choices. The

beneﬁts of this recommendation were established

by expert consensus opinion.

5. Ocular and Systemic Health Assessment

Thorough assessment of the health of the eyes and

associated structures is an important and integral

component of the comprehensive pediatric eye and

vision examination. The eyes and associated structures

are not only sites for primary ocular diseases, but they

are also subject to systemic disease processes that

affect the body as a whole (e.g., disorders of neurologic,

vascular, endocrine, immune, or neoplastic origin).

Standard procedures used in evaluating adult patients

may need to be modiﬁed or may not be optimal

in very young patients. With some modiﬁcations,

the components of the ocular and systemic health

assessment may include:

a. Assessment of Pupillary Responses

Evaluation of pupils includes size, shape, symmetry,

and direct and consensual response to light and relative

afferent pupillary defect.

b. Visual Field Evaluation

Confrontation visual ﬁeld testing can be used to detect

gross peripheral defects and areas of constricted visual

ﬁelds.

c. Evaluation of the Ocular Anterior Segment and

Adnexa

Assessment of the external eye and adnexa, ocular

surface, anterior chamber, and crystalline lens.

d. Evaluation of the Ocular Posterior Segment

Pharmacological dilation of the pupil is generally required

for thorough stereoscopic evaluation of the ocular

media, retinal vasculature, macula, optic nerve, and the

peripheral retina.

162

(Evidence Grade: B)

Examination under general anesthesia may be

considered under rare circumstances, if the retina cannot

be adequately visualized during an examination of at-risk

children.

163

e. Measurement of Intraocular Pressure

Measuring intraocular pressure (IOP) is a part of the

comprehensive pediatric eye and vision examination.

Although the prevalence of glaucoma is low in children,

measurement of IOP should be attempted. Pressure

should be assessed when ocular signs and symptoms or

risk factors for glaucoma exist. If risk factors are present

and reliable assessment of IOP under standard clinical

conditions is impossible, testing under anesthesia may

be indicated. Recording of tonometry results should

include method used and time of day.

164

(Evidence

Grade: C)

Clinical note: The Goldmann applanation

tonometer (GAT) is considered the reference

standard for the measurement of IOP; however,

its use may not be practical in very young

children. Non-contact and handheld applanation

tonometers can provide IOP measurements close

to that of the Goldmann.

165

(Evidence Grade: A)

Rebound tonometry offers an advantage over

GAT in that it is portable, easy to use, and better

tolerated.

166

(Evidence Grade: B)

6. Supplemental Testing

During an eye and vision examination, the information

obtained from the patient is continually assessed, along

with the clinical ﬁndings gathered. The interpretation of

subjective and objective data may indicate the need for

additional testing.

Additional testing may be indicated to:

• Conﬁrm or rule out differential diagnoses

• Enable more in-depth assessment

• Provide alternative means of evaluating patients

who may not be fully cooperative or who may

not comprehend testing procedures.

Supplemental procedures may be performed

immediately or during subsequent examinations.

Supplemental testing for infants and children may

include:

a. Electrodiagnostic Testing

Electrophysiological techniques may be used to assess

children with unexplained reduced vision. Testing may

include an electroretinogram (ERG) or measurement of

visual evoked potential (VEP).

b. Imaging

The following procedures may be used for imaging of

ocular structures:

• Ultrasonography can reveal congenital

anatomical abnormalities in the eye and orbit,

as well as anatomical changes secondary to

disease or injury, and measure axial length

• Optical coherence tomography (OCT) provides

cross-sectional, high-resolution imaging of the

anterior and posterior segments

• Scanning laser ophthalmoscopy provides 3-D

images of the optic nerve head

• Fundus photography, with or without auto

ﬂuorescence, is a noninvasive diagnostic

technique for examining the fundus

• Corneal topography provides an assessment of

corneal thickness, shape, power, and surface

details

• Computerized tomography (CT) scan,

magnetic resonance imaging (MRI), and other

neuroimaging may be indicated for suspicion of

neurological disease or trauma/injury

• Scheimpﬂug camera for anterior segment

tomography (Pentacam, Orbscan, and Gallilei)

may be used for detection of keratoconus.

c. Testing for Learning-related Vision Problems

Vision problems such as accommodative, binocular

vision, eye movement, and visual information processing

disorders can interfere with academic performance.

When a child’s history or initial testing indicates a

possible developmental lag or learning disorder,

additional testing should be performed to rule out a

learning-related vision disorder. This will typically require

an additional ofﬁce visit that includes more extensive

testing of accommodation, binocular vision, and eye

movements, and an assessment of visual information

processing skills. In some instances, this may require a

referral to a doctor of optometry with advanced training

in this area of practice.

CONSENSUS-BASED ACTION STATEMENT:

Children at risk for learning-related vision problems

should be evaluated by a doctor of optometry.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to result in more

in-depth evaluation and diagnosis of children with

learning-related vision problems. The beneﬁts of

this recommendation were established by expert

consensus opinion.

Click to view the (AOA Clinical Practice Guidelines

web page)

7. Children with Special Needs

a. At-risk Children

In the United States, the Individuals with Disabilities

Education Act (IDEA) allows for the development of

Individualized Education Programs (IEPs) when indicated.

The following categories of children are considered high-

risk (Health and Human Services, Health Resources

and Services Administration, Maternal and Child

Health Bureau) and recommend direct referral for a

comprehensive eye and vision examination:

• Children with obvious evidence of physical

anomaly (e.g., strabismus, ptosis, nystagmus)

• Children with central nervous system (CNS)

dysfunction (e.g., cerebral palsy, Down

syndrome, seizures, developmental delay)

• Children with Autism Spectrum Disorder

• Children enrolled in Early Intervention (EI)

Program’s

a). Children with an IEP

b). Children enrolled in Early Head Start (ages

0-3)

• Children with a family history of amblyopia,

strabismus, or other early eye disease

• Children born from high-risk pregnancy (e.g.,

maternal drug use, infection during pregnancy,

preterm delivery).

b. Developmental Disabilities

Many children with special needs have undetected

and untreated visual problems

167

(see Appendix

Table 4: Partial Listing of Ocular Manifestations of

Neurodevelopmental Disorders and Other Syndromes).

Children with developmental or intellectual disabilities

have a higher rate of vision disorders and should

receive a comprehensive pediatric eye and vision

examination.

21, 25, 168

Although clinically more challenging,

visual assessment is possible in the majority of these

children.

167

(Evidence Grade: B),

169

(Evidence Grade:

B) Early identiﬁcation of speciﬁc visual deﬁcits could

lead to interventions to improve the educational and

occupational achievement and quality of life for these

high-risk children.

CONSENSUS-BASED ACTION STATEMENT:

Many children with developmental or intellectual

disabilities have undetected and untreated vision

problems and should receive a comprehensive

pediatric eye and vision examination.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementation

of this recommendation is likely to result in

improved quality of life and educational and

occupational achievement for these high-risk

children. The beneﬁts of this recommendation

were established by expert consensus opinion.

8. Trauma and Ocular Manifestations of Child

Abuse/Neglect

a. Trauma (Accidental)

A majority of concussions occur in the pediatric and

adolescent population (5 to 17 years of age), with

the 11 to 17-year-old group representing the largest

proportion of those injured.

170, 171

Children are particularly

vulnerable to the consequences of concussion, often

having a more prolonged recovery and poorer outcomes,

from a cognitive and developmental perspective, than

adults with concussion.

172-175

A recent study found

a high prevalence of vision problems in adolescents

with concussion along with signiﬁcant symptoms

associated with these vision disorders.

176

The most

common binocular vision disorder occurring in post-

concussion syndrome is convergence insufﬁciency (CI)

with a prevalence of 49% in children. Other common

problems are accommodative insufﬁciency and saccadic

dysfunction.

All children with concussion should see their general

practitioner in the event they should need more emergent

care and should be scheduled for a comprehensive eye

examination to conﬁrm visual capabilities are protected.

b. Ocular Manifestations of Child Abuse and Neglect

(Non-accidental)

External eye trauma (e.g., conjunctival hemorrhages,

lid lacerations, corneal scars and/or opacities) and

retinal trauma (e.g., hemorrhages, folds, tears, and/

or detachments) are common ocular ﬁndings from

child abuse and can have an important role in its

diagnosis.

177-180

Most often the child is between 2 and 18

months of age at the time of abuse.

179, 181

The eyes can be direct or indirect targets of child abuse

and may provide valuable diagnostic information,

particularly when there are limited external signs

of abuse. In children, the leading cause of retinal

hemorrhages with retinal folds and macular retinoschisis,

in the absence of skull fractures or automobile accident

history, is typically abusive head trauma.

182, 183

Retinal

hemorrhages, poor visual response, and poor pupil

response in an infant may indicate abusive head trauma,

or Shaken Baby Syndrome,

177

(Evidence Grade: B),

178

(Evidence Grade: C) a form of child abuse in which the

child is injured secondary to violent shaking.

A vague history provided by the parent/caregiver that

changes on re-questioning or is inconsistent with the

age of the child or extent of the injury should be an alert

for abuse. In such cases, a detailed history is one of

the most important factors to consider when assessing

whether a child has been abused.

180

Table 5: Summary of the Signs of Child Abuse and Neglect

Ocular signs of abuse

General physical signs of abuse

or neglect

Emotional and behavioral signs

of abuse or neglect

Cortical blindness

Ruptured globe

Retinal, preretinal, vitreous hemorrhages

particularly if child is less than 2

years old

Detached retina, retinal dialysis

Chorioretinal atrophy

Papilledema

Optic atrophy

Cataracts

Dislocated, subluxated lens

Glaucoma

Shallow anterior angle

Angle recession

Iris tears, iris dialysis

Pupillary anomalies

Anisocoria

Hyphema

Hypopyon

Corneal scars, edema, opacities

Conjunctival, subconjunctival hemorrhages

Orbital, periorbital edema

Lid lacerations

Ptosis

Proptosis

Esotropia

Strabismus

Nystagmus

Disconjugate eye movements

Eyelash infestation with phthirus pubis

(crab louse)

Bruises around cheeks, jaw, eyes, ears, or

mastoid area

Soft tissue bruises on upper arms, thighs,

buttocks or genitals

Hair loss with/without subgaleal menatoma

Torn frenum of upper lip

Torn ﬂoor of mouth

Burns on any posterior part of the body,

particularly buttocks, perineum, hands,

or feet

Full thickness burns

Multiple lesions or fractures in different

stages of healing

Poor hygiene

Inferior general health

Signs of malnutrition such as sunken

cheeks and buttocks, distended

abdomen

Child not properly immunized

Venereal disease in a preadolescent child

Case history inconsistencies

No history offered

History vague or inconsistent with injuries

History changes during course of

examination

History varies between two parents or

between parents and child

Multiple ofﬁce visits for accidental injuries

Increase in severity of injuries

Delay in seeking medical attention

Frozen watchfulness

Fear of strangers

Indiscriminate attachment to strangers

Failure to thrive

Growth failure

Low intellectual performance

Sad affect

Low self-esteem

Impaired ability to enjoy life

Social withdrawal

Learned helplessness

Suicidal ideation or attempts

Drug or alcohol abuse

Misconduct in school

Academic failure

Low school attendance

Aggressive behavior

Sleeping problems

Running away

Low level of activity

Weight ﬂuctuation

Fatigue

Generalized anxiety

Sexual acting out

Source: Smith S. Child abuse and neglect: A diagnostic guide for the optometrist. J Amer Optom Assoc 1988;

59:760-66.

All 50 states and the District of Columbia have laws mandating the reporting of suspected child abuse and provide

penalties for failure to do so.

U.S. Department of Health and Human Services, Administration for Children & Families, Children’s Bureau listing of

state child abuse and neglect reporting numbers

Clinical note: Doctors of optometry should be aware of the eye-related ﬁndings associated with abusive head

trauma and report ﬁndings of possible child abuse to the proper authorities, as deﬁned by state law, for the

protection of the child.

9. Potential Beneﬁts and Harms of Testing

The potential beneﬁts of a comprehensive pediatric eye

and vision examination include:

• Optimizing visual function through diagnosis,

treatment, and management of refractive, ocular

motor, accommodative, and binocular vision

problems

• Preventing and/or minimizing vision loss through

early diagnosis, treatment, and management of

ocular health conditions

• Detecting systemic disease and referring for

appropriate care

• Counseling and educating patients/parents/

caregivers on current conditions and preventive

care to maintain ocular and systemic health and

visual function, and on the relationship between

vision problems and early learning.

Potential harms associated with a comprehensive

pediatric eye and vision examination may include:

• Patient or parent/caregiver anxiety about testing

procedures or resulting diagnosis

• Adverse ocular and/or systemic reactions and/

or temporary visual disturbances resulting from

testing, or allergic responses to diagnostic

pharmaceutical agents or materials used

• Missed or misdiagnosis of eye health or vision

problems

• Unnecessary referral or treatment.

B. ASSESSMENT AND DIAGNOSIS

At the completion of the examination, the data collected

should be assessed and evaluated to establish a

diagnosis (or diagnoses) and formulate a treatment

and management plan. The nature and severity of the

problem(s) diagnosed determine the need for optical

prescription (e.g., eyeglasses and/or contact lenses) or

other treatment (e.g., vision rehabilitation, vision therapy,

ocular pharmaceuticals).

C. MANAGEMENT

1. Prescription for Correction

A prescription for correction of refractive error, if needed,

is provided at the conclusion of the examination.

184

The

level of refractive error may be monitored rather than

prescribed as a lens correction, or full or partial optical

correction may be prescribed, depending on the speciﬁc

visual needs, refractive measurement, and related visual

ﬁndings.

2. Additional Treatment Services

Depending on the diagnosed eye and vision condition(s),

other treatment services may be needed. For conditions

such as accommodative, binocular vision, eye

movement, visual information processing disorders, or

visual impairment, treatment such as the use of prisms,

vision therapy, or vision rehabilitation may be necessary.

Ocular pharmaceuticals may also be used for the

treatment of various eye diseases.

3. Counseling and Education

It is important for children/parents/caregivers to

understand the medical information and

recommendations given to them. To enhance

understanding, open-ended questions should be used.

Children/parents/caregivers should be asked to state

their understanding of the information given to them

using their own words.

185

Eye models, diagrams, and

written materials can also be used to aid in

understanding.

Shared decision-making increases patient/parent/

caregiver satisfaction with the examination and

consultation, and may improve health outcomes. The

available options, with their beneﬁts and risks, need to

be described and patient/parent/caregiver views and

preferences elicited, before agreeing on a course of

action.

186

Language and cultural differences or misunderstandings

may prevent some individuals from accepting a doctor’s

recommendation. When communicating with patients/

parents/caregivers, it is important to take their level of

“health literacy” into consideration.

187

Health literacy is

“the degree to which individuals have the capacity to

obtain, process, and understand basic health information

and services needed to make appropriate decisions

regarding their health.”

188

Limited health literacy has been

associated with a range of adverse health outcomes

including decreased use of preventive services and poor

disease speciﬁc outcomes.

189

In addition, anxiety reduces the effectiveness of

patient-practitioner communications and results in

reduced attention, recall of information, and compliance

with treatment. The use of “patient-centered”

communications and “active listening” can help

reduce anxiety and improve patient/parent/caregiver

satisfaction and outcomes.

190

Improved doctor-patient

communications and higher levels of patient/parent/

caregiver involvement in care are linked to better clinical

outcomes.

191

In compliance with the Americans with Disabilities Act

(ADA), reasonable accommodations need to be made

to ensure that whatever is written or spoken is clear

and understandable to individuals with disabilities.

Appropriate auxiliary aids and services must be

made available, when needed, to enable effective

communications when evaluating, treating, or counseling

persons with hearing, vision, or speech impairments.

According to the ADA, auxiliary aids and services for

individuals who are hearing impaired include qualiﬁed

interpreters, note takers, computer-aided transcription

services, written materials, telephone handset ampliﬁers,

assistive listening systems, telephones compatible with

hearing aids, closed caption decoders, open and closed

captioning, telecommunications devices for the deaf

(TDD’s), videotext displays and exchange of written

notes. For individuals with vision impairments, auxiliary

aids and services include qualiﬁed readers, taped texts,

audio recordings, magniﬁcation software, optical readers,

Braille materials, and large print materials. Examples

for individuals with speech impairments include

TDD’s, computer terminals, speech synthesizers, and

communication boards.

192

Language interpreters may also be needed to assist

patients who have limited English proﬁciency. Family

members of patients may act as interpreters, with the

parent/caregiver consent for minors.

CONSENSUS-BASED ACTION STATEMENT:

At the conclusion of a comprehensive pediatric

eye and vision examination, the diagnosis should

be explained to the patient/parent/caregiver and

related to the patient’s symptoms, and a treatment

plan and prognosis discussed.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation

Beneﬁt and Harm Assessment: Implementing

this recommendation is likely to increase patient/

parent/caregiver understanding of any diagnosed

eye or vision problems and improve compliance

with any recommended treatment. The beneﬁts of

this recommendation were established by expert

consensus opinion

Patient/parent/caregiver counseling and education may

include:

• Review of the child’s visual and ocular health

status in relation to his/her visual symptoms and

complaints

• Discussion of any refractive correction that

provides improved visual efﬁciency and/or

appropriate eye protection

• Information on learning-related vision problems

• Explanation of available treatment options for

diagnosed eye or vision conditions, including

risks, beneﬁts, and expected outcomes

• Recommendation of a course of treatment with

the reasons for its selection and the prognosis

• Discussion of the importance of patient

compliance with the treatment prescribed

• Recommendation for follow-up care, re-

examination, or referral.

When appropriate, patients/parents/caregivers should

also be counseled about:

a. Eye Safety and Protection

Eye injury is a leading cause of monocular blindness in

the United States and a common reason for eye-related

emergency department visits. Eye injuries treated in U.S.

hospital emergency rooms among children younger than

18 years of age averaged over 70,000 annually in 1990

through 2009.

193

(See Table 6.) The risk for eye injuries in

children is highest among 15 to 17 year olds. The most

common eye injuries are due to abrasions or foreign

bodies.

194

The majority of eye injuries in children occur at home.

193

Frequent causes are sports and recreation activities,

chemicals, or household products.

193,195

Most eye injuries

are preventable with appropriate use of protective

eyewear;

196, 197

however, in a National Health Interview

Survey of children participating in activities that can

cause eye injury, only 14.5% were reported to wear

protective eyewear all or most of the time. Older children

(12 to 17 years of age) were more likely to use protective

eyewear than younger children.

198

Table 6: Most Common Pediatric Eye Injuries

Treated in U.S. Emergency Departments

Common Pediatric Eye Injuries

Sports and recreation (e.g., basketball, baseball, football, playground

equipment)

Household chemicals (e.g., cleaning agents, bleach, pesticides)

Housewares and furniture (e.g., microwaves, ﬂatware, tables)

Toys

Desk supplies (e.g., pens, pencils, scissors)

Tools and hardware (e.g., hammers, nails)

BB and pellet guns

Tobacco products (e.g., cigarettes, cigars, pipes)

Fireworks

Source: Rankings of common pediatric eye injuries

as reported in Pediatric eye injuries treated in U.S.

emergency departments, 1990-2009.

193

It is important to discuss eye safety issues with children/

parents/caregivers, including eye hazards at school

or home, and during sports and recreational activities,

and to promote the use of appropriate protective

eyewear to help reduce the incidence of eye injuries

among children.

193

(Evidence Grade: B),

199

(Evidence

Grade: B) Prevention strategies should focus on the

use of protective eyewear, parental supervision, and on

childhood education about both the risks of eye injury

and the utility of protective eyewear.

194

(Evidence Grade:

200

EVIDENCE-BASED ACTION STATEMENT:

Parents/caregivers and children should be

educated about potential risks for eye injuries

at home, at school, and during sports and

recreational activities, and advised about safety

precautions to decrease the risk of ocular

injury.

193,199

Prevention of eye injuries in children

should focus on the use of protective eyewear,

parental supervision, and include education about

both the risks of eye injury and the beneﬁts of

protective eyewear.

194

Evidence Quality: Grade B: Retrospective cohort

studies

Level of Conﬁdence: Medium

Clinical Recommendation Strength: Strong

Recommendation. This recommendation should

be followed unless clear and compelling rationale

for an alternative approach is present.

Evidence Statements: It is important to

discuss eye safety issues with children/parents/

caregivers.

193

(Evidence Grade: B),

199

(Evidence

Grade: B)

Prevention strategies should focus on the use

of protective eyewear, parental supervision, and

on childhood education about both the risks of

eye injury and the utility of protective eyewear.

194

(Evidence Grade: B)

Potential Beneﬁts:

Reduction in eye

injuries in children

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of counseling as part

of a pediatric eye and vision examination

Value Judgments: None

Role of Patient Preferences: Large

Intentional Vagueness: Speciﬁc type/form of

counseling is not stated, as it is patient speciﬁc

Gaps in Evidence: Research is needed to

determine the risks and methods of eye protection

associated with speciﬁc eye injuries in children in

order to design appropriate prevention strategies

b. Ultraviolet Radiation and Blue Light Protection

Children/parents/caregivers should be advised about the

need to protect children’s eyes from excessive exposure

to sunlight. Sunlight is comprised of ultraviolet (UVA

and UVB) radiation and short wavelength visible energy

(blue light), which can cause acute effects in the eye

and may also lead to chronic effects over the life of the

individual. The eyes of infants and young children are

known to have a higher level of UV and short wavelength

transmittance than older children and adults, making

them more susceptible to energy-related injury.

201, 202

Exposure to high levels of UV-containing sunlight,

especially when reﬂected from snow, can cause

acute photokeratitis and keratoconjunctivitis. Chronic

exposure to even low levels of UV radiation is a risk

factor for developing cataracts, pterygium, squamous

cell carcinoma of the cornea and conjunctiva, and skin

cancer.

203

Epidemiological evidence also shows that

excess chronic sunlight exposure leads to a signiﬁcantly

increased risk for developing age-related macular

degeneration as an older adult.

204

Exposure to high levels of short wavelength visible

energy (blue light) also has the potential to cause

photochemical retinal damage, which is known to occur

with direct sun viewing.

205, 206

In addition, the increased

evening use of laptops and other broad spectrum self-

illuminated devices rich in blue light has been suggested

to interfere with good sleep hygiene, especially in

adolescents.

207

Children can reduce the potential for eye damage from

UV radiation and blue light by not looking directly at the

sun, and wearing sunglasses and/or clear prescription

lenses and brimmed hats when outdoors.

CONSENSUS-BASED ACTION STATEMENT:

All children and their parents/caregivers should

be advised about the beneﬁts of the regular use

of sunglasses and/or clear prescription glasses

that effectively block at least 99% of UVA and

UVB radiation, the use of hats with brims when

outdoors, and the importance of not looking

directly at the sun.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementing

this recommendation is likely to decrease patient

risk of eye health problems from acute or chronic

exposure to UV radiation and blue light. The

beneﬁts of this recommendation were established

by expert consensus opinion.

c. Impact of Near Work and Reduced Time Outdoors

on Vision

The prevalence of myopia in children has been increasing

signiﬁcantly in the past few decades.

Environmental

factors such as time spent on reading and other near

activities and the limited amount of time spent outdoors

have been cited as potential factors contributing to

the development and progression of myopia.

208

Most

children spend considerable time each day using

computers, tablets, or smart phones at school and

at home. As a result, they may be spending less time

outdoors.

Although there is conﬂicting evidence, more time spent

outdoors and less time indoors doing near work may

slow myopia progression and prevent high myopia.

208

(Evidence Grade: A),

209

(Evidence Grade: B),

210

(Evidence

Grade: B),

211

(Evidence Grade: D).

212

EVIDENCE-BASED ACTION STATEMENT:

Patients/parents/caregivers should be counseled

about the beneﬁts to children’s vision of spending

more time outdoors.

208-211

Evidence Quality: Grade B. Randomized clinical

trial, Prospective cohort studies, Cross-sectional

study

Level of Conﬁdence: Medium

Clinical Recommendation Strength:

Recommendation. This recommendation should

generally be followed, but remain alert for new

information.

Evidence Statements: More time spent outdoors

and less time indoors doing near work may slow

axial elongation and prevent high myopia thereby

reducing the risk of developing sight-threatening

conditions such as retinal detachment and myopic

retinopathy.

208

(Evidence Grade: A)

More time outside may decrease myopia

progression. Less outdoor/sports activity before

myopia onset may exert a stronger inﬂuence on

the development of myopia than near work.

209

(Evidence Grade: B)

Outdoor time and near work do not have a major

effect on myopia progression.

210

(Evidence Grade:

Higher levels of outdoor activity were associated

with lower amounts of myopia in primary school

students.

211

(Evidence Grade: D)

Potential Beneﬁts:

Implementation of this

recommendation is

likely to help reduce

the development and

progression of myopia

in children

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of counseling as

part of a pediatric eye and vision examination and

parental/caregiver time off from work

Value Judgments: None

Role of Patient Preferences: Moderate

Intentional Vagueness: Speciﬁc type/form of

counseling is not stated, as it is patient speciﬁc

Gaps in Evidence: Research is needed on the

effects and possible interaction of outdoor activity

and near work on myopia in children

d. Myopia Control

Childhood is the preferred time to consider the use of

myopia control procedures, as early onset myopia is

associated with higher progression rates and increased

risk of continuing to high myopia.

213

The use of progressive addition spectacle lenses,

prismatic bifocals, multiple and dual focus contact

lenses, orthokeratology, and atropine have been studied

to slow myopia progression.

214

The approaches to

control of myopia that have been shown in studies to

be most successful are the use of low concentrations of

atropine eye drops

215

and orthokeratology.

214, 216, 217

Parents/caregivers of children who are at risk for

developing or have developed myopia should be

counseled about the potential complications of myopia

progression and the treatment options available for its

control.

4. Coordination and Frequency of Care

The diagnosis of a wide array of eye and vision

anomalies, diseases, disorders, and related systemic

conditions may result from a comprehensive pediatric

eye and vision examination. The nature and severity of

the problem(s) diagnosed determine the need for:

• Optical correction

• Vision therapy

• Vision rehabilitation services

• Prescription or nonprescription medications

• Surgery

• Follow-up for additional evaluation and/or

treatment.

a. Coordination of Care

Based on the examination, it may be determined that the

patient needs additional services. These may include:

• Intraprofessional consultation with another

doctor of optometry for treatment and

management of ocular disease, vision

rehabilitation, vision therapy, and/or specialty

contact lenses.

• Interprofessional consultation with an

ophthalmologist may be necessary for

ophthalmic surgery or other aspects of

secondary or tertiary eye care.

• Some vision problems can interfere with

learning. Children at risk for learning-related

vision problems should be evaluated by a doctor

of optometry.

• Referral for consultation with the child’s

pediatrician or other primary care physician,

developmental pediatrician, pediatric neurologist,

the school system, a child psychologist or

psychiatrist, or the local or state Department of

Special Education should be considered when

problems in other developmental areas such as

behavior, language, or social development are

suspected or when a full psychoeducational

evaluation is indicated.

• The comprehensive pediatric eye and vision

examination may reveal non-ophthalmic

conditions for which coordination of care may

be needed. The patient may be referred to

his or her pediatrician/primary care physician

or another health care provider for further

evaluation and treatment of systemic conditions

or related health problems. Information shared

with other health care providers offers a unique

and important perspective resulting in an

improved team approach to interdisciplinary care

of the patient.

• Ocular telehealth programs may be a

component of care for some patients,

particularly in areas where access to specialized

eye care services is limited. The use of ocular

telehealth-based programs has the potential

to expand access to eye care services;

however, telehealth-based evaluations are not

a substitute for an in-person comprehensive

eye examination. These programs rely on the

digital capture and transmission of standardized

ocular images and patient health information at

one location for interpretation and evaluation at

another location by trained observers who can

recommend a treatment and care plan. To date,

telehealth programs have been most widely

used for the evaluation of patients with diabetic

retinopathy.

218

b. Frequency of Care

Children should receive periodic eye and vision

examinations to diagnose and treat any eye disease in

its early stages in order to prevent or minimize vision

loss and maximize visual abilities. These examinations

can also identify problems that may be affecting visual

function and achievement at school, at home, and in

sports or leisure activities. In addition, the early signs

and symptoms of systemic medical conditions, such

as diabetes, may be revealed during a comprehensive

pediatric eye and vision examination.

The recommended frequency of a comprehensive

pediatric eye and vision examination (Table 7) varies

with a child’s age, ocular and medical history, and other

related risk factors.

• Infants and Toddlers (newborn through 2 years

of age)

Clinical experience and research have shown that at

6 months the average child has reached a number

of critical developmental milestones, making this an

appropriate age for the ﬁrst eye and vision examination.

Within the ﬁrst 6 months of life, rapid changes occur

in most components of the visual system including

visual acuity,

121, 219

accommodation,

220, 221

and binocular

vision.

222-224

Since the developing visual system is

considered most susceptible to interference during the

ﬁrst few years of life,

225-227

interference during this critical

phase of development may have signiﬁcant long-term

effects; therefore, early diagnosis and treatment are

critical to avoid vision loss.

There is a high prevalence of eye and vision problems in

preterm children.

228

Preterm infants with a history of ROP

should be closely monitored for the development of high

myopia, astigmatism, anisometropia,

229

(Evidence Grade:

B) strabismus,

and other ocular diseases.

One of the primary goals of examining young children is

to detect amblyopia so that treatment can be initiated

as early as possible. Early visual examination of infants

for amblyopia and amblyopic risk factors can lower

the prevalence and severity of amblyopia in children.

230

(Evidence Grade: B)

Assessment of infant refractive error can identify not

only vision problems, but also potential developmental

difﬁculties. Infants with hyperopia may show deﬁcits

in many visuocognitive, spatial, visuomotor, and

attention tests.

231

(Evidence Grade: B) Signiﬁcant

hyperopia is commonly found in association with the

early development of strabismus and amblyopia, with

increased risk of development by age 4 years.

The wearing of a partial correction for signiﬁcant

hyperopia and anisometropia throughout infancy can

reduce the incidence of poorer than average visual acuity

in 3 to 5 1/2 year olds.

232

Spectacle correction in infancy

also improves the chances of infants with hyperopia

having normal vision at age 4 and beyond.

233

EVIDENCE-BASED ACTION STATEMENT:

Infants should receive an in-person comprehensive

eye and vision assessment between 6 and 12

months of age for the prevention and/or early

diagnosis and treatment of sight-threatening eye

conditions and to evaluate visual

development.

229-231

Evidence Quality: Grade B: Prospective cohort

studies, Diagnostic study

Level of Conﬁdence: High

Clinical Recommendation Strength: Strong

Recommendation. This recommendation should

be followed unless clear and compelling rationale

for an alternative approach is present.

Evidence Statements: Preterm infants with a

history of ROP should be closely monitored for the

development of high myopia, astigmatism, and

anisometropia.

229

(Evidence Grade: B)

Early visual examination in infants for amblyopia

and amblyopic risk factors can lower the

prevalence and severity of amblyopia in children.

230

(Evidence Grade: B)

Assessment of infant refractive error can identify

not only vision problems, but also potential

developmental difﬁculties. Hyperopic infants may

show deﬁcits in many visuocognitive, spatial,

visuomotor, and attention tests.

231

(Evidence

Grade: B)

Potential Beneﬁts:

Early identiﬁcation and

treatment of eye and

vision problems

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of testing and

parent/caregiver time off from work

Value Judgments: None

Role of Patient Preferences: Moderate

Intentional Vagueness: None

Gaps in Evidence: None identiﬁed

• Preschool Children (3 through 5 years of age)

Vision care in preschool children is very important

because their visual system is still developing. They are

at risk for the development of amblyopia, strabismus,

and refractive error, which may lead to long term visual

impairment.

40, 41, 53, 234-236

Amblyopia is a treatable condition in children and

adolescents

(Evidence Grade: A); however, amblyopia

is more responsive to treatment among children younger

than 7 years of age.

54-60

Signiﬁcant uncorrected refractive

errors are a risk factor for the development of amblyopia.

In addition to its impact on vision, amblyopia can affect

an individual’s psychosocial functioning, warranting early

diagnosis and treatment.

Uncorrected refractive errors have been associated with

delays in development of cognitive ability and motor

skill.

10, 231, 237

The Vision in Preschoolers-Hyperopia in

Preschoolers (VIP-HIP) study found that uncorrected

hyperopia ≥4.00D, as well as uncorrected hyperopia

≥3.00D to ≤6.00D in conjunction with reduced

binocular visual acuity (20/40 or worse) or reduced

near stereoacuity (240 seconds of arc or worse), are

associated with signiﬁcantly worse performance on

a test of preschool early literacy (TOPEL) in 4 and

5 year old children.

238

(Evidence Grade: C) Children

with astigmatism tend to score lower on measures of

academic and developmental skills than children without

astigmatism.

239

Spectacle correction of children with

astigmatism during the preschool years can also result in

signiﬁcantly improved best-corrected visual acuity by the

time they reach kindergarten age.

240

(Evidence Grade: C)

Uncorrected vision problems can have a detrimental

effect on vision development, learning, school success,

and socialization. Many eye and vision problems are

asymptomatic in this age range; therefore, it is important

that preschool children receive a comprehensive eye

examination. While the U.S. Preventive Services Task

Force recommends that children have their vision

screened at least once between the ages of 3 and 5

years,

107

(Evidence Grade: B) gaps exist in the delivery

of preschool vision screening. Rates of vision screening

in preschool children are low, particularly in 3 year old

children.

241

(Evidence Grade: C)

EVIDENCE-BASED ACTION STATEMENT:

Preschool age children should receive an in-person

comprehensive eye and vision examination at least

once between the ages of 3 and 5 to prevent and/

or diagnose and treat any eye or vision conditions

that may affect visual development.

54,107, 238, 240, 241

Evidence Quality: Grade B. Systematic Review,

Case series, Cross-sectional study

Level of Conﬁdence: Medium

Clinical Recommendation Strength: Strong

Recommendation. This recommendation should

be followed, unless clear and compelling rationale

for an alternative approach is present.

Evidence Statements: Amblyopia is a treatable

condition in children and adolescents

(Evidence

Grade: A); however amblyopia is more responsive

to treatment among children younger than 7 years

of age.

Uncorrected hyperopia in 4 and 5 year old

children has been associated with delays in the

development of early literacy.

238

(Evidence Grade:

Spectacle correction of astigmatism during the

preschool years can result in signiﬁcantly improved

best-corrected visual acuity by kindergarten age.

240

(Evidence Grade: C)

The U.S. Preventive Services Task Force

recommends that children have their vision

screened at least once between the ages of

3 and 5 years of age;

107

(Evidence Grade: B)

however, gaps exist in the delivery of preschool

vision screening and rates of screening are low,

particularly in 3 year old children.

241

(Evidence

Grade: C)

Potential Beneﬁts:

Early identiﬁcation and

treatment of eye and

vision problems

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of testing and

parent/caregiver time off from work

Value Judgments: None

Role of Patient Preferences: Moderate

Intentional Vagueness: None

Gaps in Evidence: None identiﬁed

• School-age Children (6 through 11 and 12

through 18 years of age)

Vision may change frequently during the school years.

The most common problems are due to the

development and progression of refractive errors.

Myopia generally occurs in children during their early

school years and increases in magnitude as they get

older. If myopia is deﬁned as 0.50D or more, the

percentage of children becoming myopic is estimated to

be 23.4%. The age at onset ranges from 7 to 16 years.

Sixteen percent of children enrolled in the CLEERE study

developed myopia (0.75D or more) during their school-

age years. The highest percentage of new cases

occurred at age 11.

Children should receive an eye examination at the

beginning of primary school to test for the presence

of myopia

115

(Evidence Grade: B) and, if diagnosed,

they should have a comprehensive examination at least

annually or as frequently as their doctor recommends

because of rapid myopia progression.

242

(Evidence

Grade: B) Children with myopia, especially those younger

than 9 years of age and/or with two parents with myopia,

are at higher risk for myopia progression and should be

examined more than once per year.

208

(Evidence Grade:

In addition to its relationship to the development of

strabismus and amblyopia, hyperopia can also affect the

development of literacy skills. Children with uncorrected

hyperopia show reduced performance in the acquisition

of emergent literacy skills.

238

(Evidence Grade: C),

243

(Evidence Grade: C) Correction of hyperopia may, under

speciﬁc conditions, lead to increased reading speed;

therefore, eye examinations to diagnose uncorrected

hyperopia are recommended.

244

(Evidence Grade: B)

An accommodative or vergence dysfunction can have

a negative effect on a child’s school performance,

especially after third grade when the child must read

smaller print and reading demands increase. Children

with convergence insufﬁciency self-report more problems

compared to children with normal binocular vision.

245

These include somatic (e.g., eyes hurt or headaches),

visual (e.g., blur and diplopia), and performance (e.g.,

loss of concentration, frequent need to re-read and

difﬁculty remembering what is read) problems. Due to the

discomfort of these symptoms, a child may not be able

to complete reading or homework assignments and may

be easily distracted or inattentive.

Studies have reported an association between reading

and eye movements.

246-248

Efﬁcient reading requires

accurate eye movements. Treatment of children with eye

movement problems has been shown to improve reading

comprehension.

248

Diagnosis and treatment of an accommodative or

vergence problem may reduce the negative impact on

academic performance.

(Evidence Grade B)

249

Vision

therapy has been shown to be effective in improving

accommodative amplitude and accommodative facility

in school-age children with symptomatic convergence

insufﬁciency and accommodative dysfunction.

Children with Attention Deﬁcit/Hyperactivity Disorder

(AD/HD) have been reported to have a much greater

incidence of CI than those without AD/HD;

250

therefore,

these children may beneﬁt from comprehensive vision

evaluation to assess the presence of convergence

insufﬁciency.

251

(Evidence Grade: D) Treatment of

convergence insufﬁciency has been associated with

reduction in the frequency of adverse academic

behaviors.

(Evidence Grade B)

Click to view the (AOA Clinical Practice Guidelines

web page)

EVIDENCE-BASED ACTION STATEMENT:

School-age children should receive an in-person

comprehensive eye and vision examination before

beginning school to diagnose, treat, and manage

any eye or vision conditions.

65, 115, 238, 243, 244, 251

Evidence Quality: Grade B. Prospective cohort

studies, Case-control study, Cross-sectional study.

Level of Conﬁdence: Medium

Clinical Recommendation Strength: Strong

Recommendation. This recommendation should

be followed unless clear and compelling rationale

for an alternative approach is present.

Evidence Statements: Children should receive

an eye examination at the beginning of primary

school to diagnose the onset of myopia.

115

(Evidence Grade: B)

Hyperopia can affect the development of literacy

skills. Children with uncorrected hyperopia

show reduced performance in the acquisition of

emergent literacy skills.

238

(Evidence Grade: C),

243

(Evidence Grade: C)

Correction of hyperopia may, under speciﬁc

conditions, lead to increased reading speed;

therefore, eye examinations to diagnose

uncorrected hyperopia are recommended.

244

(Evidence Grade: B)

Early diagnosis and treatment of an

accommodative or vergence problem may reduce

the negative impact on academic performance.

(Evidence Grade: B)

Children with AD/HD or related learning problems

may beneﬁt from comprehensive vision evaluation

to assess the presence of convergence

insufﬁciency.

251

(Evidence Grade: D)

Treatment of convergence insufﬁciency has been

associated with reduction in the frequency of

adverse academic behaviors.

(Evidence Grade B)

Potential Beneﬁts:

Early identiﬁcation and

treatment of eye and

vision problems

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of testing and

parent/caregiver time off from work

Value Judgments: None

Role of Patient Preferences: Moderate

Intentional Vagueness: None

Gaps in Evidence: None identiﬁed

EVIDENCE-BASED ACTION STATEMENT:

Children with myopia should have an in-person

comprehensive eye and vision examination at

least annually, or as frequently as recommended

(especially until age 12), because of the potential

for rapid myopia progression.

208, 242

Evidence Quality: Grade B. Randomized clinical

trial, Prospective cohort study

Level of Conﬁdence: Medium

Clinical Recommendation Strength: Strong

Recommendation. This recommendation should

be followed unless clear and compelling rationale

for an alternative approach is present.

Evidence Statements: Children with myopia

should have an examination at least annually or as

frequently as their doctor recommends until the

age of 12 because of rapid myopia progression.

242

(Evidence Grade: B)

When both parents have myopia, children are

at higher risk for progression and should be

examined more than once per year.

208

(Evidence

Grade: A)

Potential Beneﬁts:

Early identiﬁcation and

treatment of eye and

vision problems

Potential Risks/

Harms: None

Beneﬁt and Harm Assessment: Beneﬁts

signiﬁcantly outweigh harms

Potential Costs: Direct cost of testing and

parent/caregiver time off from work

Value Judgments: None

Role of Patient Preferences: Moderate

Intentional Vagueness: None

Gaps in Evidence: None identiﬁed

CONSENSUS-BASED ACTION STATEMENT:

School-age children should receive an in-person

comprehensive eye and vision examination

annually to diagnose, treat, and manage any eye

or vision problems.

Evidence Quality: There is a lack of published

research to support or refute the use of this

recommendation.

Beneﬁt and Harm Assessment: Implementing

this recommendation is likely to result in earlier

diagnosis and treatment of eye and vision

problems and improved visual function. The

beneﬁts of this recommendation were established

by expert consensus opinion.

c. At-risk Children

The extent to which a child is at risk for the development

of eye and vision problems determines the appropriate

re-evaluation schedule. Children with ocular signs and

symptoms require a prompt comprehensive examination.

Furthermore, the presence of certain risk factors may

necessitate more frequent examinations based on

professional judgment. Factors placing an infant, toddler,

or child at signiﬁcant risk for eye and vision problems

include:

• Prematurity, low birth weight, prolonged

supplemental oxygen at birth

• Family history of myopia, amblyopia, strabismus,

retinoblastoma, congenital cataracts, metabolic,

or genetic disease

• Infection of mother during pregnancy (e.g.,

rubella, toxoplasmosis, venereal disease,

herpes, cytomegalovirus, or human

immunodeﬁciency virus)

• Maternal smoking, use of alcohol, or illicit drug

use during pregnancy

• Cortical visual impairment

• Difﬁcult or assisted labor, which may be

associated with fetal distress

• High or progressive refractive error

• Strabismus

• Anisometropia

• Academic performance problems

• Known or suspected neurodevelopmental

disorders

• Systemic health conditions with potential ocular

manifestations

• Wearing contact lenses

• Having functional vision in only one eye

• Eye surgery or previous eye injury

• Taking prescription or nonprescription

drugs (e.g., over the counter medications,

supplements, herbal remedies) with potential

ocular side effects

Table 7: Recommended Eye Examination

Frequency for the Pediatric Patient**

Examination Interval

Patient Age

Asymptomatic/

Low Risk

At-risk

Birth through 2 years

At 6 to12 months

of age

At 6 to 12 months

of age or as

recommended

3 through 5 years

At least once between

3 and 5 years of age

At least once between

3 and 5 years of age

or as recommended

6 through 18 years

Before ﬁrst grade and

annually thereafter

Before ﬁrst grade

and annually, or

as recommended,

thereafter

**The American Optometric Association Clinical

Practice Guidelines provide more information on

other eye and vision disorders and their risk factors.

Click to view the (AOA Clinical Practice Guidelines

web page)

D. Conclusion

The prevalence of eye and vision disorders is substantial

in children. Research indicates that early detection and

intervention are particularly important in children because

of the rapid development of the visual system in early

childhood and its sensitivity to interference. When visual

disorders such as amblyopia, strabismus, non-strabismic

binocular vision disorders, and signiﬁcant refractive

error are undetected, the long-term consequences can

lead to signiﬁcant vision loss, decreased educational

and occupational opportunities, and reduced quality

of life. In addition, the cost of providing appropriate

treatment for longstanding eye and vision disorders may

be signiﬁcantly higher than the cost of diagnosing and

treating these problems early in life. A comprehensive

pediatric eye and vision examination by a doctor of

optometry is imperative for the timely diagnosis and

treatment of eye and vision problems.

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V. APPENDIX

A. APPENDIX FIGURE 1:

Comprehensive Pediatric Eye and Vision Examination: A Flowchart

Final copy 3/3/17

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V. APPENDIX 2555

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A. Appendix Figure 1 2557

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Comprehensive Pediatric Eye and Vision Examination: 2559

A Flowchart 2560

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B. APPENDIX TABLE 1

Potential Components of the Comprehensive Eye and Vision Examination for Infants and Toddlers

A. Patient History

1. Nature and history of the presenting problem, including chief complaint

2. Visual and ocular history

3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgical

and/or head or ocular trauma history, and any vision or ocular treatment

4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter

medications, supplements, herbal remedies) and documentation of medication allergies

5. Family ocular and medical histories

6. Developmental history of the child

7. Time spent outdoors, on sports activities, and on near work and screen viewing

8. Names of, and contact information for, the patient’s other health care providers

B. Visual Acuity

1. Preferential looking visual acuity

2. Fixation preference test

3. Visual evoked potential

C. Refraction

1. Cycloplegic retinoscopy

2. Non-cycloplegic retinoscopy

D. Binocular Vision and Ocular Motility

1. Ocular alignment assessment (e.g., cover test, Hirschberg test, Krimsky test)

2. Brückner test

3. Stereopsis (e.g., Preschool Assessment of Stereopsis with a Smile 3 test)

4. Near point of convergence

5. Ocular motility assessment (e.g., versions, eye tracking)

E. Ocular and Systemic Health Assessment

1. Assessment of pupillary responses

2. Visual ﬁeld evaluation (e.g., confrontation)

3. Evaluation of the ocular anterior segment and adnexa

4. Evaluation of the ocular posterior segment

5. Measurement of intraocular pressure

C. APPENDIX TABLE 2

Potential Components of the Comprehensive Eye and Vision Examination for Preschool Children

A. Patient History

1. Nature and history of the presenting problem, including chief complaint

2. Visual and ocular history

3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgical

and/or head or ocular trauma history, and any vision or ocular treatment

4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter

medications, supplements, herbal remedies) and documentation of medication allergies

5. Family eye and medical histories

6. Developmental history of the child

7. Time spent outdoors, on sports activities, and on near work and screen viewing

8. Names of, and contact information for, the patient’s other health care providers

B. Visual Acuity

1. Symbol optotype or letter matching visual acuity measurement

C. Refraction

1. Static (distance) retinoscopy

2. Cycloplegic retinoscopy

3. Autorefraction

D. Binocular Vision, Ocular Motility, and Accommodation

1. Ocular alignment assessment - distance and near (e.g., cover test, Hirschberg test, Krimsky test)

2. Ocular motility assessment

3. Near point of convergence

4. Stereopsis (e.g., Preschool Assessment of Stereopsis with a Smile 3 test, Randot Preschool test)

5. Positive and negative fusional vergence ranges

6. Accommodative testing (e.g., dynamic retinoscopy)

E. Color vision testing

F. Ocular and Systemic Health Assessment

1. Assessment of pupillary responses

2. Visual ﬁeld evaluation (e.g., confrontation)

3. Evaluation of the ocular anterior segment and adnexa

4. Evaluation of the ocular posterior segment

5. Measurement of intraocular pressure

D. APPENDIX TABLE 3

Potential Components of the Comprehensive Eye and Vision Examination for School-age Children

A. Patient History

1. Nature and history of the presenting problem, including chief complaint

2. Visual and ocular history

3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgical

and/or head or ocular trauma history, and any vision or ocular treatment

4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter

medications, supplements, herbal remedies) and documentation of medication allergies

5. Family eye and medical histories

6. Developmental history of the child

7. School performance history

8. Time spent outdoors, on sports activities, and on near work and screen viewing

9. Names of, and contact information for, the patient’s other health care providers

B. Visual Acuity

1. Snellen visual acuity

2. ETDRS visual acuity

C. Refraction

1. Static (distance) retinoscopy

2. Cycloplegic retinoscopy

3. Subjective refraction

4. Autorefraction

D. Binocular Vision, Ocular Motility, and Accommodation

1. Ocular alignment assessment - distance and near (e.g., cover test, Hirschberg test, Krimsky test, Von Graefe

phoria, Modiﬁed Thorington, Maddox Rod)

2. Ocular motility assessment (e.g., ﬁxation, saccades, pursuits)

3. Near point of convergence

4. Stereopsis (e.g., Random dot stereopsis test)

5. Positive and negative fusional vergence ranges

6. Accommodative testing (e.g., amplitude, facility, and response)

E. Color Vision Testing

F. Ocular and Systemic Health Assessment

1. Assessment of pupillary responses

2. Visual ﬁeld evaluation (e.g., confrontation)

3. Evaluation of the ocular anterior segment and adnexa

4. Evaluation of the ocular posterior segment

5. Measurement of intraocular pressure

E. APPENDIX TABLE 4

Partial Listing of Ocular Manifestations of Neurodevelopmental Disorders and Other Syndromes

Neurodevelopmental Disorders Etiology Associated Ocular Manifestations

Aicardi Syndrome Dysgenesis of the corpus callosum Chorioretinal lacunae, optic nerve colobomas,

optic nerve hypoplasia

Alport Syndrome Irregular synthesis of collagen Fleck retinal dystrophy, anterior lenticonus,

corneal dystrophy, cataracts

Angelman Syndrome Deletion of maternal genetic material on

chromosome 15

Strabismus, hypopigmentation of the choroid

Attention Deﬁcit/Hyperactivity Disorder Genetic inﬂuences on dopaminergic systems,

prenatal factors such as maternal use of drugs

and alcohol

Convergence insufﬁciency, accommodative

dysfunction, oculomotor disorders

Autism Spectrum Disorders Unknown; possible link to environmental

stressors, genetic mutations and inﬂammatory

processes

Deﬁcits in visual acuity, stereoacuity and ocular

alignment; poor saccades and pursuits

Bardet-Biedl Syndrome Mutation in 14 different genes that lead to

problems with the function of cilia in cell

structures

Reduced visual acuity, problems with night vision,

tunnel vision

Batten-Mayou Syndrome Autosomal recessive disorder resulting in

accumulation of lipids

Lipofuscin accumulation in the retina, optic

atrophy, macular pigment

Behçet’s Disease Postulated to be episodic hyperactivity of immune

system

Uveitis, cataracts, optic atrophy, macular edema

Behr Syndrome Autosomal recessive disease resulting in

progressive deterioration of the nervous system

Optic atrophy, retrobulbar neuritis, nystagmus

Branchial Arch Syndrome Disruption of neural crest cell migration Strabismus, proptosis from poorly formed orbits,

coloboma of the eyelid

Cerebral Palsy Disorder of movement and posture secondary to

damage to motor control connections

Strabismus, nystagmus, optic nerve pallor,

cataracts, myopia, accommodative dysfunction

Cerebro-oculo-facial Syndrome Autosomal recessive disorder resulting in

defective swallowing mechanism

Microphthalmia, involuntary eye movements,

congenital cataracts, blepharophimosis

Charot-Marie-Tooth Syndrome Genetic anomaly resulting in progressive muscular

atrophy

Nystagmus, diminished visual acuity

CHARGE Syndrome Common mutation of chromosome 8 resulting in

association of multiple systemic defects

Bilateral retinal coloboma involving the optic

nerve, strabismus, amblyopia

Cri-du-chat Syndrome Deletion of short arm of chromosome 5 Strabismus, hypertelorism, slanting of the

palpebral ﬁssure

Dandy-Walker syndrome Absence of the cerebellar vermis and dilation of

fourth ventricle

Papilledema often seen with hydrocephalus,

ptosis and strabismus secondary to cranial nerve

palsy

de Lange Syndrome Mutation in genes responsible for chromosomal

adhesions

Long eyelashes, ptosis telecanthus, alternating

exotropia

Neurodevelopmental Disorders Etiology Associated Ocular Manifestations

Down Syndrome Triplicate 21st chromosome Epicanthal folds, upslanting palpebral ﬁssure,

high refractive error, strabismus, keratoconus,

blepharitis, accommodative dysfunction/

insufﬁciency

Dubowitz Syndrome Unknown etiology Strabismus, ptosis, telecanthus, epicanthal folds

Ehlers-Danlos Syndrome Genetic or nutritional defects that have altered the

biosynthesis of collagen

Lens subluxation, palpebral skin laxity,

keratoconus, myopia, blue sclera, angiod streaks

Fabry Disease Inherited disorder resulting from an abnormal

build-up of fat in the blood vessel walls

throughout the body

Corneal opacity

Fetal Alcohol Syndrome CNS damage secondary to alcohol crossing the

blood-brain barrier

Telecanthus, strabismus, optic nerve hypoplasia,

ptosis, microphthalmia

Fragile X Syndrome Gene (FMR1) on the X chromosome fails to

allow protein synthesis necessary for neural

development

Strabismus, astigmatism, amblyopia

Gaucher Disease Lysomal storage disease Strabismus, gaze palsies, corneal clouding,

pinguecula

Hunter Syndrome Mucopolysaccharidosis l – Lysomal storage

disease

Corneal clouding, pigmentary degeneration of the

retina, optic atrophy

Lowe Syndrome Abnormal protein transport within cellular

membranes

Bilateral congenital cataracts, glaucoma, corneal

keloids, strabismus

Marfan Syndrome Genetic disorder affecting the body’s connective

tissue

Severe nearsightedness, dislocated lens,

detached retina, glaucoma, cataracts

Prader-Willi Syndrome Deletion of paternal genetic material on

chromosome 15

Strabismus, almond-shaped palpebral ﬁssures,

myopia

Rett Syndrome Mutation of binding protein (MECP2) that alters

the development of gray matter

Difﬁculty maintaining eye contact

Septo-Optic Dysplasia/DeMorsier Syndrome Disorder of early brain/optic nerve development

associated with a number of environmental and

genetic factors

Visual impairment in one or both eyes, nystagmus,

strabismus

Spina Biﬁda Incomplete closure of embryonic neural tube Papilledema, nerve palsies, nystagmus, optic

atrophy

Stickler Syndrome Defective biosynthesis of collagen Myopia, retinal detachments, vitreous anomalies

Usher Syndrome Inherited autosomal recessive trait Retinitis pigmentosa

Williams Syndrome Vast deletion of genes on chromosome 7 Infantile esotropia, anomaly in visual-spatial

relationship

Source: Adapted from Table 7.1 Rare Neurodevelopmental Disorders in Taub MB, Bartuccio M, Maino DM.

Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins, Philadelphia, PA,

2012.

F. ABBREVIATIONS/ACRONYMS

ADA Americans with Disabilities Act

AD/HD Attention Deﬁcit/Hyperactivity Disorder

AHRQ Agency for Healthcare Research and Quality

COI Conﬂict of interest

CE Convergence excess

CI Convergence insufﬁciency

CLEERE Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error

CPG Clinical Practice Guideline

CT Computerized tomography

CVI Cortical (cerebral) visual impairment

D Diopter

DR Diabetic retinopathy

EBO Evidence-Based Optometry

ERG Electroretinogram

ETDRS Early Treatment of Diabetic Retinopathy Study

G Grams

GAT Goldmann applanation tonometer

GDG Guideline Development Group

GDRG Guideline Development Reading Group

IDEA Individuals with Disabilities Education Act

IEP Individualized Education Program

IOM Institute of Medicine

IOP Intraocular pressure

MRI Magnetic resonance imaging

NPC Near point of convergence

NRA Negative relative accommodation

OCT Optical coherence tomography

PASS Preschool Assessment of Stereopsis with a Smile

PRA Positive relative accommodation

RCT Randomized clinical trial

ROP Retinopathy of prematurity

RP Retinitis pigmentosa

SE Spherical equivalent

SR Systematic review

TOPEL Test of Preschool Early Literacy

VEP Visual evoked potential

UV Ultraviolet

VIP-HIP Vision in Preschoolers-Hyperopia in Preschoolers

G. SUMMARY OF ACTION STATEMENTS

A comprehensive pediatric eye and vision examination should include, but is not limited to:

• Review of the nature and history of the presenting problem, patient and family eye and medical histories,

including visual, ocular, general health, leisure and sports activities, and developmental and school performance

history of the child

• Measurement of visual acuity

• Determination of refractive status

• Assessment of binocular vision, ocular motility, and accommodation

• Evaluation of color vision (baseline or periodic, if needed, for qualiﬁcation purposes or if disease related)

• Assessment of ocular and systemic health, including evaluation of pupillary responses, anterior and posterior

segment, peripheral retina, and evaluation/measurement of intraocular pressure and visual ﬁeld testing.

(Consensus)

Cycloplegic retinoscopy is the preferred procedure for the ﬁrst evaluation of preschoolers. It is necessary to quantify

signiﬁcant refractive error in the presence of visual conditions such as strabismus, amblyopia, and anisometropia.

(Consensus)

Cycloplegic retinoscopy is the preferred procedure for the ﬁrst evaluation of school-age children. It is necessary

to quantify signiﬁcant refractive error in the presence of visual conditions such as strabismus, amblyopia, and

anisometropia. (Consensus)

Abnormal color vision can affect daily performance of activities involving color discrimination and may interfere

with or prevent some occupational choices later in life. Children should be tested as soon as possible for color

vision deﬁciency and the parents/caregivers of children identiﬁed with color vision deﬁciency should be counseled.

(Consensus)

Children at risk for learning-related vision problems should be evaluated by a doctor of optometry. (Consensus)

Many children with developmental or intellectual disabilities have undetected and untreated vision problems and

should receive a comprehensive pediatric eye and vision examination. (Consensus)

At the conclusion of a comprehensive pediatric eye and vision examination, the diagnosis should be explained to

the patient/parent/caregiver and related to the patient’s symptoms, and a treatment plan and prognosis discussed.

(Consensus)

Parents/caregivers and children should be educated about potential risks for eye injuries at home, at school,

and during sports and recreational activities, and advised about safety precautions to decrease the risk of ocular

injury.

193,199

Prevention of eye injuries in children should focus on the use of protective eyewear, parental supervision,

and include education about both the risks of eye injury and the beneﬁts of protective eyewear.

194

(Evidence Grade B/

Strong Recommendation)

All children and their parents/caregivers should be advised about the beneﬁts of the regular use of sunglasses and/

or clear prescription glasses that effectively block at least 99% of UVA and UVB radiation, the use of hats with brims

when outdoors, and the importance of not looking directly at the sun. (Consensus)

Patients/parents/caregivers should be counseled about the beneﬁts to children’s vision of spending more time

outdoors.

208-211

(Evidence Grade B/Recommendation)

Infants should receive an in-person comprehensive eye and vision assessment between 6 and 12 months of age

for the prevention and/or early diagnosis and treatment of sight-threatening eye conditions and to evaluate visual

development.

229-231

(Evidence Grade B/Strong Recommendation)

Preschool age children should receive an in-person comprehensive eye and vision examination at least once

between the ages of 3 and 5 to prevent and/or diagnose and treat any eye or vision conditions that may affect visual

development.

54,107,238,240,241

(Evidence Grade B/Strong Recommendation)

School-age children should receive an in-person comprehensive eye and vision examination before beginning

school to diagnose, treat and manage any eye or vision conditions.

65,115,238,243,244,251

(Evidence Grade B/Strong

Recommendation)

Children with myopia should have an in-person comprehensive eye and vision examination at least annually, or as

frequently as recommended (especially until age 12), because of the potential for rapid myopia progression.

208,242

(Evidence Grade B/Strong Recommendation)

School-age children should receive an in-person comprehensive eye and vision examination annually to diagnose,

treat, and manage eye or vision problems. (Consensus)

H. GAPS IN RESEARCH EVIDENCE

During the course of the development of this guideline, the Evidence-Based Optometry Guideline Development

Group identiﬁed the following gaps in evidence as potential areas for future research:

• Research to compare the outcomes of vision screenings versus comprehensive eye and vision examinations

• Research to determine the risks and protective factors associated with eye injuries in children in order to design

appropriate prevention strategies

• Research on the effects and possible interaction of outdoor activity with near work and myopia in children.

VI. METHODOLOGY FOR GUIDELINE DEVELOPMENT

This guideline was developed by the AOA Evidence-Based Optometry Guideline Development Group (GDG). Clinical

questions to be addressed in the guideline were identiﬁed and reﬁned during an initial meeting of the GDG and served

as the basis for a search of the clinical and research literature.

An English language search of the medical literature for the eye and vision examination of children birth through 18

years of age, for the time period January 2005 through October 2016 was conducted by trained researchers. If the

search did not produce results, the search parameters were extended an additional 5 years.

Search Inclusion Criteria (must meet all):

1. English Studies

2. Study addresses the clinical question(s)

3. Paper meets the age group being addressed (0 to 18 years for pediatrics)

4. Searched by question(s) formulated at the AOA Call to Question Meeting attended by the Guideline

Development Group (GDG)

5. Using all similar and relevant terms as deﬁned by the GDG

Exclusion Criteria (meeting any of the below):

1. Non-English studies

2. Animal studies

3. Studies outside of the patient age range

4. Studies not addressing any topic of the clinical questions searched

In addition, a review of selected earlier research publications was conducted based on previous versions of this

guideline. The literature search was conducted using the following electronic databases:

The literature search resulted in the retrieval of the number of references shown in the following chart.

Final copy 3/3/17

2942

2943

All references meeting the criteria were reviewed to determine their relevance to the clinical questions 2944

addressed in the guideline. Each article was assigned to two clinicians who independently reviewed 2945

and graded the quality of evidence and the clinical recommendations derived from the article, based 2946

on a previously defined system for grading quality. If discrepancies were found in the grading results, 2947

the article was assigned to an independent third reader for review and grading. 2948

During six articulation meetings (three face-to-face and three using a Webex platform) of the 2949

Evidence-Based Optometry Guideline Development Reading Group (GDRG), all evidence was 2950

reviewed and clinical recommendations were developed. The strength level of clinical 2951

recommendations was based on the quality grade of the research and the potential benefits and 2952

harms of the procedure or therapy recommended. Where high quality evidence to support a 2953

recommendation was weak or lacking, a group consensus was required to approve any consensus 2954

recommendations. 2955

Review and editing of the draft guideline by the Evidence-Based Optometry GDG required one face- 2956

to-face meeting and three additional Draft Reading Meetings using a Webex platform. The final Peer 2957

Review draft was reviewed and approved by the GDG by conference call, then made available for 2958

peer and public review for 30 days for numerous stakeholders (individuals and organizations). 2959

Comments were promoted and encouraged. All suggested revisions were reviewed and, if accepted 2960

by the GDG, incorporated into the guideline. All peer and public comments and all actions (and 2961

inactions) were recorded. 2962

Clinical recommendations in this guideline are evidence-based statements regarding patient care that 2963

are supported by the scientific literature or consensus of professional opinion when no quality 2964

• Agency for Healthcare Research and Quality

(AHRQ)

• American Academy of Optometry (AAO)

• American Academy of Neurology

• American Association for Pediatric

Ophthalmology and Strabismus (AAPOS)

• American Journal of Optometry and

Physiological Optics

• Centers for Disease Control and Prevention,

National Center for Health Statistics

• Cochrane Library

• Developmental Medicine & Child Neurology

(DMCN)

• Elsevier

• Epidemiology

• Google Scholar

• JAMA Ophthalmology

• Journal of Adolescent Health Care (JAHC)

• Medline Plus

• National Eye Institute

• National Institute of Health Public Access (NIH)

• National Guideline Clearinghouse

• Neurology

• Ophthalmic Epidemiology

• Ophthalmology

• PubMed

• Other medical journals meeting the search

criteria will be included in this list when used

All references meeting the criteria were reviewed to determine their relevance to the clinical questions addressed

in the guideline. Each article was assigned to two clinicians who independently reviewed and graded the quality of

evidence and the clinical recommendations derived from the article, based on a previously deﬁned system for grading

quality. If discrepancies were found in the grading results, the article was assigned to an independent third reader for

review and grading.

During six articulation meetings (three face-to-face and three using a Webex platform) of the Evidence-Based

Optometry Guideline Development Reading Group (GDRG), all evidence was reviewed and clinical recommendations

were developed. The strength level of clinical recommendations was based on the quality grade of the research

and the potential beneﬁts and harms of the procedure or therapy recommended. Where high quality evidence to

support a recommendation was weak or lacking, a group consensus was required to approve any consensus

recommendations.

Review and editing of the draft guideline by the Evidence-Based Optometry GDG required one face- to-face meeting

and three additional Draft Reading Meetings using a Webex platform. The ﬁnal Peer Review draft was reviewed and

approved by the GDG by conference call, then made available for peer and public review for 30 days for numerous

stakeholders (individuals and organizations). Comments were promoted and encouraged. All suggested revisions

were reviewed and, if accepted by the GDG, incorporated into the guideline. All peer and public comments and all

actions (and inactions) were recorded.

Clinical recommendations in this guideline are evidence-based statements regarding patient care that are supported

by the scientiﬁc literature or consensus of professional opinion when no quality evidence was discovered. The

guideline will be periodically reviewed for new scientiﬁc and clinical evidence within 3-5 years.

VII. EVIDENCE-BASED OPTOMETRY GUIDELINE DEVELOPMENT GROUP

AOA Evidence-Based Optometry Committee

Diane T. Adamczyk, O.D., Chair – State University of New York, College of Optometry, New York, New York

John F. Amos, O.D., M.S. – University of Alabama at Birmingham School of Optometry, Birmingham, Alabama, Dean and

Professor Emeritus

Felix M. Barker, II, O.D., M.S. – W. G. (Bill) Hefner VAMC, Salisbury, North Carolina

Benjamin P. Casella, OD – Private Practice – Casella Eye Center, Augusta, Georgia

Linda M. Chous, O.D. – United HealthCare Services, Inc., Minneapolis, Minnesota

Lynn D. Greenspan, O.D. – Salus University, Pennsylvania College of Optometry, Elkins Park, Pennsylvania

Lori L. Grover, O.D., Ph.D. – Health Policy, King-Devick Technologies, Inc., Oakbrook Terrace, Illinois

Tina R. MacDonald, O.D. – The Center for the Partially Sighted, Culver City, California

Harue J. Marsden, O.D., M.S. – Southern California College of Optometry, Marshall B. Ketchum University, Fullerton,

California

David K. Masihdas, O.D. – Utah Eye Associates - The Diabetic Eye Center, Salt Lake City, Utah

Bennett McAllister, O.D. – Western University of Health Sciences, College of Optometry, Pomona, California

Trennda L. Rittenbach, O.D. – Palo Alto Medical Foundation/Sutter Health, Sunnyvale, California

Carl J. Urbanski, O.D. – Private Practice, Family Vision Care of Kingston, Kingston, Pennsylvania

Multidisciplinary and Patient Stakeholders

Ida Chung, O.D. – Western University of Health Sciences, College of Optometry, Pomona, California

Beth T. Dessem – Patient Advocate; Missouri CASA Association, Columbia, Missouri

David E. Hartenbach, M.D. – Pediatrician; Creve Coeur Pediatrics, Creve Coeur, Missouri

Janet Hughes – Patient (parent); Vision First Foundation, Lemont, Illinois

Mitchell M. Scheiman, O.D. – Salus University, The Eye Institute of Pennsylvania College of Optometry, Elkins Park,

Pennsylvania

Non-voting Members

Stephen C. Miller, O.D., Chief Editor - Innovative Writing Works, St. Louis, Missouri

Beth A. Kneib, O.D., AOA Director of Clinical Resources, American Optometric Association, St. Louis, Missouri

Andrew Morgenstern, O.D., AOA Consultant for Evidence-Based Optometry, American Optometric Association, Alexandria,

Danette Miller, AOA Manager of Quality Improvement, American Optometric Association, St. Louis, Missouri

Alisa G. Krewet, AOA Quality Improvement Coordinator, American Optometric Association, St. Louis, Missouri