How to check eyes and vision in a child?
If you are concerned about your child not seeing well, it is time to figure out what and when you should do to reassure yourself (or a concerned grandma). First of all, talk to your pediatrician. While they are not eye doctors, pediatric doctors know enough about vision and eyes to do the initial check.
In this article:
- How to check eyes and vision in a child?
- What are the common vision problems in children?
- Child vision screening
- Neonatal vision screening
- When to see an ophthalmologist
- Comprehensive eye exam
- Which pediatric eye tests require general anesthesia?
- Does a healthy child need to see eye doctor?
- Optometrist vs ophthalmologist for kids
- References
How to check eyes and vision in a child?
If you are concerned about your child not seeing well, it is time to figure out what and when you should do to reassure yourself (or a concerned grandma). First of all, talk to your pediatrician. While they are not eye doctors, pediatric doctors know enough about vision and eyes to do the initial check. Many clinics will have vision screening that is age-appropriate and performed by trained nurses. Also, a doctor will look into your child’s eyes with an ophthalmoscope and make couple of simple tests to see if your baby or child is following and focusing on an object. A crossed eye can be tested also right there – by the patch test.
The frequency of ocular conditions that cause severe vision impairment or blindness in children varies considerably around the world. In low-income countries, cataracts and corneal conditions resulting from infectious disease are frequent causes of severe vision impairment and blindness. In middle-income countries, retinopathy of prematurity (ROP) is an important cause. In high-income countries, including the United States, conditions of the optic nerve and higher visual pathways, frequently associated with prematurity, are major causes of severe vision impairment and blindness.
What are the common vision problems in children?
Common childhood ocular problems causing vision impairment include:
- Strabismus (crossed eye) – an inward or outward displacement of one eye
- Amblyopia (lazy eye), which is a blindness of a completely normal eye
- Refractive problems (nearsightedness, farsightedness, astigmatism etc.)
- Uveitis (inflammation inside the eye). Uveitis can be due to many infectious or inflammatory causes, such as juvenile idiopathic arthritis and toxoplasma retinochoroiditis.
Additionally, cataract, hereditary diseases (particularly retinal dystrophies), and congenital abnormalities are important causes worldwide. In high-income countries, severe vision-threatening eye problems observed within the first year of life include:
- Congenital cataract
- Eye disease of premature babies (ROP). Children with severe ROP have a lifelong risk of developing glaucoma and retinal detachment. The visual impairment is often accompanied by cerebral palsy, epilepsy, and other motor and intellectual disabilities.
- Congenital glaucoma
- Retinoblastoma (a vision- and life-threatening malignancy)
- Cerebral visual impairment.
Child vision screening
Vision screening for children is an evaluation to detect reduced visual acuity or risk factors that threaten the healthy growth and development of the eye and visual system. It is necessary to catch certain vision problems on time, even before you notice it. For example, amblyopia does not always present with signs or symptoms that are apparent to parents or caregivers, children with amblyopia may seem to have normal visual function until formally tested.
The majority of healthy children should have several vision screenings during childhood. Comprehensive eye examinations are not necessary for healthy asymptomatic children who have passed an acceptable vision screening test, had no subjective visual symptoms, and had no personal or familial risk factors for eye disease.
Vision screening in the primary care setting is usually performed by a nurse or other trained health professional during routine pediatric examinations. Vision screening in the community setting may be performed in preschools, in daycares, at schools, or at health fairs. Community screenings can be performed by health professionals or trained lay personnel.
Neonatal vision screening
The first vision check happens at the hospital when the baby is born. Primary care providers or neonatologist should perform vision screening of newborns. Pediatrician should screen every child on a well-child exam, including infants under 6 months of age. Screening includes:
- red reflex testing to detect abnormalities of the ocular media,
- external inspection of ocular and periocular structures,
- pupillary examination,
- assessment of fixation and following behavior.
When to see an ophthalmologist
If a pediatrician or a neonatologist finds that your child fails the vision screening, it is time to make an appointment with an ophthalmologist. Also, you will need to follow with a pediatric eye doctor if:
- Baby was born premature
- Failed neonatal vision screening
- Congenital defects of the face were found
- Mom’s prenatal screen was positive for infections, such as rubella or cmv
You may want to establish care with the pediatric eye clinic if your have vision problems in the family. Many eye diseases are genetic, and can present themselves very early or delayed.
Comprehensive eye exam
Comprehensive eye examinations differ in technique, instrumentation, and diagnostic capacity from child to child. The choice of the equipment and method will depend on the child’s age, development of skills, level of cooperation, and ability to follow the commands of the examiner. A comprehensive assessment includes:
- A past medical history and family history. You will be asked to complete a questionnaire for your first appointment. In most of the offices it can be done online prior to the visit
- An eye and face examination, also a physical examination and functional abilities (crawling, walking, picking up an object, following a command etc)
- Vision test and other additional tests may be indicated. A pediatric eye doctor has many tricks to help a child with all needed examinations. many employ electronic games and distractors that help to measure visual acuity and perform intraocular measurements.
It is recommended that children be referred for a comprehensive eye examination if:
- Child fails a vision screening
- Are unable to be tested
- Have a vision complaint or exhibit observed abnormal visual behavior
- Are at risk for the development of eye problems
- Children with certain medical conditions (e.g., Down syndrome, prematurity, juvenile idiopathic arthritis, neurofibromatosis)
- Family history of amblyopia, strabismus, retinoblastoma, congenital cataracts, or congenital glaucoma, who are at higher risk for developing eye problems.
In addition, children with learning disabilities benefit from a comprehensive eye evaluation to rule out the presence of ocular comorbidities.
Finally, some children who have developmental delays, intellectual disabilities, neuropsychological conditions, and/or behavioral issues that render them untestable by other caregivers, benefit greatly from a comprehensive eye examination by an ophthalmologist who is skilled at working with developmentally challenged children.
Which pediatric eye tests require general anesthesia?
There are many safe medications for the brief or prolonged general anesthesia. In a situation when a pediatric ophthalmologist cannot perform an exam on an actively moving baby or child, an anesthesiologist will help. Your eye doctor will explain to you why the test is necessary, and why the child needs to sleep during the procedure. While it is your right to refuse this, you need to understand that the doctor is trying to do everything possible to make a correct diagnosis and not to harm your kid.
General anesthesia for the children usually cannot be done in the clinic. You will be given a schedule of the surgical days at the pediatric hospital or eye surgery center. Ask your specialist how to prepare for the procedure, and what to expect:
- Do I need to take a day off to care for the child?
- How long will the procedure take?
- Will the child be observed in a recovery room or go home right away?
- What are the benefits of the procedure?
- What are the possible side effects?
- Is there a special care that is recommended after the procedure?
Does a healthy child need to see eye doctor?
Most of the childhood concerns can be easily addressed by a primary care pediatrician or FP. We always recommend to have regular check-ups, even if the child is completely healthy. So, if there are no eye problems identified by you or your doctor, there is no need to see an ophthalmologist.
Regular eye checks should be done at school. If your child failed the test, you should not worry yet. Just schedule the appointment with an optometrist to re-check vision. Once the refractive error is determined, you will decide which specialist you want to see.
Optometrist vs ophthalmologist for kids
Optometrist is a vision specialist, who is knowledgeable about refraction errors and simple eye conditions. It is nice if you have a pediatric optometrist nearby – they are usually less expensive, spend more time, and accessible on the weekends. Optometrist is similar to a Nurse Practitioner in medicine. They can specialize on few diseases, or have broad skills.
Pediatric ophthalmologist is a doctor who specializes in pediatric eye problems. They can have a particular subspecialty, or practice as a general eye doctor. While ophthalmologists are trained in eye surgeries, not all continue to practice this way. Many are just diagnosing and referring you to a skilled surgeon.
Pediatric Eye clinics at the University medical center can be community based or private. Most of them employ many eye specialists who all work with children only. These are training centers where students learn ophthalmology. So, you may be first seen by a Resident or Fellow doctor, who will present your child’s medical history and exam to the Attending Physician (a professor or Assistant Professor). Such appointments usually longer, so get prepared to wait. But this is worth it – you may be seen by a World recognized expert in your child’s medical issue.
References
Pediatric Vision Screening. Loh AR, Chiang MF.Pediatr Rev. 2018 May;39(5):225-234. doi: 10.1542/pir.2016-0191.PMID: 29716965 Free PMC article. Review.
Vision screening for correctable visual acuity deficits in school-age children and adolescents. Evans JR, Morjaria P, Powell C.Cochrane Database Syst Rev. 2018 Feb 15;2(2):CD005023. doi: 10.1002/14651858.CD005023.pub3.PMID: 29446439 Free PMC article. Review.
Evidence-based preschool-age vision screening: health policy considerations. Zimmerman DR, Ben-Eli H, Moore B, Toledano M, Stein-Zamir C, Gordon-Shaag A.Isr J Health Policy Res. 2019 Sep 12;8(1):70. doi: 10.1186/s13584-019-0339-z.PMID: 31514739 Free PMC article.
Preschool vision screening. Snowdon SK, Stewart-Brown SL.Health Technol Assess. 1997;1(8):i-iv, 1-83.PMID: 9483159 Free article. Review.
National consensus statement regarding pediatric eye examination, refraction, and amblyopia management. Saxena R, Sharma P; Pediatric Ophthalmology Expert Group.Indian J Ophthalmol. 2020 Feb;68(2):325-332. doi: 10.4103/ijo.IJO_471_19.PMID: 31957721 Free PMC article.
Choosing appropriate tools and referral criteria for vision screening of children aged 4-5 years in Canada: a quantitative analysis. Nishimura M, Wong A, Cohen A, Thorpe K, Maurer D.BMJ Open. 2019 Sep 26;9(9):e032138. doi: 10.1136/bmjopen-2019-032138.PMID: 31558460 Free PMC article.