Vision Screening
Vision screening is one of the most important things pediatricians do, and it only happens at well-child visits. It is also an excellent example of how children are not little adults, and regular preventive care is essential to keeping children safe and healthy.
Children are constantly growing and developing, and the visual cortex of the brain does not complete development until at least 8-12 years old. Proper development depends on an accurate signal coming from the eyes. If there is a problem with one eye, the child may not notice a problem, but the brain on that side will shut down and stop developing. If the eye problem is not fixed by age 8 or so, the brain will never develop properly, and the person will have a lifelong vision problem (amblyopia) for which there is no cure.
Vision problems in children can also lead to problems with mental, motor, and social development and cause learning problems in school. It’s not just a matter of not seeing the board very well at school. There are also life-threatening conditions such as eye and brain tumors that are sometimes detected with vision screening.
Vision screening has been recommended for over 100 years; since the 1950’s and 60’s, it has been emphasized in preschoolers when it was discovered that vision problems had to be treated by 8-9 years old to prevent lifelong vision problems (amblyopia). In 2016, experts recommended testing infants and toddlers with advanced screening devices (photoscreening) when research showed screening to be effective at this age.
At CCP, we use the most advanced screening methods to ensure early detection and treatment of vision problems to prevent amblyopia and other problems.
Pediatricians start examining children’s eyes at birth for anything which might interfere with vision. We do this at the newborn hospital visit and every well visit at least through the first year of life.
With the advent of new technologies, we can now screen infants and toddlers for vision problems. This is now recommended every year from 1-2 years old and in older children who cannot complete a chart test. For example, many 3 year olds do not know enough shapes or letters, or are to nervous, to do a chart test. We use a device to scan children’s eyes, which can detect a variety of risk factors for vision problems.
Vision is checked yearly from ages 3-6 years old, then every 2 years until age 12, and every 3 years during the teenage years, as recommended by pediatric vision experts and the American Academy of Pediatrics. It is very important that your child have regular checkups so that we can check your child’s vision according to the recommended schedule.
A child who is 3-4 years old should have at least 20/40 vision; children 5 and up should have at least 20/30 vision. It is also abnormal if a child has 2 or more lines of difference between eyes, e.g. 20/20 in one eye and 20/30 in the other.
Components
Red reflex
We check for the same thing you see in a picture that needs red eye correction: for a red flash back from the eye. This means that there is a clear path to the retina, and that the retina is most likely normal. We are checking for a retinal tumor called retinoblastoma, and for cataracts, which can be present at birth or can develop in infancy. We check at birth and every well visit through at least 1 year of age.
Fixating and tracking
Infants should be able to follow an object by 6 months of age.
Wandering eye
It is normal for a baby’s eyes to cross through 4 months of age, but not afterwards. Eye wandering or deviation is called strabismus, and it is checked at every well visit. A wandering eye can indicate a brain, nerve, eye muscle, or vision problem.
Photoscreening
We use an advanced vision screening device to check baby’s vision for risk factors starting at 12 months of age and yearly through age 3. It allows us to detect the possibility of developing amblyopia much earlier, and early treatment improves vision development. This test is recommended by the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. It is not yet recommended by Bright Futures or the USPSTF, though they acknowledge its validity. Despite these recommendations, some insurance companies still don’t cover it.
Visual acuity screening
This is the traditional vision screening, looking at shapes or letters from 10 or 20 feet away. It starts at age 3 or 4 and is done at age 5, 6, 8, 10, 12, and 15 years old, or every 2-3 years if one of these years is missed. A 3 year old must see 20/50 out of each eye; a 4 year old 20/40, and older children at least 20/32. Most insurance companies no longer pay for this test, but say it is part of the well visit and don’t charge the patient for it either.
Vision risk factors
We screen children for risk factors for vision problems from birth through age 3 years; however, with the use of photoscreening, which is much better than risk factor questions, this is no longer as necessary. After age 3, it is done every year when vision screening is not performed.
Resources
- aapos.org
- childrenseyefoundation.org
References
Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, et al. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics. 2016;137(1). doi:10.1542/peds.2015-3596
Donahue SP, Baker CN, Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, et al. Procedures for the Evaluation of the Visual System by Pediatricians. Pediatrics. 2016;137(1):e20153597. doi:10.1542/peds.2015-3597
US Preventive Services Task Force. Vision screening in children aged 6 months to 5 years: US Preventive Services Task Force recommendation statement. JAMA 2017 Sep 5; 318:836. (doi:10.1001/jama.2017.11260)
Jonas DE et al. Vision screening in children aged 6 months to 5 years: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2017 Sep 5; 318:845. (doi:10.1001/jama.2017.9900)
Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th ed. Elk Grove Village, IL: American Academy of Pediatrics, 2017.