When Should Your Kids Have Their Vision Checked?

Eye doctor examining young girl's vision
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Routine vision screening is important because many abnormalities are treatable if discovered early but, if left untreated, can lead to vision loss and blindness.

What Is Vision Screening?

Beginning at three years of age, children should have a formal test of their vision. Until formal vision testing is possible after 3 years of age, younger children's vision can be assessed by observation of how they fixate and track objects and the history of the child's parents.

Visual milestones for infants include being able to follow an object to midline in the first 2 to 6 weeks, past midline by 1 to 3 months and follow an object 180 degrees by 3 to 5 months. If your child isn't meeting these developmental milestones on time, then you should see your pediatrician for an evaluation.

Eye Conditions

The vision problems that your pediatrician will evaluate your child for include:

  • Strabismus: A misalignment of the two eyes, affecting about 4% of children. Strabismus is usually described by the direction of misalignment, which can be outward (exotropia), inward (esotropia), upward (hypertropia) or downward (hypotropia). A child may also have a phoria with eye deviation only when one of the eyes is covered or when he is tired or sick.
  • Amblyopia: Reduced vision in an eye, which can be secondary to strabismus, anisometropia (unequal refractive errors in both eyes, for example, if one eye is more farsighted than the other eye), congenital cataracts, etc.
  • Refractive Errors: Such as myopia (nearsightedness) and hypermetropia (farsightedness).

In younger children, a vision evaluation will usually consist of an examination for the red reflex (checks for cataracts and retinoblastoma), eye alignment (misaligned eyes may indicate strabismus) and eye movements.

Symptoms of Eye Problems

In addition to clues that an infant may be having difficulty with tracking items with their eyes, there are other signs that may indicate eye problems. Some of these signs become more apparent as a child gets a little older.

Symptoms of eye problems include:

  • Crossed Eyes
  • Unable to see the board at school
  • Frequent headaches
  • Double vision
  • Frequently squinting

It is important to keep in mind that younger children usually don't report problems with their vision, especially if the problem is in just one eye and the other eye is accommodating for it.

Tests

Formal testing of visual acuity is usually possible once a child is 3 years old, although 2-year-olds may be able to be tested with picture cards. The Allen chart includes easily recognized pictures, including a cake, hand, bird, horse, and telephone. As a child gets older, there are lots of other tests that may be used to assess their vision.

Tumbling E Chart

The tumbling E chart or 'E' game, is a chart with the letter E in different orientations (up, down, right and left) and sizes. This test is commonly used for 3-5-year-olds. Children are tested by asking what orientation or direction the letter E is in at each letter size.

To prepare your child for this test, you can play the pointing game from Prevent Blindness America. They also have a copy of the Distance Vision Test for Younger Children, which uses the E chart, and which you can use at home.

HOTV System

For children who can recognize some letters, the HOTV system, in which the letters H, O, T and V are displayed in different sizes on a chart can be used. The child is given a board with a large H, O, T and V on it, and they are instructed to point to the letter on the board that matches the letter on the chart.

Snellen Eye Chart

Older children can be tested with the regular Snellen eye chart that is used for adults. In general, the Snellen chart is the most accurate and should be used when possible.

Corneal Light Reflex

Other testing may include the corneal light reflex test, in which a light is directed at the bridge of the nose and the light reflex is examined to make sure it is symmetrical or shines in the same spot on both eyes. If the light reflex is off-center or not symmetrical in both eyes, then it might indicate a misalignment of the eyes.

This is useful to differentiate pseudostrabismus, a condition in which the eyes appear to be misaligned because of prominent epicanthal folds or a broad nasal bridge and which doesn't require treatment, from true strabismus.

Unilateral Cover Test

The unilateral cover test can be used to determine if an infant or young child will follow an object while one of the eyes is covered. For example, your pediatrician can see if your child can fix on and follow a toy with both eyes, and then cover the left eye and see if they continue to follow it with their right eye. Then, the right eye is covered to see if they will follow the toy with their left eye. If they get really fussy or refuse to follow the object when you cover one of their eyes, then that may indicate that the vision in the other eye is reduced.

In older children, the unilateral cover test is also useful to check for strabismus. While the child is looking at a distant object, such as an eye chart or toy, cover one of their eyes. If the other eye moves out or in, then that might indicate that their eyes are misaligned and that they have strabismus. The test is then repeated by covering the other eye.

Standards for Visual Acuity

After testing is done, the next step is deciding if the child passed the test, since preschool age children don't necessarily need to have 20/20 vision to pass the test. The American Academy of Pediatrics has issued standards for visual acuity at different ages, including:

  • 20/40 for children 3-4 years old
  • 20/30 for older children
  • 20/20 for school-age children

In addition to their visual acuity, how a child's two eyes compare to each other is also important. At any age, if there is a two-line difference between the eyes, then that might indicate a serious loss of vision, like for example, if one eye is 20/20, but the other eye is 20/40. Or if one eye is 20/30 and the other eye is 20/50.

When To See a Pediatric Ophthalmologist

Children who are uncooperative or who fail a vision screening test in the pediatrician's office, especially if it is on multiple attempts, should be seen by a pediatric ophthalmologist for more formal testing.

A referral to a pediatric ophthalmologist is also a good idea for children who:

  • Have strabismus after they are six months of age
  • Have ptosis, where the upper eyelid droops
  • If either eye is fixed in place or has limited movement (although it is usually normal if a newborn or young infant's eyes occasionally cross)
  • Are at high risk of having visual problems, such as premature infants
  • Have Down syndrome, Sturge Weber syndrome, JRA, neurofibromatosis, diabetes or Marfan syndrome
  • Were born with a congenital infection
  • If there is a family history of strabismus or other childhood eye disorders

Also, if your pediatrician doesn't offer vision screening at the 3-year-old checkup, you might consider seeing a pediatric ophthalmologist to have your child's vision checked.

What Is a Pediatric Ophthalmologist

An ophthalmologist is a medical doctor (MD), whose training includes four years of college, four years of medical school, one year of internship and three years of residency training in ophthalmology. In addition to prescribing glasses or contact lenses, ophthalmologists diagnose and treat most eye disorders and perform eye surgery.

A pediatric ophthalmologist (MD), in addition to completing medical school, an internship and ophthalmology residency, has completed an extra year of fellowship training in pediatric ophthalmology.

An optometrist (OD) has usually completed two-four years of college and four years of optometric college. An optometrist can diagnose and screen for vision abnormalities and prescribe glasses and contact lenses.

According to the American Academy of Pediatrics, if your pediatrician suggests that your child has their eyes checked, a pediatric ophthalmologist is the most qualified and experienced in diagnosing and treating eye disorders in children.

Find a pediatric ophthalmologist in your area. If you do not have the financial resources to have your child's vision evaluated or their problems treated, look into Sight for Students, a program that provides vision exams and glasses to uninsured children in the United States.

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  1. American Academy of Pediatrics. What is a pediatric ophthalmologist?. Updated November 21, 2015.