Astigmatism

Vision screening is an important part of pediatric care, as children often do not complain of visual or eye problems when they are present. Screening is generally recommended between the ages of 3 and 5 years, depending on local or national guidelines, and typically focuses on amblyopia, refractive errors (including astigmatism), and strabismus. The appropriate treatment of these disorders has been shown not only to improve vision and motor skills in childhood but also to prevent visual morbidity later in life.

US screening program

The US Preventive Services Task Force (USPSTF) and American Academy of Ophthalmology (AAO) recommend vision screening at least once between the ages of 3 and 5 years.[31]Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2822%2900866-1 http://www.ncbi.nlm.nih.gov/pubmed/36543602?tool=bestpractice.com [45]US Preventive Services Task Force. Vision in children ages 6 months to 5 years: screening. Sep 2017 [internet publication]. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/vision-in-children-ages-6-months-to-5-years-screening [46]American Academy of Ophthalmology. Vision screening for infants and children - 2022​. Oct 2022 [internet publication]. https://www.aao.org/education/clinical-statement/vision-screening-infants-children-2022 The USPSTF recommends that for asymptomatic adults ages ≥65 years, the evidence is insufficient to assess the benefits and harms of screening for impaired visual acuity.[47]US Preventive Services Task Force. Impaired visual acuity in older adults: screening. May 2022 [internet publication]. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/impaired-visual-acuity-screening-older-adults#fullrecommendationstart

UK screening program

The UK National Screening Committee (NSC) recommends vision screening for children ages 4-5 years in an orthoptic-led screening service.[48]Gov.UK (UK National Screening Committee). ​Child screening programme: vision defects. Aug 2019 [inteernet publication]. https://view-health-screening-recommendations.service.gov.uk/vision-defects Many disorders causing significant visual impairment, such as cataract, cerebral visual impairment, and retinopathy of prematurity, can be detected in infancy by a trained professional through the UK newborn and infant physical examination (NIPE) screening program or by surveillance of high-risk populations.[49]Public Health England. Guidance: child vision screening​. Apr 2019 [Internet publication]. https://www.gov.uk/government/publications/child-vision-screening

Childhood screening tests and recommendations by age

In addition, the following screening tests can be performed by pediatricians or primary care providers during routine health maintenance visits from birth.[31]Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2822%2900866-1 http://www.ncbi.nlm.nih.gov/pubmed/36543602?tool=bestpractice.com

Newborn to 3 months of age

• Red reflex test with a direct ophthalmoscope. Refer if absent, white, dull, opacified, or asymmetric.

• External inspection of the eyes to assess for any structural abnormalities (penlight exam is sufficient). Refer structural abnormalities (e.g., ptosis).

• Pupillary exam. Refer if irregular shape, unequal size, and poor or unequal reaction to light.

• In a cooperative infant ≥3 months:

  • Fix and follow. Refer if failure to fix and follow.

  • Corneal light reflex to check for a symmetrical response in both eyes. Refer if asymmetric or displaced.

6 months to 3 years of age

• Repeat the tests for the previous age group.

• Consider instrument-based screening for cooperative infants ≥6 months old (e.g., photoscreening and autorefraction), especially for the young and those with developmental delays. This can detect media opacities, strabismus, or concerning refractive errors. However, subjective visual acuity testing is preferred when possible. Refer children with strong myopia, hyperopia, astigmatism, anisometropia, media opacities (>1 mm), and manifest strabismus.

3-4 years of age

• Repeat the tests for the previous age group.

• Cover/uncover test to assess for refixation movements in the fellow eye. Refer if refixation is present.

• Distance visual acuity testing, independently for each eye. Visual acuity of 20/50 or worse in either eye, or a ≥2-line difference between the two eyes, should be referred.

4-5 years of age, then every 1-2 years

• Repeat the tests for the previous age group.

• Distance visual acuity testing, independently for each eye. Visual acuity of 20/40 or worse in either eye, or a ≥2-line difference between the two eyes, should be referred.

• Practice can become more sporadic in older childhood and relies on symptom reporting.

If screening is inconclusive or unsatisfactory at any point, retest the child within 6 months; if this is not possible or testing remains inconclusive, refer for a comprehensive eye evaluation.[31]Hutchinson AK, Morse CL, Hercinovic A, et al. Pediatric eye evaluations preferred practice pattern. Ophthalmology. 2023 Mar;130(3):P222-70. https://www.aaojournal.org/action/showPdf?pii=S0161-6420%2822%2900866-1 http://www.ncbi.nlm.nih.gov/pubmed/36543602?tool=bestpractice.com [50]American Academy of Ophthalmology. Referral of persons with possible eye diseases or injury - 2014​. Apr 2014 [internet publication]. https://www.aao.org/education/clinical-statement/guidelines-appropriate-referral-of-persons-with-po Children with developmental delay may be unable to cooperate with visual acuity testing in a pediatrician’s office or during school or community-based vision screenings. If they cannot be screened, they should be referred to a pediatric ophthalmologist, orthoptist, or optometrist for a complete evaluation.