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Every optometrist performing a comprehensive pediatric eye examination should assess a child’s visual history, objective refraction, eye alignment, binocular function, and internal/external eye health.

History and General Observation

Patient and Family History: Review birth history, developmental milestones, previous treatments, and family histories of strabismus, amblyopia, or early glasses use.

Behavioral Cues: Observe how the child moves, tracks objects, fixes and follows targets, and responds to light.

Birth history: full-term/premature, birth weight, NICU/ROP history

Ocular history: squint, eye turn, watering, redness, injury, previous glasses

Medical/developmental history

Medication and allergy history

Parent/teacher concerns about vision or school performance

Visual Acuity and Functional Visual Acuity:
1. Infants (Birth to 24 Months):

Fix and Follow: Evaluates if an infant can centrally fixate on a target and smoothly track it (Central, Steady, Maintained or CSM fixation).

Preferential Looking (Teller Acuity Cards): Uses cards with stripes of varying widths paired with a blank side; the optometrist observes if the infant’s gaze is naturally drawn to the patterned stripes.

2. Toddlers and Preschoolers (2 to 5 Years):

LEA Symbols: The preferred choice for pre-literate children, featuring standard standardized shapes (apple, house, circle, square) that the child can name or match to a card.

HOTV Chart: Uses four letters (H, O, T, V) that the child matches using a key card

3. School-Age Children (5+ Years):
Snellen or Sloan Letter Charts: Standard linear letter charts used once the child reliably knows their alphabet and can read individual lines

Testing Best Practices Monocular Testing: Each eye is tested individually using an adhesive patch or occlusive tape rather than the child’s hand to prevent peeking

Standard Distance: Distance tests are typically performed at 10 to 20 feet, depending on the specific chart design

Linear Crowding: Optometrists prefer full lines of symbols with “crowding bars” over single, isolated symbols to accurately detect conditions like amblyopia (lazy eye).

Test using age-appropriate tools like fixation targets for infants, LEA symbols or matching cards for toddlers, and standard charts for older children.

Visual Fields: Perform confrontation testing or toy-based peripheral awareness checks.

Color Vision: Screen using specialized color plates when the child is old enough to cooperate.

Ocular Alignment and Motility Extraocular Movements:
Assess tracking in the cardinal positions of gaze.
An ocular motility measurement is a routine eye test where an optometrist checks how well your eye muscles move your eyes in different directions.
How the Test Works

Target tracking: The optometrist holds a small target, like a pen light or a toy, about 16 inches (40 cm) away from your face.

Head still: You keep your head completely still and follow the target with only your eyes.

Gaze directions: The optometrist moves the target in an “H” pattern or across nine specific points to test the six cardinal positions of gaze.

Checking movement: They watch for smooth, full movement, speed, and any signs of muscle weakness or double vision.

Cover Test: Check for manifest or latent eye misalignments (strabismus or phoria).

Binocular Vision & Stereopsis: Evaluate 3D depth perception using tests like random dot stereopsis or the Stereo E test.

Hirschberg/corneal light reflex

Alternate cover test

Near and distance deviation

Ocular motility in all directions

Head posture

Suppression/fusion

Worth 4-dot test when appropriate

Stereopsis

Refraction and Focusing Retinoscopy: Use objective retinoscopy (ideally cycloplegic) to measure refractive errors like nearsightedness, farsightedness, or astigmatism without relying on verbal feedback.
Cycloplegia: Apply cycloplegic eye drops when needed to temporarily relax the ciliary muscle for an accurate prescription and internal health evaluation.
Observing the reflex: The doctor watches the red reflection (red reflex) bouncing back from the retina

”With” motion: If the reflection moves in the same direction as the light, the eye is farsighted or under-powered

”Against” motion: If it moves in the opposite direction, the eye is nearsighted or over-powered.

Neutralizing with lenses: The doctor places different trial lenses or a retinoscopy rack in front of the child’s eyes. They change lenses until the movement stops and the reflex is fully “neutralized”.

Subtracting working distance: The doctor subtracts a specific value (the working distance correction, usually around -1.50 diopters depending on how far the doctor sits from the child) from the final lens power to find the correct prescription.

Ocular Health Pupillary Responses: Test direct and consensual reactions to light.
Red Reflex: Check for opacities, cataracts, or retinoblastoma.
Anterior and Posterior Segments: Examine the eyelids, cornea, iris, lens, and retina using direct ophthalmoscopy or specialized magnified viewing.
Special Screening

ROP screening/history in premature infants

Leukocoria/red reflex examination

Congenital cataract

Congenital glaucoma

Nystagmus

Optic nerve abnormalities

Signs of ocular/systemic disease

Recommended Schedule for Child Vision Screenings
A vision screening is a more efficient eye exam. A child is “screened” for eye problems and referred to an ophthalmologist for a comprehensive exam if needed.

Newborn
An optometrist should examine a newborn’s eyes to check for basic indicators of eye health. It may include testing for:

A “red reflex” (like seeing red eyes in a flash photograph). If the bright light shone in each eye does not return a red reflex, more testing may be needed

Blink and pupil response

An optometrist should do a comprehensive exam if the aby is:

Born prematurely

Has signs of eye disease

has a family history of childhood eye disease

6 to 12 months
A second screening should be done during the child’s first year of life. This screening is usually done at a well-child exam between 6 and 12 months. Your child’s pediatrician or other health care professional should:

Do the tests mentioned above

Visually inspect the eyes

Check for healthy eye alignment and movement

12 to 36 months

Between 12 and 36 months, a child is checked for healthy eye development. There may be a “photo screening” test. A special camera takes pictures of your child’s eyes. These pictures help find problems that can lead to amblyopia (lazy eye). If they see a problem, your child may be referred to an optometrist.

3 to 5 years

Between 3 and 5 years, a child’s vision and eye alignment should be checked. Visual acuity (sharpness of vision, like 20/20 for example) should be tested as soon as the child is old enough to read an eye chart.

Many children are somewhat farsighted (hyperopic), but can also see clearly even at distance. Most children will not require glasses or other vision correction. If the child struggles with the eye chart, photoscreening may be used to test vision.

An optometrist should see your child if the screening shows signs of:

Misaligned eyes (strabismus)

“lazy eye” (amblyopia)

Refractive errors (myopia, hyperopia, astigmatism)

another focusing problem

Begin treatment for these problems as soon as possible—getting early treatment for your child is the best thing you can do to protect their vision.

5 years and older

At 5, children should be screened for visual acuity and alignment. Nearsightedness (myopia) is the most common problem in this age group. It is corrected with eyeglasses. An optometrist should examine a child with misaligned eyes or signs of other eye problems. Children treated with growth hormone therapy should have their eyes tested before and during treatment.
Eye testing for older children (6 to 18 years)
A comprehensive exam for an older child is similar to that of a younger child, but includes additional tests of specific visual skills that are essential for reading, learning, and even sports performance.

The following skills should be tested during an eye exam:

Visual acuity: the ability to see clearly at three distances:

Near- for reading a book

Far- for seeing the board in class

1. Eye Focusing:

The ability to maintain clear vision when switching focus from near to distant objects— a necessary skill for looking at the board and then looking at a notebook on a desk (e.g. taking notes).

The ability to maintain clear vision for an extended period of time— when reading a book or completing homework assignments.

2. Eye tracking: the ability to move the eyes to follow a line of text on a page, or follow a moving object like a ball thrown in the air.
3. Eye teaming: the ability to use both eyes together, in coordination when reading
4. Eye-hand coordination: the ability to use visual information to accurately direct the hands when hitting a ball or drawing a picture.
5. Visual perception: the ability to visually organize images on a page into letters, words, and ideas; and to comprehend and recall text.
6. Recognition: the ability to distinguish between letters like “b” and “d”.
7. Comprehension: the ability to visualize or imagine in our mind the scene of a story
8. Retention: the ability to remember and recall details