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Am Fam Physician. 2023;108(1):40-50

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wears glasses. Routine eye examinations during childhood can identify abnormalities necessitating referral to ophthalmology, which optimizes children's vision through the early diagnosis and treatment of abnormalities. The U.S. Preventive Services Task Force recommends vision screening at least once in children three to five years of age to detect amblyopia or its risk factors to improve visual acuity. The American Academy of Family Physicians supports this recommendation. The American Academy of Pediatrics recommends screening starting at three years of age and at regular intervals in childhood, and that instrument-based screening (e.g., photoscreening, autorefraction) is an alternative to vision charts for testing visual acuity in patients three to five years of age. Eye examinations include visual acuity testing, external examinations, assessing ocular alignment and pupillary response, and assessing for opacities with the red reflex examination. Common abnormalities include refractive errors, amblyopia (reduction in visual acuity in one eye not attributable to structural abnormality), and strabismus (misalignment of the eye). Rare diagnoses include retinoblastoma (often detectable through loss of red reflex), cataracts (detectable by an abnormal red reflex), and glaucoma (often manifests as light sensitivity with corneal cloudiness and enlargement).

Approximately 7% of children in the United States younger than 18 years have a diagnosed eye disorder, and 1 in 4 children between two and 17 years of age wear glasses.1,2 Routine eye examinations and vision screening during well-child examinations can identify risk factors and abnormalities consistent with those eye disorders and lead to a referral to ophthalmology. Subsequent diagnosis and treatment can optimize a child's eye health and vision, thereby minimizing or avoiding developmental delays, impaired school performance, and problems with social interactions and self-esteem.3

RecommendationSponsoring organization
Annual comprehensive eye examinations are unnecessary for children who pass routine vision screening assessments.American Association for Pediatric Ophthalmology and Strabismus

The U.S. Preventive Services Task Force (USPSTF) recommends vision screening at least once in all children three to five years of age (grade B recommendation) to detect amblyopia or its risk factors to improve visual acuity.4 The benefits of vision screening to detect amblyopia or its risk factors in children younger than three years are uncertain according to the USPSTF, and the balance of benefits and harms cannot be determined (grade C recommendation).4 The American Academy of Family Physicians supports this recommendation.5 The American Academy of Ophthalmology recommends that components of the visual screening occur at every well-child examination6 (Table 168). The American Academy of Pediatrics recommends beginning vision screening at four to five years of age and as early as three years of age in cooperative children.9 Instrument-based screening (e.g., photoscreening) is recommended starting at 12 months of age.10,11

MethodIndications for referralImplicationRecommended age
Newborn to six monthsSix months and until the child is able to cooperate for subjective visual acuity measurementThree to four yearsFour to five yearsEvery one to two years after five years of age
External inspectionStructural abnormality (e.g., ptosis)XXXXX
Fix and follow testFailure to fix and followStrabismusCooperative infant older than three monthsX
Pupillary examinationIrregular shape, unequal size, poor or unequal reaction to lightHorner syndrome, retinoblastomaXXXXX
Red reflex examinationAbsent, white, dull, opacified, or asymmetricRetinoblastoma, cataract, glaucoma, retinal abnormalityXXXXX
Corneal light reflex testAsymmetric or displacedStrabismusXXXX
Cover testCovered eye moves back to alignment when uncoveredStrabismusXXXX
Instrument-based screening*Failure to meet screening criteria based on instrument guidelinesAmblyopia, refractive errors, strabismusCan be used to assess risk when availableXXX
Distance visual acuity (monocular)20/50 or worse in either eyeAmblyopia, vision impairmentXXX
20/40 or worse in either eyeXX
Worse than three out of five characters on 20/30 line, or two lines of difference between the eyesX


Comprehensive personal and family histories, including parental observations, are important components of visual and eye screening examinations (Table 2).11,12 A personal history that warrants a referral to ophthalmology includes premature birth, Down syndrome, and cerebral palsy.

Personal history
Cerebral palsy*
Down syndrome*
Premature birth*
Family reporting history of eye deviation (may only occur when child is tired)
Head tilting, resisting covering of one eye, concern for amblyopia
Family history
Childhood cataracts*
Childhood glaucoma*
Ocular or genetic syndrome disease*
Childhood use of eyeglasses in parents or siblings
Eye surgery
Ask at each observation
Has your child ever had an eye injury?
Does your child seem to see well?
Does your child exhibit difficulty with near or distance vision?
Do your child's eyes appear unusual?
Do your child's eyelids droop or does one eyelid tend to close?
Do your child's eyes appear straight or do they seem to cross, particularly when they are tired?

Eye Examination

The eye examination should include an external examination, pupillary response, corneal light reflex, red reflex, fixation and alignment, cover and cover-uncover, and visual acuity testing. American Family Physician provides videos demonstrating eye examinations in infants/toddlers ( and preschoolers (


Pupillary response should be assessed in light and darkness using a light source to illuminate the pupil while the child's attention is directed toward a remote target of interest (e.g., a toy). Pupils should be compared for size and symmetry. A difference in pupil size greater than 1 mm can be a sign of underlying pathology.


To test the corneal reflex, the clinician should center light on the pupils to assess if there is an equal light reflex. This can be accomplished most naturally during the external inspection and assessment of pupillary response. A toy in front of the child can help keep the child's gaze still, making the assessment easier.

Light reflex should be symmetric by four to six months of age. Light reflex helps differentiate pseudostrabismus from strabismus (i.e., a misalignment of the eyes). A light reflex in patients with pseudostrabismus is normal despite a wide nasal bridge or epicanthal fold that may initially make the eyes appear to be misaligned (Figure 1 and Figure 212).


Red reflex testing is recommended starting in the neonatal period and continuing through subsequent well-child examinations. This test is critical for detecting vision and serious abnormalities such as cataracts, glaucoma, retinoblastoma, retinal disorders, systemic diseases with ocular manifestations, and high refractive errors.6

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