Evidence-Based Clinical Practice Guideline

Comprehensive
Pediatric Eye andVision Examination

OPTOMETRY: THE PRIMARY EYE CARE PROFESSION

The American Optometric Association represents approximately 39,000 doctors of optometry, optometry students
and paraoptometric assistants and technicians. Optometrists serve individuals in nearly 6,500 communities acrossthe country, and in 3,500 of those communities are the only eye doctors. Doctors of optometry provide two-thirds ofall primary eye care in the United States.
Doctors of optometry are on the frontline of eye and vision care. They examine, diagnose, treat, and manage
diseases and disorders of the eye. In addition to providing eye and vision care, optometrists play a majorrole in an individual’s overall health and well-being by detecting systemic diseases such as diabetes andhypertension.
The mission of the profession of optometry is to fulfill the vision and eye care needs of the public throughclinical care, research, and education, all of which enhance the quality of life.
Disclosure Statement
This Clinical Practice Guideline was funded by the American Optometric Association (AOA) without financial support
from any commercial sources. The Evidence-Based Optometry Guideline Development Group and other guideline
participants provided full written disclosure of conflicts of interest prior to each meeting and prior to voting on thequality of evidence or strength of clinical recommendations contained within this guideline.
Disclaimer
Recommendations made in this guideline do not represent a standard of care. Instead, the recommendations areintended to assist the clinician in the decision-making process. Patient care and treatment should always be basedon a clinician’s independent professional judgment, given the patient’s circumstances, and in compliance with statelaws and regulations.
The information in this guideline is current to the extent possible at the time of publication.

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EVIDENCE-BASED CLINICAL PRACTICE GUIDELINECOMPREHENSIVE PEDIATRIC EYEAND VISION EXAMINATION
Developed by the AOA Evidence-Based Optometry Guideline Development Group
Approved by the AOA Board of Trustees February 12, 2017
©American Optometric Association 1995, 2002, 2015
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881

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TABLE OF CONTENTS

EVIDENCE-BASED CLINICAL GUIDELINE

c. Testing for Learning-related Vision Problems 26
7. Children with Special Needs................................. 26
a. At-risk Children.............................................. 26
b. Developmental Disabilities............................. 27
8. Trauma and Ocular Manifestations of Child Abuse/
Neglect............................................................. 27
a. Trauma (Accidental)....................................... 27
b. Ocular Manifestations of Child Abuse andNeglect (Non-accidental).............................. 27
9. Potential Benefits and Harms of Testing............... 29
B. Assessment and Diagnosis.................................. 29

A. What is the Evidence-Based Process?.................. 5
B. How to Use This Guideline..................................... 7
I. INTRODUCTION ........................................................ 10
A. Guideline Objectives............................................. 10
II. BACKGROUND.......................................................... 10
A. Visual Development............................................... 10
B. Epidemiology of Eye and Vision Disorders inChildren.................................................................. 11

C. Management ......................................................... 29

C. Access to Care...................................................... 15

1. Prescription for Correction................................... 29
2. Additional Treatment Services.............................. 29
3. Counseling and Education................................... 29
a. Eye Safety and Protection............................. 31
b. Ultraviolet Radiation and Blue Light
Protection.................................................... 32
c. Impact of Near Work and Reduced Time
Outdoors on Vision...................................... 32
d. Myopia Control.............................................. 33
4. Coordination and Frequency of Care.................... 33
a. Coordination of Care..................................... 33
b. Frequency of Care......................................... 34
c. At-risk Children.............................................. 39
D. Conclusion............................................................. 39

D. Costs of Eye and Vision Disorders in Children... 16
E. Early Detection and Prevention of Eye and Vision
Disorders............................................................... 16
III. CARE PROCESS ...................................................... 17
A. Comprehensive Pediatric Eye and Vision
Examination........................................................... 17
1. General Considerations........................................ 17
a. Infants and Toddlers...................................... 18
b. Preschool Children........................................ 18
c. School-age Children...................................... 18
2. Examination Procedures...................................... 18
3. Patient History..................................................... 19
4. Testing................................................................. 19
4.1 Testing of Infants and Toddlers........................... 19
a. Visual Acuity.................................................. 19
b. Refraction..................................................... 19
c. Binocular Vision and Ocular Motility............... 20
4.2 Testing of Preschool Children............................. 21
a. Visual Acuity.................................................. 21
b. Refraction..................................................... 21
c. Binocular Vision, Ocular Motility, andAccommodation.......................................... 22
d. Color Vision................................................... 22
4.3 Testing of School-age Children........................... 22
a. Visual Acuity.................................................. 22
b. Refraction..................................................... 23
c. Binocular Vision, Ocular Motility, andAccommodation.......................................... 23
d. Color Vision................................................... 24
5. Ocular and Systemic Health Assessment ............ 24
a. Assessment of Pupillary Responses.............. 25
b. Visual Field Evaluation................................... 25
c. Evaluation of the Ocular Anterior Segment andAdnexa........................................................ 25
d. Evaluation of the Ocular Posterior Segment... 25
e. Measurement of Intraocular Pressure............ 25
6. Supplemental Testing........................................... 25
a. Electrodiagnostic Testing............................... 25
b. Imaging......................................................... 25

IV. REFERENCES........................................................... 41
V. APPENDIX.................................................................. 55
A. Appendix Figure 1: Comprehensive Pediatric Eyeand Vision Examination: A Flowchart................. 55
B. Appendix Table 1: Potential Components of theComprehensive Eye and Vision Examination for
Infants and Toddlers............................................. 56
C. Appendix Table 2: Potential Components of theComprehensive Eye and Vision Examination for
Preschool Children............................................... 57
D. Appendix Table 3: Potential Components of theComprehensive Eye and Vision Examination for
School-age Children............................................. 58
E. Appendix Table 4: Partial Listing of Ocular
Manifestations of Neurodevelopmental Disorders
and Other Syndromes........................................... 59
F. Abbreviations/Acronyms....................................... 61
G. Summary of Action Statements........................... 62
H. Gaps in Research Evidence.................................. 64
VI. METHODOLOGY FOR GUIDELINEDEVELOPMENT........................................................ 64
VII. EVIDENCE-BASED OPTOMETRY GUIDELINEDEVELOPMENT GROUP.......................................... 66

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EVIDENCE-BASED CLINICAL GUIDELINES
A. WHAT IS THE EVIDENCE-BASED PROCESS?
As a result of the Medicare Improvement for Patients and Providers Act of 2008, Congress commissioned theSecretary of Health and Human Services to create a public-private program to develop and promote a common
set of standards for the development of clinical practice guidelines (CPGs). These standards address the structure,process, reporting, and final products of systematic reviews of comparative effectiveness research and evidencebased clinical practice guidelines.
The Institute of Medicine (IOM), now the Health and Medicine Division of the National Academies of Sciences,
Engineering, and Medicine (NASEM), in response to a request from the Agency for Healthcare Research and Quality(AHRQ), issued two reports in March 2011: Clinical Practice Guidelines We Can Trust and Finding What Works in
Health Care: Standards for Systematic Reviews.
In Clinical Practice Guidelines We Can Trust,1 the IOM redefined CPGs as follows“Clinical practice guidelines are statements that include recommendations intended to optimize patient care thatare informed by a systematic review of the evidence and an assessment of the benefits and harms of alternative
care options.”
The report states that to be trustworthy, guidelines should:•

Be based on a systematic review of existing evidence•

Be developed by a knowledgeable, multidisciplinary panel of experts and key stakeholders•

Consider important patient subgroups and preferences, as appropriate•

Be based on a transparent process that minimizes conflicts of interest and biases•

Provide a clear explanation of the logical relationships between alternative care options and health outcomes•

Provide a grading of both the quality of evidence and the strength of the clinical recommendation•

Be revised as appropriate when new evidence warrants modifications of recommendations.

Based on the IOM/NASEM reports, the American Optometric Association (AOA) Evidence-Based Optometry (EBO)
Committee developed a 14-step process to meet the new evidence-based recommendations for trustworthy
guidelines.

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AOA’s 14 Steps to Evidence-Based Clinical Practice Guideline Development
1. Guideline Development Group: Evidence-Based Optometry (EBO) Committee selects a multidisciplinary panel ofexperts, including patient and public representatives, for the Guideline Development Group (GDG).
2. Transparency and COI: GDG manages all conflict of interest (COI), which is documented by AOA staff.
3. Clinical Questions*: GDG explores and defines all clinical questions through a Question Formulation Meeting anddefines search criteria.
4. Search for Evidence: AOA Staff sends clinical questions for query (outside researchers) and provides all papers to
the Guideline Development Reading Group (GDRG). There should be no inclusion of Systematic Review (SR) writers in
the GDRG.
5. Grade Evidence and Clinical Recommendations: Two clinicians from the GDRG read and grade papers,
randomly selected according to the pre-designed evidence search criteria. They state clinical recommendation(s) fromeach paper and grade the strength of each.
6. Articulate Clinical Recommendations*: GDRG reviews all clinical recommendations and articulates each forinclusion in the guideline during an “Articulation of Recommendations” meeting and identified gaps in medical research
are documented.
7. Write Draft: AOA Staff sends the Articulation results to the writer for development of draft 1.
8. Draft Review and Edits*: GDG reads draft 1, discusses and edits.
9. Rewrite/Final Drafts: AOA Staff sends the draft results to the writer for writing/revisions for draft 2, then sends to
medical editor for copy editing, then a final review is completed as necessary.
10. Approval for Peer Review: AOA Staff or EBO Committee Chair sends the Peer Review draft to AOA Board ofTrustees for approval to post for peer and public review. This draft is posted on the AOA website, the review period isannounced, and comments are solicited.
11. Final Document Produced: GDG reviews all peer review comments and revises the final document (includes peer
review comments, documents why a peer review comment was not included, or identifies further gaps for review when
preparing the next edition).
12. Final Draft Approval and Legal Review: AOA Staff or EBO Committee Chair sends to the AOA Board ofTrustees and AOA Legal Counsel for approval that the GDG followed the evidence-based process as outlined by the
IOM and AOA EBO Committee (same management of COI).
13. Post Guidelines: AOA Staff posts the evidence-based guideline to AOA website and submits it to the National
Guideline Clearinghouse for public use, accompanied by AOA’s written process and documents.
14. Schedule Reviews: GDG reviews all previously identified gaps in medical research and any new evidence, andrevises the evidence-based guideline every 2 to 5 years.
**Denotes face-to-face meeting6B. HOW TO USE THIS GUIDELINE
The following table provides the grading system used in this guideline for rating evidence-based clinical statements.
Grades are provided for both quality of the evidence and strength of clinical recommendations.

Key to Quality of Evidence and Strength of Clinical Recommendation Grading
Grade

Quality of Evidence Levels

A

Data derived from well-designed, randomized clinical trials (RCTs); systematic reviews; meta-analyses; ordiagnostic studies (Grade A) of relevant populations with a validated reference standard. Grade A diagnostic
studies do not have a narrow population or use a poor reference standard and are not case control studies of
diseases or conditions.

B

Randomized clinical trials (RCTs) with weaker designs; cohort studies (retrospective or prospective); or
diagnostic studies (Grade B). Grade B diagnostic studies have only one of the following: a narrow population,or the sample used does not reflect the population to whom the test would apply, or uses a poor reference
standard, or the comparison between the test and reference standard is not blinded, or are case control studies
of diseases or conditions.

C

Studies of strong design, but with substantial uncertainty about conclusions or serious doubts about
generalizations, bias, research design, or sample size. Nonrandomized trials; case control studies (retrospective
or prospective); or diagnostic studies (Grade C). Grade C diagnostic studies have at least 2 or more of thefollowing: a narrow population, or the sample used does not reflect the population to whom the test would
apply, or uses a poor reference standard, or the comparison between the test and reference standard is notblinded, or are case control studies of diseases or conditions.

D

Cross sectional studies; case reports/series; reviews; position papers; expert opinion; or reasoning fromprincipal.

Strength of Clinical Recommendation Levels
Strong Recommendation: The benefits of the recommendation clearly exceed the harms (or the harms clearly exceed
the benefits in the case of a negative recommendation) and the quality of evidence is excellent (Grade A or B). In someclearly identified circumstances, a strong recommendation may be made on lesser evidence when high-quality evidence
is impossible to obtain and the anticipated benefits strongly outweigh the harms.
This recommendation should be followed unless clear and compelling rationale for an alternative approachis present.
Recommendation: The benefits of the recommendation exceed the harms (or the harms exceed the benefits in thecase of a negative recommendation) but the quality of evidence is not as strong (Grade B or C). In some clearly identified
circumstances, a recommendation may be made on lesser evidence when high-quality evidence is impossible to obtainand the anticipated benefits strongly outweigh the harms.
This recommendation should generally be followed, but remain alert for new information.
Option: The benefits of the recommendation exceed the harms (or the harms exceed the benefits in the case of anegative recommendation) but the quality of evidence is low (Grade D) or well-done studies (Grade A, B, or C) show little
clear advantage of one approach versus another. In some clearly identified circumstances, an option may be elevatedto a recommendation even with lesser evidence when high-quality evidence is impossible to obtain and the anticipatedbenefits strongly outweigh the harms.
There should be an awareness of this recommendation, but a flexibility in clinical decision-making, as well as
remaining alert for new information.

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Clinical Notes and Statements
Quality of evidence grades (A, B, C, or D) are shown throughout the guideline for clinical notes and statements. For
example, a clinical note or statement with a quality of evidence grade of “B” is shown as “(Evidence Grade: B)”.
Evidence-Based Action Statements will be highlighted in an “Action” box, with the quality of evidence, level ofconfidence, and clinical recommendation grading information listed. For example:
EVIDENCE-BASED ACTION STATEMENT: Parents/caregivers and children should be educated about
potential risks for eye injuries at home, at school, and during sports and recreational activities and advised
about safety precautions to decrease the risk of ocular injury.193,199 Prevention of eye injuries in children should
focus on the use of protective eyewear, parental supervision, and on education about both the risks of eye
injury and the benefits of protective eyewear.194
Evidence Quality: Grade B: Retrospective cohort studies
Level of Confidence: Medium
Clinical Recommendation Strength: Strong Recommendation. This recommendation should be followed
unless clear and compelling rationale for an alternative approach is present.
Evidence Statements: It is important to discuss eye safety issues with children/ parents/caregivers.193(Evidence Grade: B),199 (Evidence Grade: B)
Prevention strategies should focus on the use of protective eyewear, parental supervision, and on childhood
education about both the risks of eye injury and the utility of protective eyewear.194 (Evidence Grade: B)
Potential Benefits: Reduction in eye injuries inchildrenPotential Risks/Harms: None

Benefit and Harm Assessment: Benefits significantly outweigh harms
Potential Costs: Direct cost of counseling as part of a pediatric eye and vision examination
Value Judgments: None
Role of Patient Preferences: None
Intentional Vagueness: Specific type/form of counseling is not stated, as it is patient specificGaps in Evidence: None identified
The Action Statement profile provides additional information related to the development and implementation of theclinical recommendation. The following is an explanation of the categories listed in the profile:
Evidence Quality – The quality of evidence grade (A, B, C, or D) or the aggregate quality of evidence grade (ifmultiple studies were available for review) and the type/method of research study or studies reviewed.
Level of Confidence – The consistency of the evidence and the extent to which it can be trusted specified ashigh, medium, or low.
Clinical Recommendation Strength – The grade (Strong Recommendation, Recommendation, or Option)
assigned to the implementation of the clinical recommendation made in the Action Statement.
Evidence Statements – The clinical statements derived from research studies reviewed that support the Action
Statement.

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Potential Benefits – Favorable changes which would likely occur if the Action Statement was followed.
Potential Risks/Harms – Adverse effects or unfavorable outcomes that may occur if the Action Statement was
followed.
Benefit and Harm Assessment – A comparison of the relationship of benefits to harms specified as “benefits
significantly outweigh harms” (or vice versa) or a “balance of benefits and harms.”
Potential Costs – Direct and indirect costs refer to the costs of the procedure, test, or medication; time spentcounseling the patient; administrative time; parent/caregiver time off from work, etc.
Value Judgments – Determinations made by the Guideline Development Group in the development of the
Action Statement relating to guiding principles, ethical considerations, or other priorities.
Role of Patient Preference – The role the patient has in shared decision making regarding implementation of
the Action Statement specified as large, moderate, small, or none.
Intentional Vagueness – Specific aspects of the Action Statement that are left vague due to factors such as therole of clinical judgment, patient variability, concerns over setting legal precedent, etc.
Gaps in Evidence – Areas identified during searches and evaluations of the research that show gaps in available
evidence.
Consensus-Based Action Statements, based on consensus by the Guideline Development Reading Group, arealso highlighted in an “Action” box, but without any quality of evidence or strength of clinical recommendation grading
information listed. For example:
CONSENSUS-BASED ACTION STATEMENT: At the conclusion of a comprehensive pediatric eye and vision
examination, the diagnosis should be explained to the patient/parent/caregiver and related to the patient’s
symptoms, and treatment plans and prognosis discussed.
Evidence Quality: There is a lack of published research to support or refute the use of this recommendation.
Benefit and Harm Assessment: Implementation of this recommendation is likely to increase patient/parent/caregiver understanding of any diagnosed eye or vision problems and improve compliance with any
recommended treatment. The benefits of this recommendation were established by expert consensus opinion.

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I. INTRODUCTION

A. GUIDELINE OBJECTIVES

Eye and vision problems in children are a significant
public health concern. An estimated one in fivepreschool children have vision problems.2-8 In the UnitedStates, about one in four school-age children wear
corrective lenses.9 Since eye and vision problems canbecome worse over time, early diagnosis and treatment
are essential to optimize children’s eye health and visionand to prevent future vision loss.

This Guideline can help achieve the following objectives:

Eye and vision disorders can lead to problems in a child’s
normal development,10,11 school performance,12-16 social
interactions,17 and self-esteem.17-19 Vision disorders that
occur in childhood may manifest as problems well into
adulthood, affecting an individual’s level of education,
employment opportunities, and social interactions.20
Early recognition of visual disorders is especially
important in children with developmental and intellectual
disabilities.21,22 Children with disabilities are reported tohave significantly more eye and vision problems (e.g.,
strabismus, refractive errors, and nystagmus) thanchildren without these disabilities.22-27 The increasing
severity of the disability may be related to a higher
prevalence of vision problems.
This Evidence-Based Clinical Practice Guideline for theComprehensive Pediatric Eye and Vision Examination
describes procedures for evaluation of the eye healthand vision status of infants and children. It contains
recommendations for timely diagnosis and, whennecessary, referral for consultation with, or treatment
by, another health care provider. Other guidelines
developed to address treatment of specific eye andvision conditions can be found at AOA Clinical Practice
Guidelines web page.
The recommendations in this guideline were developed
to assist doctors of optometry and ophthalmologists
involved in providing eye and vision examinations for
infants and children. Others who assist in providing
coordinated patient care for specific services, as well as
patients, parents, and caregivers, may also gain insightfrom this document.

•

Recommend an optimal timetable for comprehensive
eye and vision examinations for infants and children(newborn through 18 years of age)•

Suggest appropriate procedures to effectively
examine the eye health, vision status, and ocular
manifestations of systemic disease of infants andchildren•

Reduce the risks and adverse effects of eye andvision problems in infants and children throughprevention, education, early diagnosis, treatment,
and management•

Inform and educate patients, parents/caregivers, andother health care providers about the importance ofeye health and good vision, and the need for andfrequency of pediatric eye and vision examinations.

II. BACKGROUND
A. VISUAL DEVELOPMENT
Development of the visual system begins prenatally andcontinues after birth.28 Basic visual functions develop
rapidly during the first year of life. By 6 months of age,vision has become the dominant sense and forms thebasis for perceptual, cognitive, and social development;29
however, maturation of the visual system continues forseveral years. From birth to about 6 years of age, thevisual system is susceptible to vision conditions thatcause either blurred visual input or abnormal binocularinteraction such as interference from amblyogenic
bilateral refractive error, amblyogenic anisometropia,
constant unilateral strabismus, congenital cataracts,hemangioma, corneal scarring, and any other condition
that obstructs vision. This interference can lead to
amblyopia, which, if left untreated, can cause serious
vision loss.
Objective testing (visual evoked response) demonstrates
that the visual cortex is capable of achieving 20/20
visual acuity by 6 months of age;30 however, the abilityof a child to respond to subjective visual acuity tests is
influenced by verbal and cognitive development. For

10some children, it may not be possible to elicit 20/20
visual acuity until after 5 years of age; therefore, it iscritical to select age appropriate tests. Stereopsis first
appears at 3 to 4 months of age and continues todevelop through the first two years of life.31, 32 Matureaccommodative behavior is present at 5 to 24 months ofage.33 Development of accommodative facility, vergenceability, and eye movements continues in the preschooland school-age years.34-37

B. EPIDEMIOLOGY OF EYE AND VISIONDISORDERS IN CHILDREN
There are many visual conditions and ocular or systemic
diseases, which may occur in childhood that canaffect visual development. Eye and vision disorders
experienced by infants and children may include:•

Refractive errors

Refractive errors (hyperopia, myopia, astigmatism,
and anisometropia) are the most common causes ofcorrectable reduced vision in children.38, 39 Estimates ofrefractive errors in children 6 months to 72 months (6years) of age are shown in Table 1.

High levels of myopia can contribute to the developmentof lattice degeneration, retinal holes, tears, or
detachment, cataracts, glaucoma, and myopic maculardegeneration.45,46
Astigmatism up to 2.00D is common in children under3 years of age. Studies show that 30 to 50% of infantsless than 12 months of age have astigmatism (≥1.00D),
which declines over the first few years of life, andbecomes stable by approximately 2 1/2 to 3 years ofage.47, 48
Anisometropia of 1.00D or more is consideredclinically significant. There is a low prevalence (4%) of
anisometropia before 6 years of age;49 however, it has
been shown to increase to nearly 6% at 12 to 15 yearsof age. Infantile anisometropia can be transient andmay decrease; however, severe anisometropia (≥3.00D)
may persist and is likely to lead to the development of
amblyopia during the preschool years.50, 51
Table 1: Prevalence of Refractive Errors in Children
6 Months to 72 Months (6 Years) of Age
White
NonHispanic

Hispanic

AfricanAmericanAsian≤1.00D sphericalequivalent (SE)

1.2%

3.7%

6.6%

4.0%

≥1.00D SE

0.7%

Condition

Hyperopia has a high prevalence among young children
up to 5 years old, with over 20% estimated to have
≥2.00 diopters (D).2,3 Hyperopia (≥2.00D) is found to be asignificant risk factor for the development of strabismus40
and amblyopia41 up to 5 years of age.

MyopiaMyopia generally develops in children during their earlyschool years and increases in magnitude, as they getolder. The age at onset typically ranges from 7 to 16
years. In the Collaborative Longitudinal Evaluation of
Ethnicity and Refractive Error Study (CLEERE), one in six
children ages 5 to 16 (Asian, Hispanic, African American,
Native American and White) developed myopia during
their school-age years. More than 75% of the new casesof myopia occurred between the ages of 9 and 13.42

5.5%

Hyperopia≥2.00D SE

25.7%≥3.00D SE

8.9%

26.9%

20.8%

13.5%

4.4%

Astigmatism≥1.50D cylindricalrefractive error≥3.00D cylindricalrefractive error

Among school-age children, the prevalence of myopia
has been increasing in recent years and developing at
a younger age.42,43 The National Health and Nutrition
Examination Survey results for 12 to 17 year olds show
the prevalence of myopia increased from 24% in 19711972 to 33.9% in 1999-200444 and it continues to rise.

6.3%

16.8%

12.7%

2.9%

1.0%

4.3%

4.2%

Anisometropia≥1.00D SE

11

8.3%

(Note: The ethnicity of children reported in Tables 1, 2, 3
and 4 is based on the categorization used in the studies
cited.)

Although amblyopia is a treatable condition in bothchildren and adults,54 the end result is better when
diagnosed and treated early.55-60 The prevalence ofamblyopia in the general population is believed to be
between 2% and 2.5%.61 Estimates of the prevalence ofamblyopia in young children in an urban population are
shown in Table 3.

Table 2: Prevalence of Refractive Errors in Children
5 to 17 Years of Age

Click to view the (AOA Clinical Practice Guidelines web
page)

Source: Multi-Ethnic Pediatric Eye Disease
Study 2-4,49 and the Baltimore Pediatric Eye Disease
Study 5

Condition

White
NonHispanic

Hispanic

4.4%

AfricanAmerican

Asian

13.2%

6.6%

18.5%

19.3%

12.7%

6.4%

6.3%

26.4%

36.9%

20.8%

33.6%

Myopia≥0.75D in eachprincipal meridianHyperopia≥1.25D in eachprincipal meridian
Astigmatism≥1.00D difference
between two
principal meridians

Source: Collaborative Longitudinal Evaluation of
Ethnicity and Refractive Error Study 52
In the school-based CLEERE study of children 5 to 17
years of age, overall 9.2% of the children were myopic,
12.8% were hyperopic, and 28.4% had astigmatism(Table 2).

•

The estimated prevalence of strabismus in the general
population varies from 2.5% to 4.6% based on various
studies.62 The prevalence of strabismus in young children
in an urban population is shown in Table 3.
Although strabismus can develop at any age, it usuallydevelops during childhood. Infantile esotropia has
an onset prior to 6 months of age; accommodative
esotropia typically has an onset between 2 to 3 yearsof age, but can develop before 6 months of age. Youngchildren with constant unilateral strabismus often develop
amblyopia and impaired stereopsis. Early identificationand treatment of children with strabismus may prevent
amblyopia and preserve stereopsis.
Table 3: Prevalence of Amblyopia and Strabismus
in Children 6 Months to 72 Months (6 Years) of Age

Click to view the (AOA Clinical Practice Guidelines web
page)•

Condition

White NonHispanic

Hispanic

AfricanAmericanAsian

Amblyopia

1.8%

2.6%

0.8% - 1.5%

1.8%Strabismus

3.2% - 3.3%

2.4%

2.1% - 2.5%

3.6%

Source: Multi-Ethnic Pediatric Eye Disease Study 6, 8
and the Baltimore Pediatric Eye Disease Study 7

Amblyopia

Amblyopia is the leading cause of monocular vision loss
in children. It is generally attributable to strabismus,
anisometropia, combined strabismus and anisometropia,
or form deprivation (e.g., media opacity). Unilateral
amblyopia is commonly associated with constantunilateral strabismus and/or amblyogenic anisometropia,
while bilateral amblyopia usually results from high bilateralrefractive error 53 or bilateral form deprivation.

Strabismus

Click to view the (AOA Clinical Practice Guidelines web
page)•

Non-strabismic binocular vision problems andaccommodative disorders

Other than refractive errors, the most prevalentvision conditions in children fall into the category ofaccommodative and binocular vision anomalies, as

12

reported in a large-scale prospective study of theprevalence of vision disorders and ocular disease in aclinical population of children between the ages of 6months and 18 years.63
Oculomotor conditions
Oculomotor conditions include a variety of eye
movement disorders, which can affect saccadic,
fixation, and vergence eye movements.
Convergence insufficiency (CI) is a binocular vision
disorder that affects up to 8.3% of school-age
children64 and is associated with symptoms suchas eyestrain, headaches, blurred vision, diplopia,
sleepiness, difficulty concentrating, movementof print while reading, loss of place, and loss ofcomprehension after short periods of reading.65-67
The Convergence Insufficiency and Reading Study
Group investigators found that 13% of fifth andsixth grade children (definite and high suspect)
had clinically significant CI (insufficient fusional
convergence, receded nearpoint of convergence,
and/or exophoria at near ≥4 prism diopters at far).68•

Color vision deficiency

Children with color vision deficiency, either inherited or
acquired, may have difficulty precisely matching colors
or discriminating fine color differences. Inherited (Xchromosome) color vision deficiency is estimated tooccur in nearly 8% of white males and less than 0.4% ofwhite females, with lower prevalence in other ethnicities 69(Table 4). The severity of color vision deficiency can
range from mild to severe. The most common form ofcolor vision deficiency is red-green. Less common isblue-yellow color vision deficiency.
Table 4: Prevalence of Inherited Color Vision
Deficiency in Children 61 Months (5 years) to 72
Months (6 Years) of Age
Color Vision
Deficiency

White NonHispanic

Hispanic

AfricanAmerican

Asian

Boys

7.8%

2.9%

2.1%

3.5%

Girls

<0.4%

<0.4%

<0.4%

<0.4%

Source: Multi-Ethnic Pediatric Eye Disease Study 69•

Convergence excess (CE) has been reported
to occur in 7.1% of children in one clinicalpediatric population.63 It may be due to a highaccommodative convergence/accommodation(AC/A) ratio. Symptoms can include blurred vision,
diplopia, headaches, and difficulty concentrating onnear tasks.

Ocular Diseases
Ocular inflammatory disease
Ocular inflammation in children involves an array ofconditions, including but not limited to conjunctivitis,
keratitis, scleritis, and uveitis. It may occur due
to infection, trauma, malignancy, or autoimmune
response. Inflammations can range from benign andself-limiting to chronic and sight-threatening.70, 71

Accommodative disorders

Systemic autoimmune diseases in children can haveocular manifestations that are vision-threatening.
Juvenile idiopathic arthritis is associated with thedevelopment of chronic anterior uveitis. Other
diseases with ocular inflammatory manifestations
include sarcoidosis, juvenile rheumatoid arthritis,
Behçet’s disease, and Sjögren’s syndrome.71, 72

Children with accommodative dysfunctions may
have difficulty focusing on near objects, maintaining
focus for long periods, or easily changing focus
from near to far and back again. Studies in clinic
populations have been conducted to determine
the prevalence of accommodative dysfunction.
A study of over 2,000 children found that 5% ofchildren between the ages of 6 and 18 years had
accommodative disorders.63

Ocular conditions of prematurity
Children born prematurely are at risk for thedevelopment of severe visual impairment andblindness. Preterm infants have higher rates ofClick to view the (AOA Clinical Practice Guidelines
web page)13

Retinitis pigmentosa

amblyopia, strabismus, optic atrophy, and refractive
errors.73-76

Retinitis pigmentosa (RP) is a group of hereditary
retinal diseases characterized by progressive lossof peripheral vision and the development of night
blindness. RP is caused by the degeneration ofphotoreceptor cells resulting in severe damage tothe retina. While RP is usually limited to the eye, it
may also occur as part of a syndrome (e.g., Usher
syndrome, Bardet-Biedl syndrome).82

Sixty percent of infants born at 28 to 31 weeks havebeen reported to develop retinopathy of prematurity(ROP) and over 80% of infants born before 28
weeks developed ROP.77 ROP is also common inchildren with birth weight of less than 1,251 grams(g). Oxygenation of infants in the hours and days
after birth may also be a contributing factor.78 The
frequency and severity of ROP is inversely related togestational age and birth weight of the baby.79 The
incidence of ROP is 47% in infants with birth weights
between 1,000 and 1,251 g and 81.6% in infants
weighing <1,000 g at birth.77

Retinitis pigmentosa is the most frequent cause
of inherited visual impairment.82 It is estimated toaffect 1 in 3,000 to 1 in 4,000 people in the UnitedStates.83

Cataract

RetinoblastomaChildhood cataracts can be classified as congenitalor developmental. They may be idiopathic, due
to infection (e.g., rubella), genetics (e.g., Down
syndrome), or the result of secondary causes suchas trauma or metabolic etiology. The prevalence ofvisually significant congenital cataracts is estimatedto be three to four infants per 10,000 live births.80
If not treated early, visually significant congenital
cataracts may cause vision impairment.

Retinoblastoma, a cancer of the retina, usuallyaffects children under age 5. The most common
signs of retinoblastoma are leukocoria (white
pupillary reflex) and strabismus. Retinoblastoma
accounts for approximately 11% of cancers
occurring in the first year of life, with 95% diagnosed
before 5 years of age.84 It is the most common
intraocular cancer of childhood and affects
approximately 300 children in the United States eachyear. More than 90% of children with retinoblastoma
could be treated with early diagnosis;85 however,significant disparities exist in the care and outcomesof children with retinoblastoma.86

GlaucomaChildhood glaucoma is an uncommon diseasecharacterized by increased intraocular pressure
leading to optic neuropathy and visual field changes,
and is often associated with significant vision loss.81
It may be inherited or associated with other eye
disorders.

Retinoblastoma is associated with a mutationof the RB1 gene. The tumor may be unilateralor bilateral and can be inherited. Prognosis forsurvival, saving the eye, and preservation of vision
are largely dependent on the stage of disease atpresentation. Early diagnosis, multidisciplinary
treatment, and genetic counseling are all priorities in
the management of this tumor.87

Glaucoma in children may be classified as congenital(present at birth), infantile (occurring between 1 to
2 years of age), or juvenile (developing after age 3).
Most cases develop during the first year of life. A
review of records of pediatric patients seen in one
county in the United States over a 40-year period
found an incidence of glaucoma of 2.29 per 100,000
persons younger than 20 years of age.81

Diabetic retinopathy
Diabetes is the third most common chronic disease
among children and a leading cause of vision
impairment among young adults. Type 1 diabetes
mellitus has historically been the most common

14occurs in isolation and is more appropriately
designated as the syndrome of optic nerve
hypoplasia.93 In the syndrome, most children
with optic nerve hypoplasia have hypothalamic
dysfunction and/or neurodevelopmental impairment,such as cerebral palsy or growth problems.

type in children, affecting approximately 2 per 1,000
school-age children in the United States; however,Type 2 diabetes mellitus now accounts for about
45% of new cases of the disease.88, 89
Diabetic retinal disease, primarily manifesting as
diabetic retinopathy (DR) and/or diabetic macularedema, is the most common microvascularcomplication of diabetes. Among pediatric patients,
the average duration of diabetes before thedevelopment of DR is 5.7 to 9.1 years; however, therisk for developing DR is greater in patients who are
diagnosed with diabetes during or after puberty.88

Cortical (cerebral) visual impairment
Cortical visual impairment (CVI) is defined as a
reduction or complete loss of visual acuity andoptokinetic nystagmus due to injury to the visualcortex, with preservation of pupillary response,
normal eye motility, and normal retina.94 In addition
to cortical visual impairment, the term cerebral visual
impairment is also used to describe not only visual
impairment associated with the visual cortex, butalso regions outside the cortex that can affect othervisual pathway structures.95

Click to view the (AOA Clinical Practice Guidelines
web page)
Optic nerve hypoplasia
Optic nerve hypoplasia is one of the most prevalentcauses of visual impairment among young children.
Although the specific prevalence is unknown,
the Babies Count Registry reported optic nerve
hypoplasia as the third most prevalent cause ofvision impairment in children age 3 years or younger
in the United States.90
The exact cause of optic nerve hypoplasia in not
known, but it may be associated with prenatal
exposure to alcohol, smoking, recreational drugs,
antidepressants and anticonvulsants, and withprenatal complications including gestational
diabetes, toxemia, viral infection, and maternal
anemia. Seventy percent of the cases identified haveno known risk factors. More recent studies haveindicated the mother’s young age (≤ 20 years) andprimiparity (that is, the affected child is the mother’s
first child, regardless of the mother’s age) are thepredominant characteristics in the background ofchildren with optic nerve hypoplasia.91
Optic nerve hypoplasia was believed to occur
either as an isolated anomaly or accompanying
the syndrome of septo-optic dysplasia or deMorsier syndrome 92 that includes midline brain
malformations and hypopituitarism. Evidence now
suggests that optic nerve hypoplasia infrequently

In children experiencing perinatal or postnatal
hypoxia/ischemia, CVI, ROP, and optic nerve
hypoplasia were commonly identified conditions.
Of the three, CVI was the most prevalent visualcondition identified and was often the last to bediagnosed.90
Vision loss associated with brain damage is reported
to be a significant cause of visual impairment
in young children. Identification of children withsuspected CVI requires neuroimaging to ascertain
the extent of the injury to specific regions in thebrain. Failure to do so will underestimate the level ofvisual dysfunction and systemic disability.96

C. ACCESS TO CARE
Although comprehensive pediatric eye and vision
examinations are essential for timely diagnosis andtreatment of eye disease and maintenance of goodvision, many children do not receive comprehensive
eye care. An estimated one in five preschool children
and one in four school-age children in the United States
has a vision problem; however, the Centers for Disease
Control and Prevention report that less than 15% ofpreschoolers receive an eye examination by an eye care15

professional and less than 22% receive some type ofvision screening.97
A factor that may limit access to comprehensive eye andvision examinations and treatment services is the false
sense of security that school screenings mistakenly giveto parents (false negative results). Other factors that limit
access include the absence of signs, symptoms, or afamily history of eye and vision problems,98 or the inabilityof parents/caregivers to afford needed services due tolack of insurance coverage or limited family income.99
Limited access may now be partially resolved because
comprehensive eye and vision examinations havereceived increased attention from the Affordable Care
Act and other insurance programs reviewing essential
health benefits necessary for children.

D. COST OF EYE AND VISION DISORDERS
IN CHILDREN
Eye and vision disorders can impose a significant burden
on patients, parents, and the public. The total economic
cost of vision loss and eye disorders among children
younger than 18 years of age in 2012 was estimatedto be $5.9 billion.100 This includes the direct medical
costs for eye examinations, eyeglasses, and low vision
aids. Also, the debilitating nature of vision loss results inmajor indirect and nonmedical costs including special
education services, federal assistance programs, anddecreased quality of life.

the loss of a child’s full potential, and limitations on his
or her occupational choices and future earnings. The
cost of treating any visual impairment later in life could
potentially be more expensive than treatment of the initialproblem.

E. EARLY DETECTION AND PREVENTIONOF EYE AND VISION DISORDERS
Many vision conditions are asymptomatic or not readily
recognized, and will not prompt a patient, caregiver,or parent to seek a comprehensive eye and vision
examination.104 Undiagnosed or uncorrected refractive
errors and other visual disorders in children can leadto developmental, academic, and social challenges
and in some cases permanent vision loss, which has
lifelong complications.105 In the preschool population, theconcern is for early diagnosis and treatment of significant
refractive error, amblyopia, strabismus, and oculardisease. For the school-age population, the concern
is the negative impact that untreated vision disorders(accommodation, binocular vision, ocular motility,and vision information processing) have on academic
performance.
A comprehensive eye examination by a doctor of
optometry or ophthalmologist is the reference standardof eye care.105 Not all children receive professional eye
examinations for various reasons including educationand language barriers, health literacy, cost, geographic
access, immigration status, and transportation
challenges.106

The above estimate does not include the costs ofeducational services for children with undiagnosed
and untreated vision conditions. Learning-related
vision problems have been reported to be significant
contributors to reading difficulties and ultimately to theneed for special education services.14, 15, 65, 101, 102 Vision
problems can increase educational costs in the form of
Individualized Education Programs (IEPs) and special
education services, which would otherwise not benecessary, if the vision problems were treated. A studyof students (ages 6-16) with IEPs found that they havehigh rates of undiagnosed and untreated vision problems
affecting reading speed and comprehension.103

The role of vision screenings in addressing the current
gaps in children’s eye care remains unclear. The U.S.
Preventive Services Task Force (USPSTF) has concluded
that the current evidence is insufficient to assess thebalance of benefits and harms of vision screening
for children 3 years of age and younger.107 While the
USPSTF concluded with moderate certainty that visionscreening for children 3 to 5 years of age has moderate
net benefit compared with no screening, they did notcompare the benefit of screening to a comprehensive
eye examination.108

In addition to the current costs of care, future costs forundiagnosed and untreated vision problems may include

Vision screening procedures lack the evidence needed,with proven high sensitivity and specificity, for identifying

16the targeted vision problems present in the populationof children being screened.104,109 The sensitivity of awide variety of screening techniques was evaluatedby the Vision in Preschoolers (VIP) study, which unlike
standard screenings used licensed eye doctors who hadcompleted VIP study specific training and certification.104
In the study, the sensitivity of 11 vision screening
techniques used for detecting clinically significant vision
problems in children 3 to 5 years of age varied from 16%
to 64%, with specificities ranging from 62% to 98%.
These tests were compared again with a specificity of
94%, and the sensitivity dropped even further.109 Whenthese same tests were performed by trained nurses orlay screeners (except for non-cycloplegic retinoscopy,
which was deemed too technically challenging), thesensitivity was similar or lower.110 Even with the use of
trained examiners, these vision screening techniques
were unable to provide high levels of both sensitivity andspecificity for detecting many vision problems in children.
Currently, widespread application of vision screenings
do not utilize licensed eye care professionals or thetechniques found to be most sensitive.

III. CARE PROCESS

When Snellen visual acuity alone was used as ascreening tool, it was 100% specific for identifying
reduced acuity, but missed 75.5% of the children foundto have binocular and oculomotor vision problems when
given a complete visual examination.111 Additionally, a
study of 1,992 school-age children found that 41% ofchildren who failed the State University of New York
screening battery would not have been identified if thescreening was based on visual acuity alone.112•

Evaluate the refractive, binocular, andaccommodative status of the eyes and visualsystem, taking into account special vision demands
and needs•

Assess ocular health and related systemic healthconditions•

Establish a diagnosis (or diagnoses)•

Formulate a treatment and management plan•Counsel and educate the patient/parent/caregiver
regarding visual, ocular, and related systemic
health care status, including recommendations forprevention, treatment, management, and future care.

Many children who fail a screening do not receive thenecessary treatment of their conditions. A study of publicschool children reported only 38.7% who failed the visionscreening received follow-up care after screenings.113
Due to a lack of follow-through, screenings alone may
not lead to the earlier diagnosis and treatment of eye
and vision problems. While screenings may identify somechildren at risk for vision problems, a comprehensive
eye exam is necessary for definitive diagnosis andappropriate treatment.114

A. COMPREHENSIVE PEDIATRIC EYE AND
VISION EXAMINATIONThe comprehensive pediatric eye and vision examination
provides the means to evaluate the structure, function,and health of the eyes and visual system. It is preferable
in most cases for the parent/caregiver to accompany
the child into the examination room. The in-person
interaction between patient/parent/caregiver and doctor
is a dynamic process. It involves collecting subjective
data from the patient/parent/caregiver and obtaining
objective data by observation, examination, and testing.
During the examination, information is obtained to
explain symptoms reported by the patient and/or parent/
caregiver and diagnose their cause. It also provides
the means to identify the presence of other ocular orsystemic conditions that may exist with or without
symptoms. (See Appendix Figure 1.)
The goals of the comprehensive pediatric eye and vision
examination are to:

1. General Considerations
Since the capabilities and needs of children varysignificantly by age, the potential components of thecomprehensive pediatric eye and vision examination
have been divided into three age groups. Thissubdivision of the pediatric population is based on thedevelopmental changes that occur from birth throughchildhood. The following age groups were also chosen

17to be compatible with those used by other medical andgovernmental groups involved with children’s health.
Because an individual child’s development can varysignificantly from expected age norms, it is important
not to rely solely upon chronological age when choosing
testing procedures. Appropriate test procedures need to
be based on the child’s developmental age and specificcapability.

patient symptoms and findings may significantly influence
the nature and course of the examination. It is importantto remain alert for new and emerging technologies,
instruments, and procedures and incorporate them into
the clinical examination, as appropriate.
CONSENSUS-BASED ACTION STATEMENT:A comprehensive pediatric eye and vision
examination should include, but is not limited to:a. Infants and Toddlers (newborn through 2 years ofage)•Children in this age group may perform best if theexamination is early in the morning or after an infant’snap. Age-appropriate examination strategies should be
used. It is necessary to rely on objective examination
procedures and to perform tests more rapidly than witholder children.

Review of the nature and history of the presenting
problem, patient and family eye and medical
histories, including visual, ocular, general health,leisure and sports activities, and developmental
and school performance history of the child•

Measurement of visual acuity•

Determination of refractive status•

Assessment of binocular vision, ocular motility, andaccommodation•

Evaluation of color vision (baseline or periodic, if
needed, for qualification purposes or if disease
related)•Assessment of ocular and systemic health,including evaluation of pupillary responses,
anterior and posterior segment, peripheral retina,
evaluation/measurement of intraocular pressure,and visual field testing.

b. Preschool Children (3 years through 5 years ofage)
At about 3 years of age, children have achieved
adequate receptive and expressive language skills
to begin to cooperate for some of the traditional eye
and vision tests; however, testing modifications areoften needed to gather useful information. Beginningthe examination with procedures that appear lessthreatening may help to put the child at ease. The use of
subjective tests requiring verbal interaction may need tobe modified.

Refer to section III. Care Process, A. 9 for a listing ofpotential benefits and harms of testing.

c. School-age Children (6 through 18 years of age)

Evidence Quality: There is a lack of publishedresearch to support or refute the use of all of
the tests and/or assessments included in thisrecommendation.

Most of the examination procedures used on
adults apply to this age group; however, for somepatients, modifications should be made to improveunderstanding and cooperation. Utilization of tests
designed for younger age groups may be appropriate.
Tests of accommodation, oculomotor skills, andbinocular function should be included as part of thecomprehensive examination.

Benefit and Harm Assessment: Implementationof this recommendation is likely to result in theenhanced ability to diagnose any eye or vision
problems in infants and children. The benefits ofthis recommendation were established by expert
consensus opinion.

2. Examination Procedures**** See Appendix Tables 1, 2, and 3 for a listing ofspecific tests by age group.

The examination procedures described are not intended
to be all-inclusive. Professional judgment and individual18

3. Patient History
The patient history is an initial and ongoing componentof the examination. The objective is to obtain specificinformation about the patient and/or parent’s/caregiver’s
perception of the child’s eye and vision status andimportant background information on related medical
issues. It helps to identify and assess problems, and it
provides an opportunity to become acquainted with thepatient and/or his/her parents or caregivers, establishinga relationship of confidence and trust.
The collection of demographic data generally precedes
the taking of the patient history. Having the parent
or caregiver fill out a questionnaire may facilitate
obtaining the patient and family history, if known. Major
components of the patient history include, but are notlimited to:•

Nature and history of the presenting problem,
including chief complaint•

Visual and ocular history•

General health history, including prenatal,
perinatal and postnatal history, and review ofsystems, surgical and/or head or ocular trauma
history, and any vision or ocular treatment•

Medication reconciliation, including prescription
and nonprescription drugs (e.g., over thecounter medications, supplements, herbal
remedies) and documentation of medication
allergies•

Family ocular and medical history•

Clinical note: It is recommended that thepatient history should also include the refractive
status of both parents,115, 116 (Evidence Grade:B) because it is a possible risk factor for the
progression of myopia in school-age children.

•

Developmental history of the child•

School performance history of school-age
children•Time spent outdoors, on sports activities, andon near work and screen viewing•

Names of, and contact information for, thepatient’s other health care providers.

4. Testing
4.1 Testing of Infants and Toddlers (newborn
through 2 years of age)a. Visual Acuity
Estimation of visual acuity in an infant or toddler can help
to confirm or reject certain hypotheses about the level ofvisual system development, including binocularity, andprovide direction for the remainder of the eye and vision
examination. Assessment of visual acuity for infants andtoddlers may include these procedures:•

Preferential looking visual acuity

Preferential looking methods are useful for theassessment of visual acuity in infants and toddlers.
Grating acuity targets (e.g., Teller acuity cards) andvanishing optotypes (e.g., Cardiff acuity test) can
provide estimates of resolution visual acuity.117•

Fixation preference test

Fixation preference testing results need to beinterpreted in the context of all other available
information (e.g., degree and type of anisometropia,
frequency and type of strabismus). Results offixation preference testing may be unreliable fordiagnosing amblyopia,118, 119 particularly secondary
to anisometropia; therefore, monocular visual acuity
measurements should be obtained, if possible.120•

Visual evoked potential

Electrodiagnostic testing, such as visual evoked
potentials, is an objective method that can be used
to provide an estimate of visual acuity in infants.121
b. Refraction
Objective measures of refraction with a lens bar or loose
lenses should be used in this age group because of theshort attention span and poor fixation of infants. The
refractive error measurement should be analyzed withother testing data obtained during the examination. This19

information is used to determine if, and in what amount,an optical correction is needed. Procedures may include:•

Cycloplegic retinoscopy

When performing cycloplegic retinoscopy in an infant
or toddler, the appropriate cycloplegic agent should
be selected carefully.122 The lowest concentrationof drug that yields the desired cycloplegia should
be used. A concentration of 0.5% cyclopentolatehydrochloride can be used in most infants under
12 months of age and a 1% concentration for
older children.123 Combination drops (0.2%cyclopentolate hydrochloride and 1% phenylephrine)
are also available for use with infants. The potential
for systemic absorption may be reduced withnasolacrimal occlusion. The cycloplegic of choice
is cyclopentolate hydrochloride; however, when it
is not available or is contraindicated, tropicamide
1% has also been shown to be effective for themeasurement of refractive error in non-strabismic
infants.124

particularly hyperopia or other accommodative
problems.133
c. Binocular Vision and Ocular Motility
Depending on the patient’s age, level of cooperation,and visual signs and symptoms, appropriate testsof binocular vision and ocular motility should beincorporated into the examination. Testing in this age
group may include:•

The unilateral cover test at distance and near can
generally be used with very young children. If cover
test results are unreliable because of the child’s
resistance to testing, use of the Hirschberg test
may be successful. Prisms can be used with theHirschberg test to align the corneal reflex (Krimskytest) and estimate the magnitude of any deviation.
•

Brückner test

If cover test results are equivocal, particularly inyoung or uncooperative patients, the Brückner test
may be helpful in detecting strabismus, including
small angle strabismus. It may also be useful inthe clinical evaluation of anisometropia in infants
and young children.134 Increasing the examination
distance from one meter to four meters can improve
its sensitivity for detecting anisometropia.135

Spray administration of cyclopentolate to the open
or closed eyes of young children is an acceptable
alternative, if necessary, to using eye drops and isoften better tolerated and less distressing than othermethods of drug administration;125-128 however, theuse of cyclopentolate spray in children with dark
irides may not achieve adequate cycloplegia.129
Spray caps are available for use on bottles ofcyclopentolate, eliminating the need to have thespray compounded by a pharmacy.
•

Ocular alignment assessment•

Stereopsis

Testing of stereopsis, after 6 months of age, canprovide a sensitive measure of visual development ininfants.136 In this population, tests like the Preschool
Assessment of Stereopsis with a Smile (PASS) 3,
which uses a preferential looking paradigm, should
be used.

Non-cycloplegic retinoscopy

Non-cycloplegic retinoscopy performed at near isan objective means of estimating refractive error
in infants and toddlers,130 but should be used withcaution as a substitute for cycloplegic retinoscopy.131
It may be useful when a child/parent is extremely
anxious about instillation of cycloplegic agents,or the child has had, or is at risk for, an adverse
reaction to cycloplegic agents.132•

Near point of convergence (NPC)

Assessment of convergence ability may be
determined objectively in infants using a penlight orother interesting targets, which include sounds or
blinking lights.

Video refraction without cycloplegia can also be
used to detect infants with significant ametropia,

20

•Ocular motility assessment•

Versions and eye tracking abilities may be assessedusing a penlight, small toy, or other object.

Spray administration of cyclopentolate to the open
or closed eyes of young children is an acceptable
alternative, if necessary, to using eye drops and isoften better tolerated and less distressing than othermethods of drug administration;125-128 however, theuse of cyclopentolate spray in children with dark
irides may not achieve adequate cyclopelgia.129
Spray caps are available for use on bottles ofcyclopentolate, eliminating the need to have thespray compounded by a pharmacy.

4.2 Testing of Preschool Children (3 through 5 yearsof age)a. Visual Acuity
The accurate measurement of visual acuity in children
allows for the early detection of amblyopia andsignificant/high refractive errors. While some children inthis age group may respond verbally, acuity testing may
require the use of a matching or a forced-choice task. An
assessment of visual acuity may include the use of:•

CONSENSUS-BASED ACTION STATEMENT:
Cycloplegic retinoscopy is the preferred procedure
for the first evaluation of preschoolers. It isnecessary to quantify significant refractive error
in the presence of visual conditions such as
strabismus, amblyopia, and anisometropia.

Symbol optotype or letter matching visual acuity
measurement

Symbol optotype or letter optotype testing (e.g., Lea
symbols) and letter matching testing (e.g., HOTV)
can be used to measure the visual acuity of mostchildren aged 3 through 5 years.137-140

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.
Benefit and Harm Assessment: Implementationof this recommendation is likely to enhance theability to evaluate and diagnose eye and vision
problems in preschool children. The benefits ofthis recommendation were established by expert
consensus opinion.

b. Refraction
A refraction should include objective and, as appropriate,
subjective assessment of the child’s refractive status;
however, the results of a refraction do not provide
all the information needed to determine an opticalprescription. The refractive error measurement should beanalyzed with other testing data and the patient’s visualneeds obtained during the in-person examination. This
information is used to determine if, and in what amount,an optical correction is needed to provide optimal visionand comfort for all viewing distances. Testing in this age
group may include:•

Cycloplegic retinoscopy•

Autorefraction

The use of a hand-held autorefractor is preferable inthis age group since it may be less intimidating thana table mounted instrument.
Autorefractors can provide an objective measureof refractive error, but may underestimate the levelof hyperopia and overestimate the level of myopia
under non-cycloplegic conditions,141, 142 and theirusefulness in testing children less than 3 years ofage may be limited.143

Static (distance) retinoscopy

Use of a lens rack or loose lenses with appropriate
control of accommodation, rather than a phoropter,enables the child’s eyes to be seen and allows forobservation if the child loses fixation. Viewing a video
may assist in capturing a child’s attention in order tosustain distance fixation.

21

Assessment of positive and negative fusionalvergence ranges can be done using a step vergenceprocedure with a hand-held prism bar. 37, 148

c. Binocular Vision, Ocular Motility, andAccommodation•

Ocular alignment assessment (distance andnear)

Testing should include use of the unilateral cover
test and alternating cover test. If cover test results
are unreliable because of the child’s resistanceto testing, use of the Hirschberg test may besuccessful. Prisms can be used with the Hirschberg
test to align the corneal reflex (Krimsky test) andestimate the magnitude of any deviation.
•

Ocular motility assessment

Examination of eye movements in this age groupinvolves an assessment of comitancy.
•

Near point of convergence (NPC)

Assessment of maximum convergence ability may
be determined objectively or subjectively.
•

Stereopsis

In the preschool population, stereopsis testing canprovide useful information about development ofbinocular vision and eye alignment. Testability in thisage group has been reported to be close to 90%
using age appropriate techniques.136, 144, 145 The
presence of global stereopsis is an indication thatthe patient is bifoveally fixating and evidence that a
constant strabismus is less likely to be present.146,
147
This information is valuable when the cover test
results are equivocal and the clinician suspects asmall angle, constant strabismus may be present.
To accomplish this objective, a stereopsis test thatassesses global, rather than local stereopsis, should
be used. The PASS 3 and the Randot Preschool
tests are examples of global stereopsis tests thatcan be used for this purpose. Stereopsis tests thathave monocular cues (local stereopsis e.g., Titmus
Test) may lead to false-positive results.147•

Positive and negative fusional vergence ranges•

Accommodative testing
Clinical note: Dynamic retinoscopy has beenshown to be a reliable method for assessing
accommodation in young children.149,150 (Evidence
Grade: B)

d. Color VisionChildren with color vision deficiency, either congenital or
acquired, may have difficulty precisely matching colors
or discriminating fine color differences.151 The severityof color vision deficiency can range from mild to severe
depending on the cause. Most children can be reliably
evaluated for color vision deficiency after 60 months (5years) of age.69
It is helpful to know whether a color vision deficiency
exists, because severe color vision deficiency may
cause a child to be misidentified as learning disabled.152
Identification of abnormal color vision prior to school
age is also important, since part of the early educational
process generally involves the use of color identificationand discrimination. The presence of a color vision
deficiency may also indicate an ocular health problem;
therefore, color vision testing may need to be repeated, if
an acquired color vision deficiency is suspected.
Although effective when used with standard illuminant,some pseudoisochromatic plate tests only detect protan
and deutan color vision deficiency,153 while other color
vision tests provide the added advantage of detectionof tritan defects and the ability to categorize defects as
mild, moderate, or severe.154
4.3 Testing of School-age Children (6 through 18
years of age)a. Visual Acuity
Visual acuity may be measured monocularly andbinocularly, at distance and near, with and without thechild’s most recent spectacle or contact lens correction.

22

An assessment of visual acuity in children age 6 years orolder may include:•

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.

Snellen visual acuity

Benefit and Harm Assessment: Implementationof this recommendation is likely to enhance theability to evaluate and diagnose eye and vision
problems in school-age children. The benefits ofthis recommendation were established by expert
consensus opinion.

For some children, Snellen visual acuity testing mayneed to be modified by isolating one line, or evenone-half line of letters. If amblyopia is suspected,
single letters with surround bars should be used.
•

Early Treatment of Diabetic Retinopathy Study(ETDRS) visual acuity chart

Clinical note: In school-age children, cycloplegic
refraction results in a more positive spherical
power measurement than that obtainedusing optical fogging techniques to relax
accommodation.156 (Evidence Grade: B) The
difference in spherical equivalent refractive errors
measured in pre- and post-cycloplegic refractions
is significant up until age 20.157 (Evidence Grade:B)

The ETDRS chart may be used to measure visualacuity in school-age children155 and can be especially
useful in diagnosing and monitoring children with
amblyopia.
b. Refraction
A refraction may include objective and subjective
assessment of a child’s refractive status; however, theresults of a refraction do not provide all the informationneeded to determine an optical prescription. The
refractive error measurement should be analyzed withother testing data and the patient’s visual needs obtained
during the in-person examination. This information isused to determine if, and in what amount, an opticalcorrection is needed to provide optimal vision andcomfort for all viewing distances.

•

Typical examination procedures used to measurerefractive error in adults can generally be used forschool-age children.
•

Static (distance) retinoscopy

Retinoscopy may be performed with a phoropter, orwithout a phoropter using a lens rack or loose lenses
and fogging glasses.
•

Cycloplegic retinoscopy

CONSENSUS-BASED ACTION STATEMENT:
Cycloplegic retinoscopy is the preferred procedure
for the first evaluation of school-age children.
It is necessary to quantify significant refractive
error in the presence of visual conditions such as
strabismus, amblyopia, and anisometropia.

Autorefraction

Autorefraction may be used as a starting point
for subjective refraction, but not as a substitutefor it; however, retinoscopy, when performed by
an experienced clinician, is more accurate thanautomated refraction for determining a starting point
for non-cycloplegic refraction.158 (Evidence Grade: C)

Both objective and subjective testing for refractive error
can generally be used in this age group. It may include:•

Subjective refraction

c. Binocular Vision, Ocular Motility, andAccommodation
In analyzing the results of these tests, it is important
to examine all the data and group findings rather thandepend on a single finding to arrive at a diagnosis.
Testing in this age group is similar to that for adults andmay include:23

•Ocular alignment assessment (distance andnear)

Testing may use the unilateral cover test andalternating cover test. If cover test results areunreliable because of the child’s resistanceto testing, use of the Hirschberg test may besuccessful. Prisms can be used with the Hirschberg
test to align the corneal reflex (Krimsky test) andestimate the magnitude of any deviation. Other tests
include the Von Graefe phoria, Modified Thorington,
and Maddox Rod.
•d. Color Vision
If not done previously, school-age children should betested for color vision deficiency. Color vision deficiency
can interfere with daily activities involving colors andprohibit some occupational choices.160 One-thirdof individuals with abnormal color vision reported
their career choice had been affected by color vision
deficiency and one-quarter had been precluded from an
occupation because of it or had problems in their current
job.161
CONSENSUS-BASED ACTION STATEMENT:
Abnormal color vision can affect daily performanceof activities involving color discrimination andmay interfere with or prevent some occupational
choices later in life. Children should be tested assoon as possible for color vision deficiency and theparents/caregivers of children identified with color
vision deficiency should be counseled.

Ocular motility assessment

Examination of eye movements in this age groupinvolves an assessment of comitancy of fixation,saccadic, and pursuit functions. Versions may also
be performed to rule out a noncomitant deviation.
•

Near point of convergence (NPC)

Determination of maximum convergence ability may
be obtained objectively or subjectively.
•

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.

Stereopsis

Benefit and Harm Assessment: Implementationof this recommendation is likely to increase early
detection of color vision deficiency and alert
parents/caregivers to any potential effects on achild’s education or occupational choices. The
benefits of this recommendation were establishedby expert consensus opinion.

School-age children should be able to complete
any of the available random dot stereopsis
tests. If random dot (global) stereopsis is notpresent, testing should continue to evaluate local
stereopsis, potential for flat fusion, and potential for
simultaneous perception.
•

Positive and negative fusional vergence ranges

Evaluation should be made of both the amplitudeand facility of fusional vergence ranges.
•

Accommodative testing

Assessment of accommodation may include
accommodative amplitude, facility, andresponse.149, 159 Testing of negative relative
accommodation (NRA) and positive relative
accommodation (PRA) may provide useful
information on both accommodative and binocular
status.149

5. Ocular and Systemic Health Assessment
Thorough assessment of the health of the eyes andassociated structures is an important and integral
component of the comprehensive pediatric eye andvision examination. The eyes and associated structures
are not only sites for primary ocular diseases, but they
are also subject to systemic disease processes that
affect the body as a whole (e.g., disorders of neurologic,
vascular, endocrine, immune, or neoplastic origin).
Standard procedures used in evaluating adult patients
may need to be modified or may not be optimalin very young patients. With some modifications,24the components of the ocular and systemic healthassessment may include:

Clinical note: The Goldmann applanation
tonometer (GAT) is considered the reference
standard for the measurement of IOP; however,its use may not be practical in very young
children. Non-contact and handheld applanation
tonometers can provide IOP measurements close
to that of the Goldmann.165 (Evidence Grade: A)
Rebound tonometry offers an advantage overGAT in that it is portable, easy to use, and better
tolerated.166 (Evidence Grade: B)

a. Assessment of Pupillary Responses
Evaluation of pupils includes size, shape, symmetry,and direct and consensual response to light and relative
afferent pupillary defect.
b. Visual Field Evaluation
Confrontation visual field testing can be used to detectgross peripheral defects and areas of constricted visual
fields.
c. Evaluation of the Ocular Anterior Segment andAdnexaAssessment of the external eye and adnexa, ocularsurface, anterior chamber, and crystalline lens.

6. Supplemental Testing
During an eye and vision examination, the information
obtained from the patient is continually assessed, alongwith the clinical findings gathered. The interpretation ofsubjective and objective data may indicate the need for
additional testing.
Additional testing may be indicated to:

d. Evaluation of the Ocular Posterior Segment
Pharmacological dilation of the pupil is generally required
for thorough stereoscopic evaluation of the ocular
media, retinal vasculature, macula, optic nerve, and the
peripheral retina.162 (Evidence Grade: B)•

Confirm or rule out differential diagnoses•

Enable more in-depth assessment•

Provide alternative means of evaluating patients
who may not be fully cooperative or who may
not comprehend testing procedures.

Examination under general anesthesia may beconsidered under rare circumstances, if the retina cannot
be adequately visualized during an examination of at-riskchildren.163

Supplemental procedures may be performed
immediately or during subsequent examinations.
Supplemental testing for infants and children may
include:e. Measurement of Intraocular Pressure

a. Electrodiagnostic Testing

Measuring intraocular pressure (IOP) is a part of thecomprehensive pediatric eye and vision examination.
Although the prevalence of glaucoma is low in children,
measurement of IOP should be attempted. Pressure
should be assessed when ocular signs and symptoms orrisk factors for glaucoma exist. If risk factors are present
and reliable assessment of IOP under standard clinicalconditions is impossible, testing under anesthesia may
be indicated. Recording of tonometry results should
include method used and time of day.164 (Evidence
Grade: C)

Electrophysiological techniques may be used to assesschildren with unexplained reduced vision. Testing may
include an electroretinogram (ERG) or measurement ofvisual evoked potential (VEP).
b. Imaging
The following procedures may be used for imaging ofocular structures:25•Ultrasonography can reveal congenital
anatomical abnormalities in the eye and orbit,
as well as anatomical changes secondary todisease or injury, and measure axial length•

Optical coherence tomography (OCT) provides
cross-sectional, high-resolution imaging of theanterior and posterior segments•

Scanning laser ophthalmoscopy provides 3-D
images of the optic nerve head•

Fundus photography, with or without auto
fluorescence, is a noninvasive diagnostic
technique for examining the fundus•

Corneal topography provides an assessment ofcorneal thickness, shape, power, and surface
details•

Computerized tomography (CT) scan,magnetic resonance imaging (MRI), and otherneuroimaging may be indicated for suspicion ofneurological disease or trauma/injury•

Scheimpflug camera for anterior segment
tomography (Pentacam, Orbscan, and Gallilei)
may be used for detection of keratoconus.

c. Testing for Learning-related Vision Problems
Vision problems such as accommodative, binocularvision, eye movement, and visual information processing
disorders can interfere with academic performance.
When a child’s history or initial testing indicates apossible developmental lag or learning disorder,
additional testing should be performed to rule out alearning-related vision disorder. This will typically require
an additional office visit that includes more extensive
testing of accommodation, binocular vision, and eye
movements, and an assessment of visual information
processing skills. In some instances, this may require areferral to a doctor of optometry with advanced training
in this area of practice.

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.
Benefit and Harm Assessment: Implementationof this recommendation is likely to result in morein-depth evaluation and diagnosis of children withlearning-related vision problems. The benefits ofthis recommendation were established by expert
consensus opinion.
Click to view the (AOA Clinical Practice Guidelines
web page)
7. Children with Special Needs
a. At-risk Children
In the United States, the Individuals with Disabilities
Education Act (IDEA) allows for the development of
Individualized Education Programs (IEPs) when indicated.

The following categories of children are considered highrisk (Health and Human Services, Health Resources
and Services Administration, Maternal and Child
Health Bureau) and recommend direct referral for acomprehensive eye and vision examination:•

Children with obvious evidence of physicalanomaly (e.g., strabismus, ptosis, nystagmus)•

Children with central nervous system (CNS)
dysfunction (e.g., cerebral palsy, Down
syndrome, seizures, developmental delay)•

Children with Autism Spectrum Disorder•Children enrolled in Early Intervention (EI)
Program’sa). Children with an IEPb). Children enrolled in Early Head Start (ages
0-3)

CONSENSUS-BASED ACTION STATEMENT:Children at risk for learning-related vision problems
should be evaluated by a doctor of optometry.

•

26

Children with a family history of amblyopia,
strabismus, or other early eye disease•Children born from high-risk pregnancy (e.g.,maternal drug use, infection during pregnancy,
preterm delivery).

b. Developmental Disabilities
Many children with special needs have undetected
and untreated visual problems 167 (see Appendix
Table 4: Partial Listing of Ocular Manifestations of
Neurodevelopmental Disorders and Other Syndromes).
Children with developmental or intellectual disabilities
have a higher rate of vision disorders and should
receive a comprehensive pediatric eye and vision
examination.21, 25, 168 Although clinically more challenging,visual assessment is possible in the majority of thesechildren.167 (Evidence Grade: B),169 (Evidence Grade:B) Early identification of specific visual deficits could
lead to interventions to improve the educational andoccupational achievement and quality of life for thesehigh-risk children.
CONSENSUS-BASED ACTION STATEMENT:
Many children with developmental or intellectual
disabilities have undetected and untreated vision
problems and should receive a comprehensive
pediatric eye and vision examination.
Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.
Benefit and Harm Assessment: Implementationof this recommendation is likely to result in
improved quality of life and educational andoccupational achievement for these high-riskchildren. The benefits of this recommendation
were established by expert consensus opinion.
8. Trauma and Ocular Manifestations of Child
Abuse/Neglecta. Trauma (Accidental)
A majority of concussions occur in the pediatric andadolescent population (5 to 17 years of age), withthe 11 to 17-year-old group representing the largest
proportion of those injured.170, 171 Children are particularly
vulnerable to the consequences of concussion, often
having a more prolonged recovery and poorer outcomes,

from a cognitive and developmental perspective, thanadults with concussion.172-175 A recent study founda high prevalence of vision problems in adolescentswith concussion along with significant symptoms
associated with these vision disorders.176 The mostcommon binocular vision disorder occurring in postconcussion syndrome is convergence insufficiency (CI)with a prevalence of 49% in children. Other common
problems are accommodative insufficiency and saccadic
dysfunction.
All children with concussion should see their generalpractitioner in the event they should need more emergent
care and should be scheduled for a comprehensive eye
examination to confirm visual capabilities are protected.
b. Ocular Manifestations of Child Abuse and Neglect(Non-accidental)
External eye trauma (e.g., conjunctival hemorrhages,
lid lacerations, corneal scars and/or opacities) andretinal trauma (e.g., hemorrhages, folds, tears, and/or detachments) are common ocular findings fromchild abuse and can have an important role in its
diagnosis.177-180 Most often the child is between 2 and 18
months of age at the time of abuse.179, 181
The eyes can be direct or indirect targets of child abuse
and may provide valuable diagnostic information,
particularly when there are limited external signsof abuse. In children, the leading cause of retinal
hemorrhages with retinal folds and macular retinoschisis,in the absence of skull fractures or automobile accident
history, is typically abusive head trauma.182, 183 Retinal
hemorrhages, poor visual response, and poor pupil
response in an infant may indicate abusive head trauma,
or Shaken Baby Syndrome,177 (Evidence Grade: B),178(Evidence Grade: C) a form of child abuse in which thechild is injured secondary to violent shaking.
A vague history provided by the parent/caregiver thatchanges on re-questioning or is inconsistent with theage of the child or extent of the injury should be an alert
for abuse. In such cases, a detailed history is one of
the most important factors to consider when assessing
whether a child has been abused.180

27

Table 5: Summary of the Signs of Child Abuse and Neglect

Ocular signs of abuse
Cortical blindness
Ruptured globe
Retinal, preretinal, vitreous hemorrhages
particularly if child is less than 2
years old
Detached retina, retinal dialysis
Chorioretinal atrophy
Papilledema
Optic atrophy
Cataracts
Dislocated, subluxated lensGlaucoma
Shallow anterior angle
Angle recession
Iris tears, iris dialysis
Pupillary anomalies
Anisocoria
Hyphema
Hypopyon
Corneal scars, edema, opacities
Conjunctival, subconjunctival hemorrhages
Orbital, periorbital edema
Lid lacerations
Ptosis
Proptosis
Esotropia
Strabismus
Nystagmus
Disconjugate eye movements
Eyelash infestation with phthirus pubis(crab louse)

General physical signs of abuseor neglect
Bruises around cheeks, jaw, eyes, ears, or
mastoid area
Soft tissue bruises on upper arms, thighs,
buttocks or genitals
Hair loss with/without subgaleal menatoma
Torn frenum of upper lip
Torn floor of mouth
Burns on any posterior part of the body,particularly buttocks, perineum, hands,
or feetFull thickness burns
Multiple lesions or fractures in different
stages of healing
Poor hygiene
Inferior general healthSigns of malnutrition such as sunken
cheeks and buttocks, distended
abdomenChild not properly immunized
Venereal disease in a preadolescent child
Case history inconsistencies
No history offered
History vague or inconsistent with injuries
History changes during course of
examination
History varies between two parents or
between parents and child
Multiple office visits for accidental injuries
Increase in severity of injuries
Delay in seeking medical attention

Emotional and behavioral signsof abuse or neglect
Frozen watchfulness
Fear of strangers
Indiscriminate attachment to strangers
Failure to thrive
Growth failure
Low intellectual performance
Sad affectLow self-esteem
Impaired ability to enjoy life
Social withdrawal
Learned helplessness
Suicidal ideation or attempts
Drug or alcohol abuse
Misconduct in school
Academic failure
Low school attendance
Aggressive behavior
Sleeping problems
Running away
Low level of activity
Weight fluctuation
Fatigue
Generalized anxiety
Sexual acting out

Source: Smith S. Child abuse and neglect: A diagnostic guide for the optometrist. J Amer Optom Assoc 1988;
59:760-66.
All 50 states and the District of Columbia have laws mandating the reporting of suspected child abuse and provide
penalties for failure to do so.
U.S. Department of Health and Human Services, Administration for Children & Families, Children’s Bureau listing ofstate child abuse and neglect reporting numbers
Clinical note: Doctors of optometry should be aware of the eye-related findings associated with abusive headtrauma and report findings of possible child abuse to the proper authorities, as defined by state law, for theprotection of the child.

28

9. Potential Benefits and Harms of Testing

C. MANAGEMENT

The potential benefits of a comprehensive pediatric eyeand vision examination include:

1. Prescription for Correction•

Optimizing visual function through diagnosis,
treatment, and management of refractive, ocularmotor, accommodative, and binocular vision
problems•

Preventing and/or minimizing vision loss throughearly diagnosis, treatment, and management ofocular health conditions•

Detecting systemic disease and referring for
appropriate care•Counseling and educating patients/parents/
caregivers on current conditions and preventive
care to maintain ocular and systemic health andvisual function, and on the relationship between
vision problems and early learning.

Potential harms associated with a comprehensive
pediatric eye and vision examination may include:•

Patient or parent/caregiver anxiety about testingprocedures or resulting diagnosis•

Adverse ocular and/or systemic reactions and/or temporary visual disturbances resulting fromtesting, or allergic responses to diagnostic
pharmaceutical agents or materials used•

Missed or misdiagnosis of eye health or vision
problems•

Unnecessary referral or treatment.

B. ASSESSMENT AND DIAGNOSISAt the completion of the examination, the data collectedshould be assessed and evaluated to establish adiagnosis (or diagnoses) and formulate a treatment
and management plan. The nature and severity of the
problem(s) diagnosed determine the need for opticalprescription (e.g., eyeglasses and/or contact lenses) orother treatment (e.g., vision rehabilitation, vision therapy,
ocular pharmaceuticals).

A prescription for correction of refractive error, if needed,
is provided at the conclusion of the examination.184 The
level of refractive error may be monitored rather thanprescribed as a lens correction, or full or partial opticalcorrection may be prescribed, depending on the specificvisual needs, refractive measurement, and related visual
findings.
2. Additional Treatment Services
Depending on the diagnosed eye and vision condition(s),other treatment services may be needed. For conditions
such as accommodative, binocular vision, eyemovement, visual information processing disorders, orvisual impairment, treatment such as the use of prisms,
vision therapy, or vision rehabilitation may be necessary.
Ocular pharmaceuticals may also be used for thetreatment of various eye diseases.
3. Counseling and Education
It is important for children/parents/caregivers tounderstand the medical information andrecommendations given to them. To enhance
understanding, open-ended questions should be used.
Children/parents/caregivers should be asked to state
their understanding of the information given to themusing their own words.185 Eye models, diagrams, andwritten materials can also be used to aid inunderstanding.
Shared decision-making increases patient/parent/
caregiver satisfaction with the examination andconsultation, and may improve health outcomes. The
available options, with their benefits and risks, need to
be described and patient/parent/caregiver views andpreferences elicited, before agreeing on a course ofaction.186
Language and cultural differences or misunderstandings
may prevent some individuals from accepting a doctor’s
recommendation. When communicating with patients/
parents/caregivers, it is important to take their level of29

“health literacy” into consideration.187 Health literacy is“the degree to which individuals have the capacity toobtain, process, and understand basic health informationand services needed to make appropriate decisions
regarding their health.”188 Limited health literacy has been
associated with a range of adverse health outcomes
including decreased use of preventive services and poordisease specific outcomes.189

members of patients may act as interpreters, with theparent/caregiver consent for minors.
CONSENSUS-BASED ACTION STATEMENT:At the conclusion of a comprehensive pediatriceye and vision examination, the diagnosis should
be explained to the patient/parent/caregiver andrelated to the patient’s symptoms, and a treatment
plan and prognosis discussed.

In addition, anxiety reduces the effectiveness ofpatient-practitioner communications and results in
reduced attention, recall of information, and compliancewith treatment. The use of “patient-centered”
communications and “active listening” can help
reduce anxiety and improve patient/parent/caregiversatisfaction and outcomes.190 Improved doctor-patientcommunications and higher levels of patient/parent/
caregiver involvement in care are linked to better clinicaloutcomes.191
In compliance with the Americans with Disabilities Act(ADA), reasonable accommodations need to be madeto ensure that whatever is written or spoken is clear
and understandable to individuals with disabilities.
Appropriate auxiliary aids and services must be
made available, when needed, to enable effective
communications when evaluating, treating, or counselingpersons with hearing, vision, or speech impairments.
According to the ADA, auxiliary aids and services forindividuals who are hearing impaired include qualified
interpreters, note takers, computer-aided transcription
services, written materials, telephone handset amplifiers,
assistive listening systems, telephones compatible withhearing aids, closed caption decoders, open and closed
captioning, telecommunications devices for the deaf
(TDD’s), videotext displays and exchange of written
notes. For individuals with vision impairments, auxiliary
aids and services include qualified readers, taped texts,
audio recordings, magnification software, optical readers,
Braille materials, and large print materials. Examples
for individuals with speech impairments include
TDD’s, computer terminals, speech synthesizers, andcommunication boards.192
Language interpreters may also be needed to assist
patients who have limited English proficiency. Family

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation
Benefit and Harm Assessment: Implementing
this recommendation is likely to increase patient/parent/caregiver understanding of any diagnosed
eye or vision problems and improve compliancewith any recommended treatment. The benefits ofthis recommendation were established by expert
consensus opinion
Patient/parent/caregiver counseling and education may
include:•Review of the child’s visual and ocular healthstatus in relation to his/her visual symptoms andcomplaints•

Discussion of any refractive correction thatprovides improved visual efficiency and/or
appropriate eye protection•

Information on learning-related vision problems•

Explanation of available treatment options fordiagnosed eye or vision conditions, including
risks, benefits, and expected outcomes•

Recommendation of a course of treatment withthe reasons for its selection and the prognosis•

Discussion of the importance of patientcompliance with the treatment prescribed•

Recommendation for follow-up care, reexamination, or referral.

When appropriate, patients/parents/caregivers should
also be counseled about:30

a. Eye Safety and Protection
Eye injury is a leading cause of monocular blindness in
the United States and a common reason for eye-related
emergency department visits. Eye injuries treated in U.S.
hospital emergency rooms among children younger than
18 years of age averaged over 70,000 annually in 1990
through 2009.193 (See Table 6.) The risk for eye injuries inchildren is highest among 15 to 17 year olds. The mostcommon eye injuries are due to abrasions or foreign
bodies.194

or home, and during sports and recreational activities,
and to promote the use of appropriate protective
eyewear to help reduce the incidence of eye injuries
among children.193 (Evidence Grade: B),199 (Evidence
Grade: B) Prevention strategies should focus on theuse of protective eyewear, parental supervision, and on
childhood education about both the risks of eye injury
and the utility of protective eyewear.194 (Evidence Grade:B) 200EVIDENCE-BASED ACTION STATEMENT:
Parents/caregivers and children should be
educated about potential risks for eye injuries
at home, at school, and during sports andrecreational activities, and advised about safety
precautions to decrease the risk of ocular
injury.193,199 Prevention of eye injuries in children
should focus on the use of protective eyewear,
parental supervision, and include education aboutboth the risks of eye injury and the benefits ofprotective eyewear.194

The majority of eye injuries in children occur at home.193
Frequent causes are sports and recreation activities,
chemicals, or household products.193,195 Most eye injuries
are preventable with appropriate use of protective
eyewear;196, 197 however, in a National Health Interview
Survey of children participating in activities that cancause eye injury, only 14.5% were reported to wear
protective eyewear all or most of the time. Older children(12 to 17 years of age) were more likely to use protective
eyewear than younger children.198

Evidence Quality: Grade B: Retrospective cohort
studiesLevel of Confidence: Medium
Clinical Recommendation Strength: Strong
Recommendation. This recommendation should
be followed unless clear and compelling rationale
for an alternative approach is present.

Table 6: Most Common Pediatric Eye Injuries
Treated in U.S. Emergency Departments

Common Pediatric Eye Injuries
Sports and recreation (e.g., basketball, baseball, football, playgroundequipment)

Evidence Statements: It is important todiscuss eye safety issues with children/parents/
caregivers.193 (Evidence Grade: B),199 (Evidence
Grade: B)

Household chemicals (e.g., cleaning agents, bleach, pesticides)
Housewares and furniture (e.g., microwaves, flatware, tables)
Toys

Prevention strategies should focus on the useof protective eyewear, parental supervision, andon childhood education about both the risks ofeye injury and the utility of protective eyewear.194(Evidence Grade: B)

Desk supplies (e.g., pens, pencils, scissors)
Tools and hardware (e.g., hammers, nails)
BB and pellet guns
Tobacco products (e.g., cigarettes, cigars, pipes)

Potential Benefits:
Reduction in eye
injuries in children

Fireworks

Source: Rankings of common pediatric eye injuries
as reported in Pediatric eye injuries treated in U.S.
emergency departments, 1990-2009.193

Potential Risks/Harms: None

Benefit and Harm Assessment: Benefits
significantly outweigh harms
Potential Costs: Direct cost of counseling as partof a pediatric eye and vision examination

It is important to discuss eye safety issues with children/
parents/caregivers, including eye hazards at school

31

Value Judgments: NoneCONSENSUS-BASED ACTION STATEMENT:All children and their parents/caregivers should
be advised about the benefits of the regular useof sunglasses and/or clear prescription glasses
that effectively block at least 99% of UVA andUVB radiation, the use of hats with brims when
outdoors, and the importance of not looking
directly at the sun.

Role of Patient Preferences: Large
Intentional Vagueness: Specific type/form ofcounseling is not stated, as it is patient specificGaps in Evidence: Research is needed todetermine the risks and methods of eye protection
associated with specific eye injuries in children inorder to design appropriate prevention strategies

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.

b. Ultraviolet Radiation and Blue Light Protection
Children/parents/caregivers should be advised about theneed to protect children’s eyes from excessive exposure
to sunlight. Sunlight is comprised of ultraviolet (UVAand UVB) radiation and short wavelength visible energy(blue light), which can cause acute effects in the eye
and may also lead to chronic effects over the life of theindividual. The eyes of infants and young children are
known to have a higher level of UV and short wavelengthtransmittance than older children and adults, making
them more susceptible to energy-related injury.201, 202
Exposure to high levels of UV-containing sunlight,
especially when reflected from snow, can cause
acute photokeratitis and keratoconjunctivitis. Chronic
exposure to even low levels of UV radiation is a risk
factor for developing cataracts, pterygium, squamouscell carcinoma of the cornea and conjunctiva, and skincancer.203 Epidemiological evidence also shows that
excess chronic sunlight exposure leads to a significantly
increased risk for developing age-related maculardegeneration as an older adult.204
Exposure to high levels of short wavelength visibleenergy (blue light) also has the potential to cause
photochemical retinal damage, which is known to occur
with direct sun viewing.205, 206 In addition, the increased
evening use of laptops and other broad spectrum selfilluminated devices rich in blue light has been suggested
to interfere with good sleep hygiene, especially inadolescents.207

Benefit and Harm Assessment: Implementing
this recommendation is likely to decrease patientrisk of eye health problems from acute or chronic
exposure to UV radiation and blue light. The
benefits of this recommendation were establishedby expert consensus opinion.
c. Impact of Near Work and Reduced Time Outdoors
on Vision
The prevalence of myopia in children has been increasing
significantly in the past few decades.44 Environmental
factors such as time spent on reading and other nearactivities and the limited amount of time spent outdoors
have been cited as potential factors contributing to
the development and progression of myopia.208 Most
children spend considerable time each day using
computers, tablets, or smart phones at school andat home. As a result, they may be spending less time
outdoors.
Although there is conflicting evidence, more time spent
outdoors and less time indoors doing near work may
slow myopia progression and prevent high myopia.208(Evidence Grade: A),209 (Evidence Grade: B),210 (Evidence
Grade: B),211 (Evidence Grade: D).212
EVIDENCE-BASED ACTION STATEMENT:
Patients/parents/caregivers should be counseled
about the benefits to children’s vision of spending
more time outdoors.208-211

Children can reduce the potential for eye damage from
UV radiation and blue light by not looking directly at thesun, and wearing sunglasses and/or clear prescription
lenses and brimmed hats when outdoors.

32

Evidence Quality: Grade B. Randomized clinical
trial, Prospective cohort studies, Cross-sectional
study
Level of Confidence: Medium
Clinical Recommendation Strength:
Recommendation. This recommendation should
generally be followed, but remain alert for new
information.
Evidence Statements: More time spent outdoors
and less time indoors doing near work may slow
axial elongation and prevent high myopia thereby
reducing the risk of developing sight-threatening
conditions such as retinal detachment and myopic
retinopathy.208 (Evidence Grade: A)
More time outside may decrease myopia
progression. Less outdoor/sports activity before
myopia onset may exert a stronger influence on
the development of myopia than near work.209(Evidence Grade: B)
Outdoor time and near work do not have a major
effect on myopia progression.210 (Evidence Grade:
B)
Higher levels of outdoor activity were associatedwith lower amounts of myopia in primary school
students.211 (Evidence Grade: D)
Potential Benefits:
Implementation of thisrecommendation is
likely to help reducethe development andprogression of myopia
in children

Potential Risks/Harms: None

Gaps in Evidence: Research is needed on theeffects and possible interaction of outdoor activity
and near work on myopia in children
d. Myopia Control
Childhood is the preferred time to consider the use of
myopia control procedures, as early onset myopia isassociated with higher progression rates and increased
risk of continuing to high myopia.213
The use of progressive addition spectacle lenses,
prismatic bifocals, multiple and dual focus contactlenses, orthokeratology, and atropine have been studied
to slow myopia progression.214 The approaches tocontrol of myopia that have been shown in studies tobe most successful are the use of low concentrations ofatropine eye drops 215 and orthokeratology.214, 216, 217.
Parents/caregivers of children who are at risk fordeveloping or have developed myopia should becounseled about the potential complications of myopia
progression and the treatment options available for its
control.
4. Coordination and Frequency of Care
The diagnosis of a wide array of eye and vision
anomalies, diseases, disorders, and related systemic
conditions may result from a comprehensive pediatriceye and vision examination. The nature and severity ofthe problem(s) diagnosed determine the need for:Benefit and Harm Assessment: Benefits
significantly outweigh harms
Potential Costs: Direct cost of counseling aspart of a pediatric eye and vision examination andparental/caregiver time off from work
Value Judgments: None•

Optical correction•

Vision therapy•

Vision rehabilitation services•

Prescription or nonprescription medications•

Surgery•

Follow-up for additional evaluation and/or
treatment.

Role of Patient Preferences: Moderatea. Coordination of CareIntentional Vagueness: Specific type/form ofcounseling is not stated, as it is patient specific

Based on the examination, it may be determined that thepatient needs additional services. These may include:33

•Intraprofessional consultation with anotherdoctor of optometry for treatment andmanagement of ocular disease, vision
rehabilitation, vision therapy, and/or specialty
contact lenses.

•

Interprofessional consultation with an
ophthalmologist may be necessary for
ophthalmic surgery or other aspects ofsecondary or tertiary eye care.

•

Some vision problems can interfere withlearning. Children at risk for learning-related
vision problems should be evaluated by a doctorof optometry.

•

Referral for consultation with the child’s
pediatrician or other primary care physician,developmental pediatrician, pediatric neurologist,
the school system, a child psychologist or
psychiatrist, or the local or state Department ofSpecial Education should be considered whenproblems in other developmental areas such as
behavior, language, or social development aresuspected or when a full psychoeducational
evaluation is indicated.

••

The comprehensive pediatric eye and vision
examination may reveal non-ophthalmic
conditions for which coordination of care may
be needed. The patient may be referred tohis or her pediatrician/primary care physician
or another health care provider for further
evaluation and treatment of systemic conditions
or related health problems. Information sharedwith other health care providers offers a uniqueand important perspective resulting in an
improved team approach to interdisciplinary careof the patient.
Ocular telehealth programs may be acomponent of care for some patients,
particularly in areas where access to specialized
eye care services is limited. The use of oculartelehealth-based programs has the potential
to expand access to eye care services;
however, telehealth-based evaluations are nota substitute for an in-person comprehensive
eye examination. These programs rely on thedigital capture and transmission of standardizedocular images and patient health information at
one location for interpretation and evaluation at
another location by trained observers who canrecommend a treatment and care plan. To date,telehealth programs have been most widelyused for the evaluation of patients with diabetic
retinopathy.218
b. Frequency of Care
Children should receive periodic eye and vision
examinations to diagnose and treat any eye disease in
its early stages in order to prevent or minimize vision
loss and maximize visual abilities. These examinations
can also identify problems that may be affecting visualfunction and achievement at school, at home, and in
sports or leisure activities. In addition, the early signs
and symptoms of systemic medical conditions, suchas diabetes, may be revealed during a comprehensive
pediatric eye and vision examination.
The recommended frequency of a comprehensive
pediatric eye and vision examination (Table 7) varies
with a child’s age, ocular and medical history, and otherrelated risk factors.
•

Infants and Toddlers (newborn through 2 yearsof age)Clinical experience and research have shown that at
6 months the average child has reached a numberof critical developmental milestones, making this anappropriate age for the first eye and vision examination.
Within the first 6 months of life, rapid changes occur
in most components of the visual system including
visual acuity,121, 219 accommodation,220, 221 and binocularvision.222-224 Since the developing visual system isconsidered most susceptible to interference during thefirst few years of life,225-227 interference during this criticalphase of development may have significant long-term
effects; therefore, early diagnosis and treatment are
critical to avoid vision loss.
There is a high prevalence of eye and vision problems inpreterm children.228 Preterm infants with a history of ROP
should be closely monitored for the development of high34

myopia, astigmatism, anisometropia,229 (Evidence Grade:B) strabismus,76 and other ocular diseases.

Evidence Statements: Preterm infants with ahistory of ROP should be closely monitored for thedevelopment of high myopia, astigmatism, andanisometropia.229 (Evidence Grade: B)

One of the primary goals of examining young children is
to detect amblyopia so that treatment can be initiatedas early as possible. Early visual examination of infants
for amblyopia and amblyopic risk factors can lower
the prevalence and severity of amblyopia in children.230(Evidence Grade: B)

Early visual examination in infants for amblyopia
and amblyopic risk factors can lower theprevalence and severity of amblyopia in children.230(Evidence Grade: B)

Assessment of infant refractive error can identify not
only vision problems, but also potential developmental
difficulties. Infants with hyperopia may show deficits
in many visuocognitive, spatial, visuomotor, andattention tests.231 (Evidence Grade: B) Significant
hyperopia is commonly found in association with theearly development of strabismus and amblyopia, withincreased risk of development by age 4 years.

Assessment of infant refractive error can identify
not only vision problems, but also potential
developmental difficulties. Hyperopic infants may
show deficits in many visuocognitive, spatial,
visuomotor, and attention tests.231 (Evidence
Grade: B)
Potential Benefits:
Early identification andtreatment of eye andvision problems

The wearing of a partial correction for significant
hyperopia and anisometropia throughout infancy can
reduce the incidence of poorer than average visual acuityin 3 to 5 1/2 year olds.232 Spectacle correction in infancy
also improves the chances of infants with hyperopia
having normal vision at age 4 and beyond.233
EVIDENCE-BASED ACTION STATEMENT:
Infants should receive an in-person comprehensive
eye and vision assessment between 6 and 12
months of age for the prevention and/or early
diagnosis and treatment of sight-threatening eye
conditions and to evaluate visualdevelopment.229-231
Evidence Quality: Grade B: Prospective cohort
studies, Diagnostic study
Level of Confidence: HighClinical Recommendation Strength: Strong
Recommendation. This recommendation should
be followed unless clear and compelling rationale
for an alternative approach is present.

Potential Risks/Harms: None

Benefit and Harm Assessment: Benefits
significantly outweigh harms
Potential Costs: Direct cost of testing andparent/caregiver time off from work
Value Judgments: None
Role of Patient Preferences: Moderate
Intentional Vagueness: None
Gaps in Evidence: None identified•

Preschool Children (3 through 5 years of age)

Vision care in preschool children is very importantbecause their visual system is still developing. They are
at risk for the development of amblyopia, strabismus,
and refractive error, which may lead to long term visual
impairment.40, 41, 53, 234-236
Amblyopia is a treatable condition in children andadolescents 54 (Evidence Grade: A); however, amblyopia
is more responsive to treatment among children younger
than 7 years of age.54-60 Significant uncorrected refractive
errors are a risk factor for the development of amblyopia.
In addition to its impact on vision, amblyopia can affectan individual’s psychosocial functioning, warranting early
diagnosis and treatment.19

35

Uncorrected refractive errors have been associated withdelays in development of cognitive ability and motor
skill.10, 231, 237 The Vision in Preschoolers-Hyperopia in
Preschoolers (VIP-HIP) study found that uncorrected
hyperopia ≥4.00D, as well as uncorrected hyperopia≥3.00D to ≤6.00D in conjunction with reduced
binocular visual acuity (20/40 or worse) or reducednear stereoacuity (240 seconds of arc or worse), areassociated with significantly worse performance on
a test of preschool early literacy (TOPEL) in 4 and5 year old children.238 (Evidence Grade: C) Children
with astigmatism tend to score lower on measures ofacademic and developmental skills than children without
astigmatism.239 Spectacle correction of children withastigmatism during the preschool years can also result insignificantly improved best-corrected visual acuity by thetime they reach kindergarten age.240 (Evidence Grade: C)

Evidence Statements: Amblyopia is a treatablecondition in children and adolescents 54 (Evidence
Grade: A); however amblyopia is more responsive
to treatment among children younger than 7 yearsof age.
Uncorrected hyperopia in 4 and 5 year oldchildren has been associated with delays in thedevelopment of early literacy.238 (Evidence Grade:C)
Spectacle correction of astigmatism during thepreschool years can result in significantly improved
best-corrected visual acuity by kindergarten age.240(Evidence Grade: C)
The U.S. Preventive Services Task Forcerecommends that children have their visionscreened at least once between the ages of
3 and 5 years of age;107 (Evidence Grade: B)
however, gaps exist in the delivery of preschool
vision screening and rates of screening are low,
particularly in 3 year old children.241 (Evidence
Grade: C)

Uncorrected vision problems can have a detrimental
effect on vision development, learning, school success,and socialization. Many eye and vision problems are
asymptomatic in this age range; therefore, it is importantthat preschool children receive a comprehensive eye
examination. While the U.S. Preventive Services Task
Force recommends that children have their visionscreened at least once between the ages of 3 and 5
years,107 (Evidence Grade: B) gaps exist in the deliveryof preschool vision screening. Rates of vision screening
in preschool children are low, particularly in 3 year oldchildren.241 (Evidence Grade: C)

Potential Benefits:
Early identification andtreatment of eye andvision problems

Benefit and Harm Assessment: Benefits
significantly outweigh harms
Potential Costs: Direct cost of testing andparent/caregiver time off from work

EVIDENCE-BASED ACTION STATEMENT:
Preschool age children should receive an in-person
comprehensive eye and vision examination at least
once between the ages of 3 and 5 to prevent and/or diagnose and treat any eye or vision conditions
that may affect visual development.54,107, 238, 240, 241
Evidence Quality: Grade B. Systematic Review,
Case series, Cross-sectional study
Level of Confidence: Medium
Clinical Recommendation Strength: Strong
Recommendation. This recommendation should
be followed, unless clear and compelling rationale
for an alternative approach is present.

Potential Risks/Harms: None

Value Judgments: None
Role of Patient Preferences: Moderate
Intentional Vagueness: None
Gaps in Evidence: None identified•

School-age Children (6 through 11 and 12
through 18 years of age)

Vision may change frequently during the school years.
The most common problems are due to thedevelopment and progression of refractive errors.
Myopia generally occurs in children during their earlyschool years and increases in magnitude as they get36older. If myopia is defined as 0.50D or more, thepercentage of children becoming myopic is estimated tobe 23.4%. The age at onset ranges from 7 to 16 years.
Sixteen percent of children enrolled in the CLEERE study
developed myopia (0.75D or more) during their schoolage years. The highest percentage of new cases
occurred at age 11.42
Children should receive an eye examination at the
beginning of primary school to test for the presenceof myopia 115 (Evidence Grade: B) and, if diagnosed,
they should have a comprehensive examination at least
annually or as frequently as their doctor recommends
because of rapid myopia progression.242 (Evidence
Grade: B) Children with myopia, especially those younger
than 9 years of age and/or with two parents with myopia,
are at higher risk for myopia progression and should be
examined more than once per year.208 (Evidence Grade:A)movement problems has been shown to improve reading
comprehension.248
Diagnosis and treatment of an accommodative orvergence problem may reduce the negative impact onacademic performance.65 (Evidence Grade B) 249 Vision
therapy has been shown to be effective in improving
accommodative amplitude and accommodative facility
in school-age children with symptomatic convergence
insufficiency and accommodative dysfunction.
Children with Attention Deficit/Hyperactivity Disorder(AD/HD) have been reported to have a much greater
incidence of CI than those without AD/HD;250 therefore,
these children may benefit from comprehensive visionevaluation to assess the presence of convergence
insufficiency.251 (Evidence Grade: D) Treatment of
convergence insufficiency has been associated with
reduction in the frequency of adverse academic
behaviors.65 (Evidence Grade B) 67

In addition to its relationship to the development ofstrabismus and amblyopia, hyperopia can also affect thedevelopment of literacy skills. Children with uncorrected
hyperopia show reduced performance in the acquisitionof emergent literacy skills.238 (Evidence Grade: C),243(Evidence Grade: C) Correction of hyperopia may, under
specific conditions, lead to increased reading speed;
therefore, eye examinations to diagnose uncorrected
hyperopia are recommended.244 (Evidence Grade: B)

Click to view the (AOA Clinical Practice Guidelines
web page)
EVIDENCE-BASED ACTION STATEMENT:
School-age children should receive an in-person
comprehensive eye and vision examination before
beginning school to diagnose, treat, and manage
any eye or vision conditions. 65, 115, 238, 243, 244, 251
Evidence Quality: Grade B. Prospective cohort
studies, Case-control study, Cross-sectional study.
Level of Confidence: Medium
Clinical Recommendation Strength: Strong
Recommendation. This recommendation should
be followed unless clear and compelling rationale
for an alternative approach is present.

An accommodative or vergence dysfunction can havea negative effect on a child’s school performance,
especially after third grade when the child must readsmaller print and reading demands increase. Children
with convergence insufficiency self-report more problems
compared to children with normal binocular vision.245
These include somatic (e.g., eyes hurt or headaches),visual (e.g., blur and diplopia), and performance (e.g.,loss of concentration, frequent need to re-read anddifficulty remembering what is read) problems. Due to thediscomfort of these symptoms, a child may not be able
to complete reading or homework assignments and may
be easily distracted or inattentive.
Studies have reported an association between readingand eye movements.246-248 Efficient reading requires
accurate eye movements. Treatment of children with eye

37

Evidence Statements: Children should receive
an eye examination at the beginning of primaryschool to diagnose the onset of myopia.115(Evidence Grade: B)

EVIDENCE-BASED ACTION STATEMENT:Children with myopia should have an in-person
comprehensive eye and vision examination atleast annually, or as frequently as recommended(especially until age 12), because of the potential
for rapid myopia progression.208, 242

Hyperopia can affect the development of literacy
skills. Children with uncorrected hyperopia
show reduced performance in the acquisition of
emergent literacy skills.238 (Evidence Grade: C),243(Evidence Grade: C)

Evidence Quality: Grade B. Randomized clinical
trial, Prospective cohort study
Level of Confidence: Medium
Clinical Recommendation Strength: Strong
Recommendation. This recommendation should
be followed unless clear and compelling rationale
for an alternative approach is present.

Correction of hyperopia may, under specificconditions, lead to increased reading speed;
therefore, eye examinations to diagnose
uncorrected hyperopia are recommended.244(Evidence Grade: B)

Evidence Statements: Children with myopia
should have an examination at least annually or as
frequently as their doctor recommends until theage of 12 because of rapid myopia progression.242(Evidence Grade: B)

Early diagnosis and treatment of an
accommodative or vergence problem may reduce
the negative impact on academic performance.65(Evidence Grade: B)

When both parents have myopia, children are
at higher risk for progression and should be
examined more than once per year.208 (Evidence
Grade: A)

Children with AD/HD or related learning problems
may benefit from comprehensive vision evaluation
to assess the presence of convergence
insufficiency.251 (Evidence Grade: D)

Potential Benefits:
Early identification andtreatment of eye andvision problems

Treatment of convergence insufficiency has been
associated with reduction in the frequency ofadverse academic behaviors.65 (Evidence Grade B)
Potential Benefits:
Early identification andtreatment of eye andvision problems

Potential Risks/Harms: None

Benefit and Harm Assessment: Benefits
significantly outweigh harms

Potential Risks/Harms: None

Potential Costs: Direct cost of testing andparent/caregiver time off from work
Value Judgments: None

Benefit and Harm Assessment: Benefits
significantly outweigh harms

Role of Patient Preferences: Moderate

Potential Costs: Direct cost of testing andparent/caregiver time off from work

Gaps in Evidence: None identified

Value Judgments: NoneCONSENSUS-BASED ACTION STATEMENT:
School-age children should receive an in-person
comprehensive eye and vision examination
annually to diagnose, treat, and manage any eye
or vision problems.

Intentional Vagueness: None

Role of Patient Preferences: Moderate
Intentional Vagueness: None
Gaps in Evidence: None identified

38

Evidence Quality: There is a lack of publishedresearch to support or refute the use of thisrecommendation.
Benefit and Harm Assessment: Implementing
this recommendation is likely to result in earlier
diagnosis and treatment of eye and vision
problems and improved visual function. The
benefits of this recommendation were establishedby expert consensus opinion.
c. At-risk Children
The extent to which a child is at risk for the developmentof eye and vision problems determines the appropriate
re-evaluation schedule. Children with ocular signs andsymptoms require a prompt comprehensive examination.
Furthermore, the presence of certain risk factors may
necessitate more frequent examinations based on
professional judgment. Factors placing an infant, toddler,or child at significant risk for eye and vision problems
include:•••Cortical visual impairment•

Difficult or assisted labor, which may be
associated with fetal distress•High or progressive refractive error•

Strabismus•

Anisometropia•

Academic performance problems

Systemic health conditions with potential ocular
manifestations•

Wearing contact lenses•

Having functional vision in only one eye•

Eye surgery or previous eye injury•

Taking prescription or nonprescription
drugs (e.g., over the counter medications,
supplements, herbal remedies) with potential
ocular side effects

Patient Age

Infection of mother during pregnancy (e.g.,rubella, toxoplasmosis, venereal disease,herpes, cytomegalovirus, or humanimmunodeficiency virus)••

Examination Interval

Family history of myopia, amblyopia, strabismus,
retinoblastoma, congenital cataracts, metabolic,or genetic disease

Maternal smoking, use of alcohol, or illicit druguse during pregnancy

Known or suspected neurodevelopmental
disordersTable 7: Recommended Eye Examination
Frequency for the Pediatric Patient**

Prematurity, low birth weight, prolonged
supplemental oxygen at birth••

Asymptomatic/
Low RiskAt-riskBirth through 2 years

At 6 to12 monthsof ageAt 6 to 12 monthsof age or asrecommended

3 through 5 years

At least once between
3 and 5 years of age

At least once between
3 and 5 years of age
or as recommended

6 through 18 years

Before first grade andannually thereafter

Before first grade
and annually, or
as recommended,
thereafter**The American Optometric Association Clinical
Practice Guidelines provide more information onother eye and vision disorders and their risk factors.
Click to view the (AOA Clinical Practice Guidelines
web page)
D. Conclusion
The prevalence of eye and vision disorders is substantial
in children. Research indicates that early detection andintervention are particularly important in children becauseof the rapid development of the visual system in earlychildhood and its sensitivity to interference. When visual
disorders such as amblyopia, strabismus, non-strabismicbinocular vision disorders, and significant refractive
error are undetected, the long-term consequences can39

lead to significant vision loss, decreased educationaland occupational opportunities, and reduced qualityof life. In addition, the cost of providing appropriate
treatment for longstanding eye and vision disorders may
be significantly higher than the cost of diagnosing andtreating these problems early in life. A comprehensive
pediatric eye and vision examination by a doctor of
optometry is imperative for the timely diagnosis andtreatment of eye and vision problems.

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2015; 92:279-85.
240. Dobson V, Clifford-Donaldson CE, Green TK, et al. Optical treatment reduces amblyopia in astigmatic children who
receive spectacles before kindergarten. Ophthalmology 2009; 116:1002-8.
241. Kemper AR, Wallace DK, Patel N, Crews JE. Preschool vision testing by health providers in the United States: findings
from the 2006-2007 Medical Expenditure Panel Survey. J AAPOS 2011; 15:480-83.
242. Comet Group. Myopia stabilization and associated factors among participants in the Correction of Myopia Evaluation
Trial (COMET). Invest Ophthalmol Vis Sci 2013; 54:7871-84.
243. Shankar S, Evans MA, Bobier WR. Hyperopia and emergent literacy of young children: pilot study. Optom Vis Sci 2007;
84:1031-38.
244. van Rijn LJ, Krijnen JS, Nefkens-Molster AE, et al. Spectacles may improve reading speed in children with hyperopia.
Optom Vis Sci 2014; 91:397-403.
245. Borsting E, Rouse MW, Deland PN, et al. Association of symptoms and convergence and accommodative insufficiency
in school-age children. Optometry 2003; 74:25-34.

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246. Kulp MT, Schmidt PP. Effect of oculomotor and other visual skills on reading performance: a literature review. Optom Vis
Sci 1996; 73:283-92.
247. Kulp MT, Schmidt PP. The relation of clinical saccadic eye movement testing to reading in kindergarteners and first
graders. Optom Vis Sci 1997; 74:37-42.
248. Solan HA, Larson S, Shelley-Tremblay J, et al. Role of visual attention in cognitive control of oculomotor readiness instudents with reading disabilities. J Learn Disabil 2001; 34:107-18.
249. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomaticconvergence insufficiency in children. Arch Ophthalmol 2008; 126:1336-49.
250. Granet DB, Gomi CF, Ventura R, Miller-Scholte A. The relationship between convergence insufficiency and ADHD.
Strabismus 2005; 13:163-68.
251. Rouse M, Borsting E, Mitchell GL, et al. Academic behaviors in children with convergence insufficiency with and withoutparent-reported ADHD. Optom Vis Sci 2009; 86:1169-77.

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V. APPENDIX
A. Appendix Figure 1
V. APPENDIX

A. APPENDIXFIGURE 1:
Comprehensive
Pediatric Eye and Vision Examination:

A Flowchart
Comprehensive Pediatric Eye and Vision Examination:
A Flowchart55

B. APPENDIX TABLE 1
Potential Components of the Comprehensive Eye and Vision Examination for Infants and Toddlers
A. Patient History
1. Nature and history of the presenting problem, including chief complaint
2. Visual and ocular history
3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgicaland/or head or ocular trauma history, and any vision or ocular treatment
4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter
medications, supplements, herbal remedies) and documentation of medication allergies
5. Family ocular and medical histories
6. Developmental history of the child
7. Time spent outdoors, on sports activities, and on near work and screen viewing
8. Names of, and contact information for, the patient’s other health care providers
B. Visual Acuity
1. Preferential looking visual acuity
2. Fixation preference test
3. Visual evoked potential
C. Refraction
1. Cycloplegic retinoscopy
2. Non-cycloplegic retinoscopy
D. Binocular Vision and Ocular Motility
1. Ocular alignment assessment (e.g., cover test, Hirschberg test, Krimsky test)
2. Brückner test
3. Stereopsis (e.g., Preschool Assessment of Stereopsis with a Smile 3 test)
4. Near point of convergence
5. Ocular motility assessment (e.g., versions, eye tracking)E. Ocular and Systemic Health Assessment
1. Assessment of pupillary responses
2. Visual field evaluation (e.g., confrontation)
3. Evaluation of the ocular anterior segment and adnexa
4. Evaluation of the ocular posterior segment
5. Measurement of intraocular pressure56

C. APPENDIX TABLE 2
Potential Components of the Comprehensive Eye and Vision Examination for Preschool Children
A. Patient History
1. Nature and history of the presenting problem, including chief complaint
2. Visual and ocular history
3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgicaland/or head or ocular trauma history, and any vision or ocular treatment
4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter
medications, supplements, herbal remedies) and documentation of medication allergies
5. Family eye and medical histories
6. Developmental history of the child
7. Time spent outdoors, on sports activities, and on near work and screen viewing
8. Names of, and contact information for, the patient’s other health care providers
B. Visual Acuity
1. Symbol optotype or letter matching visual acuity measurement
C. Refraction
1. Static (distance) retinoscopy
2. Cycloplegic retinoscopy
3. Autorefraction
D. Binocular Vision, Ocular Motility, and Accommodation
1. Ocular alignment assessment - distance and near (e.g., cover test, Hirschberg test, Krimsky test)
2. Ocular motility assessment
3. Near point of convergence
4. Stereopsis (e.g., Preschool Assessment of Stereopsis with a Smile 3 test, Randot Preschool test)
5. Positive and negative fusional vergence ranges
6. Accommodative testing (e.g., dynamic retinoscopy)
E. Color vision testingF.

Ocular and Systemic Health Assessment
1. Assessment of pupillary responses
2. Visual field evaluation (e.g., confrontation)
3. Evaluation of the ocular anterior segment and adnexa
4. Evaluation of the ocular posterior segment
5. Measurement of intraocular pressure

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D. APPENDIX TABLE 3
Potential Components of the Comprehensive Eye and Vision Examination for School-age Children
A. Patient History
1. Nature and history of the presenting problem, including chief complaint
2. Visual and ocular history
3. General health history, including prenatal, perinatal, and postnatal history and review of systems, surgicaland/or head or ocular trauma history, and any vision or ocular treatment
4. Medication reconciliation, including prescription and nonprescription drugs (e.g., over the counter
medications, supplements, herbal remedies) and documentation of medication allergies
5. Family eye and medical histories
6. Developmental history of the child
7. School performance history
8. Time spent outdoors, on sports activities, and on near work and screen viewing
9. Names of, and contact information for, the patient’s other health care providers
B. Visual Acuity
1. Snellen visual acuity
2. ETDRS visual acuity
C. Refraction
1. Static (distance) retinoscopy
2. Cycloplegic retinoscopy
3. Subjective refraction
4. Autorefraction
D. Binocular Vision, Ocular Motility, and Accommodation
1. Ocular alignment assessment - distance and near (e.g., cover test, Hirschberg test, Krimsky test, Von Graefe
phoria, Modified Thorington, Maddox Rod)
2. Ocular motility assessment (e.g., fixation, saccades, pursuits)
3. Near point of convergence
4. Stereopsis (e.g., Random dot stereopsis test)
5. Positive and negative fusional vergence ranges
6. Accommodative testing (e.g., amplitude, facility, and response)
E. Color Vision TestingF.

Ocular and Systemic Health Assessment
1. Assessment of pupillary responses
2. Visual field evaluation (e.g., confrontation)
3. Evaluation of the ocular anterior segment and adnexa
4. Evaluation of the ocular posterior segment
5. Measurement of intraocular pressure58

E. APPENDIX TABLE 4
Partial Listing of Ocular Manifestations of Neurodevelopmental Disorders and Other Syndromes

Neurodevelopmental Disorders

Etiology

Associated Ocular Manifestations

Aicardi Syndrome

Dysgenesis of the corpus callosum

Chorioretinal lacunae, optic nerve colobomas,
optic nerve hypoplasia

Alport Syndrome

Irregular synthesis of collagen

Fleck retinal dystrophy, anterior lenticonus,
corneal dystrophy, cataracts

Angelman Syndrome

Deletion of maternal genetic material on
chromosome 15

Strabismus, hypopigmentation of the choroid

Attention Deficit/Hyperactivity Disorder

Genetic influences on dopaminergic systems,
prenatal factors such as maternal use of drugs
and alcohol

Convergence insufficiency, accommodative
dysfunction, oculomotor disorders

Autism Spectrum Disorders

Unknown; possible link to environmental
stressors, genetic mutations and inflammatory
processes

Deficits in visual acuity, stereoacuity and ocularalignment; poor saccades and pursuits

Bardet-Biedl Syndrome

Mutation in 14 different genes that lead toproblems with the function of cilia in cellstructures

Reduced visual acuity, problems with night vision,tunnel vision

Batten-Mayou Syndrome

Autosomal recessive disorder resulting inaccumulation of lipids

Lipofuscin accumulation in the retina, optic
atrophy, macular pigment

Behçet’s Disease

Postulated to be episodic hyperactivity of immune
systemUveitis, cataracts, optic atrophy, macular edema

Behr Syndrome

Autosomal recessive disease resulting inprogressive deterioration of the nervous system

Optic atrophy, retrobulbar neuritis, nystagmus

Branchial Arch Syndrome

Disruption of neural crest cell migration

Strabismus, proptosis from poorly formed orbits,
coloboma of the eyelid

Cerebral Palsy

Disorder of movement and posture secondary todamage to motor control connections

Strabismus, nystagmus, optic nerve pallor,cataracts, myopia, accommodative dysfunction

Cerebro-oculo-facial Syndrome

Autosomal recessive disorder resulting in
defective swallowing mechanism

Microphthalmia, involuntary eye movements,
congenital cataracts, blepharophimosis

Charot-Marie-Tooth Syndrome

Genetic anomaly resulting in progressive muscular Nystagmus, diminished visual acuity
atrophy

CHARGE Syndrome

Common mutation of chromosome 8 resulting inassociation of multiple systemic defects

Bilateral retinal coloboma involving the optic
nerve, strabismus, amblyopia

Cri-du-chat Syndrome

Deletion of short arm of chromosome 5

Strabismus, hypertelorism, slanting of thepalpebral fissure

Dandy-Walker syndrome

Absence of the cerebellar vermis and dilation of
fourth ventricle

Papilledema often seen with hydrocephalus,
ptosis and strabismus secondary to cranial nervepalsy

de Lange Syndrome

Mutation in genes responsible for chromosomal
adhesionsLong eyelashes, ptosis telecanthus, alternating
exotropia

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Neurodevelopmental Disorders

Etiology

Associated Ocular Manifestations

Down Syndrome

Triplicate 21st chromosome

Epicanthal folds, upslanting palpebral fissure,high refractive error, strabismus, keratoconus,
blepharitis, accommodative dysfunction/
insufficiency

Dubowitz Syndrome

Unknown etiology

Strabismus, ptosis, telecanthus, epicanthal folds

Ehlers-Danlos Syndrome

Genetic or nutritional defects that have altered the Lens subluxation, palpebral skin laxity,
biosynthesis of collagen
keratoconus, myopia, blue sclera, angiod streaks

Fabry Disease

Inherited disorder resulting from an abnormalbuild-up of fat in the blood vessel walls
throughout the bodyCorneal opacity

Fetal Alcohol Syndrome

CNS damage secondary to alcohol crossing theblood-brain barrier

Telecanthus, strabismus, optic nerve hypoplasia,
ptosis, microphthalmia

Fragile X Syndrome

Gene (FMR1) on the X chromosome fails toallow protein synthesis necessary for neuraldevelopment

Strabismus, astigmatism, amblyopia

Gaucher Disease

Lysomal storage disease

Strabismus, gaze palsies, corneal clouding,pinguecula

Hunter Syndrome

Mucopolysaccharidosis l – Lysomal storage
diseaseCorneal clouding, pigmentary degeneration of theretina, optic atrophy

Lowe Syndrome

Abnormal protein transport within cellular
membranes

Bilateral congenital cataracts, glaucoma, corneal
keloids, strabismus

Marfan Syndrome

Genetic disorder affecting the body’s connective
tissueSevere nearsightedness, dislocated lens,detached retina, glaucoma, cataracts

Prader-Willi Syndrome

Deletion of paternal genetic material on
chromosome 15

Strabismus, almond-shaped palpebral fissures,
myopiaRett Syndrome

Mutation of binding protein (MECP2) that alters
the development of gray matter

Difficulty maintaining eye contact

Septo-Optic Dysplasia/DeMorsier Syndrome

Disorder of early brain/optic nerve development
associated with a number of environmental andgenetic factors

Visual impairment in one or both eyes, nystagmus,
strabismus

Spina Bifida

Incomplete closure of embryonic neural tube

Papilledema, nerve palsies, nystagmus, optic
atrophy

Stickler Syndrome

Defective biosynthesis of collagen

Myopia, retinal detachments, vitreous anomalies

Usher Syndrome

Inherited autosomal recessive trait

Retinitis pigmentosa

Williams Syndrome

Vast deletion of genes on chromosome 7

Infantile esotropia, anomaly in visual-spatial
relationship

Source: Adapted from Table 7.1 Rare Neurodevelopmental Disorders in Taub MB, Bartuccio M, Maino DM.
Visual Diagnosis and Care of the Patient with Special Needs. Lippincott Williams & Wilkins, Philadelphia, PA,
2012.

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F. ABBREVIATIONS/ACRONYMS
ADA
AD/HD
AHRQ
COI
CE
CI
CLEERE
CPG
CT
CVI
D
DR
EBO
ERG
ETDRS
G
GAT
GDG
GDRG
IDEA
IEP
IOM
IOP
MRI
NPC
NRA
OCT
PASS
PRA
RCT
ROP
RP
SE
SR
TOPEL
VEP
UV
VIP-HIP

Americans with Disabilities Act
Attention Deficit/Hyperactivity Disorder
Agency for Healthcare Research and Quality
Conflict of interest
Convergence excess
Convergence insufficiency
Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error
Clinical Practice Guideline
Computerized tomography
Cortical (cerebral) visual impairment
Diopter
Diabetic retinopathy
Evidence-Based Optometry
Electroretinogram
Early Treatment of Diabetic Retinopathy Study
Grams
Goldmann applanation tonometer
Guideline Development Group
Guideline Development Reading Group
Individuals with Disabilities Education Act
Individualized Education Program
Institute of Medicine
Intraocular pressure
Magnetic resonance imaging
Near point of convergence
Negative relative accommodation
Optical coherence tomography
Preschool Assessment of Stereopsis with a Smile
Positive relative accommodation
Randomized clinical trial
Retinopathy of prematurity
Retinitis pigmentosa
Spherical equivalent
Systematic review
Test of Preschool Early Literacy
Visual evoked potential
Ultraviolet
Vision in Preschoolers-Hyperopia in Preschoolers

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G. SUMMARY OF ACTION STATEMENTS
A comprehensive pediatric eye and vision examination should include, but is not limited to:•

Review of the nature and history of the presenting problem, patient and family eye and medical histories,
including visual, ocular, general health, leisure and sports activities, and developmental and school performance
history of the child•

Measurement of visual acuity•

Determination of refractive status•

Assessment of binocular vision, ocular motility, and accommodation•

Evaluation of color vision (baseline or periodic, if needed, for qualification purposes or if disease related)•

Assessment of ocular and systemic health, including evaluation of pupillary responses, anterior and posterior
segment, peripheral retina, and evaluation/measurement of intraocular pressure and visual field testing.
(Consensus)

Cycloplegic retinoscopy is the preferred procedure for the first evaluation of preschoolers. It is necessary to quantify
significant refractive error in the presence of visual conditions such as strabismus, amblyopia, and anisometropia.
(Consensus)

Cycloplegic retinoscopy is the preferred procedure for the first evaluation of school-age children. It is necessary
to quantify significant refractive error in the presence of visual conditions such as strabismus, amblyopia, andanisometropia. (Consensus)

Abnormal color vision can affect daily performance of activities involving color discrimination and may interferewith or prevent some occupational choices later in life. Children should be tested as soon as possible for color
vision deficiency and the parents/caregivers of children identified with color vision deficiency should be counseled.
(Consensus)Children at risk for learning-related vision problems should be evaluated by a doctor of optometry. (Consensus)

Many children with developmental or intellectual disabilities have undetected and untreated vision problems andshould receive a comprehensive pediatric eye and vision examination. (Consensus)

At the conclusion of a comprehensive pediatric eye and vision examination, the diagnosis should be explained tothe patient/parent/caregiver and related to the patient’s symptoms, and a treatment plan and prognosis discussed.
(Consensus)

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Parents/caregivers and children should be educated about potential risks for eye injuries at home, at school,and during sports and recreational activities, and advised about safety precautions to decrease the risk of ocular
injury.193,199 Prevention of eye injuries in children should focus on the use of protective eyewear, parental supervision,and include education about both the risks of eye injury and the benefits of protective eyewear.194 (Evidence Grade B/
Strong Recommendation)

All children and their parents/caregivers should be advised about the benefits of the regular use of sunglasses and/or clear prescription glasses that effectively block at least 99% of UVA and UVB radiation, the use of hats with brims
when outdoors, and the importance of not looking directly at the sun. (Consensus)

Patients/parents/caregivers should be counseled about the benefits to children’s vision of spending more time
outdoors.208-211 (Evidence Grade B/Recommendation)

Infants should receive an in-person comprehensive eye and vision assessment between 6 and 12 months of age
for the prevention and/or early diagnosis and treatment of sight-threatening eye conditions and to evaluate visualdevelopment.229-231 (Evidence Grade B/Strong Recommendation)

Preschool age children should receive an in-person comprehensive eye and vision examination at least once
between the ages of 3 and 5 to prevent and/or diagnose and treat any eye or vision conditions that may affect visualdevelopment.54,107,238,240,241 (Evidence Grade B/Strong Recommendation)

School-age children should receive an in-person comprehensive eye and vision examination before beginningschool to diagnose, treat and manage any eye or vision conditions.65,115,238,243,244,251 (Evidence Grade B/Strong
Recommendation)

Children with myopia should have an in-person comprehensive eye and vision examination at least annually, or as
frequently as recommended (especially until age 12), because of the potential for rapid myopia progression.208,242(Evidence Grade B/Strong Recommendation)

School-age children should receive an in-person comprehensive eye and vision examination annually to diagnose,
treat, and manage eye or vision problems. (Consensus)

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H. GAPS IN RESEARCH EVIDENCE
During the course of the development of this guideline, the Evidence-Based Optometry Guideline Development
Group identified the following gaps in evidence as potential areas for future research:•

Research to compare the outcomes of vision screenings versus comprehensive eye and vision examinations•

Research to determine the risks and protective factors associated with eye injuries in children in order to design
appropriate prevention strategies•

Research on the effects and possible interaction of outdoor activity with near work and myopia in children.

VI. METHODOLOGY FOR GUIDELINE DEVELOPMENT
This guideline was developed by the AOA Evidence-Based Optometry Guideline Development Group (GDG). Clinicalquestions to be addressed in the guideline were identified and refined during an initial meeting of the GDG and served
as the basis for a search of the clinical and research literature.
An English language search of the medical literature for the eye and vision examination of children birth through 18
years of age, for the time period January 2005 through October 2016 was conducted by trained researchers. If thesearch did not produce results, the search parameters were extended an additional 5 years.
Search Inclusion Criteria (must meet all):
1. English Studies
2. Study addresses the clinical question(s)3. Paper meets the age group being addressed (0 to 18 years for pediatrics)
4. Searched by question(s) formulated at the AOA Call to Question Meeting attended by the Guideline
Development Group (GDG)
5. Using all similar and relevant terms as defined by the GDG
Exclusion Criteria (meeting any of the below):
1. Non-English studies
2. Animal studies
3. Studies outside of the patient age range
4. Studies not addressing any topic of the clinical questions searched64In addition, a review of selected earlier research publications was conducted based on previous versions of thisguideline. The literature search was conducted using the following electronic databases:

2942

•

Agency for Healthcare Research and Quality(AHRQ)•

Google Scholar•

JAMA Ophthalmology•

American Academy of Optometry (AAO)•

Journal of Adolescent Health Care (JAHC)•

American Academy of Neurology•

Medline Plus•

American Association for Pediatric
Ophthalmology and Strabismus (AAPOS)•

National Eye Institute•American Journal of Optometry andPhysiological Optics•

National Institute of Health Public Access (NIH)•

National Guideline Clearinghouse•

Centers for Disease Control and Prevention,
National Center for Health Statistics•

Neurology•

Ophthalmic Epidemiology•

Cochrane Library•

Ophthalmology•

Developmental Medicine & Child Neurology(DMCN)•

PubMed•Elsevier•

Other medical journals meeting the search
criteria will be included in this list when used•

Epidemiology

The literature search resulted in the retrieval of the number of references shown in the following chart.

2943
2944
2945

65

All references meeting the criteria were reviewed to determine their relevance to the clinical questions
addressed in the guideline. Each article was assigned to two clinicians who independently reviewed

All references meeting the criteria were reviewed to determine their relevance to the clinical questions addressedin the guideline. Each article was assigned to two clinicians who independently reviewed and graded the quality ofevidence and the clinical recommendations derived from the article, based on a previously defined system for grading
quality. If discrepancies were found in the grading results, the article was assigned to an independent third reader for
review and grading.
During six articulation meetings (three face-to-face and three using a Webex platform) of the Evidence-Based
Optometry Guideline Development Reading Group (GDRG), all evidence was reviewed and clinical recommendations
were developed. The strength level of clinical recommendations was based on the quality grade of the researchand the potential benefits and harms of the procedure or therapy recommended. Where high quality evidence tosupport a recommendation was weak or lacking, a group consensus was required to approve any consensus
recommendations.
Review and editing of the draft guideline by the Evidence-Based Optometry GDG required one face- to-face meetingand three additional Draft Reading Meetings using a Webex platform. The final Peer Review draft was reviewed andapproved by the GDG by conference call, then made available for peer and public review for 30 days for numerous
stakeholders (individuals and organizations). Comments were promoted and encouraged. All suggested revisions
were reviewed and, if accepted by the GDG, incorporated into the guideline. All peer and public comments and allactions (and inactions) were recorded.
Clinical recommendations in this guideline are evidence-based statements regarding patient care that are supportedby the scientific literature or consensus of professional opinion when no quality evidence was discovered. The
guideline will be periodically reviewed for new scientific and clinical evidence within 3-5 years.

VII. EVIDENCE-BASED OPTOMETRY GUIDELINE DEVELOPMENT GROUPAOA Evidence-Based Optometry Committee
Diane T. Adamczyk, O.D., Chair – State University of New York, College of Optometry, New York, New YorkJohn F. Amos, O.D., M.S. – University of Alabama at Birmingham School of Optometry, Birmingham, Alabama, Dean andProfessor Emeritus
Felix M. Barker, II, O.D., M.S. – W. G. (Bill) Hefner VAMC, Salisbury, North Carolina
Benjamin P. Casella, OD – Private Practice – Casella Eye Center, Augusta, Georgia
Linda M. Chous, O.D. – United HealthCare Services, Inc., Minneapolis, Minnesota
Lynn D. Greenspan, O.D. – Salus University, Pennsylvania College of Optometry, Elkins Park, Pennsylvania
Lori L. Grover, O.D., Ph.D. – Health Policy, King-Devick Technologies, Inc., Oakbrook Terrace, Illinois
Tina R. MacDonald, O.D. – The Center for the Partially Sighted, Culver City, California
Harue J. Marsden, O.D., M.S. – Southern California College of Optometry, Marshall B. Ketchum University, Fullerton,
California
David K. Masihdas, O.D. – Utah Eye Associates - The Diabetic Eye Center, Salt Lake City, Utah

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Bennett McAllister, O.D. – Western University of Health Sciences, College of Optometry, Pomona, California
Trennda L. Rittenbach, O.D. – Palo Alto Medical Foundation/Sutter Health, Sunnyvale, California
Carl J. Urbanski, O.D. – Private Practice, Family Vision Care of Kingston, Kingston, Pennsylvania

Multidisciplinary and Patient Stakeholders
Ida Chung, O.D. – Western University of Health Sciences, College of Optometry, Pomona, California
Beth T. Dessem – Patient Advocate; Missouri CASA Association, Columbia, MissouriDavid E. Hartenbach, M.D. – Pediatrician; Creve Coeur Pediatrics, Creve Coeur, Missouri
Janet Hughes – Patient (parent); Vision First Foundation, Lemont, Illinois
Mitchell M. Scheiman, O.D. – Salus University, The Eye Institute of Pennsylvania College of Optometry, Elkins Park,
Pennsylvania

Non-voting Members
Stephen C. Miller, O.D., Chief Editor - Innovative Writing Works, St. Louis, Missouri
Beth A. Kneib, O.D., AOA Director of Clinical Resources, American Optometric Association, St. Louis, Missouri
Andrew Morgenstern, O.D., AOA Consultant for Evidence-Based Optometry, American Optometric Association, Alexandria,
VA
Danette Miller, AOA Manager of Quality Improvement, American Optometric Association, St. Louis, Missouri
Alisa G. Krewet, AOA Quality Improvement Coordinator, American Optometric Association, St. Louis, Missouri

67