TABLE 1

Eye Examination Guidelines

FunctionRecommended TestsReferral CriteriaComments
Newborn to 6 mo
Vision assessmentFixation and follow responseInconsistent or no response by 3 mo
Ocular media clarityRed reflexWhite, pupil, dark spots, absent or asymmetric reflex
External inspectionDirect observationAny ocular abnormality of concern
6 to 12 mo
Pupil examinationFlashlightAs above for ages newborn to 6 mo, plus
Ages 1–3 y
As above for ages 6 mo to 12 mo, plus
Instrument-based vision screening when available (CPT 99174)PhotoscreeningFailed screening as indicated by the device
Autorefraction
Distance visual acuity may be attempted at age 3 yHOTV or LEA SymbolsFewer than a simple majority of optotypes correct on the 10/25 (20/50) line with either eye tested monocularly at 10 ft
Ages 4–5 y
Distance visual acuity or instrument-based screening when available (CPT 99173)HOTV or LEA symbolsA simple majority of figures correct on the age-appropriate critical line with either eye tested monocularly at 10 ft1. Use a well-illuminated area free from distraction.
2. Either critical line testing or threshold testing may be used (see text for details).
3. Testing distance of 10 ft is recommended for all visual acuity tests.
4. A line of figures is preferred over single figures, unless the single figures are “crowded” (see text).
5. The fellow eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to the eye; the examiner should determine that it is not possible to peek with the nontested eye.
Ages:
48–59 mo: 10/20 (=20/40)
60+ mo: 10/15 (=20/30)
or
For threshold testing only: a 2-line difference between eyes, even with the passing range; eg, 20/15 (20/30) and 10/10 (20/20) for a 60-mo-old
Ocular alignmentCross cover testAny eye movementChild must be fixing on a target while cross cover test is performed.
Any asymmetry of pupil color, size, brightnessDirect ophthalmoscope used to view both red reflexes simultaneously in a darkened room from 2–3 feet away; detects asymmetric refractive errors as well.
Ocular media clarityRed reflexWhite pupil, dark spots in pupil, absent red reflexDirect ophthalmoscope, darkened room. View each red reflex separately at 12–18 inches; white reflex indicates possible retinoblastoma. Dark or absent reflex indicates possible cataract.
Ages ≥6 y
Distance visual acuity; instrument-based screening when available for children unable to perform acuitySloan letters or Snellen lettersFewer than a simple majority of optotypes correct on the 10/15 (20/30) line with either eye tested monocularly at 10 ft1. Tests are listed in decreasing order of cognitive difficulty; the highest test that the child is capable of performing should be used.
HOTV or LEA symbols2. Use a well-illuminated area free from distraction.
3. Either critical line testing or threshold testing may be used (see text for details).
4. Testing distance of 10 ft is recommended for all visual acuity tests.
5. A line of figures is preferred over single figures unless the single figures are “crowded” (see text).
6. The fellow eye should be covered by an occluder held by the examiner or by an adhesive occluder patch applied to the eye; the examiner should determine that it is not possible to peek out of the covered eye.
or
For threshold testing: only: a 2-line difference between eyes, even within the passing range; eg, 10/10 (20/20) and 10/15 (20/30)
Any eye movementSimultaneous red reflex test (Bruckner test).
Child must be fixing on a target while cross cover test is performed.
Ocular media clarityRed reflexWhite pupil, dark spots, absent reflexDirect ophthalmoscope, darkened room. View each red reflex separately at 12–18 inches; white reflex indicates possible retinoblastoma. Dark or absent reflex indicates possible cataract.