January 2016, VOLUME137 /ISSUE 1

Visual System Assessment in Infants, Children, and Young Adults by Pediatricians

    1. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    2. Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    3. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    4. All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.


    Appropriate visual assessments help identify children who may benefit from early interventions to correct or improve vision. Examination of the eyes and visual system should begin in the nursery and continue throughout both childhood and adolescence during routine well-child visits in the medical home. Newborn infants should be examined using inspection and red reflex testing to detect structural ocular abnormalities, such as cataract, corneal opacity, and ptosis. Instrument-based screening, if available, should be first attempted between 12 months and 3 years of age and at annual well-child visits until acuity can be tested directly. Direct testing of visual acuity can often begin by 4 years of age, using age-appropriate symbols (optotypes). Children found to have an ocular abnormality or who fail a vision assessment should be referred to a pediatric ophthalmologist or an eye care specialist appropriately trained to treat pediatric patients.


    This policy statement and its accompanying clinical report, “Procedures for the Evaluation of the Visual System by Pediatricians,”1 supplant the 2012 policy statement “Instrument-Based Pediatric Vision Screening,”2 the 2003 policy statement “Eye Examination in Infants, Children, and Young Adults by Pediatricians,”3 and the policy statement “Red Reflex Examination in Neonates, Infants, and Children.”4 This statement is coauthored by the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists.

    Eye examinations and vision assessments are critical for the detection of conditions that often result in visual impairment, signify serious systemic disease, lead to problems with school performance, and, in some cases, threaten the child’s life. Through careful evaluation of the visual system, retinal abnormalities, cataracts, glaucoma, retinoblastoma, strabismus, and neurologic disorders, including amblyopia, can be identified. Ocular problems can also be the first indicator of general health concerns. Timely treatment of these conditions is critical, as is the education of parents with respect to the importance of timely follow-up and documentation in the medical record that the education occurred. Regular vision screening assessments in early childhood reduce the risk of persistent amblyopia at 7 years of age by more than 50%.5 However, vision screening cannot be expected to detect all causes of amblyopia.

    Timing of Examinations And Screening

    Preterm infants should initially be evaluated under the guidance of the American Academy of Pediatrics policy statement “Retinopathy of Prematurity Screening”6 and referred for a specialized eye examination by an ophthalmologist experienced in evaluating and treating infants, if required. Similar referral to a specialist should be made for newborn infants with family histories of congenital cataracts, retinoblastoma, or metabolic disease or in whom systemic disease associated with serious ocular abnormalities is suspected. Because family history is an important risk factor for amblyopia and strabismus, pediatric clinicians should consider referring children who have first-degree relatives with these conditions; referral should take place promptly if symptoms or signs are present and, if not, once a child is of sufficient age to cooperate for examinations.7 Otherwise healthy children should be screened in the primary care setting at the intervals provided in Table 1. Because ocular problems can be the initial manifestation of neurologic or systemic disease, pediatricians should be aware of subtle but important findings that can be detected through screening or careful examination of the ocular system. A history of epiphora associated with photophobia or the presence of cloudy or enlarged corneas should prompt timely referral to rule out glaucoma. Ptosis, when associated with anisocoria, can be the harbinger of neuro-ophthalmologic disease and should also warrant referral. A bright or yellow red reflex or, conversely, a dull or absent red reflex, can be an indication of a significant abnormality that necessitates further evaluation by a pediatric eye care specialist. Details of the history and examination procedures are provided in the accompanying clinical report.

    TABLE 1

    Periodicity Schedule for Visual System Assessment in Infants, Children, and Young Adults

    Instrument-based screening devices for vision screening are available commercially and have had extensive validation, both in field studies811 and, more recently, in the pediatrician’s offices.12,13 Screening instruments detect amblyopia, high refractive error, and strabismus, which are the most common conditions producing visual impairment in children.14,15 If available, they can be used at any age but have better success after 18 months of age.9,16 Instrument-based screening can be repeated at each annual preventive medicine encounter through 5 years of age or until visual acuity can be assessed reliably using optotypes. Using these techniques in children younger than 6 years can enhance detection of conditions that may lead to amblyopia and/or strabismus compared with traditional methods of assessment.12 The recent US Preventive Services Task Force statement supporting the use of these technologies for preschool vision screening17 should prove useful in ensuring adequate payment for these services.

    The use of optotype-based (traditional) acuity algorithms remains current practice for children aged 4 years and older. Acuity screening becomes more reliable and efficient in children aged 6 years and older. Details regarding the techniques for evaluating visual acuity with optotype-based screening are provided in the accompanying clinical report.1 Instrument-based screening may be a helpful alternative in screening developmentally delayed children of any age.18

    Procedures for Eye Evaluation

    Detailed explanations for obtaining the visual system history and examining the afferent and efferent visual system in infants and children are provided in the accompanying clinical report on visual assessment in the infant and children.1


    Evaluation of the visual system should begin in infancy and continue at regular intervals throughout childhood and adolescence. Serial visual system screenings in the medical home, using validated techniques, provide an effective mechanism for the detection and subsequent referral of potentially treatable visual system disorders.

    Lead Authors

    Sean P. Donahue, MD, PhD, FAAP

    Cynthia N Baker, MD, FAAP

    AAP Committee on Practice and Ambulatory Medicine, 2014-2015

    Geoffrey R. Simon, MD, FAAP, Chairperson

    Cynthia N Baker, MD, FAAP

    Graham Arthur Barden, III, MD, FAAP

    Oscar W. “Skip” Brown, MD, FAAP

    Jesse M. Hackell, MD, FAAP

    Amy Peykoff Hardin, MD, FAAP

    Kelley E. Meade, MD, FAAP

    Scot B. Moore, MD, FAAP

    Julia Richerson, MD, FAAP


    Elizabeth Sobczyk, MPH, MSW

    AAP Section on Ophthalmology Executive Committee, 2014-2015

    Sharon S. Lehman, MD, FAAP, Chairperson

    Daniel J. Karr, MD, FAAP, Chairperson-Elect

    Geoffrey E. Bradford, MD, FAAP

    Steven E. Rubin, MD, FAAP

    R. Michael Siatkowski, MD, FAAP

    Donny Won Suh, MD, FAAP

    David B. Granet, MD, FAAP, Immediate Past Chairperson


    Shelley Klein, CO – American Association of Certified Orthoptists

    Christie Morse, MD, FAAP – American Association of Pediatric Ophthalmology and Strabismus

    Pamela E. Williams, MD, FAAP – American Academy of Ophthalmology

    Gregg T. Lueder, MD, FAAP – American Academy of Ophthalmology Council

    C. Gail Summers, MD – American Academy of Ophthalmology

    George S. Ellis, Jr, MD, FAAP – Section Historian


    Jennifer G. Riefe, MEd


    The lead author thanks Drs James B. Ruben, MD, FAAP, and Geoffrey E. Bradford, MD, FAAP, for assistance in drafting and editing this document.