Indian Journal of Ophthalmology

: 2018  |  Volume : 66  |  Issue : 7  |  Page : 889--892

Pediatric eye screening – Why, when, and how

Santosh G Honavar 
 Editor, Indian Journal of Ophthalmology, Editorial Office: Centre for Sight, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana, India

Correspondence Address:
Santosh G Honavar
Editor, Indian Journal of Ophthalmology, Editorial Office: Centre for Sight, Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana

How to cite this article:
Honavar SG. Pediatric eye screening – Why, when, and how.Indian J Ophthalmol 2018;66:889-892

How to cite this URL:
Honavar SG. Pediatric eye screening – Why, when, and how. Indian J Ophthalmol [serial online] 2018 [cited 2023 Feb 5 ];66:889-892
Available from:

Full Text

The World Health Organization (WHO) reports that there are approximately 19 million visually impaired children in the world, and 1.4 million are blind.[1] In India, 0.8 per 1000 children are estimated to be blind.[2] This is bound to be an underestimation of the overall problem because it excludes children with visual impairment that does not conform to the WHO definition of blindness. About half of the causes of blindness and visual impairment are potentially preventable or treatable.[2] Childhood blindness is second only to adult cataract in terms of the number of blind person years lived and the consequent overall economic impact on the society.[2]

Timely and periodic screening is critical for the detection of visual impairment and its etiology and to plan early intervention. Appropriate estimation of the visual function, and detection of refractive error, retinopathy of prematurity, congenital structural anomalies, congenital dacryocystitis, corneal scar, glaucoma, cataract, retinal abnormalities, retinoblastoma, strabismus, and amblyopia are the crucial components of screening in children. Protocols vary from country to country, with limited agreement on the need, modality, timing and periodicity of screening.[3],[4],[5],[6] While some countries and organizations have mandated screening at birth and thereafter periodically at every pre-scheduled point of contact with the pediatrician,[3],[4],[5],[6] recent recommendations by the United States Preventive Services Task Force (USPSTF) limit screening to children aged 3–5 years to detect amblyopia or its risk factors.[7] The USPSTF advises that the current evidence is insufficient to recommend vision screening in children <3 years of age.[7] However, a Joint Policy Statement by the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association of Certified Orthoptists emphasises that vision assessments and screening eye examinations are critical for the detection of conditions that result in visual impairment, lead to problems with school performance, harbinger serious systemic disease, and, in some cases, threaten the child's life.[8],[9] The incidence and prevalence of conditions causing visual morbidity varies widely across the world [Table 1].[10] Unfortunately, the available data on pediatric vision impairment and blindness in India are not broad-based or robust enough to generalize and make firm recommendations.[2] Glaringly, there are no formal Indian national guidelines for vision and eye screening in children.{Table 1}

Guidelines for pediatric eye screening continue to evolve as timing and methods have not been definitively established. Current guidelines are based on the available evidence and preferred practice recommendations of expert committees.[8],[9],[10] Primary care providers (pediatricians) should perform a basic eye screening of newborns.[8],[9],[10] Risk-based screening for retinopathy of prematurity, congenital anomalies, and retinoblastoma in the immediate post-natal period should be conducted by an ophthalmologist.[8],[9],[10] Pre-screening history should include the following questions: (1) Do your child's eyes appear unusual, (2) Does your child seem to see well, (3) Does your child exhibit difficulty with near or distance vision, (4) Do your child's eyes appear straight or do they seem to cross, (5) Do your child's eyelids droop or does one eyelid tend to close, and (6) Has your child ever had an eye injury.[8],[9],[10] Screening of infants under 6 months of age comprises of red reflex testing to detect abnormalities of the ocular media, external inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior.[10],[11] Findings that would warrant referral of children to an ophthalmologist for a detailed eye examination following screening are listed in [Table 2].[10],[11] Screening from 6 months to 1 year includes binocular alignment.[10],[11] Between 1 year to 2 years and 2 years to 3 years, instrument-based screening with photoscreening or autorefraction devices can be valuable in detecting amblyopia risk factors.[10],[11] These tests are rapid and non-invasive, and minimal cooperation is required on the part of the child.[10],[11] Between ages 3 and 4 years, visual acuity screening with LEA symbols or HOTV letter chart become possible.[10],[11] Older children may be tested with standard optotypes.[10],[11] Children who are untestable should be rescreened within 6 months or referred for a comprehensive eye examination.[10],[11] Children who are testable using the subjective visual acuity assessment and fail should be referred for a comprehensive eye examination after the first screening failure.[10],[11] Additional findings that would warrant referral of for a comprehensive ophthalmic examination are listed in [Table 2].[10],[11] Children should continue to have annual school-based vision screening throughout the childhood and adolescence.[10],[11] In India, screening up to age 5 years could be integrated with the Universal Immunization Program of the Government of India and performed by a trained ophthalmic assistant or an optometrist. Beyond the age of 5 years, it should be a part of annual school health check-up and performed by a trained ophthalmic assistant or an optometrist.{Table 2}

This issue of the Indian Journal of Ophthalmology carries several articles that address various issues related to vision screening in children, which indicates that there is renewed enthusiasm in Indian caregivers and researchers to study this aspect.[12],[13],[14],[15],[16] If India must relieve itself of the burden of avoidable pediatric blindness and provide the benefit of early rehabilitative intervention to those who are incurably blind, then it is imperative to accumulate reliable population-based data and use that as a base to craft a robust screening program, seamlessly linked to curative and rehabilitation facilities. A working group representing all the stakeholders seems to be an immediate primary need to prioritize this issue.


1World Health Organisation. Global data on visual impairments 2010. Available from: [Last accessed on 2018 June 19].
2Gudlavalleti, VSM. Magnitude and Temporal Trends in Avoidable Blindness in Children (ABC) in India. Indian J Pediatr 2017;84:924-9.
3American Association of Pediatric Ophthalmology and Strabismus. Vision Screening Recommendations-Techniques for Pediatric Vision Screening. Available from: [Last accessed on 2018 June 19].
4Canadian Pediatric Society. Vision screening in infants, children and youth. Paediatr Child Health 2009;14:246-8.
5Cotter SA, Cyert LA, Miller JM, Quinn GS. Vision Screening for Children 36 to <72 Months: Recommended Practices. Optom Vis Sci 2015;92:6-16.
6Public Health England. Child vision screening. Available from: [Last accessed on 2018 June 19].
7US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Davidson KW, Doubeni CA, et al Vision Screening in Children Aged 6 Months to 5 Years: US Preventive Services Task Force Recommendation Statement. JAMA 2017;318:836-44.
8Donahue SP, Nixon CN; Section on Opthamology, American Academy of Pediatrics; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2016;137:28-30.
9Donahue SP, Baker CN; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; Section on Ophthalmology, American Academy of Pediatrics; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Procedures for the Evaluation of the Visual System by Pediatricians. Pediatrics 2016 [Epub ahead of print].
10Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA, et al., American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern: I. Vision Screening in the Primary Care and Community Setting; II. Comprehensive Ophthalmic Examination. Ophthalmology 2018;125:P184-227.
11Hagan JF, Shaw JS, Duncan PM, eds. 2017, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
12Paul CM, Sathyan S. Comparison of the efficacy of Lea Symbol chart and Sheridan Gardiner chart for preschool vision screening. Indian J Ophthalmol 2018;66:924-8.
13Reddy S, Panda L, Kumar A, Nayak S, Das T. Tribal Odisha Eye Disease Study # 4: Accuracy and utility of photorefraction for refractive error correction in tribal Odisha (India) school screening. Indian J Ophthalmol 2018;66:929-33.
14Morya AK. Commentary on: “Tribal Odisha Eye Disease Study # 4: Accuracy and utility of photorefraction for refractive error correction in tribal Odisha (India) school screening”. Indian J Ophthalmol 2018;66:934.
15Shukla P, Vashist P, Singh SS, Gupta V, Gupta N, Wadhwani M, et al. Assessing the inclusion of primary school children in vision screening for refractive error program of India. Indian J Ophthalmol 2018;66:935-9.
16Magdalene D, Bhattacharjee H, Choudhury M, Multani PK, Singh A, Deshmukh S,et al. Community outreach: An indicator for assessment of prevalence of amblyopia. Indian J Ophthalmol 2018;66:940-4.