Eye Exams for Children

As a parent, you may wonder whether your pre-schooler has a vision problem or when a first eye exam should be scheduled.

Eye exams for children are extremely important. Experts say 5 to 10% of pre-schoolers and 25% of school-aged children have vision problems. Early identification of a child's vision problem is crucial because, if left untreated, some childhood vision problems can cause permanent vision loss.

A comprehensive children's vision exam includes tests performed in a routine eye exam, plus additional tests to detect learning-related vision problems. These extra tests may include an assessment of eye focusing, eye teaming, and eye movement abilities (also called accommodation, binocular vision, and ocular motility testing). Also, depending on the type of problems your child is having, we may recommend other testing, either in our office or with a children's vision and/or vision development specialist.

When should kids have their eyes examined?

According to the American Optometric Association (AOA), infants should have their first comprehensive eye exam at 6 months of age. Children then should receive additional eye exams at 3 years of age, and just before they enter kindergarten or the first grade at about age 5 or 6.

For school-aged children, the AOA recommends an eye exam every two years if no vision correction is required. Children who need eyeglasses or contact lenses should be examined annually or according to their eye doctor's recommendations.

Early eye exams also are important because children need the following basic visual skills for learning:

  • Near vision
  • Distance vision
  • Eye teaming (binocularity) skills
  • Eye movement skills
  • Focusing skills
  • Peripheral awareness
  • Eye/hand coordination

Because of the importance of good vision for learning, some states require an eye exam for all children entering school for the first time.

Scheduling Your Child's Eye Exam

Your family doctor or pediatrician likely will be the first medical professional to examine your child's eyes. If eye problems are suspected during routine physical examinations, a referral might be made to an ophthalmologist or optometrist for further evaluation. Eye doctors have specific equipment and training to help them detect and diagnose potential vision problems.

When scheduling an eye exam, choose a time when your child is usually alert and happy. Specifics of how eye exams are conducted depend on your child's age, but an exam generally will involve a case history, vision testing, determination of whether eyeglasses are needed, testing of eye alignment, an eye health examination and a consultation with you regarding the findings.

After you've made the appointment, you may be sent a case history form by mail, or you may be given one when you check in at the doctor's office. The case history form will ask about your child's birth history (also called perinatal history), such as birth weight and whether or not the child was full-term. Your eye doctor also may ask whether complications occurred during the pregnancy or delivery. The form will also inquire about your child's medical history, including current medications and past or present allergies.

Be sure to tell your eye doctor if your child has a history of prematurity, has delayed motor development, engages in frequent eye rubbing, blinks excessively, fails to maintain eye contact, cannot seem to maintain a gaze (fixation) while looking at objects, has poor eye tracking skills or has failed a pediatrician or pre-school vision screening.

Your eye doctor will also want to know about previous ocular diagnoses and treatments involving your child, such as possible surgeries and glasses or contact lens wear. Be sure you inform your eye doctor if there is a family history of eye problems requiring vision correction, such as nearsightedness or farsightedness, misaligned eyes (strabismus) or amblyopia ("lazy eye").

Learning-Related Vision Problems

There's no question that good vision is important for learning. Experts say more than 80% of what your child is taught in school is presented to them visually.

To make sure your child has the visual skills they need for school, the first step is to make sure your child has 20/20 eyesight and that any nearsightedness, farsightedness and/or astigmatism is fully corrected with glasses or contact lenses. But there are other, less obvious learning-related vision problems you should know about as well.

Good Vision is More Than 20/20 Visual Acuity

Your child can have "20/20" eyesight and still have vision problems that can affect their learning and classroom performance. Visual acuity (how well your child can see letters on a wall chart) is just one aspect of good vision, and it's not even the most important one. Many nearsighted kids may have trouble seeing the board in class, but they read exceptionally well and excel in school.

Other important visual skills needed for learning include:
  • Eye movement skills - How smoothly and accurately your child can move their eyes across a printed page in a textbook.
  • Eye focusing abilities - How well they can change focus from far to near and back again (for copying information from the board, for example).
  • Eye teaming skills - How well your child's eyes work together as a synchronized team (to converge for proper eye alignment for reading, for example).
  • Binocular vision skills - How well your child's eyes can blend visual images from both eyes into a single, three-dimensional image.
  • Visual perceptual skills - How well your child can identify and understand what they see, judge its importance, and associate it with previous visual information stored in their brain.
  • Visual-motor integration - The quality of your child's eye-hand coordination, which is important not only for sports, but also for legible handwriting and the ability to efficiently copy written information from a book or chalkboard.
  • Deficiencies in any of these important visual skills can significantly affect your child's learning ability and school performance.
Many Kids have Vision Problems that Affect Learning

Many kids have undetected learning-related vision problems. According to the College of Optometrists in Vision Development (COVD), one study indicates 13% of children between the ages of 9 and 13 suffer from moderate to severe convergence insufficiency (an eye teaming problem that can affect reading performance), and as many as one in four school-age children may have at least one learning-related vision problem.

There are many signs and symptoms of learning-related vision disorders, including:

  • Blurred distance or near vision, particularly after reading or other close work
  • Frequent headaches or eye strain
  • Difficulty changing focus from distance to near and back
  • Double vision, especially during or after reading
  • Avoidance of reading
  • Easily distracted when reading
  • Poor reading comprehension
  • Loss of place, repetition, and/or omission of words while reading
  • Letter and word reversals
  • Poor handwriting
  • Hyperactivity or impulsiveness during class
  • Poor overall school performance

If your child exhibits one or more of these signs or symptoms and is having problems in school, call us to schedule a comprehensive children's vision exam.

Eye Testing for Infants

It takes some time for a baby's vision skills to develop. To assess whether your infant's eyes are developing normally, your eye doctor may use one or more of the following tests:

  • Tests of pupil responses evaluate whether the eye's pupil opens and closes properly in the presence or absence of light.
  • "Fixate and follow" testing determines whether your baby can fixate on an object (such as a light) and follow it as it moves. Infants should be able to perform this task quite well by the time they are 3 months old.
  • Preferential looking involves using cards that are blank on one side with stripes on the other side to attract the gaze of an infant to the stripes. In this way, vision capabilities can be assessed.

Eye Testing for Pre-School Children

Pre-school children can have their eyes thoroughly tested even if they don't yet know the alphabet or are too young or too shy to answer the doctor's questions. Some common eye tests used specifically for young children include:

  • LEA Symbols for young children are similar to regular eye tests using charts with letters, except that special symbols in these tests include an apple, house, square and circle.
  • Retinoscopy is a test that involves shining a light into the eye to observing how it reflects from the retina (the light-sensitive inner lining of the back of the eye). This test helps eye doctors determine the child's eyeglass prescription.
  • Random Dot Stereopsis uses dot patterns to determine how well the two eyes work as a team.

Eye and Vision Problems that Affect Children

Besides looking for nearsightedness, farsightedness and astigmatism (refractive errors), your eye doctor will be examining your child's eyes for signs of these eye and vision problems commonly found in young children:

  • Amblyopia. Also commonly called "lazy eye," this is decreased vision in one or both eyes despite the absence of any eye health problem or damage. Common causes of amblyopia include strabismus (see below) and a significant difference in the refractive errors of the two eyes. Treatment of amblyopia may include patching the dominant eye to strengthen the weaker eye.
  • Strabismus. This is misalignment of the eyes, often caused by a congenital defect in the positioning or strength of muscles that are attached to the eye and which control eye positioning and movement. Left untreated, strabismus can cause amblyopia in the misaligned eye. Depending on its cause and severity, surgery may be required to treat strabismus.
  • Convergence Insufficiency. This is the inability to keep the eye comfortably aligned for reading and other near tasks. Convergence insufficiency can often be successfully treated with vision therapy, a specific program of eye exercises.
  • Focusing Problems. Children with focusing problems (also called accommodation problems) may have trouble changing focus from distance to near and back again (accommodative infacility) or have problems maintaining adequate focus for reading (accommodative insufficiency). These problems often can be successfully treated with vision therapy.
  • Eye Teaming Problems. Many eye teaming (binocularity) problems are more subtle than strabismus. Deficiencies in eye teaming skills can cause problems with depth perception and coordination.

Controlling Nearsightedness in Children

Myopia (nearsightedness) is a common vision problem affecting children who can see well up close, while distant objects are blurred. Nearsighted children tend to squint to see distant objects such as the board at school. They also tend to sit closer to the television to see it more clearly.

Sometimes, childhood myopia can worsen year after year. This change can be disconcerting to both children and their parents, prompting the question: "Will it ever stop? Or, someday will this get so bad that glasses won't help?"

Myopia that develops in childhood nearly always stabilizes by age 20. But by then, some kids have become very nearsighted. Here are three possible ways to slow down the progression of myopia in children:

Gas Permeable Contact Lenses
Wearing rigid gas permeable contact lenses (also referred to as "RGP" or "GP" lenses) may slow the progression of nearsightedness in children. It's been proposed that the massaging action of the rigid GP lens on the eye during blinking may keep the eye from lengthening, thereby reducing the tendency for advancing nearsightedness.

In 2001 to 2004, the National Eye Institute (NEI) conducted a controlled study to determine whether wearing GP lenses is effective in slowing the progression of myopia in children. The 116 participants in the study were 8 to 11 years old when the research began.

At the end of the three-year study period, the children who wore GP lenses had only 0.63 diopter (D) less nearsightedness than the kids in the control group who wore soft contact lenses.

The study also found that wearing GP lenses does not slow the growth of the eye, which causes most of the myopia in children. The reduced progression of myopia among those children wearing GP lenses was due only to the effect the lenses had on the front surface of the eye (the cornea). Children who wore the GP lenses had less increase in corneal curvature than those who wore soft contact lenses. The NEI researchers believe these GP lens-induced changes in corneal curvature are not likely to be permanent, and therefore the effect of GP lenses on controlling myopia progression may not be permanent.

Orthokeratology
Orthokeratology, or "ortho-k," is the use of specially-designed gas permeable contact lenses to flatten the shape of the cornea and thereby reduce or correct mild to moderate amounts of nearsightedness. The lenses are worn during sleep and removed in the morning. Though temporary eyeglasses may be required during the early stages of ortho-k, many people with low to moderate amounts of myopia can see well without glasses or contact lenses during the day after wearing the corneal reshaping lenses at night.

Recent research suggests ortho-k may also reduce the lengthening of the eye itself, indicating that wearing ortho-k lenses during childhood may actually cause a permanent reduction in myopia, even if the lenses are discontinued in adulthood.

Bifocals
Some evidence suggests wearing eyeglasses with bifocal or progressive multifocal lenses may slow the progression of nearsightedness in some children. The mechanism here appears to be that the added magnifying power in these lenses reduces focusing fatigue during reading and other close work, a problem that may contribute to increasing myopia.

A five-year study published in the February 2007 issue of Investigative Ophthalmology & Visual Science produced an interesting result involving nearsighted children whose mother and father were also nearsighted. These children, who wore eyeglasses with progressive multifocal lenses during the course of the study, had less progression of their myopia than similar children who wore eyeglasses with regular, single vision lenses.

See us for a Consultation
If you are concerned about your child becoming more nearsighted year-to-year, call us to schedule a comprehensive eye exam and consultation. We can evaluate the progression of their myopia and discuss the best treatment options with you.

Children's Vision - FAQ's

My 5-year-old daughter just had a vision screening at school and she passed. Does she still need an eye exam?

Yes. School vision screenings are designed to detect gross vision problems. But kids can pass a screening at school and still have vision problems that can affect their learning and school performance. A comprehensive eye exam by an optometrist can detect vision problems a school screening may miss. Also, a comprehensive eye exam includes an evaluation of your child's eye health, which is not part of a school vision screening.

Our active 1-year-old boy needs glasses to correct his farsightedness and the tendency for his eyes to cross. But he pulls them off the second they go on. We've tried an elastic band, holding his arms, tape... He just struggles and cries. How do we get him to wear his glasses?

In most cases, it just takes awhile for a toddler to get used to the sensation of wearing glasses. So persistence is the key. Also, you may want to put his glasses on as soon as he wakes up - this will usually help him adapt to the glasses easier. But it's also a good idea to recheck the prescription and make sure his glasses were made correctly and are fitting properly. Today, there are many styles of frames for young children, including some that come with an integrated elastic band to help keep them comfortably on the child's head. Bring your son and the eyewear to our office. Even if you didn't purchase the glasses from us, we will be happy to give you our opinion about why your son is having a tough time wearing them and what you can do about it.

Our 3-year-old daughter was just diagnosed with strabismus and amblyopia. What are the percentages of a cure at this age?

With proper treatment, the odds are very good. Many researchers believe the visual system can still develop better visual acuity up to about age 8 to 10. If your daughter's eye turn (strabismus) is constant, it's likely surgery will be necessary to straighten her eyes in order for her therapy for amblyopia (or "lazy eye") to be successful. Strabismus surgery may be needed even if her eyes alternate in their misalignment. See a pediatric ophthalmologist who specializes in strabismus surgery for more information.

My daughter (age 10) is farsighted and has been wearing glasses since age two. We think she may have problems with depth perception. How can she be tested for this, and if there is a problem, can it be treated?

We can perform a very simple stereopsis test to determine if your daughter has normal depth perception. In this test, she wears "3-D glasses" and looks at a number of objects in a special book or on a chart across the room. If she has reduced stereopsis, a program of vision therapy may help improve her depth perception.

We have an 11-year-old son who first became nearsighted when he was 7. Every year, his eyes get worse. Is there anything that can be done to prevent this?

Rigid gas permeable (GP) contact lenses may help. Research shows that, in many cases, fitting myopic youngsters with GP lenses may slow the progression of their nearsightedness. There's also a special fitting technique with GP contacts called orthokeratology (or "ortho-k") that can even reverse certain amounts of myopia. There is also research that suggests bifocals and/or reading glasses may slow down the progression of myopia in some children.

My 7-year-old son's teacher thinks he has "convergence insufficiency." What is this, and what can I do about it?

Convergence insufficiency (CI) is a common learning-related vision problem where a person's eyes don't stay comfortably aligned when they are reading or doing close work. For reading and other close-up tasks, our eyes need to be pointed slightly inward (converged). A person with convergence insufficiency has a tough time doing this, which leads to eyestrain, headaches, fatigue, blurred vision and reading problems. Usually, a program of vision therapy can effectively treat CI and reduce or eliminate these problems. Sometimes, special reading glasses can also help.

My son is 5 years old and has 20/40 vision in both eyes. Should I be concerned, or could this improve with time?

Usually, 5-year-olds can see 20/25 or better. But keep in mind that visual acuity testing is a subjective matter - during the test, your child is being asked to read smaller and smaller letters on a wall chart. Sometimes, kids give up at a certain line on the chart when they can actually read smaller letters. Other times, they may say they can't read smaller letters because they want glasses. (Yes, this happens!) Also, if your son had his vision tested at a school screening (where there can be plenty of distractions), it's a good idea to schedule a comprehensive eye exam to rule out nearsightedness, astigmatism or an eye health problem that may be keeping him from having better visual acuity.

My daughter has been diagnosed with refractive amblyopia due to severe farsightedness in one eye. She just got her glasses and the lens for her bad eye is much thicker than the other lens. She complains that the glasses make her dizzy and she refuses to wear them. Can anything be done about this?

In situations like this, where one eye needs a much stronger correction than the other, contact lenses are a better option. With glasses, the unequal lens powers cause an unequal magnification effect, so the two eyes form images in the brain that are different in size. This can cause nausea and dizziness because the brain may not be able to blend the two separate images into a single, three-dimensional one. And, of course, the glasses will be unattractive because one lens will be much thicker than the other. Even if your child is quite young, she can probably handle contact lens wear. Contact lenses don't cause the differences in image magnification that glasses do. Continuous wear lenses (worn day and night for up to 30 days, then discarded) or one-day disposable lenses may be good options. Keep in mind that amblyopia is a condition where one eye doesn't see as well as the other, even with the best possible correction lens in place. Simply wearing the contacts may not improve the vision in her weak eye. Usually a program of vision therapy will also be needed.