Vision Screening Guidelines by Age

For infants from birth to the first birthday, the NCCVEH recommends observation, followed by an eye examination when indicated. The NCCVEH developed an observation/checklist tool for assessing 18 vision development milestones during an infant’s first year. This observation tool is for screening vision within 45 days of an infant’s enrollment into Early Head Start, or any program that serves and screens the vision of infants.

The document includes instructions, a page of vision development questions for each month, as well as photographs showing examples of the questions. It also contains next steps to take if a milestone is not met, including activities for parents/caregivers.

No matter the infant’s age, the screener begins with the first milestone and answers questions on each page, including the page for the infant’s current age, to ensure all vision development milestones are met. Screeners use the document each month until instrument-based screening can begin at age 1 year.

The 18 Vision Development Milestones From Birth to Baby’s First Birthday is available in English and Spanish.

The Bright Futures/American Academy of Pediatrics Periodicity Schedule recommends vision screening at ages 1 and 2 years.

For toddlers ages 1 and 2 years (up to 36 months), the NCCVEH recommends instrument-based screening according to 2016 guidelines for pediatricians from the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology.

NCCVEH-approved instruments include:

• Welch Allyn® Spot™ Vision Screener
• Plusoptix S12C Vision Screener

The primary purpose of screening this age group is to detect amblyopia and uncorrected amblyopia risk factors, including hyperopia, myopia, astigmatism, and anisometropia.

The Bright Futures/American Academy of Pediatrics Periodicity Schedule recommends vision screening at ages 3, 4, and 5 years.

Vision screening begins with a review of signs and symptoms – or “red flags” – indicating a child may have a vision or eye health disorder that requires attention from a primary care provider or eye care professional. This external observation includes the ABCs of Observation of Possible Vision Problems that require an eye examination even if children pass vision screening.

The NCCVEH recommends either optotype-based or instrument-based screening according to 2015 guidelines from the National Expert Panel to NCCVEH for public health settings, primary care providers, early childhood agencies and educators, community organizations, and school nurses, as well as 2016 guidelines for pediatricians from the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology.

NCCVEH-approved optotypes and formats:

• Single-surrounded LEA SYMBOLS^® or HOTV Letters in flipcharts for a 5-foot screening distance
• LEA SYMBOLS^® or HOTV letters on full threshold eye charts for a 10-foot (3 meter) screening distance
• LEA SYMBOLS^® or HOTV letters presented as a single line surrounded by a rectangular crowding bar on all four sides for a 10-foot (3 meter) screening distance.

NCCVEH-approved instruments include:

• Welch Allyn® Spot™ Vision Screener
• Plusoptix S12C Vision Screener

The purpose of screening the vision of school-aged children (ages 6 years through 17 years) shifts from a primary focus on prevention of amblyopia and detection of amblyopia risk factors to detection of uncorrected refractive errors and other eye conditions that could potentially impact the students’ ability to learn or to affect their academic performance. Periodic vision screening during the school years is important for school-aged children because refractive errors, such as myopia, and other visual disorders may emerge for the first time throughout these years.

The Bright Futures/American Academy of Pediatrics Periodicity Schedule recommends vision screening at ages 8, 10, 12, and 15 years.

Recommended optotypes:

• Sloan Letters when children can identify letters in random order (beginning at ages 6 or 7 years)

Instruments should be used for children and adolescents ages 6 years and older only when these children cannot participate in optotype-based screening. This recommendation will change when high quality research is available.

Some children are at a higher risk for vision disorders and should bypass vision screening and receive an eye examination from an eye care professional. At-risk conditions include:

• Readably observable ocular abnormalities, such as strabismus and ptosis
• Maternal smoking during pregnancy
• Premature birth (prior to the 32^nd week of pregnancy)
• Parents or siblings with a history of strabismus or amblyopia
• Parental/guardian or teacher concern about the vision of a student

The NCCVEH recommends that children with special health care needs should bypass vision screening and receive an eye examination from an eye care professional because certain children are at a higher risk for vision disorders. At-risk conditions include:

• Systemic medical conditions with ocular abnormalities, including diabetes mellitus and juvenile idiopathic arthritis
• Neurodevelopmental disorders including autism spectrum disorder, Down syndrome, cerebral palsy, cognitive impairment, and developmental delay

Optotype-based distance visual acuity screening is recommended for children and adolescents, beginning at age 3 years.

Charts and Computer Software

Multiple eye charts for optotype-based screening are available for purchase, but not all charts are alike. Some are appropriate because they are standardized; others are inappropriate because they are not standardized. The optotypes selected and the layout of optotypes on an eye chart can negatively affect visual acuity scores obtained, meaning screeners could over-refer or under-refer children. Appropriate charts are standardized.

If an eye chart includes a 20/32 line, it is likely standardized. If an eye chart includes a 20/30 line, it is likely not standardized. Most standardized charts are used at a 5- or 10-foot screening distance, not 20 feet.

Refer to Non-NCCVEH Recommended Vision Screening Tools (Appendix A) for images of inappropriate charts that are no longer recommended because they are not based on evidence or standardized. Charts no longer recommended include:

• Snellen charts
• Allen Pictures
• Tumbling E
• Lighthouse (house, apple, umbrella)
• Kindergarten Eye Chart (sailboat as first optotype at the top of the chart)

Computer-based screening is acceptable if programmed to present screening methods and optotypes that have been validated in children.

Occluders

Specific occluders to cover an eye during vision screening to prevent peeking are recommended.

Distance Vision Screening

The NCCVEH recommends distance vision screening as a preferred practice for children and adolescents participating in routine and mass vision screening, beginning at age 3 years.

Distance vision screening is an option, along with instrument-based screening, for children ages 3, 4, and 5 years.

Near Vision Screening

The NCCVEH does not recommend near visual acuity screening as a preferred practice for children and adolescents. Insufficient evidence exists to support or specifically recommend its use in routine and mass vision screening. As new research emerges, the NCCVEH will review the role of near vision screening in combination with other vision screening tests.

Instrument-based screening refers to using automated autorefractors or photoscreening devices to provide information about the eyes that could affect vision, including refractive errors and eye misalignment. Instrument-based screening does not provide visual acuity information.

Instrument-based screening is useful for shy, non-communicative, or pre-verbal children.

For toddlers ages 1 and 2 years (up to 36 months), the NCCVEH recommends instrument-based screening according to 2016 guidelines for pediatricians from the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology.

For children ages 3, 4, and 5 years, the NCCVEH recommends instrument-based screening as an option to optotype-based vision screening according to 2015 guidelines from the National Expert Panel to NCCVEH for public health settings, primary care providers, early childhood agencies and educators, community organizations, and school nurses.

Instruments should be used for children and adolescents ages 6 years and older only when these children cannot participate in optotype-based screening. This recommendation will change when high quality research is available.

NCCVEH-approved instruments include the following:

• Welch Allyn® Spot™ Vision Screener
• Plusoptix S12C Vision Screener

Visual acuity testing machines or mechanical devices similar to those used at motor vehicle testing facilities screen for distance visual acuity. Some also screen for near visual acuity and other visual functions. Machines (not to be confused with instruments that do not measure visual acuity) use a variety of letter or symbol slides that may include non-recommended optotypes. Such machines prevent observation of a child’s face and eyes during screening. Child cooperation can be problematic when screening young children.

No national guidelines support machine vision screening for children and adolescents in school and community settings.

The NCCVEH does not recommend the use of machines as a preferred practice for children and adolescents. Insufficient evidence exists to support its use in routine and mass vision screening. As new research emerges, the NCCVEH will review the role of machines as a vision screening approach.