Vision Screening for Children 36 to <72 Months: Recommended Practices
The purpose of this paper is to provide recommendations for screening children aged 36 to <72 months for disorders of the eyes and visual system, primarily amblyopia, strabismus, significant refractive error, and risk factors associated with these disorders. The recommendations were developed by the National Expert Panel (NEP) to the National Center for Children’s Vision and Eye Health, sponsored by Prevent Blindness, and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, United States Department of Health and Human Services.
All children aged 36 to <72 months should be screened annually (best practice) or at least once (acceptable minimum standard) during the interval between their third and sixth birthdays. The vision screening may be performed in educational-, community-, or public health-based settings or in the medical home using recommended methods that are appropriate for the screening venue. The tests recommended herein are intended for vision screenings conducted by lay screeners, school nurses, and other screening personnel in public health settings, primary health care practices, or the child’s medical home to identify children in need of further evaluation by an eye care professional.
This webpage provides a synopsis of the article content. Read the complete journal article.
- Children That Should By-Pass Vision Screening
- Vision Screener Training and Certification
- Recognition Visual Acuity (Optotype-based) Screening
- Occlusion Techniques
- Instrument-Based Vision Screening
- Stereoacuity Testing
- Untestable Children and Rescreening Guidelines
- Components of a Comprehensive Vision Screening System
- Recommended Vision Screening Tools and Tests
- Guidance for optotype-based vision screening
Suggested Citation and Corresponding Author
Cotter SA, Cyert LA, Miller JM, Quinn GE for the National Expert Panel to the National Center for Children’s Vision and Eye Health. Vision Screening for Children 36 to <72 Months: Recommended Practices. Optom Vis Sci 2015;92(1): 6–16.
Susan Cotter, OD, MS, FAAO
Marshall B Ketchum University
2575 Yorba Linda Boulevard
Fullerton, CA 92831
e-mail: [email protected]
References for Vision Screening for Children 36 to <72 Months: Recommended Practice
1. Tarczy-Hornoch K, Cotter SA, Borchert M, McKean-Cowdin R, Lin J, Wen G, Kim J, Varma R. Prevalence and causes of visual impairment in Asian and non-Hispanic white preschool children: Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2013;120:1220-6.
2. Tarczy-Hornoch K, Varma R, Cotter SA, McKean-Cowdin R, Lin JH, Borchert MS, Torres M, Wen G, Azen SP, Tielsch JM, Friedman DS, Repka MX, Katz J, Ibironke J, Giordano L. Risk factors for decreased visual acuity in preschool children: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies. Ophthalmology 2011;118:2262-73.
3. United States Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics 2011;127:340-6.
4. Multi-ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months: The Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2008;115:1229-36.
5. Friedman DS, Repka MX, Katz J, Giordano L, Ibironke J, Hawse P, Tielsch JM. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months: The Baltimore Pediatric Eye Disease Study. Ophthalmology 2009;116:2128-34.
6. McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, Wen G, Kim J, Borchert M, Varma R. Prevalence of amblyopia or strabismus in Asian and non-Hispanic white preschool children: Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2013;120:2117-24.
7. Satterfield D, Keltner JL, Morrison TL. Psychosocial aspects of strabismus study. Arch Ophthalmol 1993;111:1100-5.
8. Mojon-Azzi SM, Kunz A, Mojon DS. Strabismus and discrimination in children: Are children with strabismus invited to fewer birthday parties? Br J Ophthalmol 2011;95:473-6.
9. Multi-ethnic Pediatric Eye Disease Study Group. Prevalence of myopia and hyperopia in 6- to 72-month-old African American and Hispanic children: The Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2010;117:140-7.
10. Giordano L, Friedman DS, Repka MX, Katz J, Ibironke J, Hawes P, Tielsch JM. Prevalence of refractive error among preschool children in an urban population: the Baltimore Pediatric Eye Disease Study. Ophthalmology 2009;116:739-46.
11. Wen G, Tarczy-Hornoch K, McKean-Cowdin R, Cotter SA, Borchert M, Lin J, Kim J, Varma R. Prevalence of myopia, hyperopia, and astigmatism in non-Hispanic white and Asian children: The Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2013;120:2109-16.
12. Fozailoff A, Tarczy-Hornoch K, Cotter S, Wen G, Lin J, Borchert M, Azen S, Varma R. Prevalence of astigmatism in 6- to 72-month-old African American and Hispanic children: The Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2011;118:284-93.
13. Ying GS, Maguire MG, Cyert LA, Ciner E, Quinn GE, Kulp MT, Orel-Bixler D, Moore B. Prevalence of Vision Disorders by Racial and Ethnic Group among Children Participating in Head Start. Ophthalmology 2013.
14. Holmes JM, Lazar EL, Melia BM, Astle WF, Dagi LR, Donahue SP, Frazier MG, Hertle RW, Repka MX, Quinn GE, Weise KK. Effect of age on response to amblyopia treatment in children. Arch Ophthalmol 2011;129:1451-7.
15. Ibironke JO, Friedman DS, Repka MX, Katz J, Giordano L, Hawse P, Tielsch JM. Child development and refractive errors in preschool children. Optom Vis Sci 2011;88:181-7.
16. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol 2008;126:252-8.
17. Atkinson J, Anker S, Nardini M, Braddick O, Hughes C, Rae S, Wattam-Bell J, Atkinson S. Infant vision screening predicts failures on motor and cognitive tests up to school age. Strabismus 2002;10:187-98.
18. Hartmann EE, Block SS, Wallace DK. Vision and eye health in children 36-72 months: Proposed data system. Optom Vis Sci January 2015 [ePub ahead of print].
19. Marsh-Tootle WL, Russ SA, Repka MX. Vision and eye health in children 36-72 months: Performance measures. Optom Vis Sci January 2015 [ePub ahead of print].
20. Nyong’o OL, Del Monte MA. Childhood visual impairment: normal and abnormal visual function in the context of developmental disability. Pediatr Clin North Am 2008;55:1403-15.
21. Menacker SJ. Visual function in children with developmental disabilities. Pediatr Clin North Am 1993;40:659-74.
22. Shevell M, Ashwal S, Donley D, Flint J, Gingold M, Hirtz D, Majnemer A, Noetzel M, Sheth RD. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology 2003;60:367-80.
23. Das M, Spowart K, Crossley S, Dutton GN. Evidence that children with special needs all require visual assessment. Arch Dis Child 2010;95:888-92.
24. Ikeda J, Davitt BV, Ultmann M, Maxim R, Cruz OA. Brief report: incidence of ophthalmologic disorders in children with autism. J Autism Dev Disord 2013;43:1447-51.
25. Amblyopia Preferred Practice Pattern ® Guidelines. San Francisco, CA: American Academy of Ophthalmology; 2012:29. Available at: http://one.aao.org/preferred-practice-pattern/amblyopia-ppp–september-2012. Accessed July 28, 2014.
26. Cotter SA, Varma R, Tarczy-Hornoch K, McKean-Cowdin R, Lin J, Wen G, Wei J, Borchert M, Azen SP, Torres M, Tielsch JM, Friedman DS, Repka MX, Katz J, Ibironke J, Giordano L. Risk factors associated with childhood strabismus: The Multi-ethnic Pediatric Eye Disease and Baltimore Pediatric Eye Disease Studies. Ophthalmology 2011;118:2251-61.
27. Bonamy AK, Holmstrom G, Stephansson O, Ludvigsson JF, Cnattingius S. Preterm birth and later retinal detachment: a population-based cohort study of more than 3 million children and young adults. Ophthalmology 2013;120:2278-85.
28. American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Association of Certified Orthoptists. Instrument-based pediatric vision screening policy statement. Pediatrics 2012;130:983-6.
29. Schmidt P, Maguire M, Dobson V, Quinn G, Ciner E, Cyert L, Kulp MT, Moore B, Orel-Bixler D, Redford M, Ying GS. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study. Vision in Preschoolers Study Group. Ophthalmology 2004;111:637-50.
30. Huang K, Tarczy-Hornoch K, Borchert M, Azen S, Cotter S, Wen G, Varma R, MEPEDS Study Group, Mckean-Cowdin R, Torres M. The Brueckner test: detection of strabismus & amblyopia in infants & young children. Optom Vis Sci 2012;89:E-abstract 120023.
31. Macaskill P, Walter SD, Irwig L, Franco EL. Assessing the gain in diagnostic performance when combining two diagnostic tests. Stat Med 2002;21:2527-46.
32. Bailey IL, Lovie JE. New design principles for visual acuity letter charts. Am J Optom Physiol Opt 1976;53:740-5.
33. Fern KD, Manny RE. Visual acuity of the preschool child: a review. Am J Optom Physiol Opt 1986;63:319-45.
34. Anstice NS, Thompson B. The measurement of visual acuity in children: an evidence-based update. Clin Exp Optom 2014;97:3-11.
35. Lippmann O. Vision of young children. Arch Ophthalmol 1969;81:763-75.
36. Friendly D. Preschool visual acuity screening tests. Trans Am Ophthalmol Soc 1978;76:383-480.
37. Hyvärinen L, Näsänen R, Laurinen P. New visual acuity test for pre-school children. Acta Ophthalmol (Copenh) 1980;58:507-11.
38. Cyert L, Schmidt P, Maguire M, Moore B, Dobson V, Quinn G. Threshold visual acuity testing of preschool children using the crowded HOTV and Lea symbols acuity tests. J AAPOS 2003;7:396-9.
39. Hered RW, Murphy S, Clancy M. Comparison of the HOTV and Lea Symbols charts for preschool vision screening. J Ophthalmic Nurs Technol 1997;16:68-73.
40. Vision in Preschoolers (VIP) Study Group. Effect of age using Lea symbols or HOTV for preschool vision screening. Optom Vis Sci 2010;87:87-95.
41. Friedman DS, Repka MX, Katz J, Giordano L, Ibironke J, Hawes P, Burkom D, Tielsch JM. Prevalence of decreased visual acuity among preschool-aged children in an American urban population: The Baltimore Pediatric Eye Disease Study, methods, and results. Ophthalmology 2008;115:1786-95.
42. Pai AS, Rose KA, Leone JF, Sharbini S, Burlutsky G, Varma R, Wong TY, Mitchell P. Amblyopia prevalence and risk factors in Australian preschool children. Ophthalmology 2012;119:138-44.
43. Cotter SA, Tarczy-Hornoch K, Wang Y, Azen SP, Dilauro A, Borchert M, Varma R. Visual acuity testability in African-American and Hispanic children: the multi-ethnic pediatric eye disease study. Am J Ophthalmol 2007;144:663-7.
44. Holmes JM, Beck RW, Repka MX, Leske DA, Kraker RT, Blair RC, Moke PS, Birch EE, Saunders RA, Hertle RW, Quinn GE, Simons KA, Miller JM. The amblyopia treatment study visual acuity testing protocol. Arch Ophthalmol 2001;119:1345-53.
45. Moke PS, Turpin AH, Beck RW, Holmes JM, Repka MX, Birch EE, Hertle RW, Kraker RT, Miller JM, Johnson CA. Computerized method of visual acuity testing: adaptation of the amblyopia treatment study visual acuity testing protocol. Am J Ophthalmol 2001;132:903-9.
46. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120:268-78.
47. Vision in Preschoolers Study Group. Preschool visual acuity screening with HOTV and Lea symbols: testability and between-test agreement. Optom Vis Sci 2004;81:678-83.
48. Pick HL. Eleanor J. Gibson: Learning to perceive and perceiving to learn. Dev Psychol 1992;28:787-94.
49. Mocan MC, Najera-Covarrubias M, Wright KW. Comparison of visual acuity levels in pediatric patients with amblyopia using Wright figures, Allen optotypes, and Snellen letters. J AAPOS 2005;9:48-52.
50. Mayer DL, Gross RD. Modified Allen pictures to assess amblyopia in young children. Ophthalmology 1990;97:827-32.
51. Simons K. Visual acuity norms in young children. Surv Ophthalmol 1983;28:84-92.
52. Flom MC, Weymouth FW, Kahneman D. Visual resolution and contour interaction. J Opt Soc Am 1963;53:1026-32.
53. Flom MC, Heath GG, Takahashi E. Contour interaction and visual resolution: contralateral effects. Science 1963;142:979-80.
54. Vision in Preschoolers Study Group. Preschool vision screening tests administered by nurse screeners compared with lay screeners in the vision in preschoolers study. Invest Ophthalmol Vis Sci 2005;46:2639-48.
55. Committee on Vision. Recommended standard procedures for the clinical measurement and specification of visual acuity. Report of working group 39. Assembly of Behavioral and Social Sciences, National Research Council, National Academy of Sciences, Washington, D.C. Adv Ophthalmol 1980;41:103-48.
56. Borchert M, Wang Y, Tarczy-Hornoch K, Cotter S, Deneen J, Azen S, Varma R. Testability of the Retinomax autorefractor and IOLMaster in preschool children: the Multi-ethnic Pediatric Eye Disease Study. Ophthalmology 2008;115:1422-5, 5 e1.
57. Pai AS, Rose KA, Samarawickrama C, Fotedar R, Burlutsky G, Varma R, Mitchell P. Testability of refraction, stereopsis, and other ocular measures in preschool children: the Sydney Paediatric Eye Disease Study. J AAPOS 2012;16:185-92.
58. Vision in Preschoolers Study Group. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci 2009;86:619-23.
59. Matta NS, Singman EL, Silbert DI. Performance of the Plusoptix S04 photoscreener for the detection of amblyopia risk factors in children aged 3 to 5. J AAPOS 2010;14:147-9.
60. Dahlmann-Noor AH, Vrotsou K, Kostakis V, Brown J, Heath J, Iron A, McGill S, Vivian AJ. Vision screening in children by Plusoptix Vision Screener compared with gold-standard orthoptic assessment. Br J Ophthalmol 2009;93:342-5.
61. Paff T, Oudesluys-Murphy AM, Wolterbeek R, Swart-van den Berg M, de Nie JM, Tijssen E, Schalij-Delfos NE. Screening for refractive errors in children: the PlusoptiX S08 and the Retinomax K-plus2 performed by a lay screener compared to cycloplegic retinoscopy. J AAPOS 2010;14:478-83.
62. Mirzajani A, Heirani M, Jafarzadehpur E, Haghani H. A comparison of the Plusoptix S08 photorefractor to retinoscopy and cycloretinoscopy. Clin Exp Optom 2013;96:394-9.
63. Ayse YK, Onder U, Suheyla K. Accuracy of Plusoptix S04 in children and teens. Can J Ophthalmol 2011;46:153-7.
64. Arthur BW, Riyaz R, Rodriguez S, Wong J. Field testing of the plusoptiX S04 photoscreener. J AAPOS 2009;13:51-7.
65. Nathan NR, Donahue SP. Modification of Plusoptix referral criteria to enhance sensitivity and specificity during pediatric vision screening. J AAPOS 2011;15:551-5.
66. Donahue SP, Arnold RW, Ruben JB. Preschool vision screening: what should we be detecting and how should we report it? Uniform guidelines for reporting results of preschool vision screening studies. J AAPOS 2003;7:314-6.
67. Singman E, Matta N, Tian J, Silbert D. A comparison of referral criteria used by the PlusoptiX photoscreener. Strabismus 2013;21:190-4.
68. Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS 2013;17:4-8.
69. Simon JW, Siegfried JB, Mills MD, Calhoun JH, Gurland JE. A new visual evoked potential system for vision screening in infants and young children. J AAPOS 2004;8:549-54.
70. Hunter DG, Nassif DS, Piskun NV, Winsor R, Gramatikov BI, Guyton DL. Pediatric Vision Screener 1: instrument design and operation. J Biomed Opt 2004;9:1363-8.
71. Loudon SE, Rook CA, Nassif DS, Piskun NV, Hunter DG. Rapid, high-accuracy detection of strabismus and amblyopia using the pediatric vision scanner. Invest Ophthalmol Vis Sci 2011;52:5043-8.
72. Vision in Preschoolers Study Group. Does assessing eye alignment along with refractive error or visual acuity increase sensitivity for detection of strabismus in preschool vision screening? Invest Ophthalmol Vis Sci 2007;48:3115-25.
73. Maguire MG. Children unable to perform screening tests in vision in preschoolers study: proportion with ocular conditions and impact on measures of test accuracy. Invest Ophthalmol Vis Sci 2007;48:83-7.