Pediatric Vision Screening

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Article initiated by:
Amna Ali, Andrew Go Lee, MD, David I. Silbert MD, FAAP, Laura Olson, Noelle S. Matta CO, CRC, COT, Tapan Darji, Seung Won Jenna Shin, Julia Moore, Sanjana Jaiswal, Elizabeth Arogundade
All contributors:
S. Grace Prakalapakorn, MD, MPH, Dr. Priyanka Kumar, MD, David I. Silbert MD, FAAP, Sarah Rodriguez, MD, MPH, Sanjana Jaiswal
Assigned editor:
Review:
Assigned status Up to Date
 by Sarah Rodriguez, MD, MPH on January 3, 2026.


Definition

Pediatric vision screening is intended to identify children with vision disorders including amblyopia (poor vision in an otherwise normal eye), strabismus (misalignment of the eyes), significant refractive error (need for glasses) or other eye abnormalities. Vision screening can be performed in the community setting, such as at health fairs[1], and at preschools[2] or grade schools[3], as well as in the medical home,[4] such as at the pediatrician or family doctor’s office. In the United States, vision screening requirements vary by state[5].

Amblyopia can be caused by significant refractive error, misalignment of the eyes (strabismus), or deprivation (anything that blocks a clear image from reaching the retina). Causes of deprivation amblyopia include visually significant ptosis (droopy eyelid), cataract, or other media opacities. Amblyopia is potentially reversible with appropriate treatment in childhood, and it is generally believed that the earlier amblyopia risk factors are identified, and the earlier amblyopia treatment is initiated, the more likely the child will develop normal vision[6]. Treatment requires proper identification of the etiology, appropriate treatment, and occlusion therapy. Left untreated, amblyopia can lead to a permanent reduction in vision in one or both eyes and is the leading cause of vision loss in adults under the age of 40[7].

Even in the absence of amblyopia, uncorrected refractive error can have a negative effect on learning and school performance[8].

There are a variety of forms of pediatric vision screening methods available, depending on the age of the child requiring screening, the environment in which screening is being performed, and the amount of money available to invest. Regardless of the type of screening method chosen, one of the keys to a successful pediatric vision screening program is to ensure that children who have been identified as having potential amblyopia risk factors receive a complete pediatric ophthalmology examination including a formal alignment exam, a dilated fundus examination, and a dilated (cycloplegic) refraction [9].

The American Association for Pediatric Ophthalmology and Strabismus has devised standards for comparing pediatric vision screening methods[10]. These guidelines are set against a child’s cycloplegic refraction performed by a pediatric ophthalmologist in order to determine if the child’s vision screening should have prompted a referral to a pediatric ophthalmologist, or if they should have passed the screening.

Types of Pediatric Vision Screening

Subjective Screening

Subjective screening requires significant participation from a child to identify optotypes such as letters and shapes. It is most effective in verbal children age 5 and older, but may be attempted in younger verbal children. Subjective screening includes various forms of visual acuity testing, see below.

Acuity Screening

Pediatric vision screening with acuity measurements is the most widely used method. See Visual acuity assessment in children for more details. This method is inexpensive, but can be difficult to execute properly. The testing distance can vary from 3 – 20 feet and it is critical that the child be tested at the appropriate distance for the chart. It is also important that an appropriate eye chart be selected. Available optotypes include Snellen, Sloan, HOTV[3], Lea symbols[10] and Patti Pics. The optotypes should be presented in a line, or as single letters with crowding bars, as isolated optotypes often over-estimate vision due to the crowding phenomenon[11]. The child should be seated comfortably in a chair or on their parents lap, and encouraged not to lean forward, if possible. The testing distance should be measured from the child’s face to the eye chart, but even if this distance is imprecise, a subjective screening value can still give useful information, especially in the setting of asymmetry between each eye. A hand should be avoided as a monocular cover, as peeking around the cupped palm, or through fingers is common. The best method is to use a stick on eye patch or large fogged or solid occluder. Regardless of the method of occlusion, it is important that the examiner pay close attention that the child is not peaking from the side of the patch or holding/turning their head sideways. Another alternative is pediatric occlusion glasses, which have a large black plastic over one eye, and large foam animal shapes around the edges making peeking nearly impossible.

Computerized visual acuity testers are also available including: Vision Quest 20/20, Innova and M&S. These devices automate the testing protocol and are performed utilizing a computer monitor. Vision Quest is fully automated and uses crowded HOTV letters in a matching game disguised as a video game.

Objective Screening

Before a child can participate in subjective screening, more objective screening requires less input from children and is faster[3]. With objective screening techniques, the child merely needs to focus on a device long enough for the machine to obtain a measurement.

Even in infancy, early vision screening is important. Red reflex testing requires no patient participation, and abnormalities in the red reflex should prompt early referral for a variety of conditions, such as Cataracts in Children, Congenital and Acquired or retinoblastoma, that range from vision to life threatening.[12]

Autorefractive screening

There are a number of autorefractors which can be used to evaluate for amblyopia risk factors. Most of these tests are done monocularly and therefore do not screen for strabismus. These devices are used on undilated eyes and will give the user an estimation of the child’s refractive error. Based on pre-determined referral criteria, as noted above, the device or examiner can quickly determine if the child passed the screening or should be referred for further evaluation by a pediatric ophthalmologist for a cycloplegic refraction and comprehensive examination. The advantage to autorefractive screening is that it can be performed not only on verbal children, but on pre-verbal and non-verbal children as well. It is also much faster than subjective acuity screening.

Current available autorefractors used for pediatric vision screening include: Grand Seiko binocular autorefractor[13], Retinomax[2] and the SureSight[2]. While the SureSight is specifically marketed as a vision screening device, both the Retinomax and SureSight auto refractors were validated in the Vision in Preschoolers Study (VIPS).[2]

Photoscreening

Photoscreeners take images of the corneal light reflex from a child’s pupil. The test is performed binocularly and is based on the reflexes an examiner or a computer program can analyze to determine if there is strabismus and/or significant refractive error, or anisometropia (unequal refractive error). Photoscreeners can also detect other anatomical abnormalities, including cataract, coloboma or ptosis due to the change in the appearance of the red reflex. Unlike autorefrefractive screening, it can directly screen for manifest strabismus. The test can be performed on both verbal and pre-verbal children, and again, is much faster than acuity screening.

Although hypothetically a photoscreener could also detect leukocoria as a potential sign of retinoblastoma, this would represent a late finding in retinoblastoma as small peripheral tumors would be missed.

Current available photoscreeners include: iScreen[14], MTI[15], plusoptiX[16], Spot, and Visiscreen[17]. The MTI photoscreener, iScreen and Visiscreen use a visible light flash while PlusoptiX and Spot utilize infrared light, which is not visible to the child.

Visual Evoked Potential/Response (VEP/VER)

There is currently one device available from Diopsys which estimates visual acuity, or the difference in visual acuity between two eyes utilizing a sweep VEP[18]. The machine analyzes the results and gives the user a pass/refer result.

Polarized laser scan

In contrast to the above photoscreening devices, a new technology created by Rebion, called the blinq™ pediatric vision scanner, utilizes a polarized laser scan that probes retinal nerve fibers to detect small angle strabismus, and thereby small misalignment of the foveas, which can identify essentially 100% of children who have amblyopia, with fewer false positives compared with photoscreeners.[19] It is an easy to use device, typically held approximately 14 inches from the child’s eyes. While the child fixates on a smiley face, the device simultaneously scans both retinas in 2.5 seconds, with the capacity to detect up to one-degree of misalignment between the foveas, which correlates closely with the presence of amblyopia. A binocularity score is generated inicated the likelihood that the child requires referral to a pediatric ophthalmologist. In a study of this device published summer 2021, an earlier model of the blinq™, the Pediatric Vision Scanner yielded a sensitivity rate of 100% (95% CI, 54%-100%), and a specificity rate of 85% (95% CI, 80%-89%), with a median acquisition time of 28 seconds.[20] The newest model of this scanner, blinq™, has been cleared by the U.S. Food and Drug Administration, and received funding from the National Eye Institute.[19] It was studied in a prospective cross-sectional diagnostic accuracy study of 200 patients age 1-20 years, and found to have 100% sensitivity, and 91% specificity for detecting referral warranted amblyopia and strabismus, with a subanalysis of children age 2-8 years providing similar results.[21]

Future possibilities

Artificial intelligence may play a role in vision screening in the future. A smartphone based deep learning system has been shown to identify visual impairment in young children with various etiologies, including anisometropia, strabismus, cataracts, congenital abnormalities, and potentially other structural abnormalities. [22]

Public Health Implications

Pediatric vision screening is a critical public health intervention, especially as up to 28% of children in the U.S. experience vision impairment—most commonly due to uncorrected refractive error.[23] A recent study of a school-based screening program in Baltimore found that one in three students failed their vision screening, with high failure rates observed across all neighborhoods, regardless of socioeconomic disadvantage. These findings underscore the widespread need for vision services for all children.[24]

Untreated vision problems in children can lead to a wide range of consequences, including setbacks in school, social and emotional challenges, and long-term financial impact. One study on a school-based vision program in Baltimore showed that giving students eyeglasses led to measurable improvements in reading and math scores, especially among those who had been underperforming, and helped address disparities in access to care[25]. Another study found that children with visible eye conditions or those receiving treatments like patching were more likely to face victimization and anxiety during their preschool years[26]. In addition, a study estimated that vision loss and blindness cost the U.S. around $134.2 billion per year, factoring in both direct medical costs and indirect costs like lost productivity[27].

Detecting vision problems early is key to preventing these long-term effects. Amblyopia, or “lazy eye,” can lead to permanent vision loss if not treated in early childhood, when the brain is still developing and most responsive to treatment. Once that window closes, the vision loss can become irreversible[28]. Refractive errors like nearsightedness, farsightedness, and astigmatism are also common but can be corrected easily if caught early. Getting the right glasses not only improves eyesight but also supports healthy visual development and school performance. If left untreated, these issues can lead to complications like amblyopia down the line[29].

Advocacy and Policy Initiatives for Pediatric Vision Screening

The National Center for Children’s Vision and Eye Health (NCCVEH) recommends that physicians observe vision from birth up to the first year. Instrument based vision screening is recommended for 1 and 2 year olds. Optotype-based (eye charts) or instrument-based screening is indicated for children between the ages of 3 and 5 years old. Currently the United States Preventive Services Task Force (USTPF), an independent volunteer panel, recommends that children between the ages of 3 and 5 years old get screened at least once for amblyopia or its risk factors. Children age 6 and above should have yearly optotype-based screening focused on identifying uncorrected refractive errors. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) recommends repeated visual acuity screenings every 1 to 2 years after the age of 5.

As of May 2025, Congress introduced H.R. 8400, titled the "Early Detection of Vision Impairments in Children (EDVI) Act," which would provide grants and cooperative agreements to state, community, and tribal entities to promote early identification, intervention, and referral for children with vision problems. The EDVI is significant because while there are public health programs supporting children's hearing and oral health, there is currently no dedicated national program for children's vision. Key objectives of the act include implementing early detection and follow-up systems, raising public awareness about the importance of pediatric eye health, reducing disparities in care, and establishing robust data and surveillance infrastructure. The bill also allocates resources to the CDC to create a national technical assistance center to support these efforts and encourages interagency collaboration between the Department of Health and Human Services and the Department of Education.

School-Based Screening Programs

Reading is fundamental. Learning involves the receipt, processing and retention of information from the environment. The visual process is the most important interface between a person and her environment.[30] Since reading is the primary means of visual communication of information; it is crucial to the learning process and academic success. Visual deficits can affect the comprehension and processing of the information, as well as lead to behavioral issues affecting attention and retention. Studies suggest from seven to twenty percent of school age children have a visual deficit[31][32], with a significantly higher percentage of minority and lower socioeconomic children having deficits that are undiagnosed and untreated. [33][34]Uncorrected vision impairs students’ ability to perform at their academic potential.[33] Early school-based diagnosis and treatment with corrective lenses can help alleviate these barriers to achievement for children already at scholastic disadvantage.[35] School based screening is crucial to address this growing problem.

Children’s vision screening requirements vary by state. Half the states require vision screening for preschool-age children, and forty require vision screening for school-age children.[36] Nevertheless, vision screening prevalence steadily declined from 2016 to 2020, and there appears to be a statistically significant continuation of the trend post pandemic onset.[37] Pre-school and grade school teachers are in the best position to detect potential problems and educate parents regarding the importance of vision evaluation regardless of apparent problems. If on-site screening is not feasible, then written information, screening promotion and resource assistance should also be provided by the schools. Vision screening, diagnosis and treatment with corrective lens is available at no cost to Medicaid enrolled children through the Early and Periodic Screening, Diagnostic, and Treatment (“EPSDT”) benefit. The same benefit is available in every state through the Children's Health Insurance Program (CHIP), which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

Links

References

  1. ↑ Arnold RW, Donahue SP. The yield and challenges of charitable state-wide photoscreening. Binocul Vis Strabismus Q. 2006;21(2):93-100
  2. ↑ 2.0 2.1 2.2 2.3 Ying GS, Maguire M, Quinn G, Kulp MT, Cyert L; Vision In Preschoolers (VIP) Study Group. ROC analysis of the accuracy of Noncycloplegic retinoscopy, Retinomax Autorefractor, and SureSight Vision Screener for preschool vision screening. Invest Ophthalmol Vis Sci. 2011 Dec 28;52(13):9658-64.
  3. ↑ 3.0 3.1 3.2 Arnold RW, Stark L, Leman R, Arnold KK, Armitage MD. Tent photoscreening and patched HOTV visual acuity by school nurses: validation of the ASD-ABCD protocol. (Anchorage School District- Alaska Blind Child Discovery program). Binocul Vis Strabismus Q. 2008;23(2):83-94.
  4. ↑ Marsh-Tootle WL, Wall TC, Tootle JS, Person SD, Kristofco RE. Quantitative pediatric vision screening in primary care settings in Alabama. Optom Vis Sci. 2008 Sep;85(9):849-56.
  5. ↑ Wahl MD, Fishman D, Block SS, Baldonado KN, Friedman DS, Repka MX, Collins ME. A Comprehensive Review of State Vision Screening Mandates for Schoolchildren in the United States. Optom Vis Sci. 2021 May 1;98(5):490-499. doi: 10.1097/OPX.0000000000001686. PMID: 33973910.
  6. ↑ Teed RG, Bui CM, Morrison DG, Estes RL, Donahue SP. Amblyopia therapy in children. Ophthalmology. 2010 Jan;117(1):159-62.
  7. ↑ Sachsenweger R. Problems of organic lesions in functional amblyopia. International Strabismus Symposium (University of Giessen, 1966). Basel and New York: S. Karger AG;1968, p. 63.
  8. ↑ Neitzel AJ, Wolf B, Guo X, Shakarchi AF, Madden NA, Repka MX, Friedman DS, Collins ME. Effect of a Randomized Interventional School-Based Vision Program on Academic Performance of Students in Grades 3 to 7: A Cluster Randomized Clinical Trial. JAMA Ophthalmol. 2021 Oct 1;139(10):1104-1114. doi: 10.1001/jamaophthalmol.2021.3544. PMID: 34499111; PMCID: PMC8430909.
  9. ↑ American Academy of Ophthalmology. Pediatric Eye Evaluations: Screening and Comprehensive Ophthalmic Evaluations Preferred Practice Pattern. September 8, 2007.
  10. ↑ 10.0 10.1 Donahue SP, Arnold RW, Ruben JB; AAPOS Vision Screening Committee. 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 Oct;7(5):314-6.
  11. ↑ Morad Y, Werker E, Nemet P. Visual acuity tests using chart, line, and single optotype in healthy and amblyopic children. J AAPOS. 1999 Apr;3(2):94-7.
  12. ↑ Loh AR, Chiang MF. Pediatric Vision Screening. Pediatr Rev. 2018 May;39(5):225-234. doi: 10.1542/pir.2016-0191. PMID: 29716965; PMCID: PMC6317790.
  13. ↑ Matta NS, Singman EL, Brubaker C, Silbert DI. Auto-objective accommodative measurements as a valid and reliable new method of pediatric, strabismus and amblyopia, vision screening. Binocul Vis Strabolog Q Simms Romano. 2011;26(3):140-5.
  14. ↑ Schmidt P, Maguire M, Dobson V, Quinn G, Ciner E, Cyert L, Kulp MT, Moore B, Orel-Bixler D, Redford M, Ying GS; Vision in Preschoolers Study Group. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study. Ophthalmology. 2004 Apr;111(4):637-50
  15. ↑ Matta NS, Arnold RW, Singman EL, Silbert DI. Comparison between the plusoptiX and MTI Photoscreeners. Arch Ophthalmol. 2009 Dec;127(12):1591-5.
  16. ↑ 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 Apr;14(2):147-9.
  17. ↑ Morgan KS, Johnson WD. Clinical evaluation of a commercial photorefractor. Arch Ophthalmol. 1987 Nov;105(11):1528-31.
  18. ↑ 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 Dec;8(6):549-54.
  19. ↑ 19.0 19.1 Vision screening device improves detection of “lazy eye”: The NEI-funded technology accurately identifies children who need treatment for amblyopia. National Eye Institute. June 3, 2020.https://www.nei.nih.gov/about/news-and-events/news/vision-screening-device-improves-detection-lazy-eye
  20. ↑ Shah SS, Jimenez JJ, Rozema EJ, Nguyen MT, Preciado M, Mehta AM. Validation of the Pediatric Vision Scanner in a normal preschool population. J AAPOS. Aug 2021; 25(4): 216-217.
  21. ↑ Bosque LE, Yamarino CR, Salcedo N, Schneier AJ, Gold RS, Blumenfeld LC, Hunter DG. Evaluation of the blinq vision scanner for detection of amblyopia and strabismus. J AAPOS Aug 2021. 25(4): 214-215.
  22. ↑ Chen, W., Li, R., Yu, Q. et al. Early detection of visual impairment in young children using a smartphone-based deep learning system. Nat Med 29, 493–503 (2023). https://doi.org/10.1038/s41591-022-02180-9
  23. ↑ Ruderman M Children’s Vision and Eye Health: A Snapshot of Current National Issues. National Center for Children’s Vision and Eye Health at Prevent Blindness; 2016. Accessed March 22, 2021. https://preventblindness.org/wp-content/uploads/2016/03/Childrens_Vision_Chartbook.pdf
  24. ↑ Vongsachang H, Guo X, Friedman DS, Yenokyan G, Collins ME. Neighbourhood Disadvantage and Vision Screening Failure Rates: Analysis of a School-Based Vision Program in Baltimore, Maryland. Ophthalmic Epidemiol. 2023 Aug;30(4):441-444. doi: 10.1080/09286586.2022.2119259. Epub 2022 Sep 16. PMID: 36111969; PMCID: PMC10017369.
  25. ↑ Basch, C. E., Basch, C. H., & Redlener, I. (2021). Improving access to vision care in urban schools: The role of school-based vision programs in reducing disparities. JAMA Ophthalmology, 139(2), 213–221. https://doi.org/10.1001/jamaophthalmol.2020.5082
  26. ↑ Horwood, A. M., & Waylen, A. (2015). The effect of childhood eye disorders on social relationships and psychological functioning: A literature review. JAMA Ophthalmology, 133(6), 681–686. https://doi.org/10.1001/jamaophthalmol.2015.0652
  27. ↑ Rein, D. B., Wittenborn, J. S., Zhang, X., Honeycutt, A., Lesesne, S., & Saaddine, J. (2022). The economic burden of vision loss and blindness in the United States. Ophthalmology, 129(4), 369–378. https://doi.org/10.1016/j.ophtha.2021.10.012
  28. ↑ Henry Ford Health. (n.d.). Lazy eye (amblyopia) in children. Retrieved May 14, 2025, from https://www.henryford.com/services/eye/treatments/pediatric-services/types/lazy-eye
  29. ↑ Johns Hopkins Medicine. (n.d.). Refractive errors. Retrieved May 14, 2025, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/refractive-errors
  30. ↑ Gallop, S., Dynamic Lens Application, Journal of Behavioral Optometry, Vol.  9, #5, 1998; Ong E., Ciuffreda K., Accommodation, Near Work and Myopia. Santa Ana: CEPF, 1997.
  31. ↑ U.S. Center for Disease Control, Vision and Eye Health, Vision and Age, May 15, 2024 , https://www.cdc.gov/vision-health/data-research/vision-loss-facts/index.html.
  32. ↑ Dudovitz, R, Izadpanah, N, Chung, P., Slusser, W., Parent, Teacher, and Student Perspectives on How Corrective Lenses Improve Child Wellbeing and School Function, Matern Child Health J DOI 10.1007/s10995-015-1882-z, ISSN 1092-7875
  33. ↑ 33.0 33.1 Vitale, S., Cotch,M., Sperduto, R., Prevalence of Visual Impairment in the United States; JAMA. 2006;295(18):2158-2163. doi:10.1001/jama.295.18.2158.
  34. ↑ Varma, R., Tarczy-Hornoch, K., Jiang, X., Visual Impairment in Preschool Children in the United States Demographic and Geographic Variations From 2015 to 2060, JAMA Ophthalmol., 2017 Jun 8;135(6):610–616. doi: 10.1001/jamaophthalmol.2017.1021.
  35. ↑ Neitzel, A. Wolf, B., Guo, X.; et al, Effect of a Randomized Interventional School-Based Vision Program on Academic Performance of Students in Grades 3 to 7A Cluster Randomized Clinical Trial JAMA Ophthalmol. 2021;139(10):1104-1114. doi:10.1001/jamaophthalmol.2021.3544.
  36. ↑ Madison D Wahl, D., Fishman, Block, S., Baldonado, K., Friedman, D., Repka, M., Collins, M., A Comprehensive Review of State Vision Screening Mandates for Schoolchildren in the United States Optom Vis Sci., 2021 May1;98(5):490-499. doi: 10.1097/OPX.0000000000001686.
  37. ↑ Chauhan, M., Elhusseiny, A., Samarah, E., Rook, B., Sallam, A., Phillips, P., Five-Year Trends in Pediatric Vision Screening and Access in the United States Ophthalmology. 2022 Oct 3;130(1):120–122. doi: 10.1016/j.ophtha.2022.09.018.
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