Vision Screening 101: When to take your child to the optometrist or ophthalmologist and what to expect

Eye health is important at all ages. When it comes to children, how do you know if you should consult an optometrist or an ophthalmologist for eye-related issues? Le Bonheur Pediatric Ophthalmologist Lauren Ditta, MD, answers some common questions.

When is my child’s vision usually tested? How?

Primary care physicians and nurses are usually the first ones to detect preventable vision loss in children. From birth through the first 12 months of your baby’s life, your primary care provider should be taking an ocular history. Important information for you to know includes knowing about your family history of eye problems, especially things that may have affected family members during their childhood, like the need for glasses, lazy eye, or childhood cataracts.

Signs of good visual behavior very early in your child’s life include:

• blinking to light
• looking directly at your face
• tracking toys that you may put in front of him or her

Your provider will examine your child’s eyelids and how his or her eyes move and, most importantly, evaluate your child for a present and equal red reflex in both eyes.

What are some signs that my child might have vision issues? 

Some signs that your child might have a vision issue include:

• your child’s inability to look directly at you, especially after 2- 3 months
• not blinking to a bright light
• eyes roving around constantly
• eye(s) constantly turning in or out
• constantly rubbing his or her eyes
• white opacity in the center of your baby’s eye
• shaking or persistent turning of your child’s eyes

By 6 months of age, your child should be able to track you and objects well and should be doing this without shaking or jerking and without persistent crossing or turning.

When might my child need to see an eye specialist? What’s the difference between an optometrist and an ophthalmologist?

It is important to follow up with an eye care specialist when your primary care provider or pediatrician refers you one. In these situations, they are seeing something abnormal with your child’s eye, or they may have a concern that your child may have an issue with his or her eyes.

However, a primary care provider is only seeing your child for a brief period of time and this is only a snapshot of what your child looks like all of the time. Therefore, if you feel that your child may have something wrong with his or her eyes, it is important that you consider taking the initiative to bring your child to an eye care specialist. Additionally, if know there is a strong family history of eye problems (ocular tumors, childhood cataract, glaucoma, lazy eye or strabismus, wearing glasses), it may be beneficial to bring your child in. 

An ophthalmologist went to medical school. An optometrist did not. An ophthalmologist can perform surgery, and optometrist cannot. Both can give your child glasses. Basically, an ophthalmologist can do everything an optometrist can do, including performing surgery when needed, and the ophthalmologist often is more familiar with complex cases of eye disease, as these often require more advanced medical or surgical treatment

What’s the difference between an optometrist and an ophthalmologist?

An ophthalmologist went to medical school. An optometrist went to optometry school. An ophthalmologist can perform surgery, and an optometrist cannot. Both can give your child glasses. Basically, an ophthalmologist can do everything an optometrist can do, including performing surgery when needed, and the ophthalmologist often is more familiar with complex cases of eye disease, as these often require more advanced medical or surgical treatment.

What kinds of things might my child need to see an ophthalmologist for? Do I need to make sure it’s a pediatric ophthalmologist?

You should see a pediatric ophthalmologist if your child may need surgical correction or a procedure done for an eye problem such lazy eye, crossing or turning of the eye, eye tumors, glaucoma, lesions of the eyelid, persistent tearing, cataracts, any type of ocular trauma or if your child has had previous eye surgery. If your child has a chronic history of eye problems, it benefits them to see an ophthalmologist. Your child may need to see an ophthalmologist if he or she needs glasses.

Pediatric ophthalmologists are trained to identify problems that are specific to children’s eyes. Additionally, they specifically know how to perform a good eye exam while being attentive to the needs of your child. Often, their offices are “kid friendly,” and the office staff are accustomed to seeing children.

What can I expect at my child’s first ophthalmologist appointment?

First and foremost, come prepared. Across the country, good pediatric ophthalmologists can often have long wait times in the office. This is in part because the examination is not quick. Additionally, like any other doctor, we try to give each patient a thorough examination and make sure the family has time to have their questions answered. The eye is an area that many people are not familiar, so sometimes it can take a long time to explain things.

The examination is not quick, and there are two parts. This is different from any other doctor’s appointment your child has had before. An examination on a normal, cooperative child from start to finish completing all parts of the examination takes at a minimum one hour. AGAIN, this is on the most cooperative of children.

Also know that drops will be given. Babies and young children hate drops and will cry. The examination on younger children is not pleasant for anyone. Sometimes children need to be held down to perform the examination. Moms need to be prepared that their child will not like this.

Vision-screening guidelines endorsed by the American Academy of Pediatric Ophthalmology and Strabismus include:

Newborn to 36 months: Evaluation by primary care provider to the external eyes and eyelids, assess vision and ability to track, ocular alignment, pupils and red reflexes.

From 36 months to 5 years: Direct measures of visual acuity should be attempted, which include reading the eye chart. This can be done in your primary care provider’s office or you may take your child directly to a pediatric ophthalmologist. Children ages 36-47 months must correctly identify the majority of the optotypes on the 20/50 line to pass. Children ages 48-69 months must correctly identify the majority of the optotypes on the 20/40 line to pass. Children 5 years and older must read at least 20/30 with either eye and must be able to identify the majority of the optotypes on the 20/30 line.

Some primary care offices may perform photoscreening, which is a test that evaluates for risk factors what may affect your child’s vision. Any child who fails to meet the visual testing criteria or has abnormal photoscreening may be referred directly to a pediatric ophthalmologist. Additionally, older children not reading at grade level may be referred.