Pediatric Eye Exams 101


Q: Both my husband and I have glasses, but my son has never complained of vision problems. How do I know when it is time to take him in for an eye exam?

A: The other day, the cutest little girl came in for her first eye exam. She was an eight year old, starting third grade and an excellent student, reading above grade level. Her parents were sure she didn’t need glasses but thought it was time for her to start having routine eye exams. She was articulate and outspoken and wanted to be done with her visit so she could get on with her day. She read the eye chart in her right eye all the way down to the tiniest letter and was eager to do the same on the left eye. But to everyone’s surprise, she struggled, barely getting halfway down the eye chart, guessing and growing frustrated as she realized something wasn’t right. She also had some trouble seeing in 3D, which indicated that her two eyes were not working together. At the end of the exam, I told her parents that, although her right eye was perfect, she was hyperopic, or farsighted, in her left eye. The large discrepancy between the two eyes had created amblyopia (lazy eye) in her left eye, and she left with a new pair of glasses and a scheduled follow-up appointment in three months.

80% of learning is visual; if your child does not see well, he or she will struggle in school. Sometimes, kids are unable to realize or articulate that something is wrong—either they will think that whatever they are experiencing is normal or they just won’t complain. Vision screenings at the pediatrician or with the school nurse are not a substitute for a full and comprehensive eye exam. Eye exams are recommended at the age of six months (by specialized infantSEE providers) and then yearly after the age of three. Early use of iPads and other digital devices creates a new challenge for children’s developing visual systems, and seeing well involves more than just seeing 20/20 on an eye chart. Evaluation of tracking, eye teaming, and convergence are crucial to ensuring optimal ocular performance and subsequent academic success.

Here are some of the most common questions I get from parents who are skeptical about having their child’s eyes checked:

1. How can you my check my child’s eyes when he does not know his letters yet?

This is a great question. Have you ever looked at a baby wearing glasses and wondered how they figured out the prescription? Not only do babies not know their letters, but they are nonverbal as well! The answer is simple—eye doctors who examine young children rely on objective, and not subjective, information. Objective information can be acquired in a couple of ways, usually involving the instillation of dilating drops and using either a retinoscope or an autorefractor to come up with a prescription.

2. My child really wants glasses and I don’t think she will be truthful when reading the eye chart—how do you deal with that?

First of all, we don’t only rely on subjective responses when we prescribe glasses. As discussed in the above section about babies, we rely more on the objective testing, so your child is not getting glasses based only on the way she reads the eye chart. Depending on the personality of the child, there are also multiple little tricks we have for getting her to answer truthfully without her even knowing that she is doing so.

3. What is a lazy eye?

Very often, a lazy eye is confused with an eye turn—these two entities are not the same. Strabismus is the proper clinical term for eye turns, which is when the eyes are abnormally aligned (what people commonly think of as lazy eye). Amblyopia, however, is the clinical term for a lazy eye and is a condition where an eye has reduced vision due to lack of development of central vision. Therefore, lazy eye can occur even when the eyes are properly aligned. It is also possible to have strabismus and amblyopia at the same time, which is why this can get confusing.

Strabismus can range from being very obvious to very subtle and can be constant or intermittent. Sometimes surgical correction is needed; sometimes vision therapy alone will be enough to get the two eyes to work together.

Amblyopia can be caused by:

●       Strabismus

●       A large difference in the degree of nearsightedness or farsightedness between the two eyes

●       Deprivation of visual input, caused by a cataract or a droopy lid that covers the eye

Treatment of amblyopia depends on its cause and can include a full-time glasses prescription, patching, vision therapy, removal of cataract when indicated or a combination of these options. Old-school thinking was that if the amblyopic eye was not treated in early childhood, there was no chance for visual improvement, but recent studies have shown improvements with treatment even at older ages. However, the younger the child is when the condition is detected and treated, the better.

4. My child passed the vision screening test at school and sees just fine—why do I need to take him to the eye doctor as well?

Vision screenings at the pediatrician usually just test distance vision. While this is useful to pick up myopia (nearsightedness), these screenings usually miss hyperopia (farsightedness) and eye turns. Screenings also don’t evaluate tracking, binocularity, or accommodative (focusing) skills, which are essential for academic success. In addition, screenings don’t evaluate the health of the ocular structures. A slit lamp exam and pupillary dilation are necessary to rule out more benign conditions, such as dry eye, ocular allergies and blepharitis, as well as more serious conditions, such as cataracts, glaucoma, and retinal diseases. Some of these diseases may not present with symptoms and are visually devastating if not detected and treated promptly.

Not all eye doctors examine children, and not all pediatric eye doctors are truly child-friendly. It’s always a great idea to get a referral from your pediatrician or from a friend whose kids wear glasses, rather than just picking someone off your insurance list. It is also important to make sure your child is checked yearly, even if they initially don’t need glasses or have any other issues. As children grow, their visual systems, as well as their visual demands, develop and change; it is important to stay on top of these changes in order to ensure your child’s optimal visual and ocular health.