• All newborn infants and all children at subsequent
well-child health supervision visits.
• All premature infants.
• Children with significant developmental delay or neurologic disorders.
• Children with systemic disease associated with eye abnormalities.
• All children with a family history of congenital cataracts, retinoblastoma,
and metabolic or genetic diseases.
(Newborn to Age 3 Years)
(Age 3 Years and Older)
• Picture tests, such as Allen cards or LEA symbols
(flash cards with figures or symbols), are suggested for children 3–4
years of age.
• Tumbling E test (which involves matching the orientation of the
legs of the letter E with the child’s fingers) or HOTV
test (which involves matching the letters H, O, T, V on a wall chart
with the correct letter on a testing board) is suggested for children
ages 3–5 years.
• Snellen acuity chart (using Snellen letters or numbers) is suggested
for children 6 years of age and older.
• Occluders are used to obtain complete coverage of the untested
of the Eyes and Lids
• Cross cover test uses any object to focus on
and an occluder.
• Random dot E stereo test uses raised and recessed E cards.
• Titmus test uses objects printed on material polarized at 90
degrees and polarized filter spectacles.
• Simultaneous red reflex test (Bruckner test) uses direct ophthalmoscope.
• When testing visual acuity, the test requiring
the highest level of cognitive function that the child is capable
of performing should be used.
• Children who wear eyeglasses should have their visual acuity
tested while wearing the eyeglasses.
• It is recommended that visual acuity be tested using commercially
available occluders that provide complete occlusion rather than
cardboard or paddle occluders, which can allow for peeking.
• When testing visual acuity, tests that use a line of figures are
preferred over tests using single figures.
• The child should be examined while in good health.
• The child should be comfortable; for younger children this may
require that the child be sitting on a parent’s or guardian’s
• Keep distractions to a minimum.
• The child should be visually fixing on an object,
particularly when assessing ocular alignment.
• When measuring visual acuity, it is imperative that the child
be 10 feet away from the testing equipment.
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