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Newborns are born with poor visual acuity, measuring 20/600 at birth, which then improves to 20/120 by 3 months and to 20/60 by 6 months of age. Binocularity begins developing by 3 to 4 months of age, and the ability to distinguish color begins at 5 months. The visual system does not reach maturity until 9 to 10 years of age. The time of development and plasticity between birth and visual maturity is known as the critical period, the time during which proper vision must develop in order to have normal visual acuity and binocular vision. Alterations or impediments to the image projected onto the retina profoundly affect visual development and can lead to vision-threatening and blinding diseases. It is, therefore, essential to identify such degradations early to prevent poor visual outcomes. Most vision loss is preventable or reversible with the right intervention for the individual etiology. The recovery depends on the maturity of the visual connections, the length of deprivation, and the age at which therapy is begun.


The newborn eye examination is essential for identifying potentially blinding eye diseases early in life and to prevent permanent vision loss or impairment. The goal of the examination is to identify sight- and eye-threatening conditions such as orbital tumors, abnormal eyelid position or function, strabismus, cataracts, corneal opacities, congenital malformations, and retinal abnormalities, prompting referral to a pediatric ophthalmologist (see also Chapter 7).

The American Academy of Pediatrics recommends an age-appropriate assessment in the newborn period. Infants at high risk of eye problems (eg, those with prematurity, significant neurologic or developmental delays, metabolic or genetic diseases, positive family history of blinding eye diseases, any systemic diseases associated with eye abnormalities) should be referred for a specialized eye examination by a pediatric ophthalmologist. Normal findings that resolve include edema, lid eversion, bruising, subconjunctival hemorrhage, and nevus simplex. Any unexpected abnormalities on examination should be referred.

  1. Ocular and family history. A full history of family eye diseases should be obtained, including history of congenital cataracts, retinoblastoma, and hereditary retinopathies.

  2. Vision assessment. Even as a newborn, an infant will blink in response to a penlight; this reflex should be equal in both eyes. The ability to fixate on and follow an object, however, may not be present for the first few months of life.

  3. External exam. External inspection of the eyes (conjunctiva, sclera, cornea, and iris) and lids should be performed to identify congenital or acquired anomalies. The lids should be completely formed without deformity, ptosis, or retraction. The cornea should be clear and 9.5 to 10.5 mm in diameter. The iris should be present, and the color should be uniform and equal in both eyes. Subconjunctival hemorrhage and eyelid edema and ecchymosis may be present and usually resolve without intervention.

  4. Motility. Transient binocular nystagmus is common in infants <6 months, but monocular or constant ...

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