Editorial

Pediatric eye screening – Why, when, and how

The World Health Organization (WHO) reports that there are approximately 19 million visually impaired children in the world,
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and 1.4 million are blind.[1] In India, 0.8 per 1000 children are estimated to be blind.[2] This is bound to be an underestimation of the
overall problem because it excludes children with visual impairment that does not conform to the WHO definition of blindness.
About half of the causes of blindness and visual impairment are potentially preventable or treatable.[2] Childhood blindness is
second only to adult cataract in terms of the number of blind person years lived and the consequent overall economic impact
on the society.[2]
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Timely and periodic screening is critical for the detection of visual impairment and its etiology and to plan early intervention.
Appropriate estimation of the visual function, and detection of refractive error, retinopathy of prematurity, congenital structural
anomalies, congenital dacryocystitis, corneal scar, glaucoma, cataract, retinal abnormalities, retinoblastoma, strabismus,
and amblyopia are the crucial components of screening in children. Protocols vary from country to country, with limited
agreement on the need, modality, timing and periodicity of screening.[3‑6] While some countries and organizations have
mandated screening at birth and thereafter periodically at every pre‑scheduled point of contact with the pediatrician, [3‑6] recent
recommendations by the United States Preventive Services Task Force (USPSTF) limit screening to children aged 3–5 years
to detect amblyopia or its risk factors.[7] The USPSTF advises that the current evidence is insufficient to recommend vision
screening in children <3 years of age.[7] However, a Joint Policy Statement by the American Academy of Pediatrics, American
Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and American Association
of Certified Orthoptists emphasises that vision assessments and screening eye examinations are critical for the detection of
conditions that result in visual impairment, lead to problems with school performance, harbinger serious systemic disease,
and, in some cases, threaten the child’s life.[8,9] The incidence and prevalence of conditions causing visual morbidity varies
widely across the world [Table 1].[10] Unfortunately, the available data on pediatric vision impairment and blindness in India
are not broad‑based or robust enough to generalize and make firm recommendations.[2] Glaringly, there are no formal Indian
national guidelines for vision and eye screening in children.

Table 1: Estimated burden of visually significant ophthalmic conditions in children

Condition Frequency*

Refractive errors
Myopia (–0.75 D or more in eye with lesser refractive error) 0.7%-9% (prevalence, age 5-17 years)
Myopia (more than –2.0 D) 0.2%‑2% (prevalence, age 3‑5 years)
Hyperopia (+3.0 D or more in eye with lesser refractive error) 4%‑9% (prevalence, age 5‑17 years)
Hyperopia (more than +3.25 D) 6%‑7% (prevalence, age 3‑5 years)
Astigmatism (worse eye cylinder power 3.0 D or more) 0.5%‑3% (prevalence, age 5‑17 years)
Astigmatism (cylinder power more than 1.5 D) 4%‑11% (prevalence, age 3‑5 years)
Amblyopia 0.8%‑3% (prevalence, age 6‑72 months)
Strabismus 0.08%‑4.6% (prevalence, age 6‑72 months)
1.2%‑6.8% (prevalence, age 6‑17 years)
Cerebral visual impairment Accurate data is lacking
Congenital cataract 0.02% (prevalence, age 0 to 1 year)
0.1% (prevalence, age 6 months to 6 years)
0.42% (prevalence, age 6 to 15 years)
Retinopathy of prematurity 8.6%‑9.2% (incidence, 1000‑1250 g at birth)
15.2%‑18.3% (incidence, 800‑999 g at birth)
Congenital glaucoma 0.0015%‑0.0054% (prevalence, new born)
Retinoblastoma 0.0011%‑0.0013% (yearly incidence, age <5 years)
Pediatric uveitis 0.004% (yearly incidence, age <16 years)
D: Diopter. *Please refer to the source document for references that support the data. Source: Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX,
Lee KA, et al., American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations
Preferred Practice Pattern: I. Vision Screening in the Primary Care and Community Setting; II. Comprehensive Ophthalmic Examination. Ophthalmology
2018;125:P184‑P227.

© 2018 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

 890 Indian Journal of Ophthalmology Volume 66 Issue 7

Guidelines for pediatric eye screening continue to evolve as timing and methods have not been definitively established. Current
guidelines are based on the available evidence and preferred practice recommendations of expert committees.[8‑10] Primary care
providers (pediatricians) should perform a basic eye screening of newborns.[8‑10] Risk‑based screening for retinopathy of prematurity,
congenital anomalies, and retinoblastoma in the immediate post-natal period should be conducted by an ophthalmologist.[8‑10]
Pre‑screening history should include the following questions: (1) Do your child’s eyes appear unusual, (2) Does your child seem
to see well, (3) Does your child exhibit difficulty with near or distance vision, (4) Do your child’s eyes appear straight or do they
seem to cross, (5) Do your child’s eyelids droop or does one eyelid tend to close, and (6) Has your child ever had an eye injury.[8‑10]
Screening of infants under 6 months of age comprises of red reflex testing to detect abnormalities of the ocular media, external
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inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior.[10,11]
Findings that would warrant referral of children to an ophthalmologist for a detailed eye examination following screening are
listed in Table 2.[10,11] Screening from 6 months to 1 year includes binocular alignment.[10,11] Between 1 year to 2 years and 2 years
to 3 years, instrument‑based screening with photoscreening or autorefraction devices can be valuable in detecting amblyopia
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risk factors.[10,11] These tests are rapid and non-invasive, and minimal cooperation is required on the part of the child.[10,11] Between
ages 3 and 4 years, visual acuity screening with LEA symbols or HOTV letter chart become possible.[10,11] Older children may

Table 2: Age‑appropriate methods for pediatric vision screening and criteria for referral
Method Screening Logistics Indications for Referral Recommended Age

0‑6 m 6‑12 m 1‑3 y 3‑4 y 4‑5 y >5 y

Comprehensive Primary screening Congenital structural anomalies

screening at birth at birth by the of the eye and adnexa, congenital
pediatrician. Risk‑based dacryocystitis, congenital corneal
primary screening opacity, congenital cataract,
for retinopathy of congenital glaucoma, retinopathy of
prematurity, congenital prematurity, and retinoblastoma
anomalies, and
retinoblastoma by the
ophthalmologist
Red reflex test Ophthalmic technician or Absent, white, dull, opacified, or Yes Yes Yes Yes Yes Yes
optometrist asymmetric
External inspection Ophthalmic technician or Structural abnormality (e.g., ptosis, Yes Yes Yes Yes Yes Yes
optometrist epiphora)
Pupillary Ophthalmic technician or Irregular shape, unequal size, and Yes Yes Yes Yes Yes Yes
examination optometrist poor or unequal reaction to light
Fix and follow Ophthalmic technician or Failure to fix and follow Yes* Yes Yes Yes Yes Yes
optometrist
Corneal light reflex Ophthalmic technician or Asymmetric or displaced Yes Yes Yes Yes Yes
optometrist
Instrument‑based Ophthalmic technician or Failure to meet screening criteria Yes Yes Yes Yes
screening optometrist
Cover test Ophthalmic technician or Refixation movement Yes Yes Yes
optometrist
Distance visual Ophthalmic technician or Worse than 20/50 either eye or 2 Yes Yes Yes
acuity (monocular) optometrist lines of differences between the eyes
Worse than 20/40 either eye Yes Yes
Worse than 3 of 5 optotypes on Yes
20/30 line, or 2 lines of difference
between the eyes
*in a cooperative child >3 m. Source: Hagan JF, Shaw JS, Duncan PM, eds. 2017, Bright Futures: Guidelines for Health Supervision of Infants, Children and
Adolescents. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2017 and Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA, et al.,
American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern:
I. Vision Screening in the Primary Care and Community Setting; II. Comprehensive Ophthalmic Examination. Ophthalmology 2018;125:P184‑P227
 Honavar: Pediatric eye screening
July 2018 891

be tested with standard optotypes.[10,11] Children who are untestable should be rescreened within 6 months or referred for a
comprehensive eye examination.[10,11] Children who are testable using the subjective visual acuity assessment and fail should be
referred for a comprehensive eye examination after the first screening failure.[10,11] Additional findings that would warrant referral
of for a comprehensive ophthalmic examination are listed in Table 2.[10,11] Children should continue to have annual school‑based
vision screening throughout the childhood and adolescence.[10,11] In India, screening up to age 5 years could be integrated with the
Universal Immunization Program of the Government of India and performed by a trained ophthalmic assistant or an optometrist.
Beyond the age of 5 years, it should be a part of annual school health check‑up and performed by a trained ophthalmic assistant
or an optometrist.
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This issue of the Indian Journal of Ophthalmology carries several articles that address various issues related to vision screening
in children, which indicates that there is renewed enthusiasm in Indian caregivers and researchers to study this aspect.[12‑16] If
India must relieve itself of the burden of avoidable pediatric blindness and provide the benefit of early rehabilitative intervention
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to those who are incurably blind, then it is imperative to accumulate reliable population‑based data and use that as a base to
craft a robust screening program, seamlessly linked to curative and rehabilitation facilities. A working group representing all
the stakeholders seems to be an immediate primary need to prioritize this issue.

Santosh G Honavar
Editor, Indian Journal of Ophthalmology, Editorial Office: Centre for Sight,
Road No 2, Banjara Hills, Hyderabad - 500 034, Telangana, India.
E‑mail: [email protected]
References
1. World Health Organisation. Global data on visual impairments 2010. Available from: http://www.who.int/blindness/GLOBALDATAFINALforweb.
pdf [Last accessed on 2018 June 19].
2. Gudlavalleti, VSM. Magnitude and Temporal Trends in Avoidable Blindness in Children (ABC) in India. Indian J Pediatr 2017;84:924‑9.
3. American Association of Pediatric Ophthalmology and Strabismus. Vision Screening Recommendations‑Techniques for Pediatric Vision
Screening. Available from: https://aapos.org//client_data/files/2014/1076_aapos_visscreen.pdf [Last accessed on 2018 June 19].
4. Canadian Pediatric Society. Vision screening in infants, children and youth. Paediatr Child Health 2009;14:246‑8.
5. Cotter SA, Cyert LA, Miller JM, Quinn GS. Vision Screening for Children 36 to <72 Months: Recommended Practices. Optom Vis Sci 2015;92:6‑16.
6. Public Health England. Child vision screening. Available from: https://www.gov.uk/government/publications/child‑vision‑screening [Last
accessed on 2018 June 19].
7. US Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Davidson KW, Doubeni CA, et al Vision Screening in
Children Aged 6 Months to 5 Years: US Preventive Services Task Force Recommendation Statement. JAMA 2017;318:836‑44.
8. Donahue SP, Nixon CN; Section on Opthamology, American Academy of Pediatrics; Committee on Practice and Ambulatory Medicine,
American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus;
American Association of Certified Orthoptists. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics
2016;137:28‑30.
9. Donahue SP, Baker CN; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; Section on Ophthalmology,
American Academy of Pediatrics; American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and
Strabismus; American Academy of Ophthalmology. Procedures for the Evaluation of the Visual System by Pediatricians. Pediatrics 2016 [Epub
ahead of print].
10. Wallace DK, Morse CL, Melia M, Sprunger DT, Repka MX, Lee KA, et al., American Academy of Ophthalmology Preferred Practice Pattern
Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern: I. Vision Screening in the Primary Care and
Community Setting; II. Comprehensive Ophthalmic Examination. Ophthalmology 2018;125:P184‑227.
11. Hagan JF, Shaw JS, Duncan PM, eds. 2017, Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 4th ed.
Elk Grove Village, IL: American Academy of Pediatrics; 2017.
12. Paul CM, Sathyan S. Comparison of the efficacy of Lea Symbol chart and Sheridan Gardiner chart for preschool vision screening. Indian J
Ophthalmol 2018;66:924-8.
13. Reddy S, Panda L, Kumar A, Nayak S, Das T. Tribal Odisha Eye Disease Study # 4: Accuracy and utility of photorefraction for refractive error
correction in tribal Odisha (India) school screening. Indian J Ophthalmol 2018;66:929-33.
14. Morya AK. Commentary on: "Tribal Odisha Eye Disease Study # 4: Accuracy and utility of photorefraction for refractive error correction in
tribal Odisha (India) school screening". Indian J Ophthalmol 2018;66:934.
 892 Indian Journal of Ophthalmology Volume 66 Issue 7

15. Shukla P, Vashist P, Singh SS, Gupta V, Gupta N, Wadhwani M, et al. Assessing the inclusion of primary school children in vision screening
for refractive error program of India. Indian J Ophthalmol 2018;66:935-9.
16. Magdalene D, Bhattacharjee H, Choudhury M, Multani PK, Singh A, Deshmukh S, et al. Community outreach: An indicator for assessment
of prevalence of amblyopia. Indian J Ophthalmol 2018;66:940-4.
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Cover Page Illustration

Bietti’s crystalline dystrophy
Bietti's crystalline dystrophy is a rare inherited retinal dystrophy, which usually
presents with progressive visual loss in the third or fourth decade. The disease is
characterized by multiple small intraretinal crystal deposits. This causes retinal
atrophy leading to peripheral visual field and visual loss often causing legal
blindness by the fifth or sixth decade. The gene responsible is cytochrome P450
4V2 (CYP4V2) which codes a protein involved in fatty acid metabolism.
Contributed by:
Dr Vinod Kumar, Dr Amit Gadkar
Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical
Sciences, New Delhi 110029, India
Cover Page Design:
T Shiva Shankar, Centre for Sight, Hyderabad, India