As a parent or caretaker, you may wonder whether your pre-schooler has a vision problem or when it may be appropriate to schedule your child's first eye exam.

You should be aware that eye exams for children are extremely important, because 5 percent to 10 percent of pre-schoolers and 25 percent of school-aged children have vision problems.* Early identification of a child's vision problem can be crucial because children often are more responsive to treatment when they are diagnosed early.

According to the American Optometric Association (AOA), infants should have their first comprehensive eye exam at six months of age. Children then should receive additional eye exams at three years of age, and just before they enter kindergarten or the first grade at about age five or six. For school-aged children, the AOA recommends an eye exam every two years if no vision correction is required. Children who need eyeglasses or contact lenses should be examined annually or according to eye doctor recommendations.

Early eye exams also are important because children need the following basic skills related to good eyesight for learning:

• Near vision
• Distance vision
• Binocular (two eyes) coordination
• Eye movement skills
• Focusing skills
• Peripheral awareness
• Eye/hand coordination

For these reasons some states require an eye exam for all children entering school for the first time.

Scheduling the Eye Exam for Your Child

The American Academy of Ophthalmology (AAO) notes on its web site that your family doctor or pediatrician likely will be the first medical professional to examine your child's eyes. If eye problems are suspected during routine physical examinations, a referral might be made to an ophthalmologist or optometrist for further evaluation. Eye doctors have specific equipment and training to assist them with spotting potential vision problems.

When scheduling an eye exam for your child, make sure to choose a time when he or she is usually alert and happy. Specifics of how eye exams are conducted depend on your child's age, but generally will involve a case history, vision testing, determination of whether eyeglasses are needed, testing of eye alignment, eye health examination, and parent education.

After you have made the appointment, you may be sent a case history form by mail, or you may be given one when you check in at the doctor's office. The case history form will ask about your child's birth history (also called perinatal history), such as birth weight and whether or not the child was full-term. Your eye doctor also may ask whether complications occurred during the pregnancy or delivery. The form will also inquire about your child's medical history, including current medications and past or present allergies.

Be sure to tell your eye doctor if your child has a history of prematurity, has delayed motor development, engages in frequent eye rubbing, blinks excessively, fails to maintain eye contact, cannot seem to maintain a gaze (fixation) while looking at objects, has poor eye tracking skills, or has failed a pediatrician or pre-school vision screening. [Read more about warning signs that a child might need glasses and vision problems of schoolchildren.]

Your eye doctor will also want to know about previous ocular diagnoses and treatments involving your child, such as possible surgeries and glasses or contact lens wear. Be sure you inform your eye doctor if you have a family history of eye problems requiring vision correction, such as nearsightedness or farsightedness (refractive errors), lazy eye (strabismus/amblyopia), or eye diseases.

Eye Testing for Infants
Babies should be able to see as well as adults in terms of focusing ability, color vision, and depth perception by three or four months of age. To assess whether your baby's eyes are developing normally, the doctor typically will use the following tests:

Tests of pupil responses evaluate whether the eye's pupil opens and closes properly in the presence or absence of light.
Fixate and follow determines whether your baby's eyes are able to fixate on and follow an object such as a light as it moves. Infants should be able to fixate on an object at birth and follow an object by the time they are three months old.
Preferential looking involves using cards that are blank on one side with stripes on the other side to attract the gaze of an infant to the stripes. In this way, vision capabilities can be assessed.

Eye Testing for Pre-School Children

Some parents are surprised to learn that children of pre-school ages do not need to know their letters in order to undergo certain eye tests, even when they are too young or too shy to verbalize. Some common eye tests used specifically for young children include:

• LEA Symbols for young children are similar to regular eye tests using charts with letters, except that special symbols in these tests include an apple, house, square, and circle.
• Retinoscopy is a test that involves shining a light into the eye to observe the reflection from the back of the eye (retina) where images reach light-sensitive cells. This test helps eye doctors determine the child's eyeglass prescription.
• Random Dot Stereopsis uses dot patterns to measure how each eye sees in relation to the other eye.

Eye tests and general examinations often are conducted to detect the possible presence of these types of eye problems commonly found in young children:

Lazy eye (amblyopia): Your eye doctor will want to rule out amblyopia, which is a lazy eye with decreased vision in one or both eyes without detectable anatomic damage. Tools for helping detect amblyopia include general assessment of vision capabilities as well as posture evaluation and determination of how each eye sees in relation to the other eye. Unfortunately, amblyopia is not always correctable with eyeglasses or contact lenses and may require eye patching to strengthen the weaker eye.

Misalignment of eyes (strabismus): Crossed or misaligned eyes (strabismus) can have different causes, such as problems with muscle control in the affected eye or eyes. If strabismus persists in young children, a condition known as lazy eye or amblyopia (see above) can develop along with related vision problems.

Inability to maintain alignment of both eyes for correct focus as distant objects move nearer (convergence insufficiency): Eye doctors will also assess the ability of eyes to pull inward (convergence) to provide correct focusing.

Focusing (accommodation), color vision, and/or depth perception problems: The eye doctor may also test your child's focusing (accommodation) ability. The child's depth perception or ability to gauge distances between objects may also be examined. Color vision may be tested through methods such as placing a dot pattern of symbols within a pattern of dots made up of other colors.

General eye and eyelid health: To assess a child's general eye health, the eye doctor will examine his or her eyelids and lid margins, looking for shape irregularity and discharge on the lashes or lid margins. The eye doctor may turn the lower lids inside out (evert) to look for abnormal or infected eyelash follicles, bumps (papillae), discharge, and swelling (edema). Your eye doctor may examine the cornea, iris, and lens to look for cloudiness (opacities) or other irregularities.

Vision Screening and Your Child's Performance in School

Remember that appropriate vision screening at an early age ultimately can be vital in terms of how well your child performs in school. A child who is unable to see print or view a blackboard can become easily frustrated, leading to poor performance in school work. Some vision problems, such as lazy eye, must be detected and corrected as early as possible while the child's vision system is still developing.