Practice Practice Pointer

How to assess eyes and vision in infants and preschool children

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1716 (Published 07 May 2015) Cite this as: BMJ 2015;350:h1716
  1. Andrew J Blaikie, consultant ophthalmologist, lead of paediatric services1,
  2. Gordon N Dutton, paediatric ophthalmologist, emeritus professor of visual science2
  1. 1Department of Ophthalmology, Fife Acute Hospitals Trust, Queen Margaret Hospital, Dunfermline KY12 0SU, UK
  2. 2Glasgow Caledonian University, Glasgow G4 0BA, UK
  1. Correspondence to: G N Dutton dutton{at}duttonhome.com

The bottom line

  • Appropriately positioning the child on the parent’s lap and using recognisable auditory distraction (whistling, humming, or singing) just before and during eye examination make assessment much easier

  • Observation from the moment of arrival may reveal conditions such as watery or red eyes, blepharitis, a swollen lacrimal sac, ptosis, squint, or lack of eye contact

  • Estimate visual acuity by checking the distance at which the child maintains eye contact

  • Identify a squint by shining a light at the child’s eyes and checking the symmetry of the “corneal reflexes”

Children for whom concerns exist about eyes or vision need competent assessment and management. For a young child, however, the general clinician in the community may find mastery of the requisite skills daunting. This article gives practical tips to guide eye assessment in infants and preschool children.

Consider the child’s comfort

Waiting and consultation areas should be welcoming and uncluttered. A feed, a recent sleep, and a short wait enhance comfort, cooperation, and the “window of opportunity.”

Beginning the consultation

Watch the child enter the room

Read any available salient information before seeing the child. Be friendly, calm, and confident and avoid appearing anxious. Smile as the child and parent(s) enter the room. Look to see if eye contact is returned and, if so, from how far away (table 1). Look at what the child looks at and consider its detail to get an idea of what the child is probably seeing.

View this table:
Table 1

Approximate maximum distances at which eye contact with a young child can be maintained and “rule of thumb” equivalent visual acuities

Taking the history

Take a brief initial open history of the presenting complaint and then seek salient additional information to help in planning the examination (tables 2 and 3). Next, examine the child while he or she is still engaged, using this to guide subsequent diagnostic history taking.

View this table:
Table 2

Conditions commonly managed in the …

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