Paediatric Optometry: Vision Testing by Age, Refraction and an Amblyopia Plan for Optometrists

Last updated: November 2026

RPC Rounds for Optometrists · B.Optom study guide

Children are not small adults: they cannot always tell you what is wrong, their vision is still developing, and an uncorrected problem in early childhood can cause lifelong amblyopia. A paediatric examination must be quick, playful and complete, with the right test for each age.

History

Birth history (prematurity, ROP screening), developmental milestones, family history (squint, amblyopia, high refractive error, retinoblastoma, childhood glaucoma), parental concerns (eye turn, head tilt, holding things close, squinting, poor school performance), and screen and outdoor time.

Visual acuity tests by age

Crowded tests are essential: single optotypes overestimate acuity in amblyopia. Expect lower "normal" acuity in young children (for example about 0.2 logMAR at 3 years, reaching adult levels by about 5–6 years).

Binocular vision and other tests

• Cover test at near and distance with an interesting target; Hirschberg and Bruckner in infants; ocular motility.
• Stereopsis: Lang (no glasses), Frisby, TNO or Titmus.
• Red reflex (Bruckner) to detect cataract, retinoblastoma and anisometropia; pupil reactions.
• Colour vision in school-age children (Ishihara, or pictorial plates for young children).

Refraction

Cycloplegic retinoscopy is the standard for a first examination and for any squint or amblyopia (cyclopentolate 1%; 0.5% under 1 year). Prescribe according to age-based guidelines (see paediatric glasses prescribing and cycloplegic refraction).

Amblyopia: an optometrist's plan

1. Confirm reduced best-corrected acuity in one eye (two or more lines difference) with no structural cause; dilate and examine the fundus.
2. Glasses first: full-time wear of the full correction (refractive adaptation over about 16 weeks improves many children).
3. If vision plateaus with a residual difference: patching (2 hours a day for moderate, 6 hours for severe amblyopia, per PEDIG) or atropine penalisation of the better eye.
4. Review every 6–8 weeks; check the better eye for reverse amblyopia; taper treatment slowly to reduce recurrence.
5. Dichoptic digital treatments are an option where available. Refer squint, dense or non-responding amblyopia, and any structural cause to a paediatric ophthalmologist.

Myopia in children

Encourage at least about 2 hours outdoors daily, limit continuous near work (20-20-20 rule), and discuss myopia control (low-dose atropine, DIMS or HAL spectacle lenses, myopia control contact lenses, ortho-k) for progressing myopes (spectacle designs compared in myopia-control lenses). See myopia control.

Red flags: refer the same day or urgently

• White pupil (leukocoria) or absent red reflex: retinoblastoma or cataract.
• New squint, especially with headache or other neurological signs; sudden onset squint in a previously normal child.
• Large cloudy corneas with watering and photophobia (congenital glaucoma).
• Nystagmus in an infant, poor visual behaviour, or a head tilt with abnormal eye movements.
• Any suspicion of non-accidental injury.

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Related: When Should My Child Have an Eye Test? Age-by-Age Guide, Cycloplegic Refraction and Refracting Children: Drugs, Technique and Prescribing, When to Prescribe Glasses in Children: AAO Thresholds by Age, Amblyopia: Classification, Severity and PEDIG Treatment Lessons, Myopia Control in 2026: Atropine, Lenslet Spectacles, Ortho-K and Red Light. Back to the optometry curriculum.

Key sources

• American Academy of Ophthalmology. Amblyopia and Pediatric Eye Evaluations Preferred Practice Patterns (current editions)
• Pediatric Eye Disease Investigator Group. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol. 2003;121:603-611
• Anstice NS, Thompson B. The measurement of visual acuity in children: an evidence-based update. Clin Exp Optom. 2014;97:3-11