Eye Spy: Why You Should Test Your Preschooler’s Vision Early

Drawing pictures, coloring with crayons, fitting a square block into a square hole and identifying shapes, faces and other features — these markers of playtime and discovery all involve important visual skills your child will develop during their early years. But when it comes to your child’s eye health, when is the right time to test their vision?

The answer, says pediatric ophthalmologist Elias Traboulsi, MD, MEd, is that your child should have their eyes checked early and at an adequate rate. Some eye problems that can have a long-term effect on vision develop in infancy. So, finding any issues early can keep a minor issue from becoming something major (and harder to treat).

What age should my child get their first eye exam?

The American Academy of Ophthalmology recommends eye screenings for newborns, babies between 6 and 12 months, babies between 12 and 36 months, toddlers between 3 and 5 years old and at age 5.

Pediatricians perform these limited vision screenings right after birth and in the first few years of life to detect a variety of abnormalities in your child’s light reflex from their pupils and in the external aspects of their eyes and their ocular alignment. These screenings become much more important in children who:

• Have a family history where a sibling or a parent has an eye disease or other major condition that affects their vision, such as crossed or turned eye(s) (strabismus) or lazy eye (amblyopia).
• Have a condition detected by a pediatrician that affects their vision.
• Are suspected by parents of having an eye issue.

If any of these apply to your child, providers recommend your child receive a comprehensive pediatric eye exam to determine what may be impacting their vision.

In general, Dr. Traboulsi recommends that your child has a comprehensive pediatric eye exam by an eye care professional by age 1, if access is available, to be repeated before kindergarten in children without any evident eye problems.

“Even if there are no obvious symptoms, your child may still have a problem with their vision,” he adds.

School vision test vs. comprehensive eye exams for kids

When parents are interested in an eye test for their preschoolers, it’s easy to get vision screenings and comprehensive pediatric eye exams confused.

Pediatric vision screenings can be handled by your child’s school officials, nurses or pediatricians who are looking for visible signs of vision problems as they inspect your child’s eyes and test their visual acuity (or how well your child can see). They aren’t merely a way to know whether your child needs glasses. Like regular physical exams with a pediatrician, vision screenings are about preventive care and they give healthcare providers a general sense of your child’s overall ability to see clearly.

A comprehensive pediatric eye exam is usually conducted when red flags are raised about your child’s vision in a vision screening. These comprehensive pediatric eye exams are more in-depth, as they measure the actual health of your child’s eyes. They also cover a wide variety of testing that includes elements like:

• An external exam.
• 3D vision image testing.
• Color vision testing.
• Eye motility testing to determine the function of your child’s eye muscles and the ability to look in different directions.
• Ocular alignment testing to make sure your child’s eyes are aligned and symmetrical.
• High magnification examination of your child’s retina, cornea and optic nerves.
• Slit-lamp testing uses a special microscope to look at every part of your child’s eye, including their insides, after dilating your child’s pupils with special eye drops.

“So far, the consensus has been that there is no need for a comprehensive eye exam in every single child unless there’s some red flag,” clarifies Dr. Traboulsi. “Having said that, my personal recommendation is that if there is access, time and availability, there’s no harm in getting a really comprehensive eye exam.”

Signs of eye and vision problems

Parents might recognize some noticeable red flags about their child’s vision simply by watching their behaviors. Some common concerns that warrant a comprehensive pediatric eye exam include:

• Not making eye contact.
• Not following moving objects with their eyes or head.
• Not recognizing facial features.
• Getting up close to the TV, books or other objects to see them better.
• Eyes that drift or turn in or out.
• Droopy eyelids that block their vision.

“Other risk factors that would make a comprehensive eye exam more important to do is if there is a very strong family history of a sibling or parent who has some serious eye disease that does manifest itself in childhood,” notes Dr. Traboulsi.

Eye diseases that show up in infancy or childhood that are genetically inherited include:

• Congenital cataracts.
• Childhood glaucoma.
• Myopia (nearsightedness).
• Inherited retinal diseases.
• Ocular malformations.

Undiagnosed conditions or abnormalities can lead to vision loss. But Dr. Traboulsi says it’s possible to reverse some problems if they’re caught early.

A classic example is lazy eye. Kids with this condition have one eye that is weaker than the other. One of the most common vision problems in children, lazy eye typically responds well to treatment (like an eye patch, eye drops or eyeglasses) the earlier it’s caught.

What if your child is nonverbal or has difficulty reading?

For children who are nonverbal or have difficulty reading, eye specialists have different kinds of testing to measure their visual health and development and to see how they interpret or respond to other images. One common way to do this with younger children ages 6 to 36 months is called the preferential looking test or Teller Acuity Card® testing.

During this test, a provider will hold up cards that have a pattern or image on one side and nothing on the other. They observe which part of the card your child looks at and how they interact with that image. They then hold up smaller and smaller cards to determine how well your child can see those images before they stop responding.

“You can expect them to look at the design on the card because there’s something interesting to look at rather than the side that has no patterns,” explains Dr. Traboulsi. “We use smaller and smaller gratings and get tighter and tighter until a point where they randomly look at the other side so that we know they’re not seeing it anymore. That grating will give us an idea about what their vision is.”

For older children ages 3 to 5 or 6 years who have difficulty reading or identifying their letters, providers may hold up pictures of images or ask your child to match letters and numbers on cards instead of reading a traditional eye chart.

Can you test your child’s vision at home?

Most children have their vision tested before they start elementary school. But Dr. Traboulsi says it’s ideal to have your child’s eyes tested before they start kindergarten or preschool. That means you should have your pediatrician or an ophthalmologist conduct a vision screening or comprehensive eye exam before they start school, especially if you notice behaviors that signal they may have issues with their vision.

Although several parenting blogs online hint at your ability to test and improve your child’s vision at home without the help of a healthcare provider, Dr. Traboulsi says this kind of advice is misleading and not at all helpful. Often, parents mistake a child’s ability to see with their ability to interpret what they’re seeing, and this is an important distinction healthcare providers are trained to look for when evaluating your child’s development.

“Many times, there’s some confusion of the two, especially in children who have a multitude of other conditions where they’re delayed, there’s some autism or some other impairments that make eye exams and interpreting the child’s vision and visual behavior much more difficult,” he explains.

“If you’re suspicious that something is wrong, you shouldn’t take any chances. You should come in for a complete, comprehensive eye exam where we can put all of these things into perspective.”

Bottom line

Having a professional healthcare provider evaluate your child’s overall eye health is key, as many of the things that can impact their vision can improve with specific kinds of treatment if they’re caught early and often enough.

“If you have astigmatism and you don’t wear your glasses, you’re not going to see well. If you have a lazy eye, you’re not going to see well unless it is treated. If your lid is droopy and in the way of your vision, you’re not going to see well unless it’s lifted up,” stresses Dr. Traboulsi.

“You cannot help develop your child’s vision, but if there are physical limitations that impact their potential vision, then those need to be addressed.”