The American Academy of Pediatrics has developed this
brochure to emphasize the importance of regular eye
examinations in infancy and childhood. This pamphlet
describes the normal function and development of an
infant's eye and vision. It gives an overview of warning
signs and other problems that should be evaluated by
your pediatrician or ophthalmologist. Regular eye exams
at proper age intervals are the key to maintaining your
child's healthy vision. The earlier the visual problems
are detected, the better the outcome.
At birth, babies have not yet attained normal adult
vision--but they can see. Newborns can make out large
shapes and faces but are unable to distinguish fine
details. Faces have strong visual appeal. Because the
visual system is immature, your baby probably cannot
distinguish between pastel colors or subtle variations
in shading, but can see bright, strong colors in contrasting
patterns of light and dark.
Your baby's visual development is very dramatic during
the first year of life. Vision usually develops rapidly
so that by the age of 3 to 4 months, most infants can
see small objects. Some babies can distinguish between
various colors (especially red and green) by this time.
They can focus clearly on close and distant objects
and can distinguish a real human face from one that
By 4 months, the baby's eyes should be well aligned
(work together) to give the perception of depth or binocular
vision. By 12 months, a child's vision reaches normal
adult levels. Vision does not develop exactly on the
same schedule in all infants, but the overall pattern
of development is the same. Because visual development
is so rapid during the first year, early detection of
visual problems is critical so that permanent visual
impairment does not occur.
Warning signs that may indicate a problem (infants
up to 1 year of age)
If your baby can't make steady eye contact by 2 or
3 months of age, or seems unable to see, you should
consult your pediatrician. A constant crossing of the
eyes or one eye that turns out is usually abnormal;
however, most babies do occasionally cross their eyes
during their first 6 months of life. Babies older than
3 months of age can usually follow or "track"
an object with their eyes as it moves across their field
of vision. You can test this by holding a colored object,
like a toy or a ball, in front of your baby until he
or she can see it. Then, slowly move the object and
watch as your baby's eyes follow. Be careful to avoid
clues aided by voices or other sounds.
Warning signs for your preschool child
The presence of any of the following requires immediate
consultation with your pediatrician or ophthalmologist.
If the eyes become misaligned (strabismus), the child
should be evaluated immediately. This may be a situation
that is easily corrected with glasses or it may represent
a more serious eye disorder. The presence of a white
pupil suggests a number of eye disorders ranging from
a cataract to a tumor ot the eye. Immediate evaluation
is indicated. The sudden development of pain and redness
in one eye or both eyes can represent a number of different
conditions ranging from simple pink eye to blinding
eye problems. If this occurs, a simple visit to your
pediatrician will generally result in the correct diagnosis
and proper treatment.
Warning signs at any age
No matter how old your child is, if you spot any one
of the following, consult your pediatrician:
Your child's eyes flutter quickly from side-to-side
or up-and-down (nystagmus).
The eyes are always watery.
The eyes are always sensitive to light.
Any change in the eyes from their usual appearance.
You see white, grayish-white, or yellow-colored
material in the pupil.
There is redness in either eye that doesn't go
away in several days.
There is continued pus or crust in either eye.
The eyes look crossed, turn out, or don't focus
Your child often rubs the eye(s).
Your child often squints.
Your child often tilts (or turns) his or her head.
The eyelid(s) appears to droop.
The eye(s) appears to bulge.
Vision screening information
Vision screening is a very important factor in identifying
vision-threatening conditions. The American Academy
of Ophthalmology and the American Academy of Pediatrics
recommend that children be screened in four stages:
1. In the newborn nursery: Pediatricians and
ophthalmic practitioners should examine all infants
prior to discharge from the nursery to check for infections
and structural defects, cataracts, or glaucoma. All
children with multiple medical problems or with a history
of prematurity and/or oxygen exposure should be examined
by an ophthalmologist. Amblyopia is common, affecting
about 2% of children. Some causes of amblyopia include
strabismus, droopy eyelids (ptosis), cataracts, or refractive
errors. Because early treatment offers the best results,
your pediatrician will refer you to an ophthalmologist.
2. By the age of 6 months: Pediatricians should
screen infants at the time of their well-baby visits
to check for alignment (eyes working together).
3. At the age of 3 to 4 years: All children
should be examined by a pediatrician. At this age, the
visual acuity is checked and the eyes are examined for
any other abnormality that may cause a problem with
the child's educational development. Any abnormality
requires referral to an ophthalmologist.
4. At the age of 5 years and older: Pediatricians
should screen children annually if this is not provided
by school personnel or volunteer organizations. Visual
acuity is tested as well as evaluation of other ocular
Specific problems that require further evaluation
Falsely misaligned eyes (pseudostrabismus)
Sometimes infants appear to have crossed eyes, yet the
eyes are truly straight. The cause for pseudostrabismus
is presence of a wide nasal bridge or extra folds of
skin between the nose and the inside of the eye that
make the child have a cross-eyed appearance. Most children
outgrow this problem, but you should contact your doctor
for an examination. Your pediatrician can tell whether
a child has misaligned eyes or just pseudostrabismus,
but in some instances, a visit to an ophthalmologist
is necessary for further tests.
Misaligned eyes (strabismus)
With strabismus, the eyes are not aligned. Strabismus
is quite common and occurs in about 4% of children.
One eye may gaze straight ahead while the other eye
turns inward, upward, downward, or outward. When an
eye turns inward, the child has "crossed"
eyes (esotropia). There are two common causes for esotropia.
Some children are born with crossed eyes (or develop
it shortly after birth), and in this situation the muscles
are too tight. Treatment for this most commonly involves
surgery on the eye muscles, generally performed prior
to the age of 2.
The second most common cause for esotropia is excessive
farsightedness. This problem can be present at birth,
but most commonly occurs between the age of 2 and 6
years. This type of esotropia is corrected with glasses.
When an eye turns outward, the child has exotropia.
Exotropia may be present at birth, but most commonly
is seen in children 2 to 7 years of age. Generally the
eyes turn out on rare occasions at first but with time
more frequent outward turning of the eyes is noted.
Children with exotropia occasionally squint one eye
when exposed to bright sunlight. The treatment for large
amounts of exotropia is usually eye muscle surgery.
Children with misaligned eyes will generally turn off
the vision in the turned eye so that they are not plagued
with double vision. Children with strabismus should
have a careful examination by an ophthalmologist because
untreated strabismus may lead to lazy eye (amblyopia)
or loss of depth perception. Rarely, strabismus may
indicate a more serious condition, such as cataract
or eye tumor (retinoblastoma).
Lazy eye (amblyopia)
Lazy eye is reduced vision from lack of use in an otherwise
normal eye. It usually happens only in one eye. Any
condition that prevents a clear image can interfere
with the development of vision and result in amblyopia.
Amblyopia is common, affecting about 2% of children.
Some causes of amblyopia include strabismus, droopy
eyelids (ptosis), cataracts, or refractive errors. Because
early treatment offers the best results, your pediatrician
will refer you to an ophthalmologist.
Cataract (cloudy lens)
A cataract is a clouding of the eye's normally clear
lens. The lens is located behind the pupil and helps
focus images on to the back of the eye (retina). Cataracts
may be present at birth or may appear later in life.
Injury may also cause this condition. Early detection
and treatment are crucial in infants and children so
that normal visual development can occur. For this reason,
most cataracts should be surgically removed soon after
they are discovered. It should be noted that cataracts
in infants and children are uncommon and not related
to cataracts that occur in adults.
Glaucoma (elevated eye pressure)
Glaucoma is a condition in which the pressure inside
the eye is too high. If left untreated, glaucoma will
eventually lead to total blindness. Warning symptoms
are extreme sensitivity to light, tearing, and persistent
pain. Signs include an enlarged eye, cloudy cornea,
and lid spasm. If any of these are present, your pediatrician
will refer you to an ophthalmologist immediately. Glaucoma
in childhood usually requires surgery to prevent blindness.
The tear duct system, which allows the tears to drain
from the eyes into the nose, usually opens in the first
few months of life. In some infants, however, the system
remains blocked, resulting in the eyes overflowing with
tears and collecting mucus. Tearing may result from
other ocular conditions, the most serious of which is
glaucoma (see above). If your child suffers from continued
tearing or watering from the eyes, please consult your
pediatrician. Gentle massage of the tear duct can occasionally
assist in relieving the blockage. If massage and observation
are unsuccessful, a tear duct probe or more involved
surgery is occasionally required.
Ptosis (droopy eyelids)
Ptosis refers to the situation in which the eyelids
are not as open as they should be. This situation is
caused by a weakness of a muscle that opens the upper
eyelid. When ptosis is mild, it is just a cosmetic problem.
However, ptosis can interfere with vision if it is severe
enough to block the vision in the eye. In infancy, it
is important that ptosis be eliminated so that vision
will develop normally. Correction of ptosis usually
requires surgery on the eyelid(s).
Blepharitis (swollen eyelids)
Blepharitis refers to inflammation in the oily glands
of the eyelid. This usually results in swollen eyelids
and excessive crusting of the eyelashes, most evident
in the morning. Tenderness of the eyelids and a foreign
body sensation in the eye may occur as well. Blepharitis
can be treated with warm compresses and eyelid scrubs
using baby shampoo. If an infection is present, antibiotics
may be necessary. If any of these findings are present,
please consult your pediatrician.
"Pink eye" (conjunctivitis)
Pink eye appears as a reddening of the white part of
the eye. It is usually associated with excessive tearing,
a discharge, and a foreign body sensation in the eyes.
Conjunctivitis has many causes and can occur at any
age. In infants and children, pink eye is usually caused
by a viral or bacterial infection. In older children,
it may also be caused by an allergy. Depending on the
cause of the conjunctivitis, eye drops or ointment may
be indicated. If your child has conjunctivitis, regular
hand washing will help prevent the spread of the infection
to other family members. If conjunctivitis occurs, call
your pediatrician's office.
Corneal abrasion (scratched cornea)
A corneal abrasion refers to a scratch of the front
clear surface of the eye (cornea). These abrasions are
very painful and usually associated with light sensitivity
and tearing. Treatment consists of antibiotics to prevent
infection and a patch to allow for the healing of the
scrape. This may be monitored by your pediatrician although
more serious injuries often need follow up by an ophthalmologist.
Children who are "nearsighted" see objects
that are close to them clearly, but objects that are
far away are unclear. Nearsightedness is very rare in
infants and toddlers, but becomes more common in school-age
children. Eyeglasses will help clear the vision but
will not "cure" the problem. Despite using
glasses, nearsightedness will generally increase in
amount until the mid-teenage years so that periodic
follow-up examinations by an ophthalmologist are indicated.
A small degree of farsightedness is normal in infants
and children. It does not interfere with vision and
requires no correction. It is only when the farsightedness
becomes excessive, or causes the eyes to cross, that
glasses are required.
Astigmatism is the result of an eye that has an irregular
corneal shape. Astigmatism may result in blurred vision.
Children with astigmatism may need glasses if the amount
of astigmatism is large.
Learning disabilities are quite common in childhood
years and have many causes. The eyes are often suspected
but are almost never the cause of learning problems.
Your pediatrician may refer you for an evaluation by
an educational specialist to pinpoint the exact cause.
When should your child's eyes be checked?
Pediatricians check the eyes shortly after birth as
part of the newborn examination. Your baby's eyes also
will be examined later during health supervision visits.
The doctor looks for eye disease and checks to see if
the eyes are functioning properly. Children with a family
history of serious vision problems are more likely to
have eye problems.
Fortunately, most babies have normal, healthy eyes.
When problems occur, early detection and treatment make
it more likely that the child's vision will develop
normally. If your pediatrician detects problems, he
or she may refer your child to an ophthalmologist for
further evaluation and care.
Vision care is an important part of preventive health
care for children. The American Academy of Pediatrics
is dedicated to working for a better future for your
children. Join us by making sure your children receive
regular eye examinations.