The Preferred Practice Pattern® (PPP) guidelines have been written on the basis of three principles.

• Each Preferred Practice Pattern should be clinically relevant and specific enough to provide useful information to practitioners.
• Each recommendation that is made should be given an explicit rating that shows its importance to the care process.
• Each recommendation should also be given an explicit rating that shows the strengt of evidence that supports the recommendation and reflects the best evidence available.

In the process of revising this document, a detailed literature search in Medline and the Cochrane Library for articles in the English language was conducted on the subject of pediatric eye evaluation for the years 2001 to 2006. The results were reviewed by the Pediatric Ophthalmology/Strabismus Panel and used to prepare the recommendations, which they rated in two ways. The panel first rated each recommendation according to its importance to the care process. This "importance to the care process" rating represents care that the panel thought would improve the quality of the patient's care in a meaningful way. The ratings of importance are divided into three levels.

• Level A, defined as most important
• Level B, defined as moderately important
• Level C, defined as relevant but not critical

The panel also rated each recommendation on the strength of evidence in the available literature to support the recommendation made. The "ratings of strength of evidence" also are divided into three levels.

• Level I includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
• Level II includes evidence obtained from the following:
  • Well-designed controlled trials without randomization
  • Well-designed cohort or case-control analytic studies, preferably from more than one center
  • Multiple-time series with or without the intervention
• Level III includes evidence obtained from one of the following:
  • Descriptive studies
  • Case reports
  • Reports of expert committees/organizations (e.g., PPP panel consensus with external peer review)

The evidence is that which supports the value of the recommendation as something that should be performed to improve the quality of care. The panel believes that it is important to make available the strength of the evidence underlying the recommendation. In this way, readers can appreciate the degree of importance the committee attached to each recommendation and they can understand what type of evidence supports the recommendation.

The ratings of importance and the ratings of strength of evidence are given in bracketed superscripts after each recommendation. For instance, "[A:II]" indicates a recommendation with high importance to clinical care [A], supported by sufficiently rigorous published evidence, though not by a randomized controlled trial [II].

The sections entitled "Orientation" and "Background" do not include recommendations; rather, they are designed to educate and provide summary background information and rationale for the recommendations that are presented in the Care Process section. A summary of the major recommendations for care is included in Appendix 1.

The Pediatric Eye Evaluations PPP has two parts. The first section focuses on pediatric eye and vision screening. It is intended to be used by pediatricians, family practice physicians, physicians, nurses, other health care professionals, and trained lay people involved in screening. The second section is the comprehensive pediatric ophthalmic evaluation. This section is designed to be used by ophthalmologists who perform comprehensive medical eye evaluations for children.

ENTITY
Childhood screening examination performed by a pediatrician, family practice physician, other physician, nurse, orthoptist, other health care professional, or trained layperson for detection of eye and vision problems.

PATIENT POPULATION
Newborns and children through age 18 years.

ACTIVITY
Pediatric eye and vision screening.

INTENDED USERS OF THE GUIDELINE
Pediatricians, family practice physicians, other physicians, nurses, orthoptists, other health care professionals, and trained lay persons.

PURPOSE
To identify children who may have eye or visual abnormalities, or risk factors for developing eye or vision problems, and refer them for a comprehensive pediatric ophthalmic evaluation.

GOALS

• Describe techniques for periodic eye and vision screening examinations for children, documentation of which includes the following information:¹
  • Risk factors for eye and visual abnormalities
  • Level of vision in each eye individually
  • Assessment of ocular alignment
  • Assessment for the presence of ocular structural abnormalities
    
    
• Communicate screening results and follow-up plan to family/caregiver
  
  
• Refer all children who fail screening (refer to Screening Examination section) or who cannot be successfully screened at their second attempt²; physicians or other practitioners providing ongoing care of the child should verify at the next visit that the recommended comprehensive eye examination has taken place
  
  
• Educate screening personnel

BACKGROUND

Amblyopia refers to an abnormality of visual development characterized by decreased best-corrected visual acuity not fully attributable to a structural abnormality of the eye. Amblyopia may be unilateral or bilateral and is best treated in early childhood. However, recent data show that amblyopia may be treated even in the teenage years.³ The prevalence of amblyopia varies by race/ethnicity. Approximately half of amblyopia is secondary to strabismus (mainly esotropia) and the other half is from other causes such as high refractive errors, anisometropia (asymmetric refractive errors), or structural ocular problems.^4-7 Amblyopia is unusual in children with intermittent exotropia.⁸ The prevalence of amblyopia in children with developmental delay is sixfold greater than in children who were healthy, full-term infants.^9,10 Over 6 million Americans have amblyopia, and it is responsible for loss of vision in more people under the age of 45 than all other causes combined.¹¹

Visually important refractive errors include high hyperopia, moderate astigmatism, moderate to high myopia, and asymmetric refractive errors. An estimated 5% to 7% of preschool children have visually important refractive errors.²⁴ Twenty-five percent of children between the ages of 6 and 18 years would benefit from corrective lenses for refractive error or other reasons.²⁵ During the school years, visual difficulties such as those caused by uncorrected refractive errors may interfere with school performance.

Premature birth is a major risk factor for severe visual impairment and blindness in childhood. The most common ocular problem in preterm infants is retinopathy of prematurity (ROP). The frequency and severity of ROP is inversely related to gestational age. Preterm infants also have higher rates of amblyopia, strabismus, refractive error, optic atrophy, and cortical visual impairment. Years later, these children may develop glaucoma and retinal detachments.^26,27 The visual impairment is often accompanied by cerebral palsy, epilepsy, and other motor and mental handicaps.²⁷

RATIONALE FOR PERIODIC SCREENINGS
Amblyopia meets the World Health Organization (WHO) guidelines for a disease that benefits from screening because it is an important health problem for which there is an accepted treatment, a recognizable latent or early symptomatic stage, and a suitable test or examination.^28,29 Eye and vision screening is most effective when performed periodically throughout childhood.^30-37 The combined sensitivity of a series of screening encounters is much higher than that of a single screening test, and it is the combined sensitivity that is applicable to the issue of screening effectiveness. Anisometropia and small-angle strabismus are the leading causes of undetected amblyopia. Because a large percentage of children with amblyopia and strabismus go undetected and untreated,^38,39 most major authorities agree that extending vision screening to all children is extremely important.^1,40,41

The purpose of periodic eye and vision screening is to detect pediatric eye disorders, especially amblyopia, at a sufficiently early age to allow effective treatment. The earlier amblyopia is detected and properly treated, the higher the likelihood of visual acuity recovery.^30,42,43 Starting treatment at a young age may also increase the likelihood of compliance and the rate of vision recovery.⁴⁴ The Amblyopia Treatment Study demonstrated that more than 75% of amblyopic children younger than 7 years can have significant improvement in the amblyopic eye (to 20/30 or better) as the result of treatment (see Amblyopia PPP⁴⁵).^31,46 Based on studies of amblyopia detected before the age of 6 years but incompletely treated, it appears that the potential for the treatment of amblyopia persists to approximately age 12 years or older, at which time the plasticity of the visual pathways decreases.^3,47 With rare exceptions,^48,49 amblyopia results in lifelong visual loss if it is untreated or insufficiently treated in early childhood.

A discussion of the statistics on eye and vision screening in children is in Appendix 2.

The optimal timing and method of pediatric vision screening has not been definitively established and is the subject of ongoing research. Guidelines for pediatric vision screening are evolving as new tests and technologies are introduced and new studies are completed.

Eyes can be examined at any age, and a series of age-appropriate screening examinations is recommended throughout childhood (see section on Screening Examination for the recommended ages for pediatric eye screening). Age-appropriate eye and vision evaluations should be performed in the newborn period and at all subsequent health supervision visits,^[A:III] because different childhood eye problems may be detected at each visit and new problems can arise during childhood. In the newborn and early infancy, the examination concentrates on detection of structural anatomical abnormalities. Detection of other abnormalities such as amblyopia and strabismus are added as the child ages.

Children should have their subjective visual acuity assessed using a vision chart.^[A:III] Children who fail a screening should be referred for a comprehensive ophthalmic evaluation after the first screening failure.^[A:III] Children who fail to complete subjective visual acuity assessment should be considered untestable. Children who are untestable on the first attempt should be referred for a comprehensive ophthalmic evaluation or a repeat screening should be attempted.^[A:III] If a child is unable to cooperate for vision testing at 3 years of age, a second attempt should be made within 6 months.^[A:III] If the child is 4 years old, a second attempt should be made within the month.¹ Although the child may be rescreened if screening is inconclusive or unsatisfactory, undue delays should be avoided; if retesting is inconclusive, referral for a comprehensive ophthalmic evaluation is indicated.^2[A:III] Children who are untestable on two occasions have been shown to have a higher incidence of pathology than children who pass screening.² The Joint Policy Statement of the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology recommends that a repeat screening attempt should be performed within 4 to 6 months for a failed screening at age 3 years and within 1 month at age 4 years.¹

HISTORY
At a child’s first examination by a new primary care provider, a history of risk factors for eye and vision abnormalities should be elicited.^[A:III] A detailed family history of eye and vision abnormalities in first-degree family members (mother, father, and siblings) and a history of past and present medical problems should be elicited. Infants detected to be at risk for eye problems because of prematurity, family history of congenital cataract, congenital glaucoma, retinoblastoma, or metabolic or genetic disease should be referred for a comprehensive ophthalmic evaluation as early as possible.^[A:III] For children with a family history of congenital or juvenile cataract, the referral is best made while the baby is still in the newborn nursery. A child with a family history of amblyopia and/or strabismus in a first-degree family member should be referred for a comprehensive ophthalmic evaluation at age 12 to 24 months or sooner if ophthalmic problems are noted. Children with a history of medical problems that are risk factors for development of eye problems should also be referred for a comprehensive ophthalmic evaluation. At each scheduled well-child examination, the primary care provider should ask the parent/caregiver about the baby’s visual interactions and possible eye or vision problems. Table 2 lists specific examples of abnormalities or observations that require referral for a comprehensive ophthalmic evaluation.

SCREENING EXAMINATION
The screening examination should include examination of the red reflex to detect abnormalities of the ocular media; external inspection to detect ocular abnormalities; pupil examination; visual acuity on an age-appropriate basis; and, after 6 months of age, the corneal light reflection test (Hirschberg reflex) and cover testing for ocular alignment as well as motility testing.^[A:III] When cooperation and pupil size permit, ophthalmoscopy should be used to view the optic nerve and posterior pole.

Table 3 indicates the screening methods to be used at each age and the indications for referral. The earliest screening takes place at the newborn medical examination and is limited to the red reflex, identification of structural abnormalities, and pupil examination. If a structural eye problem or an abnormal red reflex is detected, the baby should be referred on an urgent basis.^[A:III] At 6 months of age all infants should be evaluated for fixation preference, ocular alignment, and the health of ocular structures.^[A:III]

1. Is there a red reflex from each eye?
2. Are the red reflexes from each eye symmetrical?
3. Is the quality of the red reflex normal for the individual infant (taking into account skin tone and race or ethnicity)?

If the answer to any of the three questions is no, then the red reflex test is abnormal, and a prompt referral to an ophthalmologist skilled in the treatment of infants and children should be made.^[A:III] The See Red Card, a simple visual aid designed to help physicians who perform red reflex testing, can be ordered from the American Academy of Pediatrics (see Appendix 3).

The Brückner test, a binocular red reflex test, is superior to the conventional red reflex test, because a skilled examiner will be able to detect not only abnormalities of the red reflex but also will be able to assess alignment and large and/or asymmetric refractive errors.^51,52 The binocular red reflex test is performed in a dimly lit room with the examiner at a distance of about 30 inches (0.75 meter) from the child.⁵¹ The examiner overlaps both pupils simultaneously, creating a binocular red reflex with the largest circular light of a direct ophthalmoscope set to focus on the ocular surface, usually at zero. The examiner then assesses the quality of the redness seen within the child’s pupils. Normally, the red reflex from each eye should be of the same color and brightness. Abnormalities include asymmetric reflexes when one reflex is duller or a different color, a white reflex, a partially or totally obscured reflex, or crescents present in the reflex.

Subjective visual acuity chart testing should be performed for a child at the earliest age that is practical.^[A:III] The standard testing distance is 20 feet (6 meters), but testing at 10 feet (3 meters) is more successful in some children.

One study reported that 71% to 75% of children age 3 to 3.5 years were successfully screened with crowded HOTV and Lea symbols visual acuity testing administered by lay screeners.⁵³ The most sophisticated test that a child is capable of performing should be used.^[A:III] When possible, screeners should enlist the assistance of parents/caregivers in the testing process by showing them the figures, tumbling E game, or optotypes before the test so they can help their child understand the test. In decreasing order of cognitive difficulty, possible acuity tests include Snellen letters, Snellen numbers, tumbling E or optotypes, HOTV, and Lea symbols.¹ Because testing visual acuity with isolated targets (figures or letters) may lead to falsely elevated visual acuities,⁵⁴ crowded optotypes or linear visual acuity (a row of optotypes) should be used when possible.^[A:III] The Vision in Preschoolers Study Group reported that a crowded line of Lea symbols were more accurate for detecting reduced visual acuity.⁵⁵ Most Allen figures tests are not crowded and have been shown to be less accurate than other methods.⁵⁶ The tumbling E is less frequently used because it has a lower success rate in children compared with picture charts.⁵⁷

When performing visual acuity testing, it is critical to ensure monocular testing. To prevent peeking, the occluded eye should be completely covered. Children should not use their own hand as an occluder. If an occluding paddle or spoon is used, the child should not hold it. The screener should monitor the child for any evidence of looking around the occluder, which could include head turning, peeking, or moving the occluder. Use of an adhesive occluder patch ensures assessment of monocular visual acuity. Special broadly occluding spectacle frames such as Fun Frames (Good-Lite Co., Elgin, IL) are an option if a child will not allow patching. Visual acuity testing of the second eye should be attempted even when the child will not read the largest line with the first eye.

Another adjunctive screening method is stereovision (depth perception) assessment, which can be performed using the Titmus test, the various Randot tests, or other means.

AUTOMATED METHODS
Automated methods of conducting pediatric eye screening include photoscreening, autorefraction, and visual evoked potential. These technologies are continuing to undergo extensive study, evaluation, and innovation. Currently, there is insufficient evidence to recommend available automated methods to replace standard screening techniques and evaluation.^58-61

Photoscreening is a nonverbal method of eye and vision screening to identify children who have risk factors associated with the development of amblyopia, however, photoscreening cannot detect amblyopia. Photoscreening may be a valuable adjunct to the traditional screening process especially in preliterate children who generally have a limited attention span.⁶² Photoscreening is not a substitute for accurate visual acuity measurement, but it can provide information about the presence of sight-threatening conditions such as strabismus, refractive errors, asymmetric refractive errors (anisometropia), media opacities (e.g., cataract), retinal abnormalities (e.g., retinoblastoma), and ptosis. A uniform set of risk factors that should be detected by preschool vision screening has been developed and can be extended to photoscreening (see Table 4).³¹ Photoscreening uses off-axis photography and photorefraction to evaluate the corneal light reflection (Hirschberg reflex), the binocular red reflex (Brückner) test, and crescentic dimensions. Readers of these photographs require extensive training to identify amblyogenic risk factors such as strabismus, anisometropia, refractive errors, and media opacities. Photoscreening techniques are still evolving and may become even more useful in the future.
Autorefractive devices have been used occasionally as a surrogate for vision screening or may serve as a valuable adjunct to traditional screening. Autorefraction without cycloplegia in children is inaccurate.^63,64

Visual evoked potential as a method of vision screening is being evaluated in research studies.⁶⁵

Based on the literature,^36,55,58,66 objective screening techniques such as autorefraction or photoscreening are alternatives to visual acuity testing using charts for very young children. There is no consensus on the preferred method to screen for amblyopia in such children.

REFERRAL PLAN
If eye and vision abnormalities or their risk factors are suspected or identified at a screening examination, an appropriate referral plan should be initiated and recorded.^[A:III] Tables 2 and 3 list specific examples of indications for a referral for a comprehensive pediatric ophthalmic evaluation.

The following are examples of some conditions, not a comprehensive list, which may prompt referral for a comprehensive pediatric eye evaluation, with guidance on the urgency of the referral.

• URGENT REFERRAL (contact the ophthalmologist within 24 hours)
  • Abnormal red reflex or suspected abnormal red reflex
  • Any suspected severe eye injury
  • Severe eye pain
  • Sudden loss of vision
    
• SEMI-URGENT REFERRAL
  • New onset of strabismus or diplopia
  • Visual acuity 20/200 or worse on screening
  • Severe or new onset ptosis
  • Anisocoria
    
• STANDARD REFERRAL
  • Abnormal visual acuity for age (see Table 3)
  • Children who are untestable
  • Strabismus or suspected strabismus
    
• IMPORTANT NOTE
  • Only 50% of children identified by abnormal vision screening receive professional eye and vision care⁶⁷
  • Additional research is required to identify and address barriers to follow-up after a failed screening examination⁶⁷

  When referrals are made on the basis of screening, all parties involved should recognize that screening for any condition results in false positives and false negatives. The sensitivity and specificity of screening methods vary with the age of the child being screened, the screening modality and conditions, and the skill and patience of the examiner.

  For further information on screening, see Suggested Reading and Resources.

  PROVIDER AND SETTING
  Screening evaluations are performed by a child’s primary care physician, nurse, or other trained health professional. Such screenings should be performed in the physician’s office during primary health care visits. Auxiliary screenings may be performed in preschool and daycare settings, at schools, or at public screenings. Public and school screening evaluations may be performed by health professionals or trained lay screeners.

  The physicians, nurses, and other providers who perform eye and vision screening should be educated and trained in eliciting a history of risk factors for eye and visual abnormalities, detecting structural eye problems, and assessing visual abilities or acuities at every age.^[A:III] Screeners should also be trained in the difficulties involved in testing infants, toddlers, and older children.^[A:III]

ENTITY
A comprehensive pediatric ophthalmic evaluation.

PATIENT POPULATION
Newborns and children through age 18 years.

ACTIVITY
A child is seen for a comprehensive pediatric ophthalmic evaluation.

INTENDED USERS OF THE GUIDELINE
Ophthalmologists.

PURPOSE
A comprehensive medical eye evaluation is performed to evaluate abnormalities detected by screening to identify risk factors for disease, to detect and diagnose sight- and health-threatening disease, and to initiate a plan of treatment as necessary.

GOALS

• Identify risk factors for ocular disease
• Identify systemic disease based on associated ocular findings
• Identify factors that may predispose to visual loss early in a child's life
• Determine the health status of the eye, visual system, and related structures, and assess refractive errors
• Discuss the nature of the findings of the examination and their implications with the parent/caregiver, primary care physician and, when appropriate, the patient
• Initiate an appropriate management plan (e.g., treatment, counseling, further diagnostic tests, referral, follow-up, early intervention services*)
  
  * Under U.S. federal law, early intervention services for children of any age with visual impairments are available from public school districts and regional centers.

Background

The comprehensive pediatric ophthalmic evaluation can uncover abnormalities of a child's ocular and visual system (i.e., refractive errors, strabismus, cataracts, ptosis) that can lead to amblyopia and strabismus, among other disorders. Amblyopia can be treated effectively and permanent visual loss can be prevented if detected in early childhood. A comprehensive ophthalmic evaluation also may detect serious eye disorders such as ocular tumors (i.e., retinoblastoma), the treatment of which may be sight saving and life saving. The examination also can detect congenital eye abnormalities, some of which may be hereditary. Congenital eye abnormalities may indicate the presence of systemic disorders that affect general health or impede normal development. Childhood ocular and visual disorders are important to detect, because other family members or subsequent children may be at risk for the same disorder.

• Demographic data, including identification of parent/caregiver, and patient's gender and date of birth^[A:III]
• Documentation of identity and relationship of historian^[B:III]
• The identity of other pertinent health care providers^[A:III]
• The chief complaint and reason for the eye evaluation^[A:III]
• Current eye problems^[A:III]
• Ocular history, including prior eye problems, diseases, diagnoses, and treatments^[A:III]
• Systemic history; birth weight; prenatal and perinatal history that may be pertinent (e.g., alcohol, tobacco, and drug use during pregnancy); past hospitalizations and operations; general health and development^[A:III]
• Current medications and allergies^[A:III]
• Family history of eye conditions and relevant systemic diseases.^[A:III] A social history, including racial or ethnic heritage, is germane for certain diagnostic considerations such as sickle cell anemia or Tay-Sachs disease.
• Review of systems^[B:III]

• Assessment of visual acuity and fixation pattern^[A:III]
• Ocular alignment and motility^[A:III]
• Red reflex or binocular red reflex (Brückner) test^[A:III]
• Pupil examination^[A:III]
• External examination^[A:III]
• Anterior segment examination^[A:III]
• Cycloplegic retinoscopy/refraction^[A:III]
• Funduscopic examination^[A:III]

• Binocularity/stereoacuity testing
• Sensorimotor evaluation (e.g., strabismus, suspected neurological disease)

Verbal Preliterate Child
Quantitative visual acuity assessment in cooperative verbal children (at approximately age 3 years) involves recognition of symbols, tumbling E, or letters presented at a standardized distance, generally at 20 feet (6 meters). Linear targets or targets surrounded by crowding bars are preferred because these targets may help identify children with subtle amblyopia by detecting interocular differences in acuity. In such patients, testing with isolated figures may suggest symmetrical acuities or a false negative test.^54,72[A:III] The crowding phenomenon is important in amblyopia and may result in inconsistencies in measured visual acuity because of decreased recognition of a target within others. The Vision in Preschoolers Study Group reported that a crowded line of Lea symbols was more accurate in detecting reduced visual acuity.⁵⁵ Allen figures are not crowded and have been shown to be less accurate than other methods.⁵⁶

1. Is there a red reflex from each eye?
2. Are the red reflexes from each eye symmetrical?
3. Is the quality of the red reflex normal for the individual child (taking into account skin tone and race or ethnicity)?

• Amblyopia
  • Large refractive errors that are relatively symmetrical (the larger the refractive error, the younger the child who merits eyeglasses)
  • Anisometropia (the greater the interocular difference in refraction, the younger the child who needs eyeglasses)
    
• Strabismus
  • Accommodative esotropia
  • Intermittent exotropia
    
• Defective visual acuity due to an uncorrected refractive error
  • Can be myopia, hyperopia, astigmatism, or mixed (the higher the refractive error, the younger the child who merits eyeglasses)

Factors that enable children to successfully wear eyeglasses include a positive attitude on the part of the parent/caretaker, good fit, correct prescription, reasonable cost, and constant positive reinforcement. Children require changes in eyeglasses much more frequently than adults due to head and eye growth and corresponding changes in refraction.

Other Issues
See Appendix 4 for the Joint Policy Statement of the American Academy of Pediatrics,theAmerican Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology on Learning Disabilities, Dyslexia, and Vision. The Refractive Errors & Refractive Surgery PPP⁸⁴ discusses prevention of myopia progression, orthokeratology, and visual training exercises.

PROVIDER
A comprehensive pediatric ophthalmic evaluation is best performed by an ophthalmologist. Certain diagnostic procedures may be delegated to appropriately trained and supervised personnel under the ophthalmologist's supervision. For cases in which the diagnosis or management is difficult, consultation with or referral to an ophthalmologist who specializes in the diagnosis and treatment of pediatric patients may be desirable.

COUNSELING AND REFERRAL
The ophthalmologist should discuss the findings and any need for further evaluation, testing, or treatment with the patient’s parent/caregiver.^[A:III] The ophthalmologist, in conjunction with the primary care provider or appropriate physician, arranges for treatment and additional evaluation as indicated. The ophthalmologist may also recommend that other family members undergo a comprehensive medical eye evaluation. When a hereditary eye disease is identified, the parent/caregiver may be advised to have other family members evaluated, which may include referral to a geneticist.

APPENDIX 1. SUMMARY OF MAJOR RECOMMENDATIONS FOR CARE

Section I. Screening
Age-appropriate eye and vision evaluations should be performed in the newborn period and at all subsequent health supervision visits,^[A:III] because different childhood eye problems may be detected at each visit and new problems can arise during childhood.

At a child’s first examination by a new primary care provider, a history of risk factors for eye and vision abnormalities should be elicited.^[A:III] At each scheduled well-child examination, the primary care provider should ask the parent/caregiver about the baby’s visual interactions and possible eye or vision problems.^[A:III]

The screening examination should include examination of the red reflex to detect abnormalities of the ocular media; external inspection to detect ocular abnormalities; pupil examination; visual acuity on an age-appropriate basis; and, after 6 months of age, the corneal light reflection test (Hirschberg reflex) and cover testing for ocular alignment as well as motility testing.^[A:III]

Children who fail a screening should be referred for a comprehensive pediatric ophthalmic evaluation after the first screening failure.^[A:III]

If a child is unable to cooperate for vision testing at 3 years of age, a second attempt should be made within 6 months.^[A:III] If the child is 4 years old, a second attempt should be made within the month.^1[A:III] Although the child may be rescreened if screening is inconclusive or unsatisfactory, undue delays should be avoided; if retesting is inconclusive, referral for a comprehensive ophthalmic evaluation is indicated.^2[A:III]

REFERRAL PLAN
If eye and vision abnormalities or their risk factors are suspected or identified at a screening examination, an appropriate referral plan should be initiated and recorded.^[A:III] Tables 2 and 3 (see main text) list specific examples of indications for a referral for a comprehensive pediatric ophthalmic evaluation.

Section II. Comprehensive Ophthalmic Evaluation

HISTORY
Although a thorough history generally includes the following items, the exact composition varies with the patient's particular problems and needs:

• Demographic data, including identification of parent/caregiver, and patient's gender and date of birth^[A:III]
• Documentation of identity and relationship of historian^[B:III]
• The identity of other pertinent health care providers^[A:III]
• The chief complaint and reason for the eye evaluation^[A:III]
• Current eye problems^[A:III]
• Ocular history, including prior eye problems, diseases, diagnoses, and treatments^[A:III]
• Systemic history; birth weight; prenatal and perinatal history that may be pertinent (e.g., alcohol, drug, and tobacco use during pregnancy); past hospitalizations and operations; general health and development^[A:III]
• Current medications and allergies^[A:III]
• Family history of eye conditions and relevant systemic diseases.^[A:III] A social history, including racial or ethnic heritage, is germane for certain diagnostic considerations such as sickle cell anemia or Tay-Sachs disease.
• Review of systems^[B:III]

EXAMINATION
Documentation of the child’s level of cooperation with the examination can be useful in interpreting the results and in making comparisons among the examinations over time. In general, the examination may include the following elements:

• Assessment of visual acuity and fixation pattern^[A:III]
• Ocular alignment and motility^[A:III]
• Red reflex or binocular red reflex (Brückner) test^[A:III]
• Pupil examination^[A:III]
• External examination^[A:III]
• Anterior segment examination^[A:III]
• Cycloplegic retinoscopy/refraction^[A:III]
• Funduscopic examination^[A:III]

Other tests that may be indicated in selected patients:

• Binocularity/stereoacuity testing
• Sensorimotor evaluation (e.g., strabismus, suspected neurological disease)

DIAGNOSIS AND MANAGMENT

Category I: Low Risk
When the evaluation is normal, the ophthalmologist reassures the patient and the parent/caregiver and advises as to the appropriate interval for re-examination. Although this group of patients is considered low risk, periodic eye screening by the primary care provider should be continued.^[A:III] Patients should undergo a comprehensive pediatric ophthalmic evaluation if new ocular symptoms, signs, or risk factors for ocular disease develop.^[A:III]

Category II: High Risk
When the evaluation reveals risk factors for developing ocular disease or signs that are suggestive of an abnormal condition, the patient is considered to be at high risk. The ophthalmologist should determine an appropriate follow-up interval for each patient based on the findings.^[A:III]

Category III: Requiring Intervention
Most patients with abnormal signs and symptoms can be diagnosed and treated solely on the basis of a comprehensive pediatric eye evaluation. Recommendations for appropriate treatment and follow-up will vary with the patient. The Amblyopia PPP³ and Esotropia and Exotropia PPP⁴ contain specific recommendations for management of these conditions.

Optical correction should be considered if the visual acuity can be improved, if ocular alignment can be improved, to prevent or treat amblyopia, to treat strabismus, or if the patient has asthenopia.^[A:III] The goals when prescribing eyeglasses for young children are to achieve good vision, straight eyes, normal binocular vision, and acceptance of the eyeglasses.

REFERENCES

1. Eye examination in infants, children, and young adults by pediatricians. Pediatrics 2003;111:902-7.
2. Maguire MG. Children unable to perform screening tests in vision in preschoolers study: proportion with ocular conditions and impact on measures of test accuracy. Invest Ophthalmol Vis Sci 2007;48:83-7.
3. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Amblyopia. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.
4. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Esotropia and Exotropia. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.

APPENDIX 2. VISION SCREENING STATISTICS
Because of the high prevalence of amblyopia and the need for early treatment, many state legislatures have mandated public screening programs for preschool children.⁸⁵ It has been estimated, however, that only 20% of preschool children are actually screened in these programs.^38,86

Although a cross-sectional study of pediatric practices in the United States and Puerto Rico reported that vision screening was attempted for 66% of children 3 to 5 years old during health supervision visits, only two-thirds of these children were screened for ocular alignment or stereopsis.⁸⁷ Ninety-one percent of pediatricians reported routinely performing vision screening tests during health supervision visits in 1993. Compared with 1988, in 1993 more pediatricians report routinely performing the red reflex and the Hirschberg tests on patients in each age group, more pediatricians were performing the cover-uncover test on very young patients, and more pediatricians were performing the funduscopic examination among 5- and 6-year-olds. But, in 1993, only one-third of pediatricians reported testing patients for visual acuity at 3 years.⁸⁸ In a survey of the office practices of family physicians, 36% of 3-year-olds, 58% of 4-year-olds, and 73% of 5-year-olds underwent visual acuity screening, while only 7% of the group underwent stereopsis testing.⁸⁹

APPENDIX 3. AMERICAN ACADEMY OF PEDIATRICS “SEE RED CARD” ORDER FORM

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APPENDIX 4. LEARNING DISABILITIES, DYSLEXIA, AND VISION: JOINT POLICY STATEMENT

A joint statement of the American Academy of Pediatrics (Section on Ophthalmology, Council on Children with Disabilities), the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus and the American Association of Certified Orthoptists.

ABSTRACT
Learning disabilities, including reading disabilities, are commonly diagnosed in children. Their etiologies are multifactorial, reflecting genetic influences and dysfunction of brain systems. Learning disabilities are complex problems that require complex solutions. Early recognition and referral to qualified educational professionals for evidence-based evaluations and treatments seem necessary to achieve the best possible outcome. Most experts believe that dyslexia is a language-based disorder. Vision problems can interfere with the process of learning; however, vision problems are not the cause of primary dyslexia or learning disabilities. Scientific evidence does not support the efficacy of eye exercises, behavioral vision therapy, or special tinted filters or lenses for improving the long-term educational performance in these complex pediatric neurocognitive conditions. Diagnostic and treatment approaches that lack scientific evidence of efficacy, including eye exercises, behavioral vision therapy, or special tinted filters or lenses, are not endorsed and should not be recommended.

Key Words: learning disabilities, vision, dyslexia, ophthalmology, eye examination.

BACKGROUND
Reading is the process of extracting meaning from written symbolic characters. In elementary school, a large amount of time and effort is devoted to the complicated task of learning to read. Because of the difficulties that some children experience with learning to read, Congress mandated that the Eunice Kennedy Shriver National Institute of Child Health and Human Development assemble a national panel of educators and scientists to review the literature to research the optimal methods of teaching children to read. The 2000 report of the National Reading Panel titled "Teaching Children to Read: An Evidence-Based Assessment of the Scientific Research Literature on Reading and Its Implications for Reading Instruction"¹ linked research findings with recommendations for specific approaches to teaching reading to all children.

Learning disabilities remain a concern for the children and families involved and for the public. The inability to read and comprehend is a major obstacle to learning, which may have long-term educational, social, and economic consequences. Depending on the definition chosen, 5% to 17.5% of people in the United States have a learning disability with an estimated 2.6 million children aged 6 to 11 years affected.² Learning disabilities often prevent children from reaching their full potential. They may cause children to have difficulty learning to listen, speak, read, spell, write, reason, concentrate, solve mathematical problems, and organize information. These children may also have difficulty mastering social skills or motor coordination. Learning difficulties are frequently associated with and complicated by attention-deficit/hyperactivity disorder.² Left untreated, learning difficulties may lead to frustration, low self-confidence, and poor self-esteem and substantially increase the risk of developing psychological and emotional problems.³

Approximately 80% of people with learning disabilities have dyslexia.^2,4-7 The terms "reading disability" and "dyslexia" are often used interchangeably in the literature.⁸ Dyslexia is a primary reading disorder and results from a written word processing abnormality in the brain.^2-4 It is characterized by difficulties with accurate and/or fluent sight word recognition and by poor spelling and decoding abilities. These difficulties are unexpected in relation to the child's other cognitive skills. Dyslexia has been identified as having a strong genetic basis.^2,8,9 Recent genetic-linkage studies have identified many loci at which dyslexia-related genes are encoded. Approximately 40% of siblings, children, or parents of an affected individual will have dyslexia. Although dyslexia is often inherited, it may exist in the absence of a family history. Dyslexia can be mild or severe, occurs throughout the world, seems to affects boys more than girls,¹⁰ involves children with all levels of intelligence, and can persist for a lifetime.^{2,4,5,8,11,12} Dyslexia is identified in some people early in their lives but in others is not diagnosed until much later, when more complex reading and writing skills are required. People with dyslexia can be very bright and may be gifted in math, science, the arts, or even in unexpected areas such as writing.¹² Dyslexia should be separated from other secondary forms of reading difficulties caused by visual or hearing disorders, mental retardation, and experiential or instructional deficits.^2,8 Early reading difficulties may be caused by experiential and instructional deficits.⁸ It is important to identify and address such causes of secondary reading difficulties.^5,8

Approximately 80% of people with learning disabilities have dyslexia.2,4-7

Oral language development has been found to play a critical role in learning to read.¹ Unlike speaking, reading and writing do not develop naturally and require active learning. Reading is more difficult than speaking, because children must be aware of the sound structure in spoken language and then break the alphabetic code to acquire the sound/symbol connection.

English is a phonemically complex language in which the 26 letters of the alphabet create 44 sounds, or phonemes, in approximately 70 letter combinations.^6,7,13 The phonemic complexity of an alphabet-based language corresponds to the prevalence of dyslexia, pointing to the linguistic origin of dyslexia.^8,14 Reading involves the integration of multiple factors related to a person's experience, ability, and neurologic functioning. Most people with dyslexia have a neurobiological deficit in the processing of the sound structure of language, called a phonemic deficit,^{1,2,4-8,11,13,15} which exists despite relatively intact overall language abilities.^2,4-7 Children with more severe forms of dyslexia may have a second deficit in naming letters, numbers, and pictures, creating a double deficit,^{8,16,/a>8,/a>8,17} or they may have problems with their attention or working memory. Other children may have trouble orienting, recognizing, and remembering letter combinations. This difficulty may be a neuromaturational delay that improves with development. Importantly, the definition of dyslexia does not include reversal of letters or words or mirror reading or writing, which are commonly held misconceptions.^8,12,14

Research has shown that most children and adults with reading disabilities experience a variety of problems with language^{1,2,4-8,11,13} that stem from altered brain function^2,4,8,18-29 There is solid scientific evidence that supports the neurologic basis for the phonological coding deficit theory of reading disabilities.^2,4,8,18-29 Scientific research using functional MRI studies and positron emission tomography scans has shown that reading takes place predominantly in left-hemisphere sites including the inferior frontal, superior temporal, parietotemporal, and middle temporal-middle occipital gyri in typical readers. Children with dyslexia, on the other hand, use different areas of the brain when reading.^2,4,18-29 People with dyslexia demonstrate a dysfunction in the left-hemisphere posterior reading systems and show compensatory use of the inferior frontal gyri of both hemispheres and the right occipitotemporal area.^2,4,18-29 People with dyslexia have an abnormality in the word-analysis pathways that interferes with their ability to convert written words into spoken words. These dyslexia-specific brain abnormalities have been shown to improve after successful phonologically based intervention.^19,28,29

THE ROLE OF THE VISUAL SYSTEM AND THE EYES
Visual processing is a higher cortical function.^8,30 Decoding and interpretation of retinal images occur in the brain after visual signals are transmitted from the eyes. Reading print involves adequate vision and the neurologic ability to identify what is seen. Although vision is fundamental for reading, the brain must interpret the incoming visual images. Historically, many theories have implicated defects in the visual system as a cause of dyslexia. We now know these theories to be untrue. Improved understanding began with a series of related studies that systematically demonstrated that deficits in visual processes, such as visualization, visual sequencing, visual memory, visual perception, and perceptual-motor abilities, were not basic causes of reading difficulties.⁸ Difficulties in maintaining proper directionality have been demonstrated to be a symptom, not a cause, of reading disorders.^8,30,31 Word reversals and skipping words, which are seen in readers with dyslexia, have been shown to result from linguistic deficiencies rather than visual or perceptual disorders.⁸

Specific reading disability in a small subset of patients with dyslexia has been attributed by some researchers to a deficit in the magnocellular visual system.^32-35 The visual system comprises 2 parallel systems: the magnocellular system and the parvocellular system.^32,/a>32 The magnocellular system responds to high temporal frequency and object movement, and the parvocellular system is sensitive to low frequency and fine spatial details. It has been proposed that a magnocellular system deficit produces a visual trace of abnormal longevity that creates a masking effect and causes visual acuity blurring when reading connected text in some children with dyslexia.³⁵ There are study results that support this theory^32-35 and others that refute it.^36-44 Many researchers have concluded that magnocellular system deficits and associated visual trace persistence are not a significant cause of specific reading disability.^8,36-43 At the present, there is insufficient evidence to base any treatment on this possible deficit.</sup>

Short-duration, high-velocity, small jumping eye movements called saccades are used for reading. Readers with dyslexia characteristically have saccadic eye movements and fixations similar to the beginning reader but show normal saccadic eye movements when content is corrected for ability.^30,31 The saccadic patterns seen in readers with dyslexia seem to be the result, not the cause, of their reading disability.^30,31,45,46 Decoding and comprehension failure, rather than a primary abnormality of the oculomotor control systems, is responsible for slow reading, increased duration of fixations, and increased backward saccades.⁴⁶ Children with dyslexia often lose their place while reading because they struggle to decode a letter or word combination and/or because of lack of comprehension, not because of a "tracking abnormality." Improving reading has been shown to change saccadic patterns, but there has been no evidence to suggest that saccadic training results in better reading. Finally, children with saccadic disorders do not show an increased likelihood of dyslexia.⁴⁷ As indicated above, dyslexia is not correlated with eye or eye movement abnormalities.^{8,30,31,45-59}

Other conditions may affect reading. Convergence insufficiency and poor accommodation, both of which are uncommon in children, can interfere with the physical act of reading but not with decoding.¹⁴ Thus, treatment of these disorders can make reading more comfortable and may allow reading for longer periods of time but does not directly improve decoding or comprehension.¹⁴

Numerous studies have shown that children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions.^{8,30,31,45,46,48-59} Specifically, subtle eye or visual problems, including visual perceptual disorders, refractive error, abnormal focusing, jerky eye movements, binocular dysfunction, and misaligned or crossed eyes do not cause dyslexia.^{8,30,31,45,46,48-59} In summary, research has shown that most reading disabilities are not caused by altered visual function.^{8,30,31,45,46,48-59}

Many children with reading disabilities enjoy playing video games, including handheld games, for prolonged periods. Playing video games requires concentration, visual perception, visual processing, eye movements, and eye-hand coordination. Convergence and accommodation are also required for handheld games. Thus, if visual deficits were a major cause of reading disabilities, children with such disabilities would reject this vision-intensive activity.  

EARLY DETECTION
A family history of learning disabilities should keep parents, teachers, and physicians alert to this possibility. A history of delay or difficulty in developing speech and language, learning rhymes, or recognizing letters and sound/symbol connections may be an early indication of dyslexia.^2,4,5,8 Parents or teachers may detect early signs of learning difficulties in preschool-aged children; however, in most cases, learning disabilities are not discovered until children experience academic difficulties in elementary school.^2,4 The child may have difficulty with reading, spelling, handwriting, remembering words, or performing mathematical computation. Because remediation is more effective during the early years, prompt diagnosis is important.^{1,2,4-8,13,15,60} The effect that dyslexia has may be different for each person and depends on the severity of the condition and the effectiveness and timeliness of instruction or remediation.

THE ROLE OF EDUCATION
The educational system has the triple responsibility of early detection, evaluation, and treatment of children with learning disabilities. Elementary school teachers are often the first to detect learning difficulties. Assessments for difficulties with alphabet recognition in kindergarten and difficulties with phonemic awareness and rapid naming in kindergarten and first grade can predict many of those who will have difficulty learning to read.^{1,2,5-8,13,15} Because early reading difficulties may be caused primarily by experiential and instructional deficits, there are 2 approaches that can be used in the young underachieving child.⁸ In the traditional approach, the child would need to show significant underachievement before referral, assessment, and remediation. In the response-to-intervention method, the child will be placed directly in an educational intervention program when he or she first experiences academic difficulties. Only the children who do not show significant improvement with both the group-intervention first-tier program and second-tier targeted intensive individual intervention will undergo a full educational assessment.^8,61,62 Ideally, the response-to-intervention approach will allow earlier identification of learning disabilities than the "wait to fail" situation that occurs when an ability achievement discrepancy formula is used to determine if a student qualifies for an evaluation of a learning disability.⁶²

Because dyslexia is a language-based disorder, treatment should be directed at this etiology.^{1,2,4-8,13,15,60} Most students with dyslexia require highly structured, intensive, individualized instruction by a teacher or educational therapist who was specially trained explicitly in teaching the application of phonics.^{1,2,4-8,13,15} Longitudinal data indicate that systematic phonics instruction results in more favorable outcomes for readers with disabilities than does a context-emphasis (whole language) approach.^{1,4,8,13,15,60} The critical elements of effective intervention include individualization, feedback and guidance, ongoing assessment, and regular ongoing practice.⁴

Remediation programs should include specific instruction in decoding, fluency training, vocabulary, and comprehension.^1,4-8,13,15 The approach to learning decoding skills begins with explicit instruction in recognizing spoken sounds (phonemic awareness), becoming aware of rhyme, learning the alphabetic code, memorizing sight words, and studying phonics and spelling.^6-8 A child must first accurately decode a word before it can be read fluently.^4,6-8 The home is the ideal setting for practice and reinforcement. Just as an athlete must practice to optimize his or her skills, the child should read aloud to a parent or tutor each day to practice decoding, memorize new sight words, and develop greater fluency by rereading of previously decoded and memorized words.⁴ Fluency forms the bridge between decoding and comprehension.^4,6-8 Comprehension is gained through fluency training, vocabulary instruction, and active reading comprehension.⁴ Techniques that enhance active reading comprehension include prediction, summarization, visualization, clarification, critical thinking, making inferences, and drawing conclusions.^2,4,6-8,13 Because people with dyslexia have a persistent problem and continue to have slower reading throughout their lives, accommodations and modifications may be necessary in addition to remediation.^2,4 Examples of accommodations include extra time, shortened assignments, a separate quiet room for taking tests, testing alternatives, computers, spell checkers, tape recorders, lecture notes, recorded books, and tutors.^2,4,11

A MULTIDISCIPLINARY APPROACH
The diagnosis and treatment of learning disabilities depend on the collaboration of a team that may include educators; educational remediation specialists; audiologists; speech, physical, and occupational therapists; teachers for the visually impaired; psychologists; and physicians. Children with learning disabilities should undergo assessments of their health, development, hearing, and vision and, when appropriate, medical and psychological interventions for associated and related treatable conditions.⁶³

A formal evidence-based evaluation is needed to discover whether a child has a learning disability. Educational psychologists and neuropsychologists diagnose learning disabilities by performing appropriate testing as part of an educational assessment of the child's abilities and disabilities. A formal assessment for learning disabilities should include evaluation of cognition, memory functions, attention, intellectual ability, information processing, psycholinguistic processing, expressive and receptive language function, academic skills, social-emotional development, and adaptive behavioral functioning. These results are used to develop an individualized education plan (IEP), which includes evidence-based educational remediations, accommodations, and modifications.^2,4,7,13 Educational therapists or educators with specialized training in learning disabilities play a key role by designing and implementing remedial programs and monitoring the student's progress.

Audiologists can identify hearing problems. Speech therapists can evaluate and treat underlying oral language difficulties often associated with dyslexia and help students learn phonological awareness. Physical and occupational therapists do not treat dyslexia but do treat fine and gross motor difficulties or sensory problems that may be associated with learning disabilities. Children with low vision and learning disabilities may benefit from having a teacher of the visually impaired. Psychiatrists, psychologists, neurologists, and specialty-trained pediatricians can diagnose associated comorbid conditions. Psychiatrists, clinical psychologists, licensed clinical social workers, or licensed mental health counselors can provide strategies to help children adapt to their disabilities and provide therapy to address concurrent psychological disorders. Psychiatrists, neurologists, or specialty-trained pediatricians may prescribe medications. The role of other physicians will be elaborated in a later section of this statement.

THE ROLE OF PARENTS
Parental participation in a child's education is of utmost importance. Families with a history of dyslexia should observe their children for early language difficulties. Reading to their preschool-aged children and having their child read to them as soon as he or she is able allows parents to detect early signs of learning difficulties. Parents should collaborate with early elementary school teachers to monitor their child for academic struggles. Parents need to serve as the child's advocate, speaking with the child's teacher, pediatrician, and other professionals; requesting an educational evaluation; and coordinating remediation and other treatment. By educating themselves in the areas of learning disabilities, available services, and state education rules and regulations, parents will increase their effectiveness as the child's advocate. After a child has been diagnosed with a learning disability, an individualized educational plan or a Section 504 plan may be created. Parents should work with educators to ensure that the school provides the proper remediation and accommodations. Children with dyslexia should read aloud to their parents frequently. Parents should help with practice and reinforcement at home in a supportive and nurturing environment with adequate opportunity for their child to participate in activities in which he or she excels. As the child gets older, parents should help their child use recommended alternative learning strategies such as books on tape or computers. Parents should continue to monitor their child's progress and advocate for their child when necessary.

Because of the complex nature of learning disabilities, including dyslexia, there are no simple remedies. Teaching children with dyslexia and learning disabilities can be a challenge for educators and parents. With proper remediation, accommodations, and support, children with dyslexia and learning disabilities can succeed.

THE ROLE OF THE PHYSICIAN
Physicians, including pediatricians, family physicians, otolaryngologists, neurologists, ophthalmologists, mental health professionals, and other relevant medical specialists, may participate in the comprehensive care of children with learning disabilities including dyslexia. Pediatricians should not diagnose learning disabilities⁶³ but should inquire about the child's educational progress and be vigilant in looking for early signs of evolving learning disabilities.⁶³ When a child has suspected learning difficulties, the pediatrician or family physician should first assess the child for medical problems that could affect the child's ability to learn and refer him or her for further evaluation if deemed appropriate.^63,64

Pediatricians and family physicians have an extremely important function in acting as a medical home by helping parents decide whether further evaluations are needed and in coordinating care for the child after a diagnosis has been made.^63,64 Primary care physicians who have a strong role in assisting school districts should only recommend evidence-based treatments and accommodations. Pediatricians and family physicians should provide information and support to parents on learning disabilities and their treatment and should dispel the myths surrounding these disorders.³⁰ This should include discussion regarding the lack of efficacy of vision therapy and other "alternative treatments" with the parents.³⁰ Parents need to be informed that dyslexia is a complex disorder and that there are no quick cures. The American Academy of Pediatrics has information for families on what parents need to know about learning disabilities.⁶⁵ The primary care physician should compile and provide a resource list of local specialists from whom the child can obtain proper help and from whom the family members can learn to become advocates for the child.⁶³

The Individuals With Disabilities Education Act, Section 504 of the Rehabilitation Act, and the Americans With Disabilities Act define the rights of students with dyslexia and other specific learning disabilities.^66,67 These acts allow parents to request a formal educational evaluation by the school district to determine eligibility for special education and related services. Information for pediatricians on this legislation and its associated rights and procedures is available from the American Academy of Pediatrics.^63,64 Physicians can refer parents of children with learning disabilities to their state's parent training and information center. These parent-directed centers provide information and technical assistance to parents and professionals regarding family and student rights and responsibilities in special education.

For all children, primary care physicians should perform hearing and vision screenings according to national standards⁶⁸ so that hearing, ocular, and visual disorders are identified as early as possible. Periodic eye and vision screenings can identify children who have reduced visual acuity or other visual disorders. Vision screening with nonletter symbols may be necessary for testing children with dyslexia or other learning disabilities.

Children who do not pass vision screening should be referred to an ophthalmologist with experience in the care of children.⁶⁸ In addition, the recommended routine pediatric vision screening are unlikely to disclose near-vision problems such as convergence insufficiency, accommodative insufficiency, and significant hyperopia. Children with suspected learning disabilities in whom a vision problem is suspected by the child, parents, physicians, or educators should be seen by an ophthalmologist with experience in the assessment and treatment of children, because some of these children may also have a treatable visual problem that accompanies or contributes to their primary reading or learning dysfunction.^30,45,58 Treatable ocular conditions can include strabismus, amblyopia, convergence and/or focusing deficiencies, and refractive errors. Missing these problems could cause long-term consequences from assigning these patients to incorrect treatment categories.

The ophthalmologist should identify and treat any significant visual defect according to standard principles of treatment.^69,70 Strabismus, amblyopia, and refractive errors may require glasses, eye patching, eye drops, or eye-muscle surgery. Symptomatic convergence insufficiency can be treated with near-point exercises, prism-convergence exercises, or computer-based convergence exercises. Most of these exercises can be performed at home, and extensive in-office vision therapy is not required.^71-73 Alternatively, for other patients, reading glasses with base-in prism⁷³ or minus-lenses can be used as treatment. Treating convergence insufficiency can make reading more comfortable but does not improve the decoding or understanding of reading.¹⁴ If no ocular or visual disorder is found, the child needs no further vision assessment or management. The ophthalmologist should not diagnose learning disabilities but should provide information on learning disabilities and reinforce the need for additional medical, psychological, educational, or other appropriate evaluation or services. In addition, the ophthalmologist should discuss the lack of efficacy of vision therapy and other "alternative treatments" with the parents. The American Academy of Ophthalmology has a patient-education brochure for families titled "Learning Disabilities."⁷⁴ The ophthalmologist, when necessary, should compile and provide a resource list of local specialists who can help obtain proper help for the child.⁶⁹

CONTROVERSIES
Because they are difficult for the public to understand and for educators to treat, learning disabilities have spawned a wide variety of controversial and scientifically unsupported alternative treatments, including vision therapy.^{2,8,30,31,45,46,55-58,69,70,75-94} Scientific evidence of effectiveness should be the basis for treatment accommodations.^4,45,60 Treatments that have inadequate scientific proof of efficacy should be discouraged. Ineffective, controversial methods of treatment such as vision therapy may give parents and teachers a false sense of security that a child's learning difficulties are being addressed, may waste family and/or school resources, and may delay proper instruction or remediation.⁴⁵

Currently, there is inadequate scientific evidence to support the view that subtle eye or visual problems, including abnormal focusing, jerky eye movements, misaligned or crossed eyes, binocular dysfunction, visual-motor dysfunction, visual perceptual difficulties, or hypothetical difficulties with laterality or "trouble crossing the midline" of the visual field, cause learning disabilities.^{8,30,31,45,46,48-59} Statistically, children with dyslexia or related learning disabilities have the same visual function and ocular health as children without such conditions.^{8,30,31,45,46,48-59}  Because visual problems do not underlie dyslexia, approaches designed to improve visual function by training are misdirected.^{31,47,56,57,69,78} Other than convergence-insufficiency treatment,^{70-73,79,81,95,96} scientific evidence does not support the assumption that vision therapy is capable of correcting subtle visual defects,^{14,30,31,45,46,55,57,58,69,70,77,79-81} nor does it prove eye exercises or behavioral vision therapy to be effective direct or indirect treatments for learning disabilities.^{2,4,8,14,30,31,45,46,55-58,69,70,76-82} Detailed review of the literature supporting vision therapy reveals that most of the information is poorly validated, because it relies on anecdotes, poorly designed studies, and poorly controlled or uncontrolled studies.^{30,31,45,46,55-58,69,70,76-81} Their reported benefits can often be explained by the placebo effect or by the traditional educational remedial techniques with which they are usually combined.^{30,45,46,55,57,58,78,79} There is currently no evidence that children who participate in vision therapy are more responsive to educational instruction than are children who do not participate.^{2,4,8,14,30,31,45,46,55-58,69,70,76-82} Thus, current evidence is of poor scientific quality and does not provide adequate scientific evidence that vision training is a necessary primary or adjunctive therapy.^{2,4,8,14,30,31,45,46,55-58,69,70,76-82}

Tinted lenses and filters have been suggested to treat visual perceptual dysfunctions that lead to visual distortion caused by sensitivities to particular wavelengths of light but not to treat language-based dyslexia.⁹⁷ Scrutiny of published study results that advocated the use of these therapies to treat dyslexia have shown serious flaws in their methods and have not been sufficiently well controlled to support this assertion.^{30,70,84,85,88} There have also been many inconsistencies in the results,^89,98,99 with some studies showing some partial positive results^100-106 and others showing negative results.^84,86,90-94 The method used to select the lens or filter color has been highly variable,^89,104,106 the color selection has also shown considerable variability,¹⁰⁴ and the test-retest consistency has been poor.¹⁰⁷ Many of the studies that have been cited as proof of Irlen-lens efficiency have actually been inconclusive after deeper analysis. The evidence does not support the effectiveness of tinted lenses and tinted filters in these patients because of the weaknesses in methodology and statistics, variability in techniques in the trials, and the largely negative results.^{8,30,45,70,76,83-94,107}

RECOMMENDATIONS

1. Children who exhibit signs of learning disabilities should be referred as early in the process as possible for educational, psychological, neuropsychological, and/or medical diagnostic assessments.
2. Children with learning disabilities should receive appropriate support and individualized evidence-based educational interventions combined with psychological and medical treatments as needed.
3. Families of children with suspected learning disabilities should receive information about state and local parent support programs.
4. Pediatricians and family physicians should perform periodic eye and vision screening for all children according to national standards and refer those who do not pass screening to ophthalmologists who are experienced in the care of children.
5. Children with a suspected or diagnosed learning disability in which vision is felt to play a role by parents, the child, educators, or physicians should be referred to an ophthalmologist with experience in the care of children because routine pediatric vision screening is not designated to detect near-vision problems.
6. Ophthalmologists should identify and treat any significant ocular or visual disorder found to be present.
7. Primary care physicians should only recommend evidence-based treatments and          accommodations to school districts.
8. Diagnostic and treatment approaches for dyslexia that lack scientific evidence of efficacy such as behavioral vision therapy, eye muscle exercises, or colored filters and lenses are not endorsed or recommended.

SUMMARY
Dyslexia and learning disabilities are complex problems that have no simple solutions. The most widely accepted view is that dyslexia is a language-based disorder. The American Academy of Pediatrics, the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists strongly support the need for early diagnosis and educational intervention.

Recommendations for multidisciplinary evaluation and management must be based on evidence of proven effectiveness demonstrated by objective scientific methodology.^4,45,60 It is important that any therapy for learning disabilities be scientifically established to be valid before it can be recommended for treatment.⁶⁰

Currently, there is no adequate scientific evidence to support the view that subtle eye or visual problems cause learning disabilities.^{8,30,31,45,46,48-59} Furthermore, the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities.^{2,4,8,14,30,31,45,46,55-58,69,70,76-88,90-94} Thus, the claim that vision therapy improves visual efficiency cannot be substantiated. Diagnostic and treatment approaches that lack scientific evidence of efficacy are not endorsed or recommended. 

With early recognition and individualized, interdisciplinary management strategies, children with learning disabilities can enjoy successful academic experiences.

American Academy of Pediatrics Section on Ophthalmology Executive Committee, 2008-2009
Gregg Lueder, MD, FAAP, Chair
Richard J. Blocker, MD, FAAP
George S. Ellis Jr., MD, FAAP
David B. Granet, MD, FAAP
Daniel J. Karr, MD, FAAP
Sharon S. Lehman, MD, FAAP
James B. Ruben, MD, FAAP
Sebastian J. Troia, MD, FAAP

Liaisons
Kyle A. Arnoldi, CO, American Association of Certified Orthoptists
Christie L. Morse, MD, American Academy of Ophthalmology
Michael X. Repka, MD, American Association for Pediatric Ophthalmology and Strabismus

Lead Authors
Sheryl Handler, MD, FAAO, American Academy of Ophthalmology
Walter M. Fierson, MD, FAAO, FAAP; Chair, American Academy of Pediatrics Learning Disabilities Subcommittee, Section on Ophthalmology

Staff
Linda Lipinsky

American Academy of Pediatrics Council on Children with Disabilities Executive Committee, 2008-2009
Nancy A. Murphy, MD, FAAP, Chair
Robert Burke, MD, MPH, FAAP
Larry W. Desch, MD, FAAP
John C. Duby, MD, FAAP
Ellen Roy Elias, MD, FAAP
Susan E. Levy, MD, FAAP
Gregory S. Liptak, MD, FAAP
Douglas McNeal, MD, FAAP
Scott M. Myers, MD, FAAP
Kenneth W. Norwood Jr., MD, FAAP
Paul J. Sagerman, MD, FAAP

Ex-Officio Chairperson (Primary Reviewer)
Paul H. Lipkin, MD, FAAP

Staff
Stephanie Mucha Skipper, MPH

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17. Badian NA. Does a visual-orthographic deficit contribute to reading disability? Ann Dyslexia. 2005;55(1):28-52.
18. Shaywitz BA, Shaywitz SE, Pugh KR, et al. Disruption of posterior brain systems for reading in children with developmental dyslexia. Biol Psychiatry. 2002;52(2):101-110.
19. Shaywitz SE, Shaywitz BA, Fulbright RK, et al. Neural systems for compensation and persistence: young adult outcome of childhood reading disability. Biol Psychiatry. 2003;54(1):25-33.
20. Eden GF, Zeffiro TA. Neural systems affected in developmental dyslexia revealed by functional neuroimaging. Neuron. 1998;21(2):279-282.
21. Hynd GW, Semrud-Clikeman M, Lorys AR, Novey ES, Eliopulos D. Brain morphology in developmental dyslexia and attention deficit disorder/hyperactivity. Arch Neurol. 1990;47(8):919-926.
22. Petersen SE, Fox PT, Posner MI, Mintun M, Raichle ME. Positron emission tomographic studies of the cortical anatomy of single-word processing. Nature. 1988;331(6157):585-589.
23. Silani G, Frith U, Demonet JF, et al. Brain abnormalities underlying altered activation in dyslexia: a voxel based morphometry study. Brain. 2005;128(pt 10):2453-2461.
24. Pugh KR, Mencl WE, Jenner AR, et al. Functional neuroimaging studies of reading and reading disability (developmental dyslexia). Ment Retard Dev Disabil Res Rev. 2000;6(3):207-213.
25. Pugh KR, Mencl WE, Jenner AR, et al. Neurobiological studies of reading and reading disability. J Commun Disord. 2001;34(6):479-492.
26. Temple E, Poldrack RA, Salidis J, et al. Disrupted neural responses to phonological and orthographic processing in dyslexic children: an fMRI study. Neuroreport. 2001;12(2):299-307.
27. Cao F, Bitan T, Chou TL, Burman DD, Booth JR. Deficient orthographic and phonological representations in children with dyslexia revealed by brain activation patterns. J Child Psychol Psychiatry. 2006;47(10):1041-1050.
28. Shaywitz BA, Shaywitz SE, Blachman BA, et al. Development of left occipitotemporal systems for skilled reading in children after a phonologically- based intervention. Biol Psychiatry. 2004;55(9):926-933.
29. Temple E, Deutsch GK, Poldrack RA, et al. Neural deficits in children with dyslexia ameliorated by behavioral remediation: evidence from functional MRI. Proc Natl Acad Sci U S A. 2003;100(5):2860-2865.
30. Olitsky SE, Nelson LB. Reading disorders in children. Pediatr Clin North Am. 2003;50(1):213-224.
31. Beauchamp GR, Kosmorsky G. Learning disabilities: update comment on the visual system. Pediatr Clin North Am. 1987;34(6):1439-1446.
32. Breitmeyer B. Sensory masking, persistence and enhancement in visual exploration and reading. In: Rayner K, editor. Eye movements in reading: perceptual and language processes. New York, NY: Academic Press; 1983:3-31. p. 526 p.
33. Livingstone MS, Rosen GD, Drislane FW, Galaburda AM. Physiological and anatomical evidence for a magnocellular defect in developmental dyslexia. Proc Natl Acad Sci U S A. 1991;88(18):7943-7947.
34. Lehmkuhle S, Garzia RP, Turner L, Hash T, Baro JA. A defective visual pathway in children with reading disability. N Engl J Med. 1993;328(14):989-996.
35. Stein J. The magnocellular theory of developmental dyslexia. Dyslexia. 2001;7(1):12-36.
36. May J, Lovegrove W, Martin F, Nelson P. Pattern-elicited visual evoked potentials in good and poor readers. Clin Vision Sci. 1991;6(2):131-136.
37. Victor JD, Conte MM, Burton L, Nass RD. Visual evoked potentials in dyslexics and normals: failure to find a difference in transient or steady-state responses. Vis Neurosci. 1993;10(5):939-946.
38. Victor JD. Defective visual pathway in reading-disabled children. N Engl J Med. 1993;329(8):579.
39. Skottun BC, Parke LA. The possible relationship between visual deficits and dyslexia: examination of a critical assumption. J Learn Disabil. 1999;32(1):2-5.
40. Skottun BC. The magnocellular deficit theory of dyslexia: the evidence from contrast sensitivity. Vision Res. 2000;40(1):111-127.
41. Skottun BC, Skoyles JR. Attention, dyslexia, and the line-motion illusion. Optom Vis Sci. 2006;83(11):843-849.
42. Skottun BC, Skoyles J. Yellow filters, magnocellular responses, and reading. Int J Neurosci. 2007;117(2):287-293.
43. Conlon E, Sanders M, Zapart S. Temporal processing in poor adult readers. Neuropsychologia. 2004;42(2):142-157.
44. Amitay S, Ben-Yehudah G, Banai K, Ahissar M. Disabled readers suffer from visual and auditory impairments but not from a specific magnocellular deficit. Brain. 2002;125(pt 10):2272-2285.
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46. Hoyt CS. Visual training and reading. Am Orthoptic J. 1999;49:23-25.
47. Hodgetts DJ, Simon JW, Sibila TA, Scanlon DM, Vellutino FR. Normal reading despite limited eye movements. J AAPOS. 1998;2(3):182-183.
48. Black JL, Collins DW, De Roach JN, Zubrick S. A detailed study of sequential saccadic eye movements for normal- and poor-reading children. Percept Mot Skills. 1984;59(2):423-434.
49. Blika S. Ophthalmological findings in pupils of a primary school with particular reference to reading difficulties. Acta Ophthalmol (Copenh). 1982;60(6):927-934.
50. Brown B, Haegerstrom-Portnoy G, Yingling CD, Herron J, Galin D, Marcus M. Tracking eye movements are normal in dyslexic children. Am J Optom Physiol Opt. 1983;60(5):376-383.
51. Hall PS, Wick BC. The relationship between ocular functions and reading achievement. J Pediatr Ophthalmol Strabismus. 1991;28(1):17-19.
52. Helveston EM, Weber JC, Miller K, et al. Visual function and academic performance. Am J Ophthalmol. 1985;99(3):346-355.
53. Polatajko HJ. Visual-ocular control of normal and learning-disabled children. Dev Med Child Neurol. 1987;29(4):477-485.
54. Rayner K. Eye movements and the perceptual span in beginning and skilled readers. J Exp Child Psychol. 1986;41(2):211-236.
55. Metzger RL, Werner DB. Use of visual training for reading disabilities: a review. Pediatrics. 1984;73(6):824-829.
56. Levine MD. Reading disability: do the eyes have it? Pediatrics. 1984;73(6):869-870.
57. Beauchamp GR. Optometric vision training. Pediatrics. 1986;77(1):121-124.
58. Hertle RW, Kowal LW, Yeates KO. The ophthalmologist and learning disabilities. Focal Points: Clinical Modules for Ophthalmologists, Module 2. San Francisco, CA: American Academy of Ophthalmology; 2005.
59. Hutzler F, Kronbichler M, Jacobs AM, Wimmer H. Perhaps correlational but not causal: no effect of dyslexic readers' magnocellular system on their eye movements during reading. Neuropsychologia. 2006;44(4):637-648.
60. Shaywitz SE, Shaywitz BA. Science informing policy: the National Institute of Child Health and Human Development's contribution to reading. Pediatrics. 2002;109(3):519-521.
61. Fuchs D, Mock D, Morgan PL, Young CL. Responsiveness-to-intervention: definitions, evidence, and implications for the learning disabilities construct. Learn Disabil Res Pract. 2003;18(3):157-171.
62. National Joint Committee on Learning Disabilities. Responsiveness to intervention and learning disabilities, June 2005. Available at: www.ldonline.org/article/Responsiveness_to_Intervention_and_Learning_Disabilities?theme=print. Accessed June 8, 2008.
63. American Academy of Pediatrics Committee on Children with Disabilities. The pediatrician's role in development and implementation of an Individual Education Plan (IEP) and/or an Individual Family Service Plan (IFSP). Pediatrics. 1999;104(1 pt 1):124-127.
64. Cartwright JD. Provision of educationally related services for children and adolescents with chronic diseases and disabling conditions. Pediatrics. 2007;119(6):1218-1223.
65. American Academy of Pediatrics. Parenting corner Q&A: learning disabilities: what parents need to know. Available at: www.aap.org/publiced/BR_LearningDisabilities.htm. Accessed September 24, 2007.
66. US Department of Justice, Civil Rights Division. A guide to disability rights laws. Available at: www.usdoj.gov/crt/ada/cguide.htm. Accessed May 14, 2007.
67. US Department of Education, Office for Civil Rights. Protecting students with disabilities: frequently asked questions about Section 504 and the education of children with disabilities. Available at: www.ed.gov/about/offices/list/ocr/504faq.html. Accessed May 14, 2007.
68. Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. American Association of Certified Orthoptists; American Association for Pediatric Ophthalmology and Strabismus; American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics. 2003;111(4 pt 1):902-907.
69. Helveston EM. Management of dyslexia and related learning disabilities. J Learn Disabil. 1987;20(7):415-421.
70. Helveston EM. Visual training: current status in ophthalmology. Am J Ophthalmol. 2005;140(5):903-910.
71. Kushner BJ. The treatment of convergence insufficiency. Arch Ophthalmol. 2005;123(1):100-101.
72. Wallace DK. Treatment options for symptomatic convergence insufficiency. Arch Ophthalmol. 2008;126(10):1455-1456.
73. Petrunak JL. The treatment of convergence insufficiency. Amer Orthoptic J. 1999;49:12-16.
74. American Academy of Ophthalmology. Learning Disabilities [patient education brochure]. San Francisco, CA: American Academy of Ophthalmology; 2005.
75. Kavale K, Mattson PD. "One jumped off the balance beam": meta-analysis of perceptual-motor training. J Learn Disabil. 1983;16(3):165-173.
76. Silver LB. Controversial therapies. J Child Neurol. 1995;10 Suppl 1:S96-S100.
77. Rawstron JA, Burley CD, Elder MJ. A systematic review of the applicability and efficacy of eye exercises. J Pediatr Ophthalmol Strabismus. 2005;42(2):82-88.
78. Keogh BK, Pelland M. Vision training revisited. J Learn Disabil. 1985;18(4):228-236.
79. Institute for Clinical Systems Improvement. Technology assessment report: vision therapy. Available at: www.icsi.org/technology_assessment_reports_-_active/ta_vision_therapy.html. Accessed May 2, 2008.
80. Jennings AJ. Behavioural optometry: a critical review. Optometry in Practice. 2000;1(2):67-78.
81. Barrett B. A critical evaluation of the evidence supporting the practice of behavioural vision therapy. Ophthalmic Physiol Opt. 2009;29:4-25.
82. Sampson G, Fricke T, Metha A, McBrien NA. Efficacy of treatment for visual information processing dysfunction and its effect on educational performance. Invest Ophthalmol Vis Sci. 2005;46:E-Abstract 679.
83. Solan HA. An appraisal of the Irlen technique of correcting reading disorders using tinted overlays and tinted lenses. J Learn Disabil. 1990;23(10):621-626.
84. Evans BJ, Drasdo N. Tinted lenses and related therapies for learning disabilities--a review. Ophthalmic Physiol Opt. 1991;11(3):206-217.
85. Hoyt CS, 3rd. Irlen lenses and reading difficulties. J Learn Disabil. 1990;23(10):624-626.
86. Menacker SJ, Breton ME, Breton ML, Radcliffe J, Gole GA. Do tinted lenses improve the reading performance of dyslexic children? A cohort study. Arch Ophthalmol. 1993;111(2):213-218.
87. Romanchuk KG. Scepticism about Irlen filters to treat learning disabilities. CMAJ. 1995;153(4):397.
88. Helveston EM. Scotopic sensitivity syndrome. Arch Ophthalmol. 1990;108(9):1232-1233.
89. Cotton MM, Evans KM. A review of the use of Irlen (tinted) lenses. Aust N Z J Ophthalmol. 1990;18(3):307-312.
90. Gole GA, Dibden SN, Pearson CC, et al. Tinted lenses and dyslexics--a controlled study. SPELD (S.A.) Tinted Lenses Study Group. Aust N Z J Ophthalmol. 1989;17(2):137-141.
91. Solan HA, Richman J. Irlen lenses: a critical appraisal. J Am Optom Assoc. 1990;61(10):789-796.
92. Blaskey P, Scheiman M, Parisi M, Ciner EB, Gallaway M, Selznick R. The effectiveness of Irlen filters for improving reading performance: a pilot study. J Learn Disabil. 1990;23(10):604-612.
93. Iovino I, Fletcher JM, Breitmeyer BG, Foorman BR. Colored overlays for visual perceptual deficits in children with reading disability and attention deficit/hyperactivity disorder: are they differentially effective? J Clin Exp Neuropsychol. 1998;20(6):791-806.
94. Simmers AJ, Bex PJ, Smith FK, Wilkins AJ. Spatiotemporal visual function in tinted lens wearers. Invest Ophthalmol Vis Sci. 2001;42(3):879-884.
95. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. 2005;123(1):14-24.
96. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126(10):1336-1349.
97. Irlen H. Successful treatment of learning difficulties. Paper presented at: 91st annual convention of the American Psychological Association; Anaheim, CA; August 26-30, 1983.
98. Robinson G. Coloured lenses and reading: a review of research into reading achievement, reading strategies and causal mechanism. Australasian Journal of Special Education. 1994;18(1):3-14.
99. Coyle B. Use of filters to treat visual-perception problem creates adherents and sceptics. CMAJ. 1995;152(5):749-750.
100. O'Connor PD, Sofo F, Kendall L, Olsen G. Reading disabilities and the effects of colored filters. J Learn Disabil. 1990;23(10):597-603, 620.
101. Robinson GL, Conway RN. The effects of Irlen colored lenses on students' specific reading skills and their perception of ability: a 12-month validity study. J Learn Disabil. 1990;23(10):589-596.
102. Wilkins AJ, Evans BJ, Brown JA, et al. Double-masked placebo-controlled trial of precision spectral filters in children who use coloured overlays. Ophthalmic Physiol Opt. 1994;14(4):365-370.
103. Lightstone A, Lightstone T, Wilkins A. Both coloured overlays and coloured lenses can improve reading fluency, but their optimal chromaticities differ. Ophthalmic Physiol Opt. 1999;19(4):279-285.
104. Wilkins AJ, Sihra N, Myers A. Increasing reading speed by using colours: issues concerning reliability and specificity, and their theoretical and practical implications. Perception. 2005;34(1):109-120.
105. Ray NJ, Fowler S, Stein JF. Yellow filters can improve magnocellular function: motion sensitivity, convergence, accommodation, and reading. Ann N Y Acad Sci. 2005;1039:283-293.
106. Lopez R, Yolton RL, Kohl P, Smith DL, Saxerud MH. Comparison of Irlen scotopic sensitivity syndrome test results to academic and visual performance data. J Am Optom Assoc. 1994;65(10):705-714.
107. Woerz M, Maples WC. Test-retest reliability of colored filter testing. J Learn Disabil. 1997;30(2):214-221.

OTHER RESOURCES
International Dyslexia Association: www.interdys.org
National Center for Learning Disabilities: www.ncld.org
Learning Disabilities On Line: http://www.ldonline.org
Interdisciplinary Council on Developmental and Learning Disorders: www.icdl.com
Great Schools Inc/Schwab Learning: www.schwablearning.org
All Kinds of Minds: www.allkindsofminds.org
Children and Adults with Attention Deficit/Hyperactivity Disorder: www.chadd.org
National Center for the Study of Adult Learning and Literacy: www.ncsall.net
PACER Center: www.pacer.org
Parental Information and Resource Centers (PIRC): www.ed.gov/programs/pirc/index.html
Family Voices: www.familyvoices.org

APPROVED BY:
American Academy of Ophthalmology, 1984
American Academy of Pediatrics, 1984
American Association for Pediatric Ophthalmology and Strabismus, 1984

REVISED AND APPROVED BY: 
American Academy of Ophthalmology, 1998
American Academy of Pediatrics, 1998
American Association for Pediatric Ophthalmology and Strabismus, 1998

REVISED AND APPROVED BY:
American Academy of Ophthalmology, 2009
American Academy of Pediatrics, 2009
American Association for Pediatric Ophthalmology and Strabismus, 2009

© 2009 American Academy of Ophthalmology®        
P.O. Box 7424 / San Francisco, CA 94120 / 415.561.8500

American Academy of Pediatrics
141 Northwest Point Blvd. / Elk Grove Village, IL 60007 / 847.434.4000

American Association for Pediatric Ophthalmology and Strabismus
P.O. Box 193832 / San Francisco, CA 94119 / 415.561.8505

American Association of Certified Orthoptists
www.orthoptics.org

• Eye examination and vision screening in infants, children, and young adults by pediatricians. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine and Section on Ophthalmology,American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology. Pediatrics 2003;111:902-7.
  (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/4/902)
  
• Red reflex examination in infants. American Academy of Pediatrics. Section on Ophthalmology. Pediatrics 2002;109:980-1. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/5/980)
  
• Use of photoscreening for children's vision screening. American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine and Section on Ophthalmology. Pediatrics 2002;109:524-5. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;109/3/524)
  
• Screening for retinopathy in the pediatric patient with type 1 diabetes mellitus. American Academy of Pediatrics. Sections on Endocrinology and Ophthalmology. Pediatrics 2005;116:270-3. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/1/270)
  
• Ophthalmologic examinations in children with juvenile rheumatoid arthritis. American Academy of Pediatrics. Sections on Rheumatology and Ophthalmology. Pediatrics 2006;117;1843-5. (http://aappolicy.aappublications.org/cgi/content/full/pediatrics;117/5/1843)
  
• Broderick P. Pediatric vision screening for the family physician. Am Fam Physician 1998;58:691-700, 703-4. (http://www.aafp.org/afp/980901ap/broderic.html)
  
• American Academy of Pediatrics videotape: Pediatric Vision Screening Video. 1999. Available at 888-843-2271 or 847-434-4000 or http://www.aap.org.
  
• Vision Screening for Infants and Children. Joint Statement by the American Association for Pediatric Ophthalmology (AAPOS) and American Academy of Ophthalmology. 2007. (http://one.aao.org/)
  
• The AAPOS Web site contains a Vision Screening Information page in which the following items can be viewed: (http://www.aapos.org/displaycommon.cfm?an=1&subarticlenbr=103)
  • AAPOS Photoscreening Position Statement: Photoscreening to Detect Amblyogenic Factors. (http://www.aapos.org/displaycommon.cfm?an=1&subarticlenbr=104)
  • Home Vision Screening Test for Parents from Prevent Blindness America: Distance Vision Test for Preschool-Age Children (3 through 5). (http://www.preventblindness.org/children/distance_child.html)

Basic and Clinical Science Course
Pediatric Ophthalmology and Strabismus (Section 6, 2007-2008)

Complementary Therapy Assessment
Vision Therapy for Learning Disabilities (2001)

Eye Fact Sheet
Overflow Tearing and Chronic Eye Infections in Infants (2004)

Information Statement
Screening Examinations of Premature Infants for Retinopathy of Prematurity (2006)

LEO Clinical Update Course on CD-ROM
Pediatric Ophthalmology and Strabismus (2003)

Patient Education
Amblyopia brochure (2004)
Eye Safety for Children brochure (2005)
Learning Disabilities brochure (2005)
Personal-Eyes Printable™ Patient Handouts on CD-ROM (some handouts available in Spanish) (2007)
Pseudostrabismus brochure (2006)
Ptosis in Children and Adults brochure (2004)
Strabismus brochure (2005)

To order any of these materials, please call the Academy’s Customer Service number, 866.561.8558 (U.S. only) or 415.561.8540 or visit http://www.aao.org/store.

• Level A: Most important to the care process
• Level B: Moderately important to the care process
• Level C: Relevant but not critical to the care process

Strength of Evidence Ratings:

• Level I: Randomized controlled trial or meta-analyses
• Level II: Controlled trials, cohort, or case-control studies
• Level III: Descriptive studies or case reports

1. Eye examination in infants, children, and young adults by pediatricians. Pediatrics 2003;111:902-7.
2. Maguire MG. Children unable to perform screening tests in vision in preschoolers study: proportion with ocular conditions and impact on measures of test accuracy. Invest Ophthalmol Vis Sci 2007;48:83-7.
3. Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005;123:437-47.
4. Pediatric Eye Disease Investigator Group. The clinical profile of moderate amblyopia in children younger than 7 years. Arch Ophthalmol 2002;120:281-7.
5. Birch EE, Stager DR. Monocular acuity and stereopsis in infantile esotropia. Invest Ophthalmol Vis Sci 1985;26:1624-30.
6. Dickey CF, Metz HS, Stewart SA, Scott WE. The diagnosis of amblyopia in cross-fixation. J Pediatr Ophthalmol Strabismus 1991;28:171-5.
7. Thompson JR, Woodruff G, Hiscox FA, et al. The incidence and prevalence of amblyopia detected in childhood. Public Health 1991;105:455-62.
8. Donahue SP. Clinical practice. Pediatric strabismus. N Engl J Med 2007;356:1040-7.
9. Pike MG, Holmstrom G, de Vries LS, et al. Patterns of visual impairment associated with lesions of the preterm infant brain. Dev Med Child Neurol 1994;36:849-62.
10. van Hof-Van Duin J, Evenhuis-van Leunen A, Mohn G, et al. Effects of very low birth weight (VLBW) on visual development during the first year after term. Early Hum Dev 1989;20:255-66.
11. National Eye Institute: Visual Acuity Impairment Study Pilot Study. Bethesda, MD: Office of Biometry and Epidemiology, Department of Health and Human Services, The Institute;1984. NTIS Accession Number PB84 156173.
12. American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. Pediatric Ophthalmology and Strabismus: Section 6, 2007-2008. San Francisco, CA: American Academy of Ophthalmology; 2007:Chapter 22.
13. Good WV, Hardy RJ, Dobson V, et al. The incidence and course of retinopathy of prematurity: findings from the early treatment for retinopathy of prematurity study. Pediatrics 2005;116:15-23.
14. American Academy of Ophthalmology Basic and Clinical Science Course Subcommittee. Basic and Clinical Science Course. Glaucoma: Section 10, 2007-2008. San Francisco, CA: American Academy of Ophthalmology; 2007:Chapter 6.
15. Pendergrass TW, Davis S. Incidence of retinoblastoma in the United States. Arch Ophthalmol 1980;98:1204-10.
16. Donnelly UM, Stewart NM, Hollinger M. Prevalence and outcomes of childhood visual disorders. Ophthalmic Epidemiol 2005;12:243-50.
17. National Advisory Eye Council. Vision Research: A National Plan. Report of the Strabismus, Amblyopia, and Visual Processing Panel, Vol 2, Part 5. Bethesda: US DHHS, NIH Publ No. 83-2475, 2001.
18. Williams C, Harrad RA, Harvey I, Sparrow JM. Screening for amblyopia in preschool children: results of a population-based, randomised controlled trial. ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. Ophthalmic Epidemiol 2001;8:279-95.
19. Attebo K, Mitchell P, Cumming R, et al. Prevalence and causes of amblyopia in an adult population. Ophthalmology 1998;105:154-9.
20. Brown SA, Weih LM, Fu CL, et al. Prevalence of amblyopia and associated refractive errors in an adult population in Victoria, Australia. Ophthalmic Epidemiol 2000;7:249-58.
21. Newman DK, East MM. Prevalence of amblyopia among defaulters of preschool vision screening. Ophthalmic Epidemiol 2000;7:67-71.
22. Robaei D, Rose KA, Ojaimi E, et al. Causes and associations of amblyopia in a population-based sample of 6-year-old Australian children. Arch Ophthalmol 2006;124:878-84.
23. Kleinstein RN, Jones LA, Hullett S, et al. Refractive error and ethnicity in children. Arch Ophthalmol 2003;121:1141-7.
24. Agency for Healthcare Research and Quality. 2004 systematic evidence review number 27: Screening for visual impairment in children younger than age 5 years: a systematic evidence review for the U.S. Preventive Services Task Force. Available at: http://www.ahrq.gov/downloads/pub/prevent/pdfser/visualser.pdf. Accessed August 20, 2007.
25. Kemper AR, Bruckman D, Freed GL. Prevalence and distribution of corrective lenses among school-age children. Optom Vis Sci 2004;81:7-10.
26. Repka MX. Ophthalmological problems of the premature infant. Ment Retard Dev Disabil Res Rev 2002;8:249-57.
27. Rudanko SL, Fellman V, Laatikainen L. Visual impairment in children born prematurely from 1972 through 1989. Ophthalmology 2003;110:1639-45.
28. Wilson J, Jungner G. Principles and Practice of Screening for Disease. Geneva, Switzerland: World Health Organization; 1968. Public Health Papers No. 34. Available at: http://whqlibdoc.who.int/php/WHO_PHP_34.pdf. Accessed June 27, 2007.
29. Simons K. Preschool vision screening: rationale, methodology and outcome. Surv Ophthalmol 1996;41:3-30.
30. Kvarnstrom G, Jakobsson P, Lennerstrand G. Visual screening of Swedish children: an ophthalmological evaluation. Acta Ophthalmol Scand 2001;79:240-4.
31. Donahue SP, Arnold RW, Ruben JB. Preschool vision screening: what should we be detecting and how should we report it? Uniform guidelines for reporting results of preschool vision screening studies. J AAPOS 2003;7:314-6.
32. Arnold RW, Armitage MD, Gionet EG, et al. The cost and yield of photoscreening: impact of photoscreening on overall pediatric ophthalmic costs. J Pediatr Ophthalmol Strabismus 2005;42:103-11.
33. Kerr NC, Arnold RW. Vision screening for children: current trends, technology, and legislative issues. Curr Opin Ophthalmol 2004;15:454-9.
34. Arnold RW, Donahue SP. Compared value of amblyopia detection. Binocul Vis Strabismus Q 2006;21:78.
35. Kvarnstrom G, Jakobsson P, Lennerstrand G, Dahlgaard J. Preventable vision loss in children: a public health concern? Am Orthopt J 2006;56:3-6.
36. Joish VN, Malone DC, Miller JM. A cost-benefit analysis of vision screening methods for preschoolers and school-age children. J AAPOS 2003;7:283-90.
37. Kvarnstrom G, Jakobsson P, Lennerstrand G. Screening for visual and ocular disorders in children, evaluation of the system in Sweden. Acta Paediatr 1998;87:1173-9.
38. Ehrlich MI, Reinecke RD, Simons K. Preschool vision screening for amblyopia and strabismus. Programs, methods, guidelines, 1983. Surv Ophthalmol 1983;28:145-63.
39. Reinecke RD. Current concepts in ophthalmology. Strabismus. N Engl J Med 1979;300:1139-41.
40. American Association for Pediatric Ophthalmology and Strabismus and American Academy of Ophthalmology. Joint Policy Statement. Vision Screening for Infants and Children. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://one.aao.org/CE/PracticeGuidelines/ClinicalStatements.aspx.
41. U.S. Preventive Services Task Force. Screening for Visual Impairment in Children Younger than Age 5 Years: Recommendation Statement. May 2004. Agency for Healthcare Research and Quality, Rockville, MD. Available at: http://www.ahrq.gov/clinic/3rduspstf/visionscr/vischrs.htm. Accessed August 20, 2007.
42. Eibschitz-Tsimhoni M, Friedman T, Naor J, et al. Early screening for amblyogenic risk factors lowers the prevalence and severity of amblyopia. J AAPOS 2000;4:194-9.
43. U.S. Preventive Services Task Force. Screening for visual impairment in children younger than age 5 years: recommendation statement. Ann Fam Med 2004;2:263-6.
44. Lithander J, Sjostrand J. Anisometropic and strabismic amblyopia in the age group 2 years and above: a prospective study of the results of treatment. Br J Ophthalmol 1991;75:111-6.
45. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Amblyopia. San Francisco, CA: American Academy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.
46. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120:268-78.
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Prepared by the American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel

Pediatric Ophthalmology/Strabismus Panel Members
Linda M. Christmann, MD, Chair
Patrick J. Droste, MD
Sheryl M. Handler, MD, American Association for Pediatric Ophthalmology and Strabismus Representative
Richard A. Saunders, MD
R. Grey Weaver, Jr., MD
Susannah G. Rowe, MD, MPH, Methodologist
Norman Harbaugh, MD, FAAP, American Academy of Pediatrics Representative
Donya A. Powers, MD, American Academy of Family Physicians Representative

Preferred Practice Patterns Committee Members
Sid Mandelbaum, MD, Chair
Emily Y. Chew, MD
Linda M. Christmann, MD
Douglas E. Gaasterland, MD
Samuel Masket, MD
Stephen D. McLeod, MD
Christopher J. Rapuano, MD
Donald S. Fong, MD, MPH, Methodologist

Academy Staff
Flora C. Lum, MD
Nancy Collins, RN, MPH
Doris Mizuiri
Medical Editor: Susan Garratt
Design: Socorro Soberano
Reviewed by: Council
Approved by: Board of Trustees
September 8, 2007

Financial Disclosures:
This author has disclosed the following financial relationships occurring from January 2006 to August 2007:
Norman Harbaugh, MD, FAAP: Kids First – Grant support. Kids Time – Equity owner. Medimmune – Lecture fees. Centers for Disease Control, Merck, United Healthcare – Consultant/Advisor.

Copyright American Academy of Ophthalmology 2007
All rights reserved
2nd Printing: January 2010
AMERICAN ACADEMY OF OPHTHALMOLOGY and PREFERRED PRACTICE PATTERN are registered trademarks of the AmericanAcademy of Ophthalmology. All other trademarks are the property of their respective owners

This document should be cited as:
American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Pediatric Eye Evaluations. San Francisco, CA: AmericanAcademy of Ophthalmology; 2007. Available at: http://www.aao.org/ppp.

As a service to its members and the public, the American Academy of Ophthalmology has developed a series of guidelines called Preferred Practice Patterns that identify characteristics and components of quality eye care.