Pediatric Diagnosis and Treatment of Eye Diseases

Why? How Soon? And How Often?
Children’s vision problems are common — probably more common than your patients think.Researchers say up to 10 percent of preschoolers and up to 25 percent of school-age children have vision disorders, and many of these problems can affect learning. Unfortunately, many children’s vision problems don’t have obvious signs and symptoms and aren’t detected in school vision screenings. The only way to know for sure if children have the visual skills they need in school is to make sure they have routine comprehensive eye exams performed by an optometrist or ophthalmologist. This makes routine outreach to your patient base (like appointment reminders) so important – especially during the back to school season.

Share this information to help educate your patients on the importance of routine eye care:
Q: Why Children’s Eye Exams Are So Important?

A: Early childhood eye exams are essential to ensure normal visual development and confirm there are no vision problems that might affect academic performance when a child reaches school age. Experts say roughly 80 percent of what a child learns prior to age 13 is presented visually, so it’s not surprising that good vision is necessary for optimal learning. And, given that even preschoolers these days routinely use computers and portable electronic devices, it’s reasonable to assume that detecting vision problems early is more important than ever. Pay close attention to children’s eyes beginning in infancy. Some children are born with eye alignment problems — called strabismus — that can cause incomplete visual development (amblyopia or “lazy eye”). If not detected and treated early, strabismus and amblyopia can cause permanent visual disability.

Roughly 80 percent of what a child learns prior to age 13 is presented visually, so it’s not surprising that good vision is necessary for optimal learning.

Some cases of strabismus are obvious, with one eye being noticeably “crossed” (turned inward) or “wall-eyed” (turned outward). If you suspect your infant has misaligned eyes, be sure to mention this to your pediatrician during routine wellness visits. To completely rule out strabismus, amblyopia and other vision problems, however, take your child to an eye doctor. Many infants and toddlers are affected by common refractive errors such as farsightedness and astigmatism, which can cause eye strain, headaches, blurred vision and avoidance of reading. These vision problems pose a greater risk for learning problems than strabismus. The most common children’s vision problem is myopia (nearsightedness). Though myopia typically doesn’t affect reading, it causes blurred distance vision.

Q: When Should My Child Have Their First Eye Exam?
A: The American Optometric Association (AOA) recommends children have their first eye exam at six months of age. Though the scope of this exam is not as extensive as the comprehensive exams older children and adults receive, the eye doctor will perform tests to make sure your child’s eyes are healthy and that there are no problems that might interfere with normal visual development.
The American Optometry Association (AOA) recommends that children receive their first eye exam at 6 months of age.

Q: How Often Should I Bring My Child In For Exams?
A: Throughout the School Years According to the AOA, a child’s next eye exams should take place:
At age 3
Prior to kindergarten or first grade (age 5-6)
Every 1-2 years thereafter

Children who are diagnosed with vision problems and prescribed corrective eyewear should have annual eye exams, especially if they wear contact lenses. If your child has special risk factors for eye problems, the eye doctor might recommend more frequent exams.

Our Comprehensive Eye Exam
A comprehensive eye exam includes a number of tests and procedures to examine and evaluate the health of your eyes and the quality of your vision. These tests range from simple ones, like having you read an eye chart, to complex tests, such as using a high-powered lens to examine the health of the tissues inside of your eyes.

Here are some tests you are likely to encounter during a routine comprehensive eye exam:

This test helps your doctor get a good approximation of your eyeglasses prescription. For retinoscopy, the room lights are dimmed and an instrument containing wheels of lenses (called a phoropter) is positioned in front of your eyes. You will be asked to look at an object across the room (usually the big "E" on the wall chart or screen) while your doctor shines a light from a hand-held instrument into your eyes from arm's length and flips different lenses in front of your eyes.

Based on the way the light reflects from your eye during this procedure, your doctor can get a very good idea of what your eyeglasses prescription should be. This test is especially useful for children and non-verbal patients who are unable to accurately answer the doctor's questions.

With the widespread use of automated instruments to help determine eyeglass prescriptions today, many doctors forgo performing retinoscopy during comprehensive eye exams. However, this test can provide valuable information about the clarity of the internal lens and other media inside the eye. So doctors who no longer perform this test routinely may still use it when examining someone who may be at risk of cataracts or other internal eye problems.

This is the test your doctor uses to determine your exact eyeglasses prescription. During refraction, the doctor puts the phoropter in front of your eyes and shows you a series of lens choices. He or she will then ask you which one of the two lenses in each choice ("1 or 2," "A or B," for example) makes the letters on the wall chart look clearer.
Based on your answers, your doctor will determine the amount of nearsightedness, farsightedness and/or astigmatism you have, and the eyeglass lenses required to correct these vision problems (which are called refractive errors).

Autorefractors and Aberrometers
Your eye doctor also may use an autorefractor or aberrometer to help determine your glasses prescription. With these devices, you rest your chin and head on the instrument and look ahead at a pinpoint of light or other image.

An autorefractor evaluates the way images focus on your retina, where vision processing takes place, without the need for you to say anything. This makes autorefractors especially useful when examining young children or people who may have difficulty with a regular ("subjective") refraction. Automated refractions and subjective refractions are often used together during a comprehensive exam to determine your eyeglasses prescription.
An aberrometer uses advanced wavefront technology to detect even obscure vision errors based on the way light travels through your eye.

Cover Test
While there are many ways for your eye doctor to check how your eyes work together, the cover test is the simplest and most common.
During a cover test, the eye doctor will have you focus on a small object at distance and will then cover each of your eyes alternately while you stare at the target. As they do this, eye doctors observe how much each eye has to move when uncovered to pick up the fixation target. The test is then repeated as you focus on a near object.
Cover tests can detect even very subtle misalignments that can interfere with your eyes working together properly (binocular vision) and cause amblyopia or "lazy eye."

Slit-Lamp Examination
The slit lamp is an instrument that the eye doctor uses to examine the health of your eyes. Also called a biomicroscope, the slit lamp gives your doctor a highly magnified view of the structures of the eye, including the lens behind the pupil, in order to thoroughly evaluate them for signs of infection or disease.

The slit lamp is basically an illuminated microscope that's mounted on a table and includes a chin and head rest so you can rest comfortably while the doctor looks at your eyes. After the doctor looks at the front of your eye, additional hand-held lenses may be used to also examine your retina (the light-sensitive inner lining of the back of the eye.)

Tonometry (Glaucoma Testing)
Tonometry is the name for a variety of tests that can be performed to determine the pressure inside your eye. Elevated internal eye pressure can cause glaucoma, which is vision loss due to damage to the sensitive optic nerve in the back of the eye.

One common method used for tonometry is the "air puff" test - where an automated instrument discharges a small burst of air to the surface of your eye. Based on your eye's resistance to the puff of air, the machine calculates the pressure inside your eye - called your intraocular pressure (IOP).

Though the test itself can be startling, nothing but air touches your eye during this measurement, and there's no risk of eye injury from the air puff test.
Another popular way to measure eye pressure is with an instrument called an applanation tonometer, which is usually attached to a slit lamp. For this test, a yellow eye drop is placed on your eyes. Your eyes will feel slightly heavy when the drops start working. This is not a dilating drop — it is simply a numbing agent combined with a yellow dye. Then the doctor will have you stare straight ahead in the slit lamp while he or she gently rests the bright-blue glowing probe of the tonometer on the front of each eye and manually measures the intraocular pressure.

Like the air puff test, applanation tonometry is painless and takes just a few seconds. 
Since glaucoma is often the result of an increase of pressure inside the eye, these are important tests for ensuring the long-term health of your eyes.

Pupil Dilation
Your comprehensive exam may include the use of dilating drops. These medicated eye drops enlarge your pupil so your doctor can get a better view of the internal structures in the back of the eye. Dilating drops usually take about 20 minutes to start working. When your pupils are dilated, you will be sensitive to light, because more light is getting into your eye. You may also notice difficulty reading or focusing on close objects. These effects can last for up to several hours, depending on the strength of the drops used.

If you don't have sunglasses to wear after the exam, disposable sunglasses will be provided to help you drive home. Dilation is very important for people with risk factors for eye disease, because it allows for a more thorough evaluation of the health of the inside of your eyes.

These are the most common tests performed during a standard comprehensive eye exam. Depending on your particular needs, your doctor may perform additional tests or schedule them to be performed at a later date.


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