The role of the pediatrician in managing health concerns of the eye is to recognize early pathology and ophthalmic emergencies. Abnormalities can be detected before the child becomes symptomatic, and emergencies referred for early intervention can greatly improve morbidity and preserve visual acuity and health.

Eye screenings are often age dependent and focus on both anatomy and function. For example, preterm infants should be referred to ophthalmology regardless of their physical exam by the fourth to sixth week of life to allow for a detailed funduscopic examination and evaluation for retinopathy of prematurity. At birth, all infants should be evaluated for the presence and symmetry of the red reflex. A defect in the light reflex may be the result of a congenital cataract. Without appropriate and early intervention, a congenital cataract may lead to deprivational amblyopia and limit visual potential during a critical period of visual development. The red reflex should also be monitored at all routine well-child physicals, as an asymmetry of color or brightness of the reflex can occur at any age. Such variations in the color or brightness of the reflex, such as a “white reflex,” may reflect a refractive error or a retinoblastoma. At ages 6 months to 1 year, the physician should be able to test for strabismus in a cooperative infant through the corneal light reflex. If there is any asymmetry in the reflection, the child should be referred to ophthalmology. Similarly, infants should also be able to fix and follow by 6 months of age; any such failures in a cooperative infant should again be referred to a specialist.

Visual acuity may be difficult to measure in infancy and early childhood, but a number of tests can detect gross anomalies and alert the physician to potential deficits. In alert infants, a light stimulus should elicit wincing behavior. By age 6 months, the infant should object equally when either eye is occluded; if there is decreased fussing or “objection” when one eye is occluded, the physician should suspect decreased acuity in the occluded eye.
Preverbal children can be tested by observing their ability to reach an object (toy), when either eye is occluded. By age 3 years, charts using pictures of cartoons, shapes, or symbols can be used to measure acuity. By age 5 years, most children should be able to cooperate with the Snellen letter chart or number chart. Whenever visual acuity is <20/40 in either eye or there is a difference of two lines of acuity between the eyes, the child should be referred for further testing.