AAP Recommendations for First Eye Exam in Infants
The American Academy of Pediatrics recommends that eye examination begin in the neonatal period (at birth) and continue at all well-child visits, rather than specifying a single age for the "first" eye exam. 1
Screening Timeline from Birth
Newborn Period Through Age 3 Years
Eye screening should start immediately after birth, with infants examined before hospital discharge using inspection and red reflex testing to detect structural abnormalities such as cataracts, corneal opacity, and ptosis. 1
At every well-child visit from the newborn period through age 3 years, the examination should include: 2, 1
- Vision assessment
- Ocular history
- External inspection of eyes and lids
- Ocular motility assessment
- Pupil examination
- Red reflex examination
The standard assessment strategy for children under 3 years involves determining whether each eye can fixate on an object, maintain fixation, and follow the object into various gaze positions, performed both binocularly and monocularly. 2
Ages 12 Months to 3 Years
Instrument-based screening should be attempted for the first time between 12 months and 3 years of age, and may be offered at 12-month and 24-month well-child visits. 1
Instrumental screening is particularly valuable at 1 year of age for detecting risk factors for amblyopia. 1
Ages 3 to 5 Years
Beginning at age 3 years, add age-appropriate visual acuity measurement (using HOTV or tumbling E tests) and ophthalmoscopy to the previously mentioned screening components. 2
Direct visual acuity testing can often begin at 4 years of age using age-appropriate symbols, with routine screening recommended at ages 4 and 5 years, and in cooperative 3-year-olds. 1
Critical Developmental Milestones
Normal binocular alignment should be established by 6 months of age. 1
Any persistent eye misalignment after 6 months is abnormal and requires evaluation by a pediatric ophthalmologist, as it may indicate strabismus that can lead to amblyopia. 1
Poor eye contact after 8 weeks warrants additional evaluation. 1
Key Clinical Pitfalls
The child must be awake and alert during testing, as disinterest or poor cooperation can mimic poor vision response. 2, 1
Children with underlying medical or genetic conditions are at higher risk for ocular problems and should receive comprehensive ophthalmologic examination soon after diagnosis. 1
Any child who presents with ocular anomalies or fails vision evaluation should be referred to a pediatric ophthalmologist or appropriately trained eye care specialist. 1