Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Visual development and vision assessment in infants and children

David K Coats, MD
Section Editor
Evelyn A Paysse, MD
Deputy Editor
Carrie Armsby, MD, MPH


Vision assessment is an important part of the medical care of children (table 1). Eye abnormalities that are not treated in the first few months (eg, cataracts, pronounced ptosis) or years (asymmetric refractive errors) of life can lead to irreversible vision loss [1,2]. Visual loss also may be an early indication of serious or life-threatening diseases, such as retinoblastoma, lipid storage disorders, or peroxisomal disorders (table 2) [3,4]. (See "Retinoblastoma: Clinical presentation, evaluation, and diagnosis" and "Inborn errors of metabolism: Epidemiology, pathogenesis, and clinical features".)

The development of the visual system and vision assessment in infants and children will be reviewed here. Specific ophthalmologic problems (eg, cataract, glaucoma, strabismus, refractive error, amblyopia, retinoblastoma) are discussed separately. (See appropriate topic reviews).


The visual system (retina, optic nerves, and visual cortex) is immature at birth. It begins to mature during the first weeks of life [5]. Myelination of the optic nerves, development of the visual cortex, and growth of the lateral geniculate body occur over the first two years [6]. The fovea, the most visually sensitive part of the retina, reaches maturity at approximately four years of age.

The period of visual maturation is a critical period during which the visual system is affected by outside influences. Visual stimuli are critical to the development of normal vision. Development of the visual pathways in the central nervous system requires that the brain receive equally clear, focused images from both eyes. Ocular processes (eg, refractive error, strabismus, cataract) that interfere with or inhibit the development of the visual pathways may result in amblyopia [1,2]. (See "Refractive errors in children" and "Amblyopia in children: Classification, screening, and evaluation", section on 'Definition' and "Evaluation and management of strabismus in children", section on 'Complications' and "Cataract in children", section on 'Complications'.)

Visual behavior and performance evolve with maturation of the visual system (table 3).


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jan 21, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hyvarinen L. Assessment of visually impaired infants. Ophthalmol Clin North Am 1994; 7:219.
  2. Magramm I. Amblyopia: etiology, detection, and treatment. Pediatr Rev 1992; 13:7.
  3. Bohra LI, Weizer JS, Lee AG, Lewis RA. Vision loss as the presenting sign in juvenile neuronal ceroid lipofuscinosis. J Neuroophthalmol 2000; 20:111.
  4. Traboulsi EI, Maumenee IH. Ophthalmologic manifestations of X-linked childhood adrenoleukodystrophy. Ophthalmology 1987; 94:47.
  5. Hyvarinen L. Vision in Children: Normal and Abnormal, Canadian Deaf-Blind Rubella Association, Meaford, ON 1988.
  6. Boothe RG, Dobson V, Teller DY. Postnatal development of vision in human and nonhuman primates. Annu Rev Neurosci 1985; 8:495.
  7. Ling B. Genetic study of sustained fixation and associated behavior in the human infant from birth to six months. J Genet Psychol 1942; 61:227.
  8. Shamis DI. Collecting the "facts": Vision assessment techniques: Perils and pitfalls. Am Orthopt J 1996; 46:7.
  9. COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE, SECTION ON OPHTHALMOLOGY, AMERICAN ASSOCIATION OF CERTIFIED ORTHOPTISTS, et al. Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2016; 137:1.
  10. Cross J. What all pediatricians should know: InfantSEE--a national resource for early vision assessment in infants. Clin Pediatr (Phila) 2014; 53:1200.
  11. Goren CC, Sarty M, Wu PY. Visual following and pattern discrimination of face-like stimuli by newborn infants. Pediatrics 1975; 56:544.
  12. Simons K. Visual acuity norms in young children. Surv Ophthalmol 1983; 28:84.
  13. Quinn GE, Berlin JA, James M. The Teller acuity card procedure. Three testers in a clinical setting. Ophthalmology 1993; 100:488.
  14. Friedman DS, Katz J, Repka MX, et al. Lack of concordance between fixation preference and HOTV optotype visual acuity in preschool children: the Baltimore Pediatric Eye Disease Study. Ophthalmology 2008; 115:1796.
  15. Friendly DS. Preschool visual acuity screening tests. Trans Am Ophthalmol Soc 1978; 76:383.
  16. Morad Y, Werker E, Nemet P. Visual acuity tests using chart, line, and single optotype in healthy and amblyopic children. J AAPOS 1999; 3:94.
  17. Recommended stardard procedures for the clinical measurement and specification of visual acuity. Report of working group 39. Committee on vision. Assembly of Behavioral and Social Sciences, National Research Council, National Academy of Sciences, Washington, D.C. Adv Ophthalmol 1980; 41:103.
  18. Bachman JA, Bachman WG, Franzel AS, Marcus MC. Preteaching developmentally delayed preschoolers to aid vision screening. Optom Vis Sci 1994; 71:713.
  19. Brant JC, Nowotny M. Testing of visual acuity in young children: an evaluation of some commonly used methods. Dev Med Child Neurol 1976; 18:568.
  20. Miller JM, Lessin HR, American Academy of Pediatrics Section on Ophthalmology, et al. Instrument-based pediatric vision screening policy statement. Pediatrics 2012; 130:983.
  21. US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics 2011; 127:340.
  22. Donahue SP. Objective vision screening for amblyopia in children: a test that has finally arrived. Ophthalmology 2010; 117:1867.
  23. Schmidt P, Maguire M, Dobson V, et al. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study. Ophthalmology 2004; 111:637.
  24. Kirk VG, Clausen MM, Armitage MD, Arnold RW. Preverbal photoscreening for amblyogenic factors and outcomes in amblyopia treatment: early objective screening and visual acuities. Arch Ophthalmol 2008; 126:489.
  25. Arthur BW, Riyaz R, Rodriguez S, Wong J. Field testing of the plusoptiX S04 photoscreener. J AAPOS 2009; 13:51.
  26. Atkinson J, Braddick O, Nardini M, Anker S. Infant hyperopia: detection, distribution, changes and correlates-outcomes from the cambridge infant screening programs. Optom Vis Sci 2007; 84:84.
  27. Rowatt AJ, Donahue SP, Crosby C, et al. Field evaluation of the Welch Allyn SureSight vision screener: incorporating the vision in preschoolers study recommendations. J AAPOS 2007; 11:243.
  28. Salcido AA, Bradley J, Donahue SP. Predictive value of photoscreening and traditional screening of preschool children. J AAPOS 2005; 9:114.
  29. Matta NS, Arnold RW, Singman EL, Silbert DI. Comparison between the plusoptiX and MTI Photoscreeners. Arch Ophthalmol 2009; 127:1591.
  30. Teed RG, Bui CM, Morrison DG, et al. Amblyopia therapy in children identified by photoscreening. Ophthalmology 2010; 117:159.
  31. Leman R, Clausen MM, Bates J, et al. A comparison of patched HOTV visual acuity and photoscreening. J Sch Nurs 2006; 22:237.
  32. Guo X, Jia X, Guo L, et al. Comparison of computer-photoscreening with non-cycloplegic retinoscopy for amblyopiogenic risk factors in children. Chin Med J (Engl) 2000; 113:1007.
  33. Longmuir SQ, Boese EA, Pfeifer W, et al. Practical community photoscreening in very young children. Pediatrics 2013; 131:e764.
  34. Halegoua J, Schwartz RH. Vision photoscreening of infants and young children in a primary care pediatric office: can it identify asymptomatic treatable amblyopic risk factors? Clin Pediatr (Phila) 2015; 54:33.
  35. Xie JZ, Tarczy-Hornoch K, Lin J, et al. Color vision deficiency in preschool children: the multi-ethnic pediatric eye disease study. Ophthalmology 2014; 121:1469.
  36. Das M, Spowart K, Crossley S, Dutton GN. Evidence that children with special needs all require visual assessment. Arch Dis Child 2010; 95:888.
  37. Hoyt CS, Nickel BL, Billson FA. Ophthalmological examination of the infant. Developmental aspects. Surv Ophthalmol 1982; 26:177.
  38. BERLYNE DE. The influence of the albedo and complexity of stimuli on visual fixation in the human infant. Br J Psychol 1958; 49:315.
  39. Sternheim CE, Cavonius CR. Sensitivity of the human ERG and VECP to sinusoidally modulated light. Vision Res 1972; 12:1685.