First eye exam: when to go and what to expect

A child's visual system actively develops from birth until the age of 7-8 years. During this period, the foundation for healthy vision throughout life is laid. Many problems -- strabismus, amblyopia, congenital refractive errors -- are easily corrected if detected early. But children, especially young ones, rarely complain about poor vision: they simply do not know what it should be like. That is why regular preventive eye examinations are not a formality, but a necessity.

Recommended examination schedule

International ophthalmology associations, including the American Academy of Ophthalmology (AAO) and the European Paediatric Ophthalmological Society (EPOS), recommend the following schedule of planned examinations:

The first examination at 6-12 months may seem premature to parents: after all, the child cannot yet speak and will not be able to name letters on a chart. But at this age, the ophthalmologist checks entirely different parameters: the correctness of the eye's anatomical development, the transparency of the optical media, the pupil's reaction to light, the presence or absence of strabismus, and the ability to fixate on and follow objects.

The examination at 3 years is an important checkpoint. At this age, the visual system is mature enough to allow determination of visual acuity (using special children's charts with pictures), detection of hyperopia, astigmatism, and early signs of myopia. Binocular vision is also checked -- the ability of both eyes to work in coordination.

The pre-school examination at 6-7 years is critical. Starting school dramatically increases visual load: reading, writing, working with notebooks and textbooks. It is at this age that myopia often begins. The pre-school examination allows recording the baseline parameters of vision and refraction, to track changes at subsequent visits.

Source: American Academy of Ophthalmology. Eye Screening for Children. Recommendations on examination frequency, 2023

What the ophthalmologist checks in young children

Examining a child under 3 years differs from examining a school-age child. The doctor uses objective methods that do not require the child's active participation:

• Autorefractometry -- the device automatically determines the eye's refraction (presence of myopia, hyperopia, or astigmatism). There are portable autorefractometers that work from a distance of 1 meter -- the child only needs to look at the device for a few seconds
• Retinoscopy (skiascopy) -- the doctor directs a beam of light into the eye and determines the type and degree of refractive error by the character of the light reflex movement. This method requires no interaction from the child
• Cover test -- the doctor alternately covers one eye and then the other, observing the movement of the uncovered eye. This allows detection of latent and manifest strabismus
• Pupillary reaction assessment -- the symmetry and speed of pupil response to light is checked, which helps assess the condition of the optic nerve
• Fundus examination (ophthalmoscopy) -- using an ophthalmoscope, the doctor examines the retina, optic nerve, and fundus vessels. For this procedure, the pupils may be dilated with drops

The entire examination usually takes 15-30 minutes. Special pediatric drops with a reduced concentration of the active substance are used for pupil dilation. Dilation occurs after 20-40 minutes and persists for 3-6 hours (depending on the medication). During this period, the child may be sensitive to bright light -- bring a hat or sunglasses with you.

School-age examination: what it includes

The examination of a school-age child is more comprehensive, as the child can actively participate in the process -- naming letters, following a target, answering questions. The standard examination includes:

Visual acuity testing

The child names letters or symbols on a chart from a set distance (usually 5 meters). Each eye is checked separately and then both together. Normal visual acuity for a school-age child is 1.0 (100%). A decrease in visual acuity is the first signal of possible myopia or another problem.

Refraction measurement with cycloplegia

This is the key investigation for accurate diagnosis of myopia in children. Special drops (usually cyclopentolate or atropine) are instilled in the eyes, which temporarily relax the accommodation muscle. Without this step, children are frequently found to have "false myopia" -- accommodation spasm, in which distance vision temporarily worsens due to overexertion, but there is no actual myopia.

Measuring refraction without cycloplegia in children can lead to overdiagnosis of myopia. Accommodation spasm occurs in 15-20% of students and can mimic myopia of up to -1.5 diopters.

Axial length measurement (biometry)

Modern ophthalmological clinics perform optical biometry -- contactless measurement of eyeball length with hundredths-of-a-millimeter precision. This parameter is essential for monitoring myopia: each additional millimeter of eye growth corresponds to approximately 2.5-3 diopters of myopia. Tracking axial length over time is the most reliable method to assess whether myopia is progressing.

Biomicroscopy (slit lamp examination)

The slit lamp allows the doctor to examine the anterior segment of the eye in detail -- the eyelids, conjunctiva, cornea, iris, and lens. This is necessary for ruling out inflammatory diseases and assessing the condition of the anterior segment before potential contact lens fitting.

How to prepare your child for the visit

Proper preparation will help make the visit as informative and comfortable for the child as possible:

• Explain in advance what will happen -- tell your child that the doctor will examine their eyes with a special flashlight and ask them to name letters. Avoid the words "injection" or "pain" -- the examination is painless
• Bring sunglasses -- after pupil dilation, the child will be sensitive to light. A hat or cap will also be useful
• Bring previous examination results -- if the child has seen an ophthalmologist before, bring the records. It is important for the doctor to see the dynamics
• If the child wears contact lenses -- remove them 3 days before the examination (soft lenses) or 2 weeks in advance (rigid lenses). Lenses can distort refractometry results
• Do not plan studying after the examination -- dilated pupils make reading and close-up work difficult for several hours
• Write down your questions -- if something worries you (squinting, headaches, sitting too close to the TV), be sure to tell the doctor

Warning symptoms -- when to visit outside the schedule

In addition to planned examinations, there are situations when it is worth taking your child to the ophthalmologist without waiting for the next scheduled visit. Pay attention to the following signs:

• The child squints when looking at distant objects -- the blackboard, TV, road signs. Squinting narrows the aperture through which light passes and temporarily improves image clarity -- this is a classic compensatory mechanism in myopia
• Complaints of headaches, especially in the evening or after a school day. The pain is usually localized in the forehead and temple area and is related to accommodation overexertion
• Sits too close to the screen -- to the TV, monitor, brings a book or phone too close to their face. This may mean they have difficulty distinguishing the image from a normal distance
• Tilts or turns their head to see better. This may indicate astigmatism, strabismus, or other problems with eye coordination
• Declining school performance -- if the child has started learning worse, especially in subjects where working with the blackboard is important, this may be related to worsening distance vision
• Frequent blinking or eye rubbing -- may indicate visual fatigue, dry eyes, or allergic conjunctivitis
• Avoidance of activities that require good distance vision -- sports, outdoor games. The child may avoid situations where their poor vision becomes noticeable

It is important to remember: young school-age children rarely complain about poor vision. They may not realize they see worse than their peers or may be embarrassed to talk about it. That is why attentive parental observation is the first and most important tool for early detection of vision problems.

Why regularity matters

Myopia in schoolchildren can develop rapidly. Research shows that without control, myopia progresses by an average of 0.5-1.0 diopters per year. In a single school year, a child with initial myopia of -0.5 can reach -1.5 diopters. That is why annual examinations are the absolute minimum.

For children in the high-risk group (both parents myopic, myopia already detected, intense school workload), the ophthalmologist may recommend more frequent visits -- every 6 months. This allows timely detection of the onset of progression and taking the necessary measures.

Particularly valuable is monitoring with axial length measurement of the eye. While a routine vision check shows deterioration that has already occurred, biometry allows detection of the tendency for eyeball growth before myopia manifests clinically. This gives the doctor the opportunity to begin myopia prevention or control at the earliest stage.

Regular monitoring of axial eye length is the gold standard for surveillance of children with myopia or at risk of developing it. An increase in axial length of more than 0.3 mm in 6 months is a signal for the doctor regarding the need to start myopia control.

Do not postpone the first visit to the ophthalmologist. The earlier a specialist examines your child's eyes, the more opportunities there are to protect their vision -- for their entire life.