Healthy vision supports learning, early literacy skills, social and emotional development, motor skills, physical activity, and self-image. It is not always easy to tell when children have difficulty seeing because many vision problems are invisible. Therefore, vision screening throughout early childhood is important to identify and ensure treatment of vision disorders. This resource provides important information about vision screening and eye health for toddlers.
Head Start Program Performance Standards
Head Start Program Performance Standards require grantees to obtain the results of or perform vision screening.
Child health status and care, 45 CFR §1302.42 (b)(2-3) states:
(2) Within 45 calendar days after the child first attends the program or, for the home-based program option, receives a home visit, a program must either obtain or perform evidence-based vision and hearing screenings.
(3) If a program operates for 90 days or less, it has 30 days from the date the child first attends the program to satisfy paragraphs (b)(1) and (2) of this section.
Child Observation and Health History
Before using a vision screening tool, observe the appearance of the toddler’s eyes and the toddler’s behavior. Also note any vision concerns reported by the child’s family, teachers, or other caregivers.
Consider adding a checklist, such as Signs of Possible Vision Problems in Children (also available in Spanish), to the health assessment form that families complete during enrollment to identify children with a higher risk for vision disorders.
Children with a higher risk of vision impairment include those with:
- Easily identified eye abnormalities, like crossed or wandering eye or a droopy eye lid
- Neurodevelopmental disorders (e.g., hearing impairment, cerebral palsy, Down syndrome, cognitive impairment, autism spectrum disorder, attention-deficit/hyperactivity disorder)
- Systemic conditions known to be commonly associated with eye disorders, like diabetes and juvenile arthritis
- Parents or siblings with a history of strabismus (eye misalignment), amblyopia, or wearing glasses at a young age
- A history of premature birth (< 32 weeks)
- Families or Head Start staff who have concerns that the child has a vision problem
Acceptable Vision Screening Methods for Toddlers Ages 1 and 2
The most recent joint guidelines from the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology7 recommend instrument-based vision screening for toddlers ages 1 and 2.
Instruments use automated technology to analyze the structure of the eyes for information about risk factors that may lead to the development of amblyopia. Amblyopia (also known as “lazy eye”) is a loss of vision when the brain does not receive adequate visual stimulation while the sense of sight is developing in early childhood. Toddlers with amblyopia might develop good vision in one eye and have poor vision in another.
Instrument-based screening does not measure visual acuity (sharpness or clearness of vision at a specified distance interpreted in the brain when using eye charts or computer software). Instrument-based screening results cannot be converted to visual acuity measurements, such as 20/20.8.
The evidence for instrument-based screening as a useful tool is growing. For a list of instrument recommendations and more guidance, visit the National Center for Children’s Vision and Eye Health.
Should we screen vision annually?
Yes. Vision screening is not a one-time event. Children’s eyes change as they grow and develop. Best practice is to screen vision annually.
If young children are wearing prescription glasses, should we still screen their vision?
Head Start staff — including teachers, home visitors, nurses, health aides, and health or disability managers — can conduct instrument-based screening with proper training. Consult the vision screening instrument vendor or the product manufacturer to ensure that anyone who conducts vision screening on behalf of your program is trained and knows how to use the instrument correctly.
Text on the instrument’s screen will tell you if an eye examination is recommended. Report instrument-based screening as either a “pass” or “refer.”
Rescreening and Referral
Follow these guidelines when rescreening and referring toddlers for eye examinations:
- If you cannot get a screening result after three consecutive attempts, talk to the family about referring their child for an eye examination.
- Refer children for an eye examination when they do not receive a “pass” on their vision screening.
- Consult with the child’s family and health care provider about a referral to an eye doctor who is trained and experienced in examining and treating infants and toddlers.
- Refer toddlers with special health care needs to an eye doctor who is trained and experienced in treating infants and toddlers with special health care needs.
Eye Care Referral List
Consider contacting eye doctors in your area to create a list of nearby eye care offices. Give the list to your families and their health care providers when you refer children ages 1 and 2. Assign staff or a volunteer to update the list every six months and include the revision date to ensure families receive the up-to-date list.
Include this information:
- Eye doctor name
- Practice name
- Telephone number for appointments
- Whether or not the eye doctor accepts Medicaid
- Other types of payment accepted
- Languages spoken
- Whether or not interpreters are provided
- Whether or not the eye doctor examines and treats children from birth to age 6
- Whether or not the eye doctor examines and treats children with special health care needs
Family Engagement and Support for Follow-Up Eye Examinations
It is important for family engagement and health services staff to talk with families about how vision supports children’s learning. These conversations can also help identify possible barriers to follow-up care, such as a lack of transportation, lack of insurance, language barriers, or concerns about children wearing glasses, and develop solutions to these challenges.
Work with your program’s Health Services Advisory Committee to help everyone understand barriers to care and to identify solutions. Refer to the resources in this document for assistance.
These four actions support families in arranging for and attending eye examinations with their toddlers:
- Determine how families want to be contacted (e.g., letters, email, or text messages) and their preferred language.
- Determine who in the family can make decisions about medical procedures and work with that family member.
- Ask families how they feel about their toddlers wearing prescription eyeglasses if eyeglasses are part of the treatment plan.
- Ask families what assistance they need with getting an eye examination and eyeglasses, if needed. See “Eye Care Referral List” above for details about how to create a list of local eye doctors.
How frequently should toddlers and other young children who wear glasses receive an eye examination?
Once every 12 months. Check the date of the most recent eye examination you have on file. If the last one was more than 12 months ago, make sure an appointment is scheduled. If necessary, offer to help the family return to the eye doctor for a missed or upcoming appointment.
Resources to Share with Families During Referral for Follow-Up Procedures
- What is the Difference Between a Vision Screening and an Eye Examination?
- Importance of an Eye Examination After Receiving Referral from a Vision Screening
- Association Between Vision and Learning
- 10 Small Steps From Vision Screening to the Eye Exam and Possible Treatment for Big Vision
- How to Schedule an Eye Examination
- Financial Assistance Information
Supporting Families of Toddlers With Visual Impairment
Refer families of a toddler with a diagnosed visual impairment (partial sight or blindness) to your program’s disability services coordinator to explore eligibility for Part C of the Individuals with Disabilities Education Act (IDEA).
More resources to support parents of toddlers who are blind or visually impaired include:
- Know Your Rights as the Parent of a Blind or Visually Impaired Child
- American Printing House Directory of Services for Blind and Visually Impaired Persons
More Vision Resources for Head Start Staff to Share With Families
- Small Steps for Big Vision: An Eye Health Information Tool Kit for Parents and Caregivers (may take a few minutes to load)
- Parents Need to Know
1. Stiff, Heather, Nicholas Dimenstein, and Scott A. Larson. “Vision Screening Outcomes in Children Less Than 3 Years of Age Compared with Children 3 Years and Older.” Journal of AAPOS 24, no. 5 (October 2020): 1–293. Accessed March 10, 2021, https://doi.org/10.1016/j.jaapos.2020.05.016.
2. Bruce, Alison, Lesley Fairley, Bette Chambers, John Wright, and Trevor A. Sheldon. “Impact of Visual Acuity on Developing Literacy at Age 4-5 Years: A Cohort-Nested Cross-Sectional Study.” BMJ Open 6, no. 2 (February 2016): 010434. https://doi.org/10.1136/bmjopen-2015-010434. Accessed March 10, 2021, https://bmjopen.bmj.com/content/bmjopen/6/2/e010434.full.pdf?with-ds=yes.
3. Bruce, Alison, Brian Kelly, Bette Chambers, Brendan T. Barrett, Marina Bloj, John Bradbury, and Trevor Sheldon. “The Effect of Adherence to Spectacle Wear on Early Developing Literacy: A Longitudinal Study Based in a Large Multiethnic City, Bradford, UK.” BMJ Open 8, no. 6 (June 2018): 021277. https://doi.org/10.1136/bmjopen-2017-021277. Accessed March 10, 2021, https://bmjopen.bmj.com/content/bmjopen/8/6/e021277.full.pdf.
4. Kulp, Marjean Taylor, Elise Ciner, Maureen Maguire, Bruce Moore, Jill Pentimonti, Maxwell Pistilli, Lynn Cyert, T. Rowan Candy, Graham Quinn, and Gui-shuang Ying. “Uncorrected Hyperopia and Preschool Early Literacy: Results of the Vision in Preschoolers-Hyperopia in Preschoolers (VIP-HIP) Study.” Ophthalmology 123, no. 4 (April 2016): 681–89. https://doi.org/10.1016/j.ophtha.2015.11.023. Accessed March 10. 2021, https://www.sciencedirect.com/science/article/pii/S0161642015014128?casa_token=bSBg2eOJxWQAAAAA:X5_RO3MdtdkfLK1GR1MsLb_-fUx784xaaVtjlQzkfqhQ6ahiQdhM8MSZyMTon7ki3xqvCT4E4-w.
5. Peterseim, Mae Millicent, Carrie E. Papa, Courtney Parades, Jennifer Davidson, Amber Sturges, Carly Oslin, Isla Merritt, and Mary Morrison. “Combining Automated Vision Screening with On-Site Examinations in 23 Schools: ReFocus on Children Program 2012 to 2013.” Journal of Pediatric Ophthalmology and Strabismus 52, no. 1 (January-February 2015): 20–24. https://doi.org/10.3928/01913913-20141124-01. Accessed March 10, 2021, https://pubmed.ncbi.nlm.nih.gov/25427341/
6. National Center on Early Childhood Health and Wellness. Vision Screening Fact Sheet. Accessed March 3, 2021, https://eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/vision-screening-rev.pdf.
7. Donahue, Sean P., and Cynthia N. Baker, Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics, Section on Ophthalmology, American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and American Academy of Ophthalmology. “Procedures for the Evaluation of the Visual System by Pediatricians.” Pediatrics 137, no. 1 (January 2016): e20153597. https://doi.org/10.1542/peds.2015-3597. Accessed March 9, 2021, https://pediatrics.aappublications.org/content/pediatrics/early/2015/12/07/peds.2015-3597.full.pdf.
8. Cotter, Susan A., Sean P. Donahue, and Bruce Moore. “Position Statement on the Relationship between Visual Acuity and Refractive Error in the Context of Preschool Vision Screening Using Instrument-Based Technology.” Optometry and Vision Science 98, no. 1 (January 2021): 102. https://doi.org/10.1097/01.opx.0000725792.80874.83. Accessed March 10, 2021, https://journals.lww.com/optvissci/Fulltext/2021/01000/Position_Statement_on_the_Relationship_between.15.aspx
National Centers:Health, Behavioral Health, and Safety
Program Type:Early Head Start
Age Group:Infants and Toddlers
Last Updated: September 30, 2021