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The E Chart and other Vision Tests

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Updated March 18, 2007

Another test that is commonly used for 3-5 year olds is the tumbling E chart or 'E' game, a chart with the letter E in different orientations (up, down, right and left) and sizes. Children are tested by asking what orientation or direction the letter E is in at each letter size. To prepare your child for this test, you can play the pointing game from Prevent Blindness America. They also have a copy of the Distance Vision Test for Younger Children, which uses the E chart, and which you can use at home.

For children who can recognize some letters, the HOTV system, in which the letters H, O, T and V are displayed in different sizes on a chart can be used. The child is given a board with a large H, O, T and V on it, and he is instructed to point to the letter on the board that matches the letter on the chart.

Older children can be tested with the regular Snellen eye chart that is used for adults. In general, the Snellen chart is the most accurate and should be used when possible.

After testing is done, the next step is deciding if the child passed the test, since preschool age children don't necessarily need to have 20/20 vision to pass the test. The American Academy of Pediatrics has issued standards for visual acuity at different ages, including:

  • 20/40 for children 3-4 years old
  • 20/30 for older children
  • 20/20 for school age children
In addition to their visual acuity, how a child's two eyes compare to each other is also important. At any age, if there is a two line difference between the eyes, then that might indicate a serious loss of vision, like for example, if one eye is 20/20, but the other eye is 20/40. Or if one eye is 20/30 and the other eye is 20/50.

Children who are uncooperative or who fail a vision screening test in the Peditricians office, especially if it is on multiple attempts, should be seen by a Pediatric Ophthalmologist for more formal testing.

A referral to a Pediatric Ophthalmologist is also a good idea for children with strabismus after they are six months of age, if they have ptosis, where the upper eyelid droops, or if either eye is fixed in place or has limited movement, although it is usually normal if a newborn or young infant's eyes occasionally cross. Strabismus is another Pediatric condition in which a 'wait and see' approach to find out if a child will grow out of the problem is not appropriate. Children should also be seen by an ophthalmologist if they are at high risk of having visual problems, such as premature infants, children with Down syndrome, Sturge Weber syndrome, JRA, neurofibromotosis, diabetes or Marfan syndrome, children born with a congenital infection, or if there is a family history of strabismus or other childhood eye disorders.

Also, if your Pediatrician doesn't offer vision screening at the 3 year old checkup, you might consider seeing a Pediatric Ophthalmologist to have your child's vision checked.

What is a Pediatric Ophthalmologist?

An Ophthalmologist is a medical doctor (MD), whose training includes 4 years of college, 4 years of medical school, 1 year of internship and 3 years of residency training in ophthalmology. In addition to prescribing glasses or contact lenses, ophthalmologists diagnose and treat most eye disorders and perform eye surgery.

A Pediatric Ophthalmologist (MD), in addition to completing medical school, an internship and ophthalmology residency, has completed an extra year of fellowship training in pediatric ophthalmology.

An Optometrist (OD) has usually completed 2-4 years of college and 4 years of optometric college. An optometrist can diagnose and screen for vision abnormalities and prescribe glasses and contact lenses.

According to the American Academy of Pediatrics, 'if your pediatrician suggests that your child has his eyes checked, a pediatric ophthalmologist has the widest range of treatment options, the most extensive and comprehensive training, and the greatest expertise in dealing with children and in treating children's eye disorders.'

Find a Pediatric Ophthalmologist in your area at this link. Be sure to enter 'Pediatric Ophth' for the Subspecialty before you do your search. If you do not have the financial resources to have your child's vision evaluated or his problems treated, see these resources for help:

  • Sight for Students - This program provides vision exams and glasses to uninsured children in the United States.

Related Video
Understanding Infant Vision
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