# Paediatric Optometry > Paediatric Optometry: acuity by age, Lea and HOTV charts, cycloplegic retinoscopy, ROP screening criteria, RBSK milestones and red-flag referrals in children. - Canonical URL: https://prepelephant.com/topics/allied/optometry/paediatric-optometry - Exam / course: Allied Health · Subject: Optometry - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Paediatric Optometry", PrepElephant, https://prepelephant.com/topics/allied/optometry/paediatric-optometry ## Direct answer A three-year-old cannot read Snellen letters, but vision is measurable at every age: preferential-looking cards (Teller) estimate acuity in infants, Lea symbols and HOTV matching carry the toddler years, and Snellen or logMAR charts arrive around five. Acuity matures from roughly 6/120 at birth toward 6/9 by age two to three and adult 6/6 by four to five years; fixation and following should be established by six to eight weeks, and stereopsis consolidates through the second six months. Every paediatric refraction is cycloplegic — the average neonate carries about +2.00 D of hyperopia that emmetropises by school age. Red flags demanding urgent referral are leukocoria, any squint persisting beyond three to four months, nystagmus, ptosis, and failure to fix and follow; in premature infants, retinopathy of prematurity screening (birth weight under 2000 g or gestation under about 32 weeks, first examination within about 30 days of life) is mandatory. ## What you must remember - **Acuity milestones:** about 6/120 at birth, 6/36 to 6/18 by one year, 6/9 by two to three years, adult 6/6 by four to five — always record which chart produced the score. - **Chart ladder:** Teller and Cardiff cards under two years; Lea symbols, HOTV with matching card, Allen pictures at two to four; crowded logMAR or Snellen from about five — crowding bars matter because amblyopia hides behind single letters. - **Motility milestones:** fixation and following by 6-8 weeks, convergence and accommodation established by 3-4 months; any manifest squint beyond 3-4 months is a referral, not a wait. - **Refraction:** neonatal +2.00 DS average, emmetropising through childhood; always cycloplegic retinoscopy (cyclopentolate 1% standard, atropine 1% for the very young or esotropic). - **ROP screening (Indian national criteria):** birth weight under 2000 g or gestational age under about 32-34 weeks per current national guidance, first examination by about 30 days of life, repeated by zone and stage. - **RBSK links:** Rashtriya Bal Swasthya Karyakram screens birth-to-18-year-olds for the four Ds — defects at birth (including congenital cataract), diseases, deficiencies, developmental delays — at birth, 6 weeks, 9 months, 18 months, 2.5-3 years, then at school entry and periodically, routing eye findings to District Early Intervention Centres. - **Amblyopia risk factors:** anisometropia from about 1.00 D, hyperopia beyond roughly +3.50 D, significant astigmatism, media opacity, or a family history of squint and high refractive error. - **Never defer:** leukocoria (retinoblastoma until proven otherwise), infantile esotropia (surgery ideally inside the first two years), occluding ptosis. ## The four-year-old examination, minute by minute History first — birth, milestones, family squint or glasses — because prematurity and family history reframe everything. Engage the child with a distant toy; Hirschberg reflexes while she watches: symmetry excludes a large tropia. Cover test at distance and near, a flickering refixation grading the phoria. Acuity next, one eye occluded at a time: Lea symbols at 3 m down to the 6/9 line, then crowded bars. Near point of convergence on a fingernail; stereopsis with the Titmus fly — delight and data in one. Then drops: van Herick, cyclopentolate 1%, punctum pressed, play interval. Forty minutes later, streak retinoscopy reads +3.00/+0.75 × 90 each eye — moderate hyperopia with mild with-the-rule astigmatism in an orthophoric, symmetric 6/9 child: observe, review in six months unless symptoms intervene. Had she shown a 12-prism-dioptre esotropia, the full plus would be prescribed today, because accommodative esotropia is treated optically before surgically. Fundus with the +20 D lens closes the visit — the paediatric eye earns a full look every time. ## Camp realities examiners ask about Programme mechanics dominate: how RBSK's mobile health teams screen at anganwadis and schools and refer to District Early Intervention Centres; why school screening uses the 6/9 line as its referral trigger; and why teachers can screen acuity but never judge squint or fundus. The perennial trap is the reassured parent: "the squint will straighten itself" is false for any manifest deviation past three to four months, whereas pseudostrabismus from epicanthic folds genuinely disappears — the cover test and corneal reflex, not the family photograph, decide. ## Frequently asked questions ### Which acuity charts suit a three-year-old? Lea symbols or HOTV with a matching card at 3 metres, ideally with crowding bars; Snellen letters are reliable only from about age five. ### When must an infant's squint be referred rather than observed? Any manifest deviation beyond three to four months of age — infantile esotropia needs early assessment, often surgery within the first two years for binocular potential. ### What are India's retinopathy of prematurity screening criteria? Birth weight under 2000 g or gestational age under about 32 weeks (local protocols extend to 34), first examined within roughly 30 days of life. ### What does RBSK screen for, and where do eye findings go? The four Ds — defects at birth, diseases, deficiencies, developmental delays — from birth to 18 years at fixed ages, with eye conditions referred through District Early Intervention Centres. ### Why is paediatric retinoscopy performed under cycloplegia? Children accommodate strongly, masking hyperopia and distorting neutralisation; cycloplegia reveals the true refraction that governs safe prescribing in amblyopia and squint.