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July 16, 2013
Ask an Expert: Vision Care

Tags: Ask an Expert; Resource Guide

By: Lisa DiBonaventura, M.A., COMS

Why is it important to regularly assess a child’s vision?

Regularly assessing a child’s vision is critical starting within the first year of life. It is the only way to ensure that eyes are healthy and that the visual perception system is developing and functioning properly.  Vision impacts development, safety, health, and affects how a child learns, plays, and feels.  Some children, especially those with neurodevelopmental delays, including autism spectrum disorders, and/or who have a family history of eye problems, are at a greater risk for vision concerns.  Unfortunately some vision problems, such as having an eye turn, if left untreated in childhood can lead to life long and permanent vision loss.

Recommendations for vision screening and comprehensive eye exams differ slightly among professional organizations and states (state law).  Vision screenings are designed to detect vision problems, are typically recommended annually or once every two years. They are provided at  your primary care provider or pediatrician’s office, at school, and/or in collaboration with a Department of Public Health.   Comprehensive eye exams by an eye care provider including an optometrist, an ophthalmologist or a pediatric ophthalmologist typically occur as a follow up to a vision screening, as recommended; and lead to diagnosis and treatment.

In 2001, the American Public Health Association adopted one of the strongest policies, advocating for a “regular, comprehensive eye examination that all children have (eye) exams performed at age 6 months, 2 years and 4 years”.  Here in the Commonwealth, we are fortunate to have two laws, Massachusetts 105 CMR § 200.400, and General Law Chapter 71, Section 57, promoting vision testing for children prior to and during school aged years:

  • Parents or guardians for every child entering kindergarten must present certification that the child has passed a vision screening.  
  • For every child entering kindergarten who fails the vision screening or has neurodevelopmental delay (which includes children with an ASD), parents or guardians must present proof of a comprehensive eye exam for the child by an ophthalmologist or an optometrist.
  • Each Massachusetts school committee or board of health is also responsible to test every child in public schools annually.  

Although startling to consider, vision concerns in children can indeed be difficult to detect both from a child and caregiver perspective.

Vision problems thus can go undetected, especially if regular eye exams and/or vision screenings are missed, resulting in significant impact on growth during this critical time of brain development.

A helpful list of common signs and symptoms associated with vision problems typically experienced by children can be found on Prevent Blindness America’s “Star Pupil.” If your child presents you with any vision concerns, be sure to document your observations, and report these to your child’s primary care provider, pediatrician, or an eye care provider.

Why is it particularly important to focus on the vision of kids with Autism Spectrum Disorders?

Focusing on the vision of children with an autism spectrum disorder (ASD) is critical for two reasons:  Studies suggest that children with ASD have an increased rate of vision problems (compared to children who do not have an ASD), and  may have specific vision perception sensitivities and/or traits which impact their daily lives.  A visual behavior believed to be related to an ASD, may in fact, be a sign of an undiagnosed vision problem, making eye exams vitally important for children with ASD.

Two small scale studies published in 2013 point to higher rates of refractive error, eye turn and amblyopia among children with an ASD:

  • Refractive Error, including near sightedness, far sightedness, and/or astigmatism, which affect how clearly a child sees was found in 27-29% of children with ASD. 
  • Eye Turn, also called strabismus, which can affect a child’s depth perception and ability to see one clear image instead of double vision,   was found in 21 – 41% of children with ASD.           
  • Amblyopia, an uncorrectable decrease in vision from an eye which can impair a child’s depth perception and may result in visual field loss, was found in 10 – 11% of children with ASD.

Many of these causes of vision problems can be treated, and amblyopia prevented, if diagnosed early in life. The “eyeSmart” website hosted by the American Academy of Ophthalmology and the American Optometric Association’s website are two sources for information regarding these, and other conditions affecting vision throughout a child’s life.

A child with an ASD may also present  specific vision perception sensitivities and/or traits which can impact daily function, and  affect how an eye exam needs to be performed. Some of these traits are similar to symptoms of various eye conditions, including Cortical Vision Impairment (CVI).  Vision sensitivities and/or traits of children with an ASD may include but are not limited to:

  • Intense focus on light, people, objects, brightly colored objects
  • Focus on visual details rather than the whole
  • Focus on very small items/pieces
  • Increased ability on tasks of visual search
  • Movement of hands, fingers or objects in front of eyes
  • Avoidance of eye contact
  • Dislike/Avoidance of dark lights, bright lights and/or flashes of light

The keys for healthy eyes and  healthy development for children with an ASD include early detection of vision problems; early treatment; regular care throughout childhood by an ophthalmologist or an optometrist who understands the child’s needs; and consistent communication and follow up with eye care providers by parents or guardians.


  1. J Autism Dev Disord. 2013 Jun;43(6):1447-51.
  2. Strabismus. 2013 Jun;21(2):98-102.
  3. J Abnormal Psychology 2012 Vol. 121, No. 2, 544-551
  4. NeuroImage: Clinical 2 (2013) 303-312
  5. J of Neuroscience 2013 April 33(16);6776-6781

It can be challenging to find providers for kids with special concerns.  What do you recommend?

We are so fortunate to be living in Massachusetts, with so many resources for vision care. However, it can indeed be challenging to find providers for children with special concerns. Communication is critical to find the right provider, to make sure that the ophthalmologist or optometrist understands your child’s needs prior to the eye exam, and your child is prepared.

Help for Finding an Ophthalmologist or Optometrist:

Children’s Vision Massachusetts, a coalition dedicated to improving vision care and follow up for children, recommends that parents or guardians ask for recommendations from their child’s primary care physician, school nurse or health manager.  In addition, the following directories are available:

Eye Care Provider Directories:


Insurance Coverage for Eye Exams and Eye Glasses:

Private insurance plans vary regarding benefits for eye care.  In Massachusetts, MassHealth provides coverage for annual visits to ophthalmologists and optometrists, as well as to opticians who fit and dispense prescription eyeglasses. Depending upon your child’s insurance provider, you may need a referral from your child’s primary care provider or pediatrician prior to scheduling a visit with an eye care provider. If your child does not have insurance for eye exams or for prescription eyeglasses, assistance programs such as:

Considerations for Scheduling and Preparing for Eye Exams:

After choosing an eye care provider for your child, take care when scheduling and planning for the appointment to help create the most successful atmosphere for the exam:

  • Share specific vision related information.  Some providers will send you a packet of information, along with a questionnaire to help the ophthalmologist or optometrist best prepare for your child’s eye exam. Even if a questionnaire is not sent to you, be sure to share/include all of your questions, concerns, observations, and provide information regarding any vision perception sensitivities or traits that your child may have. 
  • If waiting is difficult, schedule the appointment to be the first of the day, the first after the provider's lunch break, or the last of the day to reduce waiting time as much as possible.
  • Prepare your child based on his/her needs.  It may be very helpful to talk about the appointment, visit the office, or watch a video about going to the eye doctor.  (Many videos are available on YouTube through a search for “eye exams for children”). Whatever approach you use, planning with your child is an important step to drawing attention to his/her eyes, and for a successful exam.

Is there anything else you recommend or advise for families?

I’d like to draw attention to the need for us all to focus on eye safety and offer information on the vision loss rehabilitation professionals who work with children in schools, and  provide a list of resources for children with ASD who have vision impairment, legal blindness or deaf-blindness.

Eye Safety & Sun Protection:

Caring for children’s vision includes focusing on eye safety and sun protection for eyes.  Prevent Blindness America’s Star Pupil website covers all bases with information to Protect Your Child from Eye Injuries. This  includes at home, at play, during sports and from the sun, and First Aid for Eye Emergencies.

Teacher of the Vision Impaired & Orientation & Mobility Specialist:

Resources for Children with Vision Impairment, Legal Blindness and Deaf-Blindness:


Thank you so very, very much for this wonderful opportunity to draw attention to children’s vision and eye care needs.

Lisa DiBonaventura, M.A., COMS
Statewide Director for Vision & Vision Loss Services
Massachusetts Department of Developmental Services (DDS)



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