As a student, once you begin your clinical experience in pediatric eyecare you will quickly notice that certain conditions appear frequently.
This guide introduces some of the most common entry-level pediatric ocular conditions likely to be encountered in clinic, including amblyopia, strabismus, myopia, and conjunctivitis.
Familiarity with their basic presentation and management will help build clinical confidence and establish a strong base for pediatric eyecare.
Amblyopia
Amblyopia is the number one thing to look out for in children, especially under 10 years old. Amblyopia is defined as having an intraocular 2-line difference in visual acuity, or visual acuity less than 20/30.1
When caught early, pediatric patients can have excellent outcomes with treatment. Below is an overview of the risk factors for amblyopia, types, classification, and treatment.
Risk factors for amblyopia include family history, prematurity, developmental disorders (i.e., autism), genetic syndromes (i.e., Down syndrome), and neurological disorders (i.e., cerebral palsy).2
There are four types of amblyopia, including:1,2,3,4
- Refractive: Unilateral or bilateral
- Strabismic: Unilateral > bilateral, constant > intermittent
- Deprivational: Unilateral or bilateral
- Concurrent: Refers to pathological causes amblyopia
Refractive amblyopia
Refractive amblyopia is the most common. Pediatric patients may have anisometropic amblyopia, a difference of refractive error between the two eyes, or isometropic amblyopia, a similar refractive error in both eyes.1,2
Table 1: There are amblyogenic factors to meet amblyopic levels for hyperopia, myopia, and astigmatism that are listed below.5
Besides thresholds, also take into account age. A 1-year-old with anisometropia of 1D and no strabismus is not likely to be prescribed glasses when compared to a 3-year-old.
This is because they are still largely in their emmetropization process, a developmental process where structures of the eye (cornea, lens, axial length) adjust to create a clear, focused image on the retina, resulting in emmetropia. The most rapid changes occur in the first 18 months of age.6
Since this patient is 12 months old and only just meets the amblyogenic threshold for anisometropia, close monitoring is recommended to assess whether the anisometropia improves with emmetropization.
The American Academy of Ophthalmology (AAO) has guidelines for refractive correction in infants and young children that addresses age, refractive error in regards to amblyopia, and when to prescribe glasses.7 Remember, this is just a guideline, as many providers have their own thresholds they have developed clinically.
Treatment of refractive amblyopia is primarily glasses. In isometropic amblyopia, this treatment alone is typically sufficient. Glasses should be worn full time.
With anisometropic amblyopia, glasses are primarily prescribed as well but these patients typically need further treatment. About 20 to 30% of patients with anisometropic amblyopia resolve with glasses only. That means as much as 80% of patients will need further treatment, like patching.1,2
Strabismic amblyopia
Strabismic amblyopia is a direct result of suppression. When in a tropic state, the patient will centrally suppress the deviated eye, which can lead to amblyopia if occurring frequently enough.
This is why constant strabismus is more amblyogenic than intermittent, and unilateral strabismus is more amblyogenic than bilateral. Frequency and laterality are most important and can be evaluated through cover testing and history.1,2
Strabismic amblyopia is treated similarly to refractive amblyopia. Oftentimes, there is a significant refractive error present; therefore, glasses are utilized first to aid in visual acuity and binocularity. If amblyopia is still present with glasses, or if there is no significant refractive error, other treatments are considered.
These include the typical battery of amblyopia treatments and surgical intervention. If the patient can be realigned, binocularity can be restored, and therefore suppression can be improved. Both of these factors lead to improved visual acuity and alignment.1,2
Deprivational amblyopia
Deprivational amblyopia refers to amblyopia secondary to an obstruction of the visual axis. It can be secondary to a ptosis, cataract, vitreous hemorrhage, or corneal scar.
This type of amblyopia is the most severe because when the visual axis is obstructed early in life, the brain's visual pathways do not develop properly. Most diagnoses that are linked to this type of amblyopia occur early in life before patients have the opportunity to develop binocularity.1,2
Treatment of deprivational amblyopia first focuses on removing the visual insult. Once that is completed, patients may be given glasses, or start treatment, to help restore visual acuity as quickly as possible. Treatment for deprivational amblyopia is typically more intense and may not be as successful as refractive or strabismic amblyopia because of the timing of insult.1,2
Unilateral cases tend to have lower success rates than bilateral cases because the depth, or severity, of amblyopia presents a more significant challenge. Still, the treatment goal should remain to get as close to 20/20 vision and best stereopsis as possible.1,2
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Common Pediatric Conditions Cheat Sheet
Use this cheat sheet to quickly identify optimal treatments for common pediatric eye diseases and master pediatric eyecare.
Concurrent amblyopia
Organic amblyopia is a more precise term used to describe amblyopia caused by underlying structural abnormalities. Examples include foveal hypoplasia, colobomas, and optic nerve hypoplasia.
Organic amblyopia may coexist with functional amblyopia, which refers to the treatable component of vision loss. When both are present, the condition is referred to as concurrent amblyopia—a form of amblyopia that persists beyond what can be attributed solely to the structural anomaly.3,4
This type of amblyopia is difficult to treat, as there is no way to know for sure what the visual potential is. The duration and cessation of treatment are focused on improvement or plateau noted clinically. If the patient shows that they are not improving with great compliance and maximal treatment, treatment should be discontinued. This is different compared to other types of amblyopia, where the treatment goal is 20/20 vision and good stereopsis.1,2,3,4
Classification of amblyopia:
- Mild to moderate: 20/80 or better
- Severe: 20/100 or worse
Amblyopia treatment options
Treatment for amblyopia usually starts with patching, but not always. When choosing a treatment option, take into account the patient’s age, health conditions, severity of amblyopia, history of patching, and perceived compliance.1,8
Treatment options for amblyopia (beyond corrective lenses) include:1,8
- Patching
- Atropine 1% penalization of the better-seeing eye
- Dichoptic digital devices
Patching
Patching is typically done with an adhesive, physical patch that is placed on the skin like a band-aid. This is preferred over a cloth patch that fits onto glasses because of the risk of peeking. Pediatric Eye Disease Investigator Group (PEDIG) guidelines for patching are recommended below.9
PEDIG patching guidelines:9
- Mild to Moderate Amblyopia (visual acuity 20/40 to 20/80)
- Recommended patching: 2 hours/day of the non-amblyopic eye
- Severe Amblyopia (visual acuity 20/100 to 20/400)
- Recommended patching: 6 hours/day of the non-amblyopic eye
There is no secret to getting pediatric patients to patch. In the clinic, we recommend creating positive reinforcement with reward systems that are unique to that child’s interests. The general recommendation for patching is consecutive hours, but compliance may be improved if broken up. It is important to monitor for improvement and compliance, then adjust accordingly.8
Atropine 1% penalization
Atropine 1% penalization is typically used on the non-amblyopic eye. Studies have shown that it can be just as effective as patching. Atropine is typically not a first choice for most providers for many reasons, but mostly because it is a medication that has side effects.
Below are the treatment recommendations by PEDIG, and some considerations for atropine treatment:1,8,9
- Atropine 1% daily OR
- Atropine 1% on weekends only
Both these options are considered equal in efficacy. If your patient is not showing improvement with weekend atropine only, consider bumping them up to atropine 1% daily.
Best candidates for atropine include moderate amblyopes as well as those with mild or moderate hyperopic anisometropic amblyopia. It is also a good option for patients with poor patching compliance. Younger children, less than school age because of visual demands, also benefit from this treatment best.
Cons for atropine:8,9
- Blurred vision for days that varies
- Photophobia
- Eye irritation
- Systemic side effects
- Interference with school work for older children
- May take longer to achieve the same results with physical patching
Dichoptic digital devices
Dichoptic digital devices treat amblyopia by presenting different images to each eye to reduce suppression of the amblyopic eye and promote binocular visual processing. Although studied and published, dichoptic training is still new. Large, multi-center, randomized controlled trials are currently in the works.
What that means for families is that oftentimes insurance companies will not cover this type of treatment and it can be costly. Be sure to explain this to your families before considering it an option. Below is a comparison of both Luminopia (FDA approved) and CureSight (FDA cleared).10,11,12
Table 2: Comparison of dichoptic digital devices.11,12
Beyond insurance coverage, it is important to note the adverse effects of utilizing dichoptic training for amblyopia treatment. The most commonly reported adverse effect of Luminopia was headaches.
Other, less common side effects include:13
- Eye strain
- Worsening visual acuity in one eye
- Eye twitching
- Facial redness
- Increased night terrors
- Dizziness
Additionally, consider the implications of the treatment. Utilizing this method increases screen time for that child. Screen time is something that a lot of families struggle with minimizing, especially when screens are now commonly used at school. Another consideration is increased near work. Routinely, increased near work can lead susceptible patients towards myopia progression.
Want a condensed version of the article? Download the Common Pediatric Conditions Cheat Sheet!
Strabismus
Similarly to retinoscopy, measuring strabismus can seem overwhelming at first. Practicing measurements will only improve your skills, even with small deviations. Each strabismus type is unique in age and presentation. History and reviewing photos, if the family has them, are important.
Secondly, appropriate evaluation of cover testing and cycloplegic refractive error are equally as important. One of the biggest questions a clinician should ask when managing a patient with strabismus is, “Can this be treated with glasses?”
Table 3: The most common strabismus noted in pediatrics are listed below, along with their typical treatments. It is important to note that not all treatments are listed below.14-20
Strabismus measurements should be performed in primary gaze and at least five additional positions of gaze—typically right, left, up, and downgaze. For vertical misalignments, right and left head tilt should also be assessed as part of the Park’s 3 Step process. This comprehensive assessment helps identify pattern deviations, such as A, V, X, or Y patterns, and is essential for evaluating comitance.14
In comitant strabismus, the angle of ocular misalignment remains consistent across all directions of gaze. In contrast, incomitant strabismus is characterized by variation in the angle of deviation depending on gaze direction, often indicating the presence of a cranial nerve palsy or mechanical restriction.
Control should be assessed both during observation of the patient and while performing cover testing to measure the deviation. Control can be quantified using a standardized scale such as the Newcastle Control Score (NCS), estimated as a percentage of time the deviation is manifest, or described qualitatively (e.g., good, fair, poor).
Regardless of the method used, evaluating control is essential and should be part of clinical decision-making and treatment.21
Myopia
Myopia is a hot topic, and rightfully so, as it is now considered a worldwide epidemic. Families with a history of myopia often have questions due to the growing number of available resources and treatment options for myopia control.
As a pediatric clinician, it is important to stay up to date on the current data, treatment options, and studies. There are now Myopia Control Clinics located throughout the US and worldwide to help slow down the next generation of myopia.
Diagnosis of myopia should only be made after cycloplegic assessment of the refractive error. Pediatric patients have strong accommodative systems. If full cycloplegia is not achieved, the clinician will likely over minus the patient.
Push plus on the cycloplegic refraction with only one click (-0.25D) more minus maximally. Historically, some doctors were taught to UNDER correct myopia in order to slow down progression. This has been proven false.22
Myopia risk factors
Table 4: List of myopia risk factors.24,25
When educating families about myopia, discuss the genetic component AND the environmental component. Both of these components are not weighed equally. Myopia progression calculator models can serve as valuable tools for estimating both the risk of onset and the anticipated rate of progression.
There is the Brian Holden Vision Institute (BHVI) Myopia Calculator, Asia Myopia Prediction Model, and more. These models take into account ethnicity, parental refractive error, age, and environmental factors. It is important to note that these are projections and not definitive.
Therapies for myopia
Medical interventions for myopia control include soft multifocal contact lenses, low-dose atropine eye drops, peripheral defocus glasses, and orthokeratology.
All treatments aim to slow the progression of refractive error by slowing axial length elongation.
Table 5: Below is a comparison of the different myopia control treatment methods. It is important to note that combined methods are now also being studied.24,25
Influential studies for myopia control
The following studies have significantly shaped how we treat myopia today:
- Spectacles:26-29
- COMET study (2003)
- Executive bifocals study (2010)
- MiYOSMART (DIMS) study (2020)
- Stellest (HAL) study (2022)
- Low-dose atropine eye drops:30-33
- ATOM studies (2006, 2012)
- LAMP studies (2019 to 2022)
- CHAMP study (2023)
- Low-Dose 0.01% Atropine Eye Drops vs Placebo for Myopia Control: A Randomized Clinical Trial (2023)
- Ortho-K:34-37
- 1. SMART study (2005 to 2009)
- 2. ROMIO study (2012)
- 3. CRAYON study (2014)
- 4. TOWER study (2021)
- Soft multi-focal contact lenses:38-40
- BLINK study (2019)
- DISC study (2014)
- MiSight 1-Day study (2019 to 2022)
Initially, methods like progressive lenses and bifocals were commonly used for myopia control. These methods have been proven inferior to current methods and, therefore, typically not utilized today.
Additionally, in 2023, the low-dose atropine 0.01% study revealed that this concentration is no better than placebo.33 This created conflict with some other studies, like the CHAMP study.32,33 Staying current with the latest research is essential when managing patients undergoing myopia control treatment. If progression continues despite therapy, consider adjusting the treatment plan or exploring alternative modalities.
Modifying environmental factors is also helpful in delaying the onset of myopia and potentially reducing myopia progression. Spending approximately 1 to 2 hours outside a day has been proven to lower the risk of developing myopia. The methodology behind outdoor time is that outdoor light is 10 to 100x brighter than indoor light which stimulates dopamine release in the retina. In turn, dopamine inhibits axial length elongation.41
Spending time outdoors is also linked to reduced near work and increased depth of focus, therefore reducing accommodative strain. Counseling on environmental factors is important in treating the whole patient.
Don't forget to check out the Common Pediatric Conditions Cheat Sheet!
Conjunctivitis
Pediatric patients are likely to experience a “pink eye,” or conjunctivitis, at least one time in their life. The history should include the color of the discharge, if they or others around them are sick, laterality, drops attempted, and medical history like allergies.
Table 6: Key characteristics that differentiate each type as well as typical treatments are listed below.42
Besides identifying the most common types of conjunctivitis, it is equally important to identify when a conjunctivitis does not fit the mold.
On the differential diagnosis for conjunctivitis in pediatric patients should be:42
- Blepharokeratoconjunctivitis
- Herpetic conjunctivitis
- Giant papillary conjunctivitis
- Chemical conjunctivitis
Pearls and perspectives on pediatric eyecare
- Early identification and treatment of amblyopia—especially before age 10—dramatically improve visual outcomes.
- Refractive amblyopia is the most common type and is often successfully treated with glasses alone—especially in isometropic cases.
- However, up to 80% of patients with anisometropic amblyopia will need further treatment, such as patching. Educate families on what to expect.
- Age, emmetropization stage, and refractive thresholds all play a role in determining whether and when to prescribe glasses.
- Treatment and management of strabismus includes accurately measuring the deviation and assessing the cycloplegic refractive error.
- Always assess alignment both with and without glasses, as well as visual acuity, to guide management.
- Myopia control is the future and treatment should incorporate a multifaceted approach. Don’t forget about counseling on environmental factors.
- Myopia control is becoming more standardized now. As clinicians, we should be the first people to suggest it to patients instead of the other way around. Myopia control also goes beyond singular medical intervention.
- When evaluating pediatric conjunctivitis, a thorough history—including discharge type, laterality, exposure, and allergy history—is key to distinguishing viral, bacterial, and allergic causes.
- If it doesn’t fit the classic picture, consider other diagnoses like blepharokeratoconjunctivitis or herpetic conjunctivitis.
Conclusion
Understanding and managing common pediatric eye conditions—such as amblyopia, strabismus, myopia, and conjunctivitis—requires a strong foundation in clinical principles and a patient-centered mindset.
This guide highlights the importance of early detection, proper refractive assessment, and individualized treatment strategies, from glasses and patching to newer therapies like dichoptic devices and myopia control options.
By recognizing the nuances of pediatric diagnoses—including the impact of emmetropization, the role of refractive error in strabismus, and the multifactorial nature of myopia—optometry students can build confidence in their clinical decision-making.
As you step into a pediatric eye clinic, remember that competence grows with every patient encounter.
