This Guidance does not change what you must do under the law.

You must not refuse to see a patient based on their age alone. You should arrange a transfer of care or a referral if a specialist assessment is in the patient’s best interests. You should make a reasonable attempt to include all appropriate tests. In exceptional circumstances, you may not be able to complete all the indicated tests for a very young child. In these situations, you should base your management on the findings you do have and act in the child's best interests. Records should reflect what was attempted and why it was not possible to complete an examination, and details of a referral made if required.  

• England NHS England Avoidance of doubt letter, 2019 [Accessed 1 Nov 2023] 
• Northern Ireland [Accessed 1 Nov 2023] 
• Scotland [Accessed 1 Nov 2023] 
• Wales [Accessed 1 Nov 2023]

This guidance relates to children you judge to be too young to have the capacity to consent.

You should:

1. find out and record the specific history of conditions which might predispose the child to visual problems, such as family history of refractive error, amblyopia or squint; a difficult birth; abnormal or delayed development
2. have a range of tests to assess the child’s monocular vision and visual acuity, based on the age and ability of the child
3. assess ocular muscle balance, using objective and, when feasible, subjective methods
4. assess stereopsis. Having good stereopsis may indicate the child does not have significant anisometropia, amblyopia or squint
5. assess near vision
6. assess refractive error. This is often only possible by objective means in young children. Where necessary use cycloplegic drops to obtain an accurate result
7. assess accommodation. This is often only possible by objective means in young children
8. assess the health of their eyes. It may be difficult to obtain a good view of the fundus in young children, but you should attempt to determine normal ocular development. At the very least, you should obtain a clear view of the ocular media, disc and macula
9. screen colour vision where relevant
10. if you are not confident in your results, or the examination was problematic, arrange to see the child again after a short interval or consult a colleague with more experience.

You should consider use of a cycloplegic agent to give:

1. an accurate assessment of the refractive error, which is the major factor in amblyopia or squint
2. the best possible view of the fundus, within the limits of the co-operation of the child.

When possible, you should use a line or array of letters, pictures or symbols to measure morphoscopic acuity, or some other method that induces crowding. This is because the use of single optotypes to measure visual acuity may overestimate the degree of visual acuity in patients with some amblyopias. Acuity charts, utilising crowding and logMAR letter-by-letter scoring, are recommended.

You should consider the following factors when prescribing spectacles for a young child (under seven years of age)⁹³:

1. Is the refractive error within the normal range for the child’s age?
2. Will this child’s refractive error emmetropise? 
3. Will this level of refractive error disrupt normal visual development or functional vision?
4. Will prescribing spectacles improve vision function or functional vision? 
5. Will prescribing spectacles interfere with the normal process of emmetropisation?

When possible, you should make arrangements for children to be accompanied during the examination by an adult who knows the child’s history and symptoms, and who can help the child feel comfortable and settled. The adult can also help the optometrist to explain instructions.

You should:

1. establish rapport with the child to ensure:
   • they are comfortable in the practice environment and your company
   • you can be confident about the validity of the results of the examination
2. communicate in a way that is appropriate to the child’s age, maturity and ability to understand
3. respect the child’s fears and concerns
4. explain the nature and purpose of the tests to the child and any accompanying adult in a way that they can understand
5. talk directly to the child and answer their questions honestly, taking into account their age and maturity
6. be aware that children who are disabled, have learning disabilities or whose preferred language is not English may have additional communication needs
7. ensure the accompanying adult is present in the consulting room throughout the examination, whenever possible. This helps ensure that the adult is fully informed and protects you and the child
8. make sure that the accompanying adult has accurate information about the outcomes of the eye examination.

You should take steps to protect yourself against unfounded allegations of inappropriate conduct or assault. These may result from children becoming distressed or uncomfortable at the close physical proximity and contact that is necessary during an eye examination. In addition to the guidance on communicating with children, you should consider these aspects of your consulting room:

1. an open access policy which means colleagues are able to knock and enter the room at any time without having to wait to be invited in after knocking
2. having windows into the consulting room or keeping the door ajar when there is no accompanying adult
3. the design and decoration so that it is not intimidating to children
4. arranging the furniture and equipment so that you are not positioned between the child and the door.

You must make the care of the child your first and continuing concern.⁹⁴  See section on Safeguarding children and vulnerable adults.

If you provide vision screening in schools, you should make parents and teachers aware that vision screening is not a substitute for a full eye examination.