Visual acuity norms in young children

There are no universally accepted standards for visual acuity tests or norms in young (3-6-year-old) children, although acuity measurement is important in both clinical and screening settings. This review outlines the requirements for such standards. Although more research is needed, available data suggest that a standard test should meet the following requirements. It should utilize a letter optotype (tumbling E, Landolt C, or HOTV variant of the STYCAR), and single optotype with contour interaction bar surround. It should permit nonverbal pointing responses in younger children and verbal responses in older children. If an orientation-specifying method is followed, as with the E or Landolt C, the test should use a three-alternative choice--up, down, and sideways with a nondifferentiated left-right--rather than the traditional four alternative choice. A C-like O pseudo-optotype should be considered in a paired-comparison test format when the Landolt C is utilized, with a similar format for the tumbling E if a suitable pseudo-optotype can be derived. The optical grating test, which is widely used in infant testing, may underestimate acuity deficits and so is not a test of choice for determination of Snellen-equivalent acuity. A letter-based variant of the grating test may hold promise. Reduction in testing distance from 6 to 3 or 4 meters is recommended.