Refractive Error in Infants & Young Children:
Development, Assessment, & Management
T. Rowan Candy, PhD, FAAO, Indiana University School of Optometry
Susan A. Cotter, O.D., FAAO, Southern California College of Optometry
Abstract
This course provides a current understanding of development of the optics of the visual system and
the emmetropization process in the context of the assessment and clinical management of
refractive error in infants and young children. Case studies are included.
Learning Objectives

To review the processes occurring in the optical visual system during human visual
development.

To understand the current state of knowledge regarding normal refractive errors as a
function of age and what is known about the emmetropization process.

To review clinical techniques appropriate for assessing refractive error in infants and young
children.

To determine an appropriate refractive correction for a young patient given the patient's
age, history, type of refractive error, and other pertinent clinical data.
I. Structural Development
A. First evidence of the eyes at 22 days of gestation
B. Major optical components forming by end of the embryonic period
C. Biometry
1. Cornea/lens – the total optical power of the eye reduces by 30D after birth
2. Axial length – the eye lengthens from approximately 17mm at birth to 24mm
3. Refraction – infants are typically hyperopic and astigmatic, with a wide range of errors
D. Media Transmittance – Increased UV transmittance and reduced macular pigment relative
to an adult
E. Accommodation – Accuracy improves over the first 3 months after birth
II. Emmetropization
A. Spherical component
1. Animal models
2. Activity dependence
a. Form deprivation
Page 1
b. Lens compensation
3. Posterior chamber growth
4. Human literature
B. Astigmatism
1. Human literature
2. Chiefly corneal
3. Typical axes
4. Animal models
5. Lens compensation
C. Anisometropia
1. Human data
D. Myopia
1. Uncommon in infancy
2. Age of onset
3. Prediction from infant refraction
III. Assessment of Refractive Error
A. Goals
1. Prevent amblyopia and/or strabismus
2. Ensure optimal development
3. Optimize treatment outcomes
B. Assessment of Refractive Error
1. Objective
2. Methods of refraction - objective
a. Retinoscopy
1.) Cycloplegic is standard of care
2.) Cycloplegic agents & dosage based on age
b. Mohindra near retinoscopy
c. Autorefraction
IV. Management of Early Refractive Error
A. Refractive Error & Emmetropization
1. Mean & standard deviation of refractive error both reduce over the first 2-3 postnatal
years
2. Prevalence of astigmatism also reduces
3. Anisometropia inconsistent in longitudinal studies
Page 2
4. Some evidence that high hyperopes do not emmetropize
B. Guidelines for Refractive Correction
1. Prescribing thresholds for different refractive errors and ages
2. Full or partial correction
3. In the presence of strabismus or amblyopia
4. Follow-up schedule
C. Case examples
Page 3