Refractive Errors in Children

What Are Refractive Errors?

Refractive errors occur when the eye is unable to properly focus light onto the retina — the light-sensitive layer at the back of the eye — resulting in blurry or distorted vision. These are some of the most common vision problems in children and often go unnoticed without a proper eye exam.

A healthy eye functions like a camera:

  • The cornea and lens bend (or “refract”) incoming light.
  • The pupil controls how much light enters.
  • The retina receives the image.
  • The brain interprets the image into what we see.

If the shape of the eye is too long, too short, or irregular, light doesn’t focus correctly on the retina — leading to a refractive error.

Types of Refractive Errors

Myopia (Nearsightedness)

In myopia, the eye is too long or the cornea is too curved, causing light rays to focus in front of the retina. Children with myopia can see well up close, but distant objects (like the board at school) appear blurry. Myopia often begins between ages 6–10 and progresses through the teen years.

Hyperopia (Farsightedness)

Hyperopia occurs when the eye is too short or the cornea is too flat. Light focuses behind the retina. Young children are often mildly farsighted, but the eye’s focusing muscles usually compensate. When hyperopia is more severe, it can lead to blurred vision, eye strain, or even inward eye crossing (esotropia).

Astigmatism

Astigmatism is caused by an irregular shape of the cornea or lens — more like a football than a soccer ball. This prevents light from focusing evenly on the retina, causing blurry or distorted vision at all distances. It often occurs alongside myopia or hyperopia.

Anisometropia

When each eye has a different prescription, it’s called anisometropia. If untreated, the brain may favor the clearer eye, leading to amblyopia (lazy eye) in the weaker eye. Treatment includes glasses, and sometimes patching, to strengthen vision in the weaker eye.

How Do You Know if Your Child Has a Refractive Error?

Children may not realize they can’t see well — especially if the issue is only in one eye. Signs parents may notice include:

  • Squinting or tilting the head
  • Holding screens or books very close
  • Complaints of headaches or eye strain
  • Avoiding visual tasks or struggling in school
  • Eye rubbing or excessive blinking
  • Trouble seeing distant objects or the classroom board

Regular vision screenings by pediatricians and at school as well as comprehensive eye exams are essential, especially if your child has a family history of eye problems.

Why Early Detection Matters

Untreated refractive errors can lead to developmental delays, reduced academic performance, and long-term visual problems. Detecting and correcting these issues early can:

  • Prevent amblyopia (lazy eye)
  • Reduce the risk of permanent vision loss from amblyopia
  • Improve comfort and concentration in school and daily activities
  • Boost self-confidence and performance in sports or social interactions

How We Determine if a Child Needs Glasses

Determining whether a child needs glasses — especially if they are preverbal, non-verbal, nervous, or have developmental delays — requires specialized skill and tools. Pediatric ophthalmologists are uniquely trained to evaluate vision in children of all ages and developmental stages, even when they can’t read letters or communicate clearly.

The Power of Retinoscopy

The cornerstone of determining a glasses prescription in children is a technique called retinoscopy. This objective method allows the doctor to measure the eye’s refractive error by observing how light reflects off the retina.

Here’s how it works:

  • The doctor shines a light into the child’s eye using a handheld tool called a retinoscope.
  • Lenses are placed in front of the eye to neutralize the movement of the reflected light.
  • This process provides an accurate measurement of the child’s prescription — without the child needing to say a word.

Retinoscopy is especially valuable for:

  • Preverbal infants and toddlers
  • Children with speech or developmental delays
  • Non-verbal children
  • Children with high anxiety or behavioral challenges

Unlike an eye exam for adults — which typically relies on asking “Which is better: 1 or 2?” — retinoscopy does not depend on responses or cooperation. It’s fast, precise, and well-tolerated by most children, even during a brief exam.

Why Dilation Is Necessary

To get the most accurate reading, we perform retinoscopy after using dilating eye drops. These drops temporarily relax the eye’s focusing muscles, allowing us to measure the full refractive error without interference from the child’s strong focusing ability. This is especially important in children, whose eyes naturally work harder to focus than adults.

More Than Just a Prescription

In addition to retinoscopy, pediatric ophthalmologists assess other factors before prescribing glasses, including:

  • Eye alignment and coordination
  • Risk for amblyopia (lazy eye)
  • Visual development milestones
  • Family history of eye conditions

Myopia in Children: A Growing Concern

The rate of childhood myopia has increased dramatically in recent decades. In the U.S., 42% of the population is now myopic — up from just 25% in the 1970s. Children who develop high myopia are at greater risk for future eye complications, including:

  • Retinal detachment
  • Myopic macular degeneration
  • Early cataracts
  • Glaucoma

Intervening early to slow myopia progression may reduce these lifelong risks.

Slowing Myopia Progression: Atropine Eye Drops

Low-dose atropine eye drops are a research-supported treatment to help slow the progression of myopia in children. Studies show that a nightly drop of low dose atropine can reduce myopia progression by about 50% — with minimal side effects.

How It Works

Atropine acts on receptors in the eye to relax the focusing system and slow elongation of the eyeball. While its exact mechanism in myopia control isn’t fully understood, it’s believed to reduce signals that stimulate eye growth.

What to Expect

  • One drop in each eye at bedtime
  • Mild pupil dilation may cause some light sensitivity
  • Minimal impact on reading vision at low doses
  • Safe and well-tolerated in children

Our Approach

At Children’s Eye Care, our goal is not just to provide clear vision — but to support healthy visual development, prevent long-term complications, and ensure your child can see, learn, and engage with the world around them. Our team of pediatric ophthalmologists provides comprehensive care backed by evidence-based research.

Learn More: Global Expert Guidance on Myopia

To better understand the latest research and international recommendations on managing childhood myopia, we encourage you to review the World Society of Pediatric Ophthalmology and Strabismus (WSPOS) Myopia Consensus Statement 2025. This statement reflects the collective expertise of global leaders in pediatric eye care and outlines evidence-based strategies — ranging from lifestyle changes to medical interventions like low-dose atropine — to help slow the progression of myopia in children.