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Refraction & detailed examination

Detailed examination should be done by a recognised cadre within the health system, with the necessary competencies in refracting children and examination of other non-refractive conditions (for example, optometrists, optometry students, ophthalmologists).


Retinoscopy only or instrument-based autorefraction is not sufficient to prescribe glasses for school-aged children. Subjective refraction must follow objective refraction. There are two alternatives for providing subjective refraction:

Directly in schools (vertical approach)

  • Ensures that a high proportion of children who fail screening are refracted; false negative monitoring can also be conducted by visiting eye health team


  • requires qualified personnel and equipment = additional costs to the programme
  • lack of ownership of eye problems by the community
  • may limit cycloplegic retinoscopy as parental consent is required and must be obtained prior to the team visit
  • does not build referral pathways to eye care services at the community level

At a local eye care facility that is engaged in the programme* (integrated approach)

  • Reduces costs to programmes and encourages community ownership, hence greater sustainability


  • high rates of non attendance
  • additional costs of travel for parents (may result in inequity)
  • potential overburdening of local eye care providers

*Referral to optical centres which are not actively involved in the program is not recommended as the quality of the refraction and the spectacles dispensed cannot be monitored.

Referral to the local eye care provider should be made for:

  • Any child presenting visual acuity is less than 6/60 in either eye, even if due to a correctable RE;
  • Any child presenting a strabismus
  • All children whose visual acuity does not improve to normal (6/9) in both eyes with refraction
  • Any child requiring cycloplegic refraction (if not done on site)
  • Any child presenting an ocular health problem in one or both eyes:
    • Cornea is not transparent
    • Pupil is not round and black
    • Eyes are red with discharge (conjunctivitis or allergy)
    • White patch on the conjunctiva (Bitot’s spot)
    • Conjunctival growths

No child with severe vision impairment (VA <6/60; 1.0) or who is blind (VA <3/60; 1.3) should be referred directly to low vision services, special education or rehabilitation without first being assessed by an primary or secondary eye care professional.


If done on site, cycloplegia should be done by a trained eye care professional.


  • Children uncooperative or difficult to refract
  • VA that doesn’t improve at refraction
  • Media opacities or irregular corneas,
  • Presence of strabismus or suspected amblyopia
  • Significant progression in myopia or suspected latent hyperopia (fails +2.00 test)

In children over the age of 5 years, 2 drops of cyclopentolate 1% should be administered per eye with 5 minutes separation between instillations. Parental consent is mandatory. Children, parents and teachers should be aware of side effects (blurriness, dilated pupils, sensitivity to light, dizziness etc.)

Binocular vision

To be included in protocol if personnel is qualified

  • Cover test both at near and far
  • Ocular motility assessment
  • Stereopsis
  • Accommodation
  • Fusion

For more information on these tests: AAO Paediatric eye evaluations PPP 2022

Prescription guidelines

Provision of quality spectacles can improve a child’s vision, reduce discomfort, and even lead to better educational outcomes. The following indications for correction provide a way to objectively prioritize refractive care in situations of limited resources, but should not override individual needs where resources permit. Some studies showed that spectacle wear is associated with poorer uncorrected VA and higher levels of refractive error, so prescription of spectacles should be made only when there is a significant improvement in VA 11,41.

Myopia Hyperopia Astigmatism Anisometropia
improvement of VA by 2 or more logMAR/Snellen lines improvement of VA by 2 or more logMAR/Snellen lines improvement of VA by 2 or more logMAR/Snellen lines significant anisometropia i.e. ≥ 2D AND one or more of the following: correctly balanced lenses improve vision of the most affected eye by 2 or more logMAR/Snellen VA lines, and/or noticeably improve eye comfort
presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable
esotropia or large esophoria noticeably improved eye comfort

Compliance: how to get children to wear their glasses?

Spectacle wear rates can be very low after school screenings. The main reasons cited for non-compliance are:

Main reasons for non-compliance Possible solutions to improve compliance
Broken/lost frames Dispensing quality frames suitable for children

Ongoing partnerships with local eye care providers for repair/replacement of spectacles

Discomfort when wearing spectacles Provision of quality frames adapted to children

Thorough adjustment when delivering the spectacles

Regular screenings to prevent children growing out of their frames

Social stigma (teasing, family disapproval, negative perceptions) & misconceptions towards spectacle wear In-class health promotion activities

Integration of eye health in the school curriculum

‘Vision champions’ in schools

Community-based eye health education

Parents’ involvement in screenings

No perceived benefits Prescription of spectacles only to those with significant VA improvement

Gathering context-specific data on reasons for non-compliance can be very useful in developing locally-relevant material 11.

Spectacle dispensing

Each child requiring correction should get a suitable, comfortable and adapted pair of spectacles.

While best practice is to provide a custom-made pair with exact prescription and PD, it can get very expensive for programmes. Approximately 85% of children who need correction should be eligible for ready-made or ready-to-clip glasses. These are acceptable and cost-effective solutions for providing quality eyewear to children when custom-made spectacles are not available or affordable42,43.

They are available in powers from −6.00 D to +6.00 D and can be dispensed on site. However, powers above 3.50 D are not recommended as there could be induced prism if there is a mismatch in pupillary distance. Frames should be selected based on the children’s preference. Ready-made spectacles should be supplied under the guidance of a qualified practitioner and should be adjusted to suit the wearer by a trained person. Children who are not eligible should have their spectacles made at a local eye center44.


Ready-made spectacles Custom-made
Improvement in vision with spherical equivalent lenses Same or only one line less than full correction VA with full correction is two lines or more than spherical equivalent
Difference in the spherical equivalent in RE/LE < 1.00D (<2.00D for ready-to-clip) >1.00D
Astigmatism max. of 0.75 cylinder in both eyes >0.75D cylinder in at least one eye
Maximum spherical equivalent* +/- 3.50D No limit
Inter-pupillary distance between the eyes and the frames available Not more than +/- 2mm Can be adapted to any PD
Comfort of spectacles frames As comfortable as custom spectacles

* Delivery of custom-made spectacles back to outreach sites can be difficult, therefore a wider range of ready-made spectacles may be needed for such programmes. Full quality assurance checks should be carried out where possible.


IAPB does not recommend other types of spectacles such as recycled or self-adjustable spectacles for SEHPs.

  • Used spectacles donated by members of the public are not an acceptable solution for children
    • The International Agency for the Prevention of Blindness (IABP) recommends that groups involved in eye care should not accept donations of recycled spectacles nor use them in their programmes as “no amount of efficiency and effectiveness in the delivery chain can justify the output and outcome of this recycling scheme.”
  • Self-adjustable spectacles should not be used in school eye health programmes unless they are used under the supervision of suitably trained eye care personnel to prevent over- or under-correction of refractive error.
    • The IAPB position paper states that while these types of spectacles may be a solution to correction of refractive error, they should meet optical standards and be supplied only in conjunction with an eye examination by trained eye care personnel.