Eye tests & check-ups

When are my child's eyes actually checked in Malaysia?

Two different teams check your child's eyes at eight fixed points between birth and Tingkatan 3, and most parents have sat through some of them without being told that is what they were. Here is the whole schedule, and how to find out which parts your child has had.

by Dr Chan Li Yen · MBBS, MOphth (UM), Fellowship in Paediatric Ophthalmology & Strabismus

Practises at Hospital Kuala Lumpur 12 min read · 2,165 words

Key takeaways

The klinik kesihatan records an eye check at birth, one month, 18 months and four years, and the four-year visit is the first one that measures sight itself.
The KKM school health team checks sight at preschool, Tahun 1, Tahun 6 and Tingkatan 3, using a Snellen chart at 6 metres, one eye at a time.
A child who reads 6/12 or worse with either eye is sent home with a referral letter. That is a screening threshold, not a diagnosis.
Coverage above 98 per cent counts government and government-aided schools and preschools registered with the education ministry, so a child in a private tadika may not be visited. Ask rather than assume.
A screening is a quick pass or refer check on one day. If your child says she cannot see the board, believe her, whatever the screening said.

Almost every week a parent puts a folded letter on my desk. It came home in a school bag, it carries a school stamp, and it says the child's eyes need looking at. The first question is never about the eyes. It is some version of this: so nobody has checked her before now?

Somebody almost certainly has. Children's eyes are checked at fixed points in Malaysia, by two teams, in two different books, and most parents sit through those checks without being told what was being looked at. Here is the schedule, and how to find which parts your child has had.

When does a children's eye check in Malaysia actually happen?

At eight fixed points between birth and Tingkatan 3. The klinik kesihatan looks at your child's eyes at birth, at one month, at 18 months and again at four years. The KKM school health team then checks sight at preschool, Tahun 1, Tahun 6 and Tingkatan 3.

The two halves belong to different systems. The first four live in the Rekod Kesihatan Bayi dan Kanak-kanak, the child health book you were handed at the start and probably keep in a drawer. The last four belong to the Perkhidmatan Kesihatan Sekolah, a joint health and education ministry programme that began in 1967, with school health teams formed in 1975 to visit schools.

These eight contacts are not eight of the same thing. Some are a look at the eye. Only some measure sight.

KLINIK KESIHATAN

Birth

1 month

18 months

4 years

SCHOOL HEALTH TEAM

Preschool

Tahun 1

Tahun 6

Tingkatan 3

Two teams, eight contacts. The upper row is recorded in your child health book at home, the lower row in the pupil's health record at school.

What eye checks does the klinik kesihatan do before school?

A look at the eyes with the red reflex at birth, one month and 18 months, then a fuller eye page at four years. That four-year page has three parts: an outside look at the lids and the white of the eye, a visual acuity test for each eye separately, and a Hirschberg test, where the doctor draws where a light reflects off each cornea.

The red reflex is the check most parents miss, because it takes seconds. A light goes into the eyes and an even reddish glow should come back from each retina. If that glow is absent, dull or white on one side, it needs an answer quickly. That is why the line is printed four separate times in the book.

Between three and six months the book stops examining and starts asking you. Does the baby fix her gaze on an object and follow it? A "no" there is a referral in itself, and a baby's first eye checks lean on that question heavily.

So the four-year visit is the first point in that book where sight itself is measured.

Is there a preschool vision screening in Malaysia for my child?

For some preschools, yes. The district school health team visits preschools and does a basic health check that includes height, weight, vision and hearing. The sight part there is done by optometrists, not by the nurses who test primary school children. KKM reported coverage above 98 per cent from 2016, with 495,183 preschool children seen in 2018.

Which is where the honest answer gets uncomfortable. That percentage counts government and government-aided preschools registered with the education ministry, so it does not tell me whether your tadika is visited. No published source does. That is a question for the centre.

The reason I would ask it is what Malaysian researchers keep finding at this age. In Kuching, 5 per cent of 400 children aged four to six had reduced vision. In Segamat, among 1,287 kindergarten children, 12.5 per cent had visual impairment and 7.53 per cent had amblyopia, what we call a lazy eye. In the Klang Valley, 15.1 per cent of 411 preschoolers failed a study screening. Nearly all of it was uncorrected refractive error, mostly astigmatism, which is to say: glasses.

These are the years when a lazy eye responds most reliably to treatment, and they are the years where the safety net depends on which preschool a child attends.

Amblyopia is the commonest cause of reduced vision in children, and the results are strongest when treatment starts before about five. Treating it before seven or eight gives the greatest improvement, and starting later still helps, it simply helps less, so a child past that age is never a lost cause. If your child is four or over and the four-year eye page is still blank, ask your klinik kesihatan for it.

What happens at the school eye screening in Tahun 1?

A Snellen chart at 6 metres, one eye at a time, a small paddle called an occluder covering the other, and a measuring tape on the floor. It is done by the school health team, usually the jururawat masyarakat, the community nurse, or a medical assistant, with a health attendant helping, and the result goes into the pupil's health record book, kept by the school.

A child who reads 6/12 or worse with at least one eye is referred: a letter goes home naming the level in each eye and asking the parent to arrange a further check, often with an optometrist, a medical officer or a hospital eye clinic. The definition changed from 6/9 to 6/12 around 2015 to 2016, so an older sibling was judged against a different line.

Coverage has stayed above 98 per cent of government and government-aided schools since 2010. In 2018 the proportion picked up with vision of 6/12 or worse was 0.46 per cent at preschool, 1.75 per cent in Tahun 1, 3.25 per cent in Tahun 6 and 2.76 per cent in Tingkatan 3. The proportion already wearing glasses climbs the whole way, from 0.16 per cent at preschool to 13.73 per cent at Tingkatan 3. Why the proportion in glasses climbs so steeply by Tingkatan 3 is its own question. Colour vision is checked separately with Ishihara plates, at Tahun 6 and Tingkatan 3.

What it is not: a full eye examination. It is a distance sight check, on one day, built to catch the children furthest below a line. It will not find the child sitting just above the cut-off who is still struggling.

How do I find out if my child's kindergarten eye check happened?

Two questions, one at the tadika and one at home. Ask the centre whether the district school health team visits them, and when they last came. Then open your child's health book at the four-year eye page, which has a space for each eye and a small diagram for the light reflections.

If that page is blank and your child is past four, ask at your klinik kesihatan. It is a scheduled part of the four-year visit, not a favour. If a letter did come home, keep it: the eye clinic will want to see what was recorded.

Nobody should feel caught out here. The system is good at what it was built to do, and it was never built to be the only pair of eyes on your child.

When should my child have a first eye test if I arrange it myself?

I am not putting a single age on this page, because the age that matters is the one attached to what you have noticed. What I can give you is the rhythm international bodies set out: a check at birth, another in the first year, one between one and three, a sight test from about age three once a child can match pictures, then at five and every one to two years after.

Those are overseas recommendations, not Malaysian rules. They are useful mainly because they line up with our own contacts.

Age three is worth marking in your diary. From about then a child can do a matching test, and testing a child who cannot yet read stops being an obstacle.

The screening found something. What happens next?

A letter, and then an appointment somebody has to make. The surat rujukan is the mechanism a government eye clinic works from, and who can test your child's eyes, and what each door costs sets the choices out in full.

A referral is not a diagnosis. In the Malaysian preschool studies nearly all the reduced vision found was uncorrected refractive error, and the treatment is glasses, which is why the first glasses conversation follows most referrals.

The children I worry about are not the ones whose letter says something serious. They are the ones whose letter is still on the fridge in December. If yours is there now, making the call this week is most of the work done.

Don't wait for the next scheduled check if…

You see a white, pale or glowing pupil in a photograph or in ordinary light.
One eye turns in or out constantly, at any age, or is still wandering past about three to four months old.
Your child objects strongly when one particular eye is covered and not the other.
Your child screws up her eyes, sits very close to the screen, or says she cannot see the whiteboard.
A school referral letter has been sitting at home for weeks. The letter is the appointment waiting to be made.

Common questions

When should my child have their first eye test in Malaysia?

Earlier than most parents expect, because the first checks are already built into the child health book: the eyes are examined at birth, at one month, at 18 months, and sight itself is measured at four years. International bodies set out a similar rhythm, with an acuity test from about age three once a child can match pictures, then again at five and every one to two years. Those are overseas recommendations rather than Malaysian rules. Any new concern at any age deserves its own appointment rather than a wait for the next scheduled contact.

Does the school eye screening in Malaysia cover kindergarten and tadika?

It covers preschools the district school health team visits, which the published figures count as government and government-aided preschools registered with the education ministry. KKM reported preschool coverage above 98 per cent of that group from 2016, and 495,183 preschool children seen in 2018. A private tadika may or may not sit inside that. Ask the centre directly whether the pasukan kesihatan sekolah visits.

What does 6/12 on my child's school referral letter mean?

It is the cut-off the school health team works to, not a diagnosis. A child who reads 6/12 or worse with at least one eye on a Snellen chart at 6 metres is referred for confirmation and, if needed, glasses. The definition changed from 6/9 to 6/12 around 2015 to 2016, so an older sibling may have been referred against a different line.

The school screening said her eyes are fine, but she says she cannot see the whiteboard. Who do I believe?

Believe your child, and book an eye test. A school screening is a quick pass or refer check at one distance, on one day, in a corridor or a classroom, and it is designed to catch the children furthest below the line. A child can sit just above the cut-off and still struggle at the back of a class. Nothing about a passed screening rules out a proper eye examination.

My child is in a private tadika. Will anyone check her eyes?

Do not assume either way, and do not assume nobody will. Ask the tadika whether the district school health team visits them. Separately, the four-year eye check in the child health book is at the klinik kesihatan and is yours to ask for, whatever preschool your child attends.

Do I need a referral letter for a government hospital eye clinic?

Yes. Hospital eye departments work from referral letters sent by klinik kesihatan, government and private clinics, optometrists and other hospitals. That letter is the mechanism the eye clinic works from, so keep the one that came home and take it with you. Some hospitals run a dedicated paediatric eye clinic for children.

What is the red reflex check, and did my baby have one?

Almost certainly yes. It is the check where a light is shone into the eyes and the doctor looks for the even reddish glow that comes back from a healthy retina, and it is a printed line in the newborn examination page of your child's health book. The same line appears again at the one month, 18 month and four year doctor checks. If you want to see it, the pages are in the book at home.

References

Kementerian Kesihatan Malaysia · Prosedur Operasi Piawai Perkhidmatan Kesihatan Sekolah (2013) · hq.moh.gov.my
Kementerian Kesihatan Malaysia · Rekod Kesihatan Bayi dan Kanak-kanak 0 hingga 6 tahun, Pindaan 03/2021 (girls' edition of the book) · hq.moh.gov.my
Bahagian Pembangunan Kesihatan Keluarga, KKM · Laporan Tahunan 2018 (school health service coverage and vision screening) · hq.moh.gov.my
MyGovernment · Kesihatan Sekolah untuk Murid Pra-Sekolah · www.malaysia.gov.my
Pejabat Kesihatan Daerah Gombak, JKN Selangor · Unit Pasukan Kesihatan Sekolah dan Remaja (programme timeline, school health teams 1975) · jknselangor.moh.gov.my
Premsenthil M et al. · Kuching pediatric eye study, BMC Ophthalmol 2013 · pmc.ncbi.nlm.nih.gov
Chew FLM et al. · Visual impairment and amblyopia in Malaysian preschool children, the SEGPAEDS study, Med J Malaysia 2018 · www.e-mjm.org
Kamaruddin H et al. · Vision screening of preschool children in the Klang Valley, Malays J Med Sci 2022 · pmc.ncbi.nlm.nih.gov
American Academy of Ophthalmology · Eye screening for children · www.aao.org
AAPOS · Vision screening · aapos.org

By Dr Chan Li Yen. General information only. It does not replace a consultation. If you are worried about your child's eyes or vision, please see an eye doctor.