FIGURE 123.1 A: HOTV visual acuity chart B: Picture visual acuity chart Chart selection is important when trying to obtain an accurate visual acuity Letter charts should be used only for patients who can clearly recognize the alphabet If there is any question by parental report, a number or picture chart should be used In general, the HOTV or picture visual acuity charts should be used for children to years ( Fig 123.1 ), and the Snellen number or letter chart for children years and older Vision assessment in infants and children less than years of age involves evaluating whether each eye can fix and follow objects A useful option for children who are not “in the mood” to verbalize their responses or are very shy is the use of matching acuity chart systems The two most common are the Sheridan Gardiner (Keeler Instruments, Inc., Broomall, PA) and HOTV (Precision Vision, La Salle, IL) In both situations, the child is holding a card that has all of the letters that are on the posted or hand-held chart 10 or 20 ft away The child need not know letters but can identify them as shapes For example, the H can be called a little ladder and the O a circle Instead of verbally responding, the child points to the matching shape (letter) on the card he/she or his/her parent is holding When using any visual acuity chart, it is not necessary to start with the largest symbol and have the patient read every symbol on every line thereafter Doing so risks losing the child’s attention Rather, one can start