Pediatricians and family physicians should be knowledgeable enough to recognize common pediatric eye disorders and early presentations because some eye diseases might be sight-threatening or life-threatening. In addition, children may lack the capability or the insight to voice out their ocular complaints, which may delay the proper healthcare and management. Thus, well-trained physicians should catch these disorders early enough. In terms of knowledge, participants’ medical understanding of eye diseases was inadequate, particularly among junior residents and staff doctors of both disciplines. The expertise and abilities of consultants, associate consultants, specialists, and fellows were satisfactory.

To begin with, participants had an excellent insight into recognizing the causes of painful red eyes in children. The most commonly reported causes were corneal traumatic abrasion (87.2%), uveitis (69.6%), and glaucoma (24.3%). Although conjunctivitis will probably cause a painless red eye, 85.1% of our participants stated inaccurately that it causes painful red eyes. These results are in line with the findings of other studies conducted in Jordan and Kenya [8, 14]. In comparison to a study conducted in the United States, in which 55% of the general practitioners were willing to prescribe eye drops or ointments to children with painful red eyes, more than half of our physicians (51.5%) were willing to refer the patient immediately to an ophthalmologist [13]. Some of the remaining participants (12.8%) chose to start their management by giving eye drops and then referring immediately or referring after three days if no improvement was observed (28.4%). The majority of eye drops prescribed by our physicians were antibiotics (14.9%), artificial tears (6.1%), antihistamines (4.7%), or steroids (2%) depending on the suspected cause. Additionally, regarding neonatal conjunctivitis, physicians’ approach was either referring the patient immediately to an ophthalmologist or giving eye drops such as ofloxacin (9.5%), erythromycin (6.1%), unspecified antibiotics (6.1%), gentamicin (4.7%), chloramphenicol (2.7%), or artificial tears (0.7%).

Knowledge of the causes of leukocoria was satisfactory, as 87.2% of the participants could recognize the most life-threatening and serious cause; i.e., retinoblastoma, and 54.7% identified the most common cause, i.e., cataracts. This was much higher than the finding of a study conducted in Brazil by Manica et al., wherein retinoblastoma was reported only by 37% of their participants [12]. Other reported causes were toxocariasis and advanced retinal disorders (12.2% and 12.8%, respectively). Although glaucoma is not a cause of leukocoria [15], 14.2% have reported incorrectly that it could be the etiology. Almost half of the physicians knew that leukocoria could be life- and/or sight-threatening, and a few (3.4%) of them believed (wrongly) that it could be a normal variation in children. Additionally, nearly all physicians (n = 144, 97.3%) would immediately refer a case of leukocoria/retinoblastoma or congenital cataract (n = 143, 96.6%) to an ophthalmologist for prompt management. On the contrary, a study conducted in the Qassim region of Saudi Arabia found that only 69% of nonophthalmic health professionals knew the correct action when encountering a retinoblastoma case; moreover, they had less than the desired knowledge about retinoblastoma [16].

Although nearly all of the participants of the study conducted in Kenya (98.4%) knew that true strabismus (i.e., strabismus) could be caused by refractive errors, only 61.5% of our participants reported that a refractive error could be a cause. Thus, the identification of those patients with refractive errors by healthcare professionals, parents, and teachers is important to prevent future consequences such as refractive strabismus or amblyopia. Signs of pseudostrabismus, including a wide nasal bridge and epicanthal fold, should be distinguished from those of true strabismus. In our study, participants showed great awareness of that distinction, with only 5% of them having difficulties with the concept. Because of their concern that the strabismus might lead to amblyopia (83.1%) or originate from a central cause (51.4%), most of the physicians were in favor of immediately referring a child with strabismus to an ophthalmologist (79.1%) or at least follow-up and refer when no improvement is seen (17.6%). A few of them reported that they might order brain imaging such as computed tomography or magnetic resonance imaging before referring to an ophthalmologist, which is an advanced step and should be done in collaboration between those physicians and ophthalmologists in certain types of pediatric strabismus [17]. Commonly, strabismus does not resolve spontaneously as the child grows, which was stated incorrectly by 12.8% of the participants. Instead, it is corrected either surgically or by wearing spectacles. Although most of the participating physicians were aware of the proper approach to a child with strabismus, which was reassuring, more effort should be directed toward being updated with joint eye examination guidelines [4, 7].

Regarding congenital glaucoma (CG), physicians’ recognition of the cardinal signs was borderline.

Although a hazy cornea, large cornea, and watering eye (51.4%, 43.9%, and 39.2%, respectively) were recognized to some extent, other unrelated symptoms such as leukocoria and eye redness were mistakenly reported to be CG presentations. While some cases could be missed because of inadequate knowledge, most physicians (n = 145, 98%) were willing to promptly refer a child with CG to an ophthalmologist for further assessment. In addition, all physicians (n = 148, 100%) showed an outstanding awareness of the risk factors for ROP in newborns. In comparison, a Saudi study conducted in the Al-Qassim region demonstrated a lack of knowledge, whereby 50% of the pediatricians had poor knowledge of ROP [9]. Even though early ROP screening is a crucial step in preventing its consequences, only 36.5% of participants knew that it should be done 4–6 weeks after birth or at the postmenstrual age of 32 weeks, whichever comes later. This percentage was comparable to that reported in the Saudi study conducted in Tabuk by Albalawi et al.; however, it was considered very low compared to that reported in the Jordanian study wherein ~ 75% of participants knew the correct timing of ROP screening [8, 10].

Eye examinations should be performed right from the neonatal period and during each follow-up visit. According to the American Academy of Ophthalmology, at the age of 12–36 months, children should have at least one eye screening [4]. When participants were asked about when an ophthalmologist should see a child, 68% responded that a child should undergo vision screening at least once before kindergarten, 24% said that there is no need for one if there are no symptoms of an eye disorder, and only 2% of them did not know when a child should be screened. All newborns and children during their regular well-baby visits should be routinely screened; however, 56 of our participants believed (inaccurately) that this should be done only by an ophthalmologist. This result was similar to that of a Jordanian study in which the authors highly recommended that hospitals should invest in training their staff and instill the importance of early screening and proper timing in referring children to ophthalmologists for further management [8].

Regarding the practices of our pediatricians and family medicine physicians, ~ 81% of our participants performed ophthalmic examinations for children. Some doctors fail to do it because they did not have the required knowledge, competence, time, or equipment. Others could not because the children in question were uncooperative, while others did not do so because thought it was not related to their specialty. Although the assessment of the red reflex is considered a major part of the newborn’s first examination and well-baby visits, 24.3% of our participants failed to do it, which is a lower percentage than that reported in a study conducted in the US wherein only 5% reported that they do not check for the red reflex [14].

This study demonstrated that most (64.8%) junior residents and staff physicians had unsatisfactory.

knowledge (Table 5). This knowledge deficiency might be attributed to inadequate teaching and training during residency. Thus, it is necessary to evaluate the pediatrics and family medicine residency curriculum to ensure that such topics are adequately covered. On the contrary, consultants, associate consultants, specialists, and fellows had satisfactory knowledge, at least to some extent. Differences in the amount of work experience and exposure may explain such differences between senior and junior physicians.

To our knowledge, this is the first study conducted in Saudi Arabia to assess the knowledge and attitude of pediatricians and family physicians toward multiple pediatric eye diseases. Our findings may provide helpful insight into how to plan future teaching. The major study limitation is that the survey was self-reported; hence, there might have been some recall bias.