Pediatric vision screening remains hot topic for clinicians, lawmakers

Study shows a discrepancy between children who would benefit from glasses and those who were prescribed correction.

Discrepancies in a recent study between the need for spectacle correction and the number of children who receive correction have raised questions about pediatric vision screening and eye care.

Jean E. Ramsey

Currently, various studies are examining vision screening methods in pediatric patients and exploring ways to identify and treat conditions such as amblyopia, strabismus and refractive error.

Vision screening methods vary widely, often according to clinical setting and population, Jean E. Ramsey, MD, MPH, said.

“People are experimenting with different approaches,” Dr. Ramsey said in an interview with Ocular Surgery News. “We don’t have the perfect vision screening. People are looking for easier, faster and more accurate methods. I think in the end we’re going to end up … with multiple ways to screen vision in children based on age and based on the site where we’re screening.”

Clinicians need to take a close look at screening methods to improve the diagnosis and treatment of pediatric eye disease, OSN Pediatrics/Strabismus Board Member Scott E. Olitsky, MD, said.

Scott E. Olitsky

“My feeling is we clearly need to look at the screening process first,” Dr. Olitsky said. “I’m not sure that we can justify the expense of a full exam for every child before they start kindergarten.”

Mary Louise Z. Collins, MD, said there is an overarching need for policy to effectively drive screening and care.

“From our standpoint as pediatric ophthalmologists, our focus is on trying to make the best use of our health care dollars and health care resources,” Dr. Collins said. “We’ve been working on the state level and federal level to try to assure that good public health policy is set for implementing good vision screening programs in the states.”

Children need to be screened early to identify treatable conditions, Dr. Collins said.

“For the youngest children, picking up conditions that are treatable, both medical eye conditions but also amblyogenic factors, things that could lead to amblyopia if not diagnosed, I think is important,” she said.

Population-based study

The Baltimore Pediatric Eye Disease Study examined the prevalence of refractive error among preschool children. The authors set out to assess the need for spectacle correction and gauge the extent to which the need was met.

The population-based study, one of the largest of its kind, delineated clinical findings based on race and ethnicity. It is the first in the United States to stratify the refractive status of preschool children by race and ethnicity, Dr. Ramsey said.

“We have to start looking at a lot of these simple questions, like refractive error. You try to see, how does that differ by race and ethnicity? It’s very hard to find,” she said. “A lot of that information is not out there. This study and the studies that are coming out from this group, it’s really giving us answers to questions that have never really been addressed in the literature.”

The study included 1,268 African-American children and 1,030 white children who were between 6 months old and 71 months old. Hyperopia was found to be the most common refractive error among both groups of children. However, black children were an average of 0.75 D less hyperopic than white children.

Overall, significant refractive errors were not found in either group. Based on the American Academy of Ophthalmology’s Preferred Practice Patterns, 5.1% of the children would have benefited from spectacle correction, but only 1.3% of children had been prescribed corrective lenses, the authors said.

“It is a big discrepancy,” Dr. Olitsky said. “Are we missing some of these kids in a screening process? Or did these children ever even get screened?”

Conversely, Dr. Olitsky said that some children did not meet refractive guidelines but were still prescribed glasses.

“It’s hard to say what that reason was,” he said. “For instance, children who were being treated for strabismus, where just looking at the refractive error may not have given you the answer as to why they were given the prescription.”

Dr. Ramsey said the study did not show how many children with high refractive error had undergone vision screening.

“I think we have to be aware of what this study isn’t showing us,” Dr. Ramsey said. “We don’t know how many children with this unmet need had a prior vision screening. We don’t know how many children with this unmet need, with this high refractive error, would have been discovered through a standard vision screening.”

Legislative initiatives

Several states require vision screening and comprehensive eye exams for preschool and elementary school children. Pending federal legislation proposes funding state grants for follow-up care for uninsured children who have been identified as possibly having a vision problem.

“That continues to be an active area,” Dr. Ramsey said. “I would say that compared to 10 years ago, we are far and away ahead. We have people advocating for that, putting demands on our public health systems.”

Cost plays a key role in determining the quantity and quality of pediatric vision screening and care, Dr. Ramsey said.

“When we’re looking at things from a public health perspective, we always want to look where we can get the biggest bang for our buck,” she said. “That’s something the community as a whole struggles with a little bit. We want to be able to make sure that every child has the opportunity to develop good vision — every child.”

State vision screening laws vary considerably, Dr. Olitsky said.

“Each state currently makes their own decision as to how to deal with these vision screening or vision exam rules,” he said. “There’s quite a bit of variability from state to state. Some states don’t mandate anything. Others mandate screening. And a few, Missouri being one of them, mandate an eye exam by an ophthalmologist or optometrist prior to starting kindergarten.”

The Massachusetts preschool vision screening law mandates that every child receive a standardized vision screening within 12 months before entry into kindergarten. Massachusetts law also currently mandates that every child in public school receive a vision screening annually.

Maryland’s vision screening law requires an initial screening at entry to preschool or kindergarten, a second screening in first grade and a third screening in eighth grade. An earlier version of Maryland’s law required screening upon entry to school, a second screening between third and fifth grade and a third screening in eighth or ninth grade, Dr. Collins said.

“That [third] screening is more to pick up refractive error changes that occur more commonly in that age group,” she said. “The ideal is to try to push for entry to school as early as we can do it, age 3, 4 or 5 at the latest, and then a second screening in first grade and a third screening in third grade.”

The U.S. House of Representatives passed a federal initiative, the Vision Care for Kids Act, on March 31 by a vote of 404 to 17. A Senate committee is reviewing the bill. If signed into law, the Vision Care for Kids Act would provide $65 million in funding over 5 years for state grants for follow-up care for uninsured children who have been identified as possibly having a vision problem. – by Matt Hasson

Reference:

• Giordano L, Friedman DS, Repka MX, et al. Prevalence of refractive error among preschool children in an urban population: the Baltimore Pediatric Eye Disease Study. Ophthalmology. 2009;116(4):739-746.

• Mary Louise Z. Collins, MD, can be reached at Greater Baltimore Medical Center, 6569 N. Charles St., Suite 505, Baltimore, MD 21204; 443-849-8082; fax: 443-849-6817; e-mail: mcollins@gbmc.org.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; e-mail: seolitsky@cmh.edu.
• Jean E. Ramsey, MD, MPH, can be reached at Yawkey Ambulatory Care Center, 850 Harrison Ave., Boston, MA 02118; 617-414-4020; fax: 617-414-4028; e-mail: jean.ramsey@bmc.org.

Dr. Giordano and colleagues used an extremely large cohort to show the need for prescribed refractive correction to be 5.1%. Thus, the prevalence of significant refractive errors is uncommon in this preschool population. With the vision screening vs. comprehensive eye examination debate continuing, even up to the congressional level, this study once again proves that with vision screening protocols utilized properly, the need for comprehensive examinations on each and every child would not be the best way to utilize “vision dollars.” As a point in fact, with the recent passage of the Vision Care Act for Kids in March, the House has confirmed and all major parties (AAO, AAPOS, AAP and the AOA) endorsed the necessity to screen young children at early ages to attempt to identify vision problems so that they can be treated at a young age. We applaud the authors for their contribution to this issue.

– Robert S. Gold, MD
OSN Pediatrics/Strabismus Section Editor