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Task force updates vision screening recommendations
Panel members debate merit of screening children younger than 3 years.
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In a Pediatrics paper recently published online, the U.S. Preventive Services Task Force recommended screening to detect amblyopia at least once for those between the ages of 3 and 5 years, but panel members said they could not find enough evidence to support or deny the screening of children younger than 3 years.
The paper provided some clarity on vision screening, which has been debated by medical organizations for some time. Previously, the task force recommended vision screening for all children younger than 5 years. However, the American Academy of Pediatrics differed in its recommendations, noting universal screening for distance visual acuity, ocular alignment and ocular media clarity at ages 3, 4, 5, 6, 8 and 10 years and once during the early-, middle- and late-adolescent phases. The American Academy of Ophthalmology and the American Association for Pediatric Ophthalmology and Strabismus recommend vision screening during the preschool years, and the American Optometric Association recommends a comprehensive examination at age 3 years, according to the panel.
A study published in the same issue of Pediatrics by Roger Chou, MD, and colleagues from the Oregon Evidence-based Practice Center and the Oregon Health and Science University, said, “Diagnostic accuracy did not clearly differ for children stratified according to age, although testability rates were generally lower in children 1 to 3 years of age.” The researchers on that study, which involved searches of Medline and the Cochrane Library and randomized trials, said treatments for amblyopia or unilateral refractive error were associated with mild improvements in visual acuity compared with no treatment.
“It should be emphasized that the ‘I’ (inconclusive) rating given by the USPSTF for screening children younger than 3 years should not be misinterpreted as ‘ineffective,’” Sean P. Donahue, MD, and James B. Ruben, MD, wrote in a commentary accompanying both papers. “We welcome the USPSTF level B recommendation for at least one vision screening in the child aged 3 to 5 years and believe that there is now adequate evidence to support an earlier screening using photorefraction or autorefraction in younger children.”
References:
- Chou R, Dana T, Bougatsos C. Screening for visual impairment in children ages 1–5 years: Update for the USPSTF. Pediatrics. 2011;127(2):e442-e479.
- US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation Statement. Pediatrics. 2011;127(2):340-346.
- Disclosures: Dr. Donahue reported that he receives research and travel support from Plusoptix and Welch Allyn and that he is a consultant for Diopsys. Dr. Ruben reported no relevant financial disclosures.
Is very early amblyopia screening beneficial? Simply screen to find a large cohort of toddlers with occult risk factors, randomize them to therapy, and wait to compare the outcome — variable visual acuity. However, pediatric ophthalmologists lack equipoise to randomize toddlers with hyperopic risk factors to non-treatment. An alternative is to mandate comprehensive exams in pre-kindergarten children. Except, the reality of the economics is this: Without a USPSTF mandate, there are limited insurance reimbursement funds for early photoscreening. Without evidence-based support for a USPSTF grade A recommendation, there will continue to be a lack of funds for early photoscreening. I doubt we will have grade A evidence in the near future. Perhaps the best paradigm is to consider what each of us would do with our own 18-month-old with 2 D of anisometropia.
– Robert W. Arnold, MD
Alaska Blind Child
Discovery Project Anchorage, Alaska
Disclosure: Dr. Arnold has no relevant
financial disclosures.