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Amblyopia detection requires concerted effort of physicians, community
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As much as 80% of a child’s early learning is dependent on good vision. It is estimated that 25% of preschool children have some defect in their visual perception if we include refractive errors. Severe disorders, such as retinopathy of prematurity, significant unilateral or bilateral cataract, retinoblastoma with significant leukocoria, nystagmus or a significant lid hemangioma with secondary ptosis, are rarely missed. Unfortunately, the more common amblyopia secondary to anisometropia or subtle strabismus is undiagnosed in as many as 50% of preschool children.
In addition, many young children are handicapped in their early development by refractive errors that could easily be treated with a pair of glasses. The best solution is early and accurate screening of all children to diagnose refractive error, anisometropia and strabismus at the earliest possible age.
The Patient Protection and Affordable Care Act states that such screening will be implemented by 2014, but it is short on details as to how this will be accomplished and who will pay for it. Thinking globally but acting locally, I will share a few personal observations.
A child with appropriate and regular examinations by a pediatrician is much less likely to have a significant eye disorder missed, but it is possible for the very busy pediatrician to miss mild anisometropia, the most common cause of undiagnosed amblyopia.
Multiple excellent screening tools take advantage of the fact that the red reflex, when observed with an ophthalmoscope and especially when photographed, is different in an eye with any ametropia as compared to emmetropia. These devices are reasonably priced and also allow detection of strabismus and even subtle leukocoria. Many such instruments are commercially available, and the testing can be done by ancillary health care personnel before seeing the doctor. With reasonable and appropriate reimbursement (perhaps an oxymoron, especially for the indigent), these devices can be expected to make vision screening easier and more effective for the often harried pediatrician. The use of these devices is increasing and can be expected to decrease undiagnosed eye pathology. Unfortunately, in many inner cities, young children do not have regular access to a pediatrician.
In Minneapolis, adjacent to the Phillips Eye Institute, there is a large population of lower-income children, many who are Somali immigrants, who have never undergone a vision screening. The Phillips Eye Institute Foundation, in response to this unmet need, working under the guidance of its attending ophthalmologists and with the support of local volunteers, created an award-winning free vision screening program called the Early Youth Eyecare (E.Y.E.) Community Initiative.
Each year this program, using trained volunteers, screens hundreds of low-income children using visual acuity charts and a cover-uncover/cross-cover test. Those children who fail the screening are referred to ophthalmologists or optometrists who have agreed to accept these often uninsured or state-covered patients, many who also require an interpreter, also not paid for by insurance in Minnesota. While extremely successful, this program uncovered another unexpected problem. When pathology — in most cases undiagnosed refractive error but in some cases more severe disease requiring medical or surgical intervention — was detected, many patients’ parents did not follow up with treatment because they could not afford even simple remedies such as eyeglasses.
In response to this, my wife, Jaci, and I created a second fund to provide glasses and appropriate treatment at no cost to those in need. Many individual and corporate donors, in particular Allergan, have generously continued to annually fund this initiative, which now includes both screening and treatment. Community support and appreciation have been significant, and many children have avoided the misfortune of lifelong visual loss. Anyone interested in learning more about these programs can look on the Web under the Phillips Eye Institute Foundation and the E.Y.E. Community Initiative, as there is need for similar programs in almost every community.
In a recent cover story and commentary, we discussed the explosion of “digital health” and the hundreds of digital apps being developed for mobile phones. Even in the more indigent populations, mobile phone ownership is common, with at least one member of nearly every extended family owning a device. Baby Check, a set of vision screening apps for any cell phone, in development by David Huang, MD, in Portland, Ore., is to me an example of an innovative approach that might make red reflex vision screening more widely available globally at a reasonable cost.
Missing preventable blindness, especially amblyopia in a young child, is tragic and potentially avoidable. Prevention requires effective screening with a low-cost, widely available method with high sensitivity and specificity. Red reflex photography is a very promising option to enhance our ability to find these children while they are still treatable. However, finding these patients is only half the problem. They must also have access to appropriate treatment, in many cases as simple as a pair of spectacles.
Surprising to me was the discovery that many children’s families could not afford the recommended treatments. Community assistance for the child’s parents in accessing and affording proper care remains a secondary barrier, and today philanthropy may be the only available solution. While the American Association for Pediatric Ophthalmology and Strabismus and its members are appropriately leading the way in this area, every ophthalmologist has a role to play in the effort to discover and treat undiagnosed amblyopia at the earliest possible date.