Children’s vision initiative moves forward — with or without legislation

States across the country continue to fight opposition from ophthalmologists and pediatricians in the effort to pass legislation to require comprehensive preschool vision exams.

“I don’t understand how they could possibly oppose this legislation,” said David Grimm, executive director of the New Jersey Society of Optometric Physicians. “I guess I can understand why pediatricians might be opposed, but I don’t understand why organized ophthalmology is.”

Despite this resistance, the effort continues. In fact, the Pennsylvania Optometric Association is so dedicated to this cause that optometrists there are determined to provide comprehensive eye exams to young children with or without legislation. “Whether we get a law or not, we will not change our program,” said James Spangler, OD, chair of the association’s Pediatric Vision Care Committee. “We want to see these kids.”

The Vision Council of America (VCA) also remains entrenched in the children’s vision initiative. At the end of February the group sent postcards to more than 7,500 state legislators describing the issue of uncorrected vision problems in children and the need for every child to have a comprehensive eye exam. The postcard also encourages recipients to contact VCA if they would like to help deliver the message to consumers in their community.

“Legislators are frequently overlooked as a resource for delivering important health information to the public,” said Joseph LaMountain, VCA vice president of Strategic Communications. “But as local leaders, they can help educate their community about the important role eye exams can play in preserving healthy vision.”

VCA has about 2,000 postcards remaining and will make them available free of charge to any member who wants them.

Kids welcome in Pa.

Instead of pursuing legislation, the Pennsylvania Optometric Association is spearheading the “Kids Welcome Here” program to promote pre-school eye exams in children at the ages of 1, 3 and 5 years. “We realized that we haven’t been seeing these children in our offices,” said Dr. Spangler. “We thought that rather than going straight to legislation, we had better step up, start doing the job and prove that we have the membership of the optometric association behind us.”

Dr. Spangler said the “Kids Welcome Here” program is now licensed in three other states: Kentucky, New Jersey and New York.

The first phase of the program is “Children’s Vision 1-3-5.” “We went with the American Optometric Association guidelines, which is 6 months, 3 years and 5 years. We spread the first exam to between 6 months and 1 year,” Dr. Spangler said. “The thought is that 6-month-olds are easier to do dilated fundus exams on, whereas the 1-year-olds start to exhibit more amblyogenic factors. So we said anywhere between 6 months and 1 year is a good start for routine vision care.

“We have also addressed the needs of school-age children,” he said. “Recognizing that school screenings are never a substitute for comprehensive eye exams, we still see them as a means to identify vision problems that require immediate attention. We feel they should be more efficacious to address children’s vision needs.”

Dr. Spangler said the state’s Department of Health was recently revising the school screening guidelines, and the optometric association volunteered to help. “Basically, all they were doing was a distance Snellen chart, which has no correlation with learning,” he said. “Most kids who can’t see the distance chart more than likely are nearsighted, and those kids tend to do better – not worse – in school.”

Based on the optometrists’ recommendations, near visual acuity and assessment of binocularity have now been added to the new Procedures for School Vision Screenings, which previously only included hyperopia screening and color vision screening in addition to the far Snellen chart. Also, parents of each child, pass or fail, will be told that the school screening is not a substitute for a comprehensive eye exam.

“It creates a lot more work for the school nurses, and they understand that these tests should be added, but they really do not have the time,” Dr. Spangler said. “So what they want is to concentrate on nursing and leave vision care to vision people. They have been very supportive of our commitment.”

Dr. Spangler said as a continuation of this program, the association has designed an educational program to teach the school nurses about the new guidelines, how to do the tests and how they relate to a child’s learning potential. They have also mailed posters and brochures to elementary schools across the state to educate parents and teachers that school screenings are not a substitute for a comprehensive eye exam. “Schools have not only requested more posters, but in certain school districts they have requested brochures to send home with every child,” he told said.

HB 1671, a school readiness bill, is being discussed in the state. “They want to have a comprehensive child health program that ensures Pennsylvania’s children are ready for elementary school,” Dr. Spangler said.

The Pennsylvania Optometric Association was invited to present testimony to the House Committee on Education concerning this bill. The response of the legislators was positive, and dialogue has continued as a result of this presentation, said Dr. Spangler.

“If they become interested in legislation to ensure every Pennsylvania child has adequate vision care, we will be happy to help them design an effective law,” he said. “But we have a responsibility to our children, law or no law, and we intend to meet it.”

Commission studies issue in Va.

A bill that would have required children to have a comprehensive eye exam by an optometrist or ophthalmologist before entering kindergarten was introduced into the House of Delegates and then referred to the House Education Committee in Virginia. According to Bruce Keeney of the Virginia Optometric Association, the legislation was carried over to the next session and the Joint Commission on Health Care was ordered to conduct a study and report back to the Education Committee by this December. If the Education Committee approves the report, the bill will be presented on the House floor next January.

Mr. Keeney said this commission, which comprises members of the legislature and is staffed by research professionals, addresses health care issues, conducts research and then presents the findings to a commission. He said the optometric association will provide the commission with all available data dealing with the benefit of a comprehensive exam in relation to vision and school achievement.

“When the medical community tried to oppose this, they were exposed as trying to protect a referral monopoly, and their opposition to this type of measure was totally contrary to medicine’s national organization policies,” said Mr. Keeney. “Our only arguable issue that needs to be addressed is to ensure that in certain localities we have a sufficient number of eye doctors to take care of the children who will need these exams before they start school.”

According to Mr. Keeney, between Medicaid and the FAMIS (Family Assistance Medical Insurance Services) program, the impact on the state budget of such a program would be zero. “The only other question would be families who are unemployed but not eligible for state or federal support,” he said. “This was a concern voiced by a new delegate in the general assembly who was from a largely rural area, one of the few areas in Virginia with a high level of unemployment. The area had one ophthalmologist and about a dozen optometrists. We called all the optometrists in that delegate’s district, and within an hour every one of them verified in writing that if they ever saw a patient who was not eligible for state or federal support and was down on their luck financially, they would be delighted to provide eye care at no cost.”

N.J. forming coalition

A New Jersey Senate bill that would have established an independent commission to consider a wide range of eye care issues expired in the last session. According to Mr. Grimm, the bill, which passed the Senate but did not make it through the Assembly, would have included low vision, scope of practice, new technology and children’s vision exams as a condition of admittance to public school.

“The bill has not been reintroduced in this session, and we at the association are considering introducing a bill that would require such examinations,” he told Primary Care Optometry News. “We’re in conversations with a number of diverse groups to form a coalition across the state to do that. I would anticipate that there will be such a bill later this spring.

“In talking with the executive directors from many of the other states, it’s apparent that there is a lot of interest in moving forward on this legislation,” Mr. Grimm continued.

Nebraska: re-tooling bill for 2003

According to David McBride, executive director of the Nebraska Optometric Association, LB578, which was introduced last year, is now in committee. “We don’t have the support that we need for it right now,” he told Primary Care Optometry News. “Our board has decided we will not actively pursue this as it’s written this year. We’ll probably let it die, re-tool it and re-introduce it for 2003.”

Mr. McBride said as it is currently written, the bill would require a comprehensive exam by an optometrist or a physician. “The terminology ‘comprehensive exam’, which we intentionally did not define in the statute, has become problematic,” he said. “We also concluded that we want the bill to require an exam by an optometrist or an ophthalmologist, not just any physician.”

According to Mr. McBride, the association has had several discussions with the leadership of the state ophthalmology group over the last 3 or 4 years about this bill. “They have indicated some support for the bill although they have not testified in favor of it,” he said. “We are attempting to work with them on it.”

Three bills in California

Three related bills were introduced in California in 2001 and are still pending. “I can’t imagine that any of the three will pass,” said Edward Hernandez, OD, chair of the California Optometric Association legislative committee. “Considering the state’s fiscal problems – a $12.5 billion deficit – it would be highly unusual for them to move at all.”

AB 1095 is modeled after the Kentucky legislation, said Dr. Hernandez, requiring a mandatory eye exam for all children entering first grade. “The Department of Finance immediately put a $17 million financial impact on it, so that never even got out of the first house,” she said.

AB 1096 is a pilot program that would allocate $500,000 to 10 schools considered “low performing” to conduct eye exams on children with reading problems related to vision deficiencies and to provide remedial vision training. “That one was pulled off the Senate floor because of unfriendly amendments that were attached to it,” Dr. Hernandez said.

SB 606 would require school nurses to do additional screenings on children. “Right now California requires acuity and color,” she said. “This bill says you would also have to check for binocular function and motility. Those children who showed unusual results would be referred to an optometrist or ophthalmologist for further testing. That one got held up in fiscal committee, too.”

Connecticut will re-introduce bill

Last year, the state of Connecticut introduced SB534, which would require children to have an eye examination by an optometrist or ophthalmologist prior to entering kindergarten. Due in large part to opposition from pediatrics, the bill was defeated, according Brian Lynch, OD, chairman of legal and legislative affairs for the Connecticut Optometric Association.

“In Connecticut, we have a unique legislative process, in that no bills are carried forward into the next legislative year,” Dr. Lynch said. “So when this bill was not acted upon favorably, it died.”

Dr. Lynch said the pediatric community, which represented the bill’s most vehement opposition, maintained that pediatricians were doing an adequate job screening children’s vision. The contention was that SB534 was redundant, a claim with which Dr. Lynch strongly disagrees.

“I believe a lot more can be done,” he said. “As screenings go, I think they are doing an adequate job, but I think a lot of children are falling through the cracks with these screenings. I think a comprehensive exam would ensure every parent that their child is fully equipped to engage in the learning process.”

Despite apparent support from the governor, the bill was killed after pediatricians insisted upon attaching an amendment “that basically neutered it,” Dr. Lynch said. “They wanted it to read that the eye examinations could be done by an ophthalmologist, optometrist or pediatrician,” he said. “I think theirs was an economic issue. I think they wanted to be in the business of doing eye examinations.”

Dr. Lynch said he is not sure whether these pediatricians represented their state association, the American Association of Pediatrics or simply their own interests. “Basically, the amendment was attached to the bill, and then we killed the bill,” he said. “We didn’t agree with pediatricians doing the eye exams.”

According to Dr. Lynch, the optometric association’s legislative committee is discussing what its next step will be.

“The debate is not over whether to introduce it again, but whether to introduce it this year,” Dr. Lynch said. “Connecticut is having a lot of fiscal issues since the downturn of the economy, and it seems as though both the House and the Senate are fairly entrenched in working out budgetary issues. So we don’t know whether much else will get done in the legislative session in Connecticut this year, due to these budgetary issues. We haven’t reached an endpoint on that decision yet.”

But Dr. Lynch maintained that sooner or later, the issue will be revisited. “I think the bill had a tremendous amount of merit, and we were so close,” he said. “There are a lot of key legislators in the state who want to see this bill go forward again.”

Missouri: “It isn’t over”

In January 2001, the Missouri Optometric Association introduced a children’s eye exam initiative bill, which would require children entering the public school system to have an eye exam by an optometrist or an ophthalmologist.

“We realize that children do most of their learning through their eyes,” said Kyle E. Brost, OD, president of the Missouri Optometric Association. “Vision will account for 80% to 90% of what we learn. So it just makes sense that before you attend school, you should have your eyes properly examined to ensure that you are seeing properly and therefore able to learn to the best of your ability.”

The legislation was voted out of committee but did not reach the floor in Missouri’s legislature last year, Dr. Brost said. “Primarily, the ophthalmological group in the state was against it,” Dr. Brost said. “They contend that vision screenings done by pediatricians and family doctors are adequate.”

The Missouri Optometric Association strongly disagrees with this contention, Dr. Brost said. “I routinely see kids who have passed vision screenings and still have vision-related problems such as headaches at school and intermittent blur. Screenings are not an eye examination. There is a big difference.”

This opposition from ophthalmology slowed the progress of the bill, Dr. Brost said. “It was viewed as a self-serving piece of legislation for optometry,” he said. “That is not what it was intended to be.”

Dr. Brost said the optometric association certainly intends to revisit this issue, but at this time is not sure how to approach the matter.

“We are disappointed as an organization that this has met with such resistance from our friends in ophthalmology,” he said. “We feel that if we simply offer the bill again this year, they will use the same tactics to fight it. We are working with state-wide elected officials and other children’s advocacy organizations at this time. But it isn’t over. We see too many kids slip through the cracks. We are still committed to assuring that the children of Missouri have quality eye care and are prepared for the demands and tasks of school.”

Impact in Kentucky

According to the Kentucky law, children are required to have a complete eye exam by an optometrist or ophthalmologist by Jan. 1 of their first year in school. Kentucky practitioner Joe Ellis, OD, says parents are now bringing their children in for exams earlier in the year instead of waiting until the school year begins.

“Like any new law, it was difficult to implement the first year because people weren’t informed,” he told Primary Care Optometry News. “But the process has become much smoother now because we have had more time to educate the population about it. When families go through their summertime orientation about preschool they get information about this.”

Data collected from a preliminary survey in Kentucky showed that 8.9% of 3-year-olds, 10.8% of 4-year-olds, 12% of 5-year-olds and 18.7% of 6-year-olds needed glasses. In addition, 2.4% had strabismus and 3.6% had amblyopia. Other previously undiagnosed conditions were found, including foreign bodies, optic atrophy, ocular albinism, blepharitis, esophoria, accommodative esotropia, convergence insufficiency and iris coloboma.

“Some practitioners may have thought that it would interrupt their schedules, but once you acclimate to it, it’s no problem at all,” said Dr. Ellis. “We are finding a lot of problems in these children. I read about it but never realized there were that many children with that many visual problems.”

To view the first part of this series on the Children's Vision Initiative, click here.

For Your Information:

• David Grimm can be reached at the New Jersey Society of Optometric Physicians, 20 Texas Ave., Lawrenceville, NJ 08648; (609) 671-0900; fax: (609) 671-1820; e-mail: Davegrimm@aol.com.
• James Spangler, OD, can be reached at 213 W. Third Ave., Warren, PA 16365; phone and fax: (814) 723-4470; e-mail: spang@penn.com.
• Joseph LaMountain can be reached at Vision Council of America, 1700 Diagonal Rd., Alexandria, VA 22314; fax: (703) 548-4580; e-mail: jlamountain@visionsite.org.
• For VCA postcards, contact Shelli Leon at (703) 548-4560, ext. 235; e-mail: sleon@visionsite.org.
• Bruce Keeney can be reached at the Virginia Optometric Association, 118 North 8^th St., Richmond, VA 23219; (804) 643-0309; fax: (804) 643-0311.
• David McBride can be reached at the Nebraska Optometric Association, 201 N. Eighth St., Suite 400, Lincoln, NE 68508; (402) 474-7716; fax: (402) 476-6547.
• Edward P. Hernandez, OD, can be reached at the California Optometric Association, Government Affairs Dept., 2415 K St., Sacramento, CA 95816; (800) 877-5738; fax: (916) 448-1423.
• Brian Lynch, OD, can be reached at the Connecticut Optometric Association,60 Montowese Street, Branford, CT 06405-3806; (860) 586-7508; fax: (203) 481-2028.
• Kyle E. Brost, OD, can be reached at 37 Doctors Park, Cape Girardeau MO 63703-4927; (573) 334-8595; fax: (573) 335-1934.
• Joe E. Ellis, OD, can be reached at 109 West 5^th Ave., Benton, KY 42025-9400; (800) 371-5580; fax: (270) 527-3118; e-mail: jellis@vci.net.