Effort to legislate preschool eye exams gains momentum across the country

More than a dozen states are involved in some type of children’s vision initiative in an effort to encourage full eye exams for children before entering school. Many supporting such initiatives and related legislation are somewhat surprised by the resistance they are encountering from ophthalmologists and pediatricians. Publicity in the lay press that has bordered on unsupportive has also surfaced in the form of a Wall Street Journal article and news programs on network television. These reports have questioned whether the eyeglass industry is targeting toddlers in response to lost revenues due to contact lenses and refractive surgery in adult patients.

Despite resistance, state optometric associations and other organizations have made great strides toward legislating preschool vision examinations, with a number of bills drafted and introduced in the individual states. The American Optometric Association (AOA) continues to support these efforts through training and educational efforts.

“Because 80% of what a child learns the first 12 years is through vision, the AOA actively encourages comprehensive eye exams,” David W. Nelson, OD, told Primary Care Optometry News. “This is in the best interest of all children. Undetected and untreated vision problems are of great concern because they can interfere with the child’s ability to perform to his or her potential.”

No states have passed legislation requiring preschool eye exams since the Kentucky law was implemented in July 2000, but the optometric community is confident that this type of legislation will prevail across the country. Efforts are also underway in Washington to address the whole issue of children and eye exams.

“The VCA [Vision Council of America] is working to have a bill introduced into Congress that would provide money to the states to pay for eye exams for children, whether it’s through increased Medicaid utilization rates or if the state just wants to apply for money to provide exams in underserved communities,” said Joseph LaMountain, vice president of strategic communications for VCA.

Ohio: the next Kentucky?

Of the states currently seeking legislation, Ohio is considered to be the closest to achieving a law that would mandate preschool eye exams. Not since Kentucky has such progress been made toward this end, according to Mr. LaMountain. “Ohio is really in a good position and has made a lot of progress to try to get a law enacted since Kentucky,” Mr. LaMountain said.

The Ohio Senate has passed a resolution creating a Task Force for Better Vision. This task force, consisting of three senators and three representatives, has conducted five hearings, the most recent of which was held on Jan. 29, according to Mr. LaMountain. The task force has heard witnesses from optometry, ophthalmology, opticianry, school districts, nursing and the state health department.

“The fact that people have testified at these hearings in support of the effort has been a very positive development,” Mr. LaMountain said. “The optometric association has made it clear that it wants Ohio to be the second state in the country to enact this law.”

After the task force renders its recommendations, the issue will be taken under advisement by the state legislature, according to Richard Cornett, executive director of the Ohio Optometric Association.

“It would be presumptuous at this time to anticipate what the legislation will be,” said Mr. Cornett. “But, certainly, optometry believes that all of the information underscores the need for all children to have a comprehensive eye examination before they start school.”

Mr. Cornett said that ophthalmology and pediatrics have recently taken an official stance against a comprehensive eye exam for preschoolers. “Now they’re saying that a screening is good enough,” Mr. Cornett said. “We’re saying that their own data totally contradicts this stance. We’re baffled and disappointed that they have departed from their own data.”

Mr. LaMountain stressed that this is an important time for Ohio optometrists and proponents of the law to show their support. “Folks in Ohio should really get involved; they should get in touch with Mr. Cornett and help make the case for why kids need eye exams,” he said. “And those in other states can learn from this and take similar action. This is part of a national push.”

Mr. LaMountain added that Ohio recently hired an actuarial firm to assess the projected cost of implementing the law. “They conducted a study and found that the cost to the state to enact such a law would be roughly $300,000, which is peanuts given the fact that the state’s budget is about $50 billion a year,” he said. “That was one of the big arguments of the opponents — that this would be too expensive. Now it’s been found that the costs aren’t that great at all.”

What sets the Ohio effort apart, Mr. LaMountain said, is that it would make the eye exams mandatory, rather than merely encouraging them. “We feel that just as children need to get their immunizations, they need to have their eyes examined,” he said.

Free exams in Kansas

In Kansas, optometrists showed their faith in the children’s vision exam initiative by providing three-year-old assessments as a free service.

“We wanted the legislature to know what we were giving to the children of Kansas,” said Karen S. Aldridge, OD, a former high school teacher and current president of the Kansas Optometric Association. “We wanted them to know how important this issue is to us.”

For the past 10 years, the Kansas Optometric Association and nearly 450 participating optometrists in 21 states have sponsored the See to Learn program, which provides a free vision assessment for any 3-year-old, Dr. Aldridge said. Because these assessments are done in the optometrist’s office, they are more in-depth than an ordinary school screening.

“So it doesn’t matter if the child has insurance or doesn’t have insurance, whether he or she is rich or poor — the assessment is free,” Dr. Aldridge said. “We wanted to try to catch any children who might have amblyopia and might have potential vision loss.”

Dr. Aldridge said the state legislature was so impressed by this contribution on the part of optometrists that it vowed to do its part as well. “They basically agreed that it must be important if we’re giving our services away free. So what happened was, we didn’t even have to ask for this legislation. They brought it up, and it passed with no hassle.”

Dr. Aldridge said an amendment to the legislation states that “each pupil needing assistance in achieving mastery of basic reading, writing and mathematics skills shall be encouraged to obtain an eye examination by an optometrist or ophthalmologist to determine if the pupil suffers from conditions that impair the ability to read. Expense for such examination, if not reimbursed through Medicaid, Healthwave, private insurance or other governmental private program, shall be the responsibility of the pupil’s parent or guardian.”

Dr. Aldridge explained that this amendment is important because it relieves the school of financial responsibility for additional testing. “Previous to this time, if the test was not part of a mass school screening, but particular to a child having a problem, the school became responsible for the cost,” Dr. Aldridge said. “Consequently, a lot of schools got to the point where they would hesitate to recommend eye exams.”

Dr. Aldridge explained that the amendment is not expected to be harmful to poorer families. “It’s a wonderful step in the right direction, because families who are poor are covered by Medicaid,” she said, “and Healthwave is a program that covers the working poor.”

As a former teacher, Dr. Aldridge emphasized the significance of vision skills in relation to reading skills. “I saw kids having trouble as sophomores in high school, and I didn’t know why,” she said. “But now I know why. These kids couldn’t see right. They could see 20/20, maybe, but they just couldn’t see well up close. So they fell through the cracks with regular school screening programs.”

Dr. Aldridge encouraged other states to follow Kansas’ example and invest in children’s vision exams. She said not only does the Kansas Optometric Association give free assessments, the group also promotes the See to Learn program through newspaper and radio advertisements.

“Not only do you have to believe in it; you have to believe in it with your pocketbook,” she said. “We invest in it because we believe in it so heavily. We can’t expect other people to be committed to our profession if we aren’t.”

South Carolina’s infant screening

A joint resolution in South Carolina establishes the Newborn Eye Screening Task Force to study the screening of ocular diseases and abnormalities in newborn children. The study should include identification of the most prevalent ocular diseases and abnormalities in newborns and the effectiveness, costs and funding of screening for these diseases and abnormalities.

“The task force comprises a primary care physician, a pediatric optometrist, a general optometrist, a neonatologist, a pediatric ophthalmologist, a general ophthalmologist, a representative from the South Carolina Hospital Association, the Department of Health and Human Services, the Department of Health and Environmental Control and the director of the Governor’s Division of Health and Human Services,” said Claire H. Holley, executive director of the South Carolina Optometric Association. “Lay members appointed include two parents representing two families with a child who is blind or who has ocular abnormalities affecting vision.”

The resolution was signed and the members named in August 2001. The task force formally met Jan. 9 and Feb. 5, after which they submitted their formal recommendations to the governor.

Tennessee’s eye, dental legislation

In Tennessee, legislation has been enacted that would amend children’s screening requirements to mandate that, upon registration or as early as is otherwise possible, schools are encouraged to make reasonable efforts to apprise parents of the health benefits of obtaining appropriate eye and dental care for children.

“It turned out to be a memorializing document, encouraging schools to promote the importance of good dental and vision care,” said Gary Odom, executive director of the Tennessee Optometric Association (TOA). “In January, legislation was introduced independently of TOA that would mandate an eye exam for every child entering school.”

Mr. Odom said he would like to see every child have a vision exam before entering school, but he is not sure the state of Tennessee is ready to take that step.

“Tennessee is a conservative state, and there is always a concern about too much intrusion by government into family matters,” he said. “Any time you start mandating what families can and can’t do, there is resistance to that, even when it is sound public policy.”

Mr. Odom added that financial restrictions could stall the legislation. “Our state is having substantial budget problems, and a mandated eye exam for children will impact the cost of our Medicaid (Tenn Care) program,” he said.

Wisconsin: a successful initiative

The “Clear Vision, Bright Future” initiative is the result of regulations signed into law by Gov. Scott McCallum in the summer 2001 budget process. Starting with the 2002-2003 academic year, children entering kindergarten in Wisconsin public schools will be encouraged to undergo an eye examination by an optometrist or eye evaluation by a physician. A document will be signed by the doctor performing the testing to confirm completion, which must be done by Dec. 31 of that academic year.

“Our goal was to encourage as many children as possible in the state of Wisconsin to receive a comprehensive eye exam,” said Peter Theo, executive director of the Wisconsin Optometric Association (WOA). “We thought that having some sort of statutory language would be a wonderful springboard for Wisconsin optometrists to educate the public on the important link between vision and learning.”

Although Mr. Theo acknowledged that the WOA would have preferred a more strongly worded law, he emphasized that the current law is an important step in the right direction.

“In a perfect world, we would want a mandate for comprehensive eye exams by an optometrist,” he said. “The reality is that, at this point in time, it may be out of our political reaches. However, we thought that having this law in place was a major step forward in recognizing the importance of this issue.”

Pilot program in New York

“In New York, we have been taking a different approach to try to get the same results,” New York State Optometric Association President Andrea Thau, OD, told Primary Care Optometry News. “We are in the process of gaining approval for a pilot program for the New York City Board of Education School System, which encompasses all public schools in the city of New York,” she said. “The idea of the pilot program is to send all children in pre-K, kindergarten and special education in schools home with letters requiring them to have an eye examination and a report form. They would then submit the completed form to the school. Those children who do not return the completed forms would receive a free examination on site at the school. The exams would be provided by volunteer optometrists. Free eyeglasses would be provided by New Eyes for the Needy, and the equipment for the exams will be loaned by SUNY Optometry.

“We wanted to have the pilot instituted on a citywide basis, have it work effectively and, with the city’s support, move on to do this on a statewide level,” Dr. Thau continued. “We felt we would probably have more success doing it that way rather than legislating it from the state down. We were hoping that once they saw its effect on the children, we’d be able to get the school system to support the concept.

“The program is an outgrowth of the New York City Children’s Vision Coalition, which is an amalgam of about 50 different organizations,” she said. “It’s not just optometry, it’s also ophthalmology and opticianry, and we have representatives from the department of health and the board of education, as well as myriad other organizations that are involved in vision care in New York.”

Proof of exam in Massachusetts

Legislation in Massachusetts would require children to provide proof of an eye exam by an optometrist or ophthalmologist, indicating any pertinent diagnosis, treatment, prognosis, recommendations and follow-up. “At this point, it has passed the joint committee on education favorably, and it’s waiting to be brought to the floor of the Senate for a vote, where we believe we have the votes in our favor,” said Neil Casey, OD, co-chair of Children’s Legislative Issues and past president of Massachusetts Society of Optometrists.

“Right now, the legislature is bogged down with the overdue budget for the state, so nothing is getting any attention yet,” he continued. “We expect it to move out of the Senate Ways and Means Committee to the floor of the Senate, and then we expect it to go before the House.”

Dr. Casey told Primary Care Optometry News that, in the meantime, the society has worked on building support among the department of education, the School Nurse Society and the department of public health. “We’re also trying to raise awareness of vision and learning, and we have been working with managed care entities in promoting eye care for children,” he said. Ophthalmologists and pediatricians have testified against the bill. “We’re trying to keep the bill to eye care specialists to provide eye care for kids — ophthalmologists or optometrists — and let pediatricians do what they do best: take care of general health issues. We’re trying to preserve the integrity of the comprehensive exam vs. a screening.”

Ophthalmology supports screening

In late January, the American Academy of Ophthalmology (AAO) released a statement in conjunction with the American Association for Pediatric Ophthalmology and Strabismus calling for increased preschool vision screening. According to the AAO, the American Academy of Pediatrics and the American Academy of Family Physicians support this policy, which recommends “screening for potentially vision-threatening conditions at specific times in a child’s life, including shortly after birth, between 6 months and 1 year, between ages 3 and 3½ and routinely during school checks.”

The statement continues: “While most children have healthy vision, the few [who] show signs of serious problems should be referred to an Eye M.D. (ophthalmologist) for further evaluation. The policy recommends that screeners inform parents and primary care providers of any problems to ensure those children get the right follow-up care.”

Michael Redmond, MD, AAO president-elect, is quoted in the statement: “I’d love to have every child come into my office for a full exam, but it just isn’t practical. The boost to my business would be great, but the ultimate cost to the health care system would be enormous. Providing screening on a wide scale would provide the most cost-effective benefit.”

APHA urges exams

Last year, the American Public Health Association (APHA) endorsed a policy resolution that urges comprehensive eye exams for all children. In the resolution, the APHA officially “encourages a regular comprehensive eye examination schedule as opposed to just screening … so that all children have exams performed at approximately age 6 months, 2 years and 4 years.”

The resolution noted, “Pediatric screening when performed is usually limited to a light reflex test, which will not detect most strabismus, hyperopia or anisometropia.” The resolution also referred to statements issued previously by the American Academy of Pediatrics (1996), the American Academy of Ophthalmology (1997), the American Association for Pediatric Ophthalmology and Strabismus (1991), the American Optometric Association (1994), the U.S. Public Health Service (1996) and Prevent Blindness America (1990) that agreed that “screening under age 3 is not successful, but there is ample evidence that amblyogenic conditions should be detected and treated as early as possible.”

Look for more coverage on children’s vision initiatives in the second part of this two-part series by clicking here.

For Your Information:

• The American Optometric Association can be reached at 243 N. Lindbergh Blvd., St. Louis, MO 63141; (800) 365-2219; fax: (314) 991-4101; Web site: www.aoanet.org.
• 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.
• Richard Cornett, can be reached at the Ohio Optometric Association, P.O. Box 6036, Worthington, OH 43085; (614) 781-0708; fax: (614) 781-6521.
• Karen S. Aldridge, OD, can be reached at 302 N. Pomeroy Ave., Hill City, KS 67642; (785) 421-3406; fax: (785) 421-5547.
• Claire H. Holley can be reached at the South Carolina Optometric Association, 2730 Devine St., Columbia, SC 29205; (803) 799-6721; fax: (803) 799-2305.
• Gary Odom, can be reached at the Tennessee Optometric Association, 2727 Branford Ave., Nashville, TN 37204; (615) 269-9092; fax: (615) 269-5986.
• Peter Theo can be reached at the Wisconsin Optometric Association, 5721 Odana Rd., Madison, WI 53719-1288; (608) 274-4322; fax: (608) 274-8646; e-mail: woapco@chorus.net.
• Andrea Thau, OD, can be reached at 77 Park Ave., New York, NY 10016; (212) 685-2457; fax: (212) 685-5989.
• Neil Casey, OD, can be reached at 67 W. Boylston St., West Boylston, MA 01583; (508) 835-3244; fax: (508) 835-6200.
• The American Academy of Ophthalmology can be reached at 655 Beach St., San Francisco, CA 94109; (415) 561-8500; fax: (415) 561-8533; Web site: www.aao.org.
• The American Public Health Association can be reached at 800 I St. NW, Washington, DC 20001-3710; (202) 777-APHA; fax: (202) 777-2534; e-mail: comments@apha.org; Web site: www.apha.org.