Efforts to improve children’s eye care move in a more definitive direction

The children’s vision initiative has moved into 2004 stronger than ever, tackling the issue on legislative, educational and outreach levels. While several studies have confirmed the importance of comprehensive eye exams to children’s educational development, legislation has been introduced on both the state and national level.

One of the most pivotal recent developments has been the introduction of legislation in New York that would require comprehensive eye exams for all children entering the state’s public schools.

“It is a very good bill. It is multisponsored, and I have been very encouraged by the response it has gotten,” said Alden N. Haffner, OD, PhD, president of the State College of Optometry, State University of New York, in an interview with Primary Care Optometry News. “We have a lot of hope that the legislation will be passed.”

Bill would require exams in New York

The New York bill would require children entering kindergarten in the state’s public school system to have a comprehensive eye exam as a condition of enrollment.

Introduced by Sen. Charles J. Fuschillo (R-8) and Assemblyman Steven Sanders (D-63), Senate Bill 5374-A states that “every child enrolling in kindergarten or first grade in a public elementary school in this state is required to present a health certificate signed by a duly licensed and qualified ophthalmologist or optometrist authorized to practice in this state. The certificate must contain a report of a comprehensive eye examination performed within 12 months prior to the date such child enters kindergarten or first grade.”

The legislation goes on to distinguish a comprehensive eye exam from a screening, defining it as “a complete and thorough examination of the eye and human vision system that includes, but is not limited to, an evaluation, determination or diagnosis of (a) visual acuity at various distances; (b) alignment and ocular motility, including eye tracking; (c) binocular fusion abnormality; (d) actual refractive error, including verification by subjective means; (e) any color vision abnormality or deficiency; (f) intraocular pressure as may be medically appropriate; and (g) ocular health, including internal and external assessment.”

“The bill spells out in some detail what a comprehensive vision exam is, that it is not just a cursory look or a screening,” Dr. Haffner said. “If screenings had worked over the years – and we have certainly had 50 years of experience with them – we would say, ‘let’s strengthen the screenings.’ But the fact of the matter is, screenings don’t work.”

Dr. Haffner said the legislation is designed to require exams for children as they first enter school, which may be in kindergarten or first grade.

“We regard that as a natural catchment area, because all kids go to school, and while we recommend that children be examined earlier, there is no mechanism to which to tie the requirement prior to starting school,” he said.

Potential costs

Dr. Haffner addressed one potential concern: that of the cost of a comprehensive eye exam to parents.

“In New York State, we have Medicaid for poor children, we have Child Health Plus, which covers eye exams, we have Medicaid managed care and we have Family Health Plus,” he said. “Most insurance carriers cover eye examinations, including dependents. So we feel this area is largely covered.”

However, the bill addresses the issue of insurance coverage for children from modest-income families, Dr. Haffner said.

“There is a section of the bill that says: the department [of education] shall, in conjunction with the Department of Health, compile and maintain the list of health care providers to which children who need eye examinations may be referred for treatment on a free or reduced-cost basis,” Dr. Haffner said. “We tried to cover everything, and we think we did. I think it’s very good public policy.”

Dr. Haffner said the bill has received a great deal of support, including that of the United Parents’ Association, a New York City-based umbrella group representing all 73 New York school districts.

“They endorsed it unanimously,” he said. “In fact, when Dr. Clemens [Rosemary Clemens, PhD, executive director, New York Children’s Vision Coalition, New York] and I presented to the UPA, one parent after another got up to talk about his or her experiences in school and asked why this wasn’t done years ago.”

Dr. Haffner said the need for comprehensive eye exams for children starting school could not be more obvious. “There are two major sensory modalities in learning. One is vision, and the other is hearing,” he said. “I have no doubt that once this bill passes, a requirement for hearing examinations will soon follow. This will once and for all regularize what should have been done many years ago.”

Federal legislation introduced

The issue of children’s vision is being addressed on a federal level through the introduction of a bill that would provide resources to promote education and diagnosis in the individual states.

HR 2173 was introduced in Congress by Rep. Bill Pascrell (D-N.J.) in May 2003. The legislation would not mandate eye examinations for children, but would provide states and local governments with funding to promote comprehensive eye exams.

The bill would fund education for parents, improve follow-up for children whose screenings failed to detect vision problems and help needy families afford full eye exams. The decision of how to use this funding is up to the local communities.

According to Joseph LaMountain of Vision Council of America, the bill has been steadily gaining momentum and support since its introduction.

“Approximately 80 representatives of Congress have agreed to cosponsor the bill,” Mr. LaMountain told Primary Care Optometry News. “A bill that is nearly identical that was introduced with the support of the American Academy of Ophthalmology has eight cosponsors. So there is a lot of hope that this bill will become law.”

Mr. LaMountain said VCA would like to see the legislation passed next year, if not this year. “It is an election year, so that makes it more difficult,” he said. “But we are coming back in the next Congress, and we are going to be working to do the exact same thing. Our hope is that we can find some common ground with the American Academy of Ophthalmology — and I think we can — to address the very real problems with the screening system.”

Task force in N. Carolina

In North Carolina, a task force has been formed to study the current needs of children who are covered by the state’s Medicaid program, according to Cathy Doty, OD, a practitioner in New Bern, N.C.

“This is the charge of the committee: to examine the current vision screening methods for children who are covered by Medicaid,” Dr. Doty told Primary Care Optometry News. “If inadequate, we are to make recommendations for improving vision coverage for these children.”

Dr. Doty was integral in forming this task force, along with North Carolina Rep. Michael Gorman (R-Craven). The committee is chaired by Chuck Wilson, MD, a pediatrician in Greenville, N.C., and comprises ODs, pediatric ophthalmologists, family practitioners, other pediatricians and the executive director of Prevent Blindness, N.C. (PBNC).

Dr. Doty said the task force has met twice in Raleigh, N.C.

“I have certainly recommended that the current vision screenings in North Carolina are sorely inadequate for our children, and that all children should have a comprehensive eye examination prior to starting kindergarten,” Dr. Doty said. “Resistance to this idea is primarily surfacing from PBNC and the pediatric ophthalmologists, even though research from their own organizations prove that vision screenings miss many children.”

Illinois PTA adopts resolution

At the 2004 convention of the Illinois Parent Teacher Association (PTA), a resolution was adopted titled, “Required Vision Examination Before Entering Kindergarten.”

The resolution gained the support of the state Illinois PTA by resolving to “support legislation to require a comprehensive eye and vision examination, by an optometrist or ophthalmologist, for all children entering kindergarten (or first grade) as a necessary prerequisite to academic learning.”

The resolution was the result of the efforts of Janet V. Hughes, a Chicago-area parent and PTA member. Mrs. Hughes has been an outspoken advocate for children’s vision examinations since her daughter’s visual problems went undetected in a screening in 2002.

The resolution also resolves that the Illinois PTA will “provide information to educate members, parents, teachers administrators and the public at large about children’s vision and the critical importance of comprehensive eye and vision examinations for all children during their school-aged years.”

“I am going to work with the PTA to get information out there and provide education,” Mrs. Hughes told Primary Care Optometry News. “It’s going to be a great vehicle to educate others and a huge lobbying force in the Illinois legislature. The resolution will also be presented at the National PTA Convention in 2005.”

Other legislation

In Florida, two pieces of children’s vision have been introduced, according to Kenneth L. Franklin, executive director of the Florida Optometric Association. HB 907/SB 2330 would mandate eye examinations for every baby born in the state prior to leaving the hospital. The required eye exams would include the use of an ophthalmoscope and pupil dilation for detecting pediatric ocular abnormalities.

In addition, the bill would call for child supervision services, including an eye examination at birth, at 6 to 8 weeks of age and at 6 to 9 months of age.

According to Mr. Franklin, the bill is currently stalled in the legislature. He said HB 907 has not been heard in any committees, and therefore is not moving. The companion bill SB 2330 has passed favorably through Senate Health, Aging & Long Term Care and on April 14 was referred to the Senate Appropriations Subcommittee on Health & Human Services.

“It is likely that this bill may not be scheduled for a subcommittee hearing and, therefore, ‘die on the committee calendar,’” he said. “Absent some act by the Senate leadership and immediate action by the House Speaker to move the bill, it is my opinion that SB 2330 is questionable as to possible passage this session.”

A second bill, HB 47/SB 1844, seeks to add vision examinations to the requirements for a child entering school. In addition, the bill would require that each child entering kindergarten present a certification of a school-entry comprehensive vision examination by an optometrist or ophthalmologist, performed within 1 year prior to enrollment in school.

Mr. Franklin said at this time, HB 47 was referred to committees in November 2003 and has not been heard by any committee to date. He said the companion SB 1844 was heard in the Senate Health, Aging & Long Term Care committee in March 2004 and was “temporarily passed,” or laid on the table.

“With the SB 1844 act, and non-movement of the HB 47, it is my opinion that no legislation will pass to address the origin of these two bills this session,” Mr. Franklin told Primary Care Optometry News.

Children’s vision legislation is also pending in Nebraska. Carried over from 2003, LB 174 would require that all children entering school show proof of having had a visual examination by a physician or optometrist within 6 months prior to beginning school.

The bill’s definition of a visual evaluation includes testing for amblyopia, strabismus and internal and external eye health, with testing sufficient to determine visual acuity.

According to Daphne Petersen, CSW, executive assistant for the Nebraska Optometric Association, this definition was amended as offered by the Nebraska Medical Association.

According to Ms. Petersen, despite being named a speaker priority bill and being accepted by the medical association, LB 174 was not scheduled for debate by the full legislature, as a result of an overcrowded agenda. “With budget issues crowding the agenda, they simply didn’t have time for it,” she told Primary Care Optometry News. “The session has concluded, which will require reintroducing the bill in January 2005.”

Study: MDs failing to refer to eye doctors

The children’s vision initiative is also making strides through several recent studies that present findings confirming the importance of comprehensive eye exams.

A study published in Vol. 14, Issue 5 of the Journal of Behavioral Optometry looked at kindergarten-age children in Kentucky, which currently mandates eye exams. The study also examined the medical history of children who have been diagnosed with a vision problem by an eye doctor.

Nearly 1 in 7 of the children who received an eye exam were found to have a vision problem needing correction, including amblyopia. This confirms the findings of an earlier study on the success of Kentucky’s law.

A more disturbing aspect of the study found that 80% of children with a vision problem had visited a primary care physician in the past year. Despite this fact, fewer than 20% had been told to visit the eye doctor.

“Children in Kentucky are required to receive a preschool physical before entering school,” said Joel Zaba, OD, coauthor of the study, in a press release, “so one can only assume that many of these vision problems were missed during a vision screening or that no screening was performed during the child’s visit.”

VCA commissions study

Mr. LaMountain said Vision Council of America is very hopeful about an upcoming study the organization has commissioned.

The study, which is designed to look at the cost effectiveness of eye exams and vision screening, will be conducted by Abt Associates, a business and government development firm that specializes in health and economic modeling and forecasting, Mr. LaMountain said.

“Opponents of eye exams like to cite the fact that eye exams are more expensive and that, therefore, screenings are cost effective,” he said. “That is not a sound argument. Using that logic, the most effective intervention would be none at all.”

Mr. LaMountain said that although it is acknowledged that comprehensive eye exams do cost more than screenings, the study is intended to determine whether the long-term benefits justify the additional costs. “We want to see if those up-front additional costs are recouped in outlying years through faster diagnosis and better treatment,” he said. “Obviously, if a child is treated sooner, he or she is less likely to have any kind of significant vision loss.”

Mr. LaMountain said VCA is optimistic about the potential implications of this study. “We are trying to pull together a group of leaders in the field to help us explore this issue,” he said. “My feeling is, if this study comes back the way we think it will, this could be a very important document that helps clarify the issues for policy makers.”

Seven out of 10 kids miss eye exams

A national survey conducted by VSP in Sacramento has found that nearly seven out of 10 patients with children younger than 6 years have never taken their children in for an eye examination. In addition, only 30% of the children who had been checked were seen by an eye care specialist.

The results of this study were based on an online survey of 1,277 parents, representing 1,846 children younger than 6, with an error of ±3%.

“Uncorrected vision problems are a treatable medical issue facing our children today,” stated Catherine Amos, OD, former chairman of the board of Vision Service Plan, in a VSP press release. “We know that numerous learning and, ultimately, societal problems stem from poor vision, yet too many children are beginning school without undergoing a complete and professional medical exam.”

The study further found that among the third of the children who received an exam, only 62% were reported to have had their first check-up by the age of 3, while nearly 80% of this group had been to the dentist.

“It is alarming that more parents have taken their kids for a dental exam than for an eye exam by the age of 6, especially when you consider the types of eye conditions that can lead to permanent problems if not detected early,” Dr. Amos added.

Washington: education for school nurses

In Washington State, the Optometric Physicians of Washington (OPW) have initiated a Nurse Outreach Program, which helps forward the cause of children’s vision by working with school nurses.

The effort is designed to educate school nurses regarding the proper screening procedures, according to an article in the Nov. 17, 2003, issue of the AOA News. Because school nurses spend a great deal of time with children and often perform vision screenings, it is essential that they are informed in this area.

To this end, the OPW sends its bi-annual “in-sight” newsletter to 125 school nurses as well as most school principals throughout the state. Topics in the most recent issue included “Children’s undetected vision problems gaining national attention: what it means for Washington State,” “Can school vision screenings be effective?” and “We can help students succeed.”

In addition, members of the OPW have held two workshops for school nurses in eastern Washington. A recent workshop was attended by 36 school nurses who were taught skills such as how to use the plus/minus flipper and stereopsis test.

Football, baseball teams join the effort

Another effort toward providing comprehensive vision exams to children involved the San Francisco 49ers teaming up with Vision Service Plan to provide testing to area youth. According to a VSP press release, in February, the 49ers made an appearance at the Excelsior Boys and Girls Club in San Francisco as part of an initiative to provide testing for about 150 children.

The program was designed as the kickoff for the 49ers Play Focused vision screening program, which targeted low-income schools, neighborhoods and after-school programs. Doctors from the San Francisco Optometric Society provided testing for the event.

VSP stated in a press release that it is also working with other teams to promote the need for regular and comprehensive vision testing for children through its Get Focused program. Events involving the San Antonio Missions, Jacksonville Suns, Scranton Red Barons, Harrisburg Senators and Buffalo Bisons will take place throughout the summer.

VCA contacts schools directly

Another educational program presented through VCA’s “Check Yearly. See Clearly.” provided for the distribution of vision health kits to 40,000 elementary schools across the country in the month of February, according to a VCA press release.

The kit included a poster and “A Parent’s Guide to Healthy Vision” that can be photocopied and sent home with every student. The kits also included a letter from Better Vision Institute Chair Susan Taub, MD, as well as Cathy Thompson, a teacher whose child’s amblyopia was missed by her pediatrician.

“School nurses don’t need to order additional materials to participate in this campaign,” Mr. LaMountain said. “All they have to do is copy and distribute the ‘Parent’s Guide’ to students or hang the posters in their schools. Nevertheless, more than 500 schools contacted us for an additional 250,000 materials. The fact that so many took the additional step of ordering Check Yearly materials is a good sign.”

The school mailer is part of Check Yearly’s larger objective of educating consumers about the importance of regular vision care for the whole family.

For Your Information:

• Alden N. Haffner, OD, PhD, is president of the College of Optometry at SUNY. He can be reached at State College of Optometry, 33 West 42nd St., New York, NY 10036; (212) 780-5050; fax: (212) 780-4949.
• Joseph LaMountain is vice president, strategic communication for Vision Council of America. He can be reached at 1700 Diagonal Road, Ste. 500, Alexandria, VA 22314; (703) 548-4560; fax: (703) 548-4580; e-mail: jlamountain@visionsite.org.
• Cathy Doty, OD, practices in New Bern, N.C. She can be reached at 2805 Village Way, New Bern, NC 28563-7351; (252) 633-0016; fax: (252) 636-3895; e-mail: eyecare@cconnect.net.
• Janet V. Hughes is a former full-time teacher and currently a stay-at-home mom in the Chicago area. She can be reached by e-mail: anetJ221@comcast.net.
• Kenneth L. Franklin, is executive director of the Florida Optometric Association. He can be reached at PO Box 13429, Tallahassee, FL 32317; (850) 877-4697; fax: (850) 878-0933; e-mail: Ken@floridaeyes.org; Web site: www.floridaeyes.org.
• Daphne Petersen, CSW, is executive assistant of the Nebraska Optometric Association. She can be reached at PO Box 81706; Lincoln, NE 68501-1706; (402) 474-7716; fax: (402) 476-6547.
• Joel Zaba, OD, is a practitioner in Virginia Beach, Va. He can be reached at Pembroke One, Ste. 105, 281 Independence Blvd., Virginia Beach, VA 23462; (757) 497-9575; (757) 497-1292.
• Catherine Amos, OD, is the former chairman of the board of Vision Service Plan. She can be reached at 2100 Data Park Dr., Birmingham, AL 35244; (205) 982-5000; fax: (205) 982-5920; e-mail: camos@webeca.com.

• Vision Council of America can be reached at (703) 548-4560; www.visionsite.org

• Vision Service Plan can be reached at (800) 852-7600, ext. 7412; www.getfocusedamerica.org or www.vsp.com.