Experts advocate vision screening guidelines for preschool children

Several reports on vision care in preschoolers outlined recommendations on how best to perform vision screening in children with the goal of increasing the screening rate in those younger than 5 years to 40%.

Three papers outlining recommended approaches to establish a public health system supporting vision and eye health in preschool-age children were published in Optometry and Vision Science in January. They were authored by the National Expert Panel to the National Center for Children’s Vision and Eye Health at Prevent Blindness and funded by the HHS Maternal and Child Health Bureau of the Health Resources and Services Administration.

The three articles outline evidence-based vision screening practices for the target age group, as well as recommendations for children who should bypass any screening and be referred directly to an eye care professional. The papers also outline approaches to integrated health information systems that can include vision data and performance measures that will enhance vision program accountability at the local, state and national level. The authors emphasize that professionals involved at different levels of eye care need to take leadership roles in the creation and implementation of this system.

Hugh R. Parry, president and chief executive officer of Prevent Blindness, the host organization for the National Center for Children’s Vision and Eye Health, highlighted the importance of the group’s work.

“The recent designation of eye exams for children as an essential health benefit is a huge step forward, but there remain millions of children who simply are not receiving care,” he told Primary Care Optometry News. “These recommendations for enhancing a public health system for children’s eye care will go a long way toward addressing this continued unmet need.”

The panels involved in the recently published articles reviewed the literature that had been published through February 2014 to determine the evidence base underlying preschool vision screening. Their recommendations, along with related resources and screening information, have been made available online by Prevent Blindness (http://visionsystems.preventblindness.org), which recently hosted a webinar where the panel members discussed the recommendations.

Susan A. Cotter, OD, MS, FAAO, a professor at the Southern California College of Optometry at Marshall B. Ketchum University, began the webinar by establishing the need for her and her colleagues’ work.

“There was little consistency and lots of confusion regarding preschool-aged vision screening,” she said. “We were tasked with developing evidence-based guidelines to provide recommendations regarding the screening tests that would deliver the most bang for the buck in identifying amblyopia, strabismus and significant refractive error in these children.”

Cotter and colleagues wrote: “Whereas vision screening is typically easier in school-aged children 6 years and older, evidence suggests that the success of amblyopia treatment is influenced by a child’s age, with children younger than 7 years old being more responsive to amblyopia treatment. The recent U.S. Preventive Services Task Force report concluded that there is adequate evidence that early treatment of amblyopia results in improved visual outcomes. In addition, optical correction of significant refractive error may be related to normal development and may improve school readiness.”

To develop sound recommendations, Cotter said during the webinar that she and her fellow panel members established the level of evidence necessary to qualify for inclusion.

“We defined best practice tests as those having sufficient evidence from scientifically rigorous studies to support their use by lay screeners and nurses in educational, community, public health or primary health care settings in identifying amblyopia, strabismus and significant refractive error in preschool children,” she said.

Practices for quantitative vision screenings

Cotter explained that there are two current best practice approaches to screening children between 36 and 72 months old – instrument-based testing and monocular visual acuity testing.

Best practice instrument-based testing utilizes the Retinomax autorefractor or the SureSight Vision Screener (version 2.24 or 2.25 in minus cylinder form with the Vision in Preschoolers referral criteria) to identify significant refractive error, Cotter said.

“There are high quality performance data in the targeted age range and appropriate FDA designation,” she stated.

Acceptable practice includes the Plusoptix Photoscreener and the Spot VS 100, which determines if a child passes or fails the screening based on an estimate of refractive error.

“Best practice monocular visual acuity testing uses single surrounded HOTV letters or LEA symbols at a distance of 5 feet while using a matching card,” Cotter said. “Occlusion should be done with an adhesive patch or 2-inch wide surgical tape. There should be good illumination and no glare.”

Cotter also noted that best practice kits are available for purchase.

Comparably, acceptable practices would consist of a single line of optotypes with a crowding rectangle, using a 10-foot distance or the use of specially constructed occluder glasses, Cotter noted.

She also explained what should not be done.

“Screeners should not use a full chart for visual acuity testing, which is very difficult for preschool kids,” she said. “Even using a single line within a chart is problematic. It’s not good for vision screening preschool children. Screeners should also not attempt occlusion of one eye by using the child’s hand, an occluder, a paper cup or a pirate patch – it’s too easy for children to peek.”

In her presentation, Cotter recognized that there are some obstacles in screening children, but that should not preclude them from being screened.

“Children who are inattentive, uncooperative, who won’t allow occlusion or don’t understand are twice as likely to have a vision problem,” she said. “They should be rescreened the same day, if possible. The alternate best practice test can be attempted if available – sometimes kids can do one test, but not the other. If rescreening is not practical that day, it should be done as soon as possible, but definitely within 6 months.”

She continued: “Untestable kids who have cognitive, physical or behavioral issues likely to preclude a successful screening; those who can’t be rescreened; those not likely to return for rescreening; and those who fail should be referred directly to an eye care professional for a comprehensive eye examination.”

Cotter clarified the particular elements that comprise high-quality vision screening.

“The key components of a comprehensive visual screening system are certified screeners using best practice methods; the results should be reported to parents and the child’s medical home, school or state agency if needed; and all fails should be referred to an optometrist or ophthalmologist,” Cotter reiterated.

Additionally, Cotter and colleagues detailed more specific recommendations in their discussion.

“Vision screening requires training and certification of screening personnel, acquiring sufficient and appropriate space, and obtaining and maintaining equipment and supplies,” they said.

Building a data system

E. Eugenie Hartmann, PhD, a professor at the University of Alabama at Birmingham School of Optometry, along with her colleagues, proposed details on developing an integrated data system.

In her presentation, Hartmann referenced Healthy People 2020, a national health initiative comprising various agencies aimed at improving the health of Americans.

“As part of Healthy People 2020, we’re looking to increase vision screening for children less than 5 years old up to 40%,” she said. “The estimates from ages 3 to 5 range from 2% up to 60%, but, realistically, are probably around 10%.

“Screening alone is not enough – there is a need for follow-up and monitoring,” she continued. “Vision changes constantly. Currently, there is no uniform approach to data collection or data reporting.”

Hartmann also said that the collected data must be stored with additional health information to provide a comprehensive look at each child.

“It’s vital to link vision screening with other health care information and follow-up eye care,” Hartmann explained. “When we can track an individual child, we’ll be able to evaluate how well we’re doing. The demographic data per child is essential. We can link the information to the individual child and minimize duplication and omission.”

Hartmann said that the CDC has established a uniform approach to collection of demographic information, which should be used as the system is established or updated.

“During the vision screening process, the following should be recorded: unique identifiers, date of screening, site of screening, specific location of screening, zip code of location, job title of screening, the provider’s ID code, visual acuity test used, testing distance, stereopsis and the device used in instrument-based photoscreening,” she said.

In alignment with Cotter’s report, Hartmann and colleagues noted that children who are not screened should have the reason why they are not screened recorded in the database as well.

Hartmann explained the specifics of how the integrated vision care data system would operate.

Hartman and colleagues recommended: “User-friendly data entry that can be accomplished through online Web-based entry or uploading of a digital file that was generated off-line at the time of vision screening.”

“It has to be user-friendly and secure,” Hartmann said in her presentation. “It has to be in accordance with both HIPAA [Health Insurance Portability and Accountability Act] and FERPA [Family Educational Rights and Privacy Act] and evaluated regularly. Electronic information is the best way to obtain and maintain information throughout the process.”

She continued: “The information would be useful on three levels – personally, for a health care provider and for the entire population. It would allow for the evaluation of health care disparities throughout the country.”

Hartmann and her colleagues provided more insight regarding the benefits of an integrated data system along with their recommendations.

“A standardized data collection, reporting format and tracking mechanism will enable better monitoring of follow-up eye care for all children who are referred after a vision screening,” they concluded. “Furthermore, this will enhance communication between providers and allow for population-level surveillance of children’s vision health.

“Involvement of ophthalmologists and optometrists in the development of integrated data systems is essential to ensure that appropriate data elements are included and that data entry requirements are concise, practical and useful for vision care and surveillance,” they said. “Optometrists and ophthalmologists are encouraged not only to participate but also take on leadership roles in this realm.”

Proposed performance measures

Wendy L. Marsh-Tootle, OD, MS, FAAO, an associate professor at the University of Alabama at Birmingham School of Optometry, spoke of her report recommending how to standardize progress measurements.

“The purpose of the data definitions was to allow precise quantification of the proportion of children in the population who complete the relevant steps in the continuum of vision care,” she said during the webinar. “Screening is a relevant first step for ‘apparently normal’ children, and eye examination is a relevant first step for some children.”

Marsh-Tootle noted that there is no system currently in place that provides accurate national or state estimates of children who completed an eye examination or a vision screening.

“Current high-quality studies show a large variation in the proportion of children receiving vision screening – anywhere from 2% to 64%,” she said. “Precise and standard definitions of the data and performance measures are therefore necessary.

“We have to agree on how we’re going to gather the data and performance measures, so everyone’s on the same page and we’re not comparing apples to oranges,” she added.

Marsh-Tootle and colleagues developed definitions for numerator and denominator measurements that would allow for better estimations of the proportion of children who receive a vision screening or eye examination between the ages of 36 and 72 months old.

Additionally, they proposed differing performance measures for children with neurodevelopmental disorders or those who received glasses or had a follow-up appointment with an optometrist or ophthalmologist as well as children who received follow-up care.

“Increasing requirements for quality and accountability at national, state, local and provider levels are driving the development of vision care performance measures,” the authors stated. “Monitoring the vision care system for preschool-aged children requires regular reporting of measures of vision screening, eye examinations and treatment.”

They concluded: “These expert panel recommendations represent the first step toward creating a comprehensive data collection and reporting system. Eye care professionals including optometrists and ophthalmologists should be in leadership positions, driving their evolution and implementation.”

Where do ODs, MDs stand?

Organized optometry and ophthalmology, which have had differing views on the role of comprehensive examinations and screenings in young children, expressed their opinions on the new guidelines.

“Given the low sensitivity of even the best screening, which consists of multiple modalities administered by doctors, selecting a single test and designating it as ‘best’ is misleading at best,” David A. Cockrell, OD, president of the American Optometric Association, told Primary Care Optometry News. “Screening fails to detect many problems, and even for those potential problems it detects it does not diagnose or treat the problem.”

Cockrell said studies show that many children who fail screenings never receive the necessary care.

“With the designation of the pediatric vision essential health benefit, a comprehensive examination, which can both diagnose and initiate treatment, is now accessible and available to America’s children through age 18,” he continued. “Why rely on an antiquated method with many false negatives that leaves a family with a false sense of security or with a positive result that requires that the parent seek further care when a comprehensive eye examination can ensure that every child has the opportunity to reach their visual potential and maximize their academic, athletic and professional success?

“As an optometrist and a parent, I believe our children deserve more than a screening just for amblyopia,” Cockrell continued, “especially being aware of the many vision disorders and subtle pathologies that exist and knowing screenings aren’t attempting to identify those problems. Furthermore, as a parent, I’m not willing to accept the risk that amblyopia has a 40% or higher chance of being missed by the most sensitive screening. The AOA will continue to advocate for a comprehensive eye exam for our children at the state and national levels.”

Michael X. Repka, MD, the American Academy of Ophthalmology’s medical director of governmental affairs, stated that the new recommendations to screen children at least once between 3 and 5 years of age with the recommended techniques are in agreement with the AAO’s guidance.

“Screening is an important part of health care,” he said. “Following these recommendations will improve the quality of the evaluations as well as provide metrics on which to assess how well the screening is being performed, both in the medical home and in the community.” – by Chelsea Frajerman