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Vision screening for all kids, exams for those in need
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To the Editor:
While debate on mandating comprehensive eye exams for children is welcome, I find the January commentary on this topic by Dr. Pierce (“Optometrists must advocate for comprehensive eye exams for all children") to unfortunately mix truths with misleading or inaccurate statements.
Dr. Pierce starts well by describing a patient with a vision complaint in need of an eye exam. He makes a diagnosis and prescribes treatment that improves the child’s vision. We eye doctors, like our colleagues in all other medical specialties, have trained extensively to help such patients in need and are passionate about doing this well. Indeed, we know 5% to 10% of very young children and about 25% of school children need our services and benefit from them.
The question then becomes: What do we do with the 75% to 95% of children of different ages who already have clear vision and no eye problems? Why do they all need comprehensive exams too? Our exams are expensive for family budgets, public health insurers and tax payers. Appointments are often difficult to schedule for busy working families and/or far to drive to. About 60% of U.S. children are insured by Medicaid, yet many of us limit these children from our practices. There are about 4 million children born every year in the U.S., yet most eye doctors prefer to treat adults and are not equipped or have trained staffs to address the unique testing needs of young children. Thus, finding a good pediatric eye doctor or getting a timely appointment with one can often be difficult, even more so for families in rural or inner-city areas.
How on earth can pediatric eye doctors regularly examine the 72 million U.S. children younger than 18 years of age while also caring for the patients of all ages who absolutely need our attention? We eye doctors alone cannot be the sole providers of children’s eye care in this country. We need help!
Fortunately we have it. Pediatricians and other primary health care providers already see children regularly and have many opportunities over the years to ask about vision concerns, examine the eyes and check for alignment problems – and they do. They also perform screening tests to identify problems that are otherwise unnoticed by a child or their family. Pediatricians then send the children they have concerns with to us to have those issues addressed, as do school nurses, Head Start programs and other community groups that assess children. And if families or teachers still have concerns for children despite good pediatrician or nursing assessments, those children, too, should have full eye exams. But mandating that all children have us examine them when they enter school (or more frequently) is impractical and unnecessary at best and, for us, selfish at worst, in that we doctors are the ones whose income is enhanced by these mandates.
Dr. Pierce mischaracterizes screening as unimportant. On the contrary, regular, periodic screening throughout childhood, with referrals when needed for comprehensive exams, is sound public health policy for all children. And when children with no eye symptoms pass periodic screenings, their families can have confidence a full eye exam is unnecessary. Advancing technology is continually improving the ability to accurately and inexpensively screen the eyes of children and more clearly identify those with a concern. Current technology allows screeners to more easily find the children with hidden but significant refractive errors, poor binocular function from strabismus and other silent problems. Indeed, many large organizations devoted to children and their vision already support vision screening and are working with each other to make it better.
Such groups include the National Association of School Nurses, Prevent Blindness, the American Academy of Optometry, the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology and the American Association of Certified Orthoptists.
While it is true that effective screening practices need to be implemented more broadly, it is inaccurate to claim that when screenings are done, large numbers of children in need slip through the cracks. Remember, screenings are for healthy children who have no outward evidence of a problem. Screenings that include acuity testing identify most children with blurred vision. For children too young for acuity testing, high-tech screening devices identify kids with significant refractive errors, strabismus and even with unusual problems like childhood cataracts. This new technology is constantly improving and is increasingly being used throughout the country to help find the kids truly in need of an eye doctor.
What specific diagnoses does Dr. Pierce feel are being missed by screening? Perhaps convergence or accommodative insufficiency? I agree. Current screening techniques are not foolproof and do not detect these issues. But school children with problems like these will also have vision signs or symptoms that are not hidden and can be recognized. So, whenever noted, these children can be referred for comprehensive exams.
Yes, public awareness to identify eye problems in children can often be low and must improve. So, we eye doctors need to work in our communities and through our professional organizations to increase this awareness. We also need to work together and with other experts to improve valid screening techniques and promote them for all children who appear to have healthy eyes. We must unite and work to improve timely access to full exams for all children who fail screening or are at risk for eye problems. And we can all work to better our pediatric exam skills and treatment regimens so we can be of most service to the children and families who depend on us. That’s a lot to do! But if we work collaboratively toward these goals, our nation’s children and future work force will truly be the beneficiaries.
- References:
- American Academy of Optometry. Policy Statement on Childhood Vision Screening. www.aaopt.org/docs/section-documents/position-papers/2016_childhood-vision-screening-position-paper.pdf?sfvrsn=d6de992a_4. August 2016. Accessed February 17, 2019.
- American Association for Pediatric Ophthalmology and Strabismus. A Practical Guide for Primary Care Physicians: Instrument Based Vision Screening In Children. aapos.org/client_data/files/2016/1419_pcpguideinstrumentbasedvisionscreeninginchildrenrev062716noaaplogopdf.pdf. Accessed February 13, 2019.
- American Association for Pediatric Ophthalmology and Strabismus. AAPOS Techniques for Pediatric Vision Screening. aapos.org/client_data/files/2014/1075_aapostechniquesforpediatricvisionscreening.pdf. May 2014. Accessed February 13, 2019.
- Centers for Disease Control and Prevention. Improving the Nation’s Vision Health: A Coordinated Public Health Approach. 2007. https://www.cdc.gov/visionhealth/pdf/improving_nations_vision_health_508_final.pdf. Accessed February 17, 2019.
- Committee on Practice and Ambulatory Medicine, et al. Pediatrics. 2016;doi:10.1542/peds.2015-3596.
- DiLibero, J. Where we fall short in pediatric optometry. Review of Optometry. November 24, 2010.
- Donahue, SP. J AAPOS. 2004;doi:10.1016/S1091853104000965.
- Donahue SP, et al. Pediatrics. 2016;doi:10.1542/peds.2015-3597.
- Kemper AR, et al. J AAPOS. 2006;doi:10.1016/j.jaapos.2006.07.009.
- Lions Clubs International. Lions KidSight USA Foundation. lionskidsightusa.org. Accessed February 17, 2019.
- National Association of School Nurses. Vision and eye health. www.nasn.org/nasn-resources/practice-topics/vision-health. Accessed February 17, 2019.
- National Center for Children’s Vision and Eye Health: A Snapshot of Current National Issues. Prevent Blindness. nationalcenter.preventblindness.org/sites/default/files/national/documents/Childrens_Vision_Chartbook_F.pdf. February 2016. Accessed February 17, 2019.
- National Center on Early Childhood Health and Wellness. Vision Screening Fact Sheet. eclkc.ohs.acf.hhs.gov/sites/default/files/pdf/vision-screening-rev.pdf. Accessed February 17, 2019.
- Wallace DK, et al. Ophthalmology. 2018;doi.org/10.1016/j.ophtha.2017.09.032.
Geoff Bradford, MS, MD
Pediatric ophthalmologist, Morgantown, W.Va.
Chairman, American Academy of Pediatrics Section on Ophthalmology
Disclosure:Bradford reports no relevant financial disclosures.