In-school eye exams identify refractive error, other vision problems
Eye examinations that evaluate children’s various vision problems, including refractive error, was feasible in a school setting, according to findings published in the Canadian Ophthalmological Society journal.
“The Baltimore Reading and Eye Disease Study (BREDS) was conducted to determine the prevalence of refractive error and other vision problems in early school-age children in high-poverty elementary schools, to identify associations between reading performance and refractive error and to investigate the impact of school-based vision interventions,” Megan E. Collins, MD, ophthalmologist at Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, and colleagues wrote. “A secondary objective was to quantify the number of children examined who would have failed a state of Maryland vision screening and explore the feasibility of conducting comprehensive school-based vision examinations in early elementary school grades.”
In a prospective, school-based cohort study, Collins and colleagues analyzed data from 321 youths in second and third grades (aged 7.9 years; 57.9% girls; 84.4% African American; 4.7% Caucasian; 9% Hispanic). The participants came from 12 different Baltimore public schools during the 2014 to 2015 school year.
The children underwent baseline eye examinations, including near- and distance-presenting visual acuity (VA), stereopsis, ocular alignment, dilated retinal examination and cycloplegic refraction to evaluate the feasibility of eye examinations in the school setting.
Of the students examined, 33.6% wore glasses previously, and 6.9% wore glasses at baseline.
The exams revealed that the mean presenting distance and near VA was 0.1 ± 0.2 logMAR (range –0.1 to 1.5) and 0.1 ± 0.2 logMAR (range 0-1.6) in the better-seeing eye. Similarly, the most common ocular findings were +1.00 D or greater hyperopia (34.7%), –0.50 D or greater myopia (29.5%), 1.00 D or greater astigmatism (23.4%) and convergence insufficiency (7.2%).
After the exams, 210 of 307 (68.4%) students received a prescription for glasses, and 37 (11.5%) students received a referral to a pediatric eye provider for further evaluation.
Overall, refractive error was the most common vision problem identified in BREDS.
“In general, participants had good distance and near acuities. However, approximately one in four students would have failed the Maryland vision screening based on reduced acuity alone,” Collins and colleagues wrote. “We were able to successfully complete comprehensive school-based eye examinations in over 95% of the study population, with provision of glasses when needed, supporting the feasibility of this approach for routine refractive needs.”
Perspective
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This study demonstrates that comprehensive school-based vision examinations in early elementary school grades are feasible, but with limitations. Only one-third of eligible students returned signed consent for participation. However, comprehensive examinations were successfully completed in over 95% of those students who did consent. The feasibility of comprehensive exams in schools is significant to practitioners given the limited scope of screenings, students lost to follow-up after screenings, and potential educational benefits of refractive correction and remediation of binocular dysfunctions.
This study used liberal prescribing guidelines as BREDS investigated the impact of mild refractive correction on reading ability. With these guidelines, glasses were prescribed for 68.4% of participants, mostly for low hyperopia. 22.7% of children in the study had 20/40 or worse VA in at least one eye and would have failed mandated VA screening in Maryland. This significant difference between the number of students who would have failed a typical acuity screening compared to the number who were prescribed glasses following these comprehensive eye exams may be interpreted as a result of the liberal prescribing criteria used or representative of the benefits of a comprehensive exam over acuity screening in a school setting. This depends on your clinical pediatric prescribing philosophy.
Prevalence of constant strabismus (3.8%) and convergence insufficiency (7.2%) were similar to frequencies reported elsewhere; however, no cases of accommodative insufficiency were identified in this cohort. This is unusual for this age group when considering previously reported prevalence rates for accommodative insufficiency. This may be due to a difference in clinical diagnostic criteria compared to study diagnostic criteria.
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