Optometrists must advocate for comprehensive eye exams for all children
This private practitioner and AOA president explains how vision screenings are allowing kids to 'slip through the cracks.'
A child comes to my office for their first eye examination, not as part of their health routine but because the child has been having issues at school and their grades are suffering. After the parents tried everything, their last-ditch attempt at seeking advice results in a recommendation for a comprehensive eye examination.
When the child and parents leave the office with a new prescription for clear vision, it is an emotional moment for everyone. There is so much joy coupled with guilt on the parents’ behalf (this could have been solved years ago), while as a doctor, the thrill of helping a patient is overshadowed by the frustration that so many do not understand the importance of regular comprehensive eye exams for children. Screenings are allowing children to slip through the cracks.
Most of us have too many stories like this. The sad state of affairs is that, today, correcting vision impairment is the clearest chance to improve eye and vision health. However, according to the National Academies of Sciences, Engineering and Medicine report, Making Eye Health a Population Health Imperative: Vision for Tomorrow, up to 16 million Americans live with uncorrected refractive error. The majority of parents (60%) do not feel that an eye examination is an essential part of a child’s healthy check-up schedule (Think About Your Eyes). This is true despite the fact that the Affordable Care Act’s essential health benefit includes annual eye exams from birth through age 19, and the research on which the American Optometric Association’s Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination was based recommends a comprehensive eye exam for children.
Shockingly, only 7% of children have had an eye exam by an eye doctor preceding the start of first grade.
The lack of public awareness about the inadequacies of screenings and the false sense of security they engender among parents and the health community is not simply frustrating, it is damaging. Unfortunately, instead of ensuring that patients and legislators understand how critical eye examinations are, in an effort to find a middle ground, some advocate for allocating precious health care resource dollars for substandard care.
School screenings miss most vision disorders for many reasons, including a reliance on assessment of distance vision with eye charts and little or no consideration of near vision or the ability of a child to use his or her eyes together. Vision screening procedures lack the evidence needed, with proven high sensitivity and specificity, for identifying the targeted vision problems present in the population of children being screened.
One study assessed the sensitivity of a wide variety of screening techniques that, unlike most screenings, used licensed eye doctors who had completed specific training and certification. The study, used as supportive evidence in the AOA’s clinical practice guideline, evaluated the sensitivity of 11 vision screening techniques used for detecting clinically significant vision problems in children 3 to 5 years of age and determined a variance from 16% to 64%, with specificities ranging from 62% to 98% (Schmidt et al.). The tests were compared again, resulting in a specificity of 94%, and the sensitivity dropped further (Ying et al.). Even when using trained examiners, these vision screening techniques were unable to provide high levels of both sensitivity and specificity for detecting many vision problems in children.
Most vision disorders are also asymptomatic, leaving many students unaware they are impaired, especially considering that they have no frame of reference as to how others may be processing visual information. Until the issue is diagnosed and treated, they don’t know what they can’t see. Coupled with the fact that school vision screenings only look for possible amblyopia and amblyopia risk factors and do not assess general vision performance related to learning or eye health, it is little wonder children are left behind when it comes to adequate vision and eye health.
Children continue to fall through the cracks at an alarming rate. When using Snellen visual acuity alone as a screening tool, one study indicated it missed more than 75% of children found to have binocular and oculomotor vision problems when given a complete visual examination (Lieberman et al.).
Of the children found to have vision problems through screenings, 61% do not receive follow-up care, according to Jacobsen.
To stem the tide, some providers erroneously advocate that photoscreening may be an effective alternative to increase access to care. However, the same fundamental flaws exist with this technology, as it fails to uncover vision-related learning problems. This, combined with the lack of skilled assessment of the complete eye and visual health, makes these types of tools adjunctive mechanisms for care, not replacements.
We cannot continue to perpetuate a discussion around lesser forms of care. Instead, doctors need to be constant advocates for and to their patients, promoting best practices for primary eye health care, including the critical role comprehensive eye examinations play in a child’s overall health and the drawbacks of screenings. To uphold those efforts, the AOA has developed resources, including a guide to help educate parents, position papers from the AOA Health Policy Institute on the population health risks associated with screenings and the recently updated clinical practice guideline.
When we all speak with a unified voice that underscores the vital role doctors of optometry play in promoting primary eye health and vision care for all patients, we can effect positive change for America’s children
- American Optometric Association. Evidence-based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination. https://www.aoa.org/optometrists/tools-and-resources/evidence-based-optometry/evidence-based-clinical-practice-guidlines/evidence-based-clinical-practice-guideline-comprehensive-pediatric-eye-and-vision-examination. Approved February 12, 2017. Accessed December 19, 2018.
- American Optometric Association. Evidence-based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination. Guideline Brief 2017. www.aoa.org/Documents/AOA%20Executive%20Summary%20Pediatric%20Eye%20Exam%20Guidelines%20Revised%2003.05.18.pdf. July 2017. Accessed December 20, 2018.
- American Optometric Association Health Policy Institute. Vision screening should be called amblyopia screening. www.aoa.org/documents/HPI/HPI%2006%20Sept%202017%20Amblyopia%20090717%20(002).pdf. September 6, 2017. Accessed December 20, 2018.
- CDC. 2002 National Health Interview Survey. MMWR. 2002;54(17):425-429.
- Jacobson J. Why can’t Johnny read? The Abell Report. 2010; 23(7):1-8. www.abell.org/sites/default/files/publications/arn910jn.pdf.
- Lieberman S, et al. Am J Optom Physiol Opt. 1985;62:165-168.
- Schmidt P, et al. Ophthalmology. 2004;doi:10.1016/j.ophtha.2004.01.022.
- Teutsch SM, for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health, The National Academies of Sciences, Engineering, and Medicine. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: National Academies Press; 2016. www.nationalacademies.org/hmd/Reports/2016/making-eye-health-a-population-health-imperative-visin-for-tomorrow.aspx.
- Think About Your Eyes. Children’s Eye Health. Thinkaboutyoureyes.com/articles/kids-vision/childrens-eye-health. Posted 2015. Accessed December 20, 2018.
- Ying GS, et al. Optom Vis Sci. 2005;82:432-438.
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- Samuel D. Pierce, OD, is in private practice in Trussville, Ala., and is president of the American Optometric Association.
Disclosure: Pierce reports no relevant financial disclosures.