Amblyopia is the leading cause of preventable vision loss in children.1,2 Successful treatment outcomes for the condition are dependent on early detection and initiation of effective treatments.3 However, although recommendations are made by the American Academy of Pediatrics, there is no uniform approach being used to achieve the consequential task of identifying children for treatment. The 2016 American Academy of Pediatrics Policy Statement on Vision Screening references a study that found “regular vision screening assessments in early childhood reduce the risk of persistent amblyopia at 7 years of age by more than 50%.”4 This American Academy of Pediatrics 2016 Policy Statement on Vision Screen titled “Visual System Assessment in Infants, Children and Young Adults by Pediatricians” recommends, among other things, that if instrument-based vision screening is available, vision screening with this technology should be first attempted between 12 months and 3 years of age and at annual well-child visits until visual acuity can be tested directly.5
It is paramount that stakeholders strive to improve and disseminate replicable, data-driven programs that improve the early detection and initiation of treatment for children with visual impairment. No child should suffer from a preventable and correctable visual impairment. To achieve such a vision, we must utilize vision screening best practices in the programs and service models we implement.6
There are many programs and models for community-based vision screening for children. Community-based preschool vision screening has been a mainstay for many Lions Clubs. In recent years, the Lions Clubs have developed the formal, nationally recognized “Lions KidSight Program.” In this program, Lions Club members provide instrument-based vision screenings in child care centers, health fairs, and wherever else they are invited to go.
In addition, several states also require vision screening prior to entering kindergarten and there are a variety of statewide and county programs to achieve this mandate.7 But despite these efforts, significant numbers of preschool children are still not being screened or screened accurately. Even when children are screened, many are not getting the critical eye examination that the screening results recommends because there are no effective tracking and follow-up systems in place.8
The Naples Lions Club has been doing preschool screenings in Collier County, Florida, in collaboration with the Early Learning Coalition of Southwest Florida for more than 10 years in private and state-supported child care centers. Together, they have annually screened on average 3,000 children ages 3 to 5 years old, which amounts to 95% of the children in these preschool settings. During this period, more than 1,000 children have been found to have eye problems needing evaluation and treatment. However, because there are approximately 9,500 children 3 to 5 years old in Collier County, it was estimated that anywhere from 60% to 70% of our community's children may not be getting screened.
To address this issue and test the hypothesis, the Naples Lions Club began the Amblyopia Elimination Project. The goal of the Amblyopia Elimination Project is simple: to increase the number of preschool-aged children receiving vision screenings and referrals for complete eye examinations if needed. One of the first steps to achieving this goal is to work closely with the pediatricians and the pediatric medical homes in the community. Research continually reinforces the notion that a medical home (physician's office) is the best choice to manage and observe a child in need of vision correction and treatment. However, a survey of pediatric offices by Kemper and Clark9 in 2005 noted the low percentage of 3-year-old children being screened (35%). It was better at ages 4 (73%) and 5 (66%) years, but still much less than it should be. In 2005, only 8% in the survey were using photoscreening. The reasons for poor screening were given as too time-consuming, uncooperative children, and financial concerns.9 Using the research findings, the Naples Lions Club made the decision to focus on eliminating the financial concerns of incorporating instrument-based vision screening equipment for pediatric medical homes in Collier County. Through its philanthropic efforts, the Naples Lions Club planned to obtain funding and purchase SPOT Vision Screeners (Welch Allyn, Skaneateles Falls, NY), which would then be loaned to pediatric medical homes in the community. Through these actions, the Naples Lions Club believed it would increase the number (and quality) of vision screenings and referral follow-up activities being made in the pediatric medical homes in Collier County.
Patients and Methods
The goal of this project was to place a SPOT Vision Screener in every pediatrician's office to test the hypothesis that making instrument-based screeners available at no cost to the practices would increase the number and quality of screenings and referrals. Photoscreening has been shown to be a reliable vision screening tool for preschool children that is objective and well tested.10 SPOT instrument-based vision screening overcomes some of the reasons given in the Kemper study for not doing vision screenings in preschool children. The time for a SPOT screening is very short, it requires limited cooperation, and it has great accuracy.
The program began when the Naples Children & Education Foundation, founder of the Naples Winter Wine Festival, purchased 6 SPOT Vision Screeners for the 6 pediatric offices of the Healthcare Network that serve low income and underserved families and children, at a cost of $7,000 each. After 2 years, each of these offices were screening approximately 300 children per month. The Naples Lions Club realized this model was successful and could be expanded to the whole community. The goal was to have all preschool children screened and, if necessary, receive treatment early enough in their life to prevent permanent treatable visual loss. If amblyopia is not found by approximately age 6 years, treatment is usually not successful.
The Naples Lions Club raised funds to purchase 12 additional SPOT Vision Screeners and printers. This purchase was possible due to the generosity of the Naples Lions Club, the Naples Children's Education Foundation, the Community Foundation of Collier County, The League Club, Lions Clubs International Foundation, Isles of Collier Preserve, the Grider/Millard Foundation, the Fred and Louise Goebel Foundation, and individual donors. Data from the early success of the program helped convince these non-profit organizations to contribute to the cost of these additional screeners. These screeners were loaned on a long-term, no-charge basis to the pediatric clinics and offices. The pediatricians agreed to help assess efficiency by reporting every quarter the summary data of the screenings and number of referrals for further evaluation.
Data collection results were done by either e-mail or sending the downloaded data files from the SPOT to the data coordinator (HF). For those few Vision Screener practices that did not report data within 1 month of the end of a quarter, a personal visit to the practice and manual downloading of the data was performed.
Quarterly reports were collected on total numbers of children screened, ages 1 to 6 years old, and referred for eye examinations (preschool and older), and the different conditions causing referrals (based on the SPOT criteria). These included astigmatism, myopia, hyperopia, anisometropia, anisocoria, and gaze (strabismus) abnormalities. Referral completion rates were also reported to gauge the efficacy of the referral program component. Children who had gaze abnormalities were rescreened immediately, because off-axis fixation can give false-positive results and rechecking with attention to proper fixation can eliminate many false-positive referrals.
By June 2017, there were 19 SPOT Vision Screeners either loaned to pediatricians or purchased by the physicians out of 25 pediatric and family practice offices (76% coverage) in Collier County. This included two pediatricians who declined the loan of the vision screeners. One pediatrician returned the loaned SPOT Vision Screener and purchased his own unit. This report includes the data from the 19 offices currently using SPOT Vision Screeners in Collier County for the 2017 calendar year.
In 2017, the Amblyopia Elimination Project pediatricians in Collier County screened 6,502 pre-school children and found 900 needing referrals for an eye examination (Table 1). Conditions for referral were astigmatism (525), myopia (105), hyperopia (70), anisometropia (64), and gaze (44). The pediatricians reported estimated referral completion rates between 13% and 100%. One group of six clinics using an electronic medical records system reported a 36% referral completion rate, but only analyzed data from the last quarter of referrals. Most other referral completion rates are by pediatrician estimate and not by accurate referral tracking systems. Most of the pediatricians estimated rates between 70% and 100%.
Screening, Referral, and Follow-up Data
One pediatrician developed an efficient system for referrals and achieved 100% referral completion by his estimate. Immediately after a positive screening, his office calls a local eye physician's office, gives the patient's insurance information, and makes an appointment for the child at that time. The physician then informs the parent, who is still present, of the details of the appointment. The parent is then encouraged to go to the appointment and not miss it “because the physician expects to see your child.”
We believe the key to the reported high referral completion rates in some of the pediatric offices is the good relationship between the pediatricians and the parents and the involvement of the physician. When the physician recommends the eye examination, it has more weight than if a lay screening group such as the Lions sends home a form recommending an eye examination. Lay screenings typically report a 30% to 40% referral completion rate when only a written communication and recommendation is sent home to the parents. KidSight programs in Iowa and Tennessee with dedicated referral follow-up coordinators communicating with parents directly report 70% to 81% referral completion rates.11,12
The number of abnormal conditions found is less than the number of referrals, because one group reported electronic medical records totals for all children referred for eye problems, not just SPOT criteria. The incidence of astigmatism is higher than normally found in the general U.S. population. The Hispanic community in Collier County has an abnormally high rate (approximately 15%) of moderate to severe astigmatism (2.00 to 6.00 diopters) and accounts for the high number of astigmatism referrals found in this community detected by the SPOT Vision Screener.13,14
The ideal screening program for children should have an accurate and reliable screening methodology, use standard and evidence-based referral criteria, and have a defined and effective process for referral follow-up that includes ensuring referred children receive an eye examination. By incorporating instrument-based screening equipment, the first two parts of an ideal screening program can be fulfilled. Through the Amblyopia Elimination Project, we have shown that financial barriers to the incorporation of instrument-based vision screening equipment in the medical home can be eliminated, and by doing so meet the objective of increasing the use of appropriate age-based vision screening. Even when this system is successful and a child obtains glasses, many are lost or broken and need replacement. Designing systems to replace lost or broken glasses is another important step to ensure children maintain their best possible vision.
One challenge for this project is the creation of a better system to obtain feedback from the eye physicians in the community who see the children being referred from the SPOT screenings. The program will then be able to track the accuracy of the referrals, the false-positive rates, and the number of children being treated for amblyopia and more serious conditions. The variable referral completion rates noted in our data chart are mostly by estimate and not by a detailed analysis of the data. Improvement in this area will be a major objective for the program in the future.
Most of the pediatric practices in our area have Medicaid populations between 30% and 70%. Because these pediatric practices in our area find it challenging to afford to purchase the SPOT Vision Screener, which costs $7,000, the loan program was developed and has been successful.
This project has proven the hypothesis that using a model of philanthropy to place instrument-based vision screeners in pediatric medical homes results in increased screening and referrals of at-risk preschool children.
We owe much gratitude to the generosity of the foundations, volunteers, and service organizations such as Lions Clubs who made this project possible. The staff in the pediatrician's offices readily learned to use the screeners and were delighted by their ease of use and accuracy. Managing referrals from within the primary care physician's office makes referral completion more easily tracked and robust, and leads to a higher referral completion rate. However, unless every referred child receives an eye examination, the screening program is not a success. More work needs to be done to obtain accurate reporting of actual referral completions rather than estimates.
After 2 years of education, coordination, and cooperation with local pediatricians, the Naples Lions Club has developed a successful early screening program worthy of dissemination and replication. To our knowledge, no other community has attempted 100% coverage of preschool screenings in pediatric medical homes. We obtained 90% coverage by the end of 2018. Our vision is that no child should suffer from a preventable and correctable visual impairment. Our strategy is to effectively identify amblyopia in children, the number one cause of preventable permanent vision loss in childhood, so it may be treated at an early age. The strategy outlined in the Amblyopia Elimination Project serves as an example of how current public and private vested interests can partner together and combine resources to implement an effective strategy for meeting this overall vision. We invite others to replicate this strategy, and improve on it, so our goal may one day be achieved.
- Keefe J. Childhood vision impairment. Br J Ophthalmol. 2004;88:728–729. doi:10.1136/bjo.2003.040006 [CrossRef]
- Bacal DA, Hertle RW. Don't be lazy about looking for amblyopia. Contemporary Pediatrics. 1998;15:9.
- Holmes JM, Lazar EL, Melia BM, et al. Effect of age on response to amblyopia in children. Arch Ophthalmol. 2011;129:1451–1457. doi:10.1001/archophthalmol.2011.179 [CrossRef]
- de Koning HJ, Groenewoud JH, Lantau VK, et al. Effectiveness of screening for amblyopia and other eye diseases in a prospective birth cohort study. J Med Screen. 2013;20:66–72. doi:10.1177/0969141313497355 [CrossRef]
- Donahue SP, Nixon CN, Section on Ophthalmology, American Academy of Pediatrics et al. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137:28–30.
- Cotter SA, Cyert LA, Miller JM, Quinn GE. Vision screening for children 36-<72 months: recommended practices. Optom Vis Sci. 2015;92:6–16. doi:10.1097/OPX.0000000000000429 [CrossRef]
- National Center for Children's Vision and Eye Health. State by state listing of preschool and school vision screening laws. https://nation-alcenter.preventblindness.org/school-requirements-childrens-vision
- Hartmann EE, Block SS, Wallace DK. Vision and eye health in children 36 to <72 months: proposed data system. Optom Vis Sci. 2015;92:24–30. doi:10.1097/OPX.0000000000000445 [CrossRef]
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- Donahue SP, Arthur B, Neely DE, et al. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013;17:4–8. doi:10.1016/j.jaapos.2012.09.012 [CrossRef]
- Williams CEM, Harrad RA, Harvey I, Sparrow JMALSPAC Study Team. Screening for amblyopia in preschool children: results of a population-based, randomized controlled trial. Ophthalmic Epidemiol. 2001;8:279–295. doi:10.1080/09286586.2001.11644257 [CrossRef]
- Longmuir SQ, Pfeifer W, Leon A, Olson RJ, Short L, Scott WE. Nine-year results of a volunteer lay network photoscreening program of 147,809 children using a photoscreener in Iowa. Ophthalmology. 2010;117:1869–1875. doi:10.1016/j.ophtha.2010.03.036 [CrossRef]
- Tarczy-Homoch K, Varma R, Cotter SA, et al. Multi-Ethnic Pediatric Eye Disease Study Group. Risk factors for decreased visual acuity in preschool children: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies. Ophthalmology. 2011;118:2262–2273. doi:10.1016/j.ophtha.2011.06.033 [CrossRef]
- Crescioni M, Miller JM, Harvey EMAccuracy of the SPOT and Plusoptix photoscreeners for detection of astigmatism. J AAPOS. 2015;19:435–440. doi:10.1016/j.jaapos.2015.07.284 [CrossRef]
Screening, Referral, and Follow-up Data
|2017 Data||Screened (Total)a||Screened (1 to 6 Years)||Referred (1 to 6 Years)||Referral Completionb|
|1st quarter||2,876||412||56||50% to 70%|
|2nd quarter||5,043||2,033||266||18% to 70%|
|3rd quarter||4,759||1,597||267||15% to 100%|
|4th quarter||4,306||2,010||311||23% to 100%|
|Total||16,984||6,052||900||15% to 100%|