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No Agreement in Sight: Children's Vision Tests Need Improving, Say Experts. But They Don't See Eye to Eye on How
http://www.washingtonpost.com/wp-dyn...082800785.html
No Agreement in Sight Children's Vision Tests Need Improving, Say Experts. But They Don't See Eye to Eye on How. By Mark Johnson Special to The Washington Post Tuesday, August 29, 2006; HE01 Schools and pediatricians have performed vision screenings for decades, perching entering kindergartners in front of the familiar "big E" eye chart and asking them to read off increasingly smaller rows of letters or, sometimes, pictures. But while these screenings often identify nearsightedness, farsightedness and other common vision disorders, the tests fail to catch these and more severe eye ailments in roughly 10 percent of the preschoolers who have these problems, according to a National Institutes of Health study published in the journal Ophthalmology in 2004. Problems missed include amblyopia, or lazy eye, and strabismus, where the eyes don't focus on the same point. Sydney Schneider was in kindergarten in Gaithersburg two years ago when a screening showed the vision in her left eye at 20/70 -- poor, but correctable with glasses. During a follow-up visit to an ophthalmologist, a physician who specializes in eye care, Sydney's parents learned that she had amblyopia. Her left eye was barely functioning, with vision of about 20/200. "Our doctor told us . . . another year or year and a half, and she would have been totally blind" in that eye, said Stephanie Friedman Schneider, Sydney's mother. Sydney wore a patch over her good eye for weeks to strengthen her weak eye's muscles. She also was given glasses. After several months, vision in the weak eye improved and the patching was scaled back. "If we don't catch [amblyopia] early, it leads to permanent and irreversible vision loss," said Jean Ramsey, director of pediatric ophthalmology service at Boston Medical Center and part of the leadership of the American Academy of Ophthalmology. She and many ophthalmologists say school vision screenings could be improved. On this point, doctors, educators and legislators generally agree. Where they and other vision professionals split sharply is on how to improve them. One solution, mandated in Kentucky, is for parents, insurance companies or Medicaid programs to spend $100 to $200 so every incoming kindergartner can visit an optometrist or an ophthalmologist. The eye professionals perform a comprehensive eye exam instead of just a screening. Here's the difference: In a screening, a doctor, nurse or a trained examiner tests the accuracy of vision in each eye and possibly whether the eyes are straight and working together. A screening flags potential problems but doesn't diagnose them. In a comprehensive eye exam -- the gold standard, according to the NIH study -- an optometrist or ophthalmologist dilates the pupils and checks the function of key parts of the eye, including the optic nerve and retina. The exam also produces a diagnosis and a prescription if the child needs glasses. In the District's public schools, only a vision screening is required before students enroll. Neither Virginia nor Maryland requires a comprehensive exam, either. Virginia requires schools to perform vision screenings on new students, including all kindergartners, within 60 days of starting classes. Students are screened again in the third, seventh and tenth grades. Maryland requires local health departments or boards of education to perform screenings upon a child's enrollment and at the start of grades 4, 5 or 6 as well as grade 9. Many ophthalmologists say multiple screenings during childhood are a more effective and cost-efficient way to identify vision ailments than a single comprehensive exam. Seeing Problems Early Early detection of vision problems is critical, say experts, because conditions such as lazy eye are far more correctable in young children. "The younger you are, the faster things change in your brain -- just like kids can learn a foreign language faster when they're young," said New Jersey optometrist Leonard Press, chairman of the American Optometric Association's pediatric vision project team. "Vision doesn't occur in your eyes. It occurs in your brain. The longer the brain is patterned to pay more attention to one eye than the other eye, the harder it is to get the brain to modify what it's doing." From a public health perspective, early intervention makes sense, too. An adult who ends up with one eye markedly stronger than the other, for example, faces a much higher chance of injuring the better eye, said Ramsey. In 2002 the American Public Health Association recommended comprehensive exams for all children at 6 months, 2 years and 4 years, warning that undiagnosed farsightedness is tied to deficits in reading achievement. Only a few states have considered requiring even a single comprehensive exam for kids. In February, Puerto Rico followed Kentucky in mandating a comprehensive exam for kindergartners. Similar legislation is pending in Florida and Missouri. Twenty-nine states and the District require vision screenings during school or before enrollment, according to a study by the Vision Council of America, a trade association for the eyeglass and optical industry. Nineteen states require no screening or exam, according to the report. Optometrists, who are trained to diagnose and correct vision problems but are not physicians, have been among the leading voices for comprehensive exams. Jim Black, an optometrist who is also speaker of the North Carolina House of Representatives, inserted a comprehensive eye exam requirement for kindergartners into the state budget last year. "It only makes sense that we would want to make sure that vision problems would not prohibit [children] from getting a good education," Black said after criticism erupted over the proposed mandate. The requirement was scaled back to a vision screening after physicians and school boards criticized the move as too costly and noted that Black had received thousands of dollars in campaign contributions from optometrists in the preceding election. Professional Rivalry Many ophthalmologists oppose mandated exams as an inefficient use of scarce health care funds. Some have derided such policy as "an employment act for optometrists," who are seen as more likely to conduct such exams than are ophthalmology specialists. "It's optometry versus ophthalmology," said Karla Zadnik, an Ohio State University optometry professor who has studied vision screenings. "There is turf involved," she added. Any testing process -- including comprehensive eye exams -- will miss some vision problems, say ophthalmologists. In July Sen. Kit Bond (R-Mo.) introduced a bill that would provide federal grants to states for follow-up care, such as a comprehensive exam for uninsured children who fail a screening. These grants would also fund treatment to correct vision, regardless of whether the ailment was identified by a screening or a comprehensive exam. The bill has the backing of the American Academy of Ophthalmology and the American Optometric Association and the Vision Council of America. "In this era of limited dollars, we need to focus our dollars on the kids that need it," said pediatric ophthalmologist Mary Louise Collins, a professor at Johns Hopkins University School of Medicine in Baltimore. "If every kid who had a headache went to the primary care physician and got an MRI, that wouldn't be the best use of health care dollars." |
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