No Agreement in Sight: Children's Vision Tests Need Improving, Say Experts. But They Don't See Eye to Eye on How

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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.

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."