Last year, Kentucky began a statewide mandate that requires all children entering school to get an eye exam. In the past two years, at least eight other states have considered similar legislation.
Like Kentucky, shouldnt all states require children to get a comprehensive vision exam by an eye care professional at least once?
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Not every child needs a comprehensive eye examination, says Michael Redmond, M.D., AAOs president-elect and a pediatric ophthalmologist in Pensacola, Fla.
It sounds like it should be an easy, white hat kind of thing, that all children should have a comprehensive eye examination, but its not that simple, Dr. Redmond says. (An M.D. spokesperson from AAPOS did not return phone calls.)
Most optometrists disagree. About 83% of respondents to Review of Optometrys National Panel, Doctors of Optometry survey say that mandated comprehensive vision exams are better policy than just vision screenings, and 75% of respondents support legislation to enforce that policy.
Regardless of a law, do all kids need a comprehensive exam in addition to screenings? In my opinion, absolutely, says Glen T. Steele, chief of pediatrics at Southern College of Optometry in Memphis, Tenn. I see too many kids who have fallen through the cracks.
Dr. Steele, whose practice sees mainly children, says he often sees children with significant refractive errors that havent been identified by a screening or previous exam.
If just one of those kids is picked up by a comprehensive exam, all the effort is worth it, Dr. Steele says. But there are many, many more than just one.
Proponents of the mandate say all children need eye exams. Mere vision screenings at school and at the family doctors office are inconsistent, incomplete and not routinely administered. Problems like amblyopia that arent caught by fourth grade can become irreversible. And parents often dont know the difference between a school screening and a comprehensive vision exam.
Opponents say that widespread mandatory vision exams are neither worthwhile nor cost-effective. Screenings pick up most pathology and refractive errors, they say. And health-care dollars are limited, so an unfunded mandate intended to identify a small number of vision problems is not a judicious use of those funds.
The Need
The need for screenings, at least, certainly exists. One yardstick could be the Baltimore Vision Screening Project, which found 7.4% of kindergarten children had refractive error, 5.3% had amblyopia and 3.2% had strabismus.1 More serious problems, such as congenital cataracts or retinoblastomas, occur only in about one in 20,000 live births a year.
Most of these things are picked up [by screening], depending on the problem, in the very young or by that 3- or 4-year-old age group anyway, Dr. Redmond says.
If Kentucky is any indicator, then no, these problems are not being picked up. After the law was passed, a survey of 5,000 children in Kentucky demonstrated numbers that were roughly similar to the Baltimore Vision Screening Project: Among children ages 3-6, 3.4% had amblyopia and 2.3% had strabismus, while almost 14% had refractive error requiring glasses.1 All were children whose problems should have already been flagged by a vision screening performed as part of their school-required physical.
If screenings were working sufficiently, then we would not be finding all these problems, says Darlene Eakin, executive director of the Kentucky Optometric Association.
What about the implication that the single-digit percentages of pathology in children dont warrant a public health mandate? If you take one single pathology, say amblyopia, and you multiply 3.4% times 21 million kids under 5, how many kids do you have? How many kids does it take to say theres an epidemic? Dr. Steele asks.
Even the numbers already reported may under represent the actual problems. Children with vision problems may not be aware of what normal vision is, so they may go undetected longer, says Jeffrey L. Weaver, O.D., director of the AOAs Clinical Care Group.
Screenings Are Lacking
How to catch these kids? Vision screening was supposed to be the answer. But screenings vary not only by method but by occurrence. There is a terrible lack of standardization of how these things should be done, Dr. Redmond says.
No doubt about it. Its a misperception that all childrenor barely even the majority of childrenare getting vision screening. One study found that 80% of preschoolers were not screened for visual problems.2 One optometric study claims that 45 states do not require screening of all preschool children.3
For their part, AAO and AAPOS have been working with pediatricians and family physicians to help standardize screenings, Dr. Redmond says. Still, he adds, screenerssuch as pediatricians, family physicians and school nursesusually do what theyre supposed to do: pick up most vision problems.
Thats certainly what they should do, but theyre not doing it. An American Academy of Pediatrics study of 8,400 children ages 3-5 found that only 66% of all children had been given screenings. Among 3-year-olds, fewer than four in 10 got a screening. Only one-third of all children were screened for strabismus. And half of all parents whose children failed the screening were still unaware of the fact two months later.4
Not only are screenings spotty, the very nature of screening will routinely miss problems. No ones saying necessarily that the vision screenings performed by the pediatrician and pediatricians staff are inaccurate due to poor administration. Its the test itself thats limited, says Michael Earley, O.D., Ph.D., chief of the pediatric clinic at Ohio State University College of Optometry. Dr. Earley recently testified before an Ohio legislative task force that is investigating improving vision programs in that state.
He says that poorly designed screening often relies on visual acuity testing. No matter how accurately you measure vision acuity, it only has a sensitivity of about 20% using a 20/40 or worse referral criterion. Its going to miss eight children out of 10 that have a vision problem, Dr. Earley says.
Even a rigorous screening (a term that AAO and AAPOS fail to define in their policy) will miss many children. The vision screening in Dr. Earleys home state of Ohio has several componentsocular observation, distance acuity, stereo acuity, a modified muscle balance test, and color vision testing for boys. Even so, he says, this screening has a maximum sensitivity of about 60%, no matter who performs it. As an optometrist specializing in pediatrics, if I went out and did that screening, Im still going to miss about four out of 10 children with vision problems.
Dr. Earley points out that a screening is not meant to be a substitute for a comprehensive exam; its meant only to refer patients with vision disorders for further examination. But many parents get a false sense of security when their child passes a screening.
The Big Picture
Kentucky is just one state. What if every child in the United States had to get an eye exam before entering school? That seems fine with the American Public Health Association, which endorses exams rather than screening for Americas children. But where will the money come from? It would require an enormous amount of health-care dollars.
The AAOs Dr. Redmond calculates it: About 4 million children enter elementary school each year. If each comprehensive exam costs $75, then thats a $300 million burden each year on an already overstrained health-care system.
And, he says, this is money thats paid on top of previous screenings. Youre talking $300 million dollars to identify very, very few people that have an unidentified problem. In other words, most of that money will be paid for vision exams that find nothing.
It may be a small percentage that is unidentified, but even 1% of 4 million kids is still 40,000 children a year.
In todays environment, you dont want to undertreat, but you also dont want to overtreat, Dr. Redmond says. Mandatory vision exams substitute a failure rate for an overtreatment rate, he says. To spend $300 million on these children is not cost-effective.
But to skip a comprehensive exam for a child who needs one creates a cost to patients and society as well. The longer you wait to identify these kids, then the more difficult it is to treat it, and the more costly long-term, Dr. Steele says.
And if required by law, wouldnt most parents willingly spend $75 on their childs eye exam? Thats the equivalent of an expensive pair of sneakers.
I grant you people spend that much going out to dinner, Dr. Redmond says. But whats going to happen is that people will expect that their insurance company will pay for this. People expect that any health care dollar is somehow paid by an insurance company.
He adds, Thats what happened in Kentucky. They passed a law, but they didnt mandate any funding for it, and nobodys paying for it, and its not being done.
Actually, Kentucky did mandate funding for it: $150,000 a year for poverty-level children who were not covered by private insurance, Medicaid or other programs. And even though that fund has been widely publicized, only a few thousand dollars have been withdrawn.
And folks in Kentucky say exams are getting done. Parents are [even] voluntarily taking their older children to have their eyes examined, says Nicki Patton, former chair of Kentuckys task force on early childhood development. She says that schools, reluctant about the legislation at first, now support it because children who get vision exams do better in school.
In addition, various organizations offer free or subsidized vision exams, including state childrens health insurance programs, Vision Service Plans Sight for Students program, the AOAs Vision USA, Operation Bright Start and other volunteer programs.
Among our National Panelists, for instance, slightly more than half say they participate in optometric outreach or volunteer activities specifically for children.
In Wisconsin, where the law requires schools to recommend exams to students, the Wisconsin Optometric Association has pledged $100,000 a year for 10 years to help families who want vision exams.
Employment Act?
Skeptics of childrens vision legislation say its part of a plan to sell more glasses. Dr. Redmond singles out Vision Council of America, a strong proponent for this legislation and also an optical industry trade group.
One Connecticut pediatrician called that states childrens vision bill an optometry employment act.
Its not certainly a way to employ ourselves, says John Lertora, O.D., president of the Connecticut Optometric Association. Were all gainfully employed as it is. We feel that it would meet a need thats not being met currently in this state, like in so many other states.
Only 6% of optometrists on our National Panel say their practices would greatly increase in size if childrens vision legislation is passed in their state.
But is it a financial issue? About 97% of panelists say they dont earn more money for performing a childs examination, and nine out of 10 say they dont earn more in providing treatment for a child. O.D.s say that although a childs exam takes about the same amount of time, they usually charge less. Also, parents dont often choose the most expensive frames and materials because the child may outgrow their glasses in a year or two.
Optometrists real goal is to educate the public that this is something that will benefit children. It will benefit society in the long run by identifying problems early and correcting them, Dr. Weaver says. And thats the message that maybe gets lost with some of the arguments that come out.
The real question, Dr. Redmond says, is how many patients can society afford to miss given that it will cost the public millions of dollars to find themmillions that could be allocated elsewhere. When you net it all out, you might be spending in the end $50,000 for one case of undetected amblyopia, he estimates.
Thats an overestimate, says Dr. Steele, and the statistics dont bear that out. But even for the sake of argument, he asks, What if its your child?
Even so, whats $50,000 to an amblyopic child, or to society, over the course of a lifetime? Theres a cost now, or theres a cost later. And in my opinion, the cost to the individual later is much greater than the initial cost to identify it, Dr. Steele says.
Says Dr. Earley: This question really comes down to this: How many children with vision problems is it OK to miss? Given the absolute importance that vision plays on academic success, athletic success and ultimately on a childs self esteem, I say that the answer to this is zero.
What do you say?
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2. Essman SW, Essman TF. Screening for pediatric eye disease. Am Fam Physician 1992 Oct;46(4):1243-52.
3. Ciner EB, Schmidt PP, Orel-Bixler D, et al. Vision screening of preschool children: evaluating the past, looking toward the future. Optom Vis Sci 1998 Aug;75(8):571-84.
4. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screening in pediatric practice: a study from the Pediatric Research in Office Settings (PROS) Network. American Academy of Pediatrics. Pediatrics 1992 May;89(5 Pt 1):834-8.
