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Childhood Vision: What the Research Tells Us

Childhood Vision: What the Research Tells Us

Vision Screenings and Exams

A majority of states require or recommend vision screenings or exams for school children.
As of 2002, 30 states plus the District of Columbia required vision screening in elementary schools or for all school-aged children. Eleven states recommended vision screenings. 1 Grades at which students should receive vision screenings vary by state with the majority requiring testing before kindergarten or first grade. Even with these recommendations and requirement, only a small percentage of preschool and school age children actually receive the recommended or required tests. In 2000, Kentucky was the first state to mandate comprehensive vision exams for all students entering kindergarten or first grade. 2

Health professionals differ on the best strategies for detecting vision problems among large groups of children.
To identify children with vision problems, the American Optometric Association3 and the American Public Health Association4 recommend comprehensive vision examinations for all children starting at 6 months of age and at regular intervals thereafter, while the American Academy of Ophthalmology5 and the American Academy of Pediatricians6 support vision screenings for all children by age 3 and at regular intervals thereafter.

Although early detection of problems is key to protecting children’s vision, vision screening and eye exam rates are low among pre-school children.
It is estimated that up to 21% of preschool children are screened for vision problems and that only 5% – 14% of children receive an eye exam by an eye care practitioner before entering school. 7,8,9

How do exams and screenings compare?

Vision exams
  • Conducted by ophthalmologist or optometrist
  • Ocular history
  • Medical history
  • Family ocular and medical history
  • Unaided acuity test
  • Best-corrected acuity test
  • External ocular examination
  • Internal ocular examination
  • Pupillarly responses
  • Binocular function
  • Accommodation and convergence
  • Color vision
  • Diagnosis
  • Recommendations

Zaba J et al. Vision examinations for all children entering public school — the new Kentucky law. Optometry. 2003;74(3):149–158.

Vision screenings
  • Conducted by wide-range of health professionals from public health nurses and non-professional volunteers to ophthalmic technicians.
  • May include anything short of a complete eye exam
  • Components can vary greatly
  • Visual acuity
  • Ocular alignment
  • Refractive Errors

U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd Edition. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 1996.

Vision in Preschoolers Study Group. Comparison of Preschool Vision Screening Tests as Administered by Licensed Eye Care Professionals in the Vision in Preschoolers Study. Ophthalmol. 2004;111(4):637–650.

Sensitivity of screening exams varies.
According to a recent study, the four most effective vision screening methods, when performed by an optometrist or pediatric ophthalmologist, detect just two in three children with a vision problem but nearly 90 percent of children with the most important conditions. The effectiveness of vision screenings performed by nurses or volunteers may very and will be assessed in a future study. 10

Among children screened for vision problems, rates for follow-up care are low and often delayed.
According to two studies, nearly 40% of the 7 – 17% of children who were screened and referred for additional testing did not receive the recommended follow-up care. 11,12Another study noted that when a 5 or 6 year old failed a vision screening, the average delay before evaluation by an eye care professional was 4 years. 13

Diagnostic Results


Lazy Eye


Eyes turned
in or out

(Refractive Errors)




































In 2002, under the Kentucky Eye Exam law, 2,916 children ages 3-6 years of age were examined. Mozlin R, Zaba JN, and Reynolds WT. Vision examinations versus vision screenings: Lessons learned in Kentucky. J Behavioral Optometry. 2003;14(5):123-126.

Medicaid enrollment does not assure that beneficiaries receive vision-screening services.
Although Medicaid EPSDT covers vision screenings for children along with other screening services, a 1997 study found that only 28% of enrolled children received screenings. 14 Independent of the EPSDT screening, Medicaid may cover a complete vision exam if it falls within state periodicity schedules. 15 Policies vary from state to state.

One-quarter of all workers in private industry have access to insurance coverage for vision services.
Although children as a group are not identified, 25% of all workers have access to insurance coverage for vision care services, 16 with 99% covering eye exams. Vision care is defined as "coverage for eyeglasses, and with few exceptions, eye exams and contact lenses." 17


  1. American Academy of Ophthalmology. State affairs secretariat. Eye screening state status. 2002.
  2. Zaba J, Johnson RA, Reynolds WT. Vision examinations for all children entering public school—the new Kentucky law. Optometry. 2003;74(3):149–158.
  3. American Optometric Association. Optometric clinical practice guideline: Pediatric eye and vision examination. St. Louis: American Optometric Association, 2002.
  4. American Public Health Association. Policy statement 2001–1: Improving early childhood eyecare. Available at
  5. American Academy of Ophthalmology. Policy statement: Vision screening for infants and children. Available at
  6. American Academy of Pediatrics. Policy statement: Eye examinations in infants, children, and young adults. Pediatr. 2003;111:902–907.
  7. Ehrlich M, Reinecke R, Simons K. Preschool vision screening for amblyopia and strabismus: programs, methods, guidelines. Surv Ophthalmol. 1983;23:145–163. See page 159 conclusion and addendum.
  8. Kushner B. Pediatric ophthalmology in the new millennium. Arch Ophthalmol. 2000;118:1277–80.
  9. Ciner EB, Schmidt P, Orel-Bixler D, et al. Vision screening of preschool children: evaluating the past, looking toward the future. Optom Vis Sci. 1998:75(8):571–84.
  10. Vision in Preschoolers Study Group. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the vision in preschoolers study. Ophthalmol. 2004;111:(4)637–650
  11. Donohue SP, Johnson TM, Leonard-Martin TC. Screening for amblyogenic factors using a volunteer lay network and the MTI photoscreener. Ophthalmol. 2000;107:1637–44.
  12. Preslan MW and Novak A. Baltimore vision screening project. Phase 2. Ophthalmol. 1998;105(1):151–153.
  13. Yawn BP, Lydick EG, Epstein R, Jacobsen SJ. Is school vision screening effective? J Sch Health. 1996;66(5):171–175.
  14. Department of Health and Human Services. Office of Inspector General. Medicaid managed care and EPSDT. May 1997. OEI–05–93–00290.
  15. Centers for Medicare and Medicaid Services. State medicaid manual. Part 5:5010–5360. Available at
  16. U.S. Department of Labor, Bureau of Labor Statistics. National compensation survey: employee benefits in private industry in the United States. Summary 04–02. April 2004. Page 3, Table 1.
  17. U.S. Department of Labor, Bureau of Labor Statistics. National Compensation Survey: Employee benefits in private industry in the United States, 2000. Bulletin 2555: January 2003. Page 53. Table 59.

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