Recent focus on school achievement due to the No Child Left Behind legislation, Healthy People 2010 recommendations for better child vision screening, and expanded computer use among school-age children have re-awakened interest in the importance of childhood vision and early treatment of problems. With a hundred years of experience in school-based vision screening programs plus extensive screening and eye examinations in private physicians’ and optometrists’ offices, government officials as well as health professionals are examining how far we have come in protecting children’s vision.

Some eye care and public health professionals have argued that every child should receive a comprehensive examination by an optometrist or ophthalmologist before school entrance. Other eye care and medical professionals maintain that vision screening is a cost-effective method for identifying those who would benefit from eye exams. These competing recommendations for how best to identify children with vision problems are prompting new research on the costs and benefits of various strategies, including an examination of the impact of untreated vision problems on school performance.

State legislatures, local school districts and federal government agencies have all begun to re-assess the effectiveness of approaches they use to assure that vision problems do not become barriers to healthy child development and academic performance. The goal of this paper is to provide a framework for policy makers, educators, health professionals, and parents to assess the adequacy of the current strategies to find and treat children with vision problems and to suggest future directions.

Key Findings

Vision problems are common among children. Vision problems affect nearly 13.5 million children. Rates for vision problems increase as children age. Nearly eight percent of young children ages 0 – 5 experience eye problems while a quarter of adolescents 12 – 17 are reported to have eye problems.

A variety of legislative and regulatory measures have been adopted to address vision problems. Thirty-nine states and the District of Columbia either recommend or require vision screening prior to school entry and periodically thereafter. Only one state, Kentucky, mandates comprehensive eye exams prior to school admission.

Office-based vision screening is the primary means of detecting vision problems among young children. For the majority of children under the age of three, vision screenings, when done, are performed during well-child visits by physicians and their staff. However, one study reported that only 66% of children ages three to five years old in a group of 102 pediatric practices covering 23 states, received vision screenings. No data on office-based vision screenings for older children is available. Health care providers may be missing opportunities to identify vision problems in children during routine visits. It is estimated that only 5-14% of children receive eye exams performed by optometrists or ophthalmologists before school entry.
Implementation difficulties seriously limit the impact of current public
policies that promote early detection and treatment of vision problems.
Low screening rate — High quality data on childhood screening rates are not available. Student mobility, changing school enrollment numbers, and variable school district policies on reporting screening data make data collection and analysis difficult. The federal government has not collected these data on a national sample for 30 years. However, based on small-scale studies, there is a widespread sense that screening rates are low.

Low follow-up rates and delayed treatment — For students who have been screened and found to have a vision problem, the average time between screening and recommended treatment was two years. Follow-up mechanisms are not adequate to assure that children who are screened and identified with problems receive treatment in a timely manner. Parents and other caregivers may not be sufficiently aware of the importance of early detection for some vision problems and the need for prompt treatment to reduce irreversible damage.

Inadequate provider training — Training for the school nurses and volunteers who typically conduct vision screenings at school depends on state requirements, availability of professionals and volunteers, staffing patterns of school health programs, equipment available, and the organization providing the training. Also, screener training may not be adequate given the difficulty of identifying some vision problems. Consistent national standards do not exist, nor have all states established mandatory guidelines.
State and federal initiatives to increase early detection and treatment of eye  problems have been proposed and in some cases implemented.
State Initiatives — Some states such as Massachusetts and Connecticut recently passed legislation to mandate screening in all school districts. Other states have commissioned studies to determine the status of vision services to children in their states and still others have proposed legislation that would require parents to provide documentation that their child had received an eye exam by an optometrist or ophthalmologist within twelve months prior to entering school. Only one state, Kentucky, has passed legislation requiring a comprehensive eye examination for school entry for the early school grades.

Proposed federal legislation –Two bills were introduced in Congress during the 2003-04 session, Senate Bill 2749 and House Bill 3602. If enacted, the Secretary of US Department of Health and Human Services, acting through the Director of the Centers for Disease Control and Prevention, would establish a grant program to provide comprehensive eye examination to children and for other purposes.
Opportunities for Action Opportunities for action exist.

They include developing research agendas that document the current prevalence of vision problems, the number of screenings and exams conducted by primary care providers, preschool and school-based programs, community providers and eye care professionals, and the evaluation of the successes and limitations of screening programs and eye examination strategies. In addition to further research on the above-mentioned topics, examination of screening techniques, screener skill levels, and follow-up on screening deserve examination. Other opportunities for continuing to refine children’s vision services might include developing common screening standards and common recommendations for eye exams that could lay the foundation for a meaningful compilation of statewide and national data. In addition, parent and care giver education on the importance of early detection and timely treatment, standardization of screener qualification and training and augmenting existing school-based vision screening with eye examination requirements could be undertaken.

Conclusion

We have insufficient research to answer many important questions that are critical to establishing good public policy around vision testing for children. Opportunities do exist to move this field forward. The challenge will be, in an era of budget constraints at the state and federal level, to find the public will to press ahead. Building upon the shared interests of private sector optometrists and ophthalmologists, as well as the public sector agencies of health and education more, effective approaches to identifying and treating vision problems among preschool children can be developed.

Childhood Vision: Public Challenges and Opportunities – A policy Brief
Annette Ferebee, MPH (PDF)