Alan Frank, OD
It’s time for universal standards on children’s vision. We’ve all seen the little 7-year-old kid who presents for her first routine eye exam. She and mom think she sees great until after seeing 20/20 in the right eye, we discover she can’t even see the big “E” with the left. Eye refraction reveals plano in the right eye and +6.00 D sph in the left. The diagnosis: Refractive Amblyopia OS. It breaks my heart.
Optometrists and ophthalmologists know that if a monocular vision deficit is detected at an early age, early and inexpensive intervention can mitigate outcomes like the one experienced by the little girl in the scenario above. For example, more than 20 percent of children up to age 5 are estimated to have over 2.00 D of hyperopia, a risk factor for the development of strabismus and amblyopia. And more than 3.00 D of anisometropia may lead to the development of amblyopia in preschool-age children. When we consider that 80 percent of what we learn is obtained through visual processing of information, undiagnosed and untreated vision problems put children at a developmental disadvantage.
In a perfect world, all children would have a comprehensive eye exam by age 3. The National Institute of Health (NIH) and the National Eye Institute (NEI) have left it up to the individual eyecare disciplines to set their standards, but the standards differ among these groups. The American Association of Pediatric Ophthalmology (AAPO) advocates rigorous screening in the pediatrician’s office since the kids will show up there most often. (For pediatric ophthalmology standards, visit the American Academy of Ophthlamology’s website at aao.org.) Pediatricians would then refer children with vision concerns to pediatric ophthalmologists. The American Optometric Association (AOA) in turn advocates for early professional eye exams, at around age 3, and a written report to the pediatrician. The AOA Comprehensive Pediatric Eye and Vision Examination Evidence-Based Clinical Practice Guideline reports, “Although comprehensive pediatric eye and vision examinations are essential for timely diagnosis and treatment of eye disease and maintenance of good vision, many children do not receive comprehensive eyecare. An estimated 1 in 5 preschool children and 1 in 4 school-age children in the United States has a vision problem; however, the Centers for Disease Control and Prevention (CDC) report that less than 5 percent of preschoolers receive an eye examination by an eyecare professional, and less than 22 percent receive some type of vision screening. (For optometry standards, go to the AOA’s website at www.aoa.org.) The AOA cites overwhelming accessibility to optometric offices and the relatively low cost of a basic eye exam. Likewise, treatment for amblyopia is easy and inexpensive.
This author proposes standardized guidelines for pediatricians, which would require them to order a comprehensive professional eye exam by either a doctor of optometry or a pediatric ophthalmologist for children at 3 years of age. A written report from the ECP should be part of the pediatrician’s file. As the AOA Practice Guideline recommends, “Information shared with other health care providers offers a unique and important perspective resulting in an improved team approach to interdisciplinary care of the patient.” This relieves the pediatrician of the burden and responsibility for the child’s eyecare and a fail-safe approach to detecting amblyopia. No doubt, regular screening of the child’s vision in the pediatrician’s office adds another layer of safety net. At the local level, workshops between the pediatricians and the eyecare professionals should be encouraged to foster collaborative pediatric health care. On a national level, I advocate for a representative from the AMA, AAPO, the AOA and the pediatrician’s medical society, under the guidance of the NIH and NEI, work together to develop universal standards across the disciplines.
In summary, early detection of vision abnormalities is essential to enhancing children’s vision and aiding learning development. Hopefully, more attention will be devoted to this important issue in the near future. It’s the right thing to do!
Alan Frank, OD, is an advocate for children’s vision and third-party vision plans that address pediatric vision needs. He resides in Northeastern Pennsylvania, where he practices primary care optometry.