Pupil dilation at the first well baby examination for documenting choroidal light reflex

Vision screening for children: current trends, technology, and legislative issues

PURPOSE OF REVIEW

The purpose of this review is to examine current trends in vision screening for children.

RECENT FINDINGS

Literature within the past year regarding children's vision screening has been dominated by clinical validation studies of autorefractors or photoscreeners that allow the detection of amblyogenic refractive errors, misalignment of the eyes, or media opacities. New technologies reported include wave-front analysis for amblyogenic factors and a visual evoked potentials-based screening tool for the preverbal child. Studies evaluating the goals of the screening program, the target population, and the physical limitations of the screening environment have prompted multipronged or hybrid studies designed to more accurately detect vision problems, particularly in the preschool child, in whom cooperation and cognitive development affect reliability of results. State and federal legislation in the United States has been proposed or adopted to regulate and partially fund pediatric vision screening and comprehensive examinations.

SUMMARY

Through improvements and new developments in technology, study design, the efforts of organized medicine, and legislative initiatives, vision screening for children continues toward the goal of bringing all children with eye disease or vision problems to treatment in a timely fashion.

Compliance with vision-screening guidelines among a national sample of pediatricians

OBJECTIVE

The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians.

METHODS

We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening.

RESULTS

Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models.

CONCLUSIONS

Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.