REQUIRED VISION EXAMINATIONS ANDVISION SCREENINGS FOR CHILDREN:CURRENT RESEARCH WILLIAM T. REYNOLDS, O.D. RICHMOND, KENTUCKY JOEL N. ZABA, M.A., O.D. VIRGINIA BEACH, VIRGINIA
PREVALENCE OF VISION PROBLEMS • Amblyopia is the most common cause of monocular visual impairment in children and young and middle-aged adults. Rutstein R. Contemporary Issues in Amblyopia Treatment. Optometry: Journal of the American Optometric Association: Volume 76/Number 10/October 2005. • It has been estimated that Amblyopia, the leading cause of vision loss in young Americans, affects 500,000 preschoolers.
PREVALENCE OF VISION PROBLEMS • "Conclusions: Visual impairment due to uncorrected refractive error is a common condition in the United States. Providing appropriate refractive correction to those individuals whose vision can be improved is an important public health endeavor with implications for safety and quality of life.” Vitale, S, Cotch, M, Sperduto, R. Prevalence of Visual Impairment in the United States: JAMA, May 10, 2006—Vol 295, No. 18.
PREVALENCE OF VISION PROBLEMS • Vision disorders have been considered the fourth most common disability in the United States and they are one of the most prevalent handicapping conditions in childhood. Ciner E, Dobson V, Schmidt P, et al. A Survey of vision screening policy of preschool children in the United States. Surv Opthalmol 1999 March-April: 43(5): 445-457.
Prevalence of Vision Problems • The Prevent Blindness America organization states that vision problems affect one in four school-aged children. Prevent Blindness America. Your child’s sight . Illinois: September 1997. • The National Parent Teacher Association reports that more than ten million children experience vision problems. National PTA Resolution. Learning-related Vision Problems Education and Evaluation, June 1999.
Vision, Child Development, and Education • “The importance of vision and its relationship to childhood development and the educational environment has been noted in both the education and vision care literature.” Zaba J, Johnson R, Reynolds W. Vision Examinations for All Children Entering Public School: The New Kentucky Law. Optometry: Journal of the American Optometric Association 2003 March: 74 (3): 149-158.
Vision, Child Development, and Education • “Impaired vision can affect a child’s cognitive, emotional, neurologic and physical development by potentially limiting the range of experiences and kinds of information to which the child is exposed.” U.S. Centers for Disease Control and Prevention (CDC) 2005.
Vision, Child Development, and Education • Two in three children do not receive any preventive vision care before entering elementary school. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, May 6, 2005.
Consequences of Undetected and Untreated Vision Problems Significant numbers of vision problems have been found in the following groups: • Behaviorally at risk children • Academically at risk children • Adjudicated adolescents • Title I children Zaba, J. Social, Emotional, & Educational Consequences of Undetected Children’s Vision Problems: Journal of Behavioral Optometry: Volume 12/2001/Number 3/Page 66.
VISION SCREENING • Examiner tests the accuracy of vision in each eye and possibly whether the eyes are straight and working together. A screening detects potential problems but does not diagnose them.
COMPREHENSIVE EYE EXAM • “Gold Standard”, according to NIH study: an Optometrist or Ophthalmologist dilates the pupils and evaluates the ocular health of the eye, including the optic nerve and retina. The examination produces a diagnosis, and, if indicated, a spectacle lens prescription.
Preschool Vision Screening in Pediatric Practices • “Our findings underscore the importance of financial issues for vision screening. We were surprised that half of the respondents reported that there should be separate reimbursement for vision screening.” Kemper, P., MD, MH, MS; Clark, S., MPH. Preschool Vision Screening in Pediatric Practices: Clinical Pediatrics, April 2006.
Preschool Vision Screening in Pediatric Practices • Among those pediatricians who routinely attempt formal preschool vision screening, half (51%) reported that they bill insurance separately for that activity. Kemper, P., MD, MH, MS; Clark, S., MPH. Preschool Vision Screening in Pediatric Practices: Clinical Pediatrics, April 2006.
Preschool Vision Screening in Pediatric Practices Barriers to Vision Screening (n= 377) Practice-related factors Children are not cooperative with screening 49% Screening is too time-consuming 23% Lack of training 15% Referral-related factors Lack of insurance for follow-up care 17% Lack of eye care provider 15% Concern about parent reaction to false-positive referral 3% Kemper, P., MD, MH, MS; Clark, S., MPH. Preschool Vision Screening in Pediatric Practices: Clinical Pediatrics, April 2006.
Follow Up After Failed Vision Screenings “Lack of Follow-up Exams after Failed School Vision Screenings: An Investigation of Contributing Factors” Kimel, L., RN, MS.: The Journal of School Nursing, June 2006. Why are so many students not receiving follow up exams?
Follow Up After Failed Vision Screenings Barriers to Follow-up Care (n=55) Financial barriers% • Cost and money concerns 31 • No insurance coverage 11 • Waiting for insurance 9 Logistical barriers % • Appointment problems 22 • Can’t plan ahead 16 • No phone 11 • No car 9
Follow Up After Failed Vision Screenings Barriers to Follow-up Care (n=55) Social/Family barriers % • All adults work 45 • Family Issues 34 • Large family 29 • Parent disabled 13 • Change in residence 11 Perceptual barriers % • Do not believe results 38 • Not a priority 38 • No need for an exam 29 • No interest in follow-up 18
Follow Up After Failed Vision Screenings • “The study population had significantly more minority and low-income families than the general school population has.” Cost was a barrier mentioned by almost one-third of the participants. When examined closer, only 11% of participants did not have readily available funding sources. Most of this group would have qualified for assistance through Vision Service Plan Sight for Students vouchers or Lions Club International, but did not request the support.” (emphasis added) Kimel, L., RN, MS. Lack of Follow-up Exams after Failed School Vision Screenings: An Investigation of Contributing Factors: The Journal of School Nursing, June 2006
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Vision Screenings SCREENING ADVOCATES ARGUE-- • Screenings do an adequate job of detecting problems • Eye exams are not cost effective • Not enough manpower for exams • Primary care O.D.’s are not qualified to do pediatric exams • Vision is not related to learning
Vision Examinations VISION EXAM ADVOCATES ARGUE-- • Screenings do not do an adequate job of detecting problems • Exams are cost effective • Vision is related to learning and every child deserves to enter school visually ready to learn
Vision Screening Performance • Vision in preschoolers study (VIP)- Under ideal circumstances about 1/3 of the children with targeted conditions were missed. • National Institute of Health Study (2004) Screenings failed to detect roughly 10% of children’s problems including Amblyopia and strabismus.
Making the Grade? An analysis of state and federal children’s vision care policy July 2005 Vision Council of America 1700 Diagonal Road #500 Alexandria, VA 22301 www.2020advocacy.com
Making the Grade? Current Updates as of September, 2006 • Seventeen states do not require children to receive any preventive vision care before starting school or during the school years. • Thirty-three states (including the District of Columbia) require vision screening, but 29 of them do not require children that fail the screening to receive an eye exam by an eye doctor.
Making the Grade? • One state requires all children to receive an eye exam by an eye doctor before entering elementary school. • Four states (Kentucky, Arkansas, Massachusetts and Ohio) have enacted or enhanced existing laws since 1999 to increase the number of children that receive an eye exam by an eye doctor.
Eye Exams for Children:Their Impact and CostEffectivenessAlan J. White, Ph.D.Prepared by Abt Associates for the Vision Council of America
Cost Effectiveness of Preschool Eye Examinations: Conclusions • Eye exams would detect, treat and cure significantly more cases of amblyopia in children than a universal vision screening program or the “usual patterns of care” that would exist without a formal vision screening program in place.
Cost Effectiveness of Preschool Eye Examinations: Conclusions 2. A universal comprehensive eye exam program would be highly cost effective and produce a greater return on investment than many other health care interventions.
Cost Effectiveness of Preschool Eye Examinations: Conclusions That a vision screening costs less to perform than an eye exam is not the only relevant factor in assessing cost effectiveness. What is relevant is a comparison of the costs and the benefits associated with each procedure.
Cost Effectiveness of Preschool Eye Examinations: Conclusions Based on our evaluation, the higher costs associated with eye exams are more than offset by the gains that result from the additional children who are successfully treated as a result of receiving an eye exam.
Vision Care for Kids Act of 2006 (Introduced in Senate)109th Congress2d SessionS. 3685To establish a grant program to provide vision care to children, and for other purposes.IN THE SENATE OF THE UNITED STATESJuly 19, 2006
Vision Care for Kids Act of 2006 Mr. Bond introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions Section 1. Short Title. This Act may be cited as the “Vision Care for Kids Act of 2006.”
Vision Care for Kids Act of 2006 Section. 2. Findings. Congress makes the following findings: • Good vision is essential for proper physical development and educational progress in growing children. • Many serious ocular conditions are treatable if identified in the preschool and early school-aged years.
Vision Care for Kids Act of 2006 Congress makes the following findings: Section 3. • Early detection of ocular conditions provides the best opportunity for effective, inexpensive treatment and can have far-reaching implications for vision.
Vision Care for Kids Act of 2006 Section 4. Various identification methods, whether vision screening or comprehensive eye exams required by state laws, will identify children needing services. A child identified through vision screening should receive a comprehensive eye exam followed by subsequent treatment as needed.
Vision Care for Kids Act of 2006 Section 4 (cont’d) A child identified through a comprehensive eye exam should receive subsequent treatment as needed. All children identified as needing services should have access to subsequent treatment as needed.
Vision Care for Kids Act of 2006 SEC. GRANTS REGARDING VISION CARE FOR CHILDREN. (2) Providing treatment or services, subsequent to the examinations described in paragraph (1), necessary to correct vision problems; and (3) developing and disseminating, to parents, teachers, and health care practitioners, educational materials on recognizing signs of visual impairment in children.
State of Arkansas House Bill 1734 (a) (1) Beginning with the 2006-2007 school year, all children in pre-kindergarten (pre-k), kindergarten (k), grade one (1), two (2), four (4), six (6), and eight (8), and all transfer students shall receive an eye and vision screening. (b) An eye and vision screening shall include the following tests, procedures, equipment, and insurance approved by the Arkansas Commission on Eye and Vision Care of School Age Children and the Department of Education:
State of Arkansas House Bill 1734 • Observation and external inspection of the eye: • Distance and visual acuity test using a Snellen Eye Chart at twenty feet (20’) or an age developmentally appropriate chart at ten feet (10’) feet outside a vision screening instrument, and • A plus lens visual acuity test using a Snellen Eye Chart at twenty feet (20’) or an age developmentally appropriate chart at ten feet (10’) feet outside a vision screening instrument, and
State of Arkansas House Bill 1734 4. Visual screening instruments which include: • Lateral muscle balance test at far; • Vertical muscle balance test at far; • Fusion or binocularity at far; • Lateral muscle balance test at near; • Fusion or binocularity at near, and • Color perception
State of Arkansas House Bill 1734 Eye exams (a) (1) A child who does not pass the eye and vision screening tests, except for the color perception test, shall be required to have a comprehensive eye and vision examination conducted by an Optometrist or Ophthalmologist within sixty (60) days of receipt of the vision screening report identifying the need for the examination.
State of Arkansas House Bill 1734 • The standardized forms shall include: • A screening form; • A parent notification form; • A doctor report form; • A form to report the results of screening and examination, and • Any other forms deemed necessary by the commission.
The Kentucky Law “A vision examination by an optometrist or ophthalmologist shall be required by the Kentucky Board of Education. The administrative regulations shall require evidence that a vision examination that meets the criteria prescribed by the Kentucky Board of Education has been performed. This evidence shall be submitted to the school no later than January 1 of the first year that the child is enrolled in public school, public preschool, or Head Start programs.”
The Kentucky Experience • Educators’ response • Lawmakers’ response • Governor’s response
The Kentucky Experience Martin L. Bell Deputy of Superintendent Jefferson County Public Schools (Louisville, KY) “The eye exam has been successful in finding numerous cases of previously undetected eye and vision problems in children. We firmly believe as the statute reads the vision exam must be completed by and Optometrist or Ophthalmologist and meet the criteria prescribed by the Kentucky Board of Education. We would oppose any amendment that would be offered to the statute to change this program. We have worked diligently and cooperatively with our local Optometrists and Ophthalmologist to see that nearly all young children are examined.”
The Kentucky Experience Bill Scott, Executive Director Kentucky School Boards Association “Schools can offer the most outstanding educational programs possible, but if children do not come to the school healthy and ready to learn they will miss the opportunities set before them to succeed. Our model of requiring every child entering public school for the first time to have an eye examination by and Optometrist or Ophthalmologist no later than January 1st of the school year is one that you may want to bring forth for replication in every state.”
The Kentucky Experience Tom Burch, Chairman-Health and Welfare Kentucky House of Representatives “Conditions from brain tumors to Amblyopia have been diagnosed in children during the comprehensive eye exam required by Kentucky law. These conditions were not suspected by the parent or found on visits to the family doctor. The eye care provider community has been generous in assisting schools when these is a need and in helping low-income families obtain the exams. There is adequate access to Optometrist and Ophthalmologist who are willing to see children for these examinations. In the past six years, I have received no complaints from parents participating in this program.”
The Kentucky Experience Robert J. “Bob” Leeper, State Senator Kentucky State Senate “As you know, I was somewhat hesitant of this mandate and anticipated a possible outcry from parents over this additional requirement. I am happy to report that after several cycles, I have yet to receive the first complaint.”
The Kentucky Experience Ernie Fletcher, M.D. Governor, Kentucky • “Our Commonwealth has made great strides in identifying and treating the vision ailments that have for too long limited the ability of many of our children to learn and make academic progress. Kentucky’s attention to this issue serves as a model for other states that want to ensure that vision problems receive early attention.”