Screening Preschool

Children to Detect Visual and Ocular Disorders policy A Ophthalmology [of

statement1 of the American Academy of asserts that "Most serious ocular conditions infants and children] which can be found at screening and which are treatable are identified in the preschool years." To an ophthalmologist, this is powerful justification for the Academy's recommendations for preschool screening and the similar advice promulgated, for years in some cases, by those devoted to pediatric and ocular health care.2-4 The potential development of irreversible amblyopia can be considered the driving force for screening programs. Early treatment can be curative, but without early treatment of amblyopia, incurable, lifelong visual deficits can be established. Possible associated conditions include refractive errors, strabismus, and cataract. Although compliance with recent

screening guidelines3 appears to promote early treatment, inappropriately late diagnosis of children's eye disorders

persists.5

Technical shortcomings notwithstanding, the main problem with past screening programs has been the absence of screening of most verbal, preschool children. It was pointed out nearly a decade ago,6 and has been reiterated by many, including the rightfully impatient editorialists who have con¬ tributed to the Archives,7·8 that fewer than a quarter of preschool children in the United States have undergone vi¬ sion screening. A survey found that 12 of 20 primary care providers performed no preschool vision screening.9 Even in states where mandated screening affects a high proportion of children, a child who does not attend a regular preschool pro¬ gram will not necessarily undergo screening. Can we sustain a reasoned plea for universal screening? Naysayers will note that screening programs for verbal pre¬ school children have detected eye disorders at a rate far be¬ low their putative prevalence6 and are not needed to find strabismus and conditions causing visual deprivation that are conspicuous in the very early months of life. Admittedly, screening methods should be improved. Potentially improved quantitative assessments of a child's eyes and vision, even before the verbal years, can be made widely available, as the extensive contemporary literature regarding vision in infants and children promises. But which tests should be performed at what age? The early, natural history of amblyopia and other children's eye disorders is imperfectly known. For in¬ stance, the unknown and variable temporal relation of early anisometropia1"12 to the onset of strabismus and amblyopia

frustrates our ability to define the lead time (the time between early detection with screening and the usual time of diagnosis) during which screening should be performed. Even with meticulous use of a test that is acceptable (to the child, to the tester, and to the cost-effectiveness analyst) and reliable and that provides high validity (eg, sensitivity of 90% and specificity of 95%), a prevalence of 2% (as is usually cited for amblyopia13) guarantees that only a few among those la¬ beled amblyopic based on results of the test would, indeed, be amblyopic (in this example, the positive predictive value would be 27%).14 And, of course, missed cases (negative pre¬ dictive value) would also exist. The costs of overreferrals and underreferrals, in terms of family anxiety, professional time, and undetected disease, would have to be weighed with the cost of screening procedures against the potential benefits of early detection and treatment. The main benefit would be reduction of preventable visual loss. Among adults, amblyopia appears to be the leading cause of unilateral visual deficit.15,16 Future loss of vision in an amblyope's good eye is disastrous.17 A child can typically look forward to more than half a century of school and employment that demand performance of visually mediated tasks. For to¬ day's preschool children alone, 20 million people-years (20 million children18x2% amblyopesX50 years) of preventable poor vision could result from amblyopia. The price this nation pays for such loss must be considerable, but there appear to be no validated procedures for quantitatively determining the cost of unilateral, amblyopic visual loss. In sum, much re¬ mains to be learned about the pathophysiologic and epidemi¬ ologie aspects of amblyopia, as well as the science of ocular and visual assessment of children, if technical improvements in early diagnosis and treatment are to be more fully used. Research in this area merits our vigorous support. But stud¬ ies take time. What can be done for children now? Educational and administrative changes do not need to wait for research. Up¬ graded educational programs must be designed to provide parents, pediatricians, and family and general practitioners with information about children's eyes as they develop and about vision and ocular disorders. Specific, practical infor¬ mation is needed, too. Reliable methods for inspection of the globes, corneal reflexes, and red reflexes must be demon¬ strated to those who are not children's eye care specialists if valid assessments are to be obtained by them. Parents should

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be taught to demand an optotype acuity test for verbal, pre¬ school children, and testers must be trained and certified in the proper use of the tests. We must teach physicians providing primary care to children about the priorities that should guide referrals for diagnosis and treatment. Without such referrals, a screening program has little value. Beyond the excellent pamphlets and home eye tests now available, dynamic presentations that permit reiteration and feedback should be accessible to help primary providers and parents retain the information presented. Videotape recorders can bring the recommendations of a knowledgeable advisor to nearly any understaffed health center. We need to advocate the case for vision screening of chil¬ dren before legislators and the public. At a minimum, the Academy's recommendations,1 which recognize that there is more to preschool screening than vision testing of 3-year-olds to 5-year-olds, should be mandated immediately, with suffi¬ cient specifications to ensure implementation. Nearly all preschool children have contact with physicians,19 suggesting that the Academy's recommended screening schedule is fea¬ sible. The red reflexes of every newborn should be inspected

for corneal and lenticular opacities and signs of posterior pole disease. Later, between the ages of 3 and 6 months, inspec¬ tion of the red reflexes should be repeated, and ocular align¬ ment should be observed to detect strabismus. Between ages 3 and 4 years, and again at age 5 years, the acuity of each eye should be tested with an optotype test. Reassessment of the red reflexes and alignment should also be performed at this time. It seems sensible that this testing, if not accomplished by a state's public health program or school program, should fall under the purview of primary providers and should be accomplished in conjunction with well-child visits.2 With a system in operation that contacts every child, and with the habit of ocular and visual assessment ingrained, new screening procedures could be routinely incorporated as they became available and validated. Universal health care cover¬ age for children that emphasizes prevention is under discus¬ sion.20 A comprehensive, nationwide plan could make early ophthalmic assessment and care realities for every preschool child. Our children deserve such a plan. Anne Fulton, MD Boston, Mass

References 1. American Academy of Ophthalmology. Policy statement: Infant and Children's Vision Screening. San Francisco, Calif: American Academy of Ophthalmology; 1991. 2. Preventive pediatrics and epidemiology: primary prevention in the pediatrician's office. In: Behrman RE, Vaughn VC, eds. Nelson Textbook of Pediatrics. 12th ed. Philadelphia, Pa: WB Saunders Co;

1983:189-192. 3. Committee on Practice and Ambulatory Medicine. Vision screening and eye examination in children. Pediatrics. 1986;77:918\x=req-\ 919. 4. Demorest BH, Beauchamp GR, Black BC, et al. Eye care for the children of America: the American Association for Pediatric Ophthalmology and Strabismus. J Pediatr Ophthalmol Strabismus.

1991;28:64-67.

5. Campbell LR, Charney E. Factors associated with delay in diagnosis of childhood amblyopia. Pediatrics. 1991;87:178-185. 6. Ehrlich MI, Reinecke RD, Simons K. Preschool vision screening for amblyopia and strabismus: programs, methods, guidelines, 1983. Surv Ophthalmol. 1983;28:145-163. 7. Reinecke RD. Screening 3-year olds for visual problems. Arch Ophthalmol. 1986;104:33. 8. Hoyt CS. Photorefraction: a technique for preschool visual screening. Arch Ophthalmol. 1987;105:1497-1498. 9. Hillis A, Flynn JT, Hawkins BS. The evolving concept of amblyopia: a challenge to epidemiologists. Am J Epidemiol. 1983; 118:192-205. 10. Abrahamsson

longitudinal study

M, Fabian G, Andersson AK, Sjostrand J. A a population based sample of astigmatic

of

Currently

children, II: the changeability of anisometropia. Acta Ophthalmol. 1990;68:435-440. 11. Almeder LM, Peck LB, Howland HC. Prevalence of anisometropia in volunteer laboratory and school screening populations. Invest Ophthalmol Vis Sci. 1990;31:2448-2455. 12. Sjostrand J, Abrahamsson M. Risk factors in amblyopia. Eye. 1990;4:787-793.

13. von Noorden GK. Burian-von Noorden's Binocular Vision and Ocular Mobility. St Louis, Mo: Mosby-Year Book; 1990:208. 14. Fletcher RH, Fletcher SW, Wagner EH. Clinical Epidemiology. 2nd ed. Baltimore, Md: Williams & Wilkins; 1988:56-58. 15. Visual Acuity Impairment Survey Directors Committee. Manual of Procedures: Visual Acuity Impairment Survey (Pilot Study, 1981-1983). Bethesda, Md: National Eye Institute of the National Institutes of Health; 1981:82. 16. Flynn JT. Amblyopia revisited: 17th annual Frank Costenbader lecture. J Pediatr Ophthalmol Strabismus. 1991;28:183-201. 17. Tommila V, Tarkkanen A. Incidence of loss of vision in the healthy eye in amblyopia. Br J Ophthalmol. 1981;65:575-577. 18. Wegman ME. Annual summary of vital statistics\p=m-\1988. Pediatrics. 1989;84:943-956. 19. Better Health for Our Children: A National Survey: A Statistical Profile. Washington, DC: Select Panel for the Promotion of Child Health; 1981;3:66-69. US Dept of Health and Human Services

publication 79-55071. 20. Harvey B. Special report: a proposal to provide health insurance to all children and all pregnant women. N Engl J Med. 1990;323:1216-1220.

in Other AMA Journals

ARCHIVES OF DERMATOLOGY

Atlas of Cutaneous Laser Surgery David F. Apfelberg, ed; reviewed (Arch Dermatol. 1992;128:1289)

by Roy Geronemus,

MD

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Screening preschool children to detect visual and ocular disorders.

Screening Preschool Children to Detect Visual and Ocular Disorders policy A Ophthalmology [of statement1 of the American Academy of asserts that "Mo...
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