The Status Quo of School Vision Screening

Nearly 1 in 4 children in the United States have not received an eye examination in the past 2 years — and the policies of the nation’s public schools may not be helping to herd children into an optometrist’s office. Last year, Optometry and Vision Science issued a report detailing state-specific variations at every step in the in-school vision screening process, from the methods and criteria of these exams, to which students are being screened and referred. The study exposed the degree to which children from families with income levels below or minority groups are disproportionately affected.¹ 

Although experts consider vision screenings an effective means of detecting disease risk in pediatric populations, no nationwide standards screening exist, and guidance varies from state to state, and some states have no requirements at all.¹ The in-school vision screening program also raises a conundrum; if children are screened for their vision in school, some parents may have the impression that seeing an optometrist separately is redundant and unnecessary. This appearance and the overall low quality of the noncomprehensive exams offered have some experts asking if in-school exams should even be continued. Afterall, even when these screenings are most effective — in preschool aged children between ages 3 and 4 — they are are under utilized.^2,3

Here, optometrists consider the use and effectiveness of these screening methods in communities and offer ideas that may help bolster their best aspects while guiding patients to comprehensive optometric care. 

Recommendations

Currently, only 41 states require any vision screenings for school-aged children — to be performed in school or elsewhere in the community for children who do not attend a public institution. All 41 of these states require screenings in public elementary school, 30 mandate them in middle schools, and 19 continue to require them into high school. Distance acuity is the most common test, followed by color vision and near vision analysis. Only 6 states require screening annually or every 2 years, according to the findings of the Optometry and Vision Science report.¹

Data on the effect of these vision screenings is scant, which undermines efforts to develop comprehensive recommendations. In fact, no universally accepted definition of “vision screening” even exists, making the methods by which screenings are implemented across states subjective and potentially at the mercy of political spending. 

“Due to the lack of documented benefits of vision screening and possible risks, support for vision screening at the population level remains unsubstantiated. Implementation of vision screening could potentially harm health, especially due to delayed interventions for a multitude of missed diseases and conditions missed with ‘vision screening’ that are identified with comprehensive eye examination,” explained eyecare policy expert and AOA board of trustees member Lori Latowski Grover, OD, PhD. In other words, parents might be under the impression their child has received a primary eye exam when they have not. And the missed diagnoses that these exams would have caught could lead to devastating outcomes for the child’s visual and ocular health. 

“Avoid ‘vision screening’ and promote health through evidence-based methods that support increased uptake of available optometric eye and vision care,” Dr Grover said. “Until future ‘vision screening’ research demonstrates evidence-based population benefit outweighing health risks, and improved health outcomes comparable to those achieved by front-line optometric eye care and comprehensive eye examination, promoting population health through advocacy for ‘vision screening’ remains a risky, low-value approach to population health and health equity.”

Benefits of School-Based Vision Programs

While the school screening system is flawed, it is in place in much of the country. And with its infrastructure, optometrists can make the most of the opportunity and even elevate them. Take, for instance, the Vision for Baltimore (V4B), a citywide school-based vision program that offers vision care for all Baltimore City Public School students between the ages of 4 and 16 years.⁵

Research into its effects show it was able to “play a critical role for students who are not accessing eye care, especially in disadvantaged communities. In the US, school-based vision programs often provide vision screenings, eye exams, and eyeglasses directly in the school setting. The rationale for involving schools in vision care delivery is the recognition of the inter-relatedness between health and education, including how poor vision can impact learning.”⁵

The program was able to achieve one particular goal that aligned with the school’s mission: it verifiably improved academic performance.⁵ Students with refractive errors who received eyeglasses after being screened in the V4B performed better on reading assessments — and that effect was especially pronounced in students enrolled in special education courses, as well as those who previously were in the lowest quartile in reading and math assessments, the research shows.⁵

“In Baltimore, based on these findings, we successfully increased program outreach through participation in school-wide events, including staffing a V4B informational booth at back-to-school nights, creating a V4B website and social media campaign, offering virtual health education for parents and teachers, and adopting telephone consent options to facilitate consent form return,” investigators reported.⁵

Getting Involved

School screenings appear most effective when they are used as an adjunct to comprehensive exams that occur in the clinic, according to William T. Reynolds, OD, past president of the AOA.

“Being involved in schools and the school system is important. For school screenings to be effective, they must be an adjunct to comprehensive exams,” he said. “School screenings don’t diagnose, and often don’t result in a child receiving care. Additionally, there are a lot of inherent problems with school screenings. Screening protocols are far from standardized; some are elaborate with well-trained screeners, and some are as rudimentary as looking at the Snellen eye chart from 20 feet away.” 

Dr Reynolds asserts that many binocular-tracking problems and issues involving prolonged use of the eyes go undetected during a routine vision screening. This is especially concerning with the proliferation of screen time associated with distance learning, excessive digital gaming, and social media use. He contends that vision screenings are a poor substitute for comprehensive examinations in determining whether children entering school are visually prepared to learn.

“There is wide disagreement on the best way to address through screenings and exams. The more discussion we can get on it, the better we can do for all our children,” he said.

Hope for a National Approach

According to Dr Reynolds, comprehensive eye exams prior to entering kindergarten should become national policy, as it is in his home state of Kentucky. 

“Screenings are regulated at a state level and there is a wide variety of protocols. It would be ideal if there was uniformity in protocols across the country but politically it would be difficult to accomplish,” he said.

Barring implementation of such a policy, Dr Reynolds believes that optometrists can work directly with school districts to ensure student accessibility to vision care. The AOA’s Comprehensive Pediatric Eye Examination Guidelines, shows that 61% of children found to have eye or vision problems through screening never visit the doctor for follow up care.⁶  Perhaps, being active in local school communities can change that.

“Doctors of optometry should reach out to the school district,” he said. “Local eye-care providers are very happy to work with school districts and make sure that children who fail the screenings get follow-up care in a doctor’s office.”

References

1. Wahl MD, Fishman D, Block SS, et al. A comprehensive review of state vision screening mandates for schoolchildren in the United States. Optom Vis Sci. 2021;98(5):490-499. doi:10.1097/opx.0000000000001686

2. Joish V, Malone D, Miller J. A cost-benefit analysis of vision screening methods for preschoolers and school-age children. J AAPOS. 2003;7(4):283-90. doi:10.1016/s1091-8531(03)00116-2.

3. Castanes M. Major review: The underutilization of vision screening (for amblyopia, optical anomalies and strabismus) among preschool age children. Binocul Vis Strabismus Q. 2003;18(4):217-32.

4. Vision in children ages 6 months to 5 years: Screening. Recommendation: Vision in Children Ages 6 Months to 5 Years: Screening. United States Preventive Services Taskforce. www.uspreventiveservicestaskforce.org/uspstf/recommendation/vision-in-children-ages-6-months-to-5-years-screening. Updated September 5, 2017. Accessed February 12, 2022.

5. Collins ME, Guo X, Repka MX, Neitzel AJ, Friedman DS. Lessons learned from school-based delivery of Vision Care in Baltimore, Maryland. Asia Pac J Ophthalmol. 2022;11(1):6-11. doi:10.1097/apo.0000000000000488 

6. Evidence-Based Optometry Process. American Optometric Association. https://www.aoa.org/practice/clinical-guidelines/evidence-based-optometry-process. Updated: July 28, 2017. Accessed March 18, 2022.