Alaska Blind Child Discovery
A cooperative, charitable research project to vision screen every preschool Alaskan
AOJ and AOC Symposium 10-16-05 Chicago
Orthoptic Symposium at AAO, Chicago 10/16/2005
Who could be opposed to mandatory comprehensive eye examinations for all children? AAP-AAPOS guidelines presented in light of WHO screening.
When we apply the WHO criteria to the most common treatable blinding disease in childhood- amblyopia- we can understand the Academy's [AAO] position on vision screening; that it should be undertaken by the child's primary care physician starting in the newborn nursery, and continuing through school age, employing other screening venues as required by the population being examined, using age-appropriate tests that will allow the detection of proven amblyogenic factors. Once signficant risk factors for vision loss have been detected, referral should be made to a specialist for further evaluation and treatment.(Kerr, 2006)
Background and Purpose: Does screening / treatment reduce amblyopia and is it worth doing it?
Materials: All children (3126) born in 1982 have been followed from virth to ten years. The second study was an investigation of foun low vision centers to see how many persons become visual handicapped due to amblyopia.
Methods: Up to age of 4, inspection of the eyes and ocular alignment is performed at the Child Health Care Centers. At the age of 4 years, visual acuity is measured at the centers and at school at the ages of 7 and 10 years. All patients at four Low Vision Centers have been investigated with regard to amblyopia. these patients have not been screened for treated for amblyopia. From these two studies, we compare the costs of screening and no screening.
Results: The prevalence of ametropia in the population was 7.7% and strabismus 3.1%. The prevalence of amblyopia (visual acuity ≤0.3) has been reduced from 2% to 0.2%. Results from the four Swedish Low Vision Centers showed that amblyopia was the main cause of decreased visual acuity in one eye in at least 1.72% of the patients. The costs for these people is higher than the cost for screening and treatment.
Conclusion: Visual screening is effective in detecting visual and ocular disorders. The prevalence of amblyopia is greatly reduced with screening. The benefits greatly outweighs the economical disadvantages of screening and treating amblyopic children.(Kvarnstrom, Jakobsson, Lennerstrand & Dahlgaard, 2006)
Intro: In the absence of universally accepted guidelines for preschool vision screening, local and state mandates for recommendations vary considerably. In an effort to promote and protect the cisual development of young children and encourage uniform testing and reporting criteria, the Vision Screening Committee of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) felt compelled to develop responsible, evidence-based guidelines for the detection of amblyogenic risk factors. Risk factors include media opacities, ptosis, strabismus, unequal or significant refractive errors, and below standard visual acuity in one or both eyes.
Results: the guidelines, as the pertain to anisometropia (>1.50 D spherical or cylindrical), hyperopia (>3.50 D in any meridian), astigmatism (>1.5D at 90° or 180° and >1.0D in oblique axis), and myopia (>3.00 D in any meridian) are presented. The pivotal studies upon which the guidelines were based are discussed.
Conclusion: the current guidelines have the endorsement of AAPOS, AACO, AAO, AAP and AAFP; compliance is encouraged.(France, 2006)
Although pediatric vision screening now passes evidence-based scrutiny, and has recent AAP guidelines, routine acuity testing in pediatric offices may still perform poorly.
From 6/2002 through 8/2005, all children aged 0-6 directly referred by pediatric care givers to one pediatric ophthalmologist were compared as to referral indication; failed acuity, strabismus and positive Bruckner test. AAPOS gold standard exam criteria was applied and compared to community photoscreening.
By referral indication, the following are numbers and predictive values: acuity (n=80, PPV 51%), Brückner (n=74, PPV = 89%), Strabismus (n=432, PPV = 81%). Community photoscreening referred n=392 with PPV = 91%. The objective tests and strabismus queries were not age-dependent.
The pediatric home best conforms to WHO guidelines due to case-continuous finding and assistance with treatment compliance particularly for strabismus. Objective tests outperform acuity testing in referral for refractive amblyopia including Brückner test in experienced hands. Observation and history best refers strabismus.(Arnold, Stange & Ryan, 2006)
Introduction: There are four vision screening devices that are currently being used to screen children in the United States.
Results: The MTI PS-100 Photoscreener (Medical Technology and Innovations, Inc, Rivera Beach, Fla) is an off-axis instant film photoscreener. It has been the instrument used by the Lions Club International foundation (LCIF) to provide free vision screening to approximately 400,000 children in eight states.
The VisiScreen OSS-C (Vision Research Corp, Birmingham, Ala) is an off axis photorefractor, that uses 35 mm film. The VisiScreen OSS-C has been used extensively in mass screenings of over 2,000,000 children in eight states.
The iScreen system (iScreen LLC, Memphis, Tenn) is a digital off-axis photoscreener. Pediatricians and general practitioners are the primary users, screening approximately 130,000 children in twelve states.
The Welch Allyn® SureSight Vision Screener is a hand-held autorefractor that is used by pediatricians, general practitioners, and public health organizations.
Conclusion: As states continue to mandate vision screening, the desire to find the most effective device will continue to fuel changes in vision screening technology.(Pfeifer, 2006)
Commonly used methods of vision screening in schools is discussed with the currently accepted criteria for pass/fail. There remain differences on the best test to use, the best age to perform subjective acuities and who should be doing the screening. Some tests are still being used that do no conform to the Snellen gold standard. Testing methods vary in part due to the diversity of the screeners. A follow up mechanism to track children failing screening must be in place in advance of the screening process. Until a standard screening protocol is in place that is both sensitive and specific, and screeners are trained in the testing technique, it will be impossible to validate data. Despite problems, screening at school entry or soon thereafter, remains a valuable tool and should be vigorously recommended to both educators and parents, as it plays an important role in amblyopia detection.(Berg, 2006)
Introduction: The design of a rational screening program is predicated upon reliable rates of referral with known sensitivity and specificity for a given referral threshold. Such decision making is facilitated through the use of Receiver Operator Characteristic (ROC) curves.
Methods: The generation of an ROC curve is demonstrated for a hypothetical vision screening technique when applied to a given population, allows reliable prediction of referral rates for a given sensitivity or specificity.
Conclusion: ROC curves provide a reliable method to facilitate decision making with regard to a screening program, and a method to compare the effectiveness of one screening program to another for the same population.(Miller, 2006)
Background and Purpose: The aim of this paper is to discuss the efficacy of treatment for amblyopia. Does amblyopia therapy work? Do we ever cure patients of amblyopia or simply see partial or temporary improvement in their vision? Is there a best method of treating amblyopia? Is recidivism too high? How do we treat with recidivism in mind? Can amblyopia treatment be effective in older children and in adults?
Method: A review of the older and contemporary literature on amblyopia management was conducted. Relevant papers concerning appropriately performed studies were collated and analyzed to shed light on these questions.
Results: Vision improvement can occur with patching therapy, atropine, and optical penalization, Bangeter foils, occlusive contact lens therapy, and drug therapy. Visual acuity can improve regardless of the type of amblyopia. Vision improvement is seen in younger as well as older patients, pas the commonly accepted age of visual maturity. However, the rate of recidivism is high. Multicenter, prospective, and randomized studies are needed to provide practitioners with the most reliable information on the best treatment for amblyopia.
Conclusion: Despite many questions, which remain unanswered about amblyopia treatment, many of our patients enjoy vastly improved vision at the cessation of treatment. Ultimately, what choice do we have? We must treat when we see amblyopia, employ our best techniques, and hope for adequate treatment compliance to achieve the best results for the most patients.(Furr, 2006)
Introduction: Pediatric ophthalmologists often see children in their office who are being evaluated for school-related difficulties. Parents may be misinformed or uninformed and thus are turning to a trusted source for direction.
Background: Since we typically use our eyes to read the printed word, it would, at first glance, seem obvious that problems with reading equate to eye problems. Therefore, many misconceptions regarding how to impact reading difficulties have ensued.
Methods: A review of pertinent literature regarding learning, reading, and visual system combined with clinical practice was performed. In addition, a review of educational literature and educational psychology literature regarding learning was done.
Results: A summary of the different aspects that compose reading and learning are created. This should help educate both the specialist and the layperson. There are uncommon ocular problems that can interfere with the physical act of reading, while most of the difficulties in understanding and comprehending are intellectual and educational issues.
Conclusion: Armed with knowledge, the pediatric ophthalmologist can assist families in insuring that their child’s efforts are spent in the areas that will most help. In this way, the pediatric ophthalmologist and parents can partner in helping each child achieve their potential.(Granet, Castro & Gomi, 2006)
Pediatric ophthalmologists, orthoptists, and others interested in the eye health of children, have long desired for vision screening to become a “hot” topic. Due to attempts by some in the optical industry to legislatively mandate comprehensive eye exams for all children in the prekindergarten age group, children’s eye health and amblyopia prevention are now being widely discussed. This paper reviews the recent history of the legislative efforts to mandate comprehensive eye exams in young children. In addition, the paper discusses the response by organized ophthalmology to assure the political and legislative decisions that are made are best from the public health standpoint.(Collins, 2006)
Background and Purpose: Despite accelerating growth in United States health care spending, expenditures for pediatric vision screening and treatment of amblyopia remain static. Recent studies have provided new insight into the value of amblyopia screening and treatment. Reasons for the relative lack of resources directed toward pediatric vision screening and proposals for future changes are discussed.
Patients and Methods: A review of pertinent literature on the topic of the economics of pediatric vision screening and amblyopia treatment is presented. Methods to evaluate the relative value of medical interventions are examined as they pertain to pediatric vision screening. Comparisons of the value to pediatric vision screening to other medical interventions and to comprehensive preschool vision examinations are presented.
Results: There is no published data on the amount of money spent in the United States on pediatric vision screening. However, current studies estimate the cost for a vision screening examination to be approximately $10 to $20. The Cost/Quality Adjusted Life-year (QALY) for pediatric vision screening over usual care is approximately $6000/QALY. Amblyopia treatment is estimated to cost approximately $2000/QALY.
Conclusions: Pediatric vision screening is highly cost-effective relative to other medical expenditures and relative to mandatory comprehensive eye examinations. Current economic incentives for performing pediatric vision screening are inadequate and are disproportionately low relative to the benefits received. Inadequate reimbursements discourage commercial interest in pediatric vision screening, bridling technical advancement and political interest for improving the status quo in vision screening. Placement on universal quality measures such as the HMO ‘report cards” or new “pay-for-performance” measures would stimulate economic interest in pediatric vision screening.(Ruben, 2006)
Symposium: “Vision Screening in Children” Conclusion:
Vision screening for amblyopia concerns all of us in the eye community. Everything from public health concerns that amblyopia poses to the natural history of the disease has been discussed by authorities on the subject. The various types of screening in the community and in the schools have been described and compared. Pediatricians, optometrists, ophthalmologists and even politicians have gotten into the heated debate of what is best for the child. Considering the health dollars involved, this is no surprise. The debate rages on. It is our hope that you have enjoyed and learned information from this symposium concerning a very critical topic.(Kutschke, 2006)
Arnold, R.W., Stange, C.A., & Ryan, C. (2006). The compared predictive value of Bruckner, acuity and strabismus from pediatric referrals. Am Orthopt J, 56 (1), 15-21.
Berg, P.H. (2006). Screening methods for the detection of preclinical vision loss in children in the schools: verbal and/or literate children. Am Orthopt J, 56 (1), 26-29.
Collins, M.L.Z. (2006). Screening methods for detection of preclinical vision loss in children: Implementing programs- the political will. Am Orthopt J, 56 (1), 50-53.
France, L.W. (2006). Evidence-based guidelines for amblyogenic risk factors. Am Orthopt J, 56 (1), 7-14.
Furr, B.A. (2006). Efficacy of treatment for amblyopia. Am Orthopt J, 56 (1), 35-43.
Granet, D.B., Castro, E.F., & Gomi, C.F. (2006). Reading: Do the eyes have it? Am Orthopt J, 56 (1), 44-49.
Kerr, N.C. (2006). Symposium: Vision Screening in Children (Introduction). Am Orthopt J, 56 (1), 1-2.
Kutschke, P.j. (2006). Symposium on vision screening in children: Conclusion. Am Orthopt J, 56 (1), 62.
Kvarnstrom, G., Jakobsson, P., Lennerstrand, G., & Dahlgaard, J. (2006). Preventable vision loss in children: A public health concern? Am Orthopt J, 56 (1), 3-6.
Miller, J.M. (2006). Designing a rational screening program. Am Orthopt J, 56 (1), 30-34.
Pfeifer, W. (2006). Screening methods for the detection of preclinical vision loss in children in the community: Technology at work. Am Orthopt J, 56 (1), 22-25.
Ruben, J.B. (2006). Reimbursements and resources for pediatric vision screening. Am Orthopt J, 56 (1), 54-61.