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Evidence-based medicine(1) supports a series of age-based vision screens during the initial amblyopia decade for children.  Technology is now available for widespread early objective screening(2).  Is it NOT best to place financial and legislative efforts toward Kindergarten Exams as the ideal societal vision "screening" in America(3). 
The ATS studies by PEDIG enroll children capable of completing the EVA surround HOTV protocol.  Many have moderate (20/40 to 20/100) amblyopic acuities whereas far less have severe amblyopia (20/125 to 20/400).  The average expected acuity gain by aggressive PEDIG sites is from about 20/63- to 20/32, about 3 logMAR lines(4, 5).  This similar level of acuity gain persisted despite ongoing therapy(6).  Recall the the younger entry age for the PEDIG studies is age 3-4 years.
There is extensive, difficult effort by PEDIG to improve treatment acuity averages to better than 20/32 in older children.
Large-scale photoscreen-detected anisometropic patients may have had the severity of their amblyopia markedly reduced or even prevented(7) when detected at an age before 3-4 years(7).  Children detected by photoscreening less than age 2 years achieved treatment acuities averaging 20/25 whereas those photoscreen detected from age 25 months to 48 months had treatment acuities averaging 20/32 (similar to ATS success levels)(8).
If photoscreened toddlers (age 1-2 years) can achieve an average treated acuity of 20/25, and later detected preschoolers and Kindergarten entry in state-of-the-art, PEDIG practices achieve an average acuity of 20/32 from an average initial amblyopia acuity of 20/63-, then the earlier photoscreening has the potential to augment our best therapy by 25-33%!
This is the reason all states should actively embrace and fund early objective screening instead of Kindergarten Exams.  It costs less(9, 10), and has the potential to yield better vision(11), and less severe amblyopia(12).
REFERENCES:
1.            Calonge N, USPSTF. Screening for visual impairment in children younger than 5 years: Recommendation Statement. Ann Fam Med 2004;2:263-266.
2.            Swanson J, Committee on practice and ambulatory medicine -. Use of photoscreening for children's vision screening (AAP Policy Statement). Pediatrics 2002;109(3):524-525.
3.            Kemper AR, Fant KE, Badgett JT. Preschool vision screening in primary care after a legislative mandate for diagnostic eye examinations. South Med J 2003;96(9):859-62.
4.            PEDIG. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2002;120(3):268-78.
5.            PEDIG, Repka MX, Beck RW, Holmes JM, Birch EE, Chandler DL, et al. A randomized trial of patching regimens for treatment of moderate amblyopia in children. Arch Ophthalmol 2003;121(5):603-611.
6.            PEDIG, Repka MX, Wallace DK, Beck RW, Kraker RT, Birch EE, et al. Two-year follow-up of a 6-month randomized trial of atropine vs patching for treatment of moderate amblyopia in children. Arch Ophthalmol 2005;123(2):149-57.
7.            Donahue SP. Relationship between anisometropia, patient age, and the development of amblyopia. Am J Ophthalmol 2006;142(1):132-140.
8.         Kirk VG, Clausen MM, Armitage MD, Arnold RW. Preverbal photoscreening for amblyogenic factors and outcomes in amblyopia treatment: early objective screening and visual acuities. Arch Ophthalmol 2008;125(4):489-492.
9.         White A. Costs and Benefits of Comprehensive Eye Exams.  2004  [cited 2004 10/28/04]; Available from: http://www.abtassociates.com/Page.cfm?PageID=12301&OWID=2109767275&CSB=1
10.       Arnold RW, Armitage MD, Gionet EG, Balinger A, Kovtoun TA, Machida CJ, et al. The cost and yield of photoscreening: Impact of photoscreening on overall pediatric ophthalmic costs. JPOS 2005;42(2):103-111.
11.            Atkinson J, Braddick O, Nardini M, Anker S. Infant hyperopia: detection, distribution, changes and correlates-outcomes from the cambridge infant screening programs. Optom Vis Sci 2007;84(2):84-96.
12.            Eibschitz-Tsimhoni M, Friedman T, Naor J, Eibschitz N, Friedman Z. Early screening for amblyogenic risk factors lowers the prevalence and severity of amblyopia. J AAPOS 2000;4(4):194-199.

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