Alaska Blind Child Discovery

2010 ABCD Favorites

"What Should Pediatricians Use / Purchase for "State-of-the-Art" 2007 Vision Screening?"
The Monumental VIPS study, in the first two of three planned phases, addressed the question: If you only had one screening tool to be most sensitive for screening pre-K children at a 90% specificity, what would perform best? VIPS used some tests with outside, predetermined referral thresholds developed at a 96-98% specificity (photoscreening) and also internally developed referral criteria for other linear output devices (Retinomax, Suresight, acuity tests). The better VIPS objective tests were Suresight and Retinomax, however the referral criteria used by VIPS are not the same as the referral criteria a pediatrician would find as the manufacturer's levels. Therefore, most pediatricians would have far too many false positives.
The AAPOS Vision Screen Committee does NOT recommend a single screening for pre-schoolers, rather it recommends a series of age-appropriate guidelines (AAP) combined with appropriate history and physical findings.
In addition to newborn red reflex testing and infant fixation / cover testing, Bruckner Testing is a useful tool for an experienced pediatrician. As Sean Donahue demonstrated with over 100,000 real community MTI photoscreenings, specific early toddler photosreening might actually "prevent" amblyopia in many cases. Carefully interpreted photoscreening and remote autorefraction in toddlers can identify one of the most important, and occult amblyopiagenic factors: inability to sufficiently accommodate in one or both eyes, in various meridia. Pediatricians can now bill for objective photoscreening with CPT 99174. In our experience, objective screening works very well in community screening from age 1 to age 7 years and takes only 20-30 seconds per child.
Objective testing varies in price with the cheapest ($100) being self-interpreted commercial digital cameras, mid-range being Suresight, iScreen and the Photoscreener (old MTI) at about $5000, and the high end being Retinomax and the German, computer-interpreted, infrared PlusOptix photoscreener at about $10,000. ABCD and District 49 Lions mainly use PlusOptix S04 and S08. ABCD suggests some modifications to enhance Plusoptix screening.
Subjective testing of acuity can be done on a few children three years or younger, however the ability of Pediatrician technicians to do this test well is more age-dependent. Unless we better educate pediatricians and improve the skills of their technicians, objective testing will out-perform acuity testing in pre-K; this is the motivation behind our own "See by Three" Projects. There are some good points about characteristics of good acuity tests; it is amazing to find how poor quality charts some "good" pediatricians are using! Another critical point is assuring monocular testing. This can be assured by patching the non-tested eye in the majority of children who accept this method. Special broadly occluding spectacle frames work for finicky patch kids. Acuity testing can seek a threshold for each eye and refer pre-K unable to achieve 20/40 or two line difference; this takes about 3-7 minutes to screen a child. Another good method is to screen only a critical line of 20/40 for each eye; this takes 2-4 minutes per child. Pediatricians can, and should, charge for monocular acuity testing using 99173.
Acuity testing becomes faster, and more efficient in older children but still MUST assure monocularity.
Pediatricians might purchase a computer, wall-mounted, multi-optotype remotely-operated screening system like we have in our lanes for over $3000, or illuminated wall charts for $100-$500, or flip charts for $20-$50. There are child-friendly computer-game acuity tests that might appeal to many pediatricians. Consistent critical line charts can be obtained free online, so no American child should "go blind" for lack of a chart.
(Financial Disclosure: ABCD received discounted vision screening materials / technology from many of the manufacturers mentioned but receives no direct payment to ABCD workers)
Warmly,
Robert Arnold, MD
Anchorage