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Improving Early Childhood Eyecare

Policy Date: 1/1/2001
Policy Number: 20011

THE AMERICAN PUBLIC HEALTH ASSOCIATION,
Recognizing that visual development from birth through school age has sensitive and critical periods where abnormalities can lead to permanent impairments, especially in the development of binocular vision, an important part of human vision; and
Realizing that conditions such as strabismus (ocular misalignment) including esotropia (crossed eyes) and exotropia (outward turned eyes) occur in up to 6.7% of children prior to age 51-5 and anisometropia (significant difference in refractive prescription between the eyes) has a 1% prevalence3-6 and clinically significant hyperopia (farsightedness) a prevalence of 3-6%6,7; and
Noting that clinically significant hyperopia causes almost half of all cases of esotropia and over 90% of cases of anisometropia, and that these and strabismus are responsible for nearly all amblyopia, the leading visual impairment in children, with a prevalence of up to 4.5%2-9; and
Noting that the majority of eye and vision conditions in infancy and preschool ages are not obvious on gross examination and go undetected until children can read standard letter acuity charts around age 5 years2,4,5,10; and
Noting that decreased binocular vision and depth perception can lead to problems in gross motor and fine motor development, and that uncorrected hyperopia is associated with deficits in visual perceptual skills, reading readiness, intelligence quotient, and reading achievement,11-19 and correction of hyperopia by age 4 improves the expected reading achievement later in school20; and
Realizing that infant and early comprehensive childhood eyecare is a neglected area, that less than half of pediatricians perform even limited vision screenings,21 and pediatric screening when performed is usually limited to a light reflex test which will not detect most strabismus, hyperopia or anisometropia; and
Noting that despite previous APHA resolutions22,23 and United States Public Health Service Preventive Services Task Force Guidelines,24 there is a paucity of public health preschool vision screening programs and those programs that exist have low sensitivity and specificity for the above conditions25; and
Recognizing that the American Academy of Pediatrics,26 the American Academy of Ophthalmology,27 The American Association for Pediatric Ophthalmology and Strabismus,28 the American Optometric Association,29 the U.S. Public Health Service30 and Prevent Blindness America31 agree that screening under age 3 is not successful but there is ample evidence that amblyogenic conditions should be detected and treated as early as possible; and;
Realizing that despite intensive efforts to develop eye screening devices such as photorefraction there is at this time no valid screening method for detecting most strabismus, amblyopia, and hyperopia prior to age 54,32,33; and
Noting that reducing blindness and vision impairment in children ages 17 years and under is an objective in Healthy People 201034; therefore
1. Encourages a regular comprehensive eye examination schedule as opposed to just screening based on the onset of strabismus and amblyopia should be set, so that all children have exams performed at approximately age 6 months, 2 years, and 4 years;
2. Encourages all children's health insurance programs to provide vision care benefits.
3. Encourages health insurers to educate parents on the value of adhering to the comprehensive eye exam schedule through the use of health care providers, health education and health promotion professionals as an important part of preventive health care just as vaccination, physical exam, hearing, and dental exams are;
4. Encourages pediatricians to recommend all children receive exams which have the ability to detect all cases of strabismus, amblyopia, and refractive errors, and refer children at high risk including but not limited to children born prematurely, children with developmental deficits, and children with family histories of strabismus and amblyopia;
5. Requests all children’s health programs require monitoring in their quality assurance programs to insure that young children’s eye and vision needs are met.
References
1. Stidwill D. Epidemiology of strabismus. Ophthalmic Physiol Opt 1997;17:536-9.
2. Moore BD. The epidemiology of ocular disorders in young children. In: Eye care for infants and young children. Boston: Butterworth-Heinemann, 1996:21-30.
3. Lennerstrand G, Jakobsson P, Kvarnstrom G. Screening for ocular dysfunction in children: approaching a common program. Acta Ophthalmol Scand 1995;77: 26-38.
4. Hatch SW. Ophthalmic research and epidemiology. Boston: Butterworth-Heinemann, 1998:265-268,193-228.
5. Blohme J, Tornqvist K. Visual impairment in Swedish children. III. Diagnoses. Acta Ophthalmol Scand 1997; 75:681-7.
6. Kleinstein RN. Vision disorders in public health. In: Newcomb RD, Marshall EC. Public health and community optometry, 2nd Ed. Boston: Butterworth-Heinemann 1990:109-125.
7. Moore B, Lyons SA, Walline J, et al. A clinical review of hyperopia in young children. J Am Optom Assoc. 1999;70:215-24.
8. Newman DK, East MM. Prevalence of amblyopia among defaulters of preschool vision screening. Ophthalmic Epidemiol 2000;7:67-71.
9. Dell W. The epidemiology of amblyopia. Problems in Optom 1991;3(2):195-207.
10. Arnaud C, Baille MF, Grandjean H, et al. Visual impairment in children: prevalence, aetiology and care, 1976-85. Paediatr Perinat Epidemiol 1998;12:228-39.
11. Grisham JD, Simons HD. Refractive error and the reading process: A literature analysis. J Am Optom Assoc. 1986;57:44-55.
12. Grosvenor T. Refractive status, intelligence test scores, and academic ability. Am J Optom Physiol Opt 1970; 47:355-61.
13. Hoffman LG. The relationship of basic visual skills to school readiness at the kindergarten level. J Am Optom Assoc 1974;45:608-13.
14. Williams SM, Sanderson GF, Share DL, Silva PA. Refractive error, IQ, and reading ability: A longitudinal study from age seven to 11. Devel Med Child Neurol 1988;30:735-42.
15. Solan HA, Mozlin R, Rumpf DA. Selected perceptual norms and their relationship to reading in kindergarten and the primary grades. J Am Optom Assoc. 1985;56:458-66.
16. Scheiman MM, Rouse MW. Optometric management of learning-related vision problems. St. Louis: Mosby Year-Book, 1994.
17. Rosner J, Gruber J. Differences in the perceptual skills development of young myopes and hyperopes. Am J Optom Physiol Opt 1985;62:501-04.
18. Rosner J, Rosner J. The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc 1997;68:648-50.
19. Rosner J, Rosner J. Some observations of the relationship between visual perceptual skills development of young hyperopes and age of first lens correction. Clin Exper Optom 1986;69:166-68.
20. Committee on Practice and Ambulatory Medicine. Vision screening and eye examination in children. Pediatrics 1986;77:918-19.
21. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screenings in pediatric practice: a study from the pediatric research in office settings (PROS) network. Pediatrics 1992;89:834-38.
22. APHA Resolution 8203: Children’s Vision Screening. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC: APHA, current volume.
23. APHA Resolution 8905: Children’s Preschool Vision and Hearing Screening and Follow-Up. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC: APHA, current volume.
24. United States Public Health Service. Vision screening in children. Am Fam Physician 1994;50:587-90.
25. Preschool Vision Screening: Maternal and Child Health Bureau and National Eye Institute Task Force on Vision Screening in the Preschool Child. Pediatrics 2000;106:1105-16.
26. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. Eye examination and vision screening in infants, children, and young adults. Pediatrics 1996; 98:153-7.
27. American Academy of Ophthalmology. Pediatric Eye Evaluations. Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 1997.
28. The American Association for Pediatric Ophthalmology and Strabismus. Eye care for the children of America. J Pediatr Ophthalmol Strabismus 1991;28:64-7
29. American Optometric Association Consensus Panel on Pediatric Eye and Vision Examination. Optometric clinical practice guidelines: pediatric eye and vision examination. St. Louis: American Optometric Association, 1994.
30. U.S. Public Health Services Task Force. Guide to clinical preventive services, Second Edition. Washington, DC: U.S. Department of Health and Human Services, 1996.
31. Gerali P, Flom MC, Raab EL. Report of Children’s Vision Screening Task Force. Schaumburg, IL: National Society to Prevent Blindness, 1990.
32. Cooper CD, Gole GA, Hall JE, et al. Evaluating photoscreeners II: MTI and Fortune videorefractor. Austral N Zealand J Ophthalmol 1999;27:387-98.
33. Mohan KM, Miller JM, Dobson V, et al. Inter-rater and intra-rater reliability in the interpretation of MTI photoscreener photographs of Native American preschool children. Optom Vis Sci 2000;77:473-82.
34. Bowyer NK, Kleinstein RN. Health People 2010—Vision objectives for the nation. Optometry 71:569-78.