In Search of Hyperopes

Last week I brought a group of 1st year optometry students to an elementary school in Brooklyn .  We performed a vision screening on roughly 80 pre-kindergarten, kindergarten and 1st grade students.  I really enjoy taking 1st year students on vision screenings.  It’s their first real clinical experiences.  They get to practice what they have been taught on patients other than their classmates.  There are so many “teachable moments.”  It never takes more than 5 minutes before one of them notices something worthy of a referral for a comprehensive vision examination.  They begin to see the connections between various measurements and visual function in a classroom (and beyond!).  And who can resist smiling when you watch a 5 year old try to take apart a student’s  ophthalmoscope.

The purpose of a vision screening is to identify children with vision problems requiring intervention.  Sometimes these vision problems are easily overlooked.  A classic example is hyperopia (farsightedness).

When children are farsighted, they are able to compensate for the hyperopia by focusing their eyes.  They have to focus even more when reading or performing other near vision tasks.  The greater the hyperopia, the greater the focusing effort.  All that focusing can cause eye fatigue, intermittent blur, headaches, and inefficiency when using the eyes to gather information.  But it also allows the young hyperope to avoid blurry vision.  These children will pass the vision screening unless you search for the hyperopes.  That is one of the tests that we perform during a vision screening.  We include a certain procedure to look specifically for hyperopes with good visual acuity.

But a little bit of hyperopia is expected in children…….. so when do you refer?  How much hyperopia warrants a comprehensive eye exam and the possibility of an eyeglass prescription?

When discussing referring or prescribing for uncorrected hyperopia, I often point to an article written by Dr. Jerome Rosner in 1997:  The relationship between moderate hyperopia and academic achievement.  Rosner looked at the correlations between refractive error and performance on reading tests in a group of 782 elementary school children.  He found that the children with uncorrected hyperopia greater than +1.25 diopters were more likely to have lower reading scores.

Dr. Rosner drew a line in the sand — for children with hyperopia greater than +1.25, a comprehensive vision examination is indicated to determine if that child would benefit from lenses.  That was the number we used at the vision screening.  We referred many children for a variety of reasons;  that included several children who were able to read the letters on the chart 10 feet away, despite uncorrected hyperopia of greater than +1.25.

But identifying these children is only the first step in the battle against learning related vision problems.  These children need comprehensive vision examinations.  Hopefully that will happen and these children will be well on their way to successful performance in and out of the classroom.

Read more about vision screenings here and here.

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The Science – A Glimpse into our Children’s Vision

As I go out and speak with parents, teachers, and doctors, I am almost invariably asked one question.  How can we do a better job of detecting vision problems in our children?  It really is a great question when you consider the following grim statistics:

• One in four children have a vision problem that can affect learning¹
• 60% of students identified as problem learners have undetected vision problems²
• 64% of children ages five and younger have never had their vision screened by a healthcare professional³
• 32-63% of vision problems identified by comprehensive eye examinations were missed in school screenings⁴

Looking at the scope of the problem, anyone can see that this issue is not going to be solved overnight.  Enhanced vision screenings in our schools, more children receiving comprehensive vision exams before entering school, and educating the public on how vision can affect school performance; these are large-scale efforts currently underway by many of COVD’s members throughout the country.  However, there are things each of us can do to help those children we work with everyday.

One great tool we have is the Convergence Insufficiency Treatment Trial (CITT) Symptom Survey.  Other than being a mouthful, this checklist represents one of the great accomplishments of evidence-based medicine.  In 2008, the Archives of Ophthalmology published the results of research sponsored by the National Institute of Health on the treatment of  Convergence Insufficiency, one of the leading vision problems in children.  This condition is often associated with headaches, double vision, and eyestrain.  The study concluded that for an overwhelming majority of these children, the condition is very treatable.

From that study, we have gleaned the CITT Symptom Survey.  In a matter of a few minutes we can now screen children with a tool that is highly predictive for both convergence insufficiency and other functional vision problems⁵.  This one-page symptom survey can easily be filled out as part of the intake process in any office or can be sent home with parents.  It is quick, easy to score, and communicates to parents the types of vision struggles their child is having.   Here is a copy of the CITT Symptom Survey.

Unfortunately, we can’t see through a child’s eyes.  The CITT symptom survey at least gives us a glimpse.

1. Comprehensive Eye Exams Particularly Important for Classroom Success. (2008, August 4). American Optometric Association.

2. ADD/ADHD and Vision. (2011).  College of Optometrists in Vision Development

3. Cotch, M. (2002). Visual Impairment and Use of Eyecare Services and Protective Eyewear Among Children. USA Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report, 425-429.

4. Danahuse, S. P., Johnson, T. M., & Leonard-Martin, T. C. (2000). Screening for Amblyogenic Factors Using a Volunteer Lay Network and the MTI Photoscreener: Initial results from 15,000 Preschool Children in a Statwide Effort. Ophthalmology, 1637-1644.

5. Rouse, M., Borsting, E., Mitchell, G., Cotter, S., Kulp, M., Scheiman, M., et al. (2009). Validity of the Convergence Insufficiency Symptom Survey: A Confirmatory Study. Optometry and Vision Science, 357-363.

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Vision Screening: What’s It Missing?

Today’s guest blogger is Dr. Michael Gallaway.  Dr. Gallaway practices in metro Philadelphia (Marlton NJ).  In addition to his private practice, he has been teaching at Pennsylvania College of Optometry at Salus University since he graduated from the New England College of Optometry.

Most children receive a vision screening in the pediatrician’s office prior to starting school, and later receive some form of vision screening once in school. That’s because vision is so important for learning – up to 80% of what children learn comes through vision.  You would think that screening for vision problems that affect a child’s development or their school performance would be technologically up to date and accurate, but the truth will surprise you!

Most vision screenings use only the Snellen chart, the same letter chart you were probably screened with as a child and which your grandparents were probably screened with when they were children.  The Snellen chart has been used since Civil War times in one room schoolhouses so teachers could know which children should sit closest to the blackboard.  One hundred and fifty years later, and it’s still the only test that most vision screening relies on, even with studies documenting that Snellen charts can miss up to 75% of vision problems. This is because seeing the board clearly is only one of many things children need to do with their eyes in school.  To read and learn, they need the skills to easily focus, move and coordinate their two eyes all day long or else reading becomes a chore…or over time – a learning, behavioral or attention problem.

Another irony is that children who fail the Snellen test are most likely to be nearsighted (or myopic).  But eighty years of research has shown that nearsighted children are more likely to be better readers. The reason?  Children who read more sometimes become nearsighted as their eye muscles adapt to lots of close vision so that their reading requires less focusing effort.  Of course, that can make their distance vision blurry, and so our efforts at vision screening do the best job of finding the children who are the best readers!  Those who are most at risk for a learning related vision problem have eye teaming (binocular), focusing (accommodative), tracking (oculo-motor) and visual processing disorders – and the vast majority have 20/20 vision or already wear eyeglasses!  They see the board easily but struggle using their eyes during reading and writing activities.

When children pass a vision screening by a pediatrician or school nurse, parents, teachers and even the children themselves think their “vision” is fine.  But too many of these children still complain of headaches, double vision or loss of place  when they read or do homework, despite having 20/20 vision.

Recent research has pointed to a potential answer to this dilemma.  VERA is a computer program that screens for both visual acuity (20/20 etc) problems and a range of visual problems that affect reading and homework. This study found that VERA was very effective in finding eye teaming, focusing and tracking problems when compared to standard eye exam tests. One school district that has been using VERA has the lowest special education rate in their county – in part because the school identifies vision problems that are affecting school performance. When these problems are treated with vision therapy or reading glasses, many of the children learn better, and some can even avoid needing special education services…a win-win for children and their schools.  Learn more about VERA at www.visualscreening.com.

So don’t assume because your child can read the small letters on the Snellen chart that their vision is fine. Ask your school about how they screen your child’s vision, and whether they know about VERA.  And inquire as to whether your eye doctor checks for the full range of vision issues that affect reading and learning. 20/20 and healthy eyes are important, but they’re not nearly enough.

Dr. Gallaway has no financial interest in VERA or visualscreening.com.

Read more about vision screenings :

Evidence Supporting the Benefits of Treatment

The Price Tag

Ready For School

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Evidence Supporting the Benefits of Treatment

Thank you American Optometric Association (AOA).  The AOA has expressed “deep disappointment and concern” about the US Preventative Services Task Force’s (USPSTF) plan to proceed with misguided recommendations on children’s vision screenings. These recommendations, which support vision screenings as the preferred method of identifying visual impairment in children aged 1 to 5, would negate the efforts of eye doctors to reverse the rates of preventable vision loss in children.

The AOA points to the many flaws in a reliance on vision screenings to identify children with visual problems.  First, there is the issue of false negatives.  Many children with vision problems, such as amblyopia, are not identified by the vision screening.  They are categorized as a negative result, meaning that no positive findings were noted.  If they had received a comprehensive eye examination, the vision problem would have been identified.  Therefore, the negative result is a false result.  Many vision screenings result in a very high rate of false negatives.  It might be years before their vision problems are identified and treatment is initiated.  Some of these children are NEVER identified.

Even if a child is identified with a problem at a vision screening, the screening does not provide either a diagnosis or a direct path to treatment.  Research has shown that between 40 and 80 percent of children who fail a vision screening do not receive appropriate follow-up care.  Although the screening has identified the problem and treatment exists, there is a missing link–the diagnostic examination.  It is the treatment that is effective at improving visual outcomes for children, and treatment follows the examination, not the screening. The USPSTF should support a recommendation that “children receive care and treatment” not that “children should be screened.”

The USPSTF seemed overly concerned that the child’s inability to cooperate would render comprehensive examinations impossible to perform on young children.  Optometrists and pediatric ophthalmologists are well-trained in procedures that enable comprehensive evaluations of very young children.  These procedures may require special equipment not typically available to doctors during vision screenings, which only increases the rate of false negatives.  Comprehensive examinations should be the preferred recommendation.

In summary, the evidence of the benefits of treatment should be used to support comprehensive eye examinations for all children, because early detection and timely treatment are essential in addressing the public health crisis of high rates of preventable vision loss in children. Earlier identification and treatment will result in an enhanced quality of life and improved academic performance among children with vision problems.

Read AOA’s statement here.

 

 

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The Price Tag

What is the most effective way to identify children with vision problems?  The American Optometric Association and the American Public Health Association support comprehensive vision examinations for all children.  The American Academy of Ophthalmology and the American Academy of Pediatrics favor vision screenings.  The latter organizations use an economic argument in support of vision screenings.  It is far less expensive to perform a vision screening vs. comprehensive vision examinations on the entire 1st grade of your local elementary school……… or is it?

The economic view of this debate considers only direct costs.  In the same amount of time it takes to examine a 6 year old child, a vision screening could be performed on 4 or 5 children.  If the screening is performed during the child’s annual visit to the pediatrician, then the cost of an “unnecessary” vision examination is eliminated.  Manpower and equipment costs are easily calculated.  Using this approach, vision screenings are less expensive.  But this type of economic analysis does not consider the INDIRECT costs.  Vision screenings fail to identify many children with vision disorders.  How do you calculate the cost of an undiagnosed vision problem on the quality of life of a school-aged child?

If every child is going to be given the opportunity to learn, then every child must have a comprehensive vision examination when they enter school. The emphasis must be on maximizing our resources, and not on minimizing the need because it translates to a lower price tag.

For more information about the limitations of vision screenings, see Volume 14, Issue 5, article by Zaba et al in the Journal of Behavioral Optometry, 2003.

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