Editor's note: The products reviewed by Dr. Andrew Schuman are of his own selection and do not reflect the opinions of Contemporary Pediatrics or of the editors. He discloses no affiliation with any company mentioned in this article.
The American Academy of Pediatrics (AAP), the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), the American Association of Certified Orthoptists, and the American Academy of Ophthalmology (AAO) last updated their guidelines on pediatric vision screening in 2016, after endorsing instrument-based vision screening 4 years earlier in 2012.1,2 Despite these recommendations, less than 40% of children have had their vision tested even once by age 5 years.3
I last reviewed instrument-based vision screening for Contemporary Pediatrics in February 2014. This update will review the importance of vision screening preschool children as well as introduce pediatricians to a new technology that will significantly improve the detection of amblyopia and strabismus in our patients.
Why screen for vision problems in children?
Approximately 2.5% of all children have amblyopia.4,5 Amblyopia is poor vision, typically in one eye, that occurs when the brain does not recognize the sight from that eye, even if the eye itself is structurally normal. Amblyopia responds best when detected and treated in the preschool years. If treatment does not start by age 7 years, amblyopia may never improve. Delayed detection of amblyopia leaves a child with permanent uncorrectable monocular vision loss that was potentially preventable. Children with amblyopia lack binocular vision and as a consequence are likely to suffer from poor school performance, reduced fine motor skills, and impaired self-esteem. Children with amblyopia are asymptomatic and remain undiagnosed and untreated unless they undergo vision screening.
Whom (and how) to vision screen
In theory, children can be screened for vision problems with traditional eye charts by the age of 3 to 5 years. Screening is possible with Snellen eye charts, Tumbling E vision charts, or picture tests such as Allen Visual Acuity Cards, but this is time consuming and can lead to inconsistent or erroneous results. In reality, however, visual acuity testing in children aged younger than 5 years in a medical office can be challenging, and few children this age can be screened with any type of vision chart.
Over the past 10 years, many pediatric practices have adopted instrument-based vision screeners, called photoscreeners, to identify children with amblyopia risk factors (ARFs) that predispose toward the development of amblyopia. These devices use an infrared camera that captures and analyzes images of the red ref lex of undilated pupils to screen for refractive error (hyperopia or myopia), astigmatism (warped lens), anisometropia (significant refractive difference between eyes), strabismus (eye misalignment) and lens opacity. (Please see my 2014 article for a detailed description of several photoscreeners—all the devices in that article are still on the market.) The advantage of photoscreeners is that little cooperation, and no verbal response, is required for testing, and the screening can be completed in less than a minute.
According to AAP guidelines, a visual acuity screen is recommended at ages 4 and 5 years, as well as in cooperative 3-year-olds. Additionally, instrument-based screening may be used for children aged 12 and 24 months, as well as for children aged 3 through 5 years. Visual acuity screening also should be performed by pediatricians at ages 6, 8, 10, 12, and 15 years and any time vision problems are suspected.6 The US Preventive Services Task Force (USPSTF) recommends that children undergo instrument-based vision screening at least once between the ages of 3 to 5 years.7
1. Donahue SP, Nixon CN; Section on Ophthalmology, American Academy of Pediatrics; Committee on Practice and Ambulatory Medicine, American Academy of Pediatrics; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):29-30.
2. Miller JM, Lessin HR; American Academy of Pediatrics Section on Ophthalmology; Committee on Practice and Ambulatory Medicine; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Instrument-based pediatric vision screening policy statement. Pediatrics. 2012;130(5):983-986.
3. National Health Interview Survey, CDC/NCHS. Data retrieved from Healthy People 2020 website. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/vision/objectives - 5373. Accessed April 2, 2019.
4. Friedman DS, Repka MX, Katz J, et al. Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study. Ophthalmology. 2009;116(11):2128-2134.e1-2.
5. Multi-ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the Multi-ethnic Pediatric Eye Disease Study. Ophthalmology. 2008;115(7):1229.e1-1236.e1.
6. Committee on Practice and Ambulatory Medicine; Bright Futures Periodicity Schedule Workgroup. 2019 recommendations for preventive pediatric health care. Pediatrics. 2019;143(3);e20183971.
7. US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force recommendation statement. Pediatrics. 2011;127(2)340-346.
8. Arnold RW. Amblyopia risk factor prevalence. J Pediatr Ophthalmol Strabismus. 2013;50(4):213-217.
9. Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB; POS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013:17(1):4-8.
10. Su Z, Marvin EK, Wang BQ, et al. Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385-390.
11. Hered RW, Wood DL. Preschool vision screening in primary care pediatric practice. Public Health Rep. 2013;128(3):189-197.
12. Lowry EA, Wang W, Nyong’o O. Objective vision screening in 3-year-old children at a multispecialty practice. J AAPOS. 2015;19(1):16-20.
13. Birch EE, Holmes JM. The clinical profile of amblyopia in children younger than 3 years of age. J AAPOS. 2010; 14(6):494-497.
14. Pediatric Eye Disease Investigator Group. The clinical profile of moderate amblyopia in children younger than 7 years. Arch Ophthalmol. 2002;120(3):281-287.
15. Donahue SP. Relationship between anisometropia, patient age, and the development of amblyopia. Am J Ophthalmol. 2006;142(1):132-140.
16. Cotter SA; Pediatric Eye Disease Investigator Group. Edwards AR, Wallace DK, Beck RW, et al. Treatment of anisometropic amblyopia in children with refractive correction. Ophthalmology. 2006;113(6):895-903.
17. Jost RM, Yanni SE, Beauchamp CL, et al. Beyond screening for risk factors: objective detection of strabismus and amblyopia. JAMA Ophthalmol. 2014;132(7):814-820.
18. Loudon SE, Rook CA, Nassif DS, Piskun NV, Hunter DG. Rapid, high-accuracy detection of strabismus and amblyopia using the pediatric vision scanner. Invest Ophthalmol Vis Sci. 2011;52(8):5043-5048.
19. Jost RM, Stager D Jr, Dao L, Katz S, McDonald R, Birch EE. High specificity of the Pediatric Vision Scanner in a private pediatric primary care setting. J AAPOS. 2015;19(6):521-525.