Eyes on a new school year

Contemporary PEDS JournalAugust 2023
Volume 40
Issue 07

Early intervention for vision screenings is integral for promoting and maintaining eye health in young children. Pediatricians should watch for and educate parents on signs and symptoms of possible vision problems.

Eyes on a new school year | Image Credit: © New Africa - © New Africa - stock.adobe.com.

Eyes on a new school year | Image Credit: © New Africa - © New Africa - stock.adobe.com.

Back-to-school preparations are on every parent’s mind right now, from school supply shopping to ensuring that all school physical forms are completed. However, one area parents often underestimate is the importance of the visual health of their child and how much reduced vision can affect classroom performance, psychosocial interactions, and athletic endeavors. Providing guidelines and recommendations for parents help lead the discussion so that all vision issues are addressed promptly.

Good vision is imperative for the academic success of our patients, and educating parents regarding the signs and symptoms of vision impairment is the first step. Although many states require a vision examination (either by a pediatrician, ophthalmologist, or optometrist) before a child can enroll in public school, it is not mandatory in all 50 states. Even in the 41 states that do have mandatory vision screenings, there is marked variability in screening methods and criteria, as well as the grade levels that are screened.1 This means the burden to catch visual issues falls to the pediatrician, parent, or teacher. Early intervention for many conditions such as amblyopia, strabismus, and even refractive error can have a beneficial long-lasting impact on a child’s visual development.

The American Academy of Ophthalmology (AAO) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) recommend timely periodic vision screenings during the preschool year.2,3 Photoscreening instruments have become increasingly popular and can be done in children as young as 12 months. Children should be tested using an eye chart by the time they are 5 years old. Comprehensive eye examinations for children without any visual symptoms or a negative family history have not been shown to have any medical benefit and are unnecessary.4

So, what signs and symptoms should parents look out for in their children that may indicate a need for a comprehensive examination by an eye doctor?

Signs for pediatricians to educate parents:

● Squinting when looking either in the distance or close up

● Eyes that turn in or wander out

● Closing 1 or both eyes in bright light

● Head tilting, turning, or covering 1 eye when performing critical vision tasks

● Headaches

● Eye rubbing

● A short attention span when reading

● Covering 1 eye

● Eye fatigue, strain, or double vision

● Difficulty with hand-eye coordination

● Positive family eye health history of patching, eye surgery, eye cancers, or glasses at a young age

Promoting healthy habits

The COVID-19 pandemic accelerated an epidemic that many pediatric ophthalmologists were already aware of—myopia (nearsightedness). Myopia occurs when the eye does not bend light appropriately to focus on the retina. Instead, light focuses in front of the retina, resulting in blurred vision.

Prior to the pandemic, myopia rates were already noted to be soaring, with a prediction that 50% of the worldwide population will be myopic by the year 2050.5 Home confinement and distance learning further exacerbated this increase in myopia progression in susceptible, younger children aged 6 to 8 years.6 The visual demand of concentrating up close on tasks such as reading, writing, and studying are thought to be a driving force for nearsightedness in children. During distance learning, many younger children were using computers for 6 to 8 hours per day, which was a marked departure from the more interactive learning that had been present pre–COVID-19 in the classroom setting. More than 400 studies and reviews have examined the association between near work and nearsightedness, and the correlation between near work and myopia is well established. Meta-analyses of these reports support the recommendation that excessive near work should be discouraged in myopic children.7,8 Near work includes reading, writing, coloring, and phone or tablet usage. So, when possible, limiting recreational phone or tablet use will allow children to complete their scholastic near work without risking progression of myopia.

Nearsightedness is problematic not because of the thickness of glasses but because of the eye health complications that arise from the axial elongation of the eye. Vision-threatening consequences such as retinal tears and detachments, myopic maculopathy, cataracts, and glaucoma are all at increased incidence in individuals who are highly myopic.9-11 Parents can directly reduce this risk by limiting screen time and near work. Advise parents to follow the screen time limits suggested by the AAO and AAPOS: 1 hour per day in children aged 2 to 5 years, 2 hours per day in children aged 5 to 12 years, and create a media plan with your child for older children with screen-free zones and screen-free time at home.12 Additionally, remind children to maintain appropriate distance from reading materials or screens. Working distances should be greater than 12 in for phones and tablets and 24 in for laptops.

Excessive screen time use can also cause asthenopia, which is eye fatigue and eye strain. Eye discomfort, dryness, and even headaches can also be a result of overuse of the eye during prolonged periods of focus. Studies show that both adults and children blink less when using a phone, tablet, or a computer than when talking to someone. A healthy blink is required to replenish the tear film of the eye and provide clear vision. Studies have shown an association between digital screen use and dry eye disease in school-aged children.13 Encourage children to take breaks during prolonged screen time by following the 20-20-20 rule.14 Every 20 minutes, take a 20-second break, during which the child looks at an object 20 ft away. Setting a timer will help ensure children don’t forget—even when they’re engrossed in their favorite show.

Outdoor time has also been shown to have a protective benefit on children’s nearsightedness.15 Several studies have shown that even moderate sunlight (11 hours/week) can be sufficient to decrease myopia by 23%.16 This protective effect has been shown in young children and young adults (in their 20s). Increasing time spent outdoors from 1 to 3 hours a day can decrease the risk of myopia by 50% in children.15 The strenuousness of the type of physical activity performed does not seem to have any impact. Even indirect outdoor light is beneficial, and the protective association appears to be related to the total time spent outdoors rather than specific engagement in sports activities.17 Two hours a day of outdoor time is the only proven preventive intervention for nearsightedness. Increased outdoor time can offset risk factors, such as parental myopia and time spent on near work. Recommending to parents that, even for children who do not wish to play outdoor sports, spending time outdoors—whether just walking or sitting—will still yield beneficial protective effects for their eyes, and that this is an essential message to get across.

Time spent outdoors should always be done with proper sun protection for the eyes. Children are more susceptible to damage, as UV transmittance is higher at younger ages.18 Well-fitting sunglasses that block 100% UVA/UVB rays can help prevent or delay future ocular conditions such as eyelid carcinomas (squamous, basal cell, and melanoma), pingueculae, pterygium, cataracts, and macular degeneration. Wearing sunglasses will not negate the protective benefit of outdoor time on myopia progression.

If your patients choose to participate in sports, this is another area in which parents can encourage the development of good eye health habits. Children and teens have higher rates of sports-related eye injuries than adults due to their tendency to play aggressively and their limited coordination and experience.19 Sports goggles are designed to reduce the risk of eye injuries during physical activities. They are made from impact-resistant material, certified by American National Standards Institute to meet strict criteria. Ball sports such as basketball, baseball, soccer, and racquet sports carry higher risks of eye injuries, and studies have demonstrated the effectiveness of sports goggles in reducing that risk.20 Children should never wear regular glasses when playing sports, even noncontact ones. Falls, stray injuries, and accidental contact can result in a part of the glasses frame penetrating the eye. Pediatricians can highlight the risks of sport-related eye injuries to parents and encourage them to have their children use recreational spectacles.

Neurodivergence and vision

Vision and learning are intimately connected. Vision problems can often be misdiagnosed as a learning disability or attention problem. This includes conditions such as dyslexia, attention-deficit hyperactivity disorder, and dysgraphia. That’s why it is imperative for children who are being evaluated for these conditions to have a comprehensive eye examination, as well. Children with learning disabilities have the same visual and ocular function as children without these disabilities. Strabismus, refractive error, and accommodative insufficiency are not the cause of dyslexia, but these conditions may coexist. Research has not uncovered a basis for abnormal eye coordination or tracking as the cause of these learning differences.21 However, there are many ocular diseases that can cause poor vision in a child and therefore result in a misdiagnosis of inattention or learning difficulties. Think about it: If you’re a 6-year-old and can’t see in the classroom, wouldn’t it be hard to pay attention? And, if your vision is blurry and you need glasses, don’t the letters “b” and “d” look similar?

A study at the University of California, Los Angeles analyzed a program that helped provide glasses to children in need. Not only did the academic performance of children improve, but their anxiety about school also decreased. They also found that 80% of classroom learning is visual. Children with undiagnosed refractive errors suffer and cannot keep up with their peers. This not only affects their academic performance but also their emotional well-being. The use of interactive classroom technologies, such as SMART Boards and tablets, can also provoke previously hidden vision problems in children.22

Make sure your children are set up for success this year. Be proactive about your child’s vision and make it a priority. Although comprehensive eye examinations are not necessary for every child, parents should see a pediatric ophthalmologist if their child fails routine vision screening, has been diagnosed with a vision problem, or has a family history of vision or eye problems. Back-to-school success depends on good vision.

For more from the August, 2023 issue of Contemporary Pediatrics®, click here.


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  10. Pan CW, Boey PY, Cheng CY, et al. Myopia, axial length, and age-related cataract: the Singapore Malay eye study. Invest Ophthalmol Vis Sci. 2013;54(7):4498-4502. doi:10.1167/iovs.13-12271
  11. Sun MT, Tran M, Singh K, Chang R, Wang H, Sun Y. Glaucoma and myopia: diagnostic challenges. Biomolecules. 2023;13(3):562. doi:10.3390/biom13030562
  12. Beyond screen time: a parent’s guide to media use. American Academy of Pediatrics. 2021. Accessed July 12, 2023. https://publications.aap.org/patiented/article/doi/10.1542/peo_document099/79942/Beyond-Screen-Time-A-Parent-s-Guide-to-Media-Use
  13. Moon JH, Lee MY, Moon NJ. Association between video display terminal use and dry eye disease in school children. J Pediatr Ophthalmol Strabismus. 2014;51(2):87-92. doi:10.3928/01913913-20140128-01
  14. Porter D. Digital devices and your eyes. Eyesmart. American Academy of Ophthalmology. October 27, 2022. Accessed July 12, 2023. https://www.aao.org/eye-health/tips-prevention/digital-devices-your-eyes
  15. Lingham G, Yazar S, Lucas RM, et al. Time spent outdoors in childhood is associated with reduced risk of myopia as an adult. Sci Rep. 2021;11(1):6337. doi:10.1038/s41598-021-85825-y
  16. Wu PC, Chen CT, Lin KK, et al. Myopia prevention and outdoor light intensity in a school-based cluster randomized trial. Ophthalmology. 2018;125(8):1239-1250. doi:10.1016/j.ophtha.2017.12.011
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  20. Weiss R, He C, Gise R, Parsikia A, Mbekeani JN. Patterns of pediatric firearm-related ocular trauma in the United States. JAMA Ophthalmol. 2019;137(12):1363-1370. doi:10.1001/jamaophthalmol.2019.3562
  21. Handler SM, Fierson WM, Section on Ophthalmology, et al. Learning disabilities, dyslexia, and vision. Pediatrics. 2011;127(3):e818-e856. doi:10.1542/peds.2010-3670
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