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Compliance With Vision-Screening Guidelines Among a National Sample of Pediatricians
Compliance With Vision-Screening Guidelines Among a National Sample of Pediatricians Terry C. Wall, MD, MPH; Wendy Marsh-Tootle, OD; H. Hughes Evans, MD, PhD; Crayton A. Fargason, Jr, MD, MM; Carolyn S. Ashworth, MD; J. Michael Hardin, PhD Objective.—The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians. Methods.—We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening. Results.—Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7–12 years (82%), and 13–18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%–33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models. Conclusions.—Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age. KEY WORDS:
guidelines; primary care; vision screening; visual acuity
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ision problems are common in children. Undetected vision problems have an estimated prevalence of 5%–10% in preschool children.1 The most common vision disorder is abnormal refractive errors, which affect approximately 10% of preschool children.2,3 Strabismus affects approximately 4% of children younger than 6 years of age.4 Cataracts have been detected in 2.49 per 10 000 infants aged birth to 12 months in the United Kingdom.5 Various professional organizations, such as the American Academy of Pediatrics (AAP), advise preschool vision screening to detect and correct vision problems before school entry.6 The AAP also recommends continued vision screening throughout childhood. Failure to detect visual impairment may have a negative effect on vision
outcomes and learning.7 The purpose of this study was to determine how closely primary care pediatricians follow the vision-screening guidelines developed by the AAP.6 The AAP vision-screening guidelines that we used were published in 1996 and were endorsed by the AAP, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. Since then, guidelines for preschool children have been updated by suggesting specific visual acuity tests8 and by recommending photoscreening for infants, toddlers, and children with developmental delays.9 These guidelines and updates are consistent in recommending that vision should be screened, using age-appropriate methods, in the newborn period and at all subsequent health supervision visits. The 1996 vision-screening guidelines reference the ‘‘Recommendations for Preventive Pediatric Health Care’’10 for frequency of screening examinations for children aged 2 to 4 years. These preventive care recommendations include vision testing, using a standard screening method, yearly from ages 3 to 5, followed by rescreening at ages 10, 12, 15, and 18 years. For infants and children up to 2 years of age, routine screening methods include history, physical examination (including gross inspection and observation of the red reflex and corneal light reflex), a cover test on patients who
From the Division of General Pediatrics, Department of Pediatrics (Drs Wall, Evans, Fargason, and Ashworth), the School of Optometry (Dr Marsh-Tootle), and the Department of Health Informatics (Dr Hardin), University of Alabama at Birmingham, Birmingham, Ala. Address correspondence to Terry C. Wall, MD, MPH, Division of General Pediatrics, Department of Pediatrics, 1616 6th Ave S, Suite 201, Birmingham, AL 35233 (e-mail: [email protected]). Received for publication December 14, 2001; accepted July 1, 2002. AMBULATORY PEDIATRICS Copyright q 2002 by Ambulatory Pediatric Association
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can fixate on a target, and observation of fixation and following. In addition, at age 3 and subsequent years, the guidelines state that physicians should screen for reduced visual acuity, as well as ocular misalignment using either the cover test or the Random Dot E test of stereopsis (an alternative to the cover test). The 1996 AAP vision-screening guidelines list several indications for referral to an eye care specialist. Among these is failure to pass a recommended visual acuity test at the 20/40 level (ages 3 to 5 years) or 20/30 level (age 6 years and older). A consistent 2-line acuity difference between the eyes, even if both are within the passing range, may result in amblyopia from the dominant eye suppressing the eye with the lesser acuity. Amblyopia (the loss of visual acuity from disuse) may be prevented with early treatment. Adherence to AAP recommendations for vision screening has been associated with earlier diagnosis of amblyopia.11 Campbell and Charney11 examined factors associated with the delayed diagnosis of childhood amblyopia, such as characteristics of the child’s vision problem, the family, and the medical system. They found that physicians who reported compliance with the AAP guidelines for vision screening made earlier diagnoses of vision problems. Many children, particularly those of preschool age, do not receive vision screening.12 In addition, children who are screened do not always receive diagnostic examinations as indicated.13–15 It is logical to assume that pediatricians play an important role in detecting vision problems and coordinating care. However, previous studies, which have focused primarily on preschool children, have revealed deficiencies in vision-screening and referral practices in pediatric practice settings.16,17 Furthermore, little is known of pediatric primary care vision-screening practices in infants or in children beyond the preschool age range. Our goal was to examine, through use of a survey instrument, the reported vision-screening and referral practices of a national sample of primary care pediatricians in order to compare reported with recommended practice. Our objective was to determine whether visionscreening practices had improved since publication of the 1996 vision-screening guidelines. METHODS We mailed a survey to a random sample of 1500 pediatricians obtained from the AAP. Initial nonrespondents were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Since the AAP membership file does not differentiate between generalists and subspecialists, surveys were sent to both. Only surveys returned by physicians who identified themselves as primary care pediatricians were included in the analysis. These physicians were identified by asking subjects to indicate whether they were pediatricians and whether they provided routine health supervision in a continuity setting. Respondents who answered yes to both questions were eligible for inclusion. These respondents, referred to as
primary care pediatricians, were asked to provide detailed information about their vision-screening practices. The survey instrument had a branching format, with the initial question for each screening test using a dichotomous format to ascertain whether the physician’s office routinely screened using that specific vision-screening technique. Respondents who answered no to the initial question on a specific screening technique were instructed to proceed to the next section. Respondents who answered yes were asked to provide further information on their screening practices, such as ages or schedules for screening, as well as criteria for referral. For areas of screening that had been described in previous studies, such as visual acuity testing, we included both categorical and open-ended questions. For areas in which we had little prior information, we used an open-ended format and converted responses into the categories that emerged from the data. Categories were generally based on the age at which screening activities occurred. We used logistic regression to explore the association between reported screening practices and physician characteristics. For this analysis, we included only those respondents who reported all demographic and practice factors (N 5 519). Each logistic regression analysis used a different screening test as the dependent variable. Independent variables included in the model were highest training (residency vs fellowship), physician sex, practice location (rural, suburban, urban), type of practice (academic, group/partnership, multispecialty, solo, health maintenance organization, or other), percentage of practice covered by Medicaid, percentage of practice in managed care, size of practice, region (Midwest, Northeast, Southeast, West), availability of eye care specialists, and years since medical school graduation. We performed a separate logistic regression examining the routine use of visual acuity testing, stereopsis screening, red reflex examination, and fundoscopic examination. We also used routine referral to an eye care specialist and routine visual acuity screening for 3-year-olds as outcome variables. RESULTS Of the 1500 surveys that were mailed, 9 surveys were returned as undeliverable due to relocation of the pediatrician or due to death; 888 surveys were returned with sufficient information for analysis, giving a response rate of 60% (888/1491). A total of 312 surveys were returned by subjects who did not meet inclusion criteria, whereas the remainder (576, 65%) were completed by pediatricians providing health supervision in a continuity setting. Demographic and practice characteristics of respondents meeting inclusion criteria are shown in Tables 1 and 2, respectively. The average reported age was 44 years. All 50 states and the District of Columbia were represented. Of the surveys returned by pediatricians meeting inclusion criteria, 115 surveys contained incomplete or unclear responses to 1 or more questions. Therefore, for descriptive analyses, individual questions were analyzed based on the number of analyzable responses per item. Ninety-two percent of pediatricians (466/509) reported
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Compliance With Vision-Screening Guidelines
Table 1. Physician Characteristics of Survey Respondents in Primary Care (N 5 576) Physician Characteristics
% of Survey Respondents
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Table 2. Practice Characteristics of Survey Respondents in Primary Care Practice Characteristics
% of Survey Respondents
Sex Male Female Not known
49 49 2
Year MD degree received Before 1980 1980–1989 1990 or After Not known
Region Midwest Northeast Southeast West
23 27 29 21
28 31 36 5
Highest training completed Fellowship Residency Not known
Practice setting Rural Suburban Urban Not known
13 54 30 3
22 75 3
Personal experience Self-reported visual deficit Child with visual deficit
68 32
Type of practice Academic Group/Partnership Multispecialty group Health maintenance organization Solo Other Not known
10 52 14 5 13 4 2
that they routinely performed visual acuity testing in their office. To test visual acuity, pediatricians (N 5 466) reported use of wall charts (74%), machines (39%), and other methods (4%), with some reporting use of more than 1 acuity method. The frequency with which pediatricians routinely performed visual acuity testing at different ages was as follows: 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7 to 12 years (82%), and 13 to 18 years (80%). The earliest age at which respondents (N 5 445) routinely tested for visual acuity was as follows: 3 years (34%), 4 years (47%), 5 years (17%), and $6 years (2%). We examined the reported periodicity schedule for rescreening beyond age 5 years using visual acuity testing. For older children, the AAP recommends objective vision screening at ages 10, 12, 15, and 18 years. For those pediatricians routinely performing visual acuity screening (N 5 466), we compared the reported schedule with the screening schedule recommended by the AAP by categorizing the response into 1 of the following: no testing beyond preschool (28%), less than AAP (5%), comparable to AAP (4%), and more than AAP (59%). Seventy-nine pediatricians (17%), included in the more than AAP category, explicitly reported yearly screening after preschool age. One percent of responses were insufficient for comparison with recommended periodicity schedules, and 3% did not indicate ages of screening. When pediatricians performing routine visual acuity testing were asked to indicate their threshold for referral for further evaluation, responses were variable, but there was a tendency toward lower referral thresholds with increasing patient age (Table 3). For children aged 5 years and under, the 1996 AAP guidelines recommend referring children with visual acuity worse than 20/40. Pediatricians commonly reported use of a referral threshold of 20/50 for each age: 36% for age 3 years, 32% for age 4 years, and 26% for age 5 years. The percentage of pediatricians who reported referral thresholds of higher than 20/50 was
Practice size ,5 physicians 5–9 physicians $10 physicians Not known
50 26 24 ,1
% of patients with Medicaid #10 11–50 .50 Not known
42 42 14 2
% of patients in managed care ,35 35–64 $65 Not known
31 30 37 2
Proximity to eye care specialists (within 20 min) Optometrist Ophthalmologist Pediatric ophthalmologist
89 94 70
14% for age 3 years, 12% for age 4 years, and 7% for age 5 years. The 1996 AAP guidelines recommend referral for children aged 6 years and older if visual acuity is worse than 20/30. Fifty-seven percent or more of pediatricians reported 20/40 as their referral threshold for these age categories. The percentage of pediatricians reporting referral thresholds higher than 20/40 was 25% for age 6 years, 19% for ages 7 to 12 years, and 18% for ages 13 years and older. A small number of pediatricians (56 of 576, 10%) reported routinely referring all children for a formal eye evaluation. Ages for routine referral were 1–3 years (7%), preschool age, 3–5 years (68%), school age, 5–8 years (14%), 10–13 years (4%), other (2%), and not specified (5%). Ninety-five percent of pediatricians (484/507) reported routinely checking red reflexes in their patients. Nearly all pediatricians (478/484) performed red reflex testing with-
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Table 3. Reported Minimum Visual Acuity Screening Levels at Which the Pediatrician Would Refer the Child to an Eye Specialist* Visual Acuity Referral Criterion
Preschool age 3y 4y 5y School age 6y 7–12 y 13–18 y
,20/30
20/30
20/40
20/50
.20/50
Total
0 2 (1) 4 (1)
5 (3) 14 (4) 35 (9)
76 (47) 176 (51) 233 (57)
58 (36) 110 (32) 108 (26)
22 (14) 42 (12) 27 (7)
161 344 407
7 (2) 12 (3) 13 (3)
53 (15) 73 (20) 78 (22)
211 (58) 215 (58) 205 (57)
75 (21) 59 (16) 54 (15)
15 (4) 12 (3) 10 (3)
361 371 360
*Values are no. (%) in each age group. Bold values correspond to highest acceptable screening levels for each age.
in the first 2 months of life. However, 111 (23%) did not check red reflexes beyond 6 months of age, and 214 (44%) did not check red reflexes beyond age 2. To test for eye alignment or binocularity, 64% of pediatricians indicated that they routinely perform a cover test, and 32% indicated that they routinely perform stereopsis testing. However, 24% of pediatricians who responded to both questions (N 5 495) report performing neither the cover test nor stereopsis screening. For the cover test, one fifth (68 pediatricians, 21%) reported performing the test once at a specified age: #4 months (9), 6–12 months (21), 15–24 months (7), 3 years (13), 4–5 years (17), and ‘‘school age’’ (1). Five percent (17) of the pediatricians did not indicate an age for the cover test. Most pediatricians (238) gave an age range in which they perform the cover test. These age ranges were grouped into the following categories: birth or infancy onward (47 pediatricians, 20%), infancy (18, 8%), infancy through preschool (47, 20%), 12 months and older (21, 9%), preschool age, 2–5 years (32, 13%), preschool age and older (41, 17%), school age (6, 3%), and all (21, 9%). Five responses (2%) could not be easily categorized. The average age of initiation reported for the cover test was 22 months, with a median of 12 months. One third of pediatricians (112/323) reported an earliest age of 2 years or older. Few pediatricians (13/565, 2%) reported use of photorefraction as a screening tool in their office. Those using photorefraction for vision screening indicated use during
infancy (7/13) or preschool age (4/13), while 2 pediatricians did not indicate an age. Pediatricians using photorefraction also indicated use of other screening techniques. The majority of pediatricians in our sample (361/557, 65%) reported performing fundoscopic examinations. However, the ages at which these examinations were performed was highly variable. Fourteen pediatricians did not indicate an age for fundoscopic examination. Pediatricians’ responses (N 5 347) were categorized as newborn or infancy (12), birth onward (22), 1–2 years and up (12), 2 years (9), 3 years and up (35), preschool age or age of cooperation (165), school age (5), teens (6), all (63), and other (18). The results of logistic regression are shown in Table 4. Variables that were not associated with routine use of any screening test included years since graduation, proximity of optometrists or general ophthalmologists (defined as within 20 minutes), presence of visual deficits among physicians or their children, practice setting, or the percentage of the patient population with Medicaid. Practicing in a larger practice was associated with an increased likelihood of screening for the majority of the tests examined. Proximity of a pediatric ophthalmologist was associated with an increased likelihood of performing the cover test or stereopsis screening. Having fellowship training was associated with a higher likelihood of performing visual acuity screening. Physicians with a greater percentage of patients in managed care were less likely to routinely refer patients for an eye examination. Male pediatricians were
Table 4. Factors Significantly Associated With the Routine Performance of the Screening Test* Screening Test Visual acuity test
Visual acuity test for 3-y-olds Red reflex test Fundoscopic examination Stereopsis test Cover test Either cover or stereopsis test Routine referral
Independent Variable
Odds Ratio
95% CI
West region fellowship training small practice size male sex academic practice small practice size small practice size small practice size proximity to pediatric ophthalmologist small practice size proximity to pediatric ophthalmologist West region low managed care
0.59 3.17 1.92 0.51 0.71 1.47 1.38 1.31 1.77 1.43 1.84 1.43 0.57
0.42–084 1.06–9.52 1.18–3.11 0.33–0.80 0.55–0.92 1.15–1.87 1.08–1.74 1.02–1.68 1.09–2.87 1.07–1.91 1.07–3.17 1.04–1.96 0.37–0.87
*Results from regression analysis. CI indicates confidence interval.
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Compliance With Vision-Screening Guidelines
Table 5. Routine Performance of Screening Tests in Pediatric Primary Care Offices, Comparing Survey Results Over a 10-Year Period Year of Survey Screening Test
1988*
1993*
1998
Visual acuity test Visual acuity test for 3-y-olds Red reflex test Fundoscopic examination Binocularity test† Cover test Photorefraction test
91% 1/3 94% 77% 54% 69% ...
91% 1/3 98% 80% 58% 71% ...
92% 35% 95% 65% 76% 64% 2%
*American Academy of Pediatrics (AAP) Periodic Surveys.18 †Specific technique for binocularity testing was not specified in the report from the AAP surveys. 1998 survey includes testing for either cover or stereopsis.
less likely than female pediatricians to report routine performance of visual acuity for 3-year-old patients, although physician sex was not significantly associated with the performance of other screening tests. DISCUSSION Our study of a national sample of primary care pediatricians shows that, using the 1996 AAP guidelines as the standard, deficiencies in vision-screening practices still exist. Results from our survey conducted in 1998 show many similarities with those of previous unpublished surveys conducted in 1988 and 1993 by the AAP (Periodic Surveys 3 and 22),18 and these comparisons are shown in Table 5. For instance, similar percentages of respondents reporting use of the following tests in 1988, 1993, and 1998: visual acuity (91%, 91%, and 92%, respectively), red reflex test (94%, 98%, and 95%), cover test (69%, 71%, and 64%), and ophthalmoscopy (77%, 80%, and 65%).18 These deficiencies can be discussed in terms of adherence to AAP guidelines for the screening tests used most frequently by the pediatricians we surveyed: the red reflex, visual acuity, and cover tests or stereopsis testing. Red Reflex Testing Most pediatricians (95%) in our sample reported screening for red reflexes in their patients. Although surveys have indicated good acceptance and use of this test in clinical settings, many pediatricians do not repeat the test as recommended at each health supervision visit. The red reflex test is the most useful method to screen for media opacities in infants and preschool children. Infants with congenital cataracts must be referred immediately, since visual acuity outcome is best for unilateral cataracts treated by age 2 months.19 Our data suggest that the majority of infants are screened during infancy, but that substantial numbers of older infants or children are not screened by red reflex testing for conditions that may present later, including acquired cataracts or retinoblastoma.20,21 Photorefraction is another method to capture and document the red reflex. Photorefraction screens for media opacity, strabismus, and high refractive error, each of which is a risk factor for amblyopia.22 However, use of
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this technique was low among this sample of pediatricians. The AAP recommends that ophthalmoscopic examination be a part of routine vision screening beginning at the earliest possible age, the majority of children being able to cooperate by 5 years of age.6 One third of the pediatricians whom we surveyed reported not routinely performing ophthalmoscopic examinations in their patients. This rate was lower than the rate from previous AAP surveys. The timing of the first ophthalmoscopic examination among our respondents ranged from birth to adolescence. Although no child is ever too young for ophthalmoscopy, examination may be very difficult if pupils are small, and fixation cannot be controlled. Adler23 has reported that dilation of pupils, using 0.5% tropicamide at the first pediatric office examination, enhances observation of the red reflex and is well accepted by parents. The AAP guidelines in force during this research did not advocate routine dilation in the primary care setting, but did recommend that children with risk factors for retinal disorders, such as congenital infectious disease or premature birth, be referred to an eye specialist for diagnostic examination.6 Visual Acuity Testing The second most common screening test among respondents was an assessment of visual acuity. Roughly two thirds of our sample reported routinely not attempting visual acuity screening of children at age 3 years as recommended. Most responding pediatricians begin testing at age 4 years. This age has been adopted in Sweden due to improved completion rates at age 4 compared with age 3, and data have shown a reduction in the prevalence of amblyopia among children who have attended the preschool vision screening.24,25 In our sample, almost one fifth of respondents reported delaying acuity screening until age 5 years or later. By school age, the majority reported either meeting or exceeding the recommended visual acuity screening schedule. In contrast, one third indicated not screening beyond the preschool age range. Although the most commonly reported visual acuity threshold for referring children aged 3 to 5 years was failure to pass the 20/40 line as recommended by the 1996 AAP guidelines, the pediatricians we surveyed referred substantial numbers of preschool children using other criteria. Our data show that many pediatricians use less stringent referral criteria than those recommended by the AAP. A national review of preschool vision-screening programs showed that most programs use either 20/30 or 20/40 as the critical line to pass in visual acuity screening.26 Therefore, the pediatricians we surveyed use criteria either similar to or less stringent than those of most community vision-screening programs. Cover Testing or Stereopsis Testing Cover testing or stereopsis testing was performed by three fourths of respondents. Neither test is necessary to detect strabismus that is apparent by gross observation or by corneal light reflex testing. Our survey only included questions about screening and referral practices for non-
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obvious strabismus. Such tests are recommended by the AAP at each health supervision visit, for all children who can fixate on a target. Only 64% of respondents indicated that they routinely perform a cover test, and 24% reported that they do not use either recommended method to screen for nonobvious strabismus. Screening is most important during the preschool years when strabismus is most likely to present. The consequences of these vision-screening deficiencies have been suggested in a study of children treated for amblyopia in one pediatric ophthalmology practice.11 Approximately two thirds of children with strabismic amblyopia had obvious deviations (.108), and roughly 70% of these children were identified before age 5 years. On the other hand, one third of children had nonobvious deviations (#108), and late detection (age 5 years or later) of these deviations occurred in 64%. In this series, the majority of children with amblyopia were first identified outside of the primary care setting; only 12% of children with late diagnoses and 33% of children with early diagnoses were first detected in the primary care setting. The remainder were first identified by school screening or by parents’ self-referral to an eye care professional. Our study, which was based on a nationally representative sample of pediatricians, examined vision-screening and referral practices in greater detail than previous studies. The results of this study confirm earlier reports of inadequate vision-screening practices in pediatric settings when compared with the 1996 AAP guidelines. The vast majority of pediatricians perform some of the recommended tests some of the time, but very few perform all of the recommended tests at each health supervision visit. Although our study focused on adherence to AAP vision-screening guidelines, guidelines from other sources differ in their recommendations. The Guide to Clinical Preventive Services, 2nd Edition, by the US Preventive Services Task Force supports vision screening for amblyopia and strabismus for all children before school entry, preferably between ages 3 and 4 (http://odphp.osophs. dhhs.gov/pubs/guidecps). However, periodic rescreening is not recommended on the basis of insufficient evidence for benefit. Both guidelines stress the importance of vision screening at preschool ages, but the pediatricians we surveyed report more vigorous vision screening at school age. Although variation in screening practices may reflect this lack of consensus among organizations, it may also reflect the personal beliefs of the individual physician that vision screening is somehow more important or successful in older children. Although various vision-screening methods have been evaluated,27–32 no single method has been implemented on a national scale. In addition, pediatric vision-screening practices may be affected by local factors such as state laws, school district guidelines, and existing community screening programs.12,17,33 Limitations There are several limitations to our study. The survey design captures reported practices, which may not reflect actual practice. Some items in the survey were not com-
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pleted by all respondents. This may have been due to the length of the survey. Our goal was to collect detailed information on screening and referral practices, and the length of the survey may have deterred some from completing it. Our response rate was 60% with a total of 4 mailings. We do not have information on the nonresponders and cannot rule this out as a source of bias. Openended responses may not have completely captured age ranges, and many responses were not specific, creating difficulty in interpretation. Much of vision screening is dependent on operator technique, which cannot be assessed using the survey design. Although the survey approach to selected areas of screening was exploratory in nature, responses indicated wide variability in visionscreening practices among pediatricians, warranting further study. Conclusions Many pediatricians do not follow AAP guidelines for vision screening, especially for younger children. In general, pediatricians also report using less stringent referral criteria for visual acuity compared with those recommended in the AAP guidelines. Since vision problems are generally more responsive to treatment in younger children and since undetected vision problems can lead to permanent, irreversible vision loss, failure to comply with guidelines may produce long-term negative consequences for patients. The reasons why pediatricians do not follow recommended vision-screening guidelines are not clear, but are likely to be multifactorial. The first reason may be related to efficiency or convenience. Vision screening, especially of 3-year-old children, requires time and patience. A decrease in efficiency, combined with concerns over adequate reimbursement for vision screening as an independent procedure, has obvious negative consequences for practicing pediatricians. Another reason for incomplete compliance with guidelines may be lack of knowledge or skill. Vision screening is dependent on operator skill, especially for the cover test and fundoscopic examinations. Pediatricians and their staff may lack the skills or technology necessary for effective screening. Finally, pediatricians may be concerned about the false-positive rates of current vision-screening techniques. Physicians may question the specific recommendations since they are based on consensus rather than evidence, and they may place more weight on the inherent cost of false-positive results from the standpoint of the parent. More information is needed on the effectiveness of current screening techniques and on the risks of not screening. Although changing physician behavior is a complicated process, it remains a worthy goal because of the negative outcome if abnormalities are detected after the visual axis has matured. REFERENCES 1. US Public Health Service. Vision screening in children. Am Fam Physician. 1994;50:587–590. 2. Atkinson J, Braddick O, Robier B, et al. Two infant vision
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18. American Academy of Pediatrics Director of Research. Executive Summary, Periodic Surveys 3 and 22. 1990. 19. Birch E, Stager D. Prevalence of good visual acuity following surgery for congenital unilateral cataract. Arch Ophthalmol. 1988;106:40–43. 20. Olitsky SE, Nelson LB. Common ophthalmologic concerns in infants and children. Pediatr Clin North Am. 1998;45:993– 1012. 21. Shields J, Shields C. Ocular tumors of childhood. Pediatr Clin North Am. 1993;40:805–826. 22. von Noorden G. Amblyopia: a multidisciplinary approach, proctor lecture. Ophthalmol Vis Sci. 1985;26:1704–1716. 23. Adler R. Pupil dilation at the first well baby examination for documenting choroidal light reflex. J Pediatr. 1991;118:249– 252. 24. Kohler L, Stigmar G. Vision screening of four-year-old children. Acta Paediatr Scand J. 1973;62:17–27. 25. Kohler L, Stigmar G. Visual disorders in 7-year-old children with and without previous vision screening. Acta Paediatr Scand J. 1978;67:373–377. 26. Schmidt P. Current vision screening programs for the preschool child. In: Hartmann E, ed. Vision Screening in the Preschool Child: Proceedings of a Conference Held September 10–11, 1998. Washington, DC: Genetic Services Branch, Maternal and Child Health Bureau, Health Resources and Services Administration, US Dept Health and Human Services; 1999. 27. Birch E, Williams C, Hunter J, Lapa M. Random dot stereoacuity of preschool children, ALSPAC ‘‘Children in Focus’’ Study Team. J Pediatr Ophthalmol Strabismus. 1997;34:217– 222. 28. Donahue S, Johnson T, Leonard-Martin T. Screening for amblyogenic factors using a volunteer lay network and the MTI photoscreener: initial results from 15,000 preschool children in a statewide effort. Ophthalmology. 2000;107:1637–1644. 29. Kemper AR, Margolis PA, Downs SM, Bordley WC. A systematic review of vision screening tests for the detection of amblyopia. Pediatrics. 1999;104:1220–1222. 30. Marsh-Tootle W, Corliss D, Alvarez S, et al. A statistical analysis of Modified Clinical Technique vision screening of preschoolers by optometry students. Optom Vis Sci. 1994;71:593– 603. 31. Preslan M, Novak A. Baltimore Vision Screening Project. Ophthalmology. 1996;103:105–109. 32. Simons K. Preschool vision screening: rationale, methodology, and outcome. Surv Ophthalmol. 1996;41:3–30. 33. Ciner EB, Dobson V, Schmidt PP, et al. A survey of vision screening policy of preschool children in the United States. Surv Ophthalmol. 1999;43:445–457.
guidelines; primary care; vision screening; visual acuity
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V
ision problems are common in children. Undetected vision problems have an estimated prevalence of 5%–10% in preschool children.1 The most common vision disorder is abnormal refractive errors, which affect approximately 10% of preschool children.2,3 Strabismus affects approximately 4% of children younger than 6 years of age.4 Cataracts have been detected in 2.49 per 10 000 infants aged birth to 12 months in the United Kingdom.5 Various professional organizations, such as the American Academy of Pediatrics (AAP), advise preschool vision screening to detect and correct vision problems before school entry.6 The AAP also recommends continued vision screening throughout childhood. Failure to detect visual impairment may have a negative effect on vision
outcomes and learning.7 The purpose of this study was to determine how closely primary care pediatricians follow the vision-screening guidelines developed by the AAP.6 The AAP vision-screening guidelines that we used were published in 1996 and were endorsed by the AAP, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology. Since then, guidelines for preschool children have been updated by suggesting specific visual acuity tests8 and by recommending photoscreening for infants, toddlers, and children with developmental delays.9 These guidelines and updates are consistent in recommending that vision should be screened, using age-appropriate methods, in the newborn period and at all subsequent health supervision visits. The 1996 vision-screening guidelines reference the ‘‘Recommendations for Preventive Pediatric Health Care’’10 for frequency of screening examinations for children aged 2 to 4 years. These preventive care recommendations include vision testing, using a standard screening method, yearly from ages 3 to 5, followed by rescreening at ages 10, 12, 15, and 18 years. For infants and children up to 2 years of age, routine screening methods include history, physical examination (including gross inspection and observation of the red reflex and corneal light reflex), a cover test on patients who
From the Division of General Pediatrics, Department of Pediatrics (Drs Wall, Evans, Fargason, and Ashworth), the School of Optometry (Dr Marsh-Tootle), and the Department of Health Informatics (Dr Hardin), University of Alabama at Birmingham, Birmingham, Ala. Address correspondence to Terry C. Wall, MD, MPH, Division of General Pediatrics, Department of Pediatrics, 1616 6th Ave S, Suite 201, Birmingham, AL 35233 (e-mail: [email protected]). Received for publication December 14, 2001; accepted July 1, 2002. AMBULATORY PEDIATRICS Copyright q 2002 by Ambulatory Pediatric Association
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can fixate on a target, and observation of fixation and following. In addition, at age 3 and subsequent years, the guidelines state that physicians should screen for reduced visual acuity, as well as ocular misalignment using either the cover test or the Random Dot E test of stereopsis (an alternative to the cover test). The 1996 AAP vision-screening guidelines list several indications for referral to an eye care specialist. Among these is failure to pass a recommended visual acuity test at the 20/40 level (ages 3 to 5 years) or 20/30 level (age 6 years and older). A consistent 2-line acuity difference between the eyes, even if both are within the passing range, may result in amblyopia from the dominant eye suppressing the eye with the lesser acuity. Amblyopia (the loss of visual acuity from disuse) may be prevented with early treatment. Adherence to AAP recommendations for vision screening has been associated with earlier diagnosis of amblyopia.11 Campbell and Charney11 examined factors associated with the delayed diagnosis of childhood amblyopia, such as characteristics of the child’s vision problem, the family, and the medical system. They found that physicians who reported compliance with the AAP guidelines for vision screening made earlier diagnoses of vision problems. Many children, particularly those of preschool age, do not receive vision screening.12 In addition, children who are screened do not always receive diagnostic examinations as indicated.13–15 It is logical to assume that pediatricians play an important role in detecting vision problems and coordinating care. However, previous studies, which have focused primarily on preschool children, have revealed deficiencies in vision-screening and referral practices in pediatric practice settings.16,17 Furthermore, little is known of pediatric primary care vision-screening practices in infants or in children beyond the preschool age range. Our goal was to examine, through use of a survey instrument, the reported vision-screening and referral practices of a national sample of primary care pediatricians in order to compare reported with recommended practice. Our objective was to determine whether visionscreening practices had improved since publication of the 1996 vision-screening guidelines. METHODS We mailed a survey to a random sample of 1500 pediatricians obtained from the AAP. Initial nonrespondents were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Since the AAP membership file does not differentiate between generalists and subspecialists, surveys were sent to both. Only surveys returned by physicians who identified themselves as primary care pediatricians were included in the analysis. These physicians were identified by asking subjects to indicate whether they were pediatricians and whether they provided routine health supervision in a continuity setting. Respondents who answered yes to both questions were eligible for inclusion. These respondents, referred to as
primary care pediatricians, were asked to provide detailed information about their vision-screening practices. The survey instrument had a branching format, with the initial question for each screening test using a dichotomous format to ascertain whether the physician’s office routinely screened using that specific vision-screening technique. Respondents who answered no to the initial question on a specific screening technique were instructed to proceed to the next section. Respondents who answered yes were asked to provide further information on their screening practices, such as ages or schedules for screening, as well as criteria for referral. For areas of screening that had been described in previous studies, such as visual acuity testing, we included both categorical and open-ended questions. For areas in which we had little prior information, we used an open-ended format and converted responses into the categories that emerged from the data. Categories were generally based on the age at which screening activities occurred. We used logistic regression to explore the association between reported screening practices and physician characteristics. For this analysis, we included only those respondents who reported all demographic and practice factors (N 5 519). Each logistic regression analysis used a different screening test as the dependent variable. Independent variables included in the model were highest training (residency vs fellowship), physician sex, practice location (rural, suburban, urban), type of practice (academic, group/partnership, multispecialty, solo, health maintenance organization, or other), percentage of practice covered by Medicaid, percentage of practice in managed care, size of practice, region (Midwest, Northeast, Southeast, West), availability of eye care specialists, and years since medical school graduation. We performed a separate logistic regression examining the routine use of visual acuity testing, stereopsis screening, red reflex examination, and fundoscopic examination. We also used routine referral to an eye care specialist and routine visual acuity screening for 3-year-olds as outcome variables. RESULTS Of the 1500 surveys that were mailed, 9 surveys were returned as undeliverable due to relocation of the pediatrician or due to death; 888 surveys were returned with sufficient information for analysis, giving a response rate of 60% (888/1491). A total of 312 surveys were returned by subjects who did not meet inclusion criteria, whereas the remainder (576, 65%) were completed by pediatricians providing health supervision in a continuity setting. Demographic and practice characteristics of respondents meeting inclusion criteria are shown in Tables 1 and 2, respectively. The average reported age was 44 years. All 50 states and the District of Columbia were represented. Of the surveys returned by pediatricians meeting inclusion criteria, 115 surveys contained incomplete or unclear responses to 1 or more questions. Therefore, for descriptive analyses, individual questions were analyzed based on the number of analyzable responses per item. Ninety-two percent of pediatricians (466/509) reported
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Table 1. Physician Characteristics of Survey Respondents in Primary Care (N 5 576) Physician Characteristics
% of Survey Respondents
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Table 2. Practice Characteristics of Survey Respondents in Primary Care Practice Characteristics
% of Survey Respondents
Sex Male Female Not known
49 49 2
Year MD degree received Before 1980 1980–1989 1990 or After Not known
Region Midwest Northeast Southeast West
23 27 29 21
28 31 36 5
Highest training completed Fellowship Residency Not known
Practice setting Rural Suburban Urban Not known
13 54 30 3
22 75 3
Personal experience Self-reported visual deficit Child with visual deficit
68 32
Type of practice Academic Group/Partnership Multispecialty group Health maintenance organization Solo Other Not known
10 52 14 5 13 4 2
that they routinely performed visual acuity testing in their office. To test visual acuity, pediatricians (N 5 466) reported use of wall charts (74%), machines (39%), and other methods (4%), with some reporting use of more than 1 acuity method. The frequency with which pediatricians routinely performed visual acuity testing at different ages was as follows: 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7 to 12 years (82%), and 13 to 18 years (80%). The earliest age at which respondents (N 5 445) routinely tested for visual acuity was as follows: 3 years (34%), 4 years (47%), 5 years (17%), and $6 years (2%). We examined the reported periodicity schedule for rescreening beyond age 5 years using visual acuity testing. For older children, the AAP recommends objective vision screening at ages 10, 12, 15, and 18 years. For those pediatricians routinely performing visual acuity screening (N 5 466), we compared the reported schedule with the screening schedule recommended by the AAP by categorizing the response into 1 of the following: no testing beyond preschool (28%), less than AAP (5%), comparable to AAP (4%), and more than AAP (59%). Seventy-nine pediatricians (17%), included in the more than AAP category, explicitly reported yearly screening after preschool age. One percent of responses were insufficient for comparison with recommended periodicity schedules, and 3% did not indicate ages of screening. When pediatricians performing routine visual acuity testing were asked to indicate their threshold for referral for further evaluation, responses were variable, but there was a tendency toward lower referral thresholds with increasing patient age (Table 3). For children aged 5 years and under, the 1996 AAP guidelines recommend referring children with visual acuity worse than 20/40. Pediatricians commonly reported use of a referral threshold of 20/50 for each age: 36% for age 3 years, 32% for age 4 years, and 26% for age 5 years. The percentage of pediatricians who reported referral thresholds of higher than 20/50 was
Practice size ,5 physicians 5–9 physicians $10 physicians Not known
50 26 24 ,1
% of patients with Medicaid #10 11–50 .50 Not known
42 42 14 2
% of patients in managed care ,35 35–64 $65 Not known
31 30 37 2
Proximity to eye care specialists (within 20 min) Optometrist Ophthalmologist Pediatric ophthalmologist
89 94 70
14% for age 3 years, 12% for age 4 years, and 7% for age 5 years. The 1996 AAP guidelines recommend referral for children aged 6 years and older if visual acuity is worse than 20/30. Fifty-seven percent or more of pediatricians reported 20/40 as their referral threshold for these age categories. The percentage of pediatricians reporting referral thresholds higher than 20/40 was 25% for age 6 years, 19% for ages 7 to 12 years, and 18% for ages 13 years and older. A small number of pediatricians (56 of 576, 10%) reported routinely referring all children for a formal eye evaluation. Ages for routine referral were 1–3 years (7%), preschool age, 3–5 years (68%), school age, 5–8 years (14%), 10–13 years (4%), other (2%), and not specified (5%). Ninety-five percent of pediatricians (484/507) reported routinely checking red reflexes in their patients. Nearly all pediatricians (478/484) performed red reflex testing with-
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Table 3. Reported Minimum Visual Acuity Screening Levels at Which the Pediatrician Would Refer the Child to an Eye Specialist* Visual Acuity Referral Criterion
Preschool age 3y 4y 5y School age 6y 7–12 y 13–18 y
,20/30
20/30
20/40
20/50
.20/50
Total
0 2 (1) 4 (1)
5 (3) 14 (4) 35 (9)
76 (47) 176 (51) 233 (57)
58 (36) 110 (32) 108 (26)
22 (14) 42 (12) 27 (7)
161 344 407
7 (2) 12 (3) 13 (3)
53 (15) 73 (20) 78 (22)
211 (58) 215 (58) 205 (57)
75 (21) 59 (16) 54 (15)
15 (4) 12 (3) 10 (3)
361 371 360
*Values are no. (%) in each age group. Bold values correspond to highest acceptable screening levels for each age.
in the first 2 months of life. However, 111 (23%) did not check red reflexes beyond 6 months of age, and 214 (44%) did not check red reflexes beyond age 2. To test for eye alignment or binocularity, 64% of pediatricians indicated that they routinely perform a cover test, and 32% indicated that they routinely perform stereopsis testing. However, 24% of pediatricians who responded to both questions (N 5 495) report performing neither the cover test nor stereopsis screening. For the cover test, one fifth (68 pediatricians, 21%) reported performing the test once at a specified age: #4 months (9), 6–12 months (21), 15–24 months (7), 3 years (13), 4–5 years (17), and ‘‘school age’’ (1). Five percent (17) of the pediatricians did not indicate an age for the cover test. Most pediatricians (238) gave an age range in which they perform the cover test. These age ranges were grouped into the following categories: birth or infancy onward (47 pediatricians, 20%), infancy (18, 8%), infancy through preschool (47, 20%), 12 months and older (21, 9%), preschool age, 2–5 years (32, 13%), preschool age and older (41, 17%), school age (6, 3%), and all (21, 9%). Five responses (2%) could not be easily categorized. The average age of initiation reported for the cover test was 22 months, with a median of 12 months. One third of pediatricians (112/323) reported an earliest age of 2 years or older. Few pediatricians (13/565, 2%) reported use of photorefraction as a screening tool in their office. Those using photorefraction for vision screening indicated use during
infancy (7/13) or preschool age (4/13), while 2 pediatricians did not indicate an age. Pediatricians using photorefraction also indicated use of other screening techniques. The majority of pediatricians in our sample (361/557, 65%) reported performing fundoscopic examinations. However, the ages at which these examinations were performed was highly variable. Fourteen pediatricians did not indicate an age for fundoscopic examination. Pediatricians’ responses (N 5 347) were categorized as newborn or infancy (12), birth onward (22), 1–2 years and up (12), 2 years (9), 3 years and up (35), preschool age or age of cooperation (165), school age (5), teens (6), all (63), and other (18). The results of logistic regression are shown in Table 4. Variables that were not associated with routine use of any screening test included years since graduation, proximity of optometrists or general ophthalmologists (defined as within 20 minutes), presence of visual deficits among physicians or their children, practice setting, or the percentage of the patient population with Medicaid. Practicing in a larger practice was associated with an increased likelihood of screening for the majority of the tests examined. Proximity of a pediatric ophthalmologist was associated with an increased likelihood of performing the cover test or stereopsis screening. Having fellowship training was associated with a higher likelihood of performing visual acuity screening. Physicians with a greater percentage of patients in managed care were less likely to routinely refer patients for an eye examination. Male pediatricians were
Table 4. Factors Significantly Associated With the Routine Performance of the Screening Test* Screening Test Visual acuity test
Visual acuity test for 3-y-olds Red reflex test Fundoscopic examination Stereopsis test Cover test Either cover or stereopsis test Routine referral
Independent Variable
Odds Ratio
95% CI
West region fellowship training small practice size male sex academic practice small practice size small practice size small practice size proximity to pediatric ophthalmologist small practice size proximity to pediatric ophthalmologist West region low managed care
0.59 3.17 1.92 0.51 0.71 1.47 1.38 1.31 1.77 1.43 1.84 1.43 0.57
0.42–084 1.06–9.52 1.18–3.11 0.33–0.80 0.55–0.92 1.15–1.87 1.08–1.74 1.02–1.68 1.09–2.87 1.07–1.91 1.07–3.17 1.04–1.96 0.37–0.87
*Results from regression analysis. CI indicates confidence interval.
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Table 5. Routine Performance of Screening Tests in Pediatric Primary Care Offices, Comparing Survey Results Over a 10-Year Period Year of Survey Screening Test
1988*
1993*
1998
Visual acuity test Visual acuity test for 3-y-olds Red reflex test Fundoscopic examination Binocularity test† Cover test Photorefraction test
91% 1/3 94% 77% 54% 69% ...
91% 1/3 98% 80% 58% 71% ...
92% 35% 95% 65% 76% 64% 2%
*American Academy of Pediatrics (AAP) Periodic Surveys.18 †Specific technique for binocularity testing was not specified in the report from the AAP surveys. 1998 survey includes testing for either cover or stereopsis.
less likely than female pediatricians to report routine performance of visual acuity for 3-year-old patients, although physician sex was not significantly associated with the performance of other screening tests. DISCUSSION Our study of a national sample of primary care pediatricians shows that, using the 1996 AAP guidelines as the standard, deficiencies in vision-screening practices still exist. Results from our survey conducted in 1998 show many similarities with those of previous unpublished surveys conducted in 1988 and 1993 by the AAP (Periodic Surveys 3 and 22),18 and these comparisons are shown in Table 5. For instance, similar percentages of respondents reporting use of the following tests in 1988, 1993, and 1998: visual acuity (91%, 91%, and 92%, respectively), red reflex test (94%, 98%, and 95%), cover test (69%, 71%, and 64%), and ophthalmoscopy (77%, 80%, and 65%).18 These deficiencies can be discussed in terms of adherence to AAP guidelines for the screening tests used most frequently by the pediatricians we surveyed: the red reflex, visual acuity, and cover tests or stereopsis testing. Red Reflex Testing Most pediatricians (95%) in our sample reported screening for red reflexes in their patients. Although surveys have indicated good acceptance and use of this test in clinical settings, many pediatricians do not repeat the test as recommended at each health supervision visit. The red reflex test is the most useful method to screen for media opacities in infants and preschool children. Infants with congenital cataracts must be referred immediately, since visual acuity outcome is best for unilateral cataracts treated by age 2 months.19 Our data suggest that the majority of infants are screened during infancy, but that substantial numbers of older infants or children are not screened by red reflex testing for conditions that may present later, including acquired cataracts or retinoblastoma.20,21 Photorefraction is another method to capture and document the red reflex. Photorefraction screens for media opacity, strabismus, and high refractive error, each of which is a risk factor for amblyopia.22 However, use of
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this technique was low among this sample of pediatricians. The AAP recommends that ophthalmoscopic examination be a part of routine vision screening beginning at the earliest possible age, the majority of children being able to cooperate by 5 years of age.6 One third of the pediatricians whom we surveyed reported not routinely performing ophthalmoscopic examinations in their patients. This rate was lower than the rate from previous AAP surveys. The timing of the first ophthalmoscopic examination among our respondents ranged from birth to adolescence. Although no child is ever too young for ophthalmoscopy, examination may be very difficult if pupils are small, and fixation cannot be controlled. Adler23 has reported that dilation of pupils, using 0.5% tropicamide at the first pediatric office examination, enhances observation of the red reflex and is well accepted by parents. The AAP guidelines in force during this research did not advocate routine dilation in the primary care setting, but did recommend that children with risk factors for retinal disorders, such as congenital infectious disease or premature birth, be referred to an eye specialist for diagnostic examination.6 Visual Acuity Testing The second most common screening test among respondents was an assessment of visual acuity. Roughly two thirds of our sample reported routinely not attempting visual acuity screening of children at age 3 years as recommended. Most responding pediatricians begin testing at age 4 years. This age has been adopted in Sweden due to improved completion rates at age 4 compared with age 3, and data have shown a reduction in the prevalence of amblyopia among children who have attended the preschool vision screening.24,25 In our sample, almost one fifth of respondents reported delaying acuity screening until age 5 years or later. By school age, the majority reported either meeting or exceeding the recommended visual acuity screening schedule. In contrast, one third indicated not screening beyond the preschool age range. Although the most commonly reported visual acuity threshold for referring children aged 3 to 5 years was failure to pass the 20/40 line as recommended by the 1996 AAP guidelines, the pediatricians we surveyed referred substantial numbers of preschool children using other criteria. Our data show that many pediatricians use less stringent referral criteria than those recommended by the AAP. A national review of preschool vision-screening programs showed that most programs use either 20/30 or 20/40 as the critical line to pass in visual acuity screening.26 Therefore, the pediatricians we surveyed use criteria either similar to or less stringent than those of most community vision-screening programs. Cover Testing or Stereopsis Testing Cover testing or stereopsis testing was performed by three fourths of respondents. Neither test is necessary to detect strabismus that is apparent by gross observation or by corneal light reflex testing. Our survey only included questions about screening and referral practices for non-
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obvious strabismus. Such tests are recommended by the AAP at each health supervision visit, for all children who can fixate on a target. Only 64% of respondents indicated that they routinely perform a cover test, and 24% reported that they do not use either recommended method to screen for nonobvious strabismus. Screening is most important during the preschool years when strabismus is most likely to present. The consequences of these vision-screening deficiencies have been suggested in a study of children treated for amblyopia in one pediatric ophthalmology practice.11 Approximately two thirds of children with strabismic amblyopia had obvious deviations (.108), and roughly 70% of these children were identified before age 5 years. On the other hand, one third of children had nonobvious deviations (#108), and late detection (age 5 years or later) of these deviations occurred in 64%. In this series, the majority of children with amblyopia were first identified outside of the primary care setting; only 12% of children with late diagnoses and 33% of children with early diagnoses were first detected in the primary care setting. The remainder were first identified by school screening or by parents’ self-referral to an eye care professional. Our study, which was based on a nationally representative sample of pediatricians, examined vision-screening and referral practices in greater detail than previous studies. The results of this study confirm earlier reports of inadequate vision-screening practices in pediatric settings when compared with the 1996 AAP guidelines. The vast majority of pediatricians perform some of the recommended tests some of the time, but very few perform all of the recommended tests at each health supervision visit. Although our study focused on adherence to AAP vision-screening guidelines, guidelines from other sources differ in their recommendations. The Guide to Clinical Preventive Services, 2nd Edition, by the US Preventive Services Task Force supports vision screening for amblyopia and strabismus for all children before school entry, preferably between ages 3 and 4 (http://odphp.osophs. dhhs.gov/pubs/guidecps). However, periodic rescreening is not recommended on the basis of insufficient evidence for benefit. Both guidelines stress the importance of vision screening at preschool ages, but the pediatricians we surveyed report more vigorous vision screening at school age. Although variation in screening practices may reflect this lack of consensus among organizations, it may also reflect the personal beliefs of the individual physician that vision screening is somehow more important or successful in older children. Although various vision-screening methods have been evaluated,27–32 no single method has been implemented on a national scale. In addition, pediatric vision-screening practices may be affected by local factors such as state laws, school district guidelines, and existing community screening programs.12,17,33 Limitations There are several limitations to our study. The survey design captures reported practices, which may not reflect actual practice. Some items in the survey were not com-
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pleted by all respondents. This may have been due to the length of the survey. Our goal was to collect detailed information on screening and referral practices, and the length of the survey may have deterred some from completing it. Our response rate was 60% with a total of 4 mailings. We do not have information on the nonresponders and cannot rule this out as a source of bias. Openended responses may not have completely captured age ranges, and many responses were not specific, creating difficulty in interpretation. Much of vision screening is dependent on operator technique, which cannot be assessed using the survey design. Although the survey approach to selected areas of screening was exploratory in nature, responses indicated wide variability in visionscreening practices among pediatricians, warranting further study. Conclusions Many pediatricians do not follow AAP guidelines for vision screening, especially for younger children. In general, pediatricians also report using less stringent referral criteria for visual acuity compared with those recommended in the AAP guidelines. Since vision problems are generally more responsive to treatment in younger children and since undetected vision problems can lead to permanent, irreversible vision loss, failure to comply with guidelines may produce long-term negative consequences for patients. The reasons why pediatricians do not follow recommended vision-screening guidelines are not clear, but are likely to be multifactorial. The first reason may be related to efficiency or convenience. Vision screening, especially of 3-year-old children, requires time and patience. A decrease in efficiency, combined with concerns over adequate reimbursement for vision screening as an independent procedure, has obvious negative consequences for practicing pediatricians. Another reason for incomplete compliance with guidelines may be lack of knowledge or skill. Vision screening is dependent on operator skill, especially for the cover test and fundoscopic examinations. Pediatricians and their staff may lack the skills or technology necessary for effective screening. Finally, pediatricians may be concerned about the false-positive rates of current vision-screening techniques. Physicians may question the specific recommendations since they are based on consensus rather than evidence, and they may place more weight on the inherent cost of false-positive results from the standpoint of the parent. More information is needed on the effectiveness of current screening techniques and on the risks of not screening. Although changing physician behavior is a complicated process, it remains a worthy goal because of the negative outcome if abnormalities are detected after the visual axis has matured. REFERENCES 1. US Public Health Service. Vision screening in children. Am Fam Physician. 1994;50:587–590. 2. Atkinson J, Braddick O, Robier B, et al. Two infant vision
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screening programmes: prediction and prevention of strabismus and amblyopia from photo- and videorefractive screening. Eye. 1996;10:189–198. De Becker I, MacPherson H, LaRoche G, et al. Negative predictive value of a population-based preschool vision screening program. Ophthalmology. 1992;99:998–1003. Lavrich JB, Nelson LB. Diagnosis and treatment of strabismus disorders. Pediatr Clin North Am. 1993;40:737–752. Rahi JS, Dezateux C. National cross sectional study of detection of congenital and infantile cataract in the United Kingdom: role of childhood screening and surveillance. BMJ. 1999;318:362– 365. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine. Eye examination and vision screening in infants, children, and young adults. Pediatrics. 1996;98:153– 157. Leske M, Rosenthal J, Soroka M. Vision screening requirements under 52 Early and Periodic Screening Diagnosis and Treatment (EPSDT) Programs. Public Health Rep. 1981;96:404–409. Hartmann EE, Dobson V, Hainline L, et al. Preschool vision screening: summary of a task force report. Pediatrics. 2000;106: 1105–1112. American Academy of Pediatrics. Use of photoscreening for children’s vision screening. Pediatrics. 2002;109:116–117. American Academy of Pediatrics. Recommendations for Preventive Pediatric Health Care, Committee on Practice and Ambulatory Medicine. Pediatrics. 1995;96:373–374. Campbell LR, Charney E. Factors associated with delay in diagnosis of childhood amblyopia. Pediatrics. 1991;87:178–185. Ehrlich MI, Reinecke RD, Simons K. Preschool vision screening for amblyopia and strabismus: programs, methods, and guidelines, 1983. Surv Ophthalmol. 1983;28:145–163. Mark H, Mark T. Parental reasons for non-response following a referral in school vision screening. J Sch Sci. 1999;69:35–38. Preslan M, Novak A. Baltimore Vision Screening Project, Phase 2. Ophthalmology. 1998;105:150–153. Yawn B, Kurland M, Butterfield L, Johnson B. Barriers to seeking care following school vision screening in Rochester, Minnesota. J Sch Health. 1998;68:319–324. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screening in pediatric practice: a study from the Pediatric Research in Office Settings (PROS) network. Pediatrics. 1992;89: 834–838. Marcinak JF, Werntz Yount SO. Evaluation of vision screening practices of Illinois pediatricians. Clin Pediatr. 1995;34:353– 357.
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