- Email: [email protected]
Referral patterns for common amblyogenic conditions
Referral Patterns for Common Amblyogenic Conditions Mrunalini Parvataneni, MD,a Stephen P. Christiansen, MD,a,b Allison A. Jensen, MD,a and C. Gail Summers, MDa,b Purpose: The early detection and management of common pediatric ophthalmic problems is crucial to assure successful visual maturation and best potential for development of binocular vision. The referring physician plays a pivotal role in this process. This study was designed to investigate the prevailing referral patterns for common amblyogenic conditions in a defined geographic region. Methods: We sent a short questionnaire to 300 pediatricians and 1500 family practitioners (FPs) in Minnesota, asking them to use a multiple choice system to indicate how long after diagnosis they would wait before referring a child to an ophthalmologist for exotropia, esotropia, ptosis, nystagmus, and abnormal red reflex. Results: The response rate was 46.9% (n ⫽ 117) for pediatricians and 17.9% (n ⫽ 240) for FPs. Of respondents, 64.6% of pediatricians and 50.2% of FPs would refer patients with exotropia within 2 months of diagnosis (P ⬍ 0.001). For esotropia, 58.8% of pediatricians would refer within 2 months, while 38.6% would wait up to 12 months. In comparison, 48.7% of FPs would refer sooner, while 47.9% would refer later. These differences in referral patterns for pediatricians and FPs were statistically significant (P ⫽ 0.037). There was less variation for referral of ptosis, nystagmus, and abnormal red reflex. These referral patterns were unaffected by years in practice. Conclusions: Pediatricians referred patients with strabismus significantly more promptly than FPs. The majority of primary care providers (PCPs) appropriately timed their referrals for these amblyogenic conditions. However, many children continue to be referred late, underscoring the need for continued education of PCPs. (J AAPOS 2005;9:22-25) he prompt detection of common pediatric ophthalmic problems is crucial to permit successful visual maturation and development of binocular vision. It is generally believed that maturation of the visual system progresses exponentially from birth and then slowly matures until approximately age 8.1 Amblyopia develops most quickly when an amblyogenic condition occurs in the first 2 years of life and may be profound if the visual insult occurs within the first 3 months of life. Conversely, if amblyopia is aggressively managed in the first 3 years of life, visual rehabilitation can often be very successful in restoring vision due to the plasticity of a child’s visual system.
T
The primary care physician (PCP) is likely the first professional to encounter amblyogenic conditions in children and, therefore, plays a pivotal role in initiating the treatment process. The variability in methodology and attitudes concerning vision screening has been noted by others.2,3 In addition, we have noticed that the timeliness of referral seems to be quite variable among family practitioners (FPs) and pediatricians in our area. We sought to objectively study the timing of referral for common amblyogenic conditions among the PCPs in the state of Minnesota. This information about referral habits would help to determine whether additional education regarding appropriate timing of referrals was necessary.
METHODS a
b
From the Department of Ophthalmology and Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA. Dr. Parvataneni is now in practice in Maple Grove, MN. Dr. Jensen is now in practice in Baltimore, MD. Poster presented at the 28th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Seattle, WA, March 20-24, 2002. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY. Submitted November 10, 2003. Revision accepted September 22, 2004. Correspondence: C. Gail Summers, MD, University of Minnesota, Department of Ophthalmology, MMC 493, 420 Delaware St., SE, Minneapolis, MN 55455.(E-mail: [email protected]). Copyright © 2005 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2005/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2004.09.007
22
February 2005
We sought to obtain information about referral patterns for five pediatric ophthalmic conditions by using a short questionnaire that was sent to 300 pediatricians and 1500 family practitioners in Minnesota. The names of these practitioners were obtained through the Continuing Medical Education Department at the University of Minnesota. The surveys were returned anonymously but were sorted for family practitioners and pediatricians, using a color-coding process. The practitioner completing the survey was unaware of the color-coding. The conditions studied were exotropia, esotropia, ptosis, nystagmus, and abnormal red reflex. The questionnaire ascertained the following information: (1) the most comJournal of AAPOS
Journal of AAPOS Volume 9 Number 1 February 2005
Parvataneni et al
23
FIG 1. Comparison of referral patterns for exotropia for pediatricians and family practitioners. The bars represent percentage of respondents for each group. The numbers above the bar represent the actual number of responding physicians.
mon age at which a diagnosis of each of the above conditions was made in their practice; (2) the length of time that each PCP felt was appropriate to wait between diagnosis and referral to an ophthalmologist; (3) the distance that a patient would have to travel to the nearest ophthalmologist; (4) the practice setting in which the PCP worked (ie, solo or group practice, academic, or HMO-based practice); and (5) the number of years of experience of the PCP. All questions were answered with a multiple choice system that provided seven or eight choices per question. The choices ranged from immediately to greater than 1 year. An arbitrary point of 2 months was used for the smallest delay in referral based on the forced choice responses. Questions 3 through 5 (noted in the above paragraph) were included to determine how these parameters impacted referral habits. Nonparametric tests were used in the statistical analysis. Comparisons between pediatricians and FPs were made with the Wilcoxon rank sum test. The Spearman correlation was used to measure the association between the number of years of practice and type of practice with the responses.
2 months of observation, while 34% would wait up to 12 months after observation. Approximately half of the FPs would refer within 2 months, while 46.4% would wait up to 12 months. The distribution of responses is shown in Figure 1. The difference in responses between the two groups for timing of referral of recognized exotropia was statistically significant (P ⬍ 0.001). Esotropia Both groups of physicians felt esotropia was most commonly seen in the first year of life (86.5% of pediatricians and 86.2% of FPs). Slightly more than half of the responding pediatricians (58.8%) would refer a child with esotropia to an ophthalmologist within 2 months, while 38.6% would wait up to 12 months. The pattern among responding FPs was slightly more variable, with 48.7% referring within 2 months and 47.9% waiting up to 12 months. The variability in referral habits is shown in Figure 2. The difference in responses between pediatricians and FPs for timing of referral for recognized esotropia was also statistically significant (P ⫽ 0.037).
RESULTS
Other Diagnoses
The response rate was 46.9% (n ⫽ 117) for pediatricians and 17.9% (n ⫽ 240) for FPs (19.8% overall response rate). Approximately 100 surveys (0.05%) were returned unanswered due to forwarding addresses being unavailable.
There was less variability in referring patients with ptosis or nystagmus: 71.2% of pediatricians and 80.6% of FPs would refer a patient with ptosis within 2 months of first observation, while 90.3% of pediatricians and 86.4% of FPs would refer a child with nystagmus within 2 months. Similarly, 97.4% of pediatricians and 93.7% of FPs would immediately refer children with an absent or reduced red reflex. These differences between pediatricians and FPs for referral patterns for ptosis, nystagmus, and absent or reduced red reflex were not significantly different. Of the responders, 85.5% of pediatricians and 63.7% of FPs practiced within a 10-mile radius of the ophthalmol-
Exotropia For intermittent or constant exotropia, 79.6% of responding pediatricians and 85.9% of responding FPs observed the condition most commonly in the first 12 months of life. Approximately two-thirds of responding pediatricians would refer these patients to an ophthalmologist within
24
Journal of AAPOS Volume 9 Number 1 February 2005
Parvataneni et al
FIG 2. Comparison of referral patterns for esotropia for pediatricians and family practitioners. The bars represent percentage of respondents for each group. The numbers above the bar represent the actual number of responding physicians for each clinical condition. TABLE 1. Number of years of experience of the responding physicians
Pediatricians Family practitioners
<5 years
6–10 years
11–15 years
>15 years
15.5% 13.8%
22.4% 15.5%
11.2% 17.2%
50.9% 53.6%
ogist to whom they most frequently referred their patients. This, combined with the large skew toward private practice (71.8% of pediatricians and 84.6% of FPs), prevented any reasonable comparison of these variables with the referral trends. It was observed, however, that the referral patterns were unaffected by the number of years in practice. Distribution of doctors by years in practice is shown for both pediatricians and FPs in the table.
DISCUSSION Table 1. Early management of amblyogenic conditions requires prompt evaluation of the child. Yu-Dong et al4 found that 42% of referrals to their center were initiated by parental observation of the ophthalmic abnormality, usually by the mother. Of these patients, 85% were under 5 years of age. This study also noted a delay in seeking evaluation by a health-care professional for several months. In most communities today, we presume that referral to an eye-care professional is commonly made after the PCP identifies the amblyogenic condition. Our study highlights the importance of the role of PCPs in the early detection and prompt referral of common pediatric ophthalmic problems. Because parents may delay in seeking care, it is essential that the PCP be dedicated to early detection of ophthalmologic problems at routine well-baby checks. Brooks suggested that ophthalmologic referrals are delayed under
the assumption that children outgrow the condition, eg, strabismus.5 Education of PCPs would be expected to reduce the frequency with which such myths guide clinical practice. While referrals to an ophthalmologist were usually made within 2 months of diagnosis, a delay in referral frequently occurred among physicians surveyed in our report. The major risks of delayed referral are loss of vision and binocular function, and in delay of diagnosis of serious systemic or neurological conditions. Amblyopia can occur in up to 30 to 50% of strabismic patients, if left untreated.6 Rarely, strabismus can be due to a life-threatening condition such as retinoblastoma. Beyond this, the visual system loses plasticity over time, making appropriately timed referrals crucial to successful recovery of visual development. PCPs showed greater variability in referring children with exotropia and esotropia, compared with other studied eye problems. We used a dividing point of 2 months as the duration of time to observe a child with strabismus. This interval was short, based on the experience that some types of strabismus can deteriorate if there is delay in the prescription of appropriate refractive correction and that amblyopia can develop.7 While more than one-half of PCPs would refer within 2 months, approximately 40% of PCPs would observe these patients for 4 months or longer. This trend was more evident among FPs than pediatricians. The majority of PCPs in Minnesota appropriately timed the referral of nonstrabismic problems in pediatric patients. This included nystagmus, ptosis, and absent or reduced red reflex, which are relatively uncommon. However, because of the association with an underlying systemic disorder that in some cases may be life-threatening, any delay in referral could be considered unacceptable.
Journal of AAPOS Volume 9 Number 1 February 2005
The American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) have published vision screening recommendations, which include detection of strabismus, vision or fixation preference, and evaluation of the red reflex.8 These recommendations state that all newborns should undergo a screening eye examination in the nursery prior to discharge, as well as between 6 months and 1 year of age, and between 3 and 3½ years of age. Certain highrisk children should also be evaluated by an ophthalmologist. The screening recommendations by the American Academy of Pediatrics (AAP) and the American Academy of Family Practice (AFP) are similar to the above guidelines.9,10 It is recommended that referral to an ophthalmologist be made when a problem is observed, but even the more recent policy gives no specific guidelines as to the appropriate timing of these referrals.11 This study detected more variability among referral patterns for FPs compared with pediatricians. This may be due to the low response rate from FPs compared with pediatricians. Ten surveys from FPs were returned with only a comment saying that the youngest patient in their practice was 10 years. An older patient population among FPs may have contributed to the low response rate from FPs, as the survey was directed at referral of young patients. Our survey inquired about referral to an ophthalmologist, whereas some PCPs may have an established referral pattern to both ophthalmologists and optometrists, impeding completion of the survey. In addition, the difference in training between FPs and pediatricians may contribute to the variance noted. This study did not address the constancy or extent of the observed ophthalmic problem. Many ophthalmologists are comfortable in observing an intermittent or smallangle strabismus and feel that an immediate ophthalmologic referral may not be necessary. Nonetheless, PCPs are not as well trained at examining the intermittency or extent of strabismus and other conditions, and early referral may be a reasonable expectation. In addition, this study was conducted as a questionnaire and did not define or illustrate the clinical abnormality. It is possible that some PCPs may have had difficulty answering the questions due to limited knowledge about the specific problem. Last, timing of referral becomes less relevant to amelioration of the condition if the PCP has difficulty performing screening eye examinations or if families are noncompliant with the recommended schedule for screening
Parvataneni et al
25
eye examinations or the recommendation for follow-up with an eye-care practitioner. Even with prompt referrals, a limiting factor in management could be insurance approvals for referrals or the availability of the ophthalmologist. Continued cooperation among PCPs, eye-care providers, families, and insurance companies is important for early detection and prompt management of vision-altering and life-threatening disorders. Despite the noted limitations, the results of this study underscore the variability in referral patterns. Because of this, we recommend further education in early detection, including appropriate time of observation prior to referral to an ophthalmologist when abnormalities are detected with screening. Appropriate degrees of urgency in making referrals have been suggested by other authors.12 Incorporating preferred practice patterns in the continuing education of the PCP will increase the likelihood of children maturing with normal vision. References 1. Day S. Normal and abnormal visual development. In: Taylor D, editor. Pediatric ophthalmology, 2nd ed. Victoria, Australia: Blackwell Science; 1997. p. 13-19. 2. 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;89:834-8. 3. Hartman EE, Dobson V, Hainline L, Marsh-Tootle W, Quinn GE, et al: Preschool vision screening: summary of a task force report. Pediatrics 2000;106:1105-12. 4. Yu-Dong W, Thompson JR, Goulstine DB, Rosenthal AR: A survey of the initial referral of children to an ophthalmology department. Br J Ophthalmol 1990;74:650-3. 5. Brooks SE: Strabismus and amblyopia in children: the role of primary care. Compr Ther 1997;23:60-6. 6. Lavrich JB, Nelson LB: Diagnosis and treatment of strabismus disorders. Pediatr Clin N Am 1993;40:737-52. 7. Keech RV, Kutschke PJ: Upper age limit for the development of amblyopia. J Pediatr Ophthalmol Strabismus 1995;32:89-93. 8. American Academy of Ophthalmology. Comprehensive pediatric eye evaluation: preferred practice pattern. San Francisco, CA: American Academy of Ophthalmology; 1992. 9. American Academy of Pediatrics. Task force on Medical Management Guidelines. Pediatrics 2001;108:1378-82. 10. Broderick P: Pediatric vision screening for the family physician. Am Fam Physician 1998;58:691-707. 11. American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics 2003;111:902-7. 12. Friedman LS, Kaufman LM: Guidelines for pediatrician referrals to the ophthalmologist. Pediatr Clin N Am 2003;50:41-53.
T
The primary care physician (PCP) is likely the first professional to encounter amblyogenic conditions in children and, therefore, plays a pivotal role in initiating the treatment process. The variability in methodology and attitudes concerning vision screening has been noted by others.2,3 In addition, we have noticed that the timeliness of referral seems to be quite variable among family practitioners (FPs) and pediatricians in our area. We sought to objectively study the timing of referral for common amblyogenic conditions among the PCPs in the state of Minnesota. This information about referral habits would help to determine whether additional education regarding appropriate timing of referrals was necessary.
METHODS a
b
From the Department of Ophthalmology and Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA. Dr. Parvataneni is now in practice in Maple Grove, MN. Dr. Jensen is now in practice in Baltimore, MD. Poster presented at the 28th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Seattle, WA, March 20-24, 2002. Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc., New York, NY. Submitted November 10, 2003. Revision accepted September 22, 2004. Correspondence: C. Gail Summers, MD, University of Minnesota, Department of Ophthalmology, MMC 493, 420 Delaware St., SE, Minneapolis, MN 55455.(E-mail: [email protected]). Copyright © 2005 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2005/$35.00 ⫹ 0 doi:10.1016/j.jaapos.2004.09.007
22
February 2005
We sought to obtain information about referral patterns for five pediatric ophthalmic conditions by using a short questionnaire that was sent to 300 pediatricians and 1500 family practitioners in Minnesota. The names of these practitioners were obtained through the Continuing Medical Education Department at the University of Minnesota. The surveys were returned anonymously but were sorted for family practitioners and pediatricians, using a color-coding process. The practitioner completing the survey was unaware of the color-coding. The conditions studied were exotropia, esotropia, ptosis, nystagmus, and abnormal red reflex. The questionnaire ascertained the following information: (1) the most comJournal of AAPOS
Journal of AAPOS Volume 9 Number 1 February 2005
Parvataneni et al
23
FIG 1. Comparison of referral patterns for exotropia for pediatricians and family practitioners. The bars represent percentage of respondents for each group. The numbers above the bar represent the actual number of responding physicians.
mon age at which a diagnosis of each of the above conditions was made in their practice; (2) the length of time that each PCP felt was appropriate to wait between diagnosis and referral to an ophthalmologist; (3) the distance that a patient would have to travel to the nearest ophthalmologist; (4) the practice setting in which the PCP worked (ie, solo or group practice, academic, or HMO-based practice); and (5) the number of years of experience of the PCP. All questions were answered with a multiple choice system that provided seven or eight choices per question. The choices ranged from immediately to greater than 1 year. An arbitrary point of 2 months was used for the smallest delay in referral based on the forced choice responses. Questions 3 through 5 (noted in the above paragraph) were included to determine how these parameters impacted referral habits. Nonparametric tests were used in the statistical analysis. Comparisons between pediatricians and FPs were made with the Wilcoxon rank sum test. The Spearman correlation was used to measure the association between the number of years of practice and type of practice with the responses.
2 months of observation, while 34% would wait up to 12 months after observation. Approximately half of the FPs would refer within 2 months, while 46.4% would wait up to 12 months. The distribution of responses is shown in Figure 1. The difference in responses between the two groups for timing of referral of recognized exotropia was statistically significant (P ⬍ 0.001). Esotropia Both groups of physicians felt esotropia was most commonly seen in the first year of life (86.5% of pediatricians and 86.2% of FPs). Slightly more than half of the responding pediatricians (58.8%) would refer a child with esotropia to an ophthalmologist within 2 months, while 38.6% would wait up to 12 months. The pattern among responding FPs was slightly more variable, with 48.7% referring within 2 months and 47.9% waiting up to 12 months. The variability in referral habits is shown in Figure 2. The difference in responses between pediatricians and FPs for timing of referral for recognized esotropia was also statistically significant (P ⫽ 0.037).
RESULTS
Other Diagnoses
The response rate was 46.9% (n ⫽ 117) for pediatricians and 17.9% (n ⫽ 240) for FPs (19.8% overall response rate). Approximately 100 surveys (0.05%) were returned unanswered due to forwarding addresses being unavailable.
There was less variability in referring patients with ptosis or nystagmus: 71.2% of pediatricians and 80.6% of FPs would refer a patient with ptosis within 2 months of first observation, while 90.3% of pediatricians and 86.4% of FPs would refer a child with nystagmus within 2 months. Similarly, 97.4% of pediatricians and 93.7% of FPs would immediately refer children with an absent or reduced red reflex. These differences between pediatricians and FPs for referral patterns for ptosis, nystagmus, and absent or reduced red reflex were not significantly different. Of the responders, 85.5% of pediatricians and 63.7% of FPs practiced within a 10-mile radius of the ophthalmol-
Exotropia For intermittent or constant exotropia, 79.6% of responding pediatricians and 85.9% of responding FPs observed the condition most commonly in the first 12 months of life. Approximately two-thirds of responding pediatricians would refer these patients to an ophthalmologist within
24
Journal of AAPOS Volume 9 Number 1 February 2005
Parvataneni et al
FIG 2. Comparison of referral patterns for esotropia for pediatricians and family practitioners. The bars represent percentage of respondents for each group. The numbers above the bar represent the actual number of responding physicians for each clinical condition. TABLE 1. Number of years of experience of the responding physicians
Pediatricians Family practitioners
<5 years
6–10 years
11–15 years
>15 years
15.5% 13.8%
22.4% 15.5%
11.2% 17.2%
50.9% 53.6%
ogist to whom they most frequently referred their patients. This, combined with the large skew toward private practice (71.8% of pediatricians and 84.6% of FPs), prevented any reasonable comparison of these variables with the referral trends. It was observed, however, that the referral patterns were unaffected by the number of years in practice. Distribution of doctors by years in practice is shown for both pediatricians and FPs in the table.
DISCUSSION Table 1. Early management of amblyogenic conditions requires prompt evaluation of the child. Yu-Dong et al4 found that 42% of referrals to their center were initiated by parental observation of the ophthalmic abnormality, usually by the mother. Of these patients, 85% were under 5 years of age. This study also noted a delay in seeking evaluation by a health-care professional for several months. In most communities today, we presume that referral to an eye-care professional is commonly made after the PCP identifies the amblyogenic condition. Our study highlights the importance of the role of PCPs in the early detection and prompt referral of common pediatric ophthalmic problems. Because parents may delay in seeking care, it is essential that the PCP be dedicated to early detection of ophthalmologic problems at routine well-baby checks. Brooks suggested that ophthalmologic referrals are delayed under
the assumption that children outgrow the condition, eg, strabismus.5 Education of PCPs would be expected to reduce the frequency with which such myths guide clinical practice. While referrals to an ophthalmologist were usually made within 2 months of diagnosis, a delay in referral frequently occurred among physicians surveyed in our report. The major risks of delayed referral are loss of vision and binocular function, and in delay of diagnosis of serious systemic or neurological conditions. Amblyopia can occur in up to 30 to 50% of strabismic patients, if left untreated.6 Rarely, strabismus can be due to a life-threatening condition such as retinoblastoma. Beyond this, the visual system loses plasticity over time, making appropriately timed referrals crucial to successful recovery of visual development. PCPs showed greater variability in referring children with exotropia and esotropia, compared with other studied eye problems. We used a dividing point of 2 months as the duration of time to observe a child with strabismus. This interval was short, based on the experience that some types of strabismus can deteriorate if there is delay in the prescription of appropriate refractive correction and that amblyopia can develop.7 While more than one-half of PCPs would refer within 2 months, approximately 40% of PCPs would observe these patients for 4 months or longer. This trend was more evident among FPs than pediatricians. The majority of PCPs in Minnesota appropriately timed the referral of nonstrabismic problems in pediatric patients. This included nystagmus, ptosis, and absent or reduced red reflex, which are relatively uncommon. However, because of the association with an underlying systemic disorder that in some cases may be life-threatening, any delay in referral could be considered unacceptable.
Journal of AAPOS Volume 9 Number 1 February 2005
The American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) have published vision screening recommendations, which include detection of strabismus, vision or fixation preference, and evaluation of the red reflex.8 These recommendations state that all newborns should undergo a screening eye examination in the nursery prior to discharge, as well as between 6 months and 1 year of age, and between 3 and 3½ years of age. Certain highrisk children should also be evaluated by an ophthalmologist. The screening recommendations by the American Academy of Pediatrics (AAP) and the American Academy of Family Practice (AFP) are similar to the above guidelines.9,10 It is recommended that referral to an ophthalmologist be made when a problem is observed, but even the more recent policy gives no specific guidelines as to the appropriate timing of these referrals.11 This study detected more variability among referral patterns for FPs compared with pediatricians. This may be due to the low response rate from FPs compared with pediatricians. Ten surveys from FPs were returned with only a comment saying that the youngest patient in their practice was 10 years. An older patient population among FPs may have contributed to the low response rate from FPs, as the survey was directed at referral of young patients. Our survey inquired about referral to an ophthalmologist, whereas some PCPs may have an established referral pattern to both ophthalmologists and optometrists, impeding completion of the survey. In addition, the difference in training between FPs and pediatricians may contribute to the variance noted. This study did not address the constancy or extent of the observed ophthalmic problem. Many ophthalmologists are comfortable in observing an intermittent or smallangle strabismus and feel that an immediate ophthalmologic referral may not be necessary. Nonetheless, PCPs are not as well trained at examining the intermittency or extent of strabismus and other conditions, and early referral may be a reasonable expectation. In addition, this study was conducted as a questionnaire and did not define or illustrate the clinical abnormality. It is possible that some PCPs may have had difficulty answering the questions due to limited knowledge about the specific problem. Last, timing of referral becomes less relevant to amelioration of the condition if the PCP has difficulty performing screening eye examinations or if families are noncompliant with the recommended schedule for screening
Parvataneni et al
25
eye examinations or the recommendation for follow-up with an eye-care practitioner. Even with prompt referrals, a limiting factor in management could be insurance approvals for referrals or the availability of the ophthalmologist. Continued cooperation among PCPs, eye-care providers, families, and insurance companies is important for early detection and prompt management of vision-altering and life-threatening disorders. Despite the noted limitations, the results of this study underscore the variability in referral patterns. Because of this, we recommend further education in early detection, including appropriate time of observation prior to referral to an ophthalmologist when abnormalities are detected with screening. Appropriate degrees of urgency in making referrals have been suggested by other authors.12 Incorporating preferred practice patterns in the continuing education of the PCP will increase the likelihood of children maturing with normal vision. References 1. Day S. Normal and abnormal visual development. In: Taylor D, editor. Pediatric ophthalmology, 2nd ed. Victoria, Australia: Blackwell Science; 1997. p. 13-19. 2. 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;89:834-8. 3. Hartman EE, Dobson V, Hainline L, Marsh-Tootle W, Quinn GE, et al: Preschool vision screening: summary of a task force report. Pediatrics 2000;106:1105-12. 4. Yu-Dong W, Thompson JR, Goulstine DB, Rosenthal AR: A survey of the initial referral of children to an ophthalmology department. Br J Ophthalmol 1990;74:650-3. 5. Brooks SE: Strabismus and amblyopia in children: the role of primary care. Compr Ther 1997;23:60-6. 6. Lavrich JB, Nelson LB: Diagnosis and treatment of strabismus disorders. Pediatr Clin N Am 1993;40:737-52. 7. Keech RV, Kutschke PJ: Upper age limit for the development of amblyopia. J Pediatr Ophthalmol Strabismus 1995;32:89-93. 8. American Academy of Ophthalmology. Comprehensive pediatric eye evaluation: preferred practice pattern. San Francisco, CA: American Academy of Ophthalmology; 1992. 9. American Academy of Pediatrics. Task force on Medical Management Guidelines. Pediatrics 2001;108:1378-82. 10. Broderick P: Pediatric vision screening for the family physician. Am Fam Physician 1998;58:691-707. 11. American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Eye examination in infants, children, and young adults by pediatricians. Pediatrics 2003;111:902-7. 12. Friedman LS, Kaufman LM: Guidelines for pediatrician referrals to the ophthalmologist. Pediatr Clin N Am 2003;50:41-53.