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Clinical Care and Practice Advancement

The Need for Comprehensive Vision Examination of Preschool and School-age Children

Only about one third of all children have had an eye examination or vision screening prior to entering school.

Vision disorders are a common pediatric health problem in the United States.1,2 It is estimated that nearly 25% of school-age children have vision problems.2-5 Despite the economic, social and health care advances which have occurred in our society, many preschool and school-age children are not receiving adequate professional eye and vision care. Only about one third of all children have had an eye examination or vision screening prior to entering school.6 Also, a recent study found that 11.5% of teenagers have undetected or untreated vision problems.7 The early detection and treatment of eye and vision problems for children needs to be a major public health goal. This is made increasingly important by the enhanced understanding of critical periods in human visual development.8-10 The earlier a vision problem is diagnosed and treated, the less the potential negative impact it may have on the child's development.11,12

The American Optometric Association believes that an eye/vision assessment conducted as part of a preschool or school physical or a vision screening in the public or private schools cannot substitute for regular professional care. Vision screening is a limited process of surveying certain aspects of vision problem areas. A professional vision examination is essential for the diagnosis and treatment of eye and vision problems prior to entry into school.

The need for vision examinations of school-aged children is supported by a review of various studies, which find that:

  • Vision screening programs for school children are intended to help identify those children who have or may potentially have a vision problem that may affect physiological or perceptual processes of vision or that could interfere with school performance. Vision screenings are not diagnostic nor do they lead to treatment, but rather only indicate a potential need for further care.13

  • Only 33 states and the District of Columbia have requirements for vision screening in public or private schools. The scope and frequency of school vision screenings vary considerably from state to state.14

  • The need for a comprehensive vision examination should not be confused with the need for quality vision screening programs. Each has a different purpose and generates different results.15

  • The fact that vision screening is a limited, non-diagnostic process is often not communicated effectively to the public. This creates the illusion that "passing" the screening means that there is no vision problem.13

  • The greatest concern in vision screening is under referrals. Failure to identify children who need further attention jeopardizes the effectiveness and credibility of well-designed and administered screening endeavors.16,17 This is especially evident when only visual acuity is used as the standard in the screening program.18 There is also the unmeasurable hidden costs and impact of the untreated vision problem on the child's quality of life.

  • Mentally and multiply handicapped children (e.g., children with such conditions as mental retardation, cerebral palsy, hearing impairment, and low birth weight syndrome) exhibit an incidence rate of vision anomalies at least twice as high as normally developed children.19 Due to their handicaps, many of these children do not respond appropriately to standard vision screening procedures.20 Unidentified vision problems in this special population can further impair their growth and development. These special children have the greatest need for comprehensive clinical vision examinations well before entering a public or private school system.

Therefore, it is the position of the American Optometric Association that:

  • Any undetected vision problem may result in the reduction of the efficiency of the visual system. This may further result in the inability of children to achieve their full potential.

  • All children should receive a comprehensive eye and vision examination assessing and treating any deficiencies in ocular health, visual acuity, refractive status, oculomotility and binocular vision prior to entering school. Asymptomatic/risk free pediatric patients should have a comprehensive examination at age 3 followed by another examination before first grade. The asymptomatic/risk free child should continue to have comprehensive eye and vision examinations every 2 years thereafter. Symptomatic/at risk children may need to have examinations more frequently at the discretion of their doctor of optometry.

  • Vision screening programs that are well-designed and properly administered in public or private schools should be utilized to assist in the identification of children in need of care who have not had access to comprehensive examination services.

References Poe GS. Eye care visits and use of eyeglasses or contact lenses. United States 1979 and 1980. Vital and health statistics, Series 10, No. 145, DDHS Publication (PHS) 84-1573, Hyattsville, MD, February 1984.Roberts J. Refraction status and motility defects of persons 4-74 years, United States 1971-72. Vital and health statistics. Series 11, No 206, DHEW Publication (PHS) 78-1654, Hyattsville, MS, August 1978.

  1. Roberts J. Eye examination findings among children, United States. Vital and health statistics, Series 11, No. 115, DHEW Publication (HSM) 72-1057, Rockville, MD, June 1972.

  2. Roberts J. Eye examination findings among youths age 12-17 years, United States. Vital and health statistics, Series 11, No. 155, DHEW Publication (HRA) 76-1637, Rockville, MD, November 1975.

  3. Peters HB. Vision care of children in a comprehensive health program. J Am Optom Assoc 1966; 37(12):1113-1118.

  4. Bloom B. Use of selected preventive care procedures United States, 1982. Vital and health statistics, Series 10, No. 157, DHHS Publication (PHS) 86-1585, Hyattsville, MD, September 1986.

  5. Prevent Blindness America. Seeing is achieving. Schaumburg, IL, 1996.

  6. Dobson V, Teller DY. Visual acuity in human infants: a review and comparison of behavioral and electrophysiological studies. Vis Res 1978; 18(11):1469-1483.

  7. Banks MS, Aslin RN. Sensitive period for the development of human binocular vision. Science 1975; 190(4215):675-677.

  8. Suchoff I. Visual development. J Am Optom Assoc 1979; 50(10):1129-1135.

  9. Gottfried A, Gilman G. Visual skills and intellectual development: a relationship in young children. J Am Optom Assoc 1985; 56(7):550-555.

  10. Woodruff ME. The visually "at risk" child. J Am Optom Assoc 1973; 44(2):130-134.

  11. Blum H, Peters HB, Bettman JW. Vision screening for elementary schools: the Orinda Study. Berkeley, CA, University of California Press, 1959.

  12. American Optometric Association. National survey of vision screenings of the pre-school and school age child: the results of the American Optometric Association 1989-90 survey. St. Louis, MO, 1990.

  13. Schmidt PP. Vision screening. In: Rosenbloom AA, Morgan MW, eds. Principles and Practice of Pediatric Optometry. Philadelphia: J.B. Lippincott Co 1990:474.

  14. McKee GW. Vision screening of preschool and school age children: the need for re-evaluation. J Am Optom Assoc 1972; 43(10):1062-1073.

  15. Ehrlich MI, Reinecke RD, Simons K. Preschool vision screening for amblyopia and strabismus. Programs, methods, guidelines, 1983. Survey of Ophth 1983; 28(3):145-163.

  16. Peters H. Vision screening with a Snellen chart. Am J Optom and Arch Am Acad Optom 1961; 38(9):487-505.
  17. Scheiman M. Assessment and management of the exceptional child. In Rosenbloom AA, Morgan MW, eds. Principles and Practice of Pediatric Optometry. Philadelphia: J.B. Lippincott Co 1990:388-419.

  18. Richman JE, Cron MT. Evaluation of the Parsons Visual Acuity Test in screening exceptional children. J Am Optom Assoc 1987; 58(1):18-21.

Resources available from the American Optometric Association

  1. Optometric Clinical Practice Guideline: Pediatric Eye and Vision Examination. St. Louis: American Optometric Association, 1994.

  2. Guidelines for School Vision Screening programs. St. Louis: American Optometric Association, 1992.