Pediatrics

Trojan Horse Returns With Preschool Vision Screening

By Lore Baker Schena, Contributing Writer

It certainly sounds good on paper—mandating a comprehensive eye exam for every child in the country. Who could argue with the concept of catching eye problems early and preventing blindness? Through state and federal legislation, every child with amblyopia, strabismus and significant refractive errors would be detected and treated. A fine idea.

Which is exactly the problem pediatric health care professionals face in the challenge to oppose this type of legislation. “On the surface, it appears that ophthalmologists and our pediatric colleagues—by opposing comprehensive eye examinations for preschoolers—are against motherhood and apple pie,” noted Mary Louise Collins, MD, director of pediatric ophthalmology and strabismus at the Greater Baltimore Medical Center and a member of the Academy’s committee for state governmental affairs. “Yet our goal is to make sure that bad public health policy doesn’t get put into law.”

A Nationwide Battle
For the past several years, optometry groups and the Vision Council of America (VCA; the trade organization for eyeglass manufacturers) have used their time and resources to “lobby politically into forcing parents to bring children to them as their first line of eye examinations,” explained Harold P. Koller, MD, clinical professor of ophthalmology at Thomas Jefferson University with a practice at Wills Eye Hospital in Philadelphia. “The problem is that the American Academy of Pediatrics and most normal-thinking lay individuals feel that the place for medical care should start at the child’s ‘medical home’—the pediatrician’s or the family practitioner’s office. It is irresponsible and self-serving for optometrists to say they have the expertise to do eye screening for a child when what this effort is really doing is usurping the primary duty and obligation of the pediatrician to serve as the first source of medical care.”

On its Web site, the VCA clearly spells out its agenda, citing as one of its objectives to “increase eye exams and grow the eyewear market” by being an “advocate for improved coverage of vision exams and mandatory vision examinations for children entering public schools.” At the state level, the VCA supported legislation in Kentucky, passed in 2000, that mandates comprehensive eye exams by optometrists and ophthalmologists. At the federal level, it backed HR 2173, which would set up a program to provide federal grants to states to pay for comprehensive eye exams performed by eye care professionals.

While from the outside the concept of comprehensive eye examinations sounds “like a wonderful idea,” dig deeper and the flaws become apparent, said Sherwin J. Isenberg, MD, professor and vice chairman of ophthalmology at the University of California, Los Angeles, and editor-in-chief of the Journal of the American Association for Pediatric Ophthalmology and Strabismus. “The two issues are the cost and who does the screening,” he said. “Does the cost of doing a comprehensive eye examination justify the benefits? And why should this exam be limited to optometrists and ophthalmologists when we are checking for visual acuity and ocular alignment? Pediatricians could do this in their office, as could family physicians.”

Cost is indeed a factor, especially in light of shrinking state budgets, said Dr. Koller. In addition, the economic burden is placed on most families, who, if HR 2173 or a similar bill is passed, must pay for a comprehensive eye exam by an optometrist or ophthalmologist before they can be allowed to send their child to school. “This doesn’t make sense when children are routinely seen by pediatricians and family physicians for well-child care,” said Dr. Collins. “And let’s face it, from the standpoint of realistic expectations, we can’t get every child vaccinated in this country. What makes anyone think we can legislate comprehensive eye exams for all? Where is the money going to come from?”

The push for mandatory comprehensive eye exams has spurred several medical organizations to join together, with ophthalmologists, pediatricians, pediatric ophthalmologists and family physicians advocating a new joint policy that calls for broad and rigorous vision screening for all children during the preschool years.¹ Optimally, the screening will occur within the context of routine health care provided by the child’s primary care physician.

“In essence, we now have a battle that pits the optometric lobby against all of medicine,” said Dr. Koller, past chairman of the section on ophthalmology of the American Academy of Pediatrics (AAP). “When the optometrists insisted that they should be able to examine a child but mandated it to the exclusion of pediatricians, they put forth an economically, medically and strategically bad idea that needs to be countered.”

Kentucky Nightmare
For the state of Kentucky, efforts to halt the passage of mandatory eye examinations are too little, too late. And for pediatric ophthalmologists like Steven J. Lichtenstein, MD, the bill passed into law in 2000 has been a recipe for disaster.

“The optometrists snuck in a clause at the end of an appropriations bill that nobody saw coming,” said Dr. Lichtenstein, who is with Louisville Children’s Eye Specialists and on the clinical faculty of the University of Louisville. “By the time we found out about it, the bill was a done deal.” Dr. Lichtenstein, chairman of the AAP’s section on ophthalmology, explained that every child up to grade 6 who is entering a public school for the first time must have full examinations by either an optometrist or an ophthalmologist or else he or she cannot attend class.

Since the law took effect, the reality of the legislation has hit home. Dr. Lichtenstein’s office has given full eye examinations to 223 children and only one child was detected to have a problem, which most likely would have been picked up by the child’s pediatrician. “We have taken glasses away from kids who had no need for them. We have some optometric ‘mills’ here that are prescribing window glass spectacles to children, with a higher emphasis on the Medicaid population. This legislation just doesn’t make sense.”

He added that the form filled out by the ophthalmologist or optometrist “says absolutely nothing about what the child’s prescription is, how a potential eye problem is going to be treated or when the child should be seen again. And there is absolutely no follow-up written into the law, so even if a problem is actually found, there is no guarantee that it will be properly treated. It is practicing medicine by legislation.”

Tennessee Success
In stark contrast, Tennessee has experienced great success in its statewide vision screening. In 2000, Sean P. Donahue, MD, associate professor of ophthalmology, pediatrics and neurology at Vanderbilt, published a paper describing the results from a statewide preschool vision screening program using the MTI PhotoScreener.² During the two years of the program, 15,059 children were screened. Children who failed the screening had a significant abnormality (strabismus, anisometropia, high hypermetropia, high astigmatism or high myopia) in 320 of the 531 cases where adequate follow-up results were reported.

“Since this report was published, more than 105,000 children have been screened in Tennessee,” said Dr. Donahue. “In 2000, our positive predictive value was in the neighborhood of 65 percent and now is over 70 percent, and 90 percent are receiving follow-up. This shows that a preschool vision screening program can be highly efficacious provided there is a high level of control from a centralized area [in this case, Vanderbilt University] and another volunteer organization setting it up and paying attention to detail [in this case, the local Lions Clubs].”

Time to Be Vigilant
The possibility of mandatory comprehensive eye examinations continues to be a reality in several states and on the federal level (see “Academy Update”). As Dr. Collins pointed out, “State societies have been great at monitoring legislation, and others have worked hard to educate legislators why this isn’t good public health policy.” However, it is a fight that shows no signs of letting up. “We are up against organizations with lots of money and massive PR campaigns,” she said. “We need to continue being vigilant.”


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1 Organizations involved are the Academy, the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Family Physicians.
2 Ophthalmology 2000;107:1637–1644.

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Academy Update

State efforts. Two states, Connecticut and Massachusetts, have preschool vision screening legislation under development. The Academy is working to ensure that the legislative language reflects ophthalmology’s concerns. For more information, contact Bob Palmer at bpalmer@aaodc.org.

Federal efforts. The Academy is taking a two-track approach toward better legislation. On the House side, the Academy continues its efforts to revise HR 2173. On the Senate side, the Academy has developed and is in the process of finding sponsors for an alternative piece of legislation. For more information, contact Steve Miller at smiller@aaodc.org.

At the Annual Meeting. Stop by the Academy Resource Center (Booth #1438) in the Exhibit Hall to talk to staff from the Washington office.

On the Web. For up-to-date status of legislation, go to “Advocacy” at www.aao.org and click “Action Center.”

To find the policy statement Vision Screening for Infants and Children, go to “Member Center” and click “Policy Statements.”