When Jillian Benoit had vision screenings as a preschooler in Jacksonville, Fla., she thought of the exercise, one that millions of schoolchildren undergo each year, as a game.
She didn’t know she couldn’t see well out of her right eye, so when screeners asked what she saw when she covered that eye, she recited what she’d read with her left. Getting the answers right during what Jillian called “the lollipop game” earned her a sucker, she told her mother.
It wasn’t until Jillian was 5½ and a teacher dressed her like a pirate, placing a patch over her left eye as the class studied the letter P, that the weakness in Jillian’s right eye was discovered. With the patch covering her good eye, Jillian was effectively blinded.
“My daughter fell to the floor screaming for help. And that is not how a parent should find out that her child is blind in one eye,” said Jillian’s mother, Robin Benoit.
Spurred by Jillian’s experience, Ms. Benoit is now an advocate for comprehensive eye exams for school-age children—exams that go beyond the vision screenings required or recommended by many states. During a meeting this month in Washington, members of the Alexandria, Va.-based American Optometric Association, public-health professionals, and physician assistants for the first time collectively endorsed comprehensive eye exams—though they can be expensive—as being key to children’s school readiness.
‘Broken’ System?
“The status quo is failing kids, and it is totally unacceptable,” said Dori Carlson, the American Optometric Association’s president-elect and an optometrist in North Dakota. Her group labeled the current system of detecting vision problems in schoolchildren “broken.”
Calls for comprehensive eye exams for children at least once before entering school are not universally endorsed, though. Such exams are required in only three states: Illinois, Kentucky, and Missouri. At least eight other states don’t require vision screenings at all, and the rest require screenings when a child starts school and typically provide them again at various grade levels. Some skeptics argue that the extra money spent on providing comprehensive eye exams would be better used on more screenings.
“Kids who fail screenings should have an eye exam,” said Dr. Oscar Cruz, a pediatric ophthalmologist in St. Louis, and the chairman of the Children’s Vision Commission in Missouri. Screenings—generally given at no cost to students’ families—involve checking for watering or swollen eyes, crusted lids, and whether children rub their eyes or tilt their heads to see. They check if children can see at a distance, which could affect whether they can see the front of the classroom or play some sports. The screenings also usually check whether a child’s eyes are straight and how well they work together.
Screenings may not be able to detect all the problems an eye exam could—in particular, nearsightedness, which may be more likely to be caught at an eye exam performed by an optometrist or ophthalmologist. But success at detection depends on the type and quality of a screening.
Approach Debated
In addition, screenings don’t solve eye problems; they only find them. Parents must follow up, and if children need glasses, someone has to make sure they wear them at home and school. In Jillian’s case, months of vision therapy eventually yielded good results. Now 12 and a 6th grader in Norman, Okla., she has perfect vision in both eyes, though she is colorblind, her mother said.
Maintaining good vision is important, experts say, because research shows that about 80 percent of what children learn is based on what they see. Last year, Charles Basch, a professor of health and education at Teachers College, Columbia University, listed vision problems as one of seven health issues critical to learning. Besides near- and farsightedness, such vision problems include astigmatism, an irregular curvature of the cornea; strabismus, or crossed or misaligned eyes; amblyopia, or lazy eye; problems with using the eyes together; and problems with what the eyes see and transmit as information to the brain. Glasses, medication, or vision therapy can treat those problems.
But Dr. Cruz, an opponent of requiring eye exams for all schoolchildren, contends that keeping students like Jillian from slipping through the cracks isn’t the real motivation of those pushing for them.
“People aren’t thinking about what’s best for the kids,” he said. “The average exam in Missouri costs just under $100,” he said, which would generate about $6 million in fees for optometrists and ophthalmologists each year based on the number of kindergartners.
He believes standardizing screenings nationwide and monitoring the quality of those screenings is a smarter solution to catching more vision problems among children. He noted that neither the American Association for Pediatric Ophthalmology and Strabismus nor the American Academy of Ophthalmology supports requiring eye exams for schoolchildren.
The American Optometric Association, which has offices in both St. Louis and Alexandria, Va., said requiring such exams could eliminate the need for vision screenings, thus saving states money.
Dr. Cruz also questioned bills in the Missouri legislature this session that propose extending the requirement, which would have expired in June 2012, for eight years without listening to his commission’s opinion on the exams.
State Sen. David Pearce, a Republican and the sponsor of the extension in his chamber, said he doesn’t need to hear the commission’s view.
“It’s worked out very well,” he said. “The big concern when we first passed this was the cost,” he added, but the exams haven’t proved expensive to the state.
Since the Missouri law passed in 2008, school districts have requested nearly 2,000 vouchers for students who couldn’t afford exams, although only a fraction were used. The vouchers are paid for by a trust fund taxpayers contribute to voluntarily by checking a box on their state taxreturns. The Missouri Association of School Nurses, which also opposes extending the exam requirement for eight years, says the vouchers are cumbersome to apply for and many parents, 61 percent, ignore the exam rule or opt out.
In neighboring Illinois, the state doesn’t pay for exams if students can’t afford them. Last school year, excluding the Chicago school system, for which data were not available, about a quarter of students statewide didn’t get an exam, according to data from the Illinois state board of education.
“All I care about is children’s vision,” Mr. Pearce said, adding that the eye-exam legislation is the most important of his career.
The optometric association’s recommendation goes beyond what the U.S. Preventive Services Task Force—an independent panel of private-sector experts in prevention and primary care sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services—recommended in January. The task force suggested at least one vision screening for children between the ages of 3 and 5.
Avoiding False Positives
At any younger age, a child’s ability to cooperate with the screening could pose its own set of problems, said Bernadette Melnyk, a member of the task force and a pediatric nurse-practitioner as well as a professor at Arizona State University in Phoenix.
“False positives from screening kids could lead to overprescribing of ... lenses,” Ms. Melnyk said.
Ms. Melnyk said one challenge is the quality of vision checks done by primary-care doctors. She said many primary-care physicians aren’t familiar with her task force’s recommendation or don’t perform the evidence-based services it recommends.
According to a 2010 report by the office of the inspector general of the U.S. Department of Health and Human Services, many children on Medicaid, for whom vision, hearing, and other screenings are required, don’t always get them. Of Medicaid recipients younger than 21 who were studied in nine states, more than half did not receive any required vision or hearing screenings.
One group that only tentatively supported the recommendation for eye exams for all students is Prevent Blindness America. Through a grant from HHS, the group is developing standards for vision screenings. The lack of standards is one reason the AOA is calling for eye exams for all children.
Vision screenings “really have to be well designed, and based in science, and well delivered,” said Jeff Todd, the Chicago group’s chief operating officer.
“I don’t think it’s a broken system,” he said. “But I do think it’s one in need of attention.”
