Brooke E. Geddie, DO, Pediatric Ophthalmologist
Spectrum Health Medical Group
Helen DeVos Children's Hospital

The American Academy of Pediatrics (AAP) recommends routine vision assessment, ocular alignment, and red reflex examination as an essential component to the neonatal, infant and child physical examination.¹ The AAP also recommends formal visual acuity testing for all children beginning at age 3, primarily to identify and treat amblyopia to reduce the risk of blindness.¹ When identified early, treatment before age 7 can lead to nearly full vision recovery in more than 75% of cases.

There have been many approaches to identify children with decreased vision, strabismus or other ocular problems; many of which have been scrutinized in recent years. Some states have incorporated mandatory eye examinations by an optometrist or ophthalmologist for all children prior to entering kindergarten. Some health departments and schools use a computerized photoscreening system. The use of computerized screening (of which there are multiple marketed devices) has also been used in the primary care office, while other physicians prefer the traditional "wall chart" visual acuity testing. The cost effectiveness, sensitivity, and specificity are all important when evaluating a screening program.

Photoscreening is based on photorefraction in which the refractive error of the eye is assessed by the light pattern of reflection. The MTI photoscreener, which is often used, has a sensitivity of 81.8% and specificity of 90.6%, similar to that of other photoscreeners.² When the machine is set at a higher specificity (94%), the sensitivity drops (37%), missing many abnormal children.²

A recent study published in Ophthalmology reported on 9 years of results of photoscreening in 147,809 Iowa children (ages 6 to 48 months) using the MIT photoscreener. The retrospective review found that 4.2% of the children screened were referred for eye examinations, a rate similar to the prevalence of amblyopia in the general population. However, only 36.1% of the children actually obtained care from an eye care professional until a follow-up coordinator was added to the program, which increased the follow-up rate to 89.5%. The positive predictive value of the screening was 94.2%, although the sensitivity for amblyopia detection only reached 52%. The screening cost of one child was estimated at $9.³

So what is the best way to screen children for ocular and vision abnormalities? I fully support the AAP guidelines of red reflex, ocular alignment, and traditional visual acuity testing by the primary care physician, with referral to a pediatric ophthalmologist or eye care professional experienced with children.

The AAP policy and examination techniques should be incorporated into all pediatric and family practice residency programs. When done correctly, it has proven to effectively identify children who require referral to an eye care professional. However, mandatory eye examinations of all healthy infants and children are not necessary. And while photoscreening techniques may play a role in future ocular screening of young children, the technology is still evolving and we need further evidence.

References
1. American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology, Policy Statement, Eye Examination in Infants, Children, and Young Adults by Pediatricians. Pediatrics 2003; 111: 902-907.

2. Longmuir SQ, et al., Nine-year results of a volunteer lay network photoscreening program of 147,809 children using a photoscreener in Iowa. Ophthalmology 2010 Oct; 117 (10):1869-75.

3. Vision in Preschoolers Study Group. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision in Preschoooler's Study. Ophthalmology 2004; 111:637-50.