AOA disappointed, concerned about USPSTF recommendations on children’s vision screening for amblyopia

The AOA asserted concerns Wednesday that new U.S. Preventive Services Task Force (USPSTF) recommendations do not effectively address vision problems among the nation's children and are potentially a stumbling block to them getting the care they need.

The task force recommendations were published in the Journal of the American Medical Association under the title, "Vision Screening in Children Ages 6 Months to 5 Years: A Systematic Review for the U.S. Preventive Services Task Force." The report addresses amblyopia, one of the most common causes of vision impairment in children.

Unfortunately, the AOA noted, the task force's recommendations reflect no changes since its last update in 2011, despite two landmark reports this year by experts on children's eye health and vision care, including:

• The National Academies of Sciences, Engineering and Medicine (NASEM)'s "Making Eye Health a Population Health Imperative: Vision for Tomorrow," which confirmed that undiagnosed and uncorrected eye and vision problems in children are a significant public health concern.
• The AOA's Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination, which stresses the need for comprehensive eye exams for children over less rigorous screenings. The guideline was recently recognized with acceptance to the National Guideline Clearinghouse.

"Doctors of optometry are extremely concerned that the USPSTF recommendations will continue to hamper ongoing efforts to combat unacceptably high rates of preventable and treatable vision loss in children—especially among vulnerable and at-risk children who deserve care in communities across America," says Christopher J. Quinn, O.D., AOA president.

"In fact, the new recommendation reiterating 'no change,' appears to overlook the NASEM report, which underscored that avoidable vision impairment occurs because of outdated assumptions, missed opportunities and shortfalls in public health policy and health care delivery,'" Dr. Quinn adds. "Promoting optimal conditions for vision and health requires changes to our current system of vision health prevention."

AOA's concerns

In March, the AOA wrote the chairperson of the USPSTF, Kirsten Bibbins-Domingo, M.D., objecting to the recommendations during a public comment period. While the AOA agreed with the task force's recommendations on the importance of detecting vision problems in children and the value of early treatment in leading to improved patient outcomes, the AOA and the task force had significant disagreement:

The AOA recommended the task force consider:

• Being as specific as possible as to the type and purpose of the screening that is being performed: screening for amblyopia.
• Providing clarity on the role of screening in the vision care system for children.
• Giving further consideration and elucidation of the possible harms of "false negatives," as well as "false positives" of screening.
• Providing greater clarity about the population for whom amblyopia screening is appropriate.

The AOA's recommendations are not reflected in the new task force recommendations.

"By focusing on the effectiveness of screenings to detect only one of the most serious visual problems—amblyopia—the task force ignores the multitude of vision problems in children that screenings have repeatedly demonstrated are not adequately detected," Dr. Quinn says. "Vision screenings give parents and educators a false sense of security. The vast majority of children's vision screenings have high rates of 'false negatives' and fail to adequately detect signs of significant vision problems in children chronically burdened by these difficulties.

"During this critical developmental stage, undiagnosed and untreated vision problems can have a massive impact on a child's ability to succeed in school and later in life as fully outlined and evidenced in the NASEM report," he says. "Routine vision screenings cannot be relied on to catch most vision problems. In fact, these tests fail to detect a wide variety of eye and overall health conditions that only a comprehensive eye exam can diagnose. Evidence upholds the importance of a regular, comprehensive eye exam schedule for children."

Screenings miss up to 75% of schoolchildren with vision problems, the AOA says. And, of the children found to have vision problems through a screening, 61% do not get treatment, AOA adds. Evidence demonstrates, and the Centers for Disease Control and Prevention and National Eye Institute agree, that the best way to ensure healthy vision is with a comprehensive eye exam by an eye doctor.

High rates of undetected and untreated eye disorders continue to plague the nation's children and impair their ability to learn, grow and function; even higher rates of disability exist among underserved populations. An estimated 1 in 5 preschool children has a vision problem.

To learn more about AOA's position on proper terminology, please view an issued brief by the AOA's Health Policy Institute.

Early intervention

Because eye and vision problems can worsen over time, early diagnosis and treatment are essential to optimizing children's eye health and vision.

The AOA recently released the Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination, for pediatric eye health, based on a three-year systematic review by doctors of optometry and other stakeholders in the pediatric health field, such as pediatricians, social workers and parents.

The research in the report underscores that comprehensive eye exams should be required, as with other annual health examinations, for children. Specifically, the guideline recommends:

• Comprehensive vision assessment by an eye doctor between age 6 months and 12 months.
• An in-person, comprehensive eye examination by an eye doctor between the ages of 3 and 5 years.

By contrast, the USPSTF recommended:

• Vision screening at least once in all children ages 3-5 years to detect amblyopia or its risk factors.
• The current evidence is insufficient to assess the balance of benefits and harms of vision screening in children younger than 3 years.

The USPSTF disregarded the vision and eye health needs of America's children by not modifying the accuracy of designation of the preventive service to "amblyopia screening" and by not issuing an "insufficient" recommendation for ages 3 through 5, the AOA says.

Screenings may identify some children at risk for vision problems, but there is no substitute for an in-person, comprehensive eye exam for children.

"We must do better for our nation's children," Dr. Quinn says