Ultimate goal

Photo by Jeff Nelson.

Excerpted from page 20 of the July/Aug 2021 edition of AOA Focus.

Growing up, Joshua Watt, O.D., never really enjoyed reading and school never came easily. As a child, he was the only one of six siblings not to be prescribed glasses by their eye doctor.

Yet, at the beginning of every school year, he would vow to stay on top of the readings assigned by his teachers, even though he soon fell behind anyway. Any time he would go to read or study, he would fall asleep within a few minutes and instead avoided reading altogether. These issues continued throughout middle school, high school, undergraduate school—and into optometry school. He thought his struggles were due to others being smarter than him, as he just managed to get by.

“It really hit home the second year of optometry school,” Dr. Watt says, “when I learned my eyes weren’t working together. In my binocular vision class, we were reading a checklist of symptoms—these were the kids who get red eyes and tired eyes and fall asleep when they read—and I’m like check, check, check, oh no! After a professor pulled me aside for falling asleep in class, I started to undergo vision therapy to correct the convergence insufficiency that I struggled with.

“All of a sudden, after going through the therapy, I could sit down, read and study and stay awake and remember what I read—and study for national boards and pass,” he says. “I had convergence insufficiency. That’s when I decided that is what I want to do professionally. I want to catch these kids at younger ages and get this fixed before they stumble across it at 24 years old. I look back on that and wonder why I didn’t mention this or talk to anybody about this. But I didn’t know any different.”

Kids shouldn’t have to wait, especially in these times.

Schooling and COVID-19

Children’s vision has long been a cause trumpeted by the AOA—former association president Reginald Augustine lamented about its state in the 1920s to audiences around the country.

Unfortunately, it has taken the COVID-19 crisis—when children were forced, out of safety concerns, into virtual learning at home, staring for prolonged periods at screen-based devices, on top of already excessive screen time—for the public to grasp the impact of children’s eye health. Schooling has become top of mind for parents, educators and policymakers. And once again the AOA is taking the lead in this pandemic period, to be the resource for the American public that emphasizes the essential role vision plays in children’s overall development and how access to comprehensive eye care is critical to their success in life.

According to a March 2021 paper produced by the AOA Health Policy Institute (HPI): 

“As U.S. schools reach the end of severely disrupted 2019-2021 academic years, administrators will need to comprehensively address students’ learning loss after months of remote schooling and this should include addressing children’s need for vision care. Problems with children’s vision have been shown to preclude or limit their lifelong academic, extracurricular and social success.

“Vision problems are correctable with timely diagnosis and treatment; however, current approaches to prevention often fall short of ensuring that all children have timely access to comprehensive and high-quality care,” the authors add.

Why do children’s vision troubles go undetected? The authors cite three reasons: 

• Most vision disorders are not symptomatic. With an absence of signs and symptoms, many students are unaware their sight is impaired. And if they don’t make a complaint, parents and teachers are in the dark, too.
• Even if there are signs and symptoms, they aren’t recognized as vision related. Instead, the signs and symptoms are misinterpreted as behavioral issues such as attention-deficit hyperactivity disorder.
• Vision screenings, though popular in U.S. schools, primarily are designed to detect amblyopia (lazy eye) and fall short of catching other conditions.

Vision screenings: A misnomer?

A second HPI paper, published in April, calls the reference to vision screenings misleading and a misnomer. Says the paper:

“Importantly, amblyopia screening does not screen for most binocular and oculomotor vision conditions, such as hyperopia (farsightedness), disorders of convergence (turning the eyes inward), disorders of divergence (turning the eyes outward), disorders of tracking (following objects in space), disorders of accommodation (focus ability at near) and disorders of fusion (the ability to fuse images from each eye in the brain into one stereoscopic 3D image). Left undiagnosed, these conditions also can adversely affect cognition, learning and socialization.”

Not only do vision screenings fail to detect these vision conditions, but the HPI also recommends federal, state and local systems of care and prevention refer to “vision screenings” as amblyopia screenings, for the sake of accuracy and to discontinue “the perpetuation of racial and social inequities in access to eye examination by an eye doctor.”

Michael Earley, O.D., Ph.D., associate dean of academic affairs at The Ohio State University College of Optometry, agrees with the HPI’s recommendation to change the terminology. Dr. Earley has long researched the role of visual deficits in children, including amblyopia and convergence insufficiency.

“Vision screenings shouldn’t be called vision screenings,” Dr. Earley insists. “They should be called amblyopia screenings. Vision screenings are designed to pick up kids with amblyopia or things that can lead to amblyopia. Even the best screening for preschoolers will pick up 60% of kids with amblyopia. Let me say it’s important to detect amblyopia. If you don’t pick up amblyopia when kids are younger, then your ability to treat it as students get older gets less and less and less and less.

“But one of the problems with screening is that parents think that a ‘vision screening’ is screening for all aspects of their children’s vision, and it’s not,” Dr. Earley continues. “It’s just screening for amblyopia. Unfortunately, what has been shown is that parents whose children have been referred after failing their screenings don’t bring their children in for treatment.”

Doctors sound the alarm

Doctors of optometry have been sharing what they’re seeing with lawmakers and the public—at Virtual AOA on Capitol Hill in May and “Seeing Beyond the Pandemic: Eye Health, Vision and Learning,” supported by AOA and industry partners in July.

The conversation launched on March 24. During the AOA-led Emergency Children’s Vision Summit, supported by AOA Visionary Supporters Johnson & Johnson Vision and Essilor of America and Executive Supporter CooperVision, frontline doctors of optometry talked about the concerning consequence of the crisis on children’s vision. Doctors of optometry aren’t alone in their concern about the impact of the pandemic on the health of America’s children, as members of Congress have started hearings to collect information and assess needed policy changes.

Just what are doctors of optometry, on the summit’s panels, seeing across the country?

A “huge increase” in cases of eyestrain, eye aches, headaches, accommodative stress and convergence insufficiency, says one doctor of optometry who practices in the state of Washington. An optometrist in California reported increased numbers of young patients with dry eye—“it just should not be there,” she says. It’s a condition more commonly diagnosed in adults. Still another doctor of optometry practicing in New York says she’s seeing more accommodative issues, binocular issues and dry eyes.

Says Andrea Thau, O.D.: “This is really an important point for all of us, because we are poised to be the ones to help the parents understand the importance of ongoing, comprehensive eye care for all children.”

The takeaways from the summit’s panels, according to Dr. Earley, who led one of two discussions at the summit: 

• The digital focus in learning has forever changed the classroom. “Computers place a much greater eyestrain on the visual system than books,” he says. “There is a tendency for kids to stare at their computers and their blink rates go down significantly. They’re also sitting much closer to their computers than their books. That places more visual strain on kids’ eyes."
• “The digital eye issues, from increased screen usage, are real,” he says. That includes headaches, eyestrain, binocular vision deficiencies and anterior segment issues such as dry eye. “It’s exacerbating already existing symptoms and, worst-case scenario, students will avoid doing their schoolwork, because their prolonged computer use causes their headaches and other problems.”
• Educating parents, beyond the policymakers, on the merits of comprehensive eye exams is key. “That’s the gold standard—it’s what every kid should get,” he says. “They should get examinations so they can do their very best in school and society.”

 Myopia, affecting nearly 30% of the U.S. population and growing, was also cited as a concern. In a Jan. 14 article in JAMA Ophthalmology, researchers from Emory University and Tianjin Medical University in China found in tests of 123,535 children that among the 6- to 8-year-old age group, a “significant myopic shift” (−0.3 diopters) had occurred. The researchers urged caution in interpreting the test results, noting study limitations (use of noncycloplegic refractions and lack of orthokeratology history or ocular biometry data) and the age group’s sensitivity to environmental changes.

Educating the public, including parents and other health care providers, on the merits of comprehensive eye exams is key to addressing children’s eye health, the summit’s doctors say.

State-by-state strategy

A child’s ability to learn and achieve academically is linked to their eye health, and a comprehensive eye exam is the way to ensure their success now and into the future, doctors of optometry say. Screenings don’t cut it—they just aren’t comprehensive enough, they add.

Beyond educating parents about comprehensive eye exams, AOA affiliates have pursued the issue through their state legislatures. Kentucky is the only state that requires students obtain a comprehensive eye exam before entering school, beginning at the age of three but no later than the age of six. The groundbreaking law, which went into effect in 2000, immediately paid dividends.

According to a study co-authored by AOA Immediate Past President William T. Reynolds, O.D., of that first school year in 37 counties under the new law, among 5,316 eye exams given to 740 children, 181 were diagnosed with amblyopia, 123 with strabismus and 44 with other eye diseases.

Kentucky is not alone; Nebraska and Illinois have laws and guidelines resembling the exacting standards of the Kentucky law. Still, it is an uphill battle.

In its 2019-20 session, the Pennsylvania General Assembly considered a bill requiring students to undergo comprehensive eye examinations at significant developmental milestones, including upon admission to school, in the fourth and eighth grades and when the student is recommended for a skills improvement program. The bill failed in that session, but the Pennsylvania Optometric Association (POA)-backed measure was reintroduced in May 2021 (H.B. 1343) by prime sponsor Rep. David Zimmerman.

“We want to reduce the barriers to comprehensive children’s eye exams,” Tracy Sepich, O.D., M.S., POA president-elect, says, “and to make it as easy as possible for parents to bring their children in. It’s really about cooperation between us and the educators, school nurse, parents, the pediatrician and family physician of the child.”

The Kentucky law stands alone, part of an early childhood development bill passed 20 years ago. Dr. Reynolds, who practices in Kentucky, recalls its passage was two years in the making. To make it happen, Dr. Reynolds says coalitions were built, and counter arguments prepared to respond to opponents’ charges, which needed to be blunted. In the end, support from the state’s governor and the bill’s allies helped put the bill over the top, along with the state’s doctors of optometry. Kentucky’s law has made a big difference to the state’s schoolchildren and remains one of his proudest achievements as an advocate in optometry, Dr. Reynolds, says.

“This is a critical time for optometry to speak from our own experience to help guide policymakers, as we work together to determine what we can all do to ensure the long-term health and prosperity of our younger generations,” he says.

A priority for workgroup

For states pursuing a legislative strategy, the Children’s Vision Workgroup of the AOA’s State Government Relations Committee (SGRC) is a key resource.

“We are here to provide help to the affiliates on matters that are important to them,” says workgroup Chair Dwight Burchett, O.D.

And states continue to request information in support of their legislative efforts, says Johndra McNeely, O.D., SGRC chair.

“We have a number of resources that are available to states interested in pursuing a children’s vision law. It’s really the responsibility of doctors of optometry, as the experts in children’s vision, to educate state and federal lawmakers on this issue.”

For doctors of optometry, the case for comprehensive eye exams is an easy one to make—regular examinations can detect and correct sight-threatening conditions if caught early and promote eye health and vision care so crucial to child development and a lifetime of learning. Yet, it’s not as easy a sell as one might suggest.

Dr. Burchett termed the legislative push for states as challenging, despite the exams’ merits. There is a well-funded opposition.

“There are opponents, most of whom you wouldn’t think: school nurses, pediatricians and ophthalmologists,” Dr. Burchett says. “This makes it an extremely difficult push for most states.”

When it comes to legislating state by state, one size does not fit all, as advocates assess political considerations on the ground.

“It is definitely difficult to manage 50 state laws regarding this topic,” Dr. McNeely says. “Obviously, the gold standard is a comprehensive eye examination before first grade. But state laws are all over the place, from a few that require a comprehensive eye exam to some that require screenings to some that require eye exams if screenings fail, etc.”

Beyond an eye exam

The eyes are integral to learning. But it’s not just about seeing, explains Glen Steele, O.D., a respected authority on children’s vision.

“The vision process is more than seeing,” says Dr. Steele, who has practiced more than 50 years with an emphasis on vision and child development. “Vision is a reach.

“I reach with my eyes out there,” he adds.

It’s why curious infants crawl— coordinating limbs to reach whatever catches their eyes and then exploring further up close with their fingers (touch), mouths (taste). That’s how babies learn, he says.

“Vision is such a leader and an instigator,” he says. “The looking process is different than just seeing. The more efficiently you can look, the better you’ll see.”

Taking it personally

Dr. Watt remembers that feeling of dread that would come over him as a boy and later, as a young man, as he struggled to learn. Today, he uses his own story to inspire, as he sees patients in his Colorado vision therapy practice. He has noted an uptick in the number of young people reporting headaches due to focusing and eye teaming issues.

“I’m a big advocate of parent education,” says Dr. Watt, chair of the AOA Sports and Performance Vision Committee. “I tell them that their kids may not be telling them these things. But, from what I see, this is probably what’s happening. I have certain demonstrations I do to help them see what their children are seeing.

“We should be alarmed at the pandemic-induced changes to schooling and the impact on kids,” he says. “We also should be alarmed at how much stuff gets missed. It’s obviously one of the reasons I do what I do, because I was one of those kids who got missed. We can’t afford that.”

To support doctors of optometry and raise public awareness, the AOA provides numerous members-only resources including: 

• The AOA’s Children’s Vision Toolkit.
• EyeLearn Professional Development Hub, where you can view a recording of the AOA Emergency Children’s Vision Summit.
• The AOA Evidence-based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination.
• AOA Health Policy Institute papers.
• The AOA takes seriously the growing myopia epidemic. To help guide implementation of myopia management in practice, AOA‘s Evidence-based Optometry Committee developed a clinical recommendation statement related to myopia management.