Keeping children’s vision in focus

Excerpted from page 30 of the July/Aug 2022 edition of AOA Focus.

Their stories could fill books; their experiences speak volumes.

There’s the 17-year-old girl suffering idiopathic headaches, neck and back pain while home-schooling during the COVID-19 pandemic. The baby boy whose bright, bubbly expression belied a congenital condition. Or the preteen labeled hyperactive and struggling with schoolwork, whose parents and teachers were left exasperated.

Each day, doctors of optometry fill in the missing pieces of these pediatric puzzles by helping families understand that what a comprehensive eye exam (CEE) detects in their children’s eyes holds clues for their overall health.

The teenage girl? Pseudotumor cerebri.

The infant boy? Congenital cataracts.

The preteen? Undiagnosed hyperopia.

“It’s really important if you’re a kid my age to go to the eye doctor and see what you need to have done to your eyes,” says Emory, the now-12-year-old boy whose cataract was first detected during an InfantSEE® assessment and subsequent CEE with Cynthia Baker, O.D., in Denham Springs, Louisiana.

Today, Emory is 20/40 without glasses after two intraocular lens implants and, because of his experience, helps advocate for regular eye care as part of the AOA’s Eye Deserve More public campaign.

Says Dr. Baker: “It truly warms my heart to know that by doing the job I love, I was able to ensure he would have clear vision for a lifetime and make a difference in his life.”

As the primary eye care providers for America’s families, doctors of optometry know the importance of ensuring all children receive appropriate, regular eye health and vision care. Annual CEEs for children, beginning as early as six months old, can make the difference in whether a child achieves their full potential, both inside and outside the classroom.

Just as doctors of optometry advocate among their patients and within their communities for children’s eye care, the AOA has long championed strategies and policies that promote families’ access to in-person CEEs.

While vision screenings serve a purpose, they cannot be the end-all-be-all for children’s vision care, and educating caregivers on the need for follow up with the gold standard of eye health care remains a priority.

“Most people don’t understand the importance of a comprehensive eye exam, and we need to bring that to the forefront, that screenings cannot give the full picture of a child’s eye health,” says E. Larry Jones, O.D.

“There are over 270 different diseases that can be detected in the eye. If something’s going wrong with a child, we can detect that very quickly, whereas vision screenings can miss almost 80% of vision problems.”

Early intervention and success

In the U.S., 1 in every 4 children has a vision disorder that requires diagnosis and treatment by an eye doctor, yet most may never see an eye doctor. The AOA Health Policy Institute (HPI) notes how vision problems are almost always correctable with timely diagnosis and treatment, but current approaches fall short due to an “overreliance on so-called vision screening to identify children requiring eye examination by an eye doctor.”

Dr. Jones, National Optometric Association president and a featured panelist in the Optometry Cares®—The AOA Foundation “Listen, Learn, Connect” series of webinars on children’s vision, says it’s a twofold problem that he has seen time and again in his own patients in Seattle: Screenings may “pass” a child and create a false impression that the child’s vision needs are met, or a flagged screening may never result in necessary follow-up care for myriad reasons.

“Undiagnosed and untreated eye disorders have enormous, long-lasting consequences for kids,” Dr. Jones says. “We see them misdiagnosed with ADD or they’re unable to read. They pass a vision test with one eye blurry—it happens all the time—they know, but they’re smart enough to cover up for it.”

In 2017, the U.S. Preventive Services Task Force recommended that amblyopia screenings were mildly effective when used appropriately in the 3-5 age range, and when parents have no concerns regarding their child’s vision or education performance. The AOA immediately expressed concerns and retorted that children may not verbalize or show signs of problems and questioned whether overreliance on screenings, such as amblyopia screenings, hampered ongoing efforts to combat high rates of prevent-able, treatable vision loss in children and even exacerbated racial disparities in care. In fact, Black and Hispanic children make up the top percentages of children who have not received a CEE by an eye doctor. This gulf is projected to increase by 45% among Hispanic children and 14% among Black children over the next 40 years, per a 2017 JAMA Ophthalmology study.

“Children ages 3-6 of families at or below 400% of the federal poverty level have greater need but less access to effective vision care,” a 2021 AOA HPI paper notes. “Children from these same disadvantaged populations are also more likely to have undiagnosed health and vision problems, which require more in-person eye examinations by an eye doctor.”

In his 37 years of practice, Dr. Jones says the domino effect from failure to intervene early in a child’s vision needs can be tragic: Vision impairment becomes a reading deficiency that begets teasing and leads to truancy or behavior issues. From providing care in detention centers, Dr. Jones surmises some 80% of these youth with vision problems have gone uncorrected.

“We know there’s an imbalance and that the health care disparities are great, but they can be fixed,” Dr. Jones says, applauding passage of the landmark Affordable Care Act’s (ACA’s) pediatric essential benefit that opened the door for more children to receive necessary eye care.

“Still, it’s really frustrating to know that we could have intervened earlier to help.”

To be certain, vision screenings can play a role, and Dr. Jones does partner with local schools to provide screenings. Yet, he’s clear with administrators and caregivers that the assessment has its limitations and CEEs are the only way to truly ensure a child’s eye health needs are met. And that’s an important message coming off the past couple of years.

The profusion of screen time

Side effects of pandemic learning—reduced time outdoors and prolonged near-device use—sharpened public attention on children’s vision. Myopia, in particular, is a consequence that researchers track intently as evidence emerges of how screen time during lockdown months may have led to increased development and progression of childhood myopia. But while pandemic waves have ebbed and flowed, children’s screen time has remained consistently high.

In fact, American children spend 17% more time on screens compared to 2019, averaging about 7-9 hours daily as opposed to just 4-5 hours before. The results from a nonprofit research organization, Common Sense Media, show why attention on myopia and other vision deficiencies are surging.

Having graduated in 2007, Erin McCleary, O.D., a presenter on the “Listen, Learn, Connect” series, as well as a pediatric expert on the AOA’s 2021 Emergency Children’s Vision Summit, supported by Johnson & Johnson Vision, Essilor of America and CooperVision, started practice at the same time the first iPhone was released.

“Just take a moment and think about how all of our lives have been changed by that simple device,” Dr. McCleary says. “I have seen a direct impact on the visual systems of young children—and now young adults—born into a world that is full of technology. Add in COVID and remote learning, and the need for strong, functional vision in our youngest patients has never been bigger.”

Technology places a greater strain on children’s visual systems than ever before, leading to headaches, eyestrain, binocular vision deficiencies and anterior segment issues, e.g., dry eyes, while so much indoor, near-work fosters an environment for myopia development and progression.

Dr. McCleary says optometry is particularly advantaged to serve the nation’s children in meeting these deficiencies because doctors of optometry view the whole scope of the vision system, not only from a visual acuity standpoint. Should a child have headaches when reading despite 20/20 vision, doctors know there could be accommodating or convergence issues. An ADHD diagnosis? Doctors can check for an uncorrected hyperope who needs glasses.

“All of these things can be caught and treated by an optometrist,” Dr. McCleary says. “And when there is a greater need for intervention, such as surgery for a severe strabismus or retinal lesions, we are poised to refer them to the best providers. We act as that reference point for holding all the specialists together to provide the best comprehensive care.”

Public health interventions and federal action

While the need is there, the question of access still looms large. An important policy statement released at the height of 2020’s pandemic remote-learning pivot helped set a public health trajectory that resonates to this day.

In November 2020, the American Public Health Association’s Vision Care Section (APHA VCS) passed a landmark policy statement that outlined action steps for federal, state, local and community agencies to implement to enable greater access to vision care for America’s children. Two years in the making, the “Increasing Access and Reducing Barriers to Children’s Vision Care Services” statement determinedly took the access question head-on.

“Children’s vision has been an invisible public health crisis,” noted Andrea Thau, O.D., APHA VCS policy chair and AOA past president. “This policy statement was an enormous win for our advocacy efforts on behalf of children.”

How enormous? Dr. Thau chalks up the APHA VCS statement in a long line of children’s vision achievements dating back to the InfantSEE program’s inception in 2005 and the AOA’s successful advocacy surrounding the pediatric essential benefit under the ACA. Dr. Thau’s assessment is due to the magnitude of action steps outlined, including:

• Directing public and private insurance to maintain comprehensive vision care coverage for children
• Enhanced data collection by federal agencies
• Allocating new resources through federal and state authorities
• Ensuring vision care service as a component of Medicaid
• Increasing access for underserved populations, especially at health centers and schools
• Directing state and local authorities to encourage vision care for students with individualized education plans, behavioral or learning difficulties
• Encouraging a collaborative response to educating parents on children’s vision care
• Reinforcing sports eyewear considerations for children’s activities

Significantly, it also reflects the National Academy of Medicine’s statement that “quality care must be safe, timely, effective, efficient, equitable and patient-centered,” and that a CEE by an eye care provider remains the gold standard of eye care, provided annually as an essential benefit under the ACA.

“The pandemic underscored how fragile visual development is and how important it is for children to receive comprehensive vision care,” Dr. Thau says. “By having the APHA call for these action steps, it provides the AOA and our colleagues the needed leverage to go to our legislators and demonstrate the need.”

She adds: “With this APHA statement in our armamentarium, we can point to this with confidence when legislators are looking to introduce and pass legislation.”

Building off this momentum, the AOA doubled down on its advocacy in support of children’s vision. The AOA not only launched a series of policy briefings and summits throughout 2021 but also devised a Children’s Vision Workgroup as part of the AOA’s State Government Relations Center that provides affiliates with resources for children’s vision legislation. What’s more, a group of 30 bipartisan members of Congress have taken notice and begun pushing for change. In February 2022, lawmakers, led by Reps. Annie Craig, D-Minnesota, and John Joyce, M.D., R-Pennsylvania, petitioned the Centers for Disease Control and Prevention (CDC) to update its efforts to encourage early detection and prevention of childhood myopia. The members of Congress called the progressive disease “the biggest threat to global eye health this century,” and urged the CDC to join the chorus of awareness efforts among parents, administrators and other physicians, helping to bolster early detection and intervention.

Says Health Care Alliance for Patient Safety Chair David Cockrell, O.D.: “We are hopeful the [CDC] will outline robust, proactive measures to tackle this public health issue, which, if left untreated, will have long-term impacts on our children’s development, opportunity and overall well-being.”

In the meantime, the AOA and doctors of optometry will continue their fight for children’s eye health and vision because setting children up for success should begin with clear vision.

AOA member resources

Access the AOA’s Children’s Vision Toolkit for public education and campaign materials for the back-to-school time frame.

Optometry Cares®—The AOA Foundation “Listen, Learn, Connect” three-part virtual series, supported by EssilorLuxottica, offers students and new doctors a panel discussion on children’s vision. Available exclusively on the AOA’s EyeLearn Professional Development Hub, “Listen, Learn, Connect” returns this fall with live webinars.

Access the AOA’s evidence-based pediatric guideline, as well as the Myopia Management Clinical Report.