Letter to the Editor: The Power of Consensus for Children's Vision

In a first-time collaborative effort, the American Academy of Optometry, American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and National Center for Children's Vision and Eye Health at Prevent Blindness approved a joint position statement that underscores their shared commitment to childhood eye and vision care. This position statement, “The Relationship between Visual Acuity and Refractive Error in the Context of Preschool Vision Screening Using Instrument-based Technology,” published in this edition of Optometry and Vision Science, was written to rectify the misconception that a child's visual acuity can be determined from an instrument-derived estimate of refractive error obtained from a vision screening. Given that screening programs across the United States have traditionally required documentation of “visual acuity” for record-keeping purposes, the recent increase in the use of automated vision screening instruments that provide estimates of refractive error rather than visual acuity measures has led to confusion regarding the proper method of documenting vision screening results. How does one report screening findings when a measurement of visual acuity is required, but only refractive error estimates are available? This question is critical because these two clinical measures are not interchangeable. Thus, the objective of the position statement is to alert those involved in vision screening that it is not appropriate to use any type of conversion chart¹ in an attempt to derive a child's uncorrected visual acuity from their estimated refractive error. The visual acuity values provided from such a chart will often be erroneous and could have grave consequences when a serious eye condition or neurological disease is present, and a false estimation of normal visual acuity was applied based on a conversion chart. Thus, the position statement's guidance is crucial for dissemination among screening constituencies who engage in vision screening services in a health or public health capacity and may not regularly study the science behind best practices for children's vision screening. Such constituencies may include state/local departments of public health and education, primary pediatric medical providers, educators, service organizations, and volunteer screening organizations.

The information provided in the position statement is an important step toward improved vision screening practices and ensuring proper referral for comprehensive eye examinations. At present, there is little uniformity in the conduct of childhood vision screening—in fact, the variations among screening programs are startling. Given the discrepancies and contradictions in recommendations from professional societies and other stakeholder organizations,^2–6 it is no wonder that there is confusion regarding best practices. The consensus-driven method of collaboration between optometry and ophthalmology that was used to develop the position statement addresses two long-standing issues that have plagued children's vision and vision screening—poor interprofessional collaboration and lack of uniformity in children's vision screening grounded in evidence-based practices. The 2016 report by the National Academies of Sciences, Engineering, and Medicine (NASEM) on “Making Eye Health a Population Health Imperative”⁷ proposed a population health framework to guide action and coordination among various stakeholders in pursuit of improved eye and vision health, and health equity in the United States. An important component of the NASEM report's proposed framework centered on vision screening. Supported by the Centers for Disease Control and Prevention and the National Eye Institute, in collaboration with the American Academy of Optometry, American Academy of Ophthalmology, American Optometric Association, Association for Research in Vision and Ophthalmology, National Alliance for Eye and Vision Research, National Center for Children's Vision and Eye Health, Prevent Blindness, and Research to Prevent Blindness, the NASEM report included a call to action for collaboration throughout the eye and vision care field (including federal and state governmental entities that focus on eye and vision health) to find ways to work together to further the goals outlined in the report. The NASEM report noted that the lack of consistent, evidence-based clinical guidelines in the eye care field,^2,3 the debate among professional and advocacy organizations about the role of vision screenings and comprehensive eye examinations,^2–6 and past disagreements between optometry and ophthalmology on scope of practice have undermined efforts to overcome the disparities and deficits in vision and eye health that persist for many Americans. We hope that the position statement on childhood vision screening published in the current journal issue is a small first step in the right direction to begin to overcome such long-standing issues. The joint statement promotes consensus across professional lines to address a goal of uniform implementation of vision screening, as was recommended by the NASEM report. Furthermore, we hope that the position statement encourages broader consensus among eye health and other health-related organizations.

This joint effort confirms that the five organizations and professional associations that have endorsed the position statement understand that this country's most important asset—its children—require healthy vision to maximize their educational potential and lifelong opportunities. There is a recognition that the goal of universal, comprehensive eye care is plagued by inequities in vision care related to medical, geographic, ethnic, and socioeconomic isolation, along with limitations of available, appropriately trained, and willing personnel. Because of these barriers to vision care access, the concept of universal, comprehensive eye examinations on school entry or earlier for all children across the United States, although perhaps optimal, is likely impractical at this time. Therefore, we must design an equitable and rational system of population-based vision care that systemizes and prioritizes care according to needs and available resources. Children diagnosed with neurodevelopmental deficits should be identified early and proceed directly to a comprehensive eye examination by an eye care professional skilled in the care of young children as early as possible because these children are at a much greater risk of consequential vision disorders that can impact their education and overall well-being.^8–12 Typically developing children should be supported by a continuum of care including parent and caregiver education, early detection strategies (including vision screening), and ensuring receipt of comprehensive eye examinations and required treatment for all referred children. All vision screening approaches should use an efficient and effective system of uniform, evidenced-based techniques followed by a robust system of follow-up care, data collection, and surveillance.^6,13,14 Furthermore, not only does vision screening provide a critical connection to clinical vision services, but receipt of professional eye and vision care services also expands entry into the broader health care system for children who require the expertise of other health care specialists; this can lead to improvements across multiple measures of health, particularly for underserved and at-risk children. All of our children deserve nothing less than good visual health and function. The joint position statement published in the current issue of Optometry and Vision Science is an important step in that direction.

Susan A. Cotter, OD, FAAO
Southern California College of Optometry
Marshall B Ketchum University
Fullerton, CA
[email protected]
Sean P. Donahue, MD, PhD
Ophthalmology and Visual Sciences
Pediatric Ophthalmology
Vanderbilt University Medical Center
Nashville, TN
Bruce Moore, OD
New England College Optometry
Boston, MA
Kira N. Baldonado, BS
Prevent Blindness
Chicago, IL