During the COVID-19 pandemic, a decrease in pediatric preventive care visits combined with a lack of in-person schooling have led to a significant drop in childhood vision screening. The result may be an increase in permanent visual impairment due to amblyopia.
Amblyopia is a disease of vision development affecting about 3% of children. Amblyopia is caused by uncorrected refractive error (need for glasses), strabismus (eye misalignment) or other conditions depriving the eye of normal images during the critical visual development period from birth to age 7. After age 7, amblyopia is more difficult to treat, and a patient diagnosed thereafter has a greater risk of permanent vision loss.
Amblyopia often goes undetected because young children can be asymptomatic. As such, vision screening and subsequent follow-up with eye care are essential to detect and treat the disease.
The AAP and other national organizations recommend all children be screened for amblyopia in primary care during early childhood when the disease is most treatable (https://bit.ly/3q2QgsB). The U.S. Preventive Services Task Force recommends vision screening for all children at least once between 3 and 5 years to detect amblyopia or its risk factors (JAMA. 2017;318:836-844).
Traditionally, screening has occurred as part of in-person well-child care visits. In-person vision screenings also take place in preschool and primary school settings, creating a safety net to help ensure that amblyopia does not go undetected.
Data from Kaiser Permanente Northern California, which tracks vision screening within primary care for tens of thousands of children, suggest the rate of vision screening during well-care visits held steady from 2019-’21. However, the opportunity to perform screenings in children ages 3-6 decreased by about 30% due to a reduction in in-person well-care visits. Rates of follow-up visits with optometry after failed screening decreased as well.
Data collected by the American Association of Certified Orthoptists also suggest that in Iowa and Oregon, two states with robust school and community screening programs, in-person vision screening of children in school and community settings decreased by 70% in 2020.
Many families also may be concerned about the effects of extended screen time on their children’s eyes due to the shift to online education during the pandemic.
Myopia (nearsightedness) may be a consequence of excessive screen time and lack of outdoor light exposure. The prevalence of myopia has increased in some areas in the past year (Zhang X, et al. Br J Ophthalmol. https://bit.ly/3k6S1B1).
Vision screening is important to help to identify myopia at an early age when behavioral modifications and treatments to slow progression, such as low-dose atropine eyedrops and specialty contact lenses, may be most effective.
As families and providers become more comfortable with telehealth for preventive care, there may be an opportunity for traditional vision screening to be supplemented by home-based screening. Systematic reviews of home-based visual acuity apps have been performed in adults (Samanta A, et al. J Telemed Telecare. https://bit.ly/3bII9Jo). While no app has been validated for home-based amblyopia screening, a systematic review is forthcoming (Sii S, et al. BMJ Open. 2021;11:e051830, https://bit.ly/3GTDPoI).
Vision screening is not just for detecting a need for glasses; it is essential for early detection of problems that can cause permanent visual impairment. Therefore, pediatricians should include vision screening on the list of catch-up items to address for patients who have delayed in-person care.
Dr. Greninger is a member of the AAP Section on Ophthalmology.
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