Less Than Meets the Eye: When ‘Expert’ Advice is False Economy
Pediatricians receive only cursory training in assessing children’s visual function, and only minimal exposure to ophthalmic disease. This is reflected in the visual screening recommendations by The American Academy of Pediatricians found here:
We know that visual functional status is one of the primary building blocks of strong development and learning for all children, so it is fair to say that all of us doctors working with children appreciate the importance of assessing visual and eye health early. The problem with recommendations by the AAP is that they are lacking in some important ways, but they also serve to highlight the lack of will on the part of AAP to work cooperatively with other professions in order to provide best care and accessibility to patients and families. Allow me to explain.
The recommendations in the link above are not bad recommendations, in fact, these are all good things to advise pediatricians to look for:
From Birth to 3 years:
- Ocular history
- Vision assessment
- External inspection of the eye and lids
- Ocular motility assessment
- Pupil examination
- Red reflex examination
From 3-5 years, physicians are to add, in addition to the above:
- Distance Visual Acuity (Minimum of 20/40)
- Ocular Alignment
- Media Clarity
At six years and beyond, the recommended assessment includes the above two lists, but stipulates Visual Acuity threshold should be no greater than 20/30.
While this all sounds like good rationale, there are significant holes in this protocol, only a few of which I will comment on below.
Failings of the AAP Vision Screening protocol:
- They fail to account for refractive concerns: The screening described will help to identify only a small number of significant refractive anomalies, myopia (nearsightedness) in particular. We know that children with significant problems with farsightedness or astigmatism will struggle with text-based near work in the classroom, so testing at 10 feet is often irrelevant and often inappropriate as these children will often pass the distance visual acuity standards.
- Pediatricians and family doctors are not equipped to assess anything but very gross deviations of ocular alignment. Significant trouble with convergence, accommodation, phoric posture, alternating strabismus, pseudostrabismus, saccades, fixations, and pursuits will not be identified.
- Most pediatricians and family doctors will not abide by even the simple steps outlined above and prefer to have front desk staff simply do a 10ft visual acuity check, followed by basic ophthalmoscopy in the exam room – if that.
- There is a recognition of health-related concerns, but only cursory attention paid to visual functional concerns, which are by far much more prevalent than classic ‘eye disease’.
- Because this statement is issued by AAP, it is taken as a ‘gold standard’ for child vision assessment, even though it is far from comprehensive.
- There is no recommendation to pursue optometric assessment, even though we know that significant visual functional concerns are masqueraders for a number of behavioural and learning problems, namely ADHD, dyslexia, and emotional disturbances.
This last point highlights the insular silo nature of Western Medicine: There is a preference to disregard the option of optometric assessment because optometry is not medicine, in spite of the fact that optometrists are specifically trained to assess and treat visual functional disorders as well as vision health problems. The final paragraph does state: “If a child identifies fewer than 4 of 6 characters at the 20/30 line, a referral for examination is needed”, but there is no specification of whom to refer to, or what that exam should entail.
The recommendations for machine screening is also misleading in that these would be sufficient. Since a child is a living organic being, we must assess their visual function in a natural context, and look for those visual functional elements that are more likely to cause problems in behaviour (read ‘learning’) and development. Close proximity devices do not provide a natural environment for vision as the visual system must adapt to the restrictive space, near proximity, and artificial visual constructs presented. Furthermore, these devices fall short of assessing refractive state and visuomotor skills.
In an attempt to provide guidance to physicians, and thereby their clients, the AAP has lowered the bar for children’s visual assessment. As an authoritative body, AAP is by extension also discouraging a more elevated, and academically and clinically rational approach to child vision assessment. AAP also encourages the use of general practitioners for the purpose of visual screening – a population that is hard pressed to define the basic principles of the physiologic optics of astigmatism, say, as one example – as opposed to the recognized experts in the field, optometrists. This belies an outdated view of child vision, its many facets, and the role visual dysfunction plays in child development.
In Alberta, the Province is considering spending millions on ‘appropriate technology’ for child vision screening, and this does not include the costs of staffing and implementation. This misguided strategy is a result of a strong bias towards detecting ocular disease, which is very rare compared to visual functional concerns. Again, this is justified based on the recommendations of an American body which is far removed from the specialty study of visual function. The AAP protocol turns out to be false economy as the resulting false negatives mean that of the 1 in 4 children on average who are burdened with visual functional concerns, most of them will be referred to ongoing treatments and assessments that will fail to address the underlying causes. For my tax dollars, I would much rather see the Province invest in a basic marketing campaign to ensure all children have the benefit of basic comprehensive visual functional exam prior to starting school. On this, at least, I will agree with the AAP that early detection is critical.
For an alternate view on vision assessment for children, see: http://oepf.org/visual-impediments-to-learning/