Sight Tests Not Needed

Every now and then, a blog post reveals truths about a writer or a body that was never intended as part of the original goal of writing. Doctors of optometric vision rehabilitation will recognize in the blog post linked below the common complaint from medical orthoptics and ophthalmology that there is ‘no science behind Vision Therapy’ and/or that children’s vision is really not all that big of an issue. In their view, a child needs to be bumping into things, falling down stairs, or have crossed eyes before anyone pays attention. To the trained vision professional, many common concerns in behaviour and learning become easily explained by assessing vision with more finesse and detail.

Like Halley’s Comet, which makes it’s self abundantly clear but only on rare occasions, every now and then the rationale behind these untenable positions in child vision management is very clearly defined in blog posts like the following:

https://orthoptics-org.wildapricot.org/news/3495013

From the article: “BIOS commends the view of the Royal College of Ophthalmologists that a routine “sight test” is unnecessary in the absence of visual symptoms in children over 5 years of age. Visual problems such as short sightedness can develop in the older child. If a parent becomes concerned about their child’s vision, progress in school, or a child complains of headaches or tired eyes they can arrange to attend a local Optometrist for an eye examination or contact their GP. … There is no robust research to support any other vision screening in childhood.”

The peculiar thing is that I agree with all these statements, but still I cry foul.

Let’s get through these first:

  • “Visual problems such as short sightedness can develop in the older child.”
    • Response: That’s true. Still, why are we always so bothered by garden variety low myopes (easy vision up close) when equivalent farsightedness or astigmatism is a much greater problem and is far more prevalent at early ages.
  • “If a parent becomes concerned about their child’s vision, progress in school, or a child complains of headaches or tired eyes they can arrange to attend a local Optometrist for an eye examination or contact their GP.”
    • Response: Yes, good advise. Except that I wouldn’t say ‘or contact their GP’ – best practice (clinically and fiscally) would be to see the optometrist first. Because MD’s are not trained to detect visual functional deficits, the child and family are far more likely to end up following a trail of unnecessary testing and treatment. Better yet, if these significant signs are present, then seek out a behavioural optometrist.
  • “There is no robust research to support any other vision screening in childhood.”
    • Response: That’s true. There is a fair bit of evidence showing the contrary – that screenings are of little use except for identifying those garden variety myopes, who by all indications, do better in the near-biased environment of the classroom. Screenings are next to useless; children, all children, need and deserve comprehensive vision exams long before they ever sit their bums in a desk.

The Real Concern

The real concern is that what is described is a ‘wait to fail’ approach which is unfair to those affected and not great clinical practice. Nearsightedness is not the problem, but there are other critical visual functional problems that are present early and should be addressed sooner. Again, this is a matter of record for those who wish to learn as opposed to rest on dogma and faith alone.

A routine sight test is, in my opinion, unnecessary, and mostly of no use, and so once again, I find myself agreeing with the BIOS statement. Best practice is that all children undergo comprehensive vision assessment early, before school and the sight test does not accomplish that. Dealing with vision-related learning and behaviour problems post-hoc is not only disrespectful of the child and his family, it overburdens healthcare and education with unnecessary costs. Again, the research is out there to clearly show ‘wait to fail’ is outdated and unfair.

Importantly, from medical-legal, ethical, and clinical science perspectives, I am curious as to how the RCO can rationalize self-reporting in a child for something they have no training in, or alternative reference to. What is the basis for this practice, the evidence that a child is capable of doing so, or that the child will do so under the right circumstances? The answer is there is no rational basis for expecting a child to report if they have vision problems: Their vision is normal to them, regardless of how bad it might be.

Overwhelming research shows us that children with visual impediments to learning and development suffer: They achieve less, are more likely to be given medication and be ‘coded’, suffer more frequent medical / psychiatric concerns. Prison populations have a much higher incidence of visual impediments than college.

Just some examples of why the RCO’s approach is misguided: Would a child self-report or display obvious signs to untrained adults if they had moderate astigmatism or hyperopia, convergence insufficiency, accommodative dysfunction, anisometropia and/or anisometropic amblyopia, visuomotor skills deficits? This list is not exhaustive, but represents some very common physical disabilities affecting some 1 of 4 kids in our entirely vision-based schools today.

It would be refreshing for once if groups like the RCO, and by extension and self-association BIOS, would actually consider the science before saying there’s no science to justify early child vision assessment. Tedious, dishonest, and a little shameful, really.

Lack of knowledge does not constitute lack of evidence. Stating there is no basis for assessing children’s vision prior to school is an indication that the knowledge, and not the evidence, is in short supply.

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