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Screening
Vision screening is important to identify vision impairments in children so they can receive treatment. Screening should begin at birth and continue at well-child visits. Early screening can detect conditions like amblyopia, which is most effectively treated in early childhood. While only 21% of preschoolers receive vision screening, screening is highly cost-effective for detecting and treating amblyopia and other vision issues. Pediatricians play a key role in regularly screening children's vision as part of comprehensive well-child care.
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Screening
- 1. Screening • screening testshould be able to quickly identify a health problem for which a prevention or treatment is available.
- 2. Vision screening • Visionscreening is an efficient and cost- effective method to identify children with visual impairment or eye conditions that are likely to lead to visual impairment so that a referral can be made to an appropriate eye care professional for further evaluation and treatment.
- 3. The Importance ofPediatric Vision Screening • Amblyopia affects up to 5% of the population (>10 million Americans). • In the first 4 decades of life amblyopia causes more vision loss than all other ocular diseases combined! • Amblyopia has a “window period” for treatment in early childhood. • Screening can prevent otherwise fatal disorders such as retinoblastoma.
- 4. Vision Screening: Scopeof Problem Only 21% of preschool children and even fewer children below preschool age are screened for these conditions. Ottar WL, Scott WE, Holgado SI. Photoscreening for amblyogenic factors. J Pediatr Ophthalmol Strabismus. 1995;32(5):289–295
- 5. Amblyopia is VeryCost-Effective to Treat • Membrano, et al: Cost/QALY $2,281 for Amblyopia Tx • Comparisons: – Hypertension screening/therapy in asymptomatic 49 yo = $25,000/QALY – Annual screening for Diabetic Retinopathy in high risk diabetics = $41,700/QALY
- 6. Pediatricians Are theNatural First Line of Defense – The Medical Home • Children already come to Pediatrician. • Vaccinations and screening are already a part of care protocol. • Screening in pediatrics should be most cost effective (no separate office visit, no extra-time off work for parent). 6
- 7. AAP Policy onVision Screening • AAP in concert with AAO and AAPOS have a joint policy statement recommending screening beginning at birth and throughout childhood during well child visit. – Serial screening in the MEDICAL HOME • Ensures age-appropriate monitoring of visual system. • Is more efficient and cost effective than comprehensive eye exams for asymptomatic children. – Pediatricians are best champions for a child’s health.
- 8. Amblyopia The Physician seesnothing and the Patient very little
- 9. Amblyopia…In Other Words: •The camera (eye) is capable of taking the picture but the computer (brain) doesn’t recognize that there is an image. • “Either use it or lose it!”
- 10. Children are Different •Developing cortical connections • Window of opportunity for diagnosis and treatment…just like with language development
- 11. Screen for Causesof Amblyopia • Refractive errors • Obstruction of optical pathway (e.g. cataract or corneal scar) • Strabismus • Other—anything that blocks input of visual information to the brain
- 12. Motility Terminology • Strabismus= ocular misalignment • Esotropia = eyes turn in • Exotropia = eyes turn out • Hypertropia = one eye higher than the other
- 13. When Should WeScreen? • Begin at birth and during all subsequent well child visits. – Think of vision screening like vaccinations! – Different screening at different developmental/age levels.
- 14. Periodicity Table forScreening Periodicity Schedule for Visual System Assessment in Infants and Children Newborn to 6 months 6 months to 12 months 1 to <3 years 3 to < 5 years 5 years and older Ocular History x x X x x External inspection of lids and eyes x x x x x Red Reflex Testing x x x x x Pupil examination x x x x Ocular Motility Assessment x x x x Instrument Based Screening x + x + * Visual Acuity Fix and follow x x Visual Acuity age- appropriate optotype assessment x ∆ x ∆ +: Bill using CPT 99174 ∆: Bill using CPT 99173 *: If unable to test visual acuity monocularly with age appropriate linear optotypes, instrument-based screening is suggested.
- 15. Age Specific Screening:NEWBORN • External evaluation for obvious ocular malformations and infections – NOTE: Too young to evaluate alignment!!! • RED REFLEX TEST—preferably prior to discharge from newborn nursery – Very important to r/o retinoblastoma or congenital cataracts • If congenital cataracts not removed in first 2 to 3 months of life, permanent loss of sight occurs
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- 17. Leukocoria is anUrgency! Diff Dx include cataract, glaucoma, PHPV, Retinoblastoma, Retinal detachment, etc. In addition to sending a consult, CALL ophthalmologist to make sure the patient is seen ASAP!
- 19. Basic Techniques forExamining Children’s Eyes • Age specific • Start with HISTORY – Moms are great diagnosticians! • Common EXAM components – Assessment of vision – External anatomy – Pupil function – Motility – Ocular fundus/Red Reflex testing
- 20. Ocular History • Doeschild appear to see well distance and near? • Any crossing? • Family history of eye disorders? • Recurrent discharge or redness? • Extreme photophobia? • NOT to worry about: – “Sits close to TV a lot”
- 21. External Examination • Areeyelids symmetric? • Pupil symmetry? • Any redness, inflammation, or discharge? • Cornea clear? • Are the eyes aligned?
- 22. Pupil Exam • Arethe pupils round? • Symmetric? – If asymmetric, is it more asymmetric in dark or light? • Reactive to light?
- 23. Motility Assessment • Isthe pupil light reflex central? • Do the eyes move fully in all directions? • Pseudostrabismus vs. true strabismus
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- 25. Vision Assessment • Infants:Eye contact, follows face, smiles • Toddlers: Cover each eye and follows objects (fix and follow) • Verbal: Visual acuity screening with appropriate optotype (symbol/letters)
- 26. Visual Acuity (VA)Testing • To have good VA both anterior and posterior visual pathways must be functioning. • VA testing is the current “gold standard. • Should be performed at earliest possible age.
- 27. Checking VA The 3common errors: • Child peaks. • Child memorizes. • Examiner only projects one letter at time (crowding phenomenon).
- 28. AAPOS Vision ScreeningKit • Can order from: – AAPOS: http://www.aapos.org/a hp/vision_screening_kit – AAP: http://tinyurl.aap.org/pu b221192
- 29. What about newvision screening technology?
- 30. New Screening Technology •Remember in the pre-verbal child, the only way to detect amblyopia is to indirectly detect the risk factors. – Refractive errors – Media opacities – Strabismus
- 31. Objective Screening Technology •Photoscreening • Automated refractors • VEP screening • Retinal birefringence
- 32. Photoscreening • Similar toBruckner Reflex. • Exploits the red-eye one gets in photography to help assess both alignment and refractive error.
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- 34. Photoscreening • Instrument-based screeningis now endorsed by the as a valid measure for screening preschool children. • A randomized controlled multi-centered cross over study demonstrated photoscreening to be superior to direct testing of visual acuity for screening well visit children ages 3–6 in the pediatrician office.* • For children older than 5 years, VA testing still preferred.
- 35. Summary • Vision screeningshould begin at birth and continue throughout well child visits. • Vision screening is age-appropriate – Early Red Reflex testing mandatory – VA testing in verbal children • Objective screening technology is effective, improving, but needs to be reimbursed for widespread adoption. • Pediatricians are our best line of defense for preventable blindness!
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