Children under the age of 4 years benefit from instrument-based vision screening rather than visual acuity tests since the former is quick, requires minimal cooperation of the child, and is not dependent on their behavioral responses, says a policy statement released by the American Academy of Pediatrics (AAP).
One of the primary goals of such screening is to detect abnormalities including amblyopia (lazy eye) - a neural deficit that is thought to be present in 1-4% of children - or its risk factors, note the statement authors.
Amblyopia is recognized via decreased visual acuity, which is typically monocular, and is not accounted for by ocular structural disorders. However, few professionals can reliably determine visual acuity in children under 3 years of age using standard vision charts, according to the statement.
"Both photoscreening and autorefraction offer hope in improving vision-screening rates in preverbal children, preliterate children, and those with developmental delays, who are the most difficult to screen," say authors Joseph Miller and Herschel Lessin (AAP, Elk Grove Village, Illinois, USA).
Yet, despite the recommendations of the policy statement - an update to the AAP's 2002 position paper - the writers acknowledge that instrument-based vision screening involves "substantial" costs to the primary care practice, and that there is "never a guarantee of payment from third-party payers, even if the appropriate code is used."
They note that vision screening is frequently, and inappropriately, bundled into global fees for pediatric health maintenance visits, despite being a separately identifiable service with real costs and "established relative value units."
They add that, "primary care physicians will likely to slow to adopt these new technologies, despite their merit, if they are expected to absorb the cost without adequate payment for their up-front costs and their time."
Photoscreening uses optical images of the eye's red reflex to estimate refractive error, media opacity, ocular alignment, and other factors, such as ocular adnexal deformities, explain Miller and Lessin, while autorefraction evaluates the refractive error of each eye with optically automated skiascopy methods or wavefront technology.
Given a 90% specificity for autorefraction to detect conditions for which early detection and treatment is vital, the method had a sensitivity of 81-88% compared with 77% for standard visual acuity testing, report the statement authors, who acknowledge these figures depend on referral criteria used.
The statement is published in Pediatrics, and co-sponsored by the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists.
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