Vision Screening in the Pediatrician’s Office

doi:10.4236/ojoph.2012.22003

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Open Journal of Ophthalmology, 2012, 2, 9-13

http://dx.doi.org/10.4236/ojoph.2012.22003 Published Online May 2012 (http://www.SciRP.org/journal/ojoph) 9

Vision Screening in the Pediatrician’s Office*

Natario L. Couser, Fatema Q. Esmail, Amy K. Hutchinson#

The Department of Ophthalmology, Emory University School of Medicine, Atlanta, USA.

Email: #[email protected]

Received January 13th, 2012; revised February 16th, 2012; accepted March 10th, 2012

ABSTRACT

Objective: To assess current practices, attitudes, and perceived barriers toward pediatric vision screening. Patients and

Methods: A link to a 9-question survey was electronically distributed to a national sample of 6000 pediatricians

through Medical Marketing Services Inc. Data were collected using Survey Monkey. Results: Email open rate was 11%;

37% of those who opened the email responded (225 respondents). Over ninety percent of respondents perform some

type of vision screening at least yearly, although age at which screening began varied, with two thirds of respondents

instituting formal v ision screen ing after three years. Fifty eight percent of respondents were either extremely u nsatisfied,

unsatisfied or only somewhat satisfied with their current screening method. Preferred methods of screening and confi-

dence of pediatricians in their ability to detect pathology varied for children under versus over age three. The least fre-

quently used methods for all age groups were autorefraction and photoscreening. The most commonly reported barriers

to screening were inadequate training (48%), time required for exam (42%), and inadequate reimbursement (32%).

Conclusions: Perceived barriers to vision screening in the pediatrician office have been previously identified, and pho-

toscreening and autorefraction h ave been identified as a possible means to circumvent them. In spite of the addition of

new procedural codes, pediatricians continue to report similar barriers to screening.

Keywords: Pediatric Vision Screening; Barriers; Reimbursement; Pediatricians; Photoscreening; Autorefraction; US

Preventative Services Task Force; CPT 99174

1. Introduction

Early detection of ocular disorders can prevent lifelong

visual impairment. The US Preventative Services Task

Force (USPSTF) has concluded that vision screening for

children ages 3 to 5 is beneficial, and recommends vision

screening at least once between the ages of 3 and 5 years

to detect the presence of amblyopia or its risk factors [1].

The USPSTF has also concluded that “the current evi-

dence is insufficien t to assess the balance of benefits and

harms of vision screening for children <3 years of age”;

[1] however, the evidence base for vision screening in

children under 3 is limited by a paucity of studies evalu-

ating the screening techniqu es that are feasible in this ag e

group of children, such as red reflex testing, and objec-

tive vision screening such as photoscreening and autore-

fraction [2].

In 2006, Kemper and Clark surveyed a national sample

of pediatricians to evaluate their preschool vision scr een-

ing practices, and reported that common barriers to

screening included perceptions that screening was con-

sidered too time consuming, children were uncooperative,

and that reimbursement was not adequate [3]. The au-

thors suggested that financial incentives and emerging

screening technologies might be important to ensure the

delivery of preschool vision screening. In January 2008 a

current procedural terminology (CPT) code 99174 was

established, and in November 2008 a relative value unit

(RVU) of 0.69 was assigned for objective screening us-

ing a photoscreener. We designed our survey to revisit

the practices and perceptions of vision screening among

pediatricians, and to determine whether these practices

and perceptions differed for patients below and above

age 3.

2. Patients and Methods

This study was approved by the Institutional Review

Board at Emory University. We designed a 9-question

survey with an additional section for general comments

to assess pediatricians’ current practices, attitudes, and

perceived barriers toward pediatric vision screening. A

link to the survey was electronically distributed to a na-

tional sample of 6000 pediatricians through Medical

Marketing Services Inc. (MMS) with a broadcast subject

line reading: “Help Us Improve Pediatric Vision Screen-

*Conflict of interest and disclosure statement: None of the authors have

a conflict of interest or a financial interest in any of the methods or

roducts described in this manuscript.

#Corresponding author.

Vision Screening in the Pediatrician’s Office

ing Methods.” Detailed practice characteristics of the

pediatricians receiving the email were not known; how-

ever MMS collects demographic information about their

participating physicians, and we designated surveys be

sent only to office based physicians whose primary spe-

cialty was pediatrics. Data were collected using Survey

Monkey (www.surveymonkey.com). Descriptive statis-

tics were used to summarize the data.

3. Results

Delivery information provided by the marketing service

confirmed that 98% of the emails were received. There

was an 11% open rate, and of the recipients who opened

the email, 37% responded to the survey, for a total of 225

respondents. Not all respondents answered every ques-

tion.

Although 15% of respondents indicated that they be-

gan vision screening at birth by testing the red reflex in

infancy, the majority of respondents (67%) indicated that

they did not begin formal visual acuity testing until age 3

or over (Question 1, Table 1). Most respondents indi-

cated that they screened their patients at every well child

visit, but 9% of respondents reported that they screened

their patients less than once a year, and 1% reported that

they did not screen vision at all (Question 2, Table 2).

Table 1. At what age do you begin screening your pediatric

patients’ vision?

Answer Options Response Percent Response Count

Birth 15% 32

2 weeks 1% 2

1 month 0% 1

2 months 1% 3

6 months 3% 7

9 months 1% 2

1 year 1% 2

2 years 2% 4

3 years 34% 71

4 years 26% 54

5 years 7% 15

Misc* 8% 17

Answered question 210

Skipped question 15

*misc respo ns es include d “infant”, respondent giving a range of answers, “ at

first visit”, “birth, but formally at age…”.

of respondents were either extremely unsatisfied, unsat-

isfied or only somewhat satisfied with their current

screening method (Question 3, Table 3), and although a

majority of respondents felt at least so mewhat adequately

trained to perform vision screening, only one third felt

well trained (Question 4, Table 4). Fifty six percent of

respondents felt confident or extremely confident in their

ability to detect a vision problem in children over age 3

compared to only 19% feeling an equal level of confi-

dence in detecting vision problems in children under age

3 (Questions 5 and 6, Figure 1). A variety of testing

methods were employed in children in both age groups

(Questions 7 and 8, Table 5), with photoscreening and

autorefraction being the least frequently employed

methods in both age groups. Finally, the most frequently

reported barriers to performing vision screening were

Inadequate training (48%), inadequate reimbursement

(32%) and time constraints (42%) (Question 9, Table 6 ).

Although a majority of respondents felt at least some-

what satisfied with their current screening methods, 58%

Table 2. How frequently do y ou perform some type of vision

screening on your pediatric patients? (Please choose one

answer that best describes your practice) .

Answer Options Response Percent Response Count

At every visit 6.7% 15

At every scheduled

well child check 68.2% 152

At least yearly 15.7% 35

Less than once a year8.5% 19

Never 0.9% 2

Don’t know 0.0% 0

Answered question 223

Skipped question 2

Table 3. How satisfied are you with your current method of

screening vision in children?

Answer options Response percent Response cou n t

Extremely s a t i s f i e d 3.6% 8

Satisfied 38.5% 85

Somewhat satisfied 44.8% 99

Unsatisfied 10.9% 24

Extremel y u nsatisfied2.3% 5

Answered question 221

Skipped question 4

Vision Screening in the Pediatrician’s Office 11

Table 4. How adequately do you feel you are trained to

perform vision screening on your pediatric patients?

Answer options Response percent Response count

Extremely w el l t rained 3.6% 8

Well trained 29.1% 65

Somewhat trained 52.5% 117

Poorly trained 13.0% 29

Very poorly tra ined 1.8% 4

Answered question 223

Skipped question 2

(a)

(b)

Figure 1. How confident are you in your ability to detect an

eye or vision problem in a child?

4. Discussion

Our survey suggests that pediatricians are still facing

substantial barriers to vision screening including poor

reimbursement for vision screening, lack of available

methods to allow individuals with limited training to

perform vision screening efficiently, and discomfort with

screening young children under age 3 in part due to lim-

ited access to automated devices available for screening

of very young children due to poor reimbursement for

these methods.

Vision screening is a cost effective way to detect am-

blyopia and amblyopia risk factors, has been endorsed by

the USPSTF in children age 3 to 5, and has been recom-

mended for children of all ages by the American Acad-

emy of Pediatrics (AAP), the American Academy of

Ophthalmology (AAO), the American Association of

Pediatric Ophthalmology and Strabismus (AAPOS), and

the American Association of Certified Orthoptists

(AACO) [4]. Amblyopia affects 2% - 4% of the popula-

tion, and treatment has been shown to be highly success-

ful and cost effective [5,6]. In addition, studies have

suggested that anisometropic amblyopia often begins

before age 3 and that children who have their amblyo-

genic refractive errors corrected earlier have a higher

likelihood of achieving 20/20 visual acuity and a lower

rate of developing amblyopia or strabismus than children

who are treated later [7-9]. Hence the recent finding by

the USPSTF of “insufficient evidence” to recommend

vision screening for children under age 3 is of concern,

and is an indication of the need for better utilization of

photorefraction and autorefraction, which are becoming

preferred methods for screening young children, so that

data can be collected to provide a sufficient evidence

base to determine conclusively whether vision screening

should be recommended by the USPSTF in these young

children [2,1 0 -15].

Our study has significant limitations, most notably that

our low response rate could bias our results such that

only the only pediatricians who responded to our survey

were those who are dissatisfied with vision screening and

were moved by our broadcast subj ect line reading: “Help

Us Improve Pediatric Vision Screening Methods,” po ten-

tially overemphasizing the concerns of pediatrician re-

garding the cost and feasibility of vision screening in

children. However, we think such a scenario is unlikely,

given the percentage of respondents who indicated that

they were satisfied with their current methods.

5. Conclusion

Our survey suggests that perceived barriers to pediatric

vision screening have not changed substantially since

2006, in spite of the fact that in January 2008 a current

procedural terminology (CPT) code 99174 was estab-

lished, and in November 2008 a relative value unit (RVU)

of 0.69 was assigned for objective screening using a

photo technique. Efforts should be devoted to improving

efficiency and reimbursement for vision screening.

Vision Screening in the Pediatrician’s Office

Table 5. What method(s) do you currently employ to screen vision in your patients (check all that apply).

Under age 3 Over age 3

Answer options Response percent Response count Response percent Response count

Visual inspection of the external eye 97.7% 217 96.0% 214

Red reflex testing 96.8% 215 73.1% 163

Observe child’s ability to fix and follow a target 91.4% 203 85.2% 190

Cover/uncover testing 71.2% 158 70.9% 158

Ophthalmoscopy 45.9% 102 57.8% 129

Visual acuity testing with pictures or symbols 23.0% 51 87.0% 194

Visual acuity testing with letters 10.4% 23 79.4% 177

Autorefraction 3.2% 7 5.4% 12

Photoscreening 4.5% 10 4.5% 10

Answered question 222

Skipped question 3

Table 6. What are the obstacles you face in performing vi-

sion screening in children? (check all that apply).

Answer options Response p e r cent Res p o n se c o u n t

Not adequately trai ned 53.7% 109

Not adequately reimbursed 34.5% 70

Too time consum ing 46.8% 95

Too difficult 23.6% 48

I don’t face any obstacles 18.2% 37

Other (please specify) 46

Answered question 203

Skipped question 22

6. Acknowledgements

Supported in part by an unrestricted grant to the Emory

Eye Center from Research to Prevent Blindness, Inc.,

New York.

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