In late 2012, the American Academy of Pediatrics (AAP) Section on Ophthalmology and Committee on Practice and Ambulatory Medicine joined the American Academy of Ophthalmology, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), and the American Association of Certified Orthoptists in issuing a policy statement endorsing the use of instrument-based vision screening in the pediatric population.1 This was the subject of the inaugural article in the Peds v2.0 series in January 2013 (Contemp Pediatr. 2013:30(1):41-44). We now revisit the topic because insurance companies are beginning to compensate pediatricians for performing photoscreening, billed under Current Procedural Terminology (CPT) code 99174. We applaud the efforts of the many pediatricians, pediatric ophthalmologists, and state chapters of the AAP who have aggressively petitioned insurance companies to cover this important service for our patients. —Andrew J Schuman, MD, Section Editor
Amblyopia, defined as poor vision caused by abnormal development of visual areas of the brain, occurs in as many as 2% to 4% of children.2 It is associated with complete or partial lack of clear visual input to 1 eye (unilateral/anisometropic refractive amblyopia), or, less often, to both eyes (bilateral refractive amblyopia), or to conflicting visual inputs to the 2 eyes (strabismic amblyopia). Less-common causes include ptosis, congenital cataract, and corneal injury or dystrophy. According to the US Preventive Services Task Force (USPSTF), amblyopia is regarded as a disease of childhood; however, its effects are irreversible if left untreated, and it is the most common cause of monocular vision loss among adults aged 20 to 70 years.3
Unfortunately only a minority of young children are screened for this disabling condition. One study reported that in a sample of 102 private pediatric practices in the United States, vision screening was attempted on only 38% of 3-year-old children and 81% of 5-year-old children.4 The study also showed that only 21% of children failing the AAP vision screening guidelines were referred for a professional eye examination.
Vision screening in pediatric practice
Vision and amblyopia screening should be viewed as a continual process beginning in mid-infancy and repeated annually throughout early childhood.5 Vision screening for infants, toddlers, and preschool children is traditionally performed by primary care physicians and nurses, using a rechargeable, battery-powered ophthalmoscope to test pupil position, equality, size, steadiness, and reaction to bright light; extraocular muscle function; ocular deviation during a cover-uncover test; and presence of unequal red reflexes in a darkened room.
Many of the major risk factors for amblyopia are poorly detected during a traditional vision screening examination. Vision acuity testing in children aged younger than 3 years in a medical office can be challenging, because few children this age can be screened with a vision chart. From ages 3 to 5 years, screening is possible with Snellen charts, Tumbling E charts, or picture tests such as Allen Visual Acuity Cards, but this is time consuming and can lead to inconsistent or erroneous results.