USPSTF finalizes recommendation on vision screening in children

Pediatricians should screen for lazy eye between ages 3 and 5 years, according to a recent recommendation that stops short of advocating for earlier screening and intervention.

The recent recommendation from the US Preventive Services Task Force (USPSTF) states that vision screening for children should occur at least once between the ages of 3 and 5 years to rule out amblyopia or its risk factors.

Amblyopia, also known as “lazy eye,” is an alteration in the visual neural pathway that can lead to permanent vision loss, and it can affect 1% to 6% of children aged younger than 6 years. Early diagnosis of amblyopia or one of its risk factors such as strabismus and/or anisometropia can prevent the development of amblyopia, according to the report.

Currently, screening rates for amblyopia vary based on race, ethnicity, and income level. The report found that 80.7% of white and black children were screened for amblyopia in 2009-2010 compared with just 69.8% of Hispanic children. Children whose families had an income at 200% of the federal poverty level also had higher rates of screening.

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Although the USPSTF recommendation champions screening in children aged 3 to 5 years, it stopped short of advocating for earlier screening based on the evidence that false-positive screening results in this age group may lead to overdiagnosis or unnecessary treatment.

“Limited evidence suggests that eye patching in children aged 3 to 5 years does not worsen visual acuity in the nonamblyopic eye but may be associated with psychological harms, such as child or parental upset or concern,” the report states.

Alex Kemper, MD, MPH, MS, USPSTF task force member, board-certified pediatrician, and professor of Pediatrics at Duke University Medical School in Durham, North Carolina, coauthored the report and says that vision screening at 3 to 5 years of age can catch serious problems such as amblyopia and allow for correction to prevent permanent vision loss.

The USPSTF report also responded to criticism about the recommendations, noting that the report did not address screening for general ocular abnormalities. Currently, the American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Certified Orthoptists, and American Academy of Ophthalmology recommend vision assessments beginning at age 6 months to age 3 years. The American Optometric Association also recommends vision screening at birth plus regular comprehensive eye exams beginning at age 6 months, then at age 3 years, and before entry to first grade followed by examinations at 2-year intervals thereafter.

Kemper says the report was based on the balance of benefits and harms of preventive service.

“After a thorough review of the available evidence, the task force found that treatment of amblyopia or its risk factors in children aged 3 to 5 years leads to improved visual acuity,” Kemper says. “There is currently not enough evidence to recommend for or against vision screening for children aged younger than 3 years. It’s important that parents discuss when to start screening with their child’s doctor, especially if they have concerns about their child’s vision. The task force hopes that there’s more evidence in the future so that the task force can reach a conclusion on vision screening in children aged younger than 3 years.”

Kemper says the recommendations in the report are consistent with the 2011 recommendations and reiterate the importance of vision screening in children aged 3 to 5 years.

“Healthcare professionals should continue to use their best judgment when deciding when to screen younger children for vision problems,” Kemper adds.

In an editorial published about the recommendation, William V. Good, MD, a pediatric ophthalmologist at Smith-Kettlewell Eye Research Institute in San Francisco, California, agrees with the USPSTF recommendation.

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“The takeaway message is that vision screening for children aged older than 3 years should be performed, but aged younger than 3 years, data are insufficient to warrant a recommendation to screen. Under 3 years, we don’t know the natural history of many eye conditions, so even their detection could lead to unnecessary treatment,” Good says. “Tests for younger children have not been adequately validated, either. I hope that pediatricians who detect conditions in children aged younger than 3 years either follow up themselves if the condition could be treated at a later age or refer if the problem seems urgent, such as no red reflex or strabismus.”

Another editorial, by Sean P. Donahue, MD, PhD, from the department of Ophthalmology at Vanderbilt University Medical Center, Nashville, Tennessee, offers another viewpoint, discussing the lack of evidence reviewed in the USPSTF recommendation and the need for more research.

“This recommendation for the younger children is disappointing. It makes no mention of the importance of red reflex testing to detect retinoblastoma, and it mentions cataract only as a potential cause of visual deprivation,” Donahue says. “Preschool vision screening and the treatment of amblyopia and related eye problems in preschool children has advanced exponentially during the past 20 years. In my office, and in that of many of my colleagues, the surgery rate for strabismus in young children appears to be declining, and many of us believe that that is owing to earlier detection and treatment of high hypermetropia and anisometropia in children prior to it producing a long-standing strabismus.”