Are unnecessary examinations or prescriptions for glasses more common with instrument-based screenings or visual acuity (VA) tests in pediatric patients?

From the Guidelines

Instrument-based screenings are generally preferred over visual acuity (VA) tests for pediatric patients, particularly for preschool-aged children, as they have lower false-positive rates and can objectively measure refractive errors and eye alignment without requiring the child's subjective response. This is supported by the most recent and highest quality study, which found that instrument-based vision screening methods like photoscreening and autorefraction are effective in detecting children at risk for amblyopia and have a lower risk of unnecessary referrals compared to VA testing 1. The American Academy of Pediatrics and other clinical authorities recommend periodic vision screening for asymptomatic children, with instrument-based screening being a preferred method for preschool-aged children. VA testing, on the other hand, is more suitable for school-aged children who can reliably participate in the testing process.

Some key points to consider when deciding between instrument-based screenings and VA tests include:

• The age and cooperation level of the child: instrument-based screenings are more suitable for younger children who may have difficulty cooperating with traditional vision charts.
• The risk of amblyopia: instrument-based screenings can detect children at risk for amblyopia, which is a major cause of permanent visual loss if left untreated.
• The potential for unnecessary referrals: VA tests can lead to more over-referrals due to factors like child cooperation, tester variability, and testing conditions, which can create anxiety for families and burden the healthcare system.

Overall, the choice between instrument-based screenings and VA tests should be based on the individual child's needs and the clinical context, with a preference for instrument-based screenings for preschool-aged children and VA testing for school-aged children. This approach can help optimize screening outcomes and reduce the risk of unnecessary referrals and excess exams.

From the Research

Comparison of Screening Methods

• The provided studies do not directly compare the rates of unnecessary examinations or prescriptions for glasses between instrument-based screenings and visual acuity (VA) tests in pediatric patients 2, 3, 4, 5, 6.
• However, the studies suggest that the choice of screening method depends on the age of the child and the refractive error profile of the population 4, 5, 6.
• The Vision in Preschoolers (VIP) Study found that the best screening tests administered by eye care professionals were non-cycloplegic retinoscopy, Retinomax Autorefractor, SureSight Vision Screener, and linear, crowded Lea Symbols VA at 10 feet 5.
• The study also found that the best screening tests administered by trained nurses and/or lay screeners were Retinomax, SureSight, and VIP single, crowded Lea Symbols VA screening test system at 5 feet 5.

Effectiveness of Screening Methods

• A study in Aotearoa New Zealand found that distance visual acuity screening alone had a sensitivity of 39% for detecting vision conditions, while the addition of the Spot Vision Screener improved sensitivity to 65% 6.
• The same study found that astigmatism is the most frequent refractive error among children aged 7-10 years living in Aotearoa New Zealand, and that distance visual acuity screening alone is ineffective in detecting refractive error in children in this population 6.
• The US Preventive Services Task Force recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors, but concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening in children younger than 3 years 3, 4.

Limitations of Current Research

• The provided studies do not address the question of whether unnecessary examinations or prescriptions for glasses are more common with instrument-based screenings or VA tests in pediatric patients 2, 3, 4, 5, 6.
• Further research is needed to evaluate the value of correcting refractive errors in preschoolers who do not have amblyopia and/or strabismus, and to determine the optimal timing and appropriate protocols for school-aged vision screening 5, 6.