Do visual acuity (VA) screenings result in unnecessary comprehensive eye exams or prescription glasses in pediatric patients?

From the Guidelines

Visual acuity screenings in children do not typically result in unnecessary comprehensive eye exams or prescription glasses when conducted properly, as they serve as a crucial first-line tool to identify potential vision problems that require further evaluation. These screenings are essential for detecting conditions that may lead to amblyopia, strabismus, or significant refractive errors, which can impact learning and development if left untreated [ 1 ]. The decision to prescribe glasses is based on specific clinical findings and established guidelines, not solely on screening results. According to the most recent guidelines, vision screening should be performed using age-appropriate methods, such as photoscreening and handheld autorefraction for children under 3 years old, and visual acuity testing with vision charts for children over 3 years old [ 1 ].

Key Considerations for Vision Screening

• The elements of vision screening vary depending on the age and level of cooperation of the child [ 1 ]
• Lay screeners should receive adequate training to carry out specific screening procedures, but they should not be expected to perform more sophisticated elements of an ophthalmic examination [ 1 ]
• Children who fail to complete subjective visual acuity assessment are considered untestable and should be rescreened within 6 months or referred for a comprehensive eye examination [ 1 ]
• The benefits of routine vision screening outweigh the risks of occasional unnecessary exams, as they help ensure that children who need vision correction receive it while minimizing unnecessary referrals [ 1 ]

Optimizing Screening Effectiveness

• Programs should use age-appropriate methods, trained screeners, and established referral criteria to minimize both under-referrals and over-referrals [ 1 ]
• Visual acuity testing should be performed monocularly and with habitual refractive correction in place [ 1 ]
• Children should continue to have periodic vision screenings throughout childhood and adolescence, as problems may arise at later stages of development [ 1 ]

From the Research

Visual Acuity Screenings in Pediatric Patients

• The effectiveness of visual acuity screenings in pediatric patients is a topic of interest, with some studies suggesting that these screenings can lead to unnecessary comprehensive eye exams or prescription glasses 2.
• According to a study published in 2021, there is moderate certainty of evidence that visual screening in children between three and five years provides a moderate net benefit, as assessed by the US Preventive Services Task Force 2.
• However, the same study found that there is uncertain evidence on whether vision screening in children under three years of age provides net benefits, and that among populations with a low prevalence of vision abnormalities, screening the youngest is associated with an increased rate of false positives, leading to unnecessary additional assessment 2.
• Another study published in 2015 provides recommendations for screening children aged 36 to younger than 72 months for eye and visual system disorders, and describes the characteristics of children who should be examined by an optometrist or ophthalmologist rather than undergo vision screening 3.
• The study also recommends that children aged 36 to younger than 72 months be screened annually using one of the best practice approaches, such as monocular visual acuity testing or instrument-based testing 3.

Potential for Unnecessary Comprehensive Eye Exams or Prescription Glasses

• A study published in 2019 found that refractive errors and amblyopia are the two most common causes of avoidable visual impairment in children, and that screening for these conditions is essential 4.
• However, the study also noted that there are significant regional disparities regarding the organization and means used for vision screening, which can lead to inconsistent results and potentially unnecessary comprehensive eye exams or prescription glasses 4.
• A clinical review published in 2024 provides evidence-based guidance for providers who care for infants from birth through 6 months of age in the primary care setting, and emphasizes the importance of early detection of ocular pathology to avoid permanent vision loss 5.
• The review also notes that the comprehensive eye exam in infants should include a thorough history and physical examination of eye structures, visual acuity, evaluation of extraocular movements and alignment, and assessment of the red reflex, and that recommended exam maneuvers differ with age as visual acuity improves and development advances through infancy 5.