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K. Zadnik, G. L. Mitchell, CLEERE Study Group; Simulated Vision Screening of School-Aged Children in the Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study. Invest. Ophthalmol. Vis. Sci. 2010;51(13):5211. doi: https://doi.org/.
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The delivery of vision care to schoolchildren is controversial. In Ohio school health personnel must perform vision screenings in grades K, 1, 3, 5, 7, and 9. The K/first grade screening protocol is more extensive and includes the assessment of distance visual acuity (VA) and strabismus (unilateral/alternate cover tests). School nurses report that cover test is difficult to perform. The CLEERE data were used to assess a model incorporating an eye exam in first grade and distance VA measurement only in grades 3, 5, and 7.
CLEERE examined 1,987 children in the first grade who were also seen at least once in grades 3, 5, or 7. An optometrist measured distance VA and performed non-cycloplegic retinoscopy (spherical equivalent [SE]) and cover test at distance and near. For the purposes of this model, which establishes the first grade examination results as a full eye exam and then calculates referral rates based on distance VA in grades 3, 5, and 7, conditions requiring referral for exam by an eye doctor were: abnormal VA in either eye = 20/40; amblyopia = interocular 2-line difference in VA; hyperopia = SE at least +2.00 D; myopia = SE at least -0.50 D; astigmatism = at least 1.00 DC; strabismus = any detectable movement on unilateral cover test.
In first grade, 437 children (22.0%) exhibited problems needing referral: 26 amblyopes (1.3%); 122 hyperopes (6.2%); 193 myopes (9.7%); 214 astigmats (10.8%); and 23 strabismics (1.2%). Presumably, a school nurse-only screening would have missed most of the hyperopes and possibly many of the strabismics. After removing those children with ocular problems in the first grade from the analysis, only an additional 13 children in the third grade (12 hyperopes and 1 strabismic), 7 in the fifth grade (2 hyperopes and 5 strabismics), and 2 strabismic children in the seventh grade exhibited ocular diagnoses according to the criteria above that would not have been detected by VA alone with 12 amblyopes, 156 myopes, and 83 astigmats presenting newly in the third grade, 21 amblyopes, 166 myopes, and 43 astigmats presenting newly in the fifth grade, and 4 amblyopes, 95 myopes, and 25 astigmats presenting newly in the seventh grade.
Most ocular problems requiring intervention in school-aged children are detectable by distance VA. Those that are not, ie most cases of hyperopia and strabismus, were evident by first grade in this dataset. A rational system for the identification and referral for eye care of school-aged children might incorporate full eye exams at school entry followed by periodic screening for distance VA only.
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