USPSTF Issues Draft Vision Screening Recommendations for Young Kids

Veronica Hackethal, MD

February 28, 2017

The US Preventive Services Task Force (USPSTF) has released new draft recommendations for vision screening in children aged 6 months to 5 years. The draft recommendations and an evidence review are available for public comment until March 27, 2017, at www.uspreventiveservicestaskforce.org.

The recommendations basically reaffirm and update the USPSTF's 2011 recommendation. They call for vision screening for amblyopia and its risk factors at least once in children aged 3 to 5 years.

"Identification of vision abnormalities in preschool-aged children allows the abnormality to be corrected while the brain is still developing, which can prevent permanent vision loss," Task Force member Alex R. Kemper, MD, MPH, MS, said in a news release. Dr Kemper is affiliated with Duke University and is deputy editor of the journal Pediatrics.

The recommendations advise neither for nor against screening in children younger than 3 years.

"For children less than 3 years of age, we found that there is not enough evidence to know whether or not to screen. The Task Force is calling for more research to better understand the balance of benefits and harms of screening in this age group," USPSTF vice chair, David C. Grossman, MD, said in a news release. Dr Grossman is affiliated with the Group Health Research Institute and the University of Washington, Seattle.

Amblyopia, or "lazy eye," is one of the most common visual problems in children. It is a neurodevelopmental disorder in which the brain and affected eye do not properly work together to process visual information.

Approximately 1% to 6% of preschool-aged children have amblyopia or its risk factors. Risk factors include strabismus ("cross-eyes"), cataracts, and anisometropia (refractive errors in which the eyes have unequal focus). Other risk factors include family history in a first-degree relative, prematurity, low birthweight, maternal substance abuse, maternal smoking during pregnancy, and low parental education level.

Positive vision screening results require referral to a specialist for confirmatory testing and treatment. Untreated amblyopia can cause permanent vision loss, usually by age 6 to 10 years. Amblyopia can also lead to physical and psychological harms, such as accidents, injuries, bullying, depression, anxiety, low self-esteem, and problems at school or work.

To review the evidence, the authors searched trial registries and three databases for studies of screening and treatment for amblyopia and its risk factors in children aged 6 months to 5 years that were published in English through June 2016. They revised the recommendation on the basis of comments by content experts, USPSTF members, and Agency for Healthcare Research and Quality medical officers.

The evidence review included 40 studies, of which 34 evaluated accuracy of vision screening tests. It included visual acuity tests, ocular alignment tests, stereoacuity tests, combinations of clinical tests, autorefractors, photoscreeners, and retinal birefringence scanning. The review did not cover surgical interventions.

According to the review, adequate evidence supports the accuracy of vision screening for identifying vision abnormalities, although inadequate evidence exists to compare vision screening across age groups. Many studies left out children younger than age 3 years.

Limited evidence about adverse effects of screening exist, but some studies have suggested high false-positive rates in populations with low prevalence rates of amblyopia. On the other hand, some studies have linked screening to decreased bullying.

The authors found adequate evidence suggesting that treating amblyopia and it risk factors moderately improves vision in children aged 3 to 5 years. Again, there was inadequate evidence to show that treating amblyopia or its risk factors improves vision in children younger than 3 years.

Limited evidence suggested that patching in children aged 3 to 5 years may cause worry and upset in the children and parents. Inadequate evidence existed about harms of treatment in children younger than 3 years.

The authors conclude with moderate certainty that vision screening for amblyopia in children aged 3 to 5 years has moderate net benefit. They add that the benefits of vision screening in children younger than 3 years are uncertain, and the balance of benefits and harms cannot be determined in this age group.

They note that most studies of test accuracy took place in Head Start programs, ophthalmology clinics, and school or community settings, so the results may not apply to primary care.

The draft recommendations along with a plain-language fact sheet are available for public comment until March 27 at www.uspreventiveservicestaskforce.org/tfcomment.htm.

The draft report was funded by the Agency for Healthcare Research and Quality.

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