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A View to the Future

At a Glance

  • Vision assessments and comprehensive, dilated/cycloplegic eye examinations are critical to ensure that children succeed in school, and to prevent academic issues at all levels
  • An estimated one in five preschool children in the US has a vision problem, yet less than 15 percent of preschoolers receive an eye exam by an eye care professional
  • Inadequate vision may cause children to become frustrated with learning, enhancing the likelihood of need for special education 
  • Reports have found that as many as 70 percent of juvenile criminal offenders tested had undetected vision problems that affected learning.

Most learning, cognition, and perception – maybe as much as 80–85 percent – is mediated through vision. Although researchers cannot be exact on this statistic, they have found significantly lower achievement test scores (1), reduced letter and work recognition, receptive vocabulary, emergent orthography (2), and verbal and performance intelligence quotients (3) among children with uncorrected hyperopia. It is also known that vision-related problems are more prevalent in children with learning disabilities compared with the entire population (4).

Inadequate vision may cause children to become frustrated with learning, enhancing the likelihood of underachievement and/or a need for special education. These children can develop a negative self-image, exhibit behavior problems, and even drop out of school. Reports have found that as many as 70 percent of juvenile criminal offenders tested had undetected vision problems affecting learning (5)(6). The societal consequences of inadequate vision care for children is significant, and the effect on workforce quality and productivity is obvious. As vision problems that can affect learning are often related to refractive error, vision evaluations are imperative in children, and especially in the management of children with learning disabilities. Here, I overview the current ‘state of play’, and how best to approach visual testing in children to unlock their learning potential.


In 2005, the enactment of the Individuals with Disabilities Education Act ensured educational services for all children with disabilities, and led to the creation of Individualized Education Programs (IEPs) (see Box: What is IEP?). To assess the relationship between success in the academic setting and vision-related problems, Jeffrey Walline and Erica Johnson  from The Ohio State University College of Optometry (Columbus, OH, USA) compared the prevalence of ocular findings among children on IEPs with population-based samples. Ohio requires that a first-time IEP student who hasn’t been examined in the past nine months undergo a comprehensive eye examination with a licensed eye care professional within three months (8). Data for 255 children reported to have an IEP was analyzed and, of the 179 children who required some form of treatment, 124 had better than 20/40 entrance visual acuity (VA) in both eyes, meaning that they would have passed the school’s vision evaluation because the condition did not affect their distance vision (9).

“Children with IEPs have a significantly higher prevalence of myopia, hyperopia, astigmatism, anisometropia and strabismus than most population-based samples in the literature,” wrote Walline and Johnson. “Many of these vision problems would be undetected by vision evaluations based on distance VA, illustrating the need for comprehensive vision examinations for children who are struggling academically.” 

Box 1: What is IEP

An IEP is a legal document that spells out educational objectives for a child with a disability. It includes a child’s present levels of academic achievement and functional performance, measurable academic and functional goals, alternate assessments aligned to alternate achievement standards (if necessary), and a description of necessary special education services, supplementary aids, and accommodations. A team of school psychologists, teachers, school nurses, speech/language teachers, and medical specialists are tasked with setting measurable goals and establishing a guide for the child’s special learning needs (7).

The need for better early recognition

In children with developmental and intellectual disabilities, early recognition of visual disorders is especially important. The American Optometric Association (AOA) reports that an estimated one in five preschool children have vision problems and that one in four school-age children wear corrective lenses. I am a committee member and the chief methodologist for the recently released AOA Evidence Based Clinical Practice Guidelines (CPG) (10). Our pediatric guideline is truly a comprehensive and multidisciplinary effort between optometrists, ophthalmologists, pediatric experts and laypeople. We are proud of the work, and it was accepted by the US Department of Health and Human Services Agency for Healthcare Research Quality National Guideline Clearinghouse in record time (11).

According to the CPG, the assessment of VA for infants and toddlers (through two years of age) may include preferential looking VA, fixation preference test and visual evoked potential. For refraction, cycloplegic retinoscopy and noncycloplegic retinoscopy are listed.

VA in preschool children aged three through five years should be measured with symbol optotype or letter matching. The CPG states that a refraction should include objective and appropriate subjective assessment of the child’s refractive status. The refractive error measurement should be analyzed with other testing data that may include static retinoscopy, cycloplegic retinoscopy and autorefraction. Binocular vision, ocular motility, and accommodation assessments should be performed.

Creating a safety net

An estimated one in five preschool children in the United States has a vision problem, yet less than 15 percent of preschoolers receive an eye exam by an eye care professional (12). The National Center for Children’s Vision Health shows that 10 states have no preschool or school-age vision evaluation requirements, and only 17 that do include preschoolers.

The Lions KidSight USA Foundation is a nationwide program that runs vision-testing events. It reaches more than one million children per year through state and local programs, many known as KidSight. The coalition seeks to brings together Lions groups that perform device-based testing on preschool and school-aged kids as an alternative way to detect ocular abnormalities that, when addressed by an eye care professional, can ensure children have every opportunity to reach their intellectual potential.

Screening programs cannot lead to the earlier diagnosis and treatment of ocular or vision problems without follow-through (comprehensive eye exam). Outreach programs may, however, identify some children at risk for vision problems who can then be referred to an eye care professional to receive a comprehensive eye exam, definitive diagnosis, and appropriate treatment.

The Colorado program

In 2017, the Colorado KidSight program screened more than 54,000 children. Executive Director Holly Rutherford, says: “We use the Plusoptix device specifically designed for children. We screen children six and younger for the following vision problems: myopia, hyperopia, astigmatism, strabismus, anisocoria and anisometropia. Some of these vision problems are risk factors for amblyopia.” According to the National Eye Institute, amblyopia is the most common cause of visual impairment among children, affecting approximately 2–3 percent (13). Unless it is successfully treated in early childhood, amblyopia usually persists into adulthood. It is also the most common cause of monocular visual impairment among young and middle-aged adults – all reasons to catch potential problems early in childhood.

Children with untreated vision problems are left behind before they even start school

More than 6,000 children in the program were referred for a comprehensive eye exam because a problem had been detected. Most children in the program are referred for astigmatism, and a significant number have multiple vision problems, she says. The highest rates of referral are in the metropolitan areas of the state, where there are low incomes and diverse neighborhoods; rates of referral are typically much lower in rural areas. “The rate of referral in Colorado is 11.1 percent, however, we have school districts with significantly diverse student populations, where our rate of referral is about 20 percent. In one pocket, the rate soars to 30 percent,” she notes. About 25 percent of the state’s population is Hispanic, a group with higher rates of astigmatism and anisometropia (12). “These kids are truly at risk because parents in these communities don’t always speak English, and come from cultures where there is no history of vision screening or correction because of a scarcity of doctors or treatment facilities.” They also tend to have lower incomes, no insurance, and are often working several jobs to make ends meet, making a visit to the eye doctor difficult to accomplish, she adds.

Rutherford knows firsthand of the “snowball effect” a child’s unidentified vision problems has on school performance and behavior, resulting in problems for teachers, trips to the school nurse and the consideration of an IEP evaluation. “Sometimes I will get a letter or a phone call that really hits home,” she says, describing a preschool child who was scheduled for IEP testing because he was struggling to focus in class. During a vision screening, a problem was identified and the child received glasses. Within a couple of weeks, the teacher told the school nurse to cancel the evaluation due to the child’s improvement. “This is an instance where a child is performing poorly, and because of the vision evaluation and the subsequent comprehensive eye examination by an eye care professional. The problem was fixed and there was an immediate difference in how the child is able to learn,” says Rutherford. “Evaluations for special services are expensive, so the school district saves money if we identify a vision problem that can be treated. It is an extra bonus.”

Doing it for the kids

“While state and federal governments and others work to improve educational opportunities for children, more work needs to be done to address one of the elemental issues affecting literacy today: poor vision in children,” writes Joel Zaba, an expert on relating vision to child and adult learning problems, literacy and school performance. “Essentially, the children with untreated vision problems are left behind before they even start school.”

There is no question that vision problems have a severe impact on children’s ability to learn. Left untreated, poor VA can thwart educational achievement and stunt overall literacy. To ensure children have the necessary vision skills to be successful, preschool and school-aged children must have a comprehensive eye examination as they progress through their school years. The take home message is that “You can’t treat what you don’t see”. The mindboggling fact is that the majority of these problems are very commonly treatable. The only way we can help these kids is if their problem is detected and they are referred for comprehensive eye examination.

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  1. J Rosner, “The relationship between moderate hyperopia and academic achievement: How much plus is enough?”, J Am Optom Assoc, 68, 648-650 (1997). PMID: 9354056.
  2. S Shankar et al., “Hyperopia and emergent literacy of young children: Pilot study”, Optom Vis Sci, 84, 1031-1038 (2007). PMID: 18043422.
  3. SM Williams et al., “Refractive error, IQ and reading ability: A longitudinal study from age seven to 11”, Dev Med Child Neurol., 30, 735-742 (1988). PMID: 3234604.
  4. M Das et al., “Evidence that children with special needs all require visual assessment”, Arch Dis Child, 95, 888-892 (2010). PMID: 20647259.
  5. J Zaba, “Children’s vision care in the 21st century. Its impact on education, literacy, social issues, and the workplace. A call to action”, (2011). Available at: Accessed February 5, 2018.
  6. P Harris, “The prevalence of visual conditions in a population of juvenile delinquents”, (1989) .
  7. S de Fur, “IEP transition planning-from compliance to quality”, Exceptionality, 11, 115-128 (2003).
  8. R Gardner, “Comprehensive Eye Examination”, (2018). Available at: orc/3323.19. Accessed February 5, 2018.
  9. JJ Walline, ED Johnson Carder, “Vision problems of children with individualized education programs”, Journal of Behavioral Optometry, 23, 87-93, (2003).
  10. American Optometric Association, “Evidence-based Clinical Practice Guidelines. Comprehensive Pediatric Eye and Vision Examination,” (2017) Available at: Accessed March 1, 2018.
  11. Agency for Healthcare Research and Quality, “Comprehensive pediatric eye and vision examination”, (2017) Available at:
  12. G Ying G et al., “Prevalence of eye disorders by racial and ethnic group among children participating in Heart Start”, Ophthalmology, 121(3), 630-636, (2014). PMID: 24183422.
  13. NIH, “NEI. Facts About Amblyopia”, (2018). Available at: Accessed March 1, 2018.
About the Author
Andrew Morgenstern

Andrew S. Morgenstern is a Diplomate and the American Board of Optometry Chief Methodologist of the American Optometric Association (AOA) Evidence Based Clinical Practice Guideline Development Group.

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