Children’s vision screening now law

Local nonprofit screens many Bend-La Pine kids

By Tara Bannow / The Bulletin / @tarabannow

After instructing the 9-year-old boy sitting in front of her to place his hand over one eye, Gretchen White told him to read the tiny row of letters at the bottom of the card in her hand, which she held about a foot away from his face.

Dakota Vanvliet, a fourth-grader at Pine Ridge Elementary School in Bend, read the letters with ease. White’s face broke into a wide smile.

“Nice job!” she said, “This is easy for you, huh?”

White is a 13-year-running volunteer with the Children’s Vision Foundation, a Bend-based nonprofit that’s among several in the state providing free vision screenings to kids in schools. A bill passed by the Oregon Legislature this year is about to make volunteers like White, of Bend, a whole lot busier. House Bill 3000 requires that all public school students in Oregon ages 7 and younger receive vision screenings or eye examinations. Big questions remain, though, including who will pay for the screenings and who will perform them.

“I think it’s wonderful it got passed; I’m just looking at the devil in the details right now,” said Daniel Karr, director of the pediatric ophthalmology fellowship program at Oregon Health & Science University’s Casey Eye Institute. “How do we make it happen, now that we have the opportunity to do it?”

The Children’s Vision Foundation — which does most of its screenings on second- and fourth-graders in the Bend-La Pine School District — tests beyond kids’ ability to see far away or close up. They’re also looking for vision abnormalities like the inability to read across a row of text or of the eyes to work together to provide a complete image of what’s in front of them.

A couple tables away from White at the CVF screening last week, a young boy being screened by CVF Program Assistant Emily Terrell wasn’t doing so well. After he left her table, Terrell said she’ll send his parents a referral similar to the one she sent home last year, when he failed the tests the first time.

“It’s unfortunate that he got to this point,” she said.

Vision screening advocates agree there’s a correlation between kids’ success and their vision, and that catching eye abnormalities early on provides a greater chance they’ll be reversible.

Common problem

Between 25 and 50 percent of children in schools have some type of vision problem, Karr said. The majority can be corrected with glasses and will be picked up by a teacher who notices a child squinting. Another 5 percent are more serious conditions that could result in lifelong vision loss if not caught, he said.

A report released this month by the Oregon Department of Education outlines the work that lies ahead when it comes to implementing the bill within the state’s 796 elementary schools. The department, which recommends the screenings cover kids in kindergarten, first, third and fifth grades, estimates the program will cost about $1.7 million to implement, or an average of $10.58 per child that gets screened. The bill doesn’t carve out any funding for screenings, which the DOE says will need to come from either a state grant appropriated by the Legislature or a grant within the State School Fund.

Karr said that despite the overwhelming bipartisan support the bill received in the House and Senate, no one is that enthusiastic when it comes to devoting money to the cause. He said he’s hopeful the Legislature will appropriate the necessary funding, which he said is a cost-effective investment given that an estimated $3 billion in U.S. gross domestic product is lost each year due to low productivity that stems from vision loss.

“It’s a huge monetary item, and much of this could have been prevented,” Karr said.

The DOE report says the best way to carry out the screenings will be through public-private partnerships between school districts and the various nonprofit organizations that provide screenings.

The problem with that, however, is that each organization has its own method of carrying out the screenings, and the new law does not denote a specific method of screening, nor does it specify which eye disorders must be tested for.

CVF, for example, takes the kids through seven tests that measure visual acuity (whether they’re near-sighted, far-sighted or have an astigmatism), convergence (double vision when looking up-close), fusion (whether the eyes can work together to acquire information) and tracking (how well the eyes move across words on a page and take in information correctly).

The tests use many of the same charts found in most optometrists’ offices: the tiny booklet with hidden 3D images that’s read using thick-rimmed black glasses and the chart with a triangle stack of letters that get increasingly smaller toward the bottom. Others are not so familiar, like the contraption used to measure fusion that requires the subject to gaze through eye holes and count the dots on a card or the tracking test, in which they read a row of numbers across a page.

CVF, whose volunteers have screened more than 30,000 children since it formed in 2001, also uses the standard Snellen eye chart test to measure distance acuity, which is all that’s used in most schools when screenings are performed by school nurses. The Snellen chart was developed during the Civil War to ensure soldiers could aim properly before shooting.

But the Elks Children’s Eye Clinic, which operates out of OHSU’s Casey Eye Clinic, performs vision screenings very differently. It uses a machine called the plusoptiX S12, which takes less than a second to screen each child and provides an immediate PDF report that tells the examiner whether to refer the child to an eye doctor. The S12 works by taking a photo of the child’s eyes and analyzing things like the way the light hits the eye and the distance between the pupils, said Joannah Vaughan, director of preschool vision screenings for the Elks Children’s Eye Clinic.

Vaughan said she’s mainly looking for a disorder called amblyopia, which occurs when the brain doesn’t process images from one of the eyes, often because it’s weaker. Amblyopia, the risk factors for which show up in 15 percent of children, can be reversed if caught early enough. It’s corrected with glasses or by putting a patch over the strong eye to force the brain to use the weak eye, she said. The treatments tend to have the most success if they happen before age 7. If left untreated, though, the child may lose vision in the weaker eye, Vaughan said.

Consistent screening

Ideally, Vaughan said, the groups providing screenings will come together and develop a consistent screening protocol. And, in the end, she said she thinks the photo screening should be used in all vision screenings. Although the S12 costs about $5,000, she said it’s worth it because it picks up on more abnormalities than other tests. Vaughan performed a study to test the S12 against other screening methods. The research involved 283 eye exams that contained 19 total cases of amblyopia. She found that the standard distance chart caught six of the cases, the test that uses the thick-rimmed glasses and 3D images caught four and the S12 caught 16.

“It’s just really difficult to say that the chart method is an objective screening,” she said. “It’s missing a lot of kids, and it’s giving people a false sense that they’ve had a screening.”

The bill also doesn’t include rules on how the results of the screenings should be reported to the children’s parents and schools.

CVF provides a copy of the child’s results to both his or her school and parents, and sometimes inquires with school officials if they see children with untreated issues year after year, said Julie Bibler, CVF’s executive director.

The Elks, which hosts a statewide vision screening program that screens 5,000 3- to 5-year-olds each year in Head Start classrooms, also sends letters to parents whose children are referred to eye doctors. The letters detail the abnormalities they found, why they’re important to treat and includes a list of eye doctors who accept Oregon Health Plan recipients, as many Head Start families rely on OHP, Vaughan said. They also follow up with phone calls, she said.

Oftentimes, kids who don’t get vision screenings don’t realize they’re seeing the world differently from everyone else, Bibler said.

“I’ve had them tell me, ‘You know, I’ve always thought I was stupid. All my fellow students, everybody else got it, and I didn’t,’” she said. “That breaks your heart, especially if they’re in fifth grade and they say that.”

Vision problems often lead to behavioral issues or problems in school, as about 80 percent of classroom learning is dependent on one’s vision, Bibler said. Because of that, a large proportion of juvenile delinquents and prison inmates have vision problems, she said.

Sometimes, the vision screenings turn on a lightbulb in parents’ heads who may have been attributing their child’s unruly behavior to something like attention-deficit hyperactivity disorder, Terrell said.

“We hear so many stories from parents or teachers that we referred the child for their vision difficulty and after getting glasses, their classroom behavior changes, their etiquette changes, their reading,” she said. “It might just be as simple as, ‘They need glasses.’”

— Reporter: 541-383-0304, tbannow@bendbulletin.com