Open Journal of Ophthalmology, 2012, 2, 9-13
http://dx.doi.org/10.4236/ojoph.2012.22003 Published Online May 2012 (http://www.SciRP.org/journal/ojoph) 9
Vision Screening in the Pediatrician’s Office*
Natario L. Couser, Fatema Q. Esmail, Amy K. Hutchinson#
The Department of Ophthalmology, Emory University School of Medicine, Atlanta, USA.
Received January 13th, 2012; revised February 16th, 2012; accepted March 10th, 2012
ABSTRACT
Objective: To assess current practices, attitudes, and perceived barriers toward pediatric vision screening. Patients and
Methods: A link to a 9-question survey was electronically distributed to a national sample of 6000 pediatricians
through Medical Marketing Services Inc. Data were collected using Survey Monkey. Results: Email open rate was 11%;
37% of those who opened the email responded (225 respondents). Over ninety percent of respondents perform some
type of vision screening at least yearly, although age at which screening began varied, with two thirds of respondents
instituting formal v ision screen ing after three years. Fifty eight percent of respondents were either extremely u nsatisfied,
unsatisfied or only somewhat satisfied with their current screening method. Preferred methods of screening and confi-
dence of pediatricians in their ability to detect pathology varied for children under versus over age three. The least fre-
quently used methods for all age groups were autorefraction and photoscreening. The most commonly reported barriers
to screening were inadequate training (48%), time required for exam (42%), and inadequate reimbursement (32%).
Conclusions: Perceived barriers to vision screening in the pediatrician office have been previously identified, and pho-
toscreening and autorefraction h ave been identified as a possible means to circumvent them. In spite of the addition of
new procedural codes, pediatricians continue to report similar barriers to screening.
Keywords: Pediatric Vision Screening; Barriers; Reimbursement; Pediatricians; Photoscreening; Autorefraction; US
Preventative Services Task Force; CPT 99174
1. Introduction
Early detection of ocular disorders can prevent lifelong
visual impairment. The US Preventative Services Task
Force (USPSTF) has concluded that vision screening for
children ages 3 to 5 is beneficial, and recommends vision
screening at least once between the ages of 3 and 5 years
to detect the presence of amblyopia or its risk factors [1].
The USPSTF has also concluded that “the current evi-
dence is insufficien t to assess the balance of benefits and
harms of vision screening for children <3 years of age”;
[1] however, the evidence base for vision screening in
children under 3 is limited by a paucity of studies evalu-
ating the screening techniqu es that are feasible in this ag e
group of children, such as red reflex testing, and objec-
tive vision screening such as photoscreening and autore-
fraction [2].
In 2006, Kemper and Clark surveyed a national sample
of pediatricians to evaluate their preschool vision scr een-
ing practices, and reported that common barriers to
screening included perceptions that screening was con-
sidered too time consuming, children were uncooperative,
and that reimbursement was not adequate [3]. The au-
thors suggested that financial incentives and emerging
screening technologies might be important to ensure the
delivery of preschool vision screening. In January 2008 a
current procedural terminology (CPT) code 99174 was
established, and in November 2008 a relative value unit
(RVU) of 0.69 was assigned for objective screening us-
ing a photoscreener. We designed our survey to revisit
the practices and perceptions of vision screening among
pediatricians, and to determine whether these practices
and perceptions differed for patients below and above
age 3.
2. Patients and Methods
This study was approved by the Institutional Review
Board at Emory University. We designed a 9-question
survey with an additional section for general comments
to assess pediatricians’ current practices, attitudes, and
perceived barriers toward pediatric vision screening. A
link to the survey was electronically distributed to a na-
tional sample of 6000 pediatricians through Medical
Marketing Services Inc. (MMS) with a broadcast subject
line reading: “Help Us Improve Pediatric Vision Screen-
*Conflict of interest and disclosure statement: None of the authors have
a conflict of interest or a financial interest in any of the methods or
p
roducts described in this manuscript.
#Corresponding author.

Vision Screening in the Pediatrician’s Office 10
ing Methods.” Detailed practice characteristics of the
pediatricians receiving the email were not known; how-
ever MMS collects demographic information about their
participating physicians, and we designated surveys be
sent only to office based physicians whose primary spe-
cialty was pediatrics. Data were collected using Survey
Monkey (www.surveymonkey.com). Descriptive statis-
tics were used to summarize the data.
3. Results
Delivery information provided by the marketing service
confirmed that 98% of the emails were received. There
was an 11% open rate, and of the recipients who opened
the email, 37% responded to the survey, for a total of 225
respondents. Not all respondents answered every ques-
tion.
Although 15% of respondents indicated that they be-
gan vision screening at birth by testing the red reflex in
infancy, the majority of respondents (67%) indicated that
they did not begin formal visual acuity testing until age 3
or over (Question 1, Table 1). Most respondents indi-
cated that they screened their patients at every well child
visit, but 9% of respondents reported that they screened
their patients less than once a year, and 1% reported that
they did not screen vision at all (Question 2, Table 2).
Table 1. At what age do you begin screening your pediatric
patients’ vision?
Answer Options Response Percent Response Count
Birth 15% 32
2 weeks 1% 2
1 month 0% 1
2 months 1% 3
6 months 3% 7
9 months 1% 2
1 year 1% 2
2 years 2% 4
3 years 34% 71
4 years 26% 54
5 years 7% 15
Misc* 8% 17
Answered question 210
Skipped question 15
*misc respo ns es include d “infant”, respondent giving a range of answers, “ at
first visit”, “birth, but formally at age…”.
of respondents were either extremely unsatisfied, unsat-
isfied or only somewhat satisfied with their current
screening method (Question 3, Table 3), and although a
majority of respondents felt at least so mewhat adequately
trained to perform vision screening, only one third felt
well trained (Question 4, Table 4). Fifty six percent of
respondents felt confident or extremely confident in their
ability to detect a vision problem in children over age 3
compared to only 19% feeling an equal level of confi-
dence in detecting vision problems in children under age
3 (Questions 5 and 6, Figure 1). A variety of testing
methods were employed in children in both age groups
(Questions 7 and 8, Table 5), with photoscreening and
autorefraction being the least frequently employed
methods in both age groups. Finally, the most frequently
reported barriers to performing vision screening were
Inadequate training (48%), inadequate reimbursement
(32%) and time constraints (42%) (Question 9, Table 6 ).
Although a majority of respondents felt at least some-
what satisfied with their current screening methods, 58%
Table 2. How frequently do y ou perform some type of vision
screening on your pediatric patients? (Please choose one
answer that best describes your practice) .
Answer Options Response Percent Response Count
At every visit 6.7% 15
At every scheduled
well child check 68.2% 152
At least yearly 15.7% 35
Less than once a year8.5% 19
Never 0.9% 2
Don’t know 0.0% 0
Answered question 223
Skipped question 2
Table 3. How satisfied are you with your current method of
screening vision in children?
Answer options Response percent Response cou n t
Extremely s a t i s f i e d 3.6% 8
Satisfied 38.5% 85
Somewhat satisfied 44.8% 99
Unsatisfied 10.9% 24
Extremel y u nsatisfied2.3% 5
Answered question 221
Skipped question 4

Vision Screening in the Pediatrician’s Office 11
Table 4. How adequately do you feel you are trained to
perform vision screening on your pediatric patients?
Answer options Response percent Response count
Extremely w el l t rained 3.6% 8
Well trained 29.1% 65
Somewhat trained 52.5% 117
Poorly trained 13.0% 29
Very poorly tra ined 1.8% 4
Answered question 223
Skipped question 2
(a)
(b)
Figure 1. How confident are you in your ability to detect an
eye or vision problem in a child?
4. Discussion
Our survey suggests that pediatricians are still facing
substantial barriers to vision screening including poor
reimbursement for vision screening, lack of available
methods to allow individuals with limited training to
perform vision screening efficiently, and discomfort with
screening young children under age 3 in part due to lim-
ited access to automated devices available for screening
of very young children due to poor reimbursement for
these methods.
Vision screening is a cost effective way to detect am-
blyopia and amblyopia risk factors, has been endorsed by
the USPSTF in children age 3 to 5, and has been recom-
mended for children of all ages by the American Acad-
emy of Pediatrics (AAP), the American Academy of
Ophthalmology (AAO), the American Association of
Pediatric Ophthalmology and Strabismus (AAPOS), and
the American Association of Certified Orthoptists
(AACO) [4]. Amblyopia affects 2% - 4% of the popula-
tion, and treatment has been shown to be highly success-
ful and cost effective [5,6]. In addition, studies have
suggested that anisometropic amblyopia often begins
before age 3 and that children who have their amblyo-
genic refractive errors corrected earlier have a higher
likelihood of achieving 20/20 visual acuity and a lower
rate of developing amblyopia or strabismus than children
who are treated later [7-9]. Hence the recent finding by
the USPSTF of “insufficient evidence” to recommend
vision screening for children under age 3 is of concern,
and is an indication of the need for better utilization of
photorefraction and autorefraction, which are becoming
preferred methods for screening young children, so that
data can be collected to provide a sufficient evidence
base to determine conclusively whether vision screening
should be recommended by the USPSTF in these young
children [2,1 0 -15].
Our study has significant limitations, most notably that
our low response rate could bias our results such that
only the only pediatricians who responded to our survey
were those who are dissatisfied with vision screening and
were moved by our broadcast subj ect line reading: “Help
Us Improve Pediatric Vision Screening Methods,” po ten-
tially overemphasizing the concerns of pediatrician re-
garding the cost and feasibility of vision screening in
children. However, we think such a scenario is unlikely,
given the percentage of respondents who indicated that
they were satisfied with their current methods.
5. Conclusion
Our survey suggests that perceived barriers to pediatric
vision screening have not changed substantially since
2006, in spite of the fact that in January 2008 a current
procedural terminology (CPT) code 99174 was estab-
lished, and in November 2008 a relative value unit (RVU)
of 0.69 was assigned for objective screening using a
photo technique. Efforts should be devoted to improving
efficiency and reimbursement for vision screening.

Vision Screening in the Pediatrician’s Office 12
Table 5. What method(s) do you currently employ to screen vision in your patients (check all that apply).
Under age 3 Over age 3
Answer options Response percent Response count Response percent Response count
Visual inspection of the external eye 97.7% 217 96.0% 214
Red reflex testing 96.8% 215 73.1% 163
Observe child’s ability to fix and follow a target 91.4% 203 85.2% 190
Cover/uncover testing 71.2% 158 70.9% 158
Ophthalmoscopy 45.9% 102 57.8% 129
Visual acuity testing with pictures or symbols 23.0% 51 87.0% 194
Visual acuity testing with letters 10.4% 23 79.4% 177
Autorefraction 3.2% 7 5.4% 12
Photoscreening 4.5% 10 4.5% 10
Answered question 222
Skipped question 3
Table 6. What are the obstacles you face in performing vi-
sion screening in children? (check all that apply).
Answer options Response p e r cent Res p o n se c o u n t
Not adequately trai ned 53.7% 109
Not adequately reimbursed 34.5% 70
Too time consum ing 46.8% 95
Too difficult 23.6% 48
I don’t face any obstacles 18.2% 37
Other (please specify) 46
Answered question 203
Skipped question 22
6. Acknowledgements
Supported in part by an unrestricted grant to the Emory
Eye Center from Research to Prevent Blindness, Inc.,
New York.
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