536 - Seeing Isn’t Believing: Rethinking Vision Screening Tools for Children Under 3

Publication Number: 4524.536

E. Eugenie Hartmann, Akron Children's Hospital, Akron, OH, United States; Megan Woodward, Akron Children's Hospital, Alliance, OH, United States; Sila Dogan Tosun, Advocate Children's Hospital, Akron, OH, United States; Ian Boydstun, Northwest Eye Surgeons, Seattle, WA, United States; Carter Carlos, Akron Children's Hospital, Akron, OH, United States

Background: Vision screening during pediatric Well Child Checks (WCCs) is essential for identifying children at risk for visual impairment during infancy and early childhood, when treatment is most effective. In recognition of this, the American Academy of Pediatrics (AAP), in collaboration with ophthalmology organizations, has endorsed instrument-based vision screening (photoscreening) as an acceptable substitute for traditional functional vision assessments beginning at age 3. They also state that if a device is available photoscreening may be performed in children 6 months to 3 years of age.

Objective: Beginning in 2021, instrument-based vision screening was adopted as standard of care for 3- to 5-year WCCs at pediatric offices affiliated with our hospital system. In practice, clinicians have extended the use of photoscreening to younger ages, requesting screenings during earlier WCCs. This presentation aims to evaluate the outcomes of these screenings, including age at screening, screening results, follow-up rates, and findings from comprehensive eye examinations (CEEs).

Design/Methods: We identified 1,365 patients from SPOT™ Vision Screening reports who underwent screening prior to 34 months of age. Age distribution is detailed in Figure 1. Notably, over half (55%) of these screenings were conducted around the 24-month WCC, rather than waiting until the recommended 36-month visit, indicating a trend toward earlier implementation of instrument-based screening in clinical practice.

Results: Of 1,365 children screened before 34 months of age, 153 (11%) were referred for a CEE. Of those, 82 (54%) completed follow-up within our system; 36 (44%) received corrective lenses, while 46 (56%) did not.
Overall, 159 children received a CEE, including 77 (6%) who were not referred but still underwent evaluation. Among these, only 7 (9%) received corrective lenses, indicating most had age-appropriate refractive findings. Some of these evaluations may have addressed other ocular concerns, such as strabismus.

Conclusion(s): Our findings reveal a trend toward early and potentially over-referral following instrument-based vision screening in children under 3 years. Fewer than half of those who were flagged for referral and completed follow-up received corrective lenses. Additionally, 6% of children not flagged still underwent CEEs, with only 9% receiving refractive correction.
These results underscore the need for age-specific screening guidelines and provider support in applying standardized referral protocols, to reduce unnecessary referrals while ensuring timely identification of true ocular pathology.

Completion of Instrument-Based Vision Screenings by Well Child Check Age
Figure 1. Number of patients screened using instrument at Well Child Checks before 36 months

Performance of SPOT™ Vision Screening for Detecting Clinically Significant Refractive Error
Confusion matrix summarizing SPOT™ screening accuracy for predicting the need for refractive correction in children screened before 34 months. Sensitivity was 70%, specificity 80%, with an overall accuracy of 76.7%. Positive predictive value (PPV) was 59.7%, and negative predictive value (NPV) was 86.0%, indicating that while the device effectively rules out refractive error, a substantial proportion of referrals do not result in corrective lens prescriptions.