Check for Visual Impairment (Amblyopia)-Child

Summary of Recommendations and Evidence

Population	Recommendation	Grade (What's This?)
Children, Age 3-5 Years	The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.	B
Children, <3 Years of Age	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age.	I

Population

Recommendation

Children, Age 3-5 Years

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.

B

Children, <3 Years of Age

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age.

I

Go to the Clinical Considerations section for additional information about suggestions for practice regarding the I statement.

Importance

Approximately 2% to 4% of preschool-aged children have amblyopia, an alteration in the visual neural pathway in the developing brain that can lead to permanent vision loss in the affected eye. Amblyopia usually occurs unilaterally but can occur bilaterally. Identification of vision impairment before school entry could help identify children who may benefit from early interventions to correct or to improve vision.

Detection

The USPSTF found adequate evidence that vision screening tools have reasonable accuracy in detecting visual impairment, including refractive errors, strabismus, and amblyopia.

Benefits of Detection and Early Intervention

The USPSTF found adequate evidence that early treatment for amblyopia, including the use of cycloplegic agents, patching, and eyeglasses, for children 3 to 5 years of age leads to improved visual outcomes. The USPSTF found inadequate evidence that early treatment of amblyopia for children <3 years of age leads to improved visual outcomes.

Harms of Detection and Early Intervention

The USPSTF found limited evidence regarding harms of screening, including psychosocial effects, for children ≥3 years of age. False-positive screening results may lead to the overprescribing of corrective lenses. Adequate evidence suggests that the harms of treatment of amblyopia for children ≥3 years of age are limited to reversible loss of visual acuity resulting from patching of the nonaffected eye. The USPSTF found inadequate evidence of the harms of screening and treatment for children <3 years of age.

USPSTF Assessment

The USPSTF concludes with moderate certainty that vision screening for children 3 to 5 years of age has a moderate net benefit. The USPSTF concludes that the benefits of vision screening for children <3 years of age are uncertain and that the balance of benefits and harms cannot be determined for this age group.

Patient Population Under Consideration

This recommendation applies to all children 1 to 5 years of age.

Screening Tests

Various screening tests that are feasible in primary care are used to identify visual impairment among children. These tests include visual acuity tests, stereoacuity tests, the cover-uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors).

Treatment

Primary treatment for amblyopia includes the use of corrective lenses, patching, or atropine treatment of the nonaffected eye. Treatment may consist of a combination of interventions.

Suggestions for Practice Regarding I Statement

In deciding whether to refer children <3 years of age for screening, clinicians should consider the following.

Potential Preventable Burden

Most studies show that screening and treatment later in the preschool years seem to be as effective at preventing amblyopia as screening and treatment earlier in life.

Costs

Potential disadvantages of using photoscreeners and autorefractors are the initial high costs associated with the instruments and the need for external interpretation of screening results with some photoscreeners.

Current Practice

Typical components of vision screening include assessments of visual acuity, strabismus, and stereoacuity. Younger children often are unable to cooperate with some of the screening tests performed in clinical practice, such as visual acuity testing. Steroacuity testing often is omitted and may be performed incorrectly when attempted. Screening of younger children may be difficult and often yields false-positive results because of the child's inability to cooperate with testing. Children with positive findings should be referred for a full ophthalmologic examination, to confirm the presence of vision problems, and further treatment.

Screening Intervals

The USPSTF did not find adequate evidence to determine the optimal screening interval.