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What the Schools Should Teach About Vision Care

But within the school's regular course of instruction, the following facts about vision care should be stressed and emphasized in all hygiene or health courses:

1. Children do not "outgrow" vision problems. A child with uncorrected or untreated vision problems is going to get worse, not better with the passage of time.

2. Difficulties in binocular coordination persisting to the age of six generally require longterm therapy. Prompt diagnosis and attention therefore are important to the solution of this serious learning problem as early in the child's school life as possible.

3. While mass-screening programs are vitally important in uncovering the existence of many unsuspected or neglected vision problems, not all such problems may be discovered in this fashion. Thus, each person should learn to recognize subtle signs of vision difficulties in himself or in children under his care or supervision.

4. Any departure from the normal which would indicate the possibility of trauma or inflammation should receive prompt professional care and treatment.

Vision care specialists are frequently amazed by the extent of vision difficulties of children who have given neither parents nor teachers any clear indication of the existence of the problem. The child may have been placed regularly in the front seats of the classroom and thus have had no occasion to complain of difficulty in seeing the blackboard. Furthermore, he never complained of difficulty in seeing at distance because he just didn't know that the fuzzy and indistinct outlines of objects he looked at were not the normal appearances of those objects to everyone else. And he may have unconsciously "covered up" poor visual adjustment to motion pictures or television programs by indicating he wasn't "interested in" or "just didn't like" movies or TV. At some point, however, the child will eventually become consciously aware that his schoolmates are seeing things he does not.

Such experience indicates that only a school-based program of adequate instruction in visual health coupled with effective vision screening can successfully prevent the unfortunate, widespread and completely unnecessary wastage of vision resources which deprives so many children of their full opportunity to live a creative life in freedom and dignity and which deprives our society and economy of the greater contribution such children could make to our over-all national goals.

AN EFFECTIVE SCREENING PROGRAM FOR VISION HEALTH

The "perfect" vision screening program in the schools would be one which, at small expense and by inconsequential demand for teacher and pupil time, would automatically and reliably single out every child needing any special vision aid, attention or training, while not causing a single "over-referral", that is, recommending a child for professional attention when he was not in need of it. The "perfect" vision screening program as several surveys of screening programs now in effect have indicated just does not exist, any more than does any "perfect" quick-screening, one hundred percent reliable, inexpensive, assembly-line mass screening program for say tuberculosis, or cancer, or other diseases or malfunctions.

This does not mean, however, that mass screening for tuberculosis, for instance, is useless because some suspects are not uncovered while occasional healthy persons are referred for further investigation. Yet some studies into vision screening programs have implied that little is to be gained by any mass examination which goes beyond the traditional Snellen test of visual acuity at 20 feet. [15]

"The misconception that the Snellen chart will do an effective job of screening out
children who need visual care is a major block in the road of those who are trying
to establish good school visual screening programs. The fact is that any school
which relies on the Snellen chart alone as a screening method will fail to detect
large numbers of children in urgent need of visual care." [31]

Regarding the subject of over-referrals and under-referrals, Blum, Peters, and Bettman

state:

"The most significant over-all cost in a vision-screening program will be the expense to the individual families, or to the community resources, for clinical examinations of the childre screened out as needing professional attention. If there is significant over-referral, the cost will be increased needlessly. In addition to wasting community resources, over-referrals may well destroy confidence in the program. If there is significant under-referral, many children needing professional attention will not be detected, although screening costs will be minimized. In terms of visual health and welfare, the hidden costs of under-referrals are inestimable." [9] Effective Screening Methods Can Be Devised

Regardless of the admittedly controversial pros and cons of the methods and procedures used in the various evaluation studies which have been conducted into vision screening, the fact is that better results can be achieved in vision screening if there is a willingness on the part of all professions and disciplines concerned in this matter to join together in a determined attack on the problem. The optometric profession is sincerely anxious to help foster such an inter-professional approach, similar to the type of approach it has fostered in the care of brain-injured children in cooperation with educators, pediatricians and/or ophthalmologists, as well as psychologists, social workers, nurses and other groups. Experience in these joint efforts has proved to our satisfaction that effective procedures can be worked out cooperatively, even though it may occasionally entail some compromise of professional prerogatives for the sake of the common good.

In any discussion of the problem of establishing a more effective vision screening program, the major consideration must be, as it always must be in any matter affecting the lives and futures of our children, how can we do the job which has to be done?

Any statement which implies that it cannot be done well enough such as, "Even the best vision screening program will not be 100 percent 'perfect' so why bother with anything more than the common Snellen test," ignores the responsibility upon all professions concerned with children to do the best job possible within the admitted limitations of vision screening techniques. Meanwhile we should bend all of our joint efforts constantly toward improving the results obtained.

Anything less than that is a confession of futility to which optometry refuses to subscribe. American Optometric Association Screening Policy

The Committee on Visual Problems of Children and Youth of the American Optometric Association realizes, and readily concedes, that the problem of developing better screening programs for the schools is a complicated one. Many factors make for this complexity. Some of the elements which must be considered are the variation in laws governing vision screening for school children in the various states, the number of school children to be screened, personnel available to do the screening, the instrumentation available, the cost of vision screening, the funds available to the school or community, facilities available for followup, and the level of professional services available in the various communities.

Vision screening should be a part of a larger vision conservation program which has as its aim prevention of visual difficulties which keep a child from achieving. It is therefore important that all of the various groups concerned with a child's welfare in school should be included in such a program: the teacher and parents (to observe symptoms of vision difficulty); parents (for parent education as to the importance of vision to a school child, and for facilitation of follow-up care); the vision and eye specialists in the community; the school nurse; and school administrative personnel. [6]

If a school vision screening program is to be practical in terms of cost, administrative ease, time and number of children referred, it is of utmost importance that the vision special

ists practicing in the community agree at the very beginning on the types of tests to be administered and on the criterion to be used in referring children for professional help. Too often, vision screening programs are caught between divergent professional approaches to eye and vision care as if there were only one acceptable method of uncovering children with vision difficulties, or as if one-eyed distance sight at 20 feet were the only criterion of seeing ability. As Dr. Martha Eliot, former Chief of the U. S. Children's Bureau, recently stated: "There is no more important subject to which we can address ourselves than the essential need for a multi-professional approach to the problems of children." Disagreements and discord among professional groups working in the field of eye care and vision care must be and certainly can be subordinated to the need for better methods of vision screening in the schools.

Limitations of Screening Must Be Understood

It is of utmost importance that all groups and individuals participating in the screening programs understand the limitations of the program. This is particularly important for parents, who must be made aware of the fact that passing a screening test or even of a battery of tests is no guarantee that a child does not have defective vision or malfunction serious enough to require treatment. Whenever a family uncritically should accept a report from school that the child has "perfect vision" at distance and fails as a result to watch for any signs of vision difficulty or fatigue in the child, the screening program has done the child a great disservice. Or, rather, the utilization and interpretation of the test has been abused.

GUIDEPOSTS TO BETTER VISION HEALTH

1. If we can discover more children, even if not all children, needing vision assistance through a practical school vision screening program, it is well worth the expense, time and effort of teacher, child, school administration staff, school nurse, volunteer PTA helpers. And, if the community had the foresight to engage them, the school optometrist and the school physician. Screening programs should always include tests of vision efficiency at the reading dis

tance.

2. Professionals in vision and the eye care field must "get together" and jointly work out constructive programs for vision conservation of school children which can be utilized in the schools throughout the school year. Architects, decorators, psychologists and pediatricians can augment this work by vision-conditioning and posture-conditioning the classroom environ

ment.

3. More avenues of communication must be opened up between all professional groups working with children and youth, for a wider sharing of research knowledge and of new techniques. This is as true for the groups working with so-called normal children as it has been proved to be true among the professions which have cooperated so splendidly in recent years in the care and advancement of brain-injured, partially-seeing and other "exceptional" children. Optometry is proud to have played a satisfying and significant role in this interprofessional teamwork approach which has resulted not only in optometry sharing its knowledge with other disciplines but in reciprocal benefits of invaluable assistance to optometry in serving the vision needs of millions of Americans.

THE IMPORTANCE OF VISION TO A

CREATIVE LIFE IN FREEDOM AND DIGNITY

PART III: Optometry's Specialized Role in Service to Children and Youth

Vision is a child's most precious sense. A child with good vision performance at near and far is usually a good student for he can spend his efforts and energy in mastering written concepts, rather than mastering the problem of seeing words. Optometry is dedicated to enhancing the child's operational vision.

As early as 1910, shortly after the first White House Conference on Children and Youth, it was recognized that vision care required a type of education which could not be assimilated in, or made adjunct to, any existing professional curriculum. It was obviously necessary to combine knowledge from many diverse sciences if the science of vision care was to emerge as a practical discipline. Consequently, leading universities began setting up specialized optometric courses for professional education in vision care, combining physics, optics and mathematics with psychology and such health subjects as anatomy, physiology and pathology. Today accredited courses require a minimum of 5 years (some require 6 years) of study at the college level.

Today, moreover, about 35 percent of all students entering optometry colleges have already completed four-year undergraduate courses of study with bachelor's degrees. If they have concentrated on science subjects in college, they can thereupon finish optometry requirements in three or four additional years, receiving customarily the degree of O.D. (doctor of optometry). Some schools grant degrees of bachelor of science in optometry and master of science in optometry, doctor of optometry and doctor of philosophy degrees in physiological optics. The accredited colleges and universities offering optometric courses include: Illinois College of Optometry; Indiana University; Los Angeles College of Optometry; The Massachusetts College of Optometry; The Ohio State University; Pacific University; The Pennsylvania State College of Optometry; Southern College of Optometry; University of California and the University of Houston.

The optometric curriculum, in addition to concentrating on subjects directly related to vision care, also devotes about one-fourth of the student's work to a broad study of the human body, with particular emphasis on eye diseases and symptoms of other diseases which can be detected in the eyes. Optometrists, of course, do not treat patients medically; however, the long study devoted to eye and other diseases enables the optometrist to refer for appropriate professional care patients whose eyes reveal evidences of possible disease.

Availibility of Vision Care

Every year more than 30,000,000 Americans obtain vision care. Millions more who need such care neglect to seek it. If all who needed vision care were to seek to make appointments with qualified practitioners, they could not all be served. At present, there are about 21,000 optometrists or one to every 8,000 persons, (the ratio of certified ophthalmologists to population is 1 to every 45,000 persons). To serve 10 years from now merely the same percentage of the population now receiving vision care, we would have to double the present number of optometrists.

The greater need for more professional optometrists is in the Southern States, where the existing ratio is as low as 1 to 15,000. (See Appendix Exhibit C for numbers and ratios of licensed optometrists and certified ophthalmologists by states.)

Nevertheless, there are today members of the optometric profession located in almost every rural community, and town, and in every city in the United States, and in nearly all instances these professional men and women devote a major share of their practices to the special vision problems of children and youth with particular emphasis on preventive care. Just as a conscientious dentist strives to save a child's permanent teeth and keep them strong for a lifetime, rather than later try to remedy the ravages of dental neglect, so the optometrist strives to prevent damage to the child's vision in preference to correcting it later in the child's life.

Functional Vision Care

In this connection, optometry has pioneered in functional vision and developmental vision, with emphasis on effective near point performance, and has developed such innovations as con tact lenses, visual training, and the use of bifocal lenses for children in improving classroom visual performance. Often bifocal lenses contain a prescription lens only in the lower segment and merely plain glass in the upper segment, for children needing no assistance in distance sight, but requiring appropriate lens prescription for nearpoint tasks. The bifocal technique has replaced the older practice of prescribing a single lens where the child needs help only in nearpoint sight but not at distance or greater help at near than at distance. This is but one illustration of optometry's development of the functional vision concept, to help the child perform better in all of his vision tasks.

The American Optometric Association, and the state associations affiliated with it, are constantly seeking new insight on means of strengthening the profession's services to the public and particularly to children and youth by disseminating new knowledge in this field. In addition, numerous post-graduate courses to keep practitioners up to date on new developments are being offered to the members of the profession through the Schools and Colleges of Optometry, through state and national associations, and by two ancilliary organizations, the American Academy of Optometry, and the Optometric Extension Program Foundation, both of which devote full time efforts to continuous research and to the further education of the practicing, licensed optometrist.

OPTOMETRY'S ORGANIZED SERVICES IN BEHALF OF THE CHILD

The continuing work of the American Optometric Association in relation to the welfare of children from birth through college is centered in the activities of the Committee on Visual Problems of Children and Youth, which is also charged with responsibility for organizing the American Optometric Association's participation each decade in the White House Conference on Children and Youth.

In the 10 years since the last White House Conference, the Committee on Visual Problems of Children and Youth has sponsored an annual multiprofessional forum on vision problems of children and youth in Cleveland. Each year since 1950 the attendance at these conferences has grown as educators, psychologists, optometrists and others have recognized in the annual forum an excellent opportunity for the exchange of information, techniques and methods for aiding and enhancing the developmental vision of children.

As the annual Cleveland conference of the American Optometric Association's Committee on Visual Problems of Children and Youth has become more and more successful, regional groups have found it worthwhile to establish similar meetings. Thus, in three successive years, such forums have been held for the Middle West in Chicago; two such annual events have occurred for the West Coast in Los Angeles, and this year the first Southern Forum is being sponsored by the Florida Optometric Association.

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