Pulling the Wool Over Your Eyes

Ben Goldacre, M.D. does a wonderful job in this video of exposing the misnomer of “Evidence Based Medicine”.  As you watch it you’ll note he gets at the very essence of how often we fall prey to biased information.  Recommendations are made by doctors to their patients with surprising frequency based on incomplete or unknowingly fraudulent information.

A corollary to this problem, if not its flip side, is when opportunities are lost to provide a better quality service to patients because of the mistaken belief that other services are adequate.  This is evident in the public health travesty that persists in this country when vision screenings are paraded as adequate alternatives to comprehensive eye examinations for children.  I want to expose this opportunity cost.

The idea of a mandated comprehensive eye examination for children either prior to school entry or at some point during their school careers should seem like a mom and apple pie piece of bipartisan legislation.  This was indeed the case in New Jersey when a bill was introduced a bill to establish a Pilot Project to study the impact of proposed mandatory eye examinations on the need for special education services.

Attesting to the strong legislative support for this bill, it sailed through the Assembly and Senate processes, and passed both houses in a unanimous vote of 79-0-0 on June 21, 2007.  The bill was featured as front-page news in the September 3, 2007 edition of the AOA News, and spread awareness of a 2006 report from the Commission on Business Efficiency of the Public Schools.  The Commission found that if students were provided with appropriate early intervention reading assistance and follow-up, including early intervention for those children with undiagnosed or untreated vision problems, the state would eventually save $200 million per year in special education costs and the rescued lives of thousands of children each year.

The bill itself contained some very powerful information:
The Legislature finds and declares that: approximately one-half of all New Jersey students with a special education classification are classified as Specific Learning Disabled (SLD); the rate of growth in SLD classified students in recent years has been 9%, while total school enrollment has grown at only 2%; nationwide, approximately 80% of SLD students have primary difficulties with reading, and as many as 70% of those students might not have been classified if they had received appropriate early intervention; undiagnosed and untreated vision-related learning problems are significant contributors to early reading difficulties and often lead to special education classification; under current State Board of Education regulations, only one vision assessment is required by the end of grade three and that screening tests only for vision acuity; the number of children classified as requiring special education continues to increase, and once classified few students return to full-time general education; it is therefore imperative that the State takes steps to study the impact of comprehensive eye examinations for students in the primary grades to assess their impact on eliminating the special education classification of students for treatable vision-related difficulties.

With this background, representatives from the New Jersey Society of Optometric Physicians (NJSOP) met with representatives of the New Jersey Academy of Ophthalmology (NJAO) to draft a report form on the results of the comprehensive eye examination that would be used in the Pilot Project.  This would serve as the basis for data analysis once the Department of Education identified the three participating districts under the guidelines of the legislation.

Given the imperatives of the Commission on Business Efficiency report, and the potential impact of the Pilot Project mandated by this legislation, one would think that school districts would line up to volunteer for participation.  This was not the case, and five years after the legislation passed New Jersey has yet to implement   the Pilot Project.  Why not?

There is evidence that organized ophthalmology campaigns to deter the passage or implementation of comprehensive eye examination bills spearheaded by organized optometry.  The American Academy of Ophthalmology, along with the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Pediatrics and the American Academy of Family Physicians, promotes screenings as an adequate mechanism to detect vision problems in children in lieu of mandatory eye examinations.  Educators in New Jersey, overburdened by compliance with statutory mandates, would be understandably pleased not to allocate resources toward documenting comprehensive eye examinations if current screening mechanisms suffice.  But they do not.  This is evident in the Preferred Practice Pattern Guidelines of the American Academy of Ophthalmology, acknowledging that only 50% of children identified by abnormal vision screening receive professional eye and vision care, and that additional research is required to identify and address barriers to follow-up after a failed screening.

The state of Kentucky has passed and implemented a mandatory children’s eye examination bill.  On its website, the Kentucky Academy of Eye Physicians and Surgeons acknowledges that many eye conditions that can impact a child’s ability to see and learn can be missed during screening.  Isn’t it about time that organized medicine adopts this forward thinking in other states?


5 thoughts on “Pulling the Wool Over Your Eyes

  1. Dr. Press,

    Mandatory comprehensive vision assessment is the most important issue facing eye care professionals today. This is not simply a matter of best practice, but is truly the balance between social equality and the maintenance of suppression of people and populations.

    If you go by the New Oxford American Dictionary:

    Democracy: the practice or principles of social equality: demands for greater democracy.
    Oppression: keep (someone) in subservience and hardship, esp. by the unjust exercise of authority; cause (someone) to feel distressed, anxious, or uncomfortable.
    Apartheid: segregation on grounds other than race.
    Fascism: extreme right-wing, authoritarian, or intolerant views or practice.

    In light of the evidence and experience (described in greater detail in a paper I co-authored with a colleague who holds a PhD in Ed Psych and slated to be published this Winter), it is clear that children who struggle with Visual Impediments to Learning (VIL) are much less likely to succeed socially, academically, professionally, and much more likely to participate in criminality and to end up in prison, or on social assistance. My own research shows, for example, that the prevalence of VIL among the aboriginal population declines with advancement through Grades 1 through 12. Anyone who is familiar with the principles involved will quickly acknowledge that VIL do not ‘disappear’, but rather cause children to leave school.

    Ignoring vision is no less than economic apartheid, leading to the subjugation and marginalization of some populations especially. The lack of initiative in this area is nothing less than another implicit form of Jim Crow. Disallowing children to participate fully in democracy by the vehicle of education is an unconscionable abuse of basic human rights, and an fully incompatible with fiscal conservatism.

    Thanks for the article.


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