s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7

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journal homepage: www.elsevier.com/locate/survophthal

Public health and the eye

Referral to community care from school-based eye

care programs in the United States

Ahmed F. Shakarchi, MBChB, MPHa, Megan E. Collins, MD, MPHa,b,c,*

a
Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
b
Dana Center for Preventive Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland,
USA
c
Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA

article info abstract

Article history: Approximately 25% of school-aged children in the United States have vision abnormalities,
Received 16 September 2018 most commonly refractive error that can be corrected with spectacles. Limited follow-up
Received in revised form 26 March adherence after failed school-based vision screening led to an increase in school-based
2019 eye care programs that provide screening, eye examinations, and spectacle prescription
Available online 9 April 2019 at the school. These programs address the access barrier and often provide the first point of
Donald Fong and Johanna Seddon, contact between children and eye care. Nevertheless, several lower prevalence conditions,
Editors such as amblyopia, strabismus, and glaucoma, cannot be adequately treated in the school
setting, and some require frequent and long-term follow-up, necessitating referral to eye
Keywords: care providers in the community. We conducted a literature review and identified 10
school-based health programs that provided school-based screening, examinations, and spectacle prescription
child and adolescent health and reviewed their referral rates, criteria, mechanisms, adherence, ocular findings at
vision screening referral, and long-term care plans. Most programs referred 1% to 5% of screened children.
school-based eye care Most communicated with parents or guardians through referral letters and used various
mobile vision clinics strategies to incentivize adherence. Referral adherence was 20-50% in the four programs
that reported these data. School-based eye care programs rarely referred children for long-
term follow-up care needs, such as updating spectacle prescriptions annually.
ª 2019 Elsevier Inc. All rights reserved.

1. Introduction problems are often asymptomatic, especially in children

In the United States, nearly a quarter of children younger than
18 years have vision abnormalities, most commonly refractive
error that can be corrected with spectacles.15,43 Many of these
children are undiagnosed. Part of the challenge is that vision
younger than 13 years.19,48 This high prevalence of vision
problems is alarming, considering that much learning in
schools is visually acquired. Furthermore, uncorrected visual
impairment in childhood is associated with reduced academic
performance and psychological stress.13 In addition, although

Financial disclosures: none.

* Corresponding author: Megan E. Collins, MD, MPH Assistant Professor of Ophthalmology, The Wilmer Eye Institute Johns Hopkins
School of Medicine, 600 North Wolfe Street, Wilmer 222 Baltimore MD 21287-9028.
E-mail address: mcolli36@jhmi.edu (M.E. Collins).
0039-6257/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.survophthal.2019.04.003
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7
vision problems may lead to permanent visual impairment in
younger children through amblyopia, spectacles correct more
than 80% of cases.41
We shall first provide an overview of school-based delivery
of vision screening and eye care. We shall then review the
published literature on school-based programs that provide
vision screening, examinations, and spectacle prescription at
school, with a focus on understanding their mechanisms for
referring children to care in the community.
2. School-based vision screening and eye
care programs
2.1. Recommendation of vision screening
Given that uncorrected vision problems can lead to serious
and irreversible consequences, may be asymptomatic, and
options exist for treatment, amblyopia meets the World
Health Organization guidelines for a condition that benefits
from screening.46,B Furthermore, earlier diagnosis of amblyo-
genic risk factors reduces the incidence of amblyopia in later
childhood.7,24 Thus, prompt identification, diagnosis, and
treatment of vision conditions in developing children are
critical. Vision screenings are important in the goal of long-
term reduction of vision loss in childhood. This is especially
important in younger children, who have a higher risk of
amblyopia and will benefit the most from early intervention.
The United States Preventive Services Task Force recom-
mends vision screening for children aged 3e5 years.18 Other
national4,46 and international27,42 health authorities echo
these recommendations.
Besides detecting amblyopia in younger children, correct-
ing refractive errors detected through screening in older
children is also important. Moreover, prospective randomized
evidence shows that amblyopia interventions can still be
beneficial through the age of 17 years, supporting periodic
vision screening.35 In a joint position statement, the American
Association of Pediatric Ophthalmology and Strabismus,
American Academy of Ophthalmology, and the American
Academy of Pediatrics recommend vision screening for
school-aged children every 1-2 years, either at the pediatri-
cian’s office or at school.10
2.2. Access to vision screening
There are data to suggest that not all children are accessing
recommended vision screenings. According to the Centers for
Disease Control and Prevention, less than 22% of preschool
children receive some type of vision screening.C Primary care
providers, including pediatricians, play an important role in
screening children’s vision45; however, less than 20% of
school-aged children had a vision screening according to one
analysis of Medicaid claims.32 In addition, vision screenings
are required as part of the Early and Periodic Screening,
Diagnostic, and Treatment program in Medicaid, but only
40% of children on Medicaid received the recommended
screening according to data from 9 states.D,E Household
income, parental education, insurance coverage, special
health care needs, race, ethnicity, and primary household
859
language are all factors influencing whether children receive
vision screening or eye examination.28,D This is even more
concerning given low-income children fail screening more
frequently.14,23
These statistics give us a glimpse into the disparities
in vision screening access; however, we lack comprehensive
national data on how many children are getting screened and
who is failing. Our lack of data extends to eye care access after
failed screenings as there is limited information about who
follows up and the outcome of their eye examinations.
This paucity of data was the rationale for a recent
Prevent Blindness report recommending the creation of a
system to collect population-level screening data and track
whether children access recommended eye care in their
community.F,22
2.3. School-based vision screening
Federal, state, and local governments institute requirements
to screen children in school.11 Forty states require vision
screening of school children; these vary markedly in the
grades screened and the components of a screening asses-
sment.F Technicians or school nurses perform vision
screening in most programs, while optometry students,2
public health nurses,6 or trained volunteers37 administer the
screening in others.
School-based screening can capture children who have not
received preschool screening, as well as children who develop
refractive or other ocular pathologies after having passed a
screening when younger. Continued vision screening is
crucial considering the rising incidence of myopia during
school years.16,33,47
2.4. The traditional approach to failed school-based
vision screening
Results of school-based vision screenings are traditionally
provided to parents or guardians in a letter. For children who
fail a vision screening, parents or guardians are instructed to
follow up with a community eye care provider. This approach
has limitations, especially in high-poverty communities, and
in most programs, only 30-60% of children failing screening
sought evaluation with an eye care professional.9,25,30,31 One
study found it took an average of two years between failing
screening and eye care provider assessment.48 Reported rea-
sons for failing to follow up include financial, logistic, social,
and perceptual barriers.25 Hereafter, we refer to these pro-
grams using the traditional approach to failed screening as
school-based vision screening programs.
2.5. An alternative approach to failed school-based
vision screening
Because many students who fail vision screening are not
accessing care in the community, alternative approaches to
connect students to care have been used. One approach is to
offer eye care in the school setting. This is part of a larger
movement toward school-based health care, especially in
high-poverty communities.5 The delivery paradigm may
differ among programs. Most often, a team, which includes
860 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7
an optometrist or an ophthalmologist, visits the school and -
performs eye examinations. Some programs conduct exami-
nations in mobile vision clinics,1,17,34 while others bring eye
care equipment into the schools21,42 or transport children to
an alternate location.G While some programs exclusively
examine students who have failed a vision screening, other
programs may also examine those whose parents or guard-
ians requested an eye examination, had been referred by
teachers, or based on their need for special education
services.42 In this article, we refer to programs providing
screening, examinations, and spectacle prescription as
school-based eye care programs.
2.6. The need for referral to community care in school-
based eye care programs
School-based programs address the access barrier and often
provide the first point of contact between children and an eye
care provider. These programs can recognize and treat
refractive error with spectacles; however, some children, such
as those with suspected amblyopia, strabismus, or suspected
glaucoma, require further assessment or treatment beyond
what can be provided in the school. Moreover, even children
who are prescribed spectacles require long-term follow-up to
update prescriptions and monitor for complications associ-
ated with significant refractive error, such as retinal detach-
ment.40 Thus, school-based programs are an effective entry
point but cannot function as a permanent home for pediatric
eye care.
We know little about existing systems to refer children
evaluated through school-based programs to the community
for further evaluation or long-term care. While most current
school-based programs refer children requiring further care to
community providers, it is not known whether they are suc-
cessful at connecting these children to providers. We specu-
lated that school-based programs face the same challenges of
connecting children to community care as traditional vision-
screening-only models do.
3. Referral to community care in school-
based eye care programs
To gain an understanding of how school-based eye care pro-
grams handle children who need referral to community eye
care providers, either because of ocular pathology identified
during a school eye examination or for long-term follow-up,
we reviewed the published literature on school-based eye care
programs. We reviewed programs that provided screening,
examination, and spectacle prescription in the United States,
specifically looking at referral rates, referral criteria, referral
mechanisms, referral adherence, and ocular findings at
referral.
In the articles reviewed, the terms screening, examination,
and referral were at times used interchangeably. In this
article, we define them as follows:

Screening: vision assessment conducted by a school nurse,
technician, or volunteer to detect children who may have
vision abnormalities. Screening results usually determine
which children are subsequently examined at the school.

School-based examination: vision examination conducted
by an eye care professional at school, often following a
failed screening assessment.

Referral after school eye examination: referral to care in the
community based on the results of the school-based
examination.

Community care: eye care services provided by optome-
trists and ophthalmologists at hospitals or clinics in the
community.
4. Published literature on school-based eye
care programs
We found 12 articles that described programs meeting our
inclusion criteria (Section 7). One article used data from a
school-based vision program, the UCLA Mobile Eye Clinic, to
assess factors associated with uncorrected refractive error.26
The article did not report results of vision screening and ex-
amination and was excluded from this review. Two articles
described two phases of one program (Baltimore Vision Proj-
ect).38,39 Thus, 10 unique programs were included in the
review.
The programs differed by geography and the number of
schools they served, with the latter ranging from one to over
200. Most programs served children in early grades, while
ChildSight exclusively served intermediate school children.37
Consent was opt-in (i.e., requiring parental permission to
participate) after vision screenings and before school-based
examination for most programs; however, some programs
used other consent schemes: A Vision for Success used opt-
out consenting,12 Vision First obtained opt-in consent before
vision screenings,17,44 and the Wills Eye Vision Screening
Program for Children (WEVSPC) required parental consent
after the school-based examination for students who required
spectacle prescription or referral.21 In the latter two programs,
the screening and examination were conducted on the same
day. Optometrists or optometry interns examined children in
seven programs. Ophthalmologists examined children in two
programs, and an ophthalmologist or an optometrist partici-
pated in the remaining program. The programs are summa-
rized in Table 1.
Referral criteria, mechanisms, adherence rates, and find-
ings at referral are summarized in Table 2. Numbers of chil-
dren eligible, screened, consented, examined, prescribed
spectacles, and referred, when available, are shown in
Table 3.
4.1. Referral rate to community care in school-based
programs
Seven programs reported the number of students referred
after school eye examinations, where referral rate was 100% in
Vision First17,44 and ranged between 7.6% and 27.8% of
examined children in the remaining six1,3,12,21,37,42 (Fig). Only
three programs reported enough data to calculate referral rate
out of children who had a vision screening: ChildSight
referred 181 (3.1%) children,37 Chu and coworkers referred 15
Table 1 e Summary of school-based eye care programs included in the review
Program and Setting School Grades Consenta Screening Screening Examination Examination Components Exam Cycloplegia
reference(s) year(s) provider Components provider setting

Baltimore Vision Steuart Hill 1993-94 Pre-K through Opt-in Technicians VA, cover test, stereo Ophthalmologist Fixation and ocular alignment, School Yes
Project34,35 Elementary, (phase 1) 2nd (phase 1) retinoscopy, fundus examination
Baltimore City, 1994-95 Pre-K and K (indirect and direct
Maryland (phase 2) (phase 2) ophthalmoscopy)
ChildSight33 4 public intermediate 1995-97 5 through 8 e Parent VA Optometrist Autorefraction, VA School e
schools, Manhattan, volunteers
New York
Philadelphia 131 public schools, 2006-08 K through 8 Opt-in School VA Optometrist VA Van Sometimesb
Eagle Eye Philadelphia, nurses
Mobile1 Pennsylvania
A Vision for 8 New York City e 1 and 2 Opt-outd ee e Optometrist e School No

s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7
Success12 public schoolsc, New
York
Toledo Public 42 Toledo Public 2011-13 K, 3, and 5 Opt-in School ef Optometrist e School e
Schools Eye Schools, Ohio nurses
Care
Program38
ReFocus on 23 Title I schools in 2012-13 Head Start, Opt-in School Plusoptix screener Ophthalmologist Alignment and motility, VA, School Yes
Children32 Charleston Country, Child nurses or or optometrist retinoscopy
South Carolina Development, trained
and K laypersons
UCLA Preschool 215 preschools in Los 2012-13 Pre-K Opt-in Technicians Retinomax 3 Ophthalmologist Alignment and motility, VA, Van Yes
Vision Angeles County, autorefractor refraction, color, slit lamp, indirect
Program30 California ophthalmoscopy
Chu et al3 2 Title I schools in 2012-13 K through 5 Opt-in Optometrist Alignment and Optometrist and Alignment and motility, VA, School Sometimesg
Santa Ana Unified and motility, VA, optometry refraction, stereo
School District, optometry retinoscopy, color interns
California interns vision
Vision First17,40 All public schools 2002-14 Pre-K, K, 1 Opt-in before Technicians Alignment and Optometrist Retinoscopy, VA, indirect Van Yes
in Cleveland, Ohio screening motility, VA, stereo, (same day as ophthalmoscopy
pupils, color vision screening)
(males only)
Wills Eye Vision 45 Philadelphia 2013-15 K through 5 Opt-in after Nurses VA, autorefraction, Optometrist Alignment and motility, refraction, School No
Screening elementary schools, examinationh stereo, color vision (same day as VA with phoropter
Program for Pennsylvania screening)
Children20

e indicates that information is not available in the cited literature.

Pre-K ¼ prekindergarten; K ¼ kindergarten; VA ¼ visual acuity; stereo ¼ stereoacuity.
a
Opt-in indicates consent was required for examination after screening failure unless otherwise stated.
b
Cycloplegia in case of subnormal best-corrected visual acuity.
c
Clinical trial design with 8 schools randomized. Results reported for the 4 schools randomized to the intervention group.
d
Opt-out consent sent to parents of children who failed mandated screening in the previous year.
e
Office of School Health (OSH). Personnel not specified.

861
f
Students were enrolled by failing screening or through referral by teacher or parent.
g
Indications for cycloplegia use not specified.
h
Opt-in consent after failing examination to provide spectacles or schedule referral ophthalmology appointment.
862 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7

Table 2 e Referral to community care in school-based eye care programs: criteria, mechanisms, adherence, and findings at
referral
Program and Criteria Mechanism Adherence Findings at referral
reference(s)

Baltimore Vision e Referral to community Fewer than 33% from e

Project34,35
ChildSight33
Philadelphia Eagle Eye
Mobile1,a
A Vision for Success12
Toledo Public Schools
Eye Care Program38
ReFocus on Children32
UCLA Preschool Vision
Program30
Chu et al3
Vision First17,40
Wills Eye Vision
Screening Program for
Children20
VA not corrected to
better than 20/25 in
either eye,
interpupillary distance
> 67 mm, anisometropia
> 1D, or optometrist’s
opinion.
Suspected amblyopia,
glaucoma, ocular
alignment or movement
abnormalities, or
nystagmus.
9 (9.8%) children were
referred for monitoring
and retinal
examination.
Refractive amblyopia,
esotropia, or anisocoria.
Suspected amblyopia,
astigmatism, glaucoma,
cataract, or corneal scar.
Pathology requiring
more than spectacle
prescription
Any eye condition that
requires treatment
other than spectacles
Amblyopia, strabismus,
convergence
insufficiency, or other
eye disease.
All children failing
screening.
Subnormal best-correct
VA or other pathology.
care. Free clinic for
uninsured children.
Referral to E. S. Harkness
Eye Institute þ up to 3
phone reminders by
parent volunteers and
school nurse.
Referral letter to one of 3
hospitals þ free
chaperoned
transportation
Referral letter þ calls by
Office of School Health.
e e
Referral to local
pediatric optometry or
ophthalmology
Referral to eye care
professional
e e
Referral letter þ call
from program
coordinator þ free
appointment to
uninsured children þ
list of referred children
given to school nurse
Referral letter to Wills
Eye Hospital þ call by
social worker þ
expedited appointments
þ 2 movie tickets for
appointment adherence
phase 1 after 1 year
31 (17%) adhered to In the 58 evaluated
referral þ 27 (15%) students, 44 had normal
examined by an eye examinations with
ophthalmologist at emmetropia. 11 of the
school remaining 14 were
correctable to 20/20 in at
least one eye. The cause
of vision loss in 17 eyes
that could not be
corrected to better than
20/40 was amblyopia
(14), trauma (2), and
optic atrophy (1).
49 (53%) within In the 49 adhering
12 months students: strabismus 21
(43%), hyperopia 15
(31%), astigmatism 15
(31%), amblyopia 9
(18%), myopia 9 (18%),
possible glaucoma 4
(8%), high refractive
error 9 (18%), and poor
best-corrected VA 5
(10%).
e e
e
e e
e e
e
e e
215 (42%) returned e
referral consent. 127/177
(72%) attended
appointment.

e indicates that information is not available in the cited literature.

VA ¼ visual acuity.
a
Published data for a sample of 28 (out of 131) schools.
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7 863

Table 3 e Numbers of children eligible, screened, failed screening, provided parental consent for examination, examined,
prescribed spectacles, and referred
Program and Eligiblea Screened Failed Consent Examined Prescribed Referredb % referred of % referred of
reference(s) screening obtained spectacles examined screened

Baltimore Vision 680 680 76 76 76 58c e e e

Project34
Baltimore Vision 285 285 49 49 49 30 e e e
Project Phase 235
ChildSight33 e 5851 1614 e 1524 1235 181 12 3.1
Philadelphia Eagle e e e e 6365 4977 921 14 e
Eye Mobile1
A Vision for e e e e 122 102 10 8 e
Success12
Toledo Public e e e 3024d 1134 924 99 9 e
Schools Eye Care
Program38
ReFocus on e 2750 741 419 419 192 e e e
Children32
UCLA Preschool 12,088 11,260 1761 1300 1007 740 e e e
Vision
Program30
Chu et al3 1382 1306 382 198 198 127 15 8 1.1
Vision First17,40 e 63,841 6386 e 6386 5355e 6386 100 10
Wills Eye Vision e 10,726 1830 1230 1830 1321f 509f 28 4.7
Screening
Program for
Children20

e indicates that information is not available in the cited literature.

a
Students enrolled in grades participating in the program.
b
Referred to eye care in the community.
c
Reported in the phase 2 paper.
d
Number providing consent was extrapolated from 37.5% reported consent return rate.
e
In the first 5 years of the program, 2274 were given vouchers for spectacles. In the following 7 years, 3081 received spectacles delivered to their
school.
f
Consent was requested after examination. A total of 1321 were found to require spectacles on examination; 1015 provided consent. A total of
509 were found to require referral; 215 provided consent for referral. Of these 215, 177 did not have an eye care provider and were referred.

(1.1%),3 and the WEVSPC found that 509 (4.7%) children
required referral; two hundred fifteen (2.0%) provided
consent.21
4.2. Criteria for referral to community care
All ten programs referred children to community care as
deemed necessary by the provider conducting the school-
based examination.
Three programs mentioned referral criteria without a
detailed breakdown of referral rates by diagnosis: Child-
Sight referred 181 (11.9%) because of visual acuity not
correctable to better than 20/25 in either eye, interpupillary
distance greater than 67 mm, or anisometropia greater than
1 diopter37; A Vision for Success referred 10 (8.9%) children
for refractive amblyopia, esotropia, and anisocoria12; and
Chu and coworkers referred 15 (7.6%) children for ambly-
opia, strabismus, convergence insufficiency, or other eye
disease.3 Finally, Vision First referred all children who
failed vision screening, including those found to have iso-
lated refractive errors or who were normal on the school-
based eye examination.17,44
Only two programs provided a detailed breakdown of
referral criteria by ocular diagnosis: the Eagle Eye Mobile (EEM)
and the Toledo Public Schools Eye Care Program. In EEM, Alvi
and coworkers described referral criteria for a subset of stu-
dents (49/92) who had successfully obtained community care:
amblyopia suspect, n ¼ 14 (28.6%); glaucoma suspect, n ¼ 5
(10.2%); ocular alignment or movement abnormalities, n ¼ 4
(8.2%); and nystagmus, n ¼ 1 (2.0%).1
In the 99 (8.7%) children referred in the Toledo program,
referral criteria included amblyopia suspect, n ¼ 58 (58.6%);
astigmatism, n ¼ 28 (28.3%); glaucoma, n ¼ 10 (10.1%), cata-
ract, n ¼ 2 (2.0%); and a corneal scar, n ¼ 1 (1.0%).42
4.3. Mechanisms of referral to community care
Four programs referred children to ophthalmology services in
the community. The EEM referred children to one of three
hospitalsdWills Eye Hospital, Children’s Hospital of Phila-
delphia, or St. Christopher’s Hospital for Children1dwhile the
WEVSPC referred children to the Wills Eye Hospital.21 Child-
Sight referred children to E. S. Harkness Eye Institute.37 Vision
First provided a referral letter that listed all practicing pedi-
atric ophthalmologists in the Cleveland metropolitan area.17
While these four programs referred children to pediatric
ophthalmologists, ReFocus on Children referred to local
optometry or ophthalmology services.36 The remaining five
programs did not specify to which type of provider they
referred children.
864 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7

100%
11.9% 14.5% 8.2% 8.7% 7.6% 27.8% 100.0%
90%

80%

70%

60%

50%

40%

30%

20%

10%

1,524 6,365 122 1,134 198 1,830 6,386

0%
ChildSight Philadelphia A Vision for Toledo Public Chu et al. Wills Eye Vision Vision First
Eagle Eye Success Schools Eye Screening
Mobile (intervenon Care Program Program for
group) Children

Examined (N) Referred (%)

Fig e The number of examined children and proportion referred to care in the community in school-based eye care
programs in the United States.

The programs also varied in their reported detail about
measures used to facilitate community referrals. Four pro-
grams mentioned the use of phone call reminders: Child-
Sight, A Vision for Success, Vision First, and
WEVSPC.12,17,21,37 In addition, four programs reported the use
of free examinations, incentives, or transportation services
to promote adherence. The WEVSPC offered expedited ap-
pointments to referred children and an incentive of free
movie tickets,21 while the EEM offered free chaperoned
transportation to free ophthalmology appointments during
school hours.1 The Baltimore Vision Project and Vision First
provided free clinic appointments to children without
insurance.38,39,44
4.4. Adherence to referral to community care
Four programs reported follow-up adherence rates for chil-
dren who had successfully connected with a local eye care
provider. Three of the four programs reported follow-up
adherence rates for all examined students. In the Baltimore
Vision Project, fewer than 33% of children obtained follow-up
community care when reassessed after one year.39 Thirty-one
(17%) children adhered to referral appointments in Child-
Sight.37 In a sample of 28 schools (92 referred students) in the
EEM, Alvi and coworkers documented adherence in 49 (53%)
children.1
In WEVSPC, 509 children were identified as needing
referral; 215 provided the required consent for referral. One
hundred seventy-seven children not currently enrolled with
an eye care provider were referred. Of those, 127 (72%)
adhered to follow-up.21
4.5. Ocular findings in referred cases at community care
Two programs reported ocular findings diagnosed at
referral examinations. The EEM reported findings for 49
adhering children as follows: strabismus, n ¼ 21 (43%);
hyperopia, n ¼ 15 (31%); astigmatism, n ¼ 15 (31%);
amblyopia, n ¼ 9 (18%); myopia, n ¼ 9 (18%); glaucoma
suspect, n ¼ 4 (8%); high refractive error, n ¼ 9 (18%); and
poor best-corrected visual acuity, n ¼ 5 (10%). Some chil-
dren had more than one ocular condition, and one child
required strabismus surgery. Twenty-two children (44.9%)
were identified as needing ongoing intervention within 1 to
3 months.1
In ChildSight, 44 of the 58 examined children (76%)
were emmetropic. The authors postulated that this high
rate of normal eye examinations may have arisen because
children intentionally failed the school-based examina-
tion to obtain spectacles. Eleven of the remaining 14 were
correctable to 20/20 in at least one eye. The causes
of vision loss in 17 eyes not correctable past 20/40
were amblyopia (n ¼ 14), trauma (n ¼ 2), and optic atro-
phy (n ¼ 1).37
4.6. Long-term follow-up plans
None of the reviewed articles discussed specific criteria or
long-term follow-up plans for children who received school-
based examinations (e.g., annual eye examination to update
prescription). Notably, the EEM mentioned referring 9 (9.8%)
children for long-term follow-up; however, further details
were not given.1
 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7
5. Discussion of referral in school-based eye
care programs
School-based eye care programs address access issues by
examining children and prescribing spectacles directly at
school. About 8 in 10 examined children needed spectacles in
the programs we reviewed. In the course of school-based care,
some children are diagnosed with ocular pathology that re-
quires further evaluation or treatment in a community-based
setting. All ten reviewed programs discussed the need to refer
a subset of children to care in the community; however,
published reports often provided limited detail on referral
criteria and mechanisms for connecting children to follow-up
care. Similarly, data on follow-up adherence rates and ocular
findings at referral were not provided in most published
reports.
While one program referred all examined children to
community care, most others referred approximately 1 in 7
children. This corresponded to 1% to 5% of the screened
population. Some programs did not report referral rates but
described comparable prevalence rates of amblyopia and
strabismus, two conditions likely to require care outside the
school setting.17,34,38,39,44
Most programs communicated with parents or guardians
through letters, summarizing findings and informing them
that their child needed to be evaluated by a local eye care
professional. Some programs used additional strategies such
as phone call reminders,12,17,21,37 expedited appointments,21
free clinics,1,38,39 free transportation,1 and token incentives
to promote adherence.21 Referral adherence rates, when re-
ported, were 20-50%, with the exception of WEVSPC, which
required consent before referrals were made.1,37,39 The
WEVSPC’s adherence rate was 72% in the subset of children
who provided consent for referral after their school-based eye
examination and were not enrolled with an eye care pro-
vider.21 We cannot directly compare this rate to the adherence
rates in other programs where consent was obtained before
school examinations. In general, adherence rates for follow-
up after school eye examinations are similar to rates re-
ported for children referred directly to a community provider
after failing a vision screening.9,25,30,31 This suggests that,
while children with refractive errors benefitted from the
school-based model, those with more serious ocular pathol-
ogy are still not being connected to necessary care. As this is
the population with the greatest medical needs, further efforts
must be made to understand barriers to establishing care with
community providers and design innovative systems to
improve access to care in the community.
Some school-based programs recognized this referral
challenge. Traboulsi et al cited parental noncompliance with
community-based pediatric ophthalmology referral as the
most important challenge facing Vision First44; others tried
novel strategies to address it: EEM created a mobile clinic
staffed by ophthalmologists, the Wills on Wheels, to evaluate
children at the school.8 While Wills on Wheels statistically
significantly increased adherence from 53% to 62%, this
approach may not be feasible in low-resource settings. Simi-
larly, in ChildSight, an ophthalmologist visited two schools in
the program because of the poor compliance with attending
865
appointments in the community.37 Interestingly, the number
of children from two schools evaluated directly at their school
was comparable to the number of children who had suc-
cessfully connected to care in the community from all four
schools in the program, highlighting the potential usefulness
of this approach.
Only two programs tracked ocular findings at referral.1,37
This is possibly because programs often do not have an
established mechanism to connect children to a specific eye
care provider and do not receive the results of community
eye examinations. The two programs that reported ocular
findings at referral were among the three that referred chil-
dren to specific hospitals.1,21,37 The ocular pathology identi-
fied at referral varied. One program reported strabismus,
amblyopia, refractive errors, and glaucoma,1 whereas in the
other program, most examined children were false positives
and had normal eye examinations.37 Of note, less than half
the referred children were adherent in either program.
In addition to providing mechanisms for immediate
referral, school-based programs should consider the need for
continued care in students who are prescribed spectacles at
school. Children already wearing spectacles are twice as likely
to fail a vision screening,20,29,48 highlighting the importance of
long-term care beyond the initial identification and provision
of spectacles. Only one program mentioned long-term eye
care plans for students with higher refractive errors.1 Further
discussion should be directed toward the optimal long-term
follow-up strategies for children with refractive errors who
are provided spectacles through school-based programs, and
the ophthalmological and optometric communities must
develop guidelines for handling referral to community care.
Potential approaches to overcome the long-term eye care
challenge in school-based programs are connecting children
to specific eye care providers and integrating results of the
school-based screening and examination into electronic
health records. The latter can help by alerting primary care
providers that a child needs professional eye evaluation and
whether that had been obtained. A national expert panel on
preschool vision screening programs recommended inte-
grating vision screening results and outcomes at referral into
the state immunization record and electronic health re-
cords.22 The same concept can be considered for school-based
vision screening and eye care programs.
While we set out to review referral to community care in
school-based eye care programs, we observed marked varia-
tion in reporting results. In addition, we are aware of many
other programs delivering care, but there are no published
results of their outcomes. Aggregating information from these
programs, as well as those available in the published litera-
ture, can help the community of providers delivering school-
based eye care gain an insight into the epidemiology of
refractive errors and other ocular pathology in the school-age
population and best approaches to address them.
Although our search was limited to programs in the United
States, there is also interest in school-based eye care inter-
nationally given the global burden of poor vision.30,H Some
initial progress in this area includes reports such as Guidelines
for School-based Eye Health Programmes whose purpose is to
engage education and health care stakeholders in delivering
vision screening at schools.I
866 s u r v e y o f o p h t h a l m o l o g y 6 4 ( 2 0 1 9 ) 8 5 8 e8 6 7
6. Conclusion
The school-based eye care model can be useful for refractive
errors amenable to spectacle correction; however, 1 in 7
examined children have, or are at risk of, more significant
ocular pathologydusually amblyopia, strabismus, or glauco-
madand require referral to care in the community. Most of
these children are not accessing care in the community
despite being identified. School-based programs send referral
letters to the parents or guardians of these children and
usually use phone call reminders, free transportation, expe-
dited appointments, or free clinics to promote adherence.
While school-based programs are addressing the immediate
refractive needs of children, long-term care is rarely
discussed.
Addressing referral and long-term care is an important
step to ensure responsible and effective delivery of care to
children served through school-based eye care programs. To
accomplish this, programs need to track and publish data on
referrals, and guidelines need to be developed for optimal
school-based eye care delivery.
7. Methods of literature search
We searched PubMed, Embase, and Education Resources In-
formation Center databases during JanuaryeApril 2018 using
the keywords school-based, vision, screening, and variations
thereof. A total of 666 articles were reviewed. We also
screened citations from relevant articles to identify additional
publications.
For sections 3, 4, and 5 of the review, we included school-
based eye care programs that provided school-based exami-
nation after vision screening, with or without spectacle
prescription. We screened articles published in English from
1990 onwards and included programs based in the United
States. We excluded programs that only provided school-
based screenings. We focused on programs in the United
States and did not include international studies because of
differences in health care access, care coverage, and school
systems, which we thought were substantial enough to not be
able to make comparisons. For each program, we extracted
and analyzed indications of referral, mechanisms, tracking of
referral adherence, and findings at referral. In addition, when
available, we extracted the number of children eligible,
screened, failed screening, consented, examined, prescribed
spectacles, and referred.
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