November 2023
Volume 12, Issue 11
Open Access
Perspective  |   November 2023
Addressing Health Disparities in Pediatric Eye Care for School-Age Children: A Call to Action
Author Affiliations & Notes
  • Bani Antonio-Aguirre
    Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
  • Christina M. Ambrosino
    Johns Hopkins School of Medicine, Baltimore, MD, USA
  • Xi Dai
    Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
  • Megan E. Collins
    Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, MD, USA
    Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
  • Correspondence: Megan E. Collins, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 N Wolfe St., Baltimore, MD 21287, USA. e-mail: 
Translational Vision Science & Technology November 2023, Vol.12, 17. doi:
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      Bani Antonio-Aguirre, Christina M. Ambrosino, Xi Dai, Megan E. Collins; Addressing Health Disparities in Pediatric Eye Care for School-Age Children: A Call to Action. Trans. Vis. Sci. Tech. 2023;12(11):17.

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Disparities in access to pediatric eye care among school-age children pose significant challenges to their health and well-being; addressing these disparities will necessitate coordination across multiple systems. Although vision screenings are mandated in most US states, differences persist in terms of who receives screenings and subsequent follow-up care. Racial, ethnic, and socioeconomic factors exacerbate the issue, with potential ramifications of unaddressed eye problems on learning performance and the risk of widening preexisting educational disparities. To address these challenges, various initiatives and strategic plans have emphasized the need to improve access, enhance diversity in the workforce, and promote health literacy. School-based vision programs (SBVPs) have shown promise in improving access to care and academic outcomes, but issues with integration into the health care system exist. This article explores opportunities to address structural barriers, establish resilient and equitable systems for delivering pediatric eye care to school-age children, and leverage the success of SBVPs to build stronger connections with community providers. Proposed strategies include developing standardized guidelines; establishing referral mechanisms; fostering communication with parents, teachers, and community providers; and promoting eye health literacy across the school community. Collectively, these measures aim to improve health outcomes, address social determinants of health, and reduce disparities in access to care.

Disparities exist in access to pediatric eye care among school-age children.13 While amblyopia and its risk factors are the primary concern in younger children,4,5 uncorrected refractive error is a major issue in the school-age population.6,7 Despite more than 80% of US states mandating vision screenings for school-age children,8,9 disparities exist in terms of who obtains screenings, as well as follow-up for eye exam referrals, when indicated.1,10 Additionally, there are reported differences in access to eye care and prevalence of refractive error influenced by race, ethnicity, and socioeconomic status.1115 This situation is particularly worrisome considering the impact of vision on learning performance and the educational disparities driven by race, ethnicity, and socioeconomic status that were further exacerbated by the recent COVID-19 pandemic.1618 
In recent years, significant national efforts have been undertaken to address health disparities and their impact on access, utilization, and care outcomes. These include initiatives such as the Department of Health and Human Services Healthy People 2030, which outlines specific objectives to address pediatric eye health disparities, such as increasing vision screenings among children age 3 to 5 years old and reducing blindness and vision impairment among adolescents.19 The National Eye Institute 2020 “Vision for the Future” emphasized public health and disparities research as a core area of their strategic plan. Furthermore, the American Academy of Ophthalmology (AAO) Taskforce on Disparities in Access to Eye Care has called for actions to enhance accessibility to eye care, promote workforce diversity, and improve eye care and health care literacy within individuals and communities, all while employing data-driven strategies to enhance health outcomes.20 The AAO Task Force also acknowledged economic inequities, geographic disparities in the distribution of eye care providers, and low health literacy as barriers to accessing care and even recommended implementing school-based programs to improve access among pediatric populations.21 
School-based vision programs (SBVPs) are one model to address barriers in access to pediatric eye care. These programs typically provide vision screenings and eye exams for students who are referred after screenings. Additionally, SBVPs provide eyeglasses or eyeglass prescriptions to students with uncorrected refractive errors. These services are most often provided directly within schools. As such, SBVPs improve access to care, particularly for the most disadvantaged students, including those without insurance, or who are underinsured, as well as refugee populations. Furthermore, studies have shown improved academic outcomes for students who receive eyeglasses through SBVPs.22 
Despite their progress in improving access to care, SBVPs are often not well integrated with local pediatric eye care and primary care providers. This lack of integration becomes apparent when students require referrals to community eye care providers for management beyond the scope of the SBVP, including strabismus, amblyopia, and other nonrefractive conditions.23 According to the 2019 World Report on Vision, non-sight-threatening conditions are major causes of eye doctor visits.24 Prior research indicates that approximately 15% of children seen in SBVPs require immediate evaluation in the community,23 and around 80% ultimately need follow-up for annual eye exams and updated prescriptions.25,26 However, formal referral mechanisms are often lacking, leaving parents to navigate the same structural barriers that historically precluded community access to eye care for their child. Establishing stronger connections between care offered in SBVPs and the community would help to address this disconnect. Additionally, enhancing health literacy and communication outreach would strengthen SBVPs and establish more resilient and equitable systems for delivering pediatric eye care. 
To tackle these challenges, SBVPs can develop standardized guidelines for screening, eye exams, prescribing eyeglasses, and providing community referrals. These guidelines should be informed by the current best evidence. Involving a diverse group of stakeholders, such as health care providers, educators, and the broader school community, in the development of these guidelines will be essential. They should outline the scope of practice for school-based interventions, which are typically limited to prescribing eyeglasses, and determine when referral to community care is necessary. For those with acute care needs, guidelines should include a time frame and pathway to see an eye care provider, either by providing names of local providers or assisting in scheduling appointments. For long-term follow-up, parents should receive clear instructions on when to seek community eye care follow-up, along with a list of local providers and accepted insurance plans. Including other information, such as interpreter services and transportation options, if available in the community, should be considered. Additionally, it would be beneficial to inform school staff and parents about resources for free eyeglasses or follow-up care that may be offered through local nonprofit organizations. These resources are often not well known, and sharing this information can enhance accessibility for all children, especially those who are uninsured or from low-middle- and low-income households. 
Establishing eye care in the community is particularly salient for those children prescribed eyeglasses for myopia and at risk for progression, especially given the evolving data on early intervention for myopia control, which falls outside the scope of a SBVP. Ongoing research continues to demonstrate the growing burden of myopia in the school-age population. SBVPs must consider how best to identify and support children with myopia, especially given the known risks associated with pathologic myopia and the potential productivity losses from poor eyesight in adulthood.27,28 
Another strategy for strengthening SBVPs involves partnering with community providers and academic medical centers in program design. Early engagement will help establish mechanisms for data sharing and referrals, while ongoing evaluation allows for quality improvement assessments to ensure programs are on target with their objectives. As we continue to build SBVPs and advance our understanding through ongoing research, it would also be valuable to establish a national registry of existing SBVP programs. This registry would serve as a platform for sharing best practices, pooling resources, and disseminating lessons learned. Moreover, it would enable better data collection and assessment of outcomes across programs. 
SBVPs should also develop effective communication channels with parents, teachers, school staff, and community providers. It is essential to keep parents well informed about the outcomes of school-based eye exams, especially since care is typically provided in school settings, often without their presence. Moreover, given that there may be a lag between when parents completed consent forms and when screenings and eye exams occur, sending interval updates and promptly sharing results are key steps for ongoing communication. These communication efforts should also include information about eyeglasses use and maintenance, prescription changes, and the need for future screenings or exams.29 Building rapport with parents regarding evaluation and management is crucial, as it is likely to enhance compliance with recommended care.10,30,31 
When care is delivered in schools, teachers become part of the care team and often play a critical role in identifying students who require eye exams.32 Teachers also assist in encouraging children to wear eyeglasses consistently in the classroom.33 Tailored communication should also be provided to teachers, helping them recognize signs and symptoms of eye problems, understand the logistics of SBVPs, and learn about proper wear and care of eyeglasses. Additionally, teachers and school staff should be informed about students requiring community referral for further evaluation, enabling them to assist in follow-up with parents, if needed. 
It is imperative to develop stronger measures to improve communication between SBVPs and local health care providers. This includes establishing effective channels with the school health team to share the screening results, as well as facilitating communication with pediatric eye care and primary care providers. Efforts can be modeled on school-based health centers, which often employ integrated systems for sharing medical data with community providers.34 Communication systems may involve shared electronic medical records or the use of letters summarizing the care provided in schools. By implementing such measures, the outcomes of SBVP exams can be made available to community providers, who can then be made aware of the value and benefits of these programs for their patients and have relevant information to strengthen continuity of care. Additionally, as SBVPs and school-based health centers often operate in parallel, better coordination across these entities could also improve communication and service delivery. 
SBVPs can also take steps to enhance eye health literacy for the students they serve, teachers, parents, and the broader school community. This can be started through the communication measures outlined above, which serve to empower parents, teachers, and students with knowledge about vision problems, the potential impact on learning, and the significance of eyeglasses, when necessary, for improving vision and academic performance. Additionally, given the ongoing relationships that SBVPs have with the school community, these connections can be leveraged to provide educational opportunities for the entire student body. Such initiatives can include organizing health fairs for students about vision and eye health, as well as careers in optometry and ophthalmology; conducting webinars or other educational activities for teachers and school staff; and hosting information sessions for parents at other schoolwide events, such as back-to-school nights and parent–teacher conferences. 
It is essential to tailor health literacy initiatives to diverse, multicultural audiences and make it a priority to involve a diverse optometry and ophthalmology workforce.35 Currently, there is a lack of diversity in these fields despite the presence of a pool of diverse students.36 Hence, this approach may serve as foundational exposure for underrepresented minorities and students from low socioeconomic backgrounds, introducing them to potential career pathways in the field of vision and eye health. This approach also has the added potential benefit of growing a pediatric eye care workforce, which is currently suffering from severe shortages that are only predicted to worsen in the coming years.3739 
Lastly, SBVPs may help as an entry point into the health system for both children and their caregivers. They offer a distinct opportunity to link children with the broader health care network, facilitating their access to resources that might otherwise have been inaccessible. School-based vision care may also serve as a model for adult eye care in the community setting, whether through school-based health centers, community health centers, or other federally qualified health centers. These community-based endeavors recognize the value of services delivered in the community and involve partnerships with local programs, with the overarching goal of improving outcomes, enhancing health literacy, and reducing disparities in access to care. 
The time to act is now. By working to develop best practice guidelines, strengthen referral mechanisms, improve communication, and promote eye health literacy, we can address social determinants of health and structural barriers that impact access to care. Collectively, this will help us achieve a more robust system of pediatric eye care delivery, leading to improved health outcomes and well-being for children. 
Disclosure: B. Antonio-Aguirre, None; C.M. Ambrosino, None; X. Dai, None; M.E. Collins, None 
Chauhan MZ, Elhusseiny AM, Rook BS, et al. Socioeconomic and racial disparities in vision care access and impairment among United States children. Ophthalmology. 2023; 130(7): 772–775. [CrossRef] [PubMed]
Ma F, Lam BL, Lee DJ, Gómez-Marín O. Uncorrected binocular distance visual impairment in U.S. Hispanic children and adolescents. Ophthalmic Epidemiol. 2001; 8(1): 57–64. [CrossRef] [PubMed]
Levinson DR. Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services. Washington, DC: US Department of Health and Human Services, Office of Inspector General; 2010.
Jonas DE, Amick HR, Wallace IF, et al. Vision screening in children aged 6 months to 5 years: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017; 318(9): 845–858. [CrossRef] [PubMed]
Pascual M, Huang J, Maguire MG, et al. Risk factors for amblyopia in the vision in preschoolers study. Ophthalmology. 2014; 121(3): 622–629.e621. [CrossRef] [PubMed]
Cao H, Cao X, Cao Z, Zhang L, Han Y, Guo C. The prevalence and causes of pediatric uncorrected refractive error: pooled data from population studies for Global Burden of Disease (GBD) sub-regions. PLoS ONE. 2022; 17(7): e0268800. [CrossRef] [PubMed]
Sharma A, Congdon N, Patel M, Gilbert C. School-based approaches to the correction of refractive error in children. Surv Ophthalmol. 2012; 57(3): 272–283. [CrossRef] [PubMed]
Wahl MD, Fishman D, Block SS, et al. A comprehensive review of state vision screening mandates for schoolchildren in the United States. Optom Vis Sci. 2021; 98(5): 490–499. [CrossRef] [PubMed]
Prevent Blindness. Children's vision screening requirements by state. 2022, Accessed June 6, 2023.
Yawn BP, Kurland M, Butterfield L, Johnson B. Barriers to seeking care following school vision screening in Rochester, Minnesota. J Sch Health. 1998; 68(8): 319–324. [CrossRef] [PubMed]
Killeen OJ, Zhou Y, Musch DC, et al. Access to eye care and prevalence of refractive error and eye conditions at a high school–based eye clinic in southeastern Michigan. J AAPOS. 2022; 26(4): 185.e181–185.e186.
Adomfeh J, Jastrzembski BG, Oke I. Association of race, ethnicity, and socioeconomic status with visual impairment in adolescent children in the US. JAMA Ophthalmol. 2022; 140(10): 1006–1010. [CrossRef] [PubMed]
Qiu M, Wang SY, Singh K, Lin SC. Racial disparities in uncorrected and undercorrected refractive error in the United States. Invest Ophthalmol Vis Sci. 2014; 55(10): 6996–7005. [CrossRef] [PubMed]
Kleinstein RN, Jones LA, Hullett S, et al. Refractive error and ethnicity in children. Arch Ophthalmol. 2003; 121(8): 1141–1147. [CrossRef] [PubMed]
Stein JD, Andrews C, Musch DC, Green C, Lee PP. Sight-threatening ocular diseases remain underdiagnosed among children of less affluent families. Health Affairs. 2016; 35(8): 1359–1366. [CrossRef] [PubMed]
Dorn E, Hancock B, Sarakatsannis J, Viruleg E. COVID-19 and learning loss—disparities grow and students need help. 2020, Accessed June 6, 2023.
Dudovitz RN, Izadpanah N, Chung PJ, Slusser W. Parent, teacher, and student perspectives on how corrective lenses improve child wellbeing and school function. Matern Child Health J. 2016; 20(5): 974–983. [CrossRef] [PubMed]
Neitzel AJ, Wolf B, Guo X, et al. Effect of a randomized interventional school-based vision program on academic performance of students in grades 3 to 7: a cluster randomized clinical trial. JAMA Ophthalmol. 2021; 139(10): 1104–1114. [CrossRef] [PubMed]
Vision Workgroup. Healthy People 2030., Accessed June 6, 2023. [PubMed]
Elam AR, Tseng VL, Rodriguez TM, et al. Disparities in vision health and eye care. Ophthalmology. 2022; 129(10): e89–e113. [CrossRef] [PubMed]
Ervin A-M, Solomon SD, Shoge RY. Access to eye care in the United States: evidence-informed decision-making is key to improving access for underserved populations. Ophthalmology. 2022; 129(10): 1079–1080. [CrossRef] [PubMed]
Collins ME, Guo X, Repka MX, Neitzel AJ, Friedman DS. Lessons learned from school-based delivery of vision care in Baltimore, Maryland. Asia Pac J Ophthalmol (Phila). 2022; 11(1): 6–11. [CrossRef] [PubMed]
Shakarchi AF, Collins ME. Referral to community care from school-based eye care programs in the United States. Surv Ophthalmol. 2019; 64(6): 858–867. [CrossRef] [PubMed]
World Health Organization. World Report on Vision. Geneva, Switzerland: World Health Organization; 2019.
Guo X, Friedman DS, Repka MX, Collins ME. Visual acuity and refractive findings in children prescribed glasses from a school-based vision program. J AAPOS. 2021; 25(6): 344.e341–344.e347. [CrossRef]
Silverstein M, Scharf K, Mayro EL, et al. Referral outcomes from a vision screening program for school-aged children. Can J Ophthalmol. 2021; 56(1): 43–48. [CrossRef] [PubMed]
Agyekum S, Chan PP, Zhang Y, et al. Cost-effectiveness analysis of myopia management: a systematic review. Front Public Health. 2023; 11: 1093836. [CrossRef] [PubMed]
Bullimore MA, Ritchey ER, Shah S, Leveziel N, Bourne RRA, Flitcroft DI. The risks and benefits of myopia control. Ophthalmology. 2021; 128(11): 1561–1579. [CrossRef] [PubMed]
Wahl M, Kretz AM, Callan J, et al. Strategies for success: parent perspectives on school-based vision programs. Invest Ophthalmol Vis Sci. 2020; 61(7): 241–241.
Lohfeld L, Graham C, Ebri AE, Congdon N, Chan VF. Parents' reasons for nonadherence to referral to follow-up eye care for schoolchildren who failed school-based vision screening in Cross River State, Nigeria: a descriptive qualitative study. PLoS One. 2021; 16(11): e0259309. [CrossRef] [PubMed]
Neville K, Radil E, Velmer G. Improving parental adherence to a failed vision screening referral in the United States. Br J Sch Nurs. 2015; 10(3): 136–143. [CrossRef]
Vongsachang H, Callan J, Kretz AM, et al. Teacher and school staff perspectives on their role in school-based vision programs. Can J Ophthalmol. 2022; 57(6): 381–387. [CrossRef] [PubMed]
Stanford University. Rural education action program—role of teachers in boosting eyeglasses wear, Accessed June 19, 2023.
Schwartz T, Thomas M. Demonstrating the value of school-based health centers in Maryland: a roadmap. 2019, Accessed September 1, 2023.
Pineles S. Racial diversity among United States ophthalmology residents: a call to action. Ophthalmology. 2022; 129(8): 960–961. [CrossRef] [PubMed]
Xierali IM, Nivet MA, Wilson MR. Current and future status of diversity in ophthalmologist workforce. JAMA Ophthalmol. 2016; 134(9): 1016–1023. [CrossRef] [PubMed]
Oatts JT, Indaram M, De Alba Campomanes AG. Where have all the pediatric ophthalmologists gone? Pediatric eye care scarcity and the challenge of creating equitable health care access. JAMA Ophthalmol. 2023; 141(3): 249. [CrossRef] [PubMed]
Bernstein BK, Nelson LB. Workforce issues in pediatric ophthalmology. J Pediatr Ophthalmol Strabismus. 2020; 57(1): 9–11. [CrossRef] [PubMed]
Walsh HL, Parrish A, Hucko L, Sridhar J, Cavuoto KM. Access to pediatric ophthalmological care by geographic distribution and US population demographic characteristics in 2022. JAMA Ophthalmol. 2023; 141(3): 242–249. [CrossRef] [PubMed]

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