Vision quests

Luke Nease was an unusually squirmy kid, but his mother never suspected vision problems.

Luke regularly saw his pediatrician, who also never suspected the boy couldn’t see out of his left eye. It took a school vision screening to raise a flag; a subsequent eye exam found he has refractive amblyopia, aka “lazy eye.”

“It was really very frustrating, because it was not until he was 4 or 5 that it was caught,” Teresa Nease said Friday, as Luke underwent a vision check at the Spokane Eye Clinic. “And we should have been patching” – now Luke wears a patch over his right eye to improve his left.

As required by state law, public schools throughout Washington screen students and refer those with vision problems for professional eye exams. The idea is that kids who need them will get glasses and more serious problems can be identified. In Luke Nease’s case, the screening – the family lived in the Seattle area at the time – had the intended effect. But in Spokane, many kids who are referred for eye exams don’t get them, said the nurse who oversees the school district’s screening effort.

Screenings will begin in September after the start of school. About 13,500 Spokane students a year get screened for vision problems. Of those, 10 percent to 14 percent have trouble seeing, said Marianne Fischer, the nurse who leads the district’s vision screening program.

Parents of children who don’t pass get letters referring the students for professional eye exams.

Follow-up rates – the number of kids who then get an exam and glasses if they need them – aren’t tracked, Fischer said, and she was reluctant to provide an estimate for the district. But at Logan Elementary, where she serves as lead nurse, she said about 50 percent don’t get the care they need. That leaves those students at a disadvantage in the classroom.

“Vision is how most kids learn,” Fischer said. “We’re a very visual society. Most of what we pick up is through vision. Those kids in the back row (who can’t see well) – they’re not picking up anything.”

A good student’s performance might tank. Unable to follow along in class, another student might become disruptive. Teachers often can recognize the signs of vision problems, Fischer said. But when students don’t get their glasses or other treatment, they fall further behind.

Dr. Jeffrey Colburn, a pediatric ophthalmologist at the Spokane Eye Clinic, said he’s seen a few kids thought to have learning disabilities who actually just needed glasses.

Many kids who can’t see well truly don’t know what they’re missing, he said. They think what they see, or don’t see, is normal.

“You put them in glasses, and their whole world opens up,” Colburn said.

‘Not high on their list’

Logan wouldn’t be alone if only half the kids who failed vision screenings got follow-up care. Studies in recent decades have examined follow-up rates for failed screenings, the reasons for low ones, and the effects of poor vision on students.

In 1998, fewer than 33 percent of students in a Baltimore study who showed signs of vision problems got follow-up exams. A 1999 study at Vanderbilt University in Tennessee found as few as 32 percent of kids who failed day-care screenings got exams.

The assumption, noted a 2006 study published in The Journal of School Nursing, was that a lack of money and access to services led to low follow-up rates.

And that study did find some trends related to income.

Parents without cars, phones, vision insurance and less than a high school diploma or GED were less likely to get follow-up eye care for their children. Families who earned more than twice the federal poverty level were more likely to seek eye care, wrote Linda Kimel, the study’s author and an Illinois school nurse.

Paying for exams might pose the most trouble for families that fall in the gap between Medicaid and private insurance, said Colburn, the pediatric ophthalmologist. They don’t qualify for assistance but can’t swing an exam and glasses. Colburn said his clinic works with patients through Project Access, a network of doctors and hospitals that provides health care to low-income, uninsured Spokane County residents.

But other factors are at play, too. In the ’06 study, some families cited logistical complications – when all the adults work, no one’s available to take children to appointments. In other cases, parents simply don’t believe the results of the test or consider vision care a low priority compared to concerns like food and shelter.

In general, paying for the exam isn’t the problem for Spokane parents – even when they can’t afford it, Fischer said. Plenty of clinicians provide free screenings to those who need them, she said, and nurses refer families to the Lions Club or eyewear retailers who offer free or reduced rates.

The problems, she said, are getting to the exam, for families with no phone and no car; paying for glasses; and then paying for replacement glasses when the student’s prescription changes or he loses or breaks them.

“Here (at Logan) we’re giving them food on Fridays to take home for the weekend,” Fischer said. “(Eye care is) just not high on their list.”

Add to that the fact that many Logan students don’t speak English at home. Nurses work through translators to communicate with their parents. The process can take weeks or months.

“We screen them in the fall,” Fischer said. “We hope they have glasses by spring break” – the better part of an academic year spent in a blur.

‘They never told anyone’

In some cases, like Luke Nease’s, school referrals for eye exams lead kids to eye doctors who spot more serious problems than a need for glasses, Colburn said.

“I’ll have kids who come in and (the parents) tell me, ‘Yeah, they failed their eye exam (at school) for the last three years,’ ” Colburn said. “And I’m like, ‘We could have been working on this for three years.’ ”

Children’s vision develops from birth until around age 8. But some may never see an eye doctor until they’re teenagers, when a vision test required for sports participation might send them in.

“And sometimes these kids will have an eye issue that impacts their eye development as a younger kid, and we can’t do anything about it,” Colburn said.

One example: anisometropic amblyopia. Both eyes appear normal, but one is sending blurred or wrong images to the brain because a nerve pathway failed to develop. The brain learns to ignore the weaker eye, so the child essentially operates with just one eye without anyone knowing it.

Caught before 8 or so, the condition can be treated with glasses and maybe a patch, Colburn said. By the early teens, it’s too late.

From children’s perspective, he said, their vision grows slowly blurrier, and they don’t notice. Or they assume everyone else sees the same way. Or they fear teasing once they’re in glasses.

“You start asking them, ‘How long have things been blurry?’ The kid will say, ‘Oh, a couple years.’ And they never told anyone,” Colburn said.

Piecemeal approach

Citing a need to catch problems that could inhibit learning, Washington state requires public schools to test students’ vision five times – in kindergarten and first, second, third, fifth and seventh grades.

Nurses work most aggressively to follow up with parents of kids with the worst vision, Fischer said. Several each year are identified at Logan with 20/100 vision, meaning they can see only from 20 feet away what could normally be seen at 100 feet. Beyond sending those referral letters, they don’t have time to do the same for every student, she said.

She worries about those who still don’t have glasses by the end of seventh grade – or whose vision problems develop after that.

“Now they’re completely through the cracks,” Fischer said. And in high school, “the pace is so fast that if you can’t see, you get left behind.”

Fischer wishes there were an easy way for every kid whose family couldn’t afford them to get free glasses. Nurses try to help by referring families to resources, but it’s a piecemeal approach.

One piece she’s excited about: the 8-foot-wide, 62-foot-long trailer that will visit three of the district’s poorer elementary schools soon after classes start. In September, students at Logan, Bemiss and Whitman will receive vision and hearing tests in the Lions Club’s health-screening trailer.

Students with vision problems will receive applications for glasses paid for by the club.

Members of the Lions Club sell hot dogs and crab dinners, run beer gardens and demolition derbies – among other fundraising efforts – to pay for glasses for children and adults who can’t afford them.

“If (children) have vision problems and they’re not identified, it will affect their ability to learn, how they feel about themselves, which will lead to many other issues throughout their lives,” club member Rick Keinholz said.

As a child, Keinholz said, he had no idea he couldn’t see. He squinted to make out distant objects, but he thought that was normal. Finally assessed in the fifth grade, his vision was 20/650.

“I cannot describe for you what it was like,” he said, “to put on glasses and sit in the third row and see the board clearly.”