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Eyes on the school prize - Missouri law requires comprehensive eye exams (Part 1)

This article first appeared in the St. Louis Beacon, Dec. 20, 2008 - For all the concern about low reading comprehension and short attention span, sometimes the reason for poor school performance is just the eyes. Students whose vision problems go undetected or are not found until their first screening or eye exam late in elementary school are likely to have fallen so far behind in reading that remediation is difficult.

Preventing these struggles is the stated goal of legislation signed by Gov. Matt Blunt in June 2007. The law, which took effect at the start of this academic year, requires Missouri public school students to receive a comprehensive eye exam in kindergarten or first grade. It also requires schools to conduct vision screenings – simplified exams that don’t require ophthalmologists or optometrists -- for students during first and third grades.

With the Jan. 1 deadline for parents or legal guardians to submit to schools either evidence of the vision exam or a written request to opt out of the requirement, school districts and state officials are awaiting the first indication of the law’s impact.

While the legislation is addressing a compelling public health problem, it isn’t without controversy. Optometrists and ophthalmologists tend to have different views of the cost effectiveness of widespread exams. Complaints about non-mandatory compliance continue to arise. And an incomplete data reporting system threatens to diminish the value of the results obtained.

These issues are explored in the second installment of this story. First, a look at why supporters of the law believe it to be important and what’s being done to make it work.

The Need for Early Eye Exams

Studies from across the country show that fewer than half of students have an eye exam and about half are screened before entering school for the first time, according to Timothy A. Wingert, chief of primary care at the University of Missouri at St. Louis’ College of Optometry. When a problem is identified at a screening, the average time until a student receives follow-up care is more than a year, he said.

At the time he signed the bill, Blunt said he expected the law to help more than 136,000 children read and see chalkboards more clearly in the first year alone. A goal is to get an accurate count of the number of students who are receiving exams and a sense of how many have problems that otherwise might have gone unnoticed.

The Missouri Optometric Association has long supported mandatory exams, arguing that screenings don’t always catch subtle eye problems that lead to students being unnecessarily classified as having special learning needs.

“We thought we could put an end to this if optometrists started seeing kids when they started school,” said LeeAnn Barrett, the association’s executive director, “For a kid who gets labeled learning disabled, for what’s spent on their education, it’s far cheaper to provide an eye exam and glasses if that was the problem.”

Missouri and Illinois are among the few states requiring comprehensive exams for students entering public elementary schools. Illinois’ law requires each child starting kindergarten or school for the first time to show proof of a comprehensive eye exam before Oct. 15. School districts can withhold the report cards of students who haven’t completed the exams.

Vision Commission Gets to Work

The Missouri law seeks not only to find more at-risk students through comprehensive exams performed by a state-licensed optometrist or physician, but also to standardize eye screening procedures. Nurses or other staff members have long conducted these screenings using whatever method is preferred at a given school. Whether tests occurred before school or during the year also varied from school to school.

Michael Frier, an optometrist and chair of the children’s vision commission that was established to implement the law, said the group plans to create a training manual on how to conduct the screenings. New guidelines are set to be in place for the next school year.

When a student fails a screening, the school district is supposed to send a notice home with the results and a suggestion that the student seek medical help. Parents are asked to report back to the school about whether their child has gotten the follow-up exam within a year.

Marjorie Cole, school health services program manager at the Missouri Department of Health and Senior Services, which oversees the vision commission, said the agency wants raw data about the number of students in a grade who are found to have problems through screenings and the number of referrals offered and accepted.

The commission has already created the comprehensive exam form. The idea is for doctors to eventually be able to upload information that goes directly to the state health department. But the DHSS is waiting to receive funding for its electronic filing system, and some doctors have stacks of forms in their offices waiting to be sent. Other doctors have sent information back to the schools (with parent consent) or to the health department itself.

Cole said the information is supposed to come to the DHSS without student names – the department just wants to track statistics on the number of exams, what they cost and method of payment, and whether a student received the recommended treatment. In three years, the commission is to report back to the state general assembly on its findings.

Early Results

Barrett, the Missouri Optometric Association director, said it’s already evident that some school districts are embracing the law. The Odessa R-VII School District, for instance, asked students this fall to give notice of their comprehensive exams before school started.

Of the 159 kindergarten students enrolled in the district, 155 followed those guidelines and four opted out (mostly for insurance reasons) said Jill Phillips, director of health service for the district.

The exams found a host of previously undiagnosed problems, including six students with farsightedness, three with nearsightedness, six with astigmatism, one with glaucoma and several with lazy eyes. Fourteen students were told they needed glasses.

“These are great results and would not have been caught otherwise,” Phillips said. “Who would think a kindergarten student would have glaucoma?”

Getting the word out to students and their parents is a far greater task at the St. Louis Public School District. Richelle S. Clark, executive director of student support services and the interim director of health services, said the district mailed parents several reminders this spring about the exams.

Clark said she doesn’t yet have a sense of completion rates, but she’s confident that more at-risk students will be examined because of the law. With so many students in the district, Clark said it’s been difficult in years past to know whether parents ever got word of screening results. That should change with the new reporting system, she said.

To improve access to eye care providers, both the University of Missouri-St. Louis School of Optometry and Crown Vision Center have offered to conduct examinations on site at the schools. Clark said school nurses are identifying families who haven’t already set up a vision appointment. So long as a school has 10 or more students ready to be examined, doctors will come to campus – and at least one school has had more than 20 students express interest.

Clark said that, because she hasn’t received specifics from the state on how to report exam data, she’s going to continue to find students who need exams through at least January.

Missouri isn’t the only state that’s trying to bring vision services to students. In Massachusetts, where a state law requires that all children must have their eyes screened before starting kindergarten, public school students in one city can visit a nonprofit center that operates out of a middle school.

The Framingham Public Schools Vision Center isn’t free, but a vast majority of patients are insured for eye care. The center offers full financial aid to students who quality, and offers eyeglasses to low-income students through partners in the community. Many of the patients do not speak English as a first language.

Stacy Lyons, director of the center and an associate professor in pediatric optometry at the New England College of Optometry, which collaborates in running the center, said that students there were getting screened but typically not getting comprehensive exams. “Us being essentially aligned with the school and being on site helps to improve access, which is our main goal,” she said.

Elia Powers
Elia Powers is a Freelance Writer in St. Louis. He worked on several stories for the STL Beacon.

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