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Many children today lack good vision care


Although an estimated 80% of what people learn comes through visual information processing, two-thirds of children in the United States do not receive any preventive vision care before starting elementary school, according to Joel N. Zaba, MA, OD. Here is Dr. Zaba’s complete white paper on the subject.

Editor’s Note: Although an estimated 80% of what people learn comes through visual information processing, two-thirds of children in the United States do not receive any preventive vision care before starting elementary school, according to Joel N. Zaba, MA, OD. Here is Dr. Zaba’s complete white paper on the subject.

Dr. Zaba

A literate population is the backbone of a healthy society. Today, literacy is defined as the way in which people use written information to function in society, rather than merely the basic ability to read. More than ever, adults need a higher level of literacy to function well. As society has become more complex, low-skill jobs have been disappearing. Therefore, inadequate levels of literacy among a broad section of the population potentially threaten the strength of economies and the social cohesion of nations.1

To this end, federal and state governments, educational institutions, businesses, and non-profit organizations are working to improve educational opportunities for children. The No Child Left Behind Act of 2001, the proliferation of standardized testing, and the U.S. Department of Health and Human Services’ Healthy People 2010 initiative are evidence of this effort. Even so, only a few organizations outside of those dedicated to eye care are addressing one of the elemental issues affecting literacy today: poor vision in children. Essentially, the children with untreated vision problems are left behind before they even start school.2

School performance

As people work to improve schools and get more books and computers into the hands of children, a prerequisite learning tool, good vision, must not be overlooked. Simply put, when children cannot see well, their school performance suffers. Experts estimate that 80% of what people learn comes through the visual processing of information,3,4,5,6 yet two-thirds of children in the United States do not receive any preventive vision care before entering elementary school.7 Once children enter school, the problem only gets worse.

According to the National Parent Teacher Association, more than 10 million children in this country have vision problems that may contribute to poor academic performance.8

Vision disorders are the fourth most common disability in the United States, and they are one of the most prevalent handicapping conditions in childhood.9

Vision problems are estimated to be prevalent in 25% of all schoolchildren.10,11,12

A study of 5,851 children aged 9 to 15 years indicated that nearly 20% need eyeglasses; only 10% of that group had them, however.13 “Thus, 90% of those children requiring prescriptive eyeglasses were not wearing them,” according to an American Optometric Association practice guideline brochure, which cites that study.14

In school districts in disadvantaged areas, the statistics are even more alarming.15

In research with Title I students in the fifth through eighth grades and academically and behaviorally at-risk children aged 8 to 18 years, up to 85% of these children had vision problems that were either undetected or untreated.16

Children from poor urban areas, many of whom are members of ethnic minority groups, experience more than twice the normal rate of vision problems.17 Without the proper vision skills, these children will be at risk of dropping out of high school.18

Teenagers with mediocre high school academic records and low scholastic aptitude test scores have been found to have significant numbers of undetected or untreated vision problems. They are at risk of not completing their college programs.19

By any measure, the level of inadequate vision care for children is significant. Moreover, its societal consequences have been linked to high school dropout rates, social and emotional problems, juvenile delinquency, adult literacy problems, and incarcerations. The effect on workforce quality and productivity is evident as well.

What schools do

Most of us assume that schools address children’s vision problems. Unfortunately, 16 states do not require children to receive any preventive vision care before starting school or during the school years. Further, 33 states-including the District of Columbia-require vision screening, but 27 states do not require children for whom screening reveals a potential vision problem to undergo a vision exam by an eye doctor.20

When schools conduct vision screenings, in most cases they test only distance vision, but most classroom activity involves near vision. Reliance on the Snellen visual acuity chart, a 150-year-old test, often determines whether a child has “good eyesight” or “good vision” for the classroom. In fact, today, the Snellen chart is nearly synonymous with good vision, although its 20/20 eye chart tests only whether a child can clearly see letters that are three-eighths of an inch in height from a distance of 20 feet. That standard is fine when determining whether a child can see the chalkboard at the front of the room but not for establishing whether he or she can see well close up-to read a book, for example, or view a computer screen.

A new definition

The deficiencies in school vision screenings would not be so important if most parents did not rely on them to assess their children’s visual health. To that end, the definition of good vision must be updated to reflect the technical requirements of the learning environment of the 21st century, and the use of the Snellen chart as the sole arbiter of good vision also must be addressed. More tests need to be added to school screening protocols to detect near-vision problems or other potential vision issues that may hinder a child’s ability to read, learn, and perform well in school.

Only about half of the children for whom screenings identify potential vision issues get the help they need. When children are found to possibly have vision problems during school screenings, an estimated 40% to 67% of them do not receive the recommended follow-up care by a vision care professional.21,22 For example, in the state of Arkansas, 45% of the children referred by school nurses for follow-up vision examinations never underwent them.23 In Texas, according to state health officials, 42% of such children did not receive appropriate follow-up care.24 Findings are similar across the United States.

Why are these percentages of non-adherence by parents and guardians so high? There are three types of barriers to vision care for children:

Financial. Many families do not have vision insurance and cannot afford to take their children to see eye-care professionals or pay for glasses.

Planning. Logistical issues include transportation to the doctor’s office, child care for other family members, and taking time off work, especially when the caretaker works in a low-skilled job for an hourly wage.

Priority.25 In some cases, families often view vision care as an expense that can be deferred. In other cases, parents simply do not believe that their children have vision problems.

Given the low rate of follow-up to school vision screenings and the resulting high number of children needing eye exams and glasses, is it any wonder Johnny can’t read?

Negative consequences

When vision problems are not detected early, they can negatively affect a child throughout his or her lifetime. Research has found that Title 1 students, juvenile offenders, illiterate adults, academically at-risk college students, and academically and behaviorally at-risk public school students have a higher prevalence of undetected vision problems.26

"Every year across the country, a dangerously high prevalence of students-disproportionately poor and minority-disappear from the educational pipeline before graduation from high school," according to findings from the Civil Rights Project at Harvard University.27

“Only about one-half (52%) of students in the principal school systems of the 50 largest cities complete high school with a diploma. That rate is well below the national graduation rate of 70%, and even falls short of the average for urban school districts across the country (60%),” according to a report from the Editorial Projects in Education Research Center.28

“Only six of these 50 principal districts reach or exceed the national average. In the most extreme cases (Baltimore, Cleveland, Detroit, and Indianapolis), fewer than 35% of students graduate with a diploma,” the same report found.28

How many of these dropouts had vision problems and could have had their life trajectories changed if they had received appropriate vision care as children? Consider:

Research has demonstrated a significant number of undetected and untreated vision problems in adults in the lowest levels of literacy.29

When evaluating adults with literacy problems, studies have indicated that 66% to 74% of their populations failed vision screenings.30

Between 1992 and 2003, the average prose literacy rate of adults aged 25 to 39 years declined.31

Many of these adults had undiagnosed and untreated vision problems as children. They grew up to become part of the adult literacy problem facing the country today.32


Undetected and untreated vision problems can lead to poor academic performance in school, self-esteem issues with attendant emotional components, and, when triggered by other factors, antisocial behavior.33 In the United States, the incarceration of juvenile and adult offenders is continually increasing in numbers and cost. At the beginning of 2008, the total inmate count at state, federal, and local jails stood at more than 2.3 million people. With the number of adults in the United States totaling 230 million, the incarceration rate is about one in every 99.1 adults.34

In 2000, previously undetected vision problems were found in populations of adjudicated adolescents, with percentages as high as 74%.35 In a 2003 national assessment of prison inmates published in May 2007, only 43% of the inmates had obtained a high school diploma or a high school equivalency certification before the start of their incarceration.36 Social and economic dynamics such as literacy, high school dropout rates, juvenile delinquency, and adult criminality are complex issues. Even so, vision often is overlooked as a contributing factor despite overwhelming evidence that it plays a critical role in childhood development and school performance.

One economist estimates that the United States “could reduce the number of crimes committed by 100,000 each year and save $1.4 billion annually, if 1% more males graduated from high school each year.37

Workplace productivity

Better vision care means a more literate and productive workforce. It has been estimated that “a 1% rise in literacy scores translates into a 2.5% relative rise in labor productivity and a 1.5% increase in [gross domestic product] per person.38

Today the goal of almost all employers is "high performance workplaces that integrate technology, work process, and organization [and] practices that can adapt to changing business conditions."39,40 To achieve this goal, employers are spending billions of dollars to upgrade the basic skills of many employees. In fact, in 2006, U.S. organizations spent $5.8 billion on teaching basic skills such as remedial reading, writing, and math.41 Smaller companies often do not offer training in basic skills. The limited literacy skills of employees cost businesses and taxpayers $20 billion annually in low wages, profits, and productivity.42,39

Healthy vision is vital for a productive and efficient workplace. The U.S. Census Bureau predicts that between 2000 and 2040, the number of Americans aged 65 or more years will more than double to 77 million, whereas the number of prime working-age adults between 25 and 54 years old will increase only by 12%.43 Today’s children must have the necessary vision skills to perform successfully in school and in the workplace.

To attain this goal:

Children must be screened for vision problems as they progress through their school years.

These screenings should include multiple tests to identify a wider spectrum of vision problems, especially those affecting near-vision.

Parents must be educated on these points so that they do not defer vision care for their children.

Resources must be provided for parents who cannot afford eye exams or glasses for their children and to ease follow through for them.

Leaders in business, education, government, health, and the non-profit sector must come together to make vision care, including access to affordable prescription eyeglasses for all children, a priority in society. By doing so, a more literate society and a strong economic future may be ensured.


  • Literacy, economy, and society page. Ohio Literary Resource Center Web page. Available at: http://literacy.kent.edu/Oasis/Pubs/0700-6.htm.

  • Zaba JN, Mozlin R, Reynolds WT. Insights on the efficacy of vision examinations and vision screenings for children first entering school. J Behav Optom. 2003;14:123–126.

  • Glezer VD. Vision and Mind: Modeling Mental Functions. Mahwah, NJ: Lawrence Erlbaum; 1995.

  • Zeki S, ed. A Vision of the Brain. Oxford, England: Wiley-Blackwell; 1993.

  • Gazzaniga MS, Ivry RB, Mangun GR. Cognitive Neuroscience: the Biology of the Mind. 3rd ed. New York, NY: W.W. Norton & Co; 1998.

  • Parker S. The Eye and Seeing. Rev. ed. New York, NY: Franklin Watts Ltd.; 1989: 4.

  • Centers for Disease Control and Prevention. Visual impairment and use of eye-care services and protective eyewear among children – United States, 2002. Morbidity and Mortality Weekly Report 2005;54:1–5.

  • Learning Related Vision Problems Education and Evaluation. Resolution adopted at: National PTA convention; June 26–29, 1999; Portland, Ore.

  • Ciner EB, Schmidt PP, Orel-Bixler D, et al. Vision screening of preschool children: evaluating the past, looking toward the future. Optom Vis Sci.1998;75:571–574, 577–584.

  • Prevent Blindness America. Your Child’s Sight. Chicago, Ill; September 1997.

  • Peters HB. Vision care of children in a comprehensive health program. J Am Optom Assoc. 1966;37:1113–1118.

  • Bloom B. UseofSelectedPreventiveCareProcedures,UnitedStates,1982. Hyattsville, MD: National Center for Health Statistics; 1986. DHHS publication (PHS) 86–1585. Vital and Health Statistics, Series 10, No. 157.

  • Pizzarello L, Tilp M, Tiezzi L, Vaughn R, McCarthy J. A new school-based program to provide eyeglasses: childsight. J AAPOS. 1998;2:372–374.

  • American Optometric Association. Optometric Clinical Practice Guideline: Pediatric Eye and Vision Examination, 2nd ed. St. Louis, Mo: 2002.

  • Suchoff IB, Mozlin R. Vision screening of an adolescent inner city population: a high failure rate and low compliance on follow-up care. J Am Optom Assoc. 1991;62:598–603.

  •  Johnson RA, Blair RJ, Zaba J. The visual science of Title 1 reading students. J Behav Optom. 2000;11:3–8.

  • Ethan D, Basch CE. Promoting healthy vision in students: progress and challenges in policy, programs, and research. J Sch Health. 2008;78:411-416.

  •  Johnson RA, Nottingham MS, Stratton R, Zaba J. The vision screening of academically and behaviorally at-risk pupils. J Behav Optom. 1996;7:39–42.

  • Johnson RA, Zaba J. Vision screening of at risk college students. J Behav Optom. 1995;6:63–65.

  • Vision Council of America. Making the Grade? Update. Alexandria, Va: 2007.

  • Donahue SP, Johnson TM, Leonard-Martin TC. Screening for amblyogenic factors using a volunteer lay network and the MTI photoscreener. Initial results from 15,000 preschool children in a statewide effort. Ophthalmology. 2000;107:1637–1644.

  • Preslan MW, Novak A. Baltimore vision screening project. Phase 2. Ophthalmology. 1998;105:150–153.

  • Smith N. Eye advice unused by 45% of parents. Arkansas Democrat Gazette. September 5, 2007:11, 15.

  • Texas Dept of State Health Services. Annual vision screening report; 2007.

  • Kimel LS. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nurs. 2006 Jun;22:156–162.

  • Zaba JN. Social, emotional & educational consequences of undetected children’s vision problems. J Behav Optom. 2001;12:66–70.

  • Losen D, Orfield G, Balfanz R. ConfrontingtheGraduationRateCrisisinTexas. Cambridge, Mass: The Civil Rights Project at Harvard University; 2006:41–43.

  • Swanson CB. CitiesinCrisis:ASpecialAnalyticReportonHighSchoolGraduation. Bethesda, Md: EPE Research Center; 2008.

  • Thau AP. Vision and literacy. J Reading. 1991 Nov;33:196–199.

  •  Johnson R, Zaba J. The link between vision & illiteracy. J Behav Optom. 1994;5:41–43.

  • Kutner M, Greenberg E, Jin Y, Boyle B, Hsu Y, Dunleavy E. LiteracyinEverydayLife:Resultsfromthe2003NationalAssessmentofAdultLiteracy. Washington, DC: US Dept of Education, Institute of Education Sciences, National Center for Education Statistics; 2007; 13.

  • Zaba JN, Johnson RA. Literacy: the vision, learning and volunteer connection. J Behav Optom. 1992;3:128–231.

  •  Johnson RA, Zaba JN. The visual screening of adjudicated adolescents. J Behav Optom. 1999;10:13–17.

  • Warren J. Onein100:BehindBarsinAmerica2008. Washington, DC: The Public Safety Performance Project, Pew Center on the States, Pew Charitable Trusts; 2008; 5.

  • Barber A, Ed. BehavioralAspectsofVisionCare:ConsultingWithSchools. Santa Ana, Calif: Optometric Extension Program Foundation; 2002;1–7.

  • Greenberg E, Dunleavy E, Kutner M. LiteracyBehindBars:Resultsfromthe2003NationalAssessmentofAdultLiteracyPrisonSurvey. Washington, DC: US Dept of Education, Institute of Education Sciences, National Center for Education Statistics; 2007.

  • Lochner L, Moretti E. The Social Savings from Reducing Crime Through Education. Joint Center for Poverty Research Policy Brief.

  • Coulombe S, Tremblay J, Marchand S. International Adult Literacy Survey: Scores, Human Capital and Growth Across Fourteen OECD Countries. Ottawa: Statistics Canada; 2004.

  • Proliteracy America. Adult Literacy Programs: Making a Difference. Syracuse, NY: ProLiteracy Worldwide; 2003; 7.

  • McCain ML, Pantazis C. Responding to Workplace Change: A National Vision for a System for Continuous Learning. Alexandria, Va: American Society of Training and Development; 1997.

  • American Society for Training & Development. State of the Industry Report 2007. Alexandria Va: American Society for Training & Development; 4, 12.

  • Adult literacy fact sheet: The economics of literacy. Ohio Literacy Resource Center Web page. Available at: http://literacy.kent.edu/Oasis/Pubs/econlit.htm.

  •  Johnson RW. Trends in job demands among older workers, 1992–2002. Monthly Labor Review. July 2004;27:48–56.

About the author

Joel N. Zaba, MA, OD, is a practitioner, researcher, lecturer, and the author of numerous research articles relating vision to child and adult learning problems, literacy problems, school performance, and social-emotional problems. Dr. Zaba may be contacted at 757/497-9575 or joelzaba@cox.net. Support for Dr. Zaba’s project was made possible by the Essilor Vision Foundation.

About the Essilor Vision Foundation

The Essilor Vision Foundation is a 501(c)(3) public charity committed to eliminating poor vision and its lifelong consequences. The foundation works to increase community and corporate awareness, raise funds, encourage collaboration between the vision industry and non-profit organizations, and engage individuals in programs that support good vision. For more information, visit www.essilorvisionfoundation.org/Welcome

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