Pre-Kindergarten Eye Exams Costly, But Improve Follow-Up

A state-mandated program found similar disease rates as large-scale screening programs, but had a low cost-benefit ratio.

Illinois state-mandated complete eye exams prior to kindergarten entrance found similar rates of ocular diseases, had a reduced cost-benefit ratio, and higher follow-up in a suburban population compared with traditional screening programs, according to research published in Clinical Ophthalmology.1

Prior studies have discussed whether vision screening programs are sufficiently predictive to merit their costs. The study authors, who are affiliated with Wheaton Eye Clinic in Illinois, conducted the first report of clinical findings on the complete eye exams that the state began mandating in 2008.

They retrospectively reviewed charts of the exams that had been performed at the clinic between September 2008 and February 2017 and included the 1085 records of exams conducted on 4- to 6-year-old patients (48% girls) that were the primary purpose of the ophthalmological visit and included cycloplegic refraction.

In all, 146 patients had a clinically relevant diagnosis such as amblyopia (n=59), manifest strabismus (without phorias) (n=1), convergence insufficiency (n=20) or were prescribed spectacles.

Most exams charged $220 according to 1 billing code. The cost per diagnosis on the 146 patients with clinically relevant diagnoses was $1635 while the cost per eyeglasses given, not including the cost of eyeglasses, was $2363.

These costs were higher than those calculated in a San Francisco screening program (with community-based follow-up, $664; mobile unit follow-up, $776) and a Cleveland, Ohio, program that estimated annual screenings per year cost $23 without glasses.2,3

However, the investigators said that having complete eye exams in the office enables a one-time visit for the completion of the screening and the launch of initial treatment without further referral, which encourages follow-up.

Nine percent of patients required glasses or follow-up in less than 1 year to treat or monitor ocular conditions, and follow-up rates were 83%, the researchers reported. This rate exceeded the rate found in 3 other studies: 65% of 6300 children when 5% required referral, 55% to 59% of the San Francisco community-based mobile programs, and 46.6% follow-up rate with 29.3% of parents not knowing that their child had failed the vision screening.2,4,5

With the data and the “relatively high” cost per positive finding, “one could argue that a less expensive digital screening program or using well-trained vision screeners may be a more cost-effective way to screen children for vision problems before school,” investigators report. 

However, the potential for failure to follow up needs to be considered. Mandating follow-up with eye care providers following screening programs may eliminate the need for state-mandated ocular exams, the report says.

Limitations of the study included its retrospective nature in addition to solely including patients who received cycloplegic refractions. In addition, not all kindergarteners received eye dilation, and many had family history of amblyopia, strabismus, or wearing glasses.


1. Ekdawi N, Kipp MA, Kipp MP. Mandated Kindergarten Eye Examinations in a US Suburban Clinic. Is it Worth the Cost? Clinical Ophthalmol. 2021:15:1331-1337. doi:10.2147/OPTH.S300725

2. Lowry EA, de Alba Campomanes AG. Cost-effectiveness of school-based eye examinations in preschoolers referred for follow-up from visual screening. JAMA Ophthalmol. 2016;134 (6):658–664. doi:10.1001/jamaophthalmol.2016.0619

3. Traboulsi EI, Cimino H, Mash C, Wilson R, Crowe S, Lewis H. Vision first, a program to detect and treat eye diseases in young children: the first four years. Trans Am Ophthalmol Soc. 2008;106:176–179.

4. Arnold RW, Arnold AW, Hunt-Smith TT, Grendahl RL, Winkle RK. The positive predictive value of smartphone photoscreening in pediatric practices. J Pediatr Ophthalmol Strabismus. 2018;55 (6):393–396. doi:10.3928/01913913-20180710-01

5. Su Z, Marvin EK, Wang BQ, et al. Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting. J AAPOS. 2013;17(4):385–390. doi:10.1016/j.jaapos.2013.05.008