Clearer Vision, Brighter Futures: Addressing Unmet Pediatric Eye Care Needs Through School‐Based Vision Programs

ABSTRACT

Background

Vision impairment affects approximately 1 in 4 school‐aged children in the United States, and yet challenges in connecting to care exist. Poor vision has been linked to diminished academic performance, social development challenges, and poor mental health. School‐based vision programs (SBVPs), which typically provide vision screenings, eye exams, and eyeglasses directly in schools, are one promising avenue to improve access to care, especially in underserved communities.

Contributions to Theory

Vision is a foundational component of both health and educational equity, and SBVPs are interventions that address gaps in access to care for disadvantaged populations.

Implications for School Health Policy, Practice, and Equity

SBVPs would benefit from better integration with school health services and more robust systems to coordinate referrals to eye care providers. States should monitor the impact of SBVPs on access to care. Implementation and expansion of SBVPs should prioritize under‐resourced schools and students who face the greatest access barriers.

Conclusion

Evidence for the impact of SBVPs in addressing unmet eye care needs among our most vulnerable students is robust. Evidence‐based policy, financing, data infrastructure, and community partnerships are needed to embed vision care in school health to advance both health and educational equity.

1. Introduction

In his seminal 2011 article, Vision and the Achievement Gap Among Urban Minority Youth [1], Charles Basch argued that vision problems are highly prevalent, disproportionately affect students from low‐income and minority backgrounds, and undermine academic achievement through adverse effects on causal pathways of sensory perception, cognition, and school connectedness. He identified schools as a critical setting for early detection and intervention. Almost two decades later, a preponderance of studies confirms Basch's thesis, and yet inequities persist. Building on Basch's framework, this article reviews evidence on the continued burden and disparities of pediatric vision problems across the United States, the links between vision and educational outcomes, the effectiveness and implementation challenges of school‐based vision programs (SBVPs), and future opportunities for expansion and policy considerations to ensure success.

2. Rising Burden of Vision Problems in U.S. School‐Aged Children

Poor visual function in childhood has been linked to diminished academic performance, social development challenges, poor mental health, and long‐term health disparities [2]. Most children with vision issues have uncorrected refractive error (i.e., myopia, hyperopia, astigmatism) that can be readily addressed with eyeglasses, thus improving their ability to see and engage in learning. Emerging data points to a growing burden of visual impairment and uncorrected refractive error among school‐aged youth, underscoring the need for more robust strategies to support pediatric vision health, including through school‐based programs [3, 4].

Pediatric vision screenings, which detect children at risk for vision problems, are recommended by professional organizations, such as the American Academy of Ophthalmology, American Academy of Pediatrics, and the National Association of School Nurses [5, 6]. Forty‐one U.S. states require vision screenings for school‐aged children at various intervals between kindergarten and twelfth grade [7, 8]. These screenings are typically conducted in primary care or community settings [9]. Children referred for an abnormal vision screening result need an eye exam by an eye care professional. Timely screening and referral are emphasized to detect children at risk for vision threatening problems, including amblyopia, a condition that can result in irreversible vision loss if not treated early. However, many children fail to receive needed eye care, especially among children from lower socioeconomic backgrounds, as well as racial and ethnic minorities [8].

Uncorrected refractive error, most frequently myopia (or nearsightedness), is the most common cause of pediatric vision impairment [10]. National data show that the prevalence of myopia was significantly higher in the early 2000s compared to the early 1970s and has increased since the COVID‐19 pandemic [11]. High myopia, the more severe form of nearsightedness associated with greater risk of vision‐threatening sequelae, also more than doubled during this period [11, 12]. Global estimates projected that high myopia will continue to rise markedly, from 2.7% of the world population in 2000 to 9.8% by 2050 [13]. The increase in myopia is thought to be driven largely by environmental factors, particularly reduced outdoor time and increased near work, although the mechanisms remain incompletely understood [14, 15].

Trends in eye care needs are further shaped by shifting U.S. demographics with Hispanic, Asian, and multiracial children comprising a growing share of the pediatric population [16]. It is predicted that by 2060, over 64% of children under 18 are expected to belong to racial and ethnic minority groups [16]. Hispanic white children are projected to remain the largest group with visual impairment, while multiracial American children will experience the greatest proportional increase in cases [17].

3. Disparities in Pediatric Vision Burden and Access

3.1. Disparities in Prevalence, Vision Screening and Access to Care

Adding to the challenging picture of growing eye care needs among children is a parallel rise in unmet vision care. Hispanic, Asian, or Black children, as well as those living in low‐income or non‐English‐speaking households, face multiple barriers along the vision care continuum [18, 19, 20, 21]. National survey data demonstrate that they are screened less frequently, have higher rates of referral for comprehensive eye exams, and are less likely to access follow‐up care with a specialist [19]. These disparities are primarily related to systemic factors that drive social determinants of health, rather than biologic susceptibility [22]. Similar inequities are also observed in school settings. In one high‐school‐based screening initiative, Hispanic students were less likely than their peers to have received a prior eye exam or to wear corrective lenses [21]. Black students presented with worse baseline visual acuity and were more likely to achieve significant improvements with corrective lenses, which suggests that unmet needs were disproportionately higher in this population [21]. Additionally, another study found that Black and Latinx students who failed screening were more likely to have myopia and astigmatism, while Latinx ethnicity was associated with greater odds of clinically significant refractive error [23]. In a Texas SBVP, students of Black and Hispanic backgrounds were also more likely to fail screening compared to their White and non‐Hispanic peers [24].

3.2. Geographic Disparities and Structural Barriers

Geographic location and community resources are both determinants of access to pediatric vision care. Living in states without mandated vision screening policies is associated with lower vision screening rates among school‐aged children [24, 25]. In 2023, only 6.5% of U.S. counties had at least 1 pediatric optometrist and only 9.7% had at least 1 pediatric ophthalmologist [26]. In rural areas and underserved urban neighborhoods where eye care providers are more limited, families can face additional logistical challenges in securing care. Recent national data show that counties in the U.S. without a pediatric ophthalmologist tend to have significantly lower household incomes, higher proportions of families without internet service, and households without access to a vehicle compared to counties with at least one pediatric ophthalmologist [27].

Insurance status also plays a critical role. Compared to those with private insurance, children with no insurance or public insurance are less likely to receive vision testing in the primary care setting [28]. Notably, persistent gaps among publicly insured children suggest that coverage alone is insufficient. Additional structural barriers, such as limited English proficiency, transportation, competing caregiver demands, and challenges navigating referrals, also impede timely care. These barriers underscore the value of school‐based vision programs as one point of access to needed pediatric eye care.

Taken together, these data paint a clear picture: children from minority racial and ethnic groups and economically disadvantaged households face greater risk of undiagnosed vision problems yet are less likely to access the care needed to address them. These disparities reflect the intersection of multiple social and structural factors. The Centers for Disease Control and Prevention identified several social determinants of health that particularly influence eye health and access to care, including lower income, limited educational attainment, neighborhood safety, and barriers related to health care access (e.g., cost, insurance, transportation) [29]. Structural inequities, such as residential segregation, underinvestment in low‐income communities, and systemic racism can all affect exposure to outdoor spaces (a protective factor for myopia) [15], quality of education, and proximity to eye care providers [22]. Racial and socioeconomic disparities in vision reflect unequal access to social, economic, and environmental resources that can influence eye health across the life course.

4. Evidence of Association of Vision With Educational Outcomes

Visual health plays a foundational role in children's ability to learn, yet many students experience undiagnosed or uncorrected vision problems that can hinder academic progress. While vision problems in school‐aged children are often asymptomatic, some children report symptoms that interfere with classroom engagement, such as difficulty seeing the board or eye strain [30].

Emerging evidence suggests that uncorrected refractive errors can negatively impact early learning. Preschoolers with uncorrected moderate hyperopia, also known as farsightedness, scored significantly lower on standardized tests of emergent literacy compared to their peers [31]. More significant hyperopia (≥ 4.0 D) was associated with lower scores. A similar trend has been observed in a study of children aged 4 to 5 years, where reduced visual acuity was associated with significantly lower early literacy scores [32]. These findings suggest that vision deficits may interfere with the development of essential skills during a critical window for academic growth.

The impact of vision problems on academic performance is also seen in adolescents. Adolescents aged 14–16 years with uncorrected refractive error are more likely to receive lower grades [33]. They also report eye pain, headache, and musculoskeletal pain during screen use, suggesting that uncorrected vision problems may place added strain on both the visual and postural systems [33]. In addition, a recent systematic review of studies involving children aged 5–18 years with vision impairment found that these students generally performed worse than their peers on reading and literacy measures, particularly reading speed [34].

Collectively, these findings provide strong evidence that vision care should be considered a foundational component of educational success. Reading proficiency and skill by the end of third grade is highly predictive of future academic success, such as the likelihood of graduating from high school [35]. Early detection and timely correction of visual impairment may offer a meaningful opportunity to improve school readiness and learning outcomes.

5. The Role of Schools in Eye Care Delivery: School‐Based Vision Programs

Children who may otherwise face barriers to accessing primary eye care services stand to benefit from school‐based delivery models. SBVPs are partnerships between schools, community organizations, health systems, or public health agencies that deliver vision care directly in the school setting [36]. For example, a Chicago SBVP was a partnership between Chicago Public Schools and the Chicago Department of Public Health [37]. In contrast, program partners for a Baltimore SBVP include Johns Hopkins University, Baltimore City Public Schools, Baltimore City Health Department, nonprofit optometric provider Vision To Learn, and eyewear retailer Warby Parker [38]. While individual programs can vary in their operational models, they typically serve socioeconomically disadvantaged school populations, including students eligible for free or reduced‐price meals. These programs may include the provision of school‐based vision screenings, on‐site eye exams by optometrists or ophthalmologists for students who fail their screening, and provision of eyeglasses when needed [9]. SBVPs often involve school staff, community eye care professionals, and parent volunteers to support program operations.

These programs can address substantial unmet needs and serve as an initial access point for eye care by supporting both children who have never received screening and children who have previously passed screening but later develop refractive or ocular pathologies. For example, in a Baltimore‐based SBVP, approximately one‐third of students failed school vision screenings, underscoring the often disproportionate burden of vision needs in a high‐poverty urban school setting [39, 40]. Provision of eyeglasses through SBVPs has been associated with measured gains in visual acuity as well as subjective reports of being able to see clearly and engage in classrooms more effectively [41, 42].

5.1. Funding and Cost Considerations

SBVPs can be funded through a variety of sources, including philanthropy, state and local funding, insurance, or a combination of these sources [43]. Preparation of a budget should account for both start‐up costs and recurring operating expenses [43]. Published cost analyses suggest that school‐based vision care can be delivered efficiently. In a Baltimore SBVP, the program cost per student screened was less than $50, which was 0.3% of the average annual cost of education per student in a Maryland public school [44].

5.2. The Role of School Nurses

School nurses are important partners in school‐based vision care. Historically, school nurses have played an important role in supporting state‐mandated vision screenings and follow‐up for students who fail vision screenings. In underserved schools, the presence of full‐time school nurses has been associated with increased follow‐up after failed vision screening [45]. Their on‐site presence at schools and their longitudinal relationship with families are also critical to support all aspects of SBVPs. Because they maintain ongoing relationships with the school community and have ties to school health care services, they play an important role in supporting screening implementation, communicating results to family, coordinating referrals for ongoing care needs, and reinforcing eyeglass wear among students [43].

5.3. Evidence on Improving Academic Outcomes and Classroom Engagement

In addition to measured benefits in vision, SBVPs can positively impact academic outcomes and learning [46]. A cluster randomized trial in Baltimore public schools found significant improvements in reading scores among students who failed vision screening and received eye exams and eyeglasses [47]. Improvements were more pronounced for students with special educational needs and in the lowest quartile of baseline performance. A study of a SBVP in Florida observed similar improvements [48]. Additional studies in Baltimore and Los Angeles showed that students who received eyeglasses had significantly greater improvement on Woodcock Language Proficiency Battery measures and teacher assessment scores for English Language Arts, respectively [49, 50]. These findings support the promising potential of SBVPs in narrowing achievement gaps, particularly among students with lower baseline performance and unaddressed vision problems.

While reading improvements have been more consistently observed, findings related to math performance are more variable. The Vision to Learn and Florida Vision Quest SBVPs found no significant effect on math scores [48, 50]. However, a study in rural China demonstrated significant improvement in standardized math test scores among children who received free eyeglasses, particularly among those with worse baseline vision [51]. This discrepancy in findings may reflect differences in study populations, educational environments, curricula, and outcome assessments.

In addition to measurable gains on standardized testing, SBVPs have been associated with qualitative improvements in classroom behavior, confidence, and psychosocial well‐being. Anecdotal evidence from teachers suggests that eyeglasses improve attention in the classroom, persistence on tasks, and willingness to participate in practice of academic skills [52, 53].

5.4. Conceptual Model of the School‐Based Vision Care Pathway

Structural and social determinants of health contribute to disparities in vision care access, leaving many children with uncorrected visual problems that can undermine classroom engagement and, ultimately, academic outcomes. SBVPs are positioned as a key intervention along this pathway by bringing vision screening, eye exams, eyeglass provision, and linkage to community eye care directly into schools (Figure 1). Addressing vision problems directly in the school setting enables downstream improvements in academic outcomes. While their impact can be substantial, the success and sustainability of SBVPs are shaped by resources and implementation conditions, such as participation/consent processes, funding, teacher and school staff support, and partnerships with eye care providers.

FIGURE 1.

Conceptual model of school‐based vision programs.

6. Implementation Challenges of School‐Based Vision Programs

There are important considerations in SBVP implementation, including supporting program participation, ensuring compliance with eyeglasses when prescribed, and connecting children to community providers for eye care needs beyond the program scope.

6.1. Consent for SBVP Participation

Parental awareness and consent represent major obstacles to program participation. Prior work has reported participation rates between 30% and 60% for SBVPs, limited by barriers such as lack of awareness about the program, misconceptions about cost or insurance requirements, and negative attitudes toward vision care [38]. Targeted outreach, such as participation in school events, virtual eye health education, and telephone consent options, can dramatically improve uptake [38]. Furthermore, multi‐modal consent approaches, leveraging paper, telephone, and electronic communication with parents, have proven effective at increasing SBVP participation to rates of 85% and above [54].

6.2. Eyeglass Compliance

Children who received eyeglasses from SBVPs were more likely to wear them compared to those receiving only a prescription [55]. However, regular wear of eyeglasses presents further challenges. Systematic reviews have reported that eyeglass compliance ranges from 40% to 53% [55, 56]. Teachers and school staff play an important role in increasing eyeglass compliance by helping to remind students to wear and care for their eyeglasses [49, 55, 57]. They also participate in program outreach and support healthy eyeglass‐wearing habits [58]. However, educators report needing additional support to manage program logistics, reinforce eyeglasses wear, and follow up with students [58]. Identifying strategies to support teachers can facilitate more effective integration of vision care and eyeglass compliance into the school setting.

6.3. Eye Care Needs Beyond SBVPs: Challenges and Opportunities

SBVPs can successfully support children with uncorrected refractive error who need eyeglasses. While less common in children, those detected with more significant ocular conditions (e.g., strabismus or amblyopia) need to be connected to community providers for further evaluation and treatment. One central challenge is ensuring successful referral and follow‐up for community eye care. Prior research has found that 15% of screened children are referred to community eye care [59]. Among children who are referred, less than 50% may be successfully connecting with follow‐up care, highlighting persistent access barriers despite initial in‐school intervention [60, 61]. Outside the school setting, insurance gaps, out‐of‐pocket costs, and other structural barriers may further limit whether children receive recommended community eye care [62, 63, 64]. By delivering screening, eye examinations, and eyeglasses directly in schools, SBVPs may help mitigate many of these barriers by reducing financial, logistical, and access burdens on families.

7. Challenges and Opportunities in Translating Evidence for School‐Based Programs Into Policy and Practice

Despite substantial evidence about the relatedness of poor vision and academic outcomes, as well as the success of SBVPs in delivering care directly in schools, challenges exist in expanding and sustaining the impact of such programs.

7.1. Variability in State Screening Mandates

There is no national mandate for vision screenings in school‐aged children. While most states mandate vision screenings at certain grade levels, there is marked variation across states in which grades are screened. For example, while 41 states mandate vision screening in elementary school and 30 states in middle school, only 6 states require this annually or biannually [7]. The lack of coordinated policy efforts for vision screening has motivated the introduction of the Early Detection of Vision Impairments for Children (EDVI) Act by Representatives Marc Veasey and Gus Bilirakis in May 2024 to support grants to strengthen children's vision screening, referral, follow‐up, and coordinated care [65]. The EDVI Act would establish the first national program in the U.S. to improve children's vision and eye health [66]. While over 100 organizations nationally have endorsed the EDVI Act, it has not been enacted, and the current version remains in committee.

7.2. Financial Barriers

While the need for SBVPs is growing, challenges remain as most programs rely wholly or partially on philanthropic funding [67]. Although Medicaid's Early and Periodic Screening, Diagnosis and Treatment Program covers vision screenings and eye exams in children, many private insurance plans do not cover routine eye exams without supplemental vision insurance [68].

These coverage limitations are particularly burdensome for undocumented or uninsured students, who may have no alternative resources. A recent report by the National Academy of Science, Engineering and Medicine on myopia identified this gap as a barrier to care and recommended classifying myopia as a disease and a medical diagnosis, which would make prevention and treatment easier to code and reimburse [69].

7.3. Competing Demands in Schools

Despite the benefits of SBVPs, schools, especially with limited resources, can face competing demands. For example, in the post‐pandemic period, children's mental health needs have risen and chronic absenteeism has surged [70, 71]. These pressures, among many others increasing strains on schools, illustrate how schools are tasked with supporting a host of unmet health needs for children, often without sufficient staffing or sustainable financial resources.

7.4. Challenges in Referral Coordination and the Role of Other School Health Providers

There is a need to connect students served through SBVPs with eye care in the community, when needed, for acute issues and for longitudinal management (e.g., updating prescriptions). As newer treatment options other than eyeglasses for myopia become available (e.g., multifocal contact lenses, orthokeratology), coordinated referral beyond the scope of SBVPs becomes even more essential [72]. However, connecting children served through SBVPs with community care remains challenging. School nurses may also help coordinate screening logistics, manage parent communication, initiate or track referrals, and support eyeglass wear [9]. In addition, both the optometric and ophthalmic communities have pointed to the potential role of federally qualified health centers and other community health centers to facilitate these linkages [73, 74]. School‐based health centers, which are comprehensive primary care clinics located in or adjacent to schools, can also support vision services and have been linked to improved health outcomes [75]. An additional opportunity is the development of school‐linked or school district‐based vision centers that provide a dedicated site for referral and follow‐up. For example, the Alcon Children's Vision Center has a clinic for eligible students in the Fort Worth Independent School District [76]. Opportunities include expanding vision screening or eye exam capacity, establishing direct referral pathways, and providing case management for more complex needs.

7.5. Leveraging SBVPs to Promote Eye Health Literacy

There is an opportunity to design SBVPs to improve health literacy among the communities served. This can start with universal health education on vision and eye health for all students and expand to experiential learning opportunities for older students and trainees in the fields of public health, nursing, optometry, and ophthalmology. Such investments can strengthen relationships in the community and help build a pipeline of trainees into eye care careers [77]. Beyond students, there is an opportunity to serve the wider school community. Small‐scale initiatives include educational sessions for teachers, school staff, and parents. Since poor health literacy impacts the likelihood of accessing eye care [78], improving eye health literacy of the school community at large, including parents and teachers, can also promote compliance in follow‐up with community care providers and consistent eyeglass wear among students served through SBVPs [79]. Where feasible, offering school‐based screenings for adults can address unmet needs and highlight the continuum of eye care from childhood into adulthood.

8. Discussion

8.1. Implications for School Health Research

Over the past decade, substantial progress has been made in recognizing the interrelatedness of vision and education and in building SBVPs to meet this need. Building on Basch's framework, the next priority is to ensure that the benefits of SBVPs are realized through reliable follow‐up, sustained eyeglass compliance, and coordination across schools, families, and community care. Accordingly, the next research priority is investigating continuity after screening, including eyeglass compliance over time and referral completion for children requiring further care. As SBVPs scale, there is an opportunity to establish a multi‐site registry and leverage data collection across programs, both to document impact and to disseminate guidelines based on evolving best evidence.

8.2. Implications for School Health Policy, Practice, and Equity

Looking forward, states should align screening requirements with current evidence, as well as strengthen payer policies (coverage, reimbursement, and cost‐sharing) to reduce financial barriers to exam and treatment. State and national policies should further support the establishment and expansion of SBVPs and promote tighter integration with other school‐based health services, such as school nurses and school‐based health centers, as well as community eye care and primary care providers.

Implementation should prioritize under‐resourced schools and students who face the greatest access barriers. Teachers and school staff play critical roles in identifying vision problems and reinforcing health eyeglass‐wearing habits. Programs should support the efforts of teachers and school staff to ensure optimal eyeglass compliance and incorporate systems that sustain eyeglass wear, such as no‐cost replacements and repairs.

9. Conclusions

In 2011, Basch highlighted SBVPs as important school‐based health interventions with the potential to reduce inequities in access for students who have historically faced barriers to receiving timely eye care. Achieving this will require effectively incorporating these programs into the health care ecosystem by leveraging policy, data, health literacy initiatives, community engagement, and strategic partnerships across school health and community providers. To build strong, resilient students well‐positioned for academic success, ensuring clear vision remains a foundational step toward a brighter future.

Funding

This work was supported by the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Center for School Health.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

Megan Collins serves on the board of directors for Warby Parker Impact Foundation. This relationship has been reviewed and approved by the Johns Hopkins University in accordance with its conflicts of interest policies. The others authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.