Paediatric community vision screening with combined optometric and orthoptic care: a 64-month review

Approaches for delivery of refractive and optical care services in community and primary care settings

BACKGROUND

Uncorrected refractive error is a leading cause of vision impairment which, in most cases, can be managed with the appropriate spectacle correction. In 2021, the World Health Assembly endorsed a global target of a 40-percentage-point increase in effective coverage of refractive error by 2030. To achieve this global target, equitable access to refractive and optical services within community and primary care settings needs to be strengthened. This review will inform the development of technical guidance to support improvements in the testing and correction of refractive error among World Health Organization (WHO) member states.

OBJECTIVES

To determine the range of approaches for delivery of refractive and optical care services in community and primary care settings, and the methods employed for their evaluation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Global Health databases, grey literature, and annual reports and websites of relevant organizations involved in eye-care delivery from January 2002 to November 2022 to identify approaches for refractive and optical service delivery.

SELECTION CRITERIA

We included observational and interventional studies, reviews, and reports from relevant organizations related to delivering refractive services and optical services for preschool and school-aged children and adults in community and primary care settings published between January 2002 and November 2022. We searched for studies and reports published within the last 20 years because vision impairment due to uncorrected refractive error has only recently become a public health and eye health priority, therefore we did not expect to find much relevant literature until after 2002.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles, abstracts and full texts, and extracted data. We resolved any discrepancies through discussion. We synthesized data, and presented results as tables, figures, and case studies. This project was led by the World Health Organization (WHO) Vision and Eye Care Programme.

MAIN RESULTS

We identified 175 studies from searches of databases and grey literature, 146 records from company reports, and 81 records from website searches of relevant organizations that matched our inclusion criteria. Delivery approaches for refractive and optical services in community care included school-based, pharmacy, and outreach models, whereas primary care approaches comprised vision centre, health centre, and a combination of vision or health centre and door-to-door delivery. In community care, school-based and outreach approaches were predominant, while in primary care, a vision-centre approach was mainly used. In the WHO African region, the school-based and outreach approaches were mainly reported while, in the Americas, the outreach approach was mostly used. Very few approaches for service delivery were reported in the WHO Eastern Mediterranean region. Prominent gaps exist in the evaluation of the approaches, and few studies attempted to evaluate the approaches for delivery of refractive and optical care services.

AUTHORS' CONCLUSIONS

We comprehensively describe a range of approaches for delivery of refractive and optical services in community and primary care. Further evaluation of their effectiveness will better inform the application of these service-delivery approaches. The study outcomes will help guide WHO member states in strengthening refractive and optical services at community and primary care levels.

FUNDING

This scoping review was supported by the Vision and Eye care Programme, World Health Organization and ATscale Global Partnership.

REGISTRATION

The protocol of this scoping review was published in the Open Source Framework.

Worsening vision at age 4-5 in England post-COVID: Evidence from a large database of vision screening data

PURPOSE

Myopia prevalence has increased in the UK at age 10-16y, but little is known about younger children. We hypothesise that if the 'myopia epidemic' is affecting young children, then there will be increasing rates of bilateral reduced unaided vision (V) at vision screenings of children 4-5 years of age.

METHODS

Retrospective anonymised data from computerised vision screening at age 4-5 years were analysed from serial cross-sectional data. Refractive error is not assessed in UK vision screening, so vision was investigated. Data were only included from schools that screened every year from 2015/16 to 2021/22. The criterion used was unaided monocular logMAR (automated letter-by-letter scoring) vision >0.20 in both the right and left eyes, so as to maximise the chances of detecting bilateral, moderate myopia rather than amblyopia.

RESULTS

Anonymised raw data were obtained for 359,634 screening episodes from 2075 schools. Once schools were excluded where data were not available for every year and data were cleaned, the final database comprised 110,076 episodes. The proportion (percentage and 95% CI) failing the criterion from 2015/16 to 2021/22 were 7.6 (7.2-8.0), 8.5 (8.1-8.9), 7.5 (7.1-7.9), 7.8 (7.4-8.2), 8.7 (8.1-9.2), 8.5 (7.9-9.0) and 9.3 (8.8-9.7), respectively. The slope of the regression line showed a trend for increasing rates of reduced bilateral unaided vision, consistent with increasing frequency of myopia (p = 0.06). A decreasing linear trendline was noted for children 'Under Professional Care'.

CONCLUSIONS

For children 4-5 years of age, there were signs of reduced vision over the last 7 years in England. Consideration of the most likely causes support the hypothesis of increasing myopia. The increase in screening failures highlights the importance of eye care in this young population.

Visual Profile of Children who Passed or Failed the UK School Vision Screening Protocol

Background:

We applied the National Screening Committee vision screening protocol [pass criterion monocular acuity ≤ 0.2 LogMAR in both eyes(BE)] to children four to five years old to investigate the visual profile of children who passed/failed. Previous studies have only evaluated those failing. The aim was to derive false positive and negative values, specificity/sensitivity of the vision screening protocol for detecting significant visual defects (strabismus and/or significant refractive error) and the utility of a ‘plus blur test’ in identifying hyperopia.

Methods:

Participants included 294 children (5.2 ± 0.4 yrs). In addition to the vision screening protocol (monocular acuity–3 m crowded Keeler LogMAR letters), acuities were recorded through +2.50D and +4.00D lenses and ocular alignment and cycloplegic refractive error were assessed. Using acuity measures, participants were classed as passing/failing the screening protocol. Each participant was also classed as having a strabismus and/or significant refractive error (hyperopia ≥ +4.00DS; myopia ≤ –0.50DS; astigmatism ≤ –1.50DC; anisometropia ≥ +1.50DS) or no significant visual defects.

Results:

Of the 284 children who completed all tests, 27.8% failed to achieve 0.2 LogMAR in BE. The acuity pass/fail criterion had a sensitivity of 70.4% and specificity of 82.2% for detecting strabismus and/or significant refractive error. Of those who failed, 51.9% (n = 41/79) had no strabismus and/or significant refractive error (false positives). Of those who passed, 7.8% (n = 16/205) had visual defects (false negatives). The ‘plus blur tests’ improved sensitivity in detecting significant refractive error (+2.50D & +4.00D 90.7%) but significantly reduced specificity (+2.50D = 65.2%; +4.00D = 60.9%).

Conclusions:

School-entry vision screening is reasonably sensitive and specific for detecting strabismus and/or significant refractive error. Most children with visions poorer than 0.2 LogMAR need refractive intervention, and the majority of the remainder are likely false positives for significant visual defects. One in 13 children who pass have either strabismus and/or significant refractive error (7.8%). The inclusion of a ‘plus blur test’ was not a useful addition to the vision screening protocol.

Screening for ophthalmic disorders and visual impairment in a Nigerian school for the deaf

PURPOSE

To detect the presence of ophthalmic abnormalities and visual impairment in deaf students.

METHODS

A cross-sectional survey of all students in the school for the deaf was conducted following ethical clearance from the Ministry of Health. Age, sex, and previous eye examination was recorded for each student as well as visual acuity, penlight eye examination, intraocular pressure, dilated funduscopy, and refraction (when applicable). Data were analyzed with SPSS version 11 and statistical significance inferred at p<0.05.

RESULTS

The 156 (100%) students at the school for the deaf with age range 6-25 years, mean +/- standard deviation of 15.6+/-3.3 years, and modal age of 14 years were studied. A total of 110 (70.5%) had no previous eye examination, 2 (1.3%) students were blind, 5 (3.2%) were visually impaired, 4 (2.6%) had unilateral visual impairment, and 4 (2.6%) had unilateral blindness. Blindness was caused by Usher syndrome in 1 (50%) and bilateral pigmented macular scar in 1 (50%) patient. Uncorrected refractive errors were the leading cause of unilateral visual impairment (75%), visual impairment (60%), and unilateral blindness (50%). Ocular abnormality was present in 53 (34%) students while uncorrected refractive error (18.6%), retina changes (7%), and allergic conjunctivitis (3.8%) were the leading disorders. Previous eye examination was more common among primary school students (p<0.0001) and students with ocular abnormalities (p=0.046).

CONCLUSIONS

Institutions for deaf children should be aware of the high prevalence of ophthalmic disorders and the importance of vision to development of a deaf child, and conduct an initial and periodic eye examination for every intake.

Assessment and management of children with visual impairment

PURPOSE

The aim of this work was to evaluate the role of low vision aids in improving visual performance and response in children with low vision.

STUDY DESIGN

Prospective clinical case series.

MATERIALS AND METHODS

This study was conducted on 50 patients that met the international criteria for a diagnosis of low vision. Their ages ranged from 5 to 15 years. Assessment of low vision included distance and near visual acuity assessment, color vision and contrast sensitivity function. Low vision aids were prescribed based on initial evaluation and the patient's visual needs. Patients were followed up for 1 year using the tests done at the initial examination and a visual function assessment questionnaire.

RESULTS

The duration of visual impairment ranged from 1 to 10 years, with mean duration +/- SD being 4.6+/- 2.3299. The near visual acuities ranged from A10 to A20, with mean near acuity +/- SD being A13.632 +/- 3.17171. Far visual acuities ranged from 6/60 (0.06) to 6/24 (0.25), with mean far visual acuity +/- SD being 0.122 +/- 0.1191. All patients had impaired contrast sensitivity function as tested using the vision contrast testing system (VCTS) chart for all spatial frequencies. Distance and near vision aids were prescribed according to the visual acuity and the visual needs of every patient. All patients in the age group 5-7 years could be integrated in mainstream schools. The remaining patients that were already integrated in schools demonstrated greater independency regarding reading books and copying from blackboards.

CONCLUSION

Our study confirmed that low vision aids could play an effective role in minimizing the impact of low vision and improving the visual performance of children with low vision, leading to maximizing their social and educational integration.