Teacher and school staff perspectives on their role in school-based vision programs

OBJECTIVE

School-based vision programs (SBVPs) are one approach to increase access to vision care by providing vision screenings, eye examinations, and eyeglasses directly in schools. Few studies report on the perspectives of teachers and staff, who are important stakeholders, on SBVPs. We examined teacher and staff perspectives on their involvement in SBVPs.

DESIGN

Qualitative study using focus groups.

PARTICIPANTS

Teachers and staff at Baltimore and Chicago public schools served by SBVPs between 2016 and 2018.

METHODS

We conducted 21 semistructured focus groups with 117 teachers and staff in 10 Baltimore and 11 Chicago public preK-12 schools that participated in SBVPs. Sessions were recorded, transcribed, and coded using inductive thematic analysis.

RESULTS

Participants identified 2 main themes regarding teacher and staff involvement in SBVPs: (i) program outreach, including using multiple communication modalities to engage parents, explaining program details to families, and helping with program consent form return and (ii) promoting vision health, including identifying vision problems in the classroom, encouraging eyeglasses wear, and supporting eyeglasses maintenance. Participants also discussed limitations in capacity to partake in these activities.

CONCLUSION

Teachers interact with parents and students throughout the SBVP process, undertaking important roles in outreach and health promotion to ensure uptake of SBVP services. SBVPs and other school-based health programs should explore strategies to support teachers in the roles they fill to optimize program impact.

Feasibility of a school-based vision screening program to detect undiagnosed visual problems in kindergarten children in Ontario

BACKGROUND

Visual problems can negatively affect visual development and learning but often go undetected. We assessed the feasibility of scaling up a school-based screening program to identify and treat kindergarten children with visual problems.

METHODS

We conducted a prospective cohort study offering vision screening to junior (JK) and senior kindergarten (SK) children attending 43 schools in 15 Ontario communities. Screening comprised photoscreeners and tests of visual acuity, stereoacuity and eye alignment. Children who failed any test were referred for a comprehensive eye examination, with treatment as needed (e.g., glasses).

RESULTS

Using a passive consent model, 89% of children were screened compared with 62% using an active consent model (p < 0.001). Referral rates to an optometrist varied across schools (mean referral rate for children in JK 53%, range 25%-83%; mean referral rate for children in SK 34%, range 12%-61%). Among 4811 children who were screened, a visual problem was detected in 516 (10.7%), including 164 (3.4%) with amblyopia and 324 (6.7%) with clinically significant refractive errors. For 347 (67.2%) of the children with a visual problem, this was their first eye examination. Rescreening in Year 2 did not lead to detection of additional problems among children who passed screening in Year 1. Regardless of location (child's school or optometrist's office), 1563 (68.9%) of children attended the follow-up optometry examination. Most of the children who were surveyed (291 of 322, 90.4%) indicated that they enjoyed vision screening.

INTERPRETATION

Many children in Ontario with a visual problem were not being identified by the status quo in 2015-2017. We found that in-school vision screening with follow-up eye examinations is an effective strategy for identifying at-risk children and placing them in eye care before grade 1.

Validity and feasibility of a self-administered home vision examination in Yueqing, China: a cross-sectional study

OBJECTIVE

To investigate the validity and feasibility of a self-administered home vision examination programme in China.

DESIGN

Cross-sectional study.

SETTING

Yueqing, China.

PARTICIPANTS

A two-stage convenience sampling procedure was used to randomly select 600 households from 30 communities participating in the Yueqing Eye Study (YES). The aim of YES is to encourage home-based vision screening, reporting of visual acuity (VA) annually through social media and encouraging people to attend follow-up clinic appointments as a way to improve eye care access for adults with VA ≤+0.5 log of the minimum angle of resolution (logMAR).

INTERVENTIONS

Household screeners (one per household) who tested other family members' VA completed a questionnaire on family structure, demographic information and knowledge about screening procedures. Other family members then underwent confirmatory VA testing by researchers.

OUTCOME MEASURES

The completion rate of home-based VA screening, its sensitivity and specificity were used to evaluate validity. Factors that determined whether families participated in the self-VA screening were used to evaluate feasibility.

RESULTS

345 (66%) of the 523 (87.2%) households with valid data form their home-based vision examinations also were retested by researchers. There was no statistically significant difference in scores on the family-administerd or researcher-administerd VA test (VA≤+0.5 logMAR, p=0.607; VA >+0.5 logMAR, p=0.612). The sensitivity and specificity of home-based vision screening were 80.5% (95% CI 70.2% to 86.9%) and 95.1% (95% CI 92.6% to 96.8%), respectively. 14.7% (77/523) of tested respondents had VA ≤+0.5 logMAR. Predictors of performing home screening for VA remaining in regression models included higher economic status ('fair and above' vs 'poor': OR 1.74; 95% CI 1.08 to 2.76; p=0.022), age (<45 years vs ≥45 years: OR 0.46; 95% CI 0.25 to 0.85; p=0.014) and living in a nuclear (OR 5.17; 95% CI 2.86 to 9.36; p<0.001) or extended family (OR 8.37; 95% CI 4.93 to 14.20; p<0.001).

CONCLUSION

Self-administered home vision screening is reliable and highly accepted by Chinese adults.

Screening for diabetic retinopathy: new perspectives and challenges

Although the prevalence of all stages of diabetic retinopathy has been declining since 1980 in populations with improved diabetes control, the crude prevalence of visual impairment and blindness caused by diabetic retinopathy worldwide increased between 1990 and 2015, largely because of the increasing prevalence of type 2 diabetes, particularly in low-income and middle-income countries. Screening for diabetic retinopathy is essential to detect referable cases that need timely full ophthalmic examination and treatment to avoid permanent visual loss. In the past few years, personalised screening intervals that take into account several risk factors have been proposed, with good cost-effectiveness ratios. However, resources for nationwide screening programmes are scarce in many countries. New technologies, such as scanning confocal ophthalmology with ultrawide field imaging and handheld mobile devices, teleophthalmology for remote grading, and artificial intelligence for automated detection and classification of diabetic retinopathy, are changing screening strategies and improving cost-effectiveness. Additionally, emerging evidence suggests that retinal imaging could be useful for identifying individuals at risk of cardiovascular disease or cognitive impairment, which could expand the role of diabetic retinopathy screening beyond the prevention of sight-threatening disease.

Paediatric vision screening by non-healthcare volunteers: evidence based practices

BACKGROUND

The purpose of this study was to test the sensitivity and specificity of eight undergraduate volunteer examiners conducting vision screening tests in a community setting, in order to determine if non-eye care professionals were able to be trained to an appropriate level of skill.

METHODS

Eight undergraduate volunteer examiners were trained to conduct vision screening tests to address a gap in pediatric community eye care. Phase I of the study was implemented in the pediatric ophthalmology clinic, and phase II was conducted in nine local schools. Phase I consisted of 40 h of training for each volunteer regarding specific vision tests. Phase II consisted of screening children at nine local schools.

RESULTS

A total of 690 children from nine local schools were screened by both the volunteer examiners and the optometrist during the course of this study. Volunteer examiners had a screening sensitivity of 0.80 (95%CI 0.66-0.90) and screening specificity of 0.75 (95%CI 0.71-0.78) when compared to the study optometrist. The overall accuracy of volunteer examiners was 75%. The resulting positive likelihood ratio was 3.24 (95%CI 2.6-3.9), indicating that a child with vision impairment was 3.2 times more likely to fail the vision test performed by the volunteer examiners compared to a child with no vision impairment.

CONCLUSIONS

Non-healthcare professionals can be trained to an acceptable degree of accuracy to perform vision screening tests on children, which may assist in mitigating existing gaps in paediatric eye care.

Recommendation for ophthalmic care in German preschool health examination and its adherence: Results of the prospective cohort study ikidS

Background

Each child in Germany undergoes a preschool health examination including vision screening and recommendations for further ophthalmic care. This study investigated the frequency of and adherence to these recommendations.

Methods

A population-based prospective cohort study was performed in the area of Mainz-Bingen (Rhineland-Palatinate, Germany). All preschoolers were examined at the statutory preschool health examination, which includes vision testing (Rodenstock vision screener) with available correction in the last preschool year. Based on the results, recommendations for further ophthalmic care were given to the parents. Six weeks prior to school entry, parents were surveyed concerning ophthalmic health care visits, diagnoses, and treatments. Ophthalmic care recommendation frequency and its adherence were investigated using logistic regression analysis adjusted for potential confounders.

Results

1226 children were included in this study, and 109 children received a recommendation for ophthalmic care based on the preschool health examination. At the follow-up, 84% of children who had received a recommendation had visited an ophthalmologist within the preceding year compared to 47% of children who had not received a recommendation. The recommendation for ophthalmic care was clearly associated with a higher number of ophthalmological visits (odds ratio = 7.63; 95% confidence interval: 3.96–14.7). In a subgroup analysis, adherence to a recommendation was lower in children with migrant background (OR = 2.26; 95%-CI: 0.64–7.90, compared to: OR = 11.6; 95%-CI: 4.95–27.4) and in those with low socio-economic status.

Conclusions

Adherence to preschool recommendations for ophthalmic care is high in German preschoolers. However, a migrant background and low socio-economic status may reduce this adherence.

[Practising appropriate vision check scheme in eye diseases mass screening works]

Vision check is the first step of mass screening works of most blinding diseases. In recent China, the primary childhood vision check is mainly conducted by hygiene teachers in educational institutions, following the Chinese traditional poor vision classification system, which is based on uncorrected distance visual acuity. However, this classification system does not meet childhood vision developmental mechanism, and may lead to massive unnecessary repetitive screening, diagnosis and treatment of corrected ametropia. In some Chinese communities and villages, the vision check is still based on uncorrected distance visual acuity during eye diseases mass screening procedures in adults. The critical point of preschool children vision impairment screening is then suggested to follow novel Chinese amblyopia diagnostic criteria. Combination of uncorrected, presenting and corrected visual acuity indexes may be used for children' vision check. Collaboration of children health care workers, pediatric ophthalmologists and optometrists in children eye diseases screening projects should be realized as soon as possible. In the adult population, presenting vision is suggested to be used in vision impairment screening works, and appropriate vision check scheme should be adopted in specific eye diseases screening works.

Why are there defaulters in eye health projects?

PURPOSE

To identify barriers to attendance for eye examination of schoolchildren.

METHODS

Cross-sectional study. Students in grades 1-4 in elementary school in Guarulhos (Brazil) were screened and referred for ophthalmic examination in 2006. Facilities offered in this project were: examination arranged during weekends, free transportation, spectacle donation and two different opportunities for exam. A questionnaire was applied, by interview, to a sample consisted of students' parents attended in a community project who missed the first call and attended the recall, to identify the reasons for non-attendance.

RESULTS

The sample consisted of 767 parents or guardians, corresponding to an equal number of schoolchildren. Personal characteristics of the students: 49.2% male and 50.8% female, 60.2% of them had never received previous ophthalmologic evaluation. Reported reasons for no-show to the project: parents had not received appropriate orientation (35.6%), loss of working day (20.6%), illness (12.4%), had another appointment (10.0%). The need for eyeglasses was higher in the recall.

CONCLUSIONS

A significant number of parents did not take their children for ophthalmological exams, even when a second opportunity was offered in projects with transportation facilities, free exams performed during weekends and spectacle donation. The main causes of absenteeism were lack of awareness and work. For 87.1% of the absenteeism cases, the difficulties could be overcome via improved structuring of the first call. A recall increases attendance coverage of target population by only 15.2% (59.3 to 74.5%). Notably, the eye exam campaign was the first exam for most of the absent students.

Literature review on preschool vision screening

Amblyopia results from degradation of the retinal image during a sensitive period of visual development. Amblyopia is the most common cause of visual loss in children. Because of the failure in detection and in treatment, amblyopia is still an important cause of visual loss in adults. Results from recent randomised trials in amblyopia should change our approach to screening and treatment. Based on the current evidence, if a single screening session is used, screening at school entry could be the most efficient screening moment. Between researchers, however, there still exists a lot of controversy on the benefit of visual screening.

Retinal examination of diabetic patients: knowledge, attitudes and practices of physicians in Oman

Knowledge, attitudes and practices of 40 randomly selected physicians was assessed in the North Sharqiya region of Oman in 2003. We evaluated non-ophthalmologist physicians' knowledge of techniques of eye examination of diabetic patients, attitudes towards fundus examination and practices of detailed eye examination. Knowledge about different parts of the eye was satisfactory in only 58% of physicians and knowledge about method of fundus examination for diabetic retinopathy was poor in 40%. Attitudes towards eye examination by non-ophthalmologists at primary level were positive. In practice 20 physicians had attempted to use an ophthalmoscope and only 9 could see details of the retina. Our general physicians would need detailed training if they are to be involved in early detection of diabetic retinopathy.

Vision First, a program to detect and treat eye diseases in young children: the first four years

PURPOSE

The Vision First program began in the fall of 2002 as a community outreach initiative by the Cleveland Clinic Cole Eye Institute in partnership with the Cleveland Metropolitan School District. It was designed to provide free eye examinations to all prekindergarten, kindergarten, and first grade students enrolled in Cleveland City public schools in order to diagnose refractive errors, amblyopia, and strabismus, so that treatment is instituted and the best possible visual outcome attained.

METHODS

Examinations are performed in 2 lanes of a specially outfitted recreational vehicle. All children undergo monocular visual acuity testing at distance and near, stereopsis testing, cover testing at distance and near, testing of versions, and external ocular inspection. If a child fails any part of this examination according to the guidelines set by the American Academy of Pediatrics, cycloplegic drops are instilled and an optometrist refracts the child on location and performs indirect ophthalmoscopy. Glasses are prescribed and follow-up with a pediatric ophthamologist is arranged.

RESULTS

During the first 4 years of the program, 22,988 examinations were performed. Seven percent of children had errors of refraction that necessitated optical correction, about 2.1% had strabismus, and 1.7% had amblyopia. The cost per student per year was around $23 excluding glasses.

CONCLUSIONS

About 10% of 5- and 6-year-old schoolchildren have eye problems that require either glasses or treatment for strabismus or amblyopia. The Vision First model brings eye care professionals to the schools and provides effective comprehensive screening of all children, as well as detailed examination and referral of those with significant eye problems.

Rapid assessment of cataract at pension pay points in South Africa

AIM

To test a method for the rapid assessment of cataract blindness in South Africa.

DESIGN

Randomised cluster-based cross-sectional survey (20 clusters of 50 each).

SETTING

Pension pay points in Moretele district, North West Province, South Africa.

SUBJECTS

Female pensioners aged >or=60 years, and male pensioners aged >or=65 years.

OUTCOME MEASURES

(1) Prevalence of cataract requiring surgery; (2) prevalence of blindness due to cataract; (3) cataract surgical coverage; (4) cataract surgery outcome; and (5) barriers to cataract surgery.

RESULTS

1000 pensioners were screened (681 women and 319 men). 17.2% of pensioners had operable cataract (visual acuity <6/60); 95% CI -3.4% to 3.4%); 15.6% of pensioners were blind due to cataract (95% CI -3.1% to 3.4%); and 5.6% of pensioners had had previous cataract surgery, 55.4% with intraocular lens implant and 44.6% without intraocular lens implant. The cataract surgical coverage was 24.6%. 80% of people who had had surgery were satisfied with the result, but 26.8% had a poor outcome according to the World Health Organization criteria. The main barrier to uptake of surgery was a lack of awareness of the availability of the surgery.

CONCLUSIONS

Rapid assessment of cataract at pension pay points is a useful and effective tool for our district Vision 2020 programmes in South Africa. Steps need to be taken to raise awareness of the availability of cataract surgery among indigent pensioners, and to improve the quality of visual outcome after surgery by ensuring routine monitoring of postoperative visual acuity.

The Results of Screening Frequency Doubling Technology Perimetry in Different Locations of the Community

PURPOSE

To determine the effect of screening location on the frequency of abnormal test results with Frequency Doubling Technology (FDT) perimetry.

DESIGN

Retrospective cross-sectional study.

METHODS

The Vision Screening Outreach Project conducted FDT testing in community sites surrounding Portland, Oregon. The sites were separated into a specific location type: health care clinics, work sites, senior centers, festivals/fairs, food banks/shelters, and other locations. These locations were compared for differences in the proportion of screening failures.

MAIN OUTCOME MEASURES

Screening failure (defined as a repeatable, abnormal FDT result in either eye).

RESULTS

There were 9052 participants from 211 locations in Oregon and Washington. On initial FDT testing, the right and left eye had abnormal results in 18% (1654/9052) and 21% (1918/9052) of participants. Of those with abnormal FDT results, approximately 30% of eyes reverted to normal on repeat testing. Overall, 13% of participants were screening failures. Screening failure was highly associated with age (P<0.001). After controlling for age, participants at senior centers (P<0.001) were most likely to be screening failures and participants at work sites (P=0.006) were least likely to be screening failures when compared with health clinics.

CONCLUSIONS

An investigator should repeat an initially abnormal FDT result when screening with FDT. Age and the location of testing influence the probability of a screening failure. Screening in senior centers is most likely to result in screening failure. However, only a randomized controlled trial can determine the true benefit of FDT screening in these locations.

Glaucoma screening during regular optician visits: can the population at risk of developing glaucoma be reached?

AIM

To determine the percentage of the population at risk of developing glaucoma, which can potentially be reached by conducting glaucoma screening during regular optician visits.

METHODS

1,200 inhabitants aged >40 years were randomly selected from Dutch community population databases. A questionnaire was mailed to these inhabitants with questions on their latest optician visit and risk factors for glaucoma. A second questionnaire was sent to their opticians, who were asked about their willingness to conduct an additional glaucoma screening programme in the future.

RESULTS

The questionnaire was returned by 959 of 1,200 inhabitants and 37 of 50 opticians. The percentage of inhabitants who visited an optician during a 5-year period was 83% (95% confidence interval (CI) 80% to 85%). This percentage was adjusted for the presence of risk factors for glaucoma to obtain the percentage of the population at risk of developing glaucoma. The percentage of opticians willing to cooperate in a glaucoma screening programme extended beyond a non-contact tonometry measurement alone was 91% (95% CI 77% to 98%).

CONCLUSION

By conducting glaucoma screening during regular optician visits, a large section of the population at risk of developing glaucoma can be reached.

Do infants of birth weight less than 1500 g require additional long term ophthalmic follow up?

AIM

To survey existing ophthalmic follow up protocols in the United Kingdom for very low birthweight (VLBW) children. In addition, relative risk analysis was performed using data from a cohort study to assess which factors (birth weight, gestational age, retinopathy of prematurity (ROP) status) led to a high risk of developing amblyogenic factors.

METHODS

Questionnaires were sent to every orthoptic department in the United Kingdom (n = 288) for information on their policy on the follow up of VLBW children.

RESULTS

Responses were received from 125 departments (43%). There was a large variation in criteria used for follow up; 21% of respondents using birth weight (BW) and gestational age (GA), 22% using stage 3 or treated ROP, the remainder using a combination of these factors. There was no consensus regarding when follow up should commence (from 3 months to 3 years) or cease (1-8 years). Relative risk analysis revealed that birth weight under 1500 g, GA under 33 weeks, and the presence of severe ROP were significant risk factors for developing one or more amblyogenic factors.

CONCLUSION

There is no consensus on whether VLBW children need to be reviewed. There is a greatly increased risk of ophthalmic deficits in those with severe ROP or severe neurological disorders, and also in those with mild or no ROP. Children in the latter group who are not routinely followed up, have a high risk of developing treatable refractive errors and strabismus. This raises the question of whether an additional screening examination is merited.

The ORBIS Flying Eye Hospital

In the mid 1970s, Dr David Paton, a Houston ophthalmologist, conceived the idea of an airborne ophthalmic teaching hospital. He wanted to share eye care skills and expertise with health personnel in developing countries. With the help of benefactors, the charity ORBIS was formed 24 years ago with the aim of eliminating avoidable blindness worldwide by taking medical and surgical skills, readily available in the Western world, to areas of greatest need.

Lions Clubs International Foundation Core Four Photoscreening: results from 17 programs and 400,000 preschool children

INTRODUCTION

Photoscreening programs for preschool vision screening have been promoted by Lions Clubs International Foundation (LCIF) via their 17 Core Four grant project awards since 1999. Results from 15 Core Four grant programs in the United States and one in Taiwan are presented here.

METHODS

Photoscreening was modeled after the Tennessee program and instituted statewide in each area. Programs were given latitude with respect to screening instrument and referral criteria, but a partnering academic institution and medical director were expected. Preschool children were screened by volunteers; referred children were examined by community optometrists and ophthalmologists who returned results to each program's coordinating center. Outcome data included number of children screened, referral rate, follow-up rate, and positive predictive value, which was generally determined using AAPOS-defined vision screening criteria.

RESULTS

All but one program used the MTI photoscreener (it chose not to participate); photoscreening referral criteria were standard for 13 programs. Through December 2004, more than 400,000 preschool children had been screened. The referral rate for programs using the MTI photoscreener averaged 5.2% (range, 3.7-12.6%). The predictive value of a positive photoscreen was 80%. Overall, 54% of referred children received follow-up examinations. Follow-up rate was the largest variable: 4 programs, screening nearly 250,000 children, had follow-up rates 70% or greater; 10 programs had follow-up data from fewer than 40% of referred children.

CONCLUSIONS

Volunteer-led photoscreening programs can be instituted in other locations, including overseas, with high levels of effectiveness. Limitations include the possibility of poor success and variable attention to follow-up.

The yield and challenges of charitable state-wide photoscreening

INTRODUCTION

State-wide cooperative programs for pediatric vision screening utilizing the MTI photoscreener and centralized interpretation were established in Alaska (The Alaska Blind Child Discovery, ABCD) and in Tennessee (Tennessee Lions Outreach).

METHODS

Details of setup, implementation and interpretation of the state-wide MTI photoscreening programs are compared through 2002. The absolute numbers of children screened and the breakdown in interpretation categories are presented.

RESULTS

ABCD screened 14,000 children while Tennessee Lions screened 100,800. Similarities between ABCD and Tennessee programs were funded by Lions Clubs and other charitable and public health organizations, community screening and each had coordinated centralized image interpretation and notification. The programs differed by clinic focus (Tennessee Lions organized pre-schools while ABCD used village and community health fairs and schools), parent notification (Tennessee Lions communicated through pre- schools and ABCD mailed directly to parents), and image interpretation (Tennessee used VOIC age-based and pupil-size crescents while ABCD used "delta-center crescent"). Predictive value positive was 73% for Tennessee and 89% for ABCD. Tennessee achieved better followup on referrals after a specific coordinator was employed. Image interpretation breakdown for ABCD: Tennessee Lions Outreach were anisometropia (29%:34%), high hyperopia (33%:16%), astigmatism (18%:30%), strabismus (7%:15%), myopia (5%:2%), cataract (0.7%:0.2%). Two state-wide programs detected 3216 amblyopic children at a charity borne-cost of 1.5 million dollars. If the parents persisted with appropriate amblyopia therapy, the expected societal value was estimated at 17 million dollars. Lacking societal mandate and funding, these concerted charitable efforts only achieved a community penetration rate of 10% to 14%.

CONCLUSION

National adoption of preschool vision screening by a method with similar or even better validity and cost effectiveness as MTI photoscreening, ideally in the pediatric medical home, is warranted.

Ophthalmic nurse practitioner led diabetic retinopathy screening. Results of a 3-month trial

PURPOSE

To describe the design and implementation of a nurse led diabetic retinopathy screening clinic. To present the results of a 3-month trial period assessing the concordance of retinopathy grading between a nurse practitioner and an ophthalmologist.

METHOD

Patients attending for annual diabetic eye review during an initial 3-month trial period were assessed in a dedicated diabetic eye clinic by an ophthalmic nurse practitioner and an ophthalmologist, with both grading the degree of diabetic retinopathy using to the Wisconsin grading system. Each was masked as to the other's findings. The concordance of retinopathy grading between ophthalmic nurse practitioner and ophthalmologist was assessed.

RESULTS

A total of 95 patients (189 eyes) were assessed during the study period. A 92% concordance was achieved between the ophthalmologist and the ophthalmic nurse practitioner. In total, 72 eyes were graded as having some degree of retinopathy by the ophthalmologist. The sensitivity of the nurse practitioner for diagnosing the presence of diabetic retinopathy was 93%, and the specificity 91%. Nine eyes with severe nonproliferative diabetic retinopathy or worse, and four with clinically significant macular oedema were seen. All were correctly identified by the nurse practitioner.

CONCLUSIONS

The structure and management protocols of the clinic are described. An excellent concordance between ophthalmologist and nurse practitioner was achieved in this group of patients with relatively less advanced retinopathy.

Model simulation of the patient flow through a screening centre for diabetic retinopathy

PURPOSE

To construct a quantitative, flexible and simplified mathematical model of the patient flow through the Eye Clinic at the Steno Diabetes Centre (SDC) in order to enable rational dimensioning and assess the effects of modifications.

METHODS

Patient data were drawn from the Eye Care database at the SDC. A simple patient flow model was constructed, allowing simultaneous adjustments of all variables, and the model was tested. Two scenarios were simulated: (1) adjusting the algorithm that assigns the follow-up intervals, and (2) increasing the population size to include all patients with diabetes in Copenhagen County.

RESULTS

The model can describe the patient flow under steady state conditions, but is less precise in predicting transient changes with the present set-up. Accordingly all simulations were run for a substantial number of iterations. The two scenarios illustrate the usefulness of the model by calculating the required photographic examination capacity for the specific population, thereby allowing better estimations of future dimensioning of the organization.

CONCLUSION

The study presents a patient flow model that can be used to illustrate the effects of proposed changes prior to their implementation, specifically with respect to the capacity of the system.

An evaluation of the change in activity and workload arising from diabetic ophthalmology referrals following the introduction of a community based digital retinal photographic screening programme

AIMS

To determine how the workload of an ophthalmology department changed following the introduction of an organised retinal screening programme.

METHODS

Information was collected from the hospital medical record of people with diabetes attending eye clinics over 4 years. The first year was before screening, the next 2 years the first round, and the fourth year the second round.

RESULTS

The total number of people with diabetes referred each year over the 4 year period was 853, 954, 974, 1051 consecutively. The number of people with diabetes in the county rose by 1400 per annum. The total number of referrals for an opinion about diabetic retinopathy was 227, 333, 363, 368, for cataract was 64, 57, 77, 93, and for glaucoma was 57, 62, 61, 68. The total number of patients referred for laser treatment over the 4 years was 77, 124, 111, and 63

CONCLUSION

This study suggests that the workload in the eye clinic increases in the first round of screening but in subsequent rounds it does not fall below the pre-screening level, except for laser treatment. This may be partly because of increasing numbers of people with diabetes. With the introduction of a national screening programme, this has significant workload implications for the National Health Service.

Rapid assessment of cataract surgical services in age group 50 years and above in Lower Dir District Malakand, Pakistan

OBJECTIVE

To assess the rapid assessment of cataract blindness and surgical services in age group 50 years and above.

DESIGN

A cross-sectional survey.

PLACE AND DURATION OF STUDY

This survey was conducted in District Lower Dir, Malakand Division, NWFP, Pakistan, from March 9-23, 2003.

PATIENTS AND METHODS

A community-based survey was carried out with systematic cluster random sampling. The survey was preceded by a pilot study in which the proforma and operational methods were field-tested and refined. One thousand, one hundred and fifty eligible adults of 50 years and older were selected by systematic random sampling from the whole lower Dir district of Malakand, Pakistan. A total of 1076 subjects (93.6%) were examined. The visual acuity of each eye was assessed using tumble Snellen's E Card method at 6 and 3 meters. Any subject having visual acuity <3/60 with or without obvious lens opacity or with aphakia (removal of lens) or pseudophakia (removal of cataract lens and implantation of artificial lens) was examined in detail. The surgical services were assessed by measuring the prevalence of pseudophakia, surgical outcome of visual acuity and also the effect of place of surgery on outcome.

RESULTS

Prevalence of total bilateral blindness was 2.6%, and unilateral blindness 2.46%. Total prevalence of aphakia was 2.4%, which was almost equal in both sexes, male 2.3% and female 2.4%. Prevalence of unilateral aphakia was 0.3 % in females being slightly higher than males, 0.16 %. The prevalence of bilateral aphakia was 2.2% and 2% in males and females respectively. Prevalence of total pseudophakic eyes was 2.74%. Surgical outcome showed good, borderline and poor visual acuity of 40.5%, 22% and 14.3% respectively. Surgical outcome was also seemed to be better in private hospitals as compared to field camps.

CONCLUSION

It is concluded that to reduce the prevalence of blindness there was a need to improve the quality of services in mobile camps and fixed facilities. At the same time the visual outcome of surgery could be improved by expanding the number of Intraocular lens procedures and routine monitoring of cataract outcome.

Evaluation of the traveling vision examiner program in the submacular surgery trials pilot study

PURPOSE

To describe methods and results and to assess the value of a Traveling Vision Examiner (TVE) Program designed to provide masked vision measurements by expert vision examiners who were independent of, and traveled to, local clinical centers.

METHODS

The Submacular Surgery Trials (SST) Pilot Study was conducted to refine the design and methods for a set of multicenter, randomized clinical trials to evaluate submacular surgery in patients with subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration (AMD) or ocular histoplasmosis (OHS), or idiopathic CNV in which the primary study outcome would be change in 2-year best-corrected vision from baseline. As part of the SST Pilot Study, the feasibility and value of a TVE Program was assessed. The goal of the program was to obtain unbiased vision measurements, according to a standard protocol, of best-corrected visual acuity, reading speed, and contrast threshold, of each patient at 2 and 4 years after enrollment.

RESULTS

Eighty-three visits by TVEs were made to 16 centers participating in the SST Pilot Study; 239 patients had at least one masked vision examination. Comparison of pairs of vision measurements of the traveling vision examiners and local vision examiners for 71 patients made on the same day showed good agreement overall (intraclass correlation coefficient > or = 0.81).

CONCLUSIONS

The proposed TVE Program was judged to be a feasible and useful method of providing standardized, unbiased, masked vision measurements. This approach was incorporated into the larger clinical trials conducted by the SST Research Group.

School vision screening, ages 5-16 years: the evidence-base for content, provision and efficacy

The optometric profession in the UK has a major role in the detection, assessment and management of ocular anomalies in children between 5 and 16 years of age. The role complements a variety of associated screening services provided across several health care sectors. The review examines the evidence-base for the content, provision and efficacy of these screening services in terms of the prevalence of anomalies such as refractive error, amblyopia, binocular vision and colour vision and considers the consequences of their curtailment. Vision screening must focus on pre-school children if the aim of the screening is to detect and treat conditions that may lead to amblyopia, whereas if the aim is to detect and correct significant refractive errors (not likely to lead to amblyopia) then it would be expedient for the optometric profession to act as the major provider of refractive (and colour vision) screening at 5-6 years of age. Myopia is the refractive error most likely to develop during primary school presenting typically between 8 and 12 years of age, thus screening at entry to secondary school is warranted. Given the inevitable restriction on resources for health care, establishing screening at 5 and 11 years of age, with exclusion of any subsequent screening, is the preferred option.

A review of preschool vision screening for strabismus and amblyopia in France: 23 years experience in the Alsace region

The authors report their experience in preschool vision screening in the east of France, involving the Mother and Child Welfare Service and the School Health Service, under the administration of the National Ministry of Education. The review underlines the importance of early diagnosis of visual disorders in children before they reach three years of age. They recommend screening of every child at least once before the age of four years.

Screening for diabetic retinopathy in remote Australia: a program description and evaluation of a devolved model

OBJECTIVES

To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure.

METHOD

Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database.

RESULTS

The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley-wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics' home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting.

CONCLUSIONS

Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area.

Incidence of sight-threatening retinopathy in Type 1 diabetes in a systematic screening programme

AIM

To measure the cumulative incidence of any retinopathy, maculopathy and sight-threatening diabetic retinopathy (STDR), and calculate optimal screening intervals by retinopathy grade at baseline for patients with Type 1 diabetes attending an established systematic retinal screening programme.

METHODS

All patients with Type 1 diabetes registered with enrolled general practitioners, excluding only those attending an ophthalmologist, were studied if retinopathy data was available at baseline and at least one further screen event. Screening utilized non-stereoscopic 3-field mydriatic photography and modified Wisconsin grading. STDR was defined as moderate pre-proliferative retinopathy or greater and/or significant maculopathy in any eye.

RESULTS

Patients (n=501) underwent 2742 screen events. Cumulative incidence of STDR in patients without baseline retinopathy was 0.3% (95% CI 0.0-0.9) at 1 year, rising to 3.9% (1.4-5.4) at 5 years. Rates of progression to STDR in patients with background and mild pre-proliferative retinopathy at 1 year were 3.6% (0.5-6.6) and 13.5% (4.2-22.7), respectively. Progression to STDR was greater in patients with a higher grade of baseline retinopathy (P=0.001) or a longer disease duration (P=0.003). For a 95% likelihood of remaining free of STDR, mean screening intervals by baseline status were: no retinopathy 5.7 (95% CI 3.5-7.6) years, background 1.3 (0.4-2.0) years and mild pre-proliferative 0.4 (0-0.8) years.

CONCLUSIONS

Screening at 2-3 year intervals, rather than annually, for patients without retinopathy in Type 1 diabetes is feasible because of the low risk of progression to STDR, and may result in significant cost savings for a screening programme. Patients with higher grades of retinopathy require screening at least annually or more frequent.

Amblyopia treatment outcomes after preschool screening v school entry screening: observational data from a prospective cohort study

BACKGROUND/AIMS

Preschool screening for amblyopia has controversially been abandoned in some localities within the United Kingdom, on the basis that there is no clear evidence of benefit to support its continuation. Data collected within a birth cohort study were used to examine visual outcomes at 7(1/2) years in children who did or did not receive preschool vision screening.

METHODS

Monocular logMAR visual acuity with and without a pinhole was assessed by orthoptists. Contemporary records were used to identify children who had been offered and/or received preschool screening.

RESULTS

Of 6081 children, 24.9% had been offered preschool screening and 16.7% had attended. The prevalence of amblyopia was approximately 45% lower in the children who received preschool screening than in those who did not (1.1% v 2.0%, p = 0.05). The mean acuity in the worse seeing eyes after patching treatment was better for amblyopic children who received preschool screening than for those who did not; 0.14 v 0.20 logMAR (p <0.001). These effects did not persist in an intention to screen analysis.

CONCLUSIONS

Preschool screening at 37 months was associated with an improved treatment outcome for individuals with amblyopia. However, the improvement was clinically small and disappeared when considering all children offered screening rather than only those who received it. Further research is needed into improving the effectiveness of vision screening for preschool children, while in the interim these data do not conflict with current recommendations for school entry screening by orthoptists.

Ambulatory photographic screening for diabetic retinopathy in nursing homes

PURPOSE

To evaluate the feasibility and cost of screening for diabetic eye disease in homebound nursing home residents not attending a systematic screening programme.

METHODS

Postal survey identification of residents with diabetes in all nursing homes in Liverpool. An ophthalmologist and nurse performed Bailey-Lovie logmar visual acuity (VA), portable slit-lamp examination, fundus photography, and subjective assessment of ability to cooperate with treatment in a sample of homes. Modified Wisconsin photographic grading was performed. Screen-positive patients were invited to a dedicated assessment clinic. Sight-threatening diabetic eye disease (STED) was defined as any of: moderate preproliferative retinopathy or worse, circinate maculopathy, or exudate within 1 disc diameter of fixation.

RESULTS

A total of 54 (78%) nursing homes responded reporting 199/2427 (8.2%) residents with diabetes. Of these, 64/80 (80%) residents in 17 homes were examined: VA possible in 50 (78%); slit-lamp examination in 56 (88%); gradable photographs in at least one eye in 34 (53%); STED in 12 (35%) patients. In all, 35 (70%) patients had Snellen-equivalent VA worse than 6/12 in the better eye, of whom 13 (26%) were worse than 6/60. Of 29 screen positive patients, 12 attended the assessment clinic: one was unable to cooperate outside the home; 11 continue under ophthalmic review, four for previously undetected STED of which one listed for laser photocoagulation. Total cost pound 16,980; cost per screen event pound 60.30.

CONCLUSIONS

Systematic eye screening in homebound patients with diabetes detects disease but follow-up and treatment is only feasible in a small proportion and at high cost. Alternative targeted assessment is recommended.

Conducting community-based, culturally specific, eye disease screening clinics for urban African Americans with diabetes

The purpose of this study was to evaluate the need for, and efficacy of, community-based culturally specific eye disease screening clinics for urban African Americans with diabetes. The study employed a variety of culturally specific methods in the design and performance of 43 community-based eye disease screening clinics in southeastern Michigan. One thousand, thirty-seven subjects were recruited for the study. Of that number, 817 identified themselves as African Americans and are the focus of this report. Of the 817 African-American patients screened, 84 (10%) needed to be examined by an ophthalmologist immediately (< 30 days), and 180 (22%) needed to be examined soon (within 1 to 3 months), while 544 (67%) were advised to return for another exam a year later. The project demonstrated that it was possible to use culturally specific techniques to identify a significant number of urban African Americans with diabetes in need of eye screening and treatment. However, lack of health insurance proved to be the primary barrier to receiving needed treatment. Although the project was successful, it is not a solution to what is essentially a health systems problem, ie, inadequate access to appropriate diabetes care for a significant number of our population.