Through a Child’s Eyes

Tiny babies gaze intently at an adult face to pick up emotional and social cues. Pre-schoolers memorise their ABCs from looking at bright and colourful displays in the nursery. School kids learn about the rise and fall of civilisations by reading information chalked up on the school blackboard (or, as is more likely these days, displayed on an interactive smart board or device).

Vision’s importance to childhood development is recognised to the extent that all Australian states and territories do have systems in place to offer screening of children’s vision – to some degree.

Optometry Australia says “there remains no agreed vision screening protocol for children within Australia which is likely a result of the lack of strong evidence supporting the benefits and cost-effectiveness of screening programs, along with limited consistency of the existing programs”.

Behavioural optometrists look at visual input skills and visual processing skills, and at how visual information is stored and retrieved

“Australian children would benefit from improved collaboration between jurisdictions and participating health professionals in an effort to maximise early detection for eye and visual problems,” Optometry Australia said.

So, if the assumption is that paediatric vision problems will be picked up through screening programs, then dealt with by a subset of highly trained specialist ophthalmologists and optometrists, the reality is – and should be – far more complex and nuanced.

Paediatric Optometry ≠ Vision Screening

Lacking a basis for comparison, and with little or no verbal skills, children almost never complain about vision problems, so at first brush, universal vision screening of all children at key developmental stages sounds like a grand idea.

Not so, according to the most comprehensive report on vision screening ever conducted in Australia. The National Children’s Vision Screening Project Final Report, was prepared for the federal government by the Murdoch Children’s Research Institute Centre for Community Child Health.¹ Although released in 2009, the wheels of government sometimes turn slowly and the report’s analysis remains relevant.

The report concluded it was “challenged by the lack of formal evidence in some areas of vision screening”.

Certainly, the report indicates there is strong “expert and public support to continue the vision check that is current practice during the neonatal period”. The red reflex check is vital for the early detection of vision – and potentially life threatening abnormalities – such as cataracts, glaucoma, retinoblastoma, retinal abnormalities and systemic diseases with ocular manifestations.

The report also indicated its support for screening for amblyopia at about four years, concluding it provided “the best balance between reliability/accuracy and early diagnosis aiding successful treatment”.

It also supported universal screening programs that included comprehensive eye examinations be conducted for children considered at risk of vision impairment – Indigenous children, premature infants
and children with a developmental delay or disability.

However, it also recognised major limitations to the effectiveness of screening programs.

“Much of the screening or assessment that currently occurs prior to a child entering school relies on parents or caregivers being vigilant in taking their child along to regular checks… many of these checks have a poor uptake rate,” the report says.

In other words, despite the availability of free, accessible screening programs, many parents and carers just don’t follow through.

Spectrum

Rod Baker directs a practice based in Sunbury, Victoria, which includes specialised services for children, and is an Associate Professor in Paediatric Optometry at Flinders University in Adelaide.

Associate Professor Baker said the “paediatric space” is the subject of “a bit of antagonism, debate and dispute” – a situation he sees as unnecessary and detrimental to the best outcomes for children.

Paediatric vision care is best viewed as a spectrum, he said. At one end of the scale are paediatric ophthalmologists, who provide “high level surgical and medical care to a very small percentage of children who are blind or vision impaired.

“Very few optometrists will work with that small group (of children). This really is the domain of medicine. We (as optometrists) have a role in screening and we might work in an integrated way in rehabilitation or helping kids with vision impairment learn techniques for dealing with that.

“The next group – those with ambloyopia – is a “crossover” between ophthalmology and optometry,” he said, “with treatment options including surgery, glasses, eye patches and eye exercises”.

The third group was those with uncorrected refractive error. “Most preschoolers who need glasses are in the first two groups,” Associate Professor Baker said. “But when they hit school age, this group starts to need glasses. This is the domain of …‘bread and butter’ optometry,” he said.

Travel further down the spectrum and you find children with convergence issues that need vision therapy, rather than glasses. This is where the practice of behavioural optometry comes into its own, he said, with practice models and support staff that allow optometrists to provide the intensive level of care required over the course of a program that may last a number of weeks.

The fifth group, Assoc Prof Baker said, was the cross over into education. Children in this category may have specific learning difficulties, such as dyslexia, or disorders such as autism

Collapsing Silos

Associate Professor Baker says he’s “gone to great lengths” to straddle the spectrum – working collaboratively with paediatric ophthalmologists at one end of the scale, crossing right over into the “educational developmental kind of area.

“I don’t like the either/or paradigm,” he told mivision. They might have educational problems, they might have medical problems – they might have both.”

He said it was not helpful to build “silos” that excluded cooperation and recognition of eye care professionals working at either end of the spectrum of child vision problems… or to silo eye health from other health issues.

“Very much the future for optometry in the paediatric space is in interdisciplinary working together with other professionals. Eye care professionals working in a silo leads to strain – not just in the eye care space but in medicine and the education system. There are so many dysfunctional silos going on out there. We have a great opportunity to provide leadership and better models of interdisciplinary care,” he said.

Assoc. Prof. Baker said while public and parental education about the warning signs of vision problems was important a smarter approach was to coordinate with allied health and child professionals, “we’ll reach more of the kids in more need and its actually achievable, we have the resource to do that as opposed to the bottomless pits of marketing and health screening”.

Core Competency

Assoc. Prof. Baker said he’s a strong believer in all optometrists being able to deal with children in their practices.

“There are professional skills that need to be learned, particularly in examining pre-verbal children. “A lot of the emphasis (in optometry university degrees) is on communication skills and technical skills to provide proper eye-screening procedures to children. After university, the average optometrist needs to keep up with it in CPD. Although they may not treat many children, the average practice still has got to have competence and the tools to know what to do.

“One of the key things is to recognise your own limitations and refer on… many other optometrists refer kids to me and that’s healthy, but I have always pushed for… the average optom to do more, to be more competent rather than do just the bare minimum and refer on.

“There is a place for people with a high level of skills in a particular area, but we want the floor to be higher overall.”

Behavioural Optometry

In recent years, despite some questioning the scientific evidence of its efficacy, the practice of behavioural optometry has gained ground, particularly in the paediatric space. Aspects of behavioural optometry are now taught at most Australian universities as part of the undergraduate optometry courses.

The Australasian College of Behavioural Optometry says defining the field of practice involves “understanding vision and how it is different than eyesight”.

“Eyesight essentially refers to the physical attributes and performance of the many organic components involved in the visual system… 20/20 vision is a commonly quoted measure of normal vision, yet it simply describes the sensitivity of the eye to see fine detail in the distance,” ACBO said.

“While this is an important measurement… vision is a thought process. Vision combines information from many sensory systems to create a perception of reality,” the organisation said.²

Behavioural optometrist Keith Miller, from Visique Greerton, in the Bay of Plenty on the northern coast of New Zealand, has been practising behavioural optometry for the past 30 years.

Mr. Miller said that “vision is a dominant sensory process” – 70 per cent of all our sensory information gets in from the eyes and integrates with the other senses.

“Behavioural optometrists look at visual input skills and visual processing skills, and at how visual information is stored and retrieved. These are learned skills and can be improved with appropriate lenses or vision training,” he said.

“Approximately one in five children in a classroom have not developed adequate visual skills to function properly, especially when working up close during tasks such as reading, writing and computer use.

“These (tasks) place high demands on our visual systems. Parents and teachers often attribute a child’s difficulties in the classroom to learning disabilities or attention deficit disorders because they have 20/20 vision, when the real problem may be an undiagnosed vision problem,” Mr. Miller said

Visual Skills
Mr. Miller describes six main visual skills that are targeted in behavioural optometry and improved with appropriate lenses or vision training.

Eye tracking
Also known as oculomotility or eye movement control, requires that the eyes move together with exquisite precision. When well-integrated, this allows for following the lines of print in a book, quick and accurate shifts from far to near and sure tracking in sports.

Focusing
The ability to sustain and maintain clarity on targets at different distances, such as reading and writing, as well as rapidly and efficiently changing clarity from far to near, such as copying from the whiteboard. Visual focus is intimately related to the ability to sustain visual attention.

Binocularity
The ability to keep a target single. The closer the target, the more your eyes have to turn in to keep it single, such as when reading. If the eyes are not accurate where they target, or cannot maintain their ability to target, it takes more effort to take in and process visual information. This can result in reduced visual attention, negatively affect spatial judgments and cause crossed or wandering eyes.

Depth perception
Closely related to eye teaming. If the eyes do not work together efficiently as a team, the brain will not perceive depth accurately. This can affect sporting ability and the riding of bikes and scooters, and cause clumsier behaviour such as knocking over cups and tripping on steps.

Eye-hand-body coordination
Also known as visual motor integration, it is essential for accurate and stress-free writing and efficient performance in sports. It is important that the visual system sends a signal to the body’s motor centres for good gross and fine motor coordination and overall balance.

Visual form perception
A group of visual abilities needed for quick and accurate identification and discrimination of objects, for comparing similarities and differences, recognising and generalising forms, and coming to valid conclusions based on the accurate analysis of available visual information.

Vision Training
Sydney optometrist Russell Lazarus said vision therapy was an area of clinical care where optometrists can “still occupy the primary space in treatment options for patients”.

He said some optometrists were reluctant to include vision therapy.

“The primary reasons given generally include complexity for patients and staff, lack of professional reputation and cost in both time and money,” Mr. Lazarus said.

But Mr. Lazarus said there was a strong case for the benefits of vision therapy.

He said US studies showed that up to 85 per cent of children classed as academically or behaviourally at risk have vision problems that are either undetected or untreated.

“We have similar statistics in Australia – that’s one million kids in Australia that have vision problems.

Mr. Lazarus said his practice sees many children diagnosed with learning and behavioural difficulties who make rapid improvements after vision therapy.

It’s a point also made by Associate Professor Baker, who references the case of one patient – a child diagnosed with attention deficit disorder. Despite seeing a number of child medical specialists, he had never had an eye exam. Assoc. Prof. Baker said the child had severe vision problems.

“We’ve got a lot of work to do in that inter-professional space to ensure that other professionals are twigging onto the things in that checklist, that might signal vision problems,” he said.

“A child with developmental difficulties is more than twice as likely to have a concurrent vision problem as well. That’s not to say it is causative. We describe it as co-existing. Sometimes it (addressing the vision problems) has a big impact, sometimes not, but at least it is one less thing that child has to deal with,” Assoc. Prof Baker said.

References
1. Centre for Community Child Health, Murdoch Children’s Research Institute National Children’s Vision Screening Project: Final Report, May 2009 accessed at: www.rch.org.au/uploadedFiles/Main/Content/ccch/Vision_Screening_Final_Report_May_2009.pdf [13 March 2014].
2. Australasian College of Behavioural Optometrists, Patient Information – Behavioural Optometry available at: www.acbo.org.au/news-views/for-patients/249-patient-information-behavioural-optometry [accessed 20 March 2013].