The two most common childhood vision problems – amblyopia and refractive error – can only be detected with monocular visual acuity screening. Who conducts the screening programs, how often the screening takes place, and whether or not a comprehensive eye test would be more beneficial, have become hot topics of debate.
The most appropriate approach to screening the vision of young children is in dispute, with the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) questioning the involvement of all optometrists in free screening programs in schools. Instead the College supports government organised screening of four year olds and the reintroduction of screening by GPs.
Dr. Maree Flaherty, a member of the RANZCO Paediatrics Special Interest Group said, “If there are no significant signs of vision problems earlier, then around four years old is an appropriate time for eye screening. Screening in schools should be performed as part of an official screening program, such as the NSW StEPS (Statewide Eyesight Preschooler Screening) Program, by practitioners who have no financial interest in the outcome of the screening process.”1
Dr. Flaherty’s comments, along with those of Dr. Alan Hilton, Brisbane North Eye Centre, were published in Insight in August and they sparked a strong reaction from Optometry Australia (OA), the Australian College of Behavioural Optometry (ACBO), and other representative groups. mivision decided to dig deeper to find out why optometrists believe they have an important role to play in school screening.
One in four children have a vision issue and one in five have an undetected eye health issue
Speaking with mivision, Lyn Brodie, CEO of OA said, although StEPS is an effective program, “existing screening programs for children differ by jurisdiction and are often inadequate to fully identify vision and eye health needs. “One in four children have a vision issue and one in five have an undetected eye health issue. Furthermore, myopia is said to be the fastest growing health epidemic in the world,” said Ms. Brodie. “Bearing this in mind, government led screening programs should be enhanced to provide better access to eye care that supports prevention and early identification and we would welcome collaboration with RANZCO in advocating this to state and territory governments”.
STEPS PROGRAM
Within the StEPS Vision Screening Program, “suitably trained” and equipped StEPS vision screening staff check the vision of all four year old preschool children in Local Health Districts of New South Wales.2 If the child’s vision is abnormal, they are referred for secondary screening or to a paediatric ophthalmologist for a comprehensive assessment.
According to Dr. Flaherty, “The StEPS screening model used in NSW can be held up as a best practice example of eyesight preschooler screening and its success has been published in the Medical Journal of Australia. The Australian Capital Territory and Queensland also have screening programs. Unfortunately, not all states provide this important service. RANZCO would strongly support the rolling out of StEPS model across all states in Australia, as well as the reintroduction of screening by GPs as part of a four year old health check, along with vaccination, hearing, physical measurements and other school/ preschool readiness checks.”
Ms. Flaherty continued, “A simple, monocular vision test with clear pass/ fail criteria, as could be quickly performed by GPs as part of the appointment already taking place for the four year old health check, would take very little time and resource. While not an eye care professional per se, a GP is well equipped to perform a primary eye check of this type. A separate eye test by an optometrist generally involves more in-depth eye examinations, which are unnecessary for a screening program. This in-depth level of the eye examination should be undertaken if a vision problem is suspected, as opposed to as a matter of course.”
SUPPORT NEEDED
Greg Johnson, CEO of Essilor Vision Foundation agrees that programs like the NSW StEPS program are ideal, however like Ms. Brodie, he said it needs support.
“The Foundation certainly supports Dr. Flaherty’s comment that ‘official programs were the ideal way to ensure children received an appropriate eye test’1 and would be pleased to partner with any state/ territory government,” said Mr. Johnson.
“In our short two year life we have made representations to most education ministers/shadow ministers to roll-out local programs with various levels of success. Certainly the best outcome to date is our ongoing funding from the City of Greater Geelong Council, which is helping us to provide screening to low socioeconomic schools in the Geelong area with the generous assistance of the Deakin University, School of Medicine Optometry Program. Indeed the screening forms part of the course curriculum.”
According to Mr. Johnson, a significant number of children who are screened are deemed in need of a full consultation, demonstrating the value of screening outside the government led programs.
“Around one third of children receiving free screening receive a recommendation to their parents/guardians to make an appointment with a local optometrist who has volunteered to take school screening referrals.” At the time of writing, Mr. Johnson said Essilor Vision Foundation had screened 7,150 children in Australia and 875 pairs of free spectacles had been dispensed.
Steve Leslie, president of the Australasian College of Behavioural Optometrists said inadequate screening may be due to government funding. “Attacks on optometrists providing vision screenings in schools by some ophthalmologists have occurred periodically for decades, on the bases that government screenings are sufficient, and that optometrists over-refer children for full examinations. Over the years, governments in all states have devoted less money to school vision screenings, cancelled programs and then later started a different program,” he said.
SCREENINGS WASTEFUL AND A CONFLICT OF INTEREST
Medicare items cannot typically be claimed for school screenings and according to Mr. Leslie, “It is part of the Medicare agreement all optometrists sign that vision screenings cannot be charged under Medicare.”
However, Dr. Flaherty told mivision that RANZCO has seen “many” instances where optometry practices are working in schools to offer non-compulsory comprehensive eye examinations, with costs covered by Medicare.
Around one third of children receiving free screening receive a recommendation to… make an appointment with a local optometrist…
One newsletter to parents from John Palmer Public School, The Ponds in NSW dated February 2018 stated, “An optometrist will be onsite during school hours to provide students with a comprehensive eye examination… Each attendee will receive an individual report regarding the eye health and a prescription will be provided if glasses are required… this service does not sell glasses and the prescription can be taken to any optical store.” The newsletter did not nominate the optometrist. It included a form for parents to complete Medicare details.
Dr. Flaherty commented, “If the eye exams undertaken in schools require parents to provide a child’s Medicare number for the exams, as with many of the cases we have seen, then the eye exam cost is likely being covered by public resources. In addition, if a significant number of children are being sent unnecessarily, for full optometric testing following eye testing in schools as the evidence suggests, then this further draws on both public resources and those of the parents.”
Some ophthalmologists have also expressed concern about a potential conflict of interest when optometrists and behavioural optometrists undertake screening.1
In the Insight article Dr. Hilton said, “Optometrists should not be able to take part in any school screening procedure involving children as there is a potential financial advantage to that person or group, for example, by way of selling glasses… Similarly, behavioural optometrists should not partake in screening children’s vision in schools as there is a potential financial advantage to them of not only selling glasses, but selling the use of exercises. This is especially concerning when there are no evidence-based studies to support such practices.”1
In the case of Essilor Vision Foundation, screening programs are conducted by volunteer optometry students under the observation of volunteer optometrist/s. “Usually the optometrist overseeing the school screening is doing it for purely humanitarian reasons, the screening is not ‘local’ to them, and the optometrist is very unlikely to see the child for a full consult,” said Mr. Johnson.
“The screenings are simply a guide and if the student doesn’t meet the screening protocol, parents/guardians are invited to seek out a local optometrist for a full consult,” he said.
He said the screening is entirely free, and glasses dispensed are purchased by the Foundation and provided free. “If a parent/guardian elects to take their child to the optometrist post screening, the practitioner will forego their usual commercial fee and bulk-bill, knowing there is no possibility of selling a pair of glasses,” said Mr. Johnson.
OVER SCREENING, OVER PRESCRIBING
According to the World Health Organisation, any screening test needs to be simple and quick to perform. Results should be accurate, quantitative, sensitive and specific.
With this in mind, Dr. Flaherty asserts that it is, “a waste of resources for optometrists, who are highly trained in a range of complicated vision testing procedures, to be involved at this stage.”
However, ACBO believes more can be done to detect and assist children with vision problems.
“Formal screening programs can be very basic, designed to detect reduced distance acuity due to major refractive error or amblyopia, and strabismus, which are all that is necessary from an ophthalmological point of view. Yet many children present to optometrists with significant undetected refractive and binocular vision problems, as well as important accommodativeconvergence dysfunctions.”
Mr. Leslie said results from Essilor Vision Foundation’s optometric vision screening program attest to the significant need for comprehensive vision assessment of all school children.
“Optometrists comprehensively assess visual acuity, eye health, binocular vision and accommodative convergence function, eye movements, and where indicated prescribe glasses and/or vision therapy, in accordance with evidence-based standards, for instance for myopia, convergence and accommodative dysfunctions, often in the presence of low levels of refractive error,” he said.
“As an example, some eye care practitioners believe that moderate hyperopia is not necessarily in need of correction, that a child’s natural accommodation will cope with it, and the child will grow out of it over time. The optometric approach is to assess accommodative convergence function, to detect and treat if necessary, accommodative dysfunctions, significant eso or exophoria, and convergence insufficiency,” said Mr. Leslie.
In the Insight article, Dr. Flaherty said, “a diagnosis of ‘tracking’, ‘eye-teaming’ or ‘focusing’ problems by behaviouraloptometrists or other practitioners” can lead to overtreatment. “When a paediatric ophthalmologist sees these children for a second opinion, the overwhelming majority of them have an entirely normal eye exam – including refraction, dynamic retinoscopy, cover test, eye movements, convergence and stereoacuity. This indicates major flaws in the diagnostic process, leading to overtreatment at significant expense to the parent.”1
She told mivision, “Most optometrists provide excellent, evidence-based assessment and interventions for both adults and children. However, some behavioural optometrists are going beyond that and offering unproven treatments for learning disorders.”
Further, Dr. Flaherty asserted that, “Language used on many behavioural optometry websites often either explicitly says that the optometrist provides treatments for learning disorders or uses language that very strongly gives that impression.
“RANZCO is concerned that children who are prescribed these unproven treatments are delayed in accessing proven educational assessments and learning interventions, thus delaying or impeding their development.”
Additionally, citing results from the Sydney Myopia Study, Dr. Flaherty said the prescribing rates for spectacles by school eye testing programs may be unnecessarily high.
“If school eye testing shows significantly higher numbers of children needing glasses than is indicated in population studies, this indicates a serious flaw in the diagnostic criteria being used for that testing, resulting in children being prescribed glasses when they do not need them. The Sydney Myopia Study found 33.8 per cent of six year olds and 38.3 per cent of 12 year olds in the study had been prescribed glasses in the absence of any significant refractive error or visual impairment. Importantly, official screening programs such as StEPS have cost/benefit analysis and established pass or fail criteria, reporting processes and implementation procedures.”
DIFFERENT APPROACHES
Mr. Leslie said the disagreements over school screening programs is simply due to different approaches. “Many ophthalmologists have told me over the years that the main reason some of their colleagues vehemently criticise paediatric optometrists, and optometric school vision screenings, is that some children present to the eye surgeon with a screening referral, or with glasses prescribed by an optometrist, which are not justified from an ophthalmological point of view. The doctor’s assumption may then be that optometrists are over-prescribing glasses for financial gain rather than clinical need. “
ACBO supports high quality screenings of school children by optometrists. Concerns expressed about the quality of screenings are misguided. The results for mass screenings clearly show that some children referred for further testing do not need further treatment, and this is to be expected. False positives are the very nature of a screening program. They are designed to be more inclusive than exclusive, and false positives are common in many other health screening programs. It is far better to complete an eye examination and not find a problem, than to potentially miss problems that can have lasting and significant effects,” said Mr. Leslie.
“A more rational interpretation is that optometrists and ophthalmologists have very different approaches to some issues such as early myopia, low to moderate hyperopia, and accommodative convergence dysfunctions, and to prescribing glasses for these conditions.
RANZCO is concerned that children who are prescribed these unproven treatments are delayed in accessing proven educational assessments and learning interventions…
“These continued attacks on optometry and in particular behavioural optometry are inaccurate and unjustly malign optometrists offering comprehensive care in their community. Neither do they foster care in the best interests of the patient. Discussion and a sharing of professional perspectives would be a far more productive approach.
“ACBO will continue to pursue rational and constructive discussions among eye care practitioner group representatives to maximise mutual understanding and minimise ongoing and unnecessary conflicts,” said Mr. Leslie.
SCREENING INTERVALS
The NSW Public Health Record recommends a vision examination at the newborn health check, vision surveillance at the one to four week, six to eight week, six month, 12 month, 18 month, two year and three year child health checks, and a monocular visual acuity screen at the four year child health check.
Dr. Flaherty said, “If there are concerns at any stage, then referral to an appropriate health care professional can be arranged”. She said following the general screening of four year olds, as in the StEPS program, “children should be assessed if they are complaining of symptoms or a parent/ caregiver has concerns. From kindergarten age, a child can verbalise their symptoms (e.g. blurriness, headache), prompting parents to investigate.”
At Optometry Australia, Ms. Brodie and her team is currently working with aligned stakeholders, “to develop an evidence-based recommendation as to at what points in early childhood, eye assessments offer greatest benefit and whether screening, as opposed to a comprehensive examination, is sufficient.
“Recently released, evidence-backed guidelines from America suggest regular comprehensive eye examinations are necessary for all, and offer strong benefit in early childhood,” said Ms. Brodie.
Andrew Hogan, Chairman of Optometry Australia, believes seeing children a few weeks after they start school can be beneficial as problems can often only become apparent as kids’ school work gets harder.
“Kids won’t complain about blurry vision, and when they aren’t paying attention in class, it’s sometimes simply because they can’t see and they don’t realise that everyone else can see, because they’ve got nothing to compare it to.
“Often a problem that hasn’t caused any symptoms up until now can suddenly start, so those first few weeks of school are often when we see parents bringing kids in.”
In New South Wales, there are no current plans to expand the existing government led screening programs to school aged children.
A spokesperson for NSW Health told mivision, “The program focus is on maximum coverage of children prior to starting school to facilitate early diagnosis and treatment.
“StEPS coordinators develop local strategies that meet the needs of their local health districts to ensure maximum vision screening and equity of access to the StEPS program for all four year old children. Disadvantaged groups of children, and children with special needs, are also actively identified to ensure they are offered StEPS screening.
“All parents are also encouraged to ensure their child attends a Before School Health Assessment at four years of age, as per the NSW Personal Health Record (Blue Book).”
References
- https://www.insightnews.com.au/Article3/1775/ Concerns-over-behavioural-optometry-school-screenings
- www1.health.nsw.gov.au/pds/ActivePDSDocuments/
