Towards National Vision Screening for Children

As Yvonne Press reports, Australia has some of the best eye care screening programs for children in the world. However, there is no consistent, national, evidence-based approach to screening, meaning some children with vision problems fall through the cracks.

Optimum vision is one of the main contributors to long-term success in almost every aspect of our lives. Research has shown that nearly 80% of learning is done through sight.1  Without support, uncorrected vision impairment or untreated eye health problems can have significant impact on the development of a child’s sensory cognitive, social, and language abilities.¹

Children entering the education system with undiagnosed vision problems will not only struggle with teaching materials in school but face being disadvantaged for the rest of their lives.^2,3

“Children who don’t see well don’t do as well on reading and writing tests as their peers”, said Skye Cappuccio, Chief Executive Officer of Optometry Australia.

“[They] are negatively impacted later in life in educational opportunities, economic gain and general quality of life.”

According to Ms Cappuccio, Medicare billing data reveals that children and adolescents across Australia are accessing optometric care services less frequently than best practice would recommend.

TOWARDS A NATIONAL FRAMEWORK

The Vision 2020 Australia National Framework for Vision Screening for 3.5–5 year olds, developed with input from a range of eye health organisations, was released in 2021.⁴

The Framework noted there was “broad agreement across the eye health sector that pre-school vision screening is necessary to help detect visual problems and prevent life-long vision loss in children”.

The ages of 3.5 to five years were nominated as this represents “an age young enough for the visual system to be amendable to the treatment of significant visual conditions such as amblyopia, strabismus, and refractive errors”.

The document outlined national minimum standards for vision screening as well as post-screening follow-up services.

Vision 2020 continues its advocacy to implement the Framework, recently calling on the federal Government to allocate funding support for the adoption of the Framework in next month’s federal budget.

WHAT’S STOPPING KIDS FROM GETTING EYE CARE?

In our interviews with optometrists and ophthalmologists, we came across several recurring themes. Socioeconomic factors were just as much part of the problem as different approaches between different states, and a lack of awareness about the importance of screenings among parents.

New South Wales ophthalmologist Dr Rushmia Karim, who has a special interest in children’s eye health, believes that factors like the parents’ level of education and disposable income, geographic location, and ethnicity affect access to eye health services. While anecdotal in some cases, those differences have been well documented for Aboriginal and Torres Strait Islander populations.^5.6

“Socioeconomics has always played a role in access to healthcare. Those that can afford it have the choice to seek private services and participate in preventative strategies,” Dr Karim said.

Paediatric ophthalmologist Dr Caroline Catt, Chair of Australia and New Zealand Paediatric Ophthalmology Society (ANZPOS), said while Australian children do have access to free, high-quality healthcare, “there is pressure on some of these services”.

“Particularly following on from the COVID-19 pandemic and the resulting backlog in public health services, but every state and territory in Australia has free health checks including vision screening available for children.”

Indeed, the Royal Australian College of Ophthalmology (RANZCO), in its vision statement for the future of eye health in Australia and New Zealand, has described both adult and paediatric public ophthalmology services in Australia as “under-resourced”.⁷

“More than half of public ophthalmology outpatient facilities have reduced their services and no longer offer comprehensive ophthalmology services,” the Vision 2030 and Beyond document reads.

The document indicated that 30% of the entire population, and more than 60% of the Aboriginal and Torres Strait Islander population have no access to publicly funded outpatient services.⁷

Australian Society of Ophthalmology (ASO) Vice President Associate Professor Ashish Agar said there’s a huge gap between the supply of publicly funded eye care services and demand. “Paediatric ophthalmology has been affected especially hard by declining funding,” Assoc Prof Agar said. “We’re now facing a situation where there’s simply no publicly funded alternative in some places.”

For children in regions where public eye care services are not available, travel can provide a significant barrier to accessing specialist healthcare. In many cases, their eye care involves repeated appointments over an extended period. Choosing this option is simply not possible for everyone.

FUNDING RESPONSIBILITY

To further complicate the landscape of Australian paediatric ophthalmology and optometry, the responsibility for funding lies with both state and federal authorities. That division makes it harder to implement meaningful changes that benefit all children.

Professor Frank Martin has spent his career in paediatric ophthalmology and is currently the President of the Children’s Medical Research Institute at Westmead as well as continuing to practise. He said a more coherent approach would benefit families across the country.

“In New South Wales, the excellent StEPS (Statewide Eyesight Preschooler Screening) program is offered to over 90% of preschoolers”, Prof Martin said. “The ACT also has a very good screening program, as does Queensland, although kids are screened one year later there. Things are a bit patchier in the rest of the country.”

The National Framework acknowledges it drew heavily on protocols and data from StEPS.

For some states, the difficulties start with determining where the greatest needs lie, which interventions are most critical and what level of funding is needed. Assoc Prof Agar pointed to a lack of data: “Not every state currently has a database collecting information on paediatric eye care. That means all potential evidence is anecdotal. We simply don’t have eyes on the extent of the problem.”

Paediatric specialist Dr Stephen Hing, former Head of the Department of Ophthalmology at Sydney’s Children’s Hospital, Westmead, believes that increasing screening rates is the key to improving kids’ eye health.

“Before the coronavirus pandemic, we had screening rates of 85% of NSW children which is really good already,” Dr Hing explained. “Those [numbers] dropped dramatically, and we need to work on getting them back up and moving toward 99%.”

INCREASING PARENTAL AWARENESS

2022’s Little Aussie Eyes report,⁸  compiled by Australian specialist paediatric eyewear company, Kids Eye Gear, surveyed more than 500 Australian parents about their child’s vision and eye care. The research found that more than 25% of Australian parents believed there was no specific recommended time for childhood eye screening.

“Rather, parents believe they should only be tested if problems arise or the child complains. This is clearly an issue given our 2021 Little Aussie Eyes report showed that a child complaining about headaches or other issues was an instigator for an optometrist visit for only 7% of respondents,” the report said.

Dr Hing believes that helping parents understand the importance of screenings remains the key to ensuring every child is seen around the age of four.

“Parents need to understand that correcting refractive errors and addressing refractive errors early is in the best interest of the child,” he said.

Dr Karim also believes that limited parental awareness remains a problem in paediatric eye care in Australia. She cited examples from her practice where parents are shocked when they find out that their children are suffering from serious ophthalmic conditions like amblyopia or high refractive errors.

“Many claim there were no red flags from their children and the child never complained,” Dr Karim explained. “We certainly need national campaigns to really target [the fact] that children may not complain at a young age that they have a vision problem.”

SooJin Nam, an optometrist based in Sydney with a special interest in children’s vision and myopia management, agreed that parents need to know they can’t wait for their kids to raise red flags. “Children are unlikely to complain about their sight because they don’t know any different. But if a child can’t see well, how can you expect them to be an efficient learner in the classroom?”

Dr Hing said appropriate vision correction can have a profound impact on children. “Some parents have commented on having a different child once they start wearing glasses. It’s not just about seeing, but glasses or other methods of correction also improve a child’s ability to focus and concentrate.”

Ms Cappuccio said a “greater investment in a campaign to enhance awareness of the need for children to have regular eye examinations is needed”.

“It is vital, too, that we enhance awareness of increasing rates of childhood myopia and the need and opportunity for timely intervention.”

ROLE OF THE GENERAL MEDICAL COMMUNITY

Involving the wider medical community is equally important, according to Dr Catt.

“It is important for us to inform our colleagues and patients of the state-based vision screening services available to children and encourage them to participate in preschool vision screening,” she suggested.

“This is particularly important for children with risk factors such as prematurity, those with neurodevelopmental conditions, and those with a family history of eye diseases such as strabismus and amblyopia.

“All of us who work in healthcare have the opportunity and responsibility to inform parents, and also our colleagues of the screening services that are available and the importance of participating in them,” Dr Catt continued.

“It is particularly important this information is shared with general practitioners and paediatricians as these are the healthcare professionals that young children and their families will interact with most frequently.”

AN IDEAL AGE

Ideally, kids’ eyes should be screened during their early childhood, and as noted above, the proposed National Framework has recommended a national screening program that targets children aged 3.5 to five years. However, with some Australian children starting school later than their peers in other countries, Dr Karim said reaching children for screening within the 3.5 to five year age group was a challenge.

“[If children were enrolled in school] by age four and a half, then we could screen in schools and that would capture the largest number of children.

“Daycare screening, whilst successful, misses children who are looked after full time at home, Dr Karim said.

“Newborn screenings are excellent. [They] have proven to be very successful. But newborns are too young for amblyopia screening.”

Dr Hing also nominated four as the ideal age for vision screening.

“At four years old, kids are capable of doing a proper test,” he explained. “With younger kids, we may get too many false positives.”

And, if children are screened later, valuable treatment time is lost.

A STATE OR NATIONAL APPROACH?

Vision 2020 said its National Framework approach would “ensure all children have the opportunity to get their eyes tested before starting school and encourage a proactive attitude to regular eye testing throughout the schooling years”.¹

With broad agreement from the eye sector that the NSW StEPS program is the template to follow, Assoc Prof Agar pointed out that one of its biggest advantages was cohesion between the professionals involved.

“There is very clear collaboration between optometry and ophthalmology,” he said.

Dr Catt believes some of the benefits of a nationwide, rather than a state-based approach, would be to “improve awareness of this important form of health screening” and “facilitate a streamlined and efficient service for children and their families”.

Professor Martin said rolling out the NSW model across Australia and moving screening from school age to pre-school will benefit kids and their families greatly. “The potential long-term benefits are tremendous, and the program is affordable.” NSW spends $5 million per year on the StEPS screening program.

However, contrary to his colleagues, Dr Hing believes streamlining screening across the country is unlikely to trigger big improvements. “Across the nation, free screening is already available before kids go to school,” he said. “I don’t believe that having the same approach nationwide would make a huge difference.

“Every state has its own health department with a different take on how to manage things and different funding,” Dr Hing continued. “Streamlining all states may take too long compared to the expected outcome.”

In the meantime, optometrist SooJin Nam believes there’s also a role for the education sector to play.

“What if kindergartens and schools could encourage parents to take their kids for a primary optometric eye exam before they start a new school year?”

Having had the opportunity to present to teachers locally who then communicated this message to parents, Ms Nam said the feedback was overwhelmingly positive.

“Once a comprehensive exam has picked up a visual problem, parents have been so grateful because it was caught early and hopefully before it impacts their education,” Ms Nam explained.

Yvonne Press is a writer with more than 15 years’ experience covering various topics, including healthcare.

References

1. Vision 2020 Australia, Budget Submission 2024–2025. Available at: vision2020australia.org.au/wp-content/ uploads/2024/01/Vision-2020-Australia-2024-25-FederalBudget-Submission-Final.pdf [accessed 13 Feb 2024].
2. Resnikoff, S., Pascolini, D., Mariotti, S.P., Pokharel, G.P., Global magnitude of visual impairment caused by uncorrected refractive errors in 2004. Bull World Health Organ. 2008 Jan;86(1):63–70. DOI: 10.2471/ blt.07.041210.
3. Rosner, J., The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc. 1997 Oct;68(10):648–50.
4. Vision 2020 Australia, National Framework for Vision Screening for 3.5–5-year-olds, 18 November 2021. Available at: vision2020australia.org.au/wp-content/ uploads/2024/02/CV-National-Framework-for-VisionScreening_160123-FINAL.pdf [accessed Feb 2024].
5. New South Wales Health, Review of Eye Health Services for Aboriginal People – Greater Western Region of NSW. Available at: health.nsw.gov.au/aboriginal/Publications/ review-of-aboriginal-eye.pdf. [Accessed Dec 2023].
6. Royal Australian and New Zealand College of Ophthalmologists, Established and effective models of eye healthcare delivery for Aboriginal and Torres Strait Islander Peoples and their implementation. Available at: ranzco.edu/wp-content/uploads/2022/06/Established-andEffective-Models-of-Eye-Healthcare-Delivery-for-Aboriginaland-Torres-Strait-Islander-Peoples-and-their-Implemen.pdf. [Accessed Dec 2023].
7. Royal Australian and New Zealand College of Ophthalmologists, RANZCO’s vision for Australia’s eye healthcare 2030 and beyond, available at ranzco.edu/ wp-content/uploads/2023/06/RANZCO-Vision-2030-andbeyond-v2.pdf [accessed Feb 2024].
8. Kids Eye Gear, Little Aussie Eye Report 2022. Available at: kidseyegear.com.au/resources/little-aussie-eyesreport-2022/ [accessed Dec 2023].