The National Framework for Preschool Vision Standards in 3.5–5-year-olds is an important initiative from Vision 2020 that deserves to be a high priority in the ongoing debate surrounding accessible eye care for all Australians.
In this article, Marion Rivers AM explains the process undertaken to determine an efficient, cost-effective universal screening program, and why its introduction is critical to the health, wellbeing, and development of our next generation.
Achieving change to any policy in a federated democracy is a difficult road.
As eye care professionals, we know the importance of early detection of eye disease. We know that if amblyopia, or other blinding eye disease, is detected prior to school entry, the chance of achieving good eyesight in both eyes is considerably enhanced.
Across Australia, every state and territory has differing standards and testing regimes for preschool vision screening interventions. Some states have policies in place, but these are not adhered to. While exact eye screening figures for preschoolers are impossible to find, indications are that at least half to one-third of all children are not screened at all prior to school entry.
The Australian gold standard for preschool vision screening continues to be upheld in NSW and the ACT, where the Statewide Eyesight Preschooler Program (StEPS) was introduced in 2008. This program was positively evaluated against its objectives in a paper published by NSW Health in 2019.1
All children deserve to have eye conditions effectively identified at an early age
In Search of a National Approach
Orthoptics Australia and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) have long advocated for universal preschool screening as the most efficient and economical way to find early signs of treatable eye disease. In 2018, the opportunity arose, through the auspices of Vision 2020 (the peak body for the eye health care industry), to form a subcommittee that would investigate such a program. Representatives from Optometry Australia, Orthoptics Australia, and RANZCO formed a subcommittee within Vision 2020 (with some other members of Vision 2020 taking a watching brief) in an attempt to reach a uniform measure of screening across Australia.
Fact Finding
The committee agreed that vision is the largest contributor to normal childhood development, and that eye disorders are one of the most common long-term health problems in childhood, alongside asthma and allergies.2
However, as was to be expected, there were competing priorities among different member organisations as to the benefits or otherwise of full examinations versus a straightforward non-invasive screening program.
Vision 2020 gave the clinicians on the committee a chance to debate the pros and cons of different early detection interventions. Committee members listened intently to various arguments for and against preschool interventions, citing academic studies from all over the world. They were reminded of research evidence of the benefits of early intervention for amblyopia screening. From its earliest inception in Missouri in the United States in 1899, to now, most developed countries operate a universal eye screening program for preschoolers.3
The committee members analysed numerous studies including those that showed there was no economic or health benefit to post-school entry screening. They were reminded of the increasing amount of myopia in school-age children but considered that this was well covered by other programs and well corrected in the community.
They also carefully reviewed the 2018 StEPS program evaluation published by NSW Health and its reported benefits. Nearly 90% of age-appropriate children are screened in NSW across a range of settings.1,4
Accepted Premises
When determining whether to advocate for early screening versus a full-service eye exam performed with a Medicare rebate, the committee agreed on the following premises:
- Committing to a full-service eye exam will not enable the required level of intervention and coverage across Australia.
- Screening vision at an age when poor vision can be treated will give children the best outcome for life.
- Evidence demonstrates that poor vision in later life causes poorer economic outcomes, and reduced vision can cause a range of personal and societal costs.2
When considering the age bracket for early screening, the committee accepted the available evidence from Australian studies at that time, that vision screening should be conducted no earlier than 18 months, except for newborn checks of the retina for congenital cataract and eye cancers (retinoblastomas).2
The committee members agreed that numerous studies indicated 3.5–5-year-olds screening was the ideal age in Australia to perform a screening test that was reliable and repeatable across the nation. This approach considers all the World Health Organization (WHO) criteria for a successful screening program.5
The objective also aligns with the World Health Assembly 2020 resolution on eye health and United Nations resolution of ‘Vision for Everyone’.6 The committee accepted the criteria from WHO in forming the guidelines that it was imperative there could be adequate follow-up and available treatment for those children that failed a screening program.
The committee then discussed the most appropriate testing regime to meet the above goals. There was debate about the most appropriate vision test, but the committee decision was to adopt a flexible crowded Logmar style test.
Final Recommendations
In the final document of the National Framework, the committee has included pre-screening information for parents and carers in the most common languages for the appropriate area. This includes process, importance, and common eye conditions being screened.
The Framework stipulates informed consent from parents /carers and requests a brief history of any current spectacles and any concerns.
Screening will include any gross observational anomalies, and monocular vision will be performed with a suitable occluder at six metres, and with a distance chart that includes measures for at least 6/6, 6/69.5, 6/12, and 6/18 with a crowded optotype.
It was determined that the policy must include appropriate referral criteria that is appropriate to all regions of Australia. The policy must also advise that those children already receiving eye care should continue with their current provider.
Resourcing the Program
Across Australia, eye care practitioners are not always readily available. Ophthalmologists are based in bigger rural towns and cities, often with long waiting lists, and orthoptists are usually found in paediatric and general hospital centres and some health centres.
Optometrists are much more universally spread across all areas of Australia, even if only sporadic visits are made to some remote and regional communities. The Visiting Optometry Service and some ophthalmology/paediatric services are offered across small, isolated communities, so even in very remote areas referral pathways can be followed. Examples are the two Northern Territory offerings, the government’s visiting medical service and the Visiting Optometrists Scheme. Similar outreach services are offered in other states.
The guideline recommends that when an eye health practitioner is not available to provide a required follow-up within the appropriate time frame, a medical practitioner or health care worker may act in their place.
The policy also recommends secondary screening clinics staffed by orthoptists or secondary screeners to provide follow-up screenings to reduce false positives and reduce the burden on the public purse. These secondary screeners may also act as a conduit for referrals and between practitioners and families.
To achieve successful outcomes, collaborative and shared care across all jurisdictions will be essential.
The policy clearly states the ‘pass and refer’ criteria and includes high priority referrals of less than 6/18 in one eye.
Facilities and existing infrastructure should be used for screening. A broad range of community preschools, kindergartens, childcare centres, and community health centres should all be used. It is recommended that rooms should be at least three metres in length, well lit, quiet, and conducive to preschoolers of all abilities.
Engaging a Workforce
The screening workforce should be a broad workforce of screeners. Screeners should be employed following WHO guidelines, with no commercial or conflict of interest in the outcome of the screening.
Screeners will need skills and training with an empathy for young children and their families and carers. They will need to understand cultural safety practices within the Australian community, should understand confidentiality, and be able to communicate effectively to provide referrals and information to families and providers.
Additionally, screeners will need to have a good knowledge of local eye care and paediatric services, so they can work closely with local optometrists and the nearest paediatric eye health care providers.
Optometry services in most states and territories will be vital to the ongoing success of this program. It is hoped that feedback will be provided to the screening program with outcomes of findings, so that improvements can be made to the process and referrals.
Next Steps
It’s not good enough to accept reported vague figures of between 30–60% of preschool children having access to vision screening. All children deserve to have eye conditions effectively identified at an early age.
If the learnings from well over 10 years of successful, effective screening in NSW are followed, and the recommendations of the StEPS 2018 review are taken into consideration, we can achieve an effective, cost-efficient, nationwide program – a program that allows for some individual state and territory differences.
Vision 2020, along with peak professional bodies, is now engaging with federal, state and territory ministers who are responsible for health and early education to promote a universal program following StEPS guidelines.
So far, contact has been made with the office of the Minister for Health Western Australia. In that state, regional screening and pathways for intervention remain below ideal levels. In Tasmania and Queensland, advocacy continues to enhance referral pathways. South Australia and Victoria remain outliers in both coverage of preschool screening and referral pathways.
However, we need a commitment from state and territory governments to move this forward. We need all peak bodies: Optometry Australia, Orthoptics Australia, and RANZCO, as well as other members of the Vision 2020 community and the Primary Healthcare Networks to continue to advocate for this screening.
Even in a time of funding restraints and pressure on health budgets, the eye health community must embrace and promote this important early intervention.
A federal election is looming in 2025. Now is the time to promote this universal program.
My thanks to Vision 2020 for its support in continuing to promote this screening program.
To read the full policy visit: vision2020australia.org.au/resources-national-framework-for-vision-screening-for-3-5-5-year-olds.
Marion Rivers AM is an experienced paediatric orthoptist with expertise in low vision services. She is a past president of Orthoptics Australia and has represented Australia on the International Orthoptic Council. She was a Chair and member of the Prevention and Early Intervention Committee for Vision 2020. Ms Rivers was made a Member of the Order of Australia for her services to eye care and the profession of orthoptics in 2021.
References
- NSW Health. Statewide Eyesight Preschooler Screening (StEPS) Program Evaluation Final Report 2018. Published October 2019. Available at health.nsw.gov.au/kidsfamilies/MCFhealth/Pages/steps-evaluation-report.aspx [accessed Nov 2024].
- Discussion Paper. Melbourne, Victoria: Centre for Community Child Health.
- Appelboom TM. A history of vision screening. J Sch Health. 1985 Apr;55(4):138-41. doi: 10.1111/j.1746-1561.1985.tb04102.x.
- French AN, Murphy, Rose KA, et al. Vision screening in children: The New South Wales Statewide Eyesight Preschooler Screening Program. Asia Pac J Ophthalmol (Phila). 2022 Sep 1;11(5):425-433. doi: 10.1097/APO.0000000000000558.
- World Health Organization, WHO Resolution 73.4 2020. Available at apps.who.int/gb/e/e_WHA74.html [accessed Nov 2024].
- Wilson JMG, Junger G. Principles and practice of screening for disease. J R Coll Gen Pract. 1968 Oct;16(4):318. PMCID: PMC2236670.
