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Assessment of Vision for School Aged Children in Queensland - Which Horse to Back, if Any!



Optomtom Tom Roger – Opinion Piece December 2016

There has just recently been a significant increase in interest in the provision of vision assessments for school aged children In Queensland.  This is a sudden change from no formalised screenings which resulted after the Newman Liberal Queensland Government axed nine primary school based nursing positions in 2013. These nurses where responsible for providing both vision and hearing screenings with their state funded program shut down as, according to Children’s Health Queensland and Health Service chief executive Peter Steer, “There was no evidence that school-based nursing services, particularly hearing and vision screening effectively addresses health needs”. (Brisbanetimes.com.au, 2013)  

Mr Steer’s option remains well supported with a recent study by Hopkins et al, suggesting the cost effectiveness of paediatric vision screenings remains debatable and that no agreed vision screening protocol currently exists. (Hopkins, 2013). Some benefits were suggested due to the detection and subsequent treatment of amblyopia, (Mathers, 2010) though to my knowledge, no research exists on the improvements to quality of life and related economic benefits from school screenings. 

It is incredible to think that in light of the scant evidence 3 separate school student vision assessment strategies are currently being proposed in Queensland for 2017. 

Essilor Vision Foundation's – School Screenings 

This world-wide school screening is a privately funded philanthropic venture which aims to invite all schools to participate in a school screening. In Australia, this program is headed by the all-round top bloke, Greg Jonson, the previous CEO of Optometry Queensland and Northern Territory (OQNT). It is my understanding that all primary, secondary, public and private schools will be invited to participate. At the completion of the screening, children that fail are recommended to consult with a local optometrist, get a “free eye test” and then a “free pair of glasses” if required. (Essilor Vision Foundation)   

The concept of providing such valuable services and products for free has been received with mixed feeling by optometrists. While there are obvious concerns relating the erosion of potential optometry sales another valid concern is with the devaluation of optometry products and services.  I am personally apprehensive regarding the effectiveness of any therapeutic intervention without commitment from all invested parties. If a parent is provided with free advice for their child to a wear free glasses are going to be as motivated to ensure that their child wears the glasses compared to the scenario where they have paid for an eye examination and glasses because of their concerns for their child’s vision.   

Interestingly, there is no set screening protocol with the tests to be conducted suggested by volunteer optometrists and the clinical supervisors at the local universities who provide students to assist in the screening.  However, the literature supports the extremely high sensitivity and specificity of screenings to detect vision problems when screenings involve trained observers such as qualified optometrists. (Hopkins, 2013)

Smart Eye Start - Optometry Queensland & Northern Territory

This OQNT initiative encourages all parents to take their children for full eye examination with their local optometrist prior to starting school. This program provides a form to be included in prep enrollment packs in addition to providing promotional material to participating schools and kindergartens.  According to OQNT, over 70% of Catholic Education Schools have agreed to the program and “advanced discussions” have occurred with the QLD department of education.   

While OQNT may have best intentions of its members and pre-schoolers at heart, it remains to be seen how successful such a campaign will be given that it relies on parents making the effort to take their child to an optometrist compared to have a screening conducted at school.   

It will be interesting to see how these discussions advance given the State Government has committed over $14 million dollars to the delivery of the Primary School Nurse Health Readiness Program.

Primary School Nurse Health Readiness Program 

This state funded initiative has been designed to screen for amblyopia and amblyogenic risk factors and will be available to all primary schools across Queensland in 2017. The screening involves an assessment of visual acuity using the 4m Parr letter matching test and a Welch Allyn Spot Vision Screener assessment (handheld electronic auto refractor). (Childrens Health Qld )   While the program states that the Spot Vision Screener has been rated as “acceptable” practice by the US National Centre for Children’s Vision and Eye Health (National Centre for Children's Vision & Eye Health ), this results from this device has never been adequately validated against other traditional methods of vision screening. As such the Lady Cilento Children’s Hospital (LCCH) Ophthalmology Department have decided to conduct a validation study to assess the suitability of this device due to the clear lack of evidence of the benefits of it use in school based vision screenings. While there is legitimate reason for such a study, it begs the question as to why tax payer funds are being used to support this study.   

The referral pathways for students failing this screening is also questionable with over 59 Queensland optometrists being discriminated against providing care for the children found with “significant concerns” due to their membership with the Australasian College of Behavioural Optometrists. 

Summary 

In my opinion vision assessments of school aged children are extremely beneficial to our community. Not only do they promote vision care and eye health awareness, they have the potential to identify vision problems that if addressed can remove barriers to information acquisition and significantly improve a child’s quality of life.  While there is no question of their caring intentions, there appears to be some serious operational concerns with all three school student vision assessment strategies. My biggest concern is the potential for false negatives with school screenings. This is where a child is passed as having normal that in fact has a significant visual problem. Bodack et al have suggested that screenings that rely on visual acuity alone will miss up to 40% of potentially important vision problems including hyperopia, binocular vision disorders and ocular disease. (Bodack. M., 2010)  

I do not envy our local school principal and administrators who are being pressured into choosing which option will best provide for their students. 

Bibliography 

Bodack. M., C. I. (2010). An Analysis of Vision Screening Data from New York State Optometric Association. Optometry, 81, 476/484.

Brisbanetimes.com.au. (2013, January 24). Retrieved December 21, 2016, from http://www.brisbanetimes.com.au/queensland/school-nurses-axed-20130123-2d7rb.html 

Childrens Health Qld . (n.d.). Retrieved Dec 21, 2016, from https://www.childrens.health.qld.gov.au/chq/our-services/community-health-services/primary-school-nurse-health-readiness-program/ 

Essilor Vision Foundation. (n.d.). Essilor Vision Foundation. Retrieved December 21, 2016, from http://usa.essilorvisionfoundation.org/ 

Hopkins, S. S. (2013). Review of the guidelines for children's vision screenings. Clinical and Experimental Optometry, 1 - 7. 

Mathers, M. K. (2010). A review of the evidence on the effectiveness of children's vision screening. Child: care, health and development, 756 - 780. 

National Centre for Children's Vision & Eye Health . (n.d.). Retrieved December 21, 2016, from http://nationalcenter.preventblindness.org/

Vision in Preschoolers (VIP) Study Group . (2009, June). Findings from the Vision in Preschoolers (VIP) Study. Optometry and Vision Science, 86(6), 619-623.  



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