Children who don’t see well do not progress in reading and writing tests at the same rate as their peers, and are negatively impacted later in life in educational opportunities, economic gain and general quality of life. Correcting vision impairment with spectacles is one of the most cost effective interventions for improving learning, productivity and quality of life.2 Poor vision can have significant negative impacts on the physical and mental wellbeing of children; correlations have been found between both high and even low level refractive error and poor academic performance.

COMMON PAEDIATRIC VISION ISSUES 

Amblyopia

Amblyopia is a common vision condition seen in children, where there is reduced best corrected vision and an amblyogenic risk factor such as strabismus or refractive error, with the absence of pathology. Amblyopia is often the target condition for vision screening programs, as without intervention before the age of 12 the effectiveness of treatment reduces, with minimal improvement if treatment is attempted in adulthood.

Adults with untreated amblyopia are more likely to have significant issues in stereopsis and binocular vision, and are at significantly higher risk of becoming visually impaired due to pathology or injury to the better eye.

Myopia

The increasing rates of myopia among the child and adolescent population is dramatically escalating worldwide, including in Australia. The Sydney Myopia Study, upon publication in 2012, found that 4.4% of children of European Caucasian descent and 37.1% of children of East Asian ethnicity had myopia.6 Reduced outdoor time and increased near work, especially in the context of the COVID-19 pandemic, has already begun to show that rates of myopia have further continued to rise.7

Given the effectiveness of myopia control to reduce progression and the subsequent risk of myopia pathology, early intervention and detection for children with emerging myopia is crucial.8 Every 1.00D increment of myopia progression increases risk by 67% of myopic maculopathy, conversely every 1.00D reduction in myopia decreases this risk by 40%; making early detection not only important for the eye health of an individual but of significant cost benefit to the wider community.8

Hyperopia

Hyperopia is also an important childhood vision condition, with clear correlations between uncorrected high hyperopia and reduced educational outcomes and future quality of life. The incidence of significant hyperopia, or hyperopia ≥ +2.00DS in six-year-old Australian children has been reported as between 8.4–9.8%,11-13 representing a significant proportion of children trying to learn to read. These rates do decrease as age increases, but clear vision in the crucial early stages of educational development is of critical importance.

THE IMPORTANCE OF VISION SCREENING

Vision screening provides a quick and efficient way to recognise children who have a vision condition and refer them on to community care that is ready and established to provide comprehensive examination and attention. Children are generally poor historians when it comes to their vision, and recent research in South Australia has found parents often do not recognise when their children have issues with their vision. Even if they do, they may not be able or know where to take their child if they are concerned about their vision.

We are fortunate in Australia to have comprehensive vision testing with an optometrist accessible to families as primary care, and often bulk billed. However, Optometry Australia reports that only 68% of Australian parents have taken their children to an optometrist for an eye test, and 35% of those children required prescription glasses.14 In the 2023 calendar year, 328,135 children aged five to 14 had a 10910 comprehensive vision exam billed, 15 while the Australian Bureau of Statistics (ABS) reported 1,680,039 children in the same cohort;16 suggesting a potential large gap in annual care despite the available billing frequency of 10910 being a three year cycle. Vision screening may provide a way to bridge that access to care for the most vulnerable children.

WHAT SHOULD BE INCLUDED IN VISION SCREENING?

Unfortunately, because Australia does not have standardised vision screening across the country, a wide variety of tests are used and even with these, there are variations among practitioners.

Visual Acuity

Visual acuity is the most common and first test used to establish a child’s visual status. Vision 2020’s National Minimum Vision Screening Standards17 recommend a distance vision chart, with linear or crowded optotypes. The inclusion of crowding, or contour interaction in visual acuity screening – when a box is placed around the symbols or letters on a visual acuity chart – reduces the over-estimation of visual acuity that can be seen when using single, isolated letters.18 

The choice of optotype presented for vision screening is important, as some are known to overestimate the visual acuity potential due to shape cues present in picture optotypes.19 To be useful, therefore, visual acuity testing requires standardised spacing, and only evidencebased and established tests should be used. Vision 2020 recommends the HOTV eye chart or the Lea vision test system in younger age groups, as vision screening using other picture based optotypes can be highly varied, with some variations being easier to identify than others 20 such as Kay Pictures, which have been demonstrated to over-estimate visual acuity.19

While visual acuity is minimum standard, other tests may improve the sensitivity of the screening process, with results from the Vision in Pre-schoolers (VIP) study showing, through large scale multi-centre studies, that visual acuity alone may not be the best at detecting children with issues.21 When screening is conducted by eye care professionals, noncycloplegic retinoscopy, autorefractors, and crowded Lea symbols are the most effective, with combinations of the above demonstrating highest sensitivity in paediatric populations.21 

Deciding on a cut-off value is also an important part of a vision screening protocol. Again, Vision 2020 recommends referral when visual acuity is worse than 6/12 in either eye in the younger age group,17 but when screening primary school or high school children one would expect better visual acuity. Children with impactful but lower levels of astigmatism may struggle with reading comprehension, but pass visual acuity at 6/7.5 or 6/9, and would be missed if cut-off values of 6/12 were used.

The age that is ideal for vision screening is multifactorial. Earlier detection of amblyopia or significant refractive error is well established to improve outcomes and treatment effectiveness.5 The Vision 2020 guidelines recommend screening between 3.5 to five years of age, with almost universal agreement that screening should occur before, or shortly after starting primary school.17,22 Screening a primary school population provides an easier way to capture children with the vast majority of children attending school, and more compliance with children at school age, which may improve the specificity of testing results. As the rates of myopia increase into secondary school,6 programs targeting myopia specifically may be better suited to an older cohort. The American Academy of Ophthalmology, in its 2022 Joint Policy statement, recommended at minimum, visual acuity screening as early as possible and essential before five years of age, then repeat screening at routine school checks or well-child visits every one to two years throughout school.2 

Objective Screening

Objective screening measurements tend to be faster, require less input from the child, and may make screening easier in younger children. There are a few different options for a prescription estimate.

Retinoscopy is an incredibly powerful tool and one of the most sensitive tests that can be included in a vision screening program, performing better than autorefraction, photo-screeners, and even visual acuity measurement.21 When performed by an eye care professional – even without cycloplegia – it is quick, accurate, and has been found to be attainable on most children.21

Autorefractive screening is often conducted monocularly and has a high risk of an underestimation or overestimation, with a mean rate of error of +/0.50DS. However, the variation can be from +3.65DS to -3.55D,23 which can become problematic as it may suggest children have refractive error that doesn’t exist, or more concerningly, miss high refractive errors. The Sure Sight and Retino max, however, were used in the VIP study, with high sensitivity found when used in conjunction with visual acuity. Photo screeners refer to devices that binocularly look at corneal light reflexes and may use either a flash or infrared. A feature of these is that they can often detect other pathologies that affect the light reflex such as strabismus, ptosis, or cataract. The VIP study did conclude that including the cover/uncover test improved detection of strabismus, especially when combined with autorefraction or retinoscopy,21 and should be considered if a screening program is targeting amblyopia specifically, or similar variants that measure ocular position such as cover/uncover with prism neutralisation, extraocular movement assessment or Howell Phoria measurements.

Colour Vision Testing

Colour vision testing in vision screening is a contested issue. While there are limited treatment options for most colour vision conditions, with the overwhelming majority being a congenital issue, early detection of colour confusion may assist children in education.24,25 Many studies have concluded Ishihara is both sensitive and specific (83%)26 for detecting congenital colour issues,24,26 yet the validity of performing this test is questionable when colour vision disorders seem to have limited impact on an individual’s outcomes.24

Colour vision testing may be inappropriate for screening pre-school children, particularly in large scale population screening for high refractive error or amblyopia, but may be of benefit in school screening or when specifically requested by schools. Given the non-invasive and quick nature of colour vision screening tests, and that they are often enjoyed by children, it may be a simple addition if reporting to families is done in a sensitive way that does not raise alarm.

Other Testing

Other tests included in vision screening should be carefully considered to ensure they are targeting key paediatric conditions that have been shown to impact life and learning such as amblyopia, refractive error, and pathology. Tests should be clearly targeted for treatable conditions and need to be sensitive, in that they accurately capture children with the condition, to ensure families are not being incorrectly told their child is normal when they have a visual condition. Falsely reassuring a visual status may reduce the chance of a child being taken for further care. Testing still however, needs to have high specificity, as over-referral can cause health anxiety and negative results cause distress in patients and parents.27

VISION SCREENING IN AUSTRALIA

There are several vision screening programs currently occurring across the country. In Victoria, children are screened at 3.5–4.5 years of age through the Melbourne Initial Screening Test (MIST),28 and children at participating schools in years prep to year three receive vision screening, follow-up tests and glasses through the Glasses for Kids program funding by the State Schools’ Relief.29 In NSW, the Statewide Eyesight Preschooler Screening (StEPS)30 is offered to four-year-old children and the ACT includes a visual acuity screen in its Kindergarten Health Check.31 Queensland offers vision screening to all children in the first year of school, with the Prep Vision Screening Program.32 Across the rest of the country there are government programs and general health wellness checks offered to children in targeted demographics or areas.

Capturing children in preschool can be quite challenging, and balance needs to be struck between achieving high participation rates and the benefits of early intervention to amblyopia and similar conditions. With many children in the country not being offered a formal vision screening, programs run by independent practitioners or corporations are often used to fill the gap.

The National Framework for Vision Screening for 3.5 to five year olds, ]17 produced by Vision 2020, highlights the importance of vision screening and calls for a minimum vision screening program to be established across the country, with clear international evidence supporting this as best practice.

The Lions Eye Health Program, funded by Lions Clubs Australia, provides screening to a wide variety of ages and locations across Australia, including in some regional communities.33

OneSight is a global foundation founded by Luxottica, that offers vision screening and vouchers for glasses, and The Fred Hollows Foundation provides rural and remote screenings with a focus on Aboriginal and Torres Strait Islander Eye Health. 

Many independent community optometrists also provide screening for local schools in their area. 

PRACTICAL TIPS FOR VISION SCREENING

Schools that don’t have access to any vision screening are often keen to provide this service to children at their school. Most have a person who manages allied health services, so phoning and asking for the best email contact is a good way to start. When emailing, ensure that you are clear as to: the purpose of your email, any costs involved to the school, the tests a screening would contain, how you will communicate responses to parents, and include a copy of any consent or history forms. Schools will also need information about the space required; often a room at least three metres long that has the capacity to be made a bit darker to allow for photo-screening or direct ophthalmoscopy screening.

Some schools will provide assistance in organising children to attend the screening, and you should try to keep children in at least pairs at all times. Children waiting for their turn can use this time to observe the children undergoing screening before them, which reduces anxiety. Children who have completed screening should be directed back to class as soon as possible to minimise disruption to learning. Ensure that tests are conducted in a way that is fun and engaging. Consider starting with more ‘fun’ tests, such as stereopsis in anxious children. Rewards are also key; the most important part of an eye test is the sticker so ensure all children are praised and rewarded whatever the outcome.

MEDICARE AND VISION SCREENING

As per the Medicare Benefits Schedule (MBS) updates to explanatory notes relating to optometry items,34 vision screening is not eligible for Medicare. Follow-up appointments, conducted by an optometrist at a practice or other location, would be considered covered if they include the requirements as per the MBS.

COMMUNITY OPTOMETRIST VISION SCREENING

Funding for screening programs is an ongoing challenge. While some of the programs discussed earlier may have resourced funding through non-government organisations or grants, a substantial amount of vision screening is done through volunteer work by local optometrists. There are many optometrists offering services to schools, nursing homes, and outreach clinics, serving a meaningful and valuable service to the community, and these optometrists should be commended for their contribution to the community. 

There may be a number of benefits to a local practice to conduct screening in schools, such as an increased awareness of the existence of the practice and the services provided at the clinic. Children who need follow-up appointments or a full examination may be brought to the practice, and those children may have presbyopic parents or grandparents who may attend based on the building relationship. Communities need glasses and eye care; and this is a way to improve those connections to local families.

SETTING UP SCREENING IN YOUR LOCAL AREA

Given the lack of available screening programs in many areas, it is key that limited resources are not spent on duplicating an over-serviced area. Many established screening programs, both large scale government programs and smaller scale community programs are already providing screening, and practitioners interested in developing programs should research available resources that already exist in their communities.

Calling government providers and asking to be involved in screening, or in receiving referrals for children who fail screening, may help expand or continue current programs. Many universities are providing expansive screening services to nearby areas and may be keen on volunteers or help with student supervision. Rural and regional areas are often covered by the visiting optometrists’ scheme or outreach providers, who may require volunteers or additional clinicians.

COMMUNICATION AND CONSENT

In any vision screening program, when communicating with parents or guardians, it is important to provide clear explanations about the purpose of the vision screening and the testing that may be involved, with written information about common eye conditions that may impact children, the importance of vision screening, and the process of the vision screening.17 Explicit written consent is necessary before screening any child, and forms should include basic history questions regarding any eye conditions/glasses or parental concerns.

Children themselves are unable to consent but may assent, and it is important that even if parents have consented on behalf of a child, the children agree to testing and feel comfortable and safe during the process.

Communicating the outcome to parents or guardians is crucial, however in most cases, children should not be exposed to the results as doing so may cause anxiety.

Minimum standards for vision screening include a referral pathway for children who do not pass screening, where there is clear communication to parents about outcomes through the form of a written letter given to children on the day of screening. If the screening program is through a school, a letter that the school can provide parents on the day that includes how to access follow-up care is a quick communication option.

Vision 2020 vision screening guidelines advise having a person with a dedicated role to ensuring appropriate communication of outcomes; the eye health practitioner is principally responsible for communicating when further care is needed, however this should be balanced against the burden of administration where feasible.

Additionally, Vision 2020 recommends at least two documented attempts to contact families of children who did not pass.17 A reminder call or text message may help with this communication, and children with sightthreatening conditions or amblyogenic risk factors should be pursued thoroughly.

Attending follow-up appointments may be a challenge for families for a number of reasons including lack of understanding, language barriers, or concerns about cost. Providing appropriate options for followup care that may include opportunities for repeat screening, local optometrists, or general practitioners, may help aid families in attending further examinations. Having a robust monitoring and follow-up protocol may improve attendance, including a designated role within the screening program for following up children and reporting back any barriers to care. This may be aided by an electronic management system or involving schools in children’s outcomes of screening; both of which require explicit consent from participating families.

RESOURCES AVAILABLE

Optometry Australia has several resources available to members including posters, social media tools, and fliers to help encourage parents to bring their children to eye examinations. There is also a letter template that can be used to introduce not only your local practice, but the importance of eyes to development and learning to schools. To assist during a screening or during a talk to parents, there are some handouts for children on the incredible science of eyes and vision that promote healthy eye behaviours like protective eyewear in sports and sun protection.

Other community groups, such as Lions clubs, Rotary clubs, and libraries are often looking for speakers on a variety of topics, and eye health is often interesting and well received. Parents are bombarded with information about various health topics, but eye health is often undervalued and parents unaware of the necessity of regular check-ups and taking care of our vision.

CONCLUSION

Vision screening is a cost-effective way to identify children with vision conditions that need further treatment. Programs that have strong links of evidence-based practice to the tests chosen can effectively capture children and help direct families to available care resources. Awareness of the importance of eye health early in life, and support and funding for screening initiatives from schools, communities, and governments, is necessary for these important services to continue. Follow-up capabilities that ensure parents know of screening outcomes and where to go for accessible follow-up care should be wrapped around screening, with strong links to optometrists, who are well placed to provide further community-based care to those who need it.

This article was sponsored by EssilorLuxottica. 

To earn your CPD hours from this article visit: mieducation.com/seeing-clearly-learning-well-vision-screening-in-australia.

References available at mieducation.com.