POSITION STATEMENT AND POLICY Optometry in Support of Children’s Vision Screening and Testing in Victoria Adopted November 2009 1. Background Vision problems in children are not uncommon. Children can experience a variety of vision problems. These can include refractive errors, such as myopia (short-sightedness), hyperopia (long-sightedness) or astigmatism (irregularity of eye shape that can affect both near and distance vision). Other eye problems that children can be affected by include binocular vision problems like amblyopia (‘lazy eye’) or strabismus (a ‘turned eye’). Children may also suffer from colour vision problems, accommodation and convergence problems, or visual information processing problems that may express themselves as learning difficulties. Most of these conditions can be easily and cost-effectively treated with, for example, the prescription of glasses, or other techniques, including patching or occluding the eye (for amblyopia). Other problems may take a longer or more complex course of treatment. The effective treatment of a vision problem in a child obviously depends on that problem being identified and the child referred for further evaluation and treatment. Under Medicare, optometrists have access to a specific item number related to the comprehensive testing of children with suspected binocular vision problems, as well as general consultation items that are applicable for testing children. Throughout 2008 and 2009, Optometrists Association Victoria participated in the Advisory Group of the National Children’s Vision Screening Project. Funded by the Commonwealth government, and led by researchers at the Centre for Community Child Health at the Murdoch Children’s Research Institute, this project consisted of a comprehensive review and critical assessment of the literature related to vision problems in children – including reviews of prevalence and the effectiveness of interventions – and a report providing comment on the policy directions best supported by this evidence. The final report of the project was completed in May 2009. This report outlined key findings from the project, and provided comment on the policy directions best supported by the current evidence. The research involved consultation with a range of children’s health and eye health professionals including: optometrists; ophthalmologists; paediatricians; orthoptists; child public health experts; and nurses. 2. Policy Direction Supported by the Evidence Optometrists Association Victoria believes that the following policy directions are those best supported by the evidence, as detailed in the Literature Review and Final Report of the National Children’s Vision Screening Project, 2009.1 2.1 Screening • • It is advised that a red reflex check is retained as part of a universal health check for newborns. A universal vision screening program for all children in the year prior to commencing formal school is supported by the literature and the consultation. The most appropriate age for visual acuity testing is when a child is four years old (with an acceptable range from 3.5 to 5 years of age). 2.2 Screening personnel A co-management system is suggested for the screening, evaluation and treatment of children identified with or suspected of having vision problems. This would involve child and family health nurses, optometrists, orthoptists or GPs as primary screeners, and collaboration between eye health providers for the further evaluation and treatment or diagnosis. The personnel used in screening may vary according to the professionals available in any situation or jurisdiction. However, it is strongly suggested that an eye health professional should be responsible for further evaluation where this is indicated by the primary screen. There is strong support for the role of training and workforce development, including the training of primary screeners, which was seen as a critical part of the implementation of any screening program. 2.3 Screening and referral protocols • • • 1 In four year olds, a visual acuity level of less than 6/9 in either eye, and/or two lines’ difference on a chart, was considered to require onward referral. A visual acuity level in a four year old of less than 6/18 in either eye requires a priority or urgent referral. Children who are considered to be at greater risk of vision impairment (Indigenous children; premature infants; and children with developmental delay or disability) should be included in any universal screening program, however, an additional scheme is necessary to ensure these children receive a comprehensive eye examination. Wright, M, et.al. National Children’s Vision Screening Project, Literature Review and Final Report, Murdoch Childrens Research Institute Centre for Community Child Health, 2008, 2009. Figure 2.1 Children’s Vision Screening And Referral Flowchart2 4 year old Child in year prior to commencing formal schooling Primary Screen Conducted by trained screeners e.g. Child and Family health nurses, Area/Aboriginal health workers, eye health professionals as available in area or jurisdiction No further action unless in high risk group – refer if not already under care VA <6/9 or better in both eyes VA 6/9 or better both eyes VA 6/9 or worse in either eye, 2 or more lines difference; other concerns Refer for evaluation to confirm reduced VA <6/9: Conducted by optometrist, orthoptist or opthalmologist Confirmed VA < 6/9 or =/+ 2 lines difference Detailed evaluation, treatment or further referral required Confirmed VA 6/18 or worse is trigger for detailed evaluation and treatment or priority referral conducted by optometrist, orthoptist or ophthalmologist 2.4 Further research and gaps in the current evidence base The Project Advisory Group for the National Children’s Vision Screening Project was challenged by the lack of evidence in some areas of vision screening, and identified the following areas for future research: • • • • 2 Functional vision in school-aged children The effects of reduced levels of vision on quality of life at different stages moving into adulthood The efficacy of interventions Prevalence data for key children’s vision problems in the Australian community and Australian States and Territories. Wright, M, et.al. National Children’s Vision Screening Project, Literature Review and Final Report, Murdoch Childrens Research Institute Centre for Community Child Health, 2008, 2009. • An economic analysis of vision screening in children using quality of life data and in the context of Australian prevalence data and the Australian health system. 3. How optometry can support vision screening programs for children Optometrists have a unique role to play in the delivery of eye-care services for children in our communities. Optometrists are able to: • participate in screening programs, either as primary screeners or by assisting in the training of primary screeners such as nurses; • see children on referral from primary screening, to provide further evaluation; • diagnose and treat vision problems in children, including refractive error; • work with other eye health providers, such as ophthalmologists, as part of a care team to support children identified with eye health problems through screening. 3.1 Optometrists: Primary eye care providers in the community Optometrists are widely accessible, and have all of the knowledge and equipment necessary for testing children’s vision. Optometrists can treat many children’s vision problems, and are able to refer to ophthalmologists under Medicare as required. General medical practitioners see many eye problems. Depending on the nature of the problem, they will generally refer children with problems such as binocular vision problems or poor visual acuity to either an optometrist or ophthalmologist for a more comprehensive assessment. GPs and optometrists both refer patients on to ophthalmologists when required. In Victoria, there are only a few specialised paediatric ophthalmologists, in private practice and at the Royal Children’s Hospital. It is often the case that the optometrist will be the most accessible and practical point of referral for children requiring vision assessment. 3.2 Optometry, Medicare and children Optometrists provide over one million services to Victorians each year. According to the 2007-8 Medicare Annual Report, just on 97 percent per of all services provided by optometrists were bulk-billed. Over ninety nine per cent of optometry services are charged at or below the Medicare schedule fee. The Medicare schedule for optometrists includes a specific item for the comprehensive testing of children with specific identified vision problems, as well as some general items that are applicable to all routine eye test consultations. There are some services for children which are not covered by Medicare, including treatment with vision therapy. 3.3 Victorian Eyecare Service The Victorian Eyecare Service, a partnership between optometrists and the Victorian government, can assist in the purchase of glasses for families on low incomes. The VES provides eye examinations and glasses at a nominal cost, ensuring that all Victorians have access to good vision. The VES runs a paediatric clinic for eligible children. This service primarily operates out of the Victorian College of Optometry in Carlton, and its regional clinics, but some rural optometrists in private practice also see a component of VES patients. 3.4 Geographical accessibility There are around 900 optometrists practicing across Victoria, both in both public and private practice. A geographical listing of optometrists is available on our website, www.optometrists.asn.au/victoria. Optometrists have excellent coverage across the State and in rural areas. 3.5 Therapeutic endorsement Over one third of Victoria’s optometrists now have therapeutic endorsement. These optometrists are able to prescribe topical treatments to manage some of the eye conditions that can commonly affect children, such as minor infections or conjunctivitis, and which may be readily picked up by trained personnel in screening programs 3.6 Access for all communities The Australian College of Optometry currently carries out vision screenings annually at indigenous kindergartens, and offers services through the Victorian Aboriginal Health Service. 3.7 Specialist optometry services All optometrists are trained to be able to manage and diagnose vision problems in children. However there are also a number of optometrists across the state with specific interests and additional qualifications in children’s vision. These optometrists may provide particular services in which they have additional training (such as vision therapy), or may have training and clinical expertise in eye conditions that can affect children. POLICY POSITION Optometry in Support of Children’s Vision Screening and Testing in Victoria 1. PROMOTION AND AWARENESS OF TESTING AND TREATMENT, AND OF THE ACCESSIBILITY OF CURRENT SERVICES Optometrists Association Victoria will work with government, the profession, schools, and other health care providers to: promote the value of regular eye examinations for school aged children, including the value of a comprehensive eye examination for all children starting school; ensure that teachers, parents and other health providers are aware that comprehensive eye testing for children is available through community-based optometrists and covered by Medicare; and promote programs that are equitably available, and supported by regularlyreviewed evidence-based referral protocols for children with or at risk of problems. 2. PROFESSIONAL EDUCATION AND RESOURCES Optometrists Association Victoria will work with key parties and within the optometry profession to: contribute to the continuing professional education of optometrists to support them in the diagnosis and management of children’s vision problems; and support and promote the work of those members of the profession with specialist interest in children’s vision. This will include strategies such as ensuring that our Continuing Professional Development programs, resources, publications, and conferences including the Southern Regional Congress regularly provide up-to-date information and research on children’s vision. 3. SUPPORTING AND WORKING WITH OTHER HEALTH PROFESSIONALS AND EXISTING PROGRAMS Optometrists Association Victoria will: work strategically with other partners who provide health or eye care services for children ensures that we make the most of all adjunct opportunities to identify children and risk, test them, and where necessary, refer for treatment: this includes groups such as general practitioners, Aboriginal health service providers, and teachers; and work to promote programs provided by groups such as school nurses that are equitably available across the State; work with children’s health and eye health professionals to promote and support appropriate high-level training for staff involved in children’s vision screening protocols; promote optometrists as a primary point of referral for children identified in screening programs as requiring further assessment. 4. PROMOTE STRATEGIC RESEARCH AND IMPROVED DATA COLLECTION RELATING TO EYE HEALTH IN CHILDREN IN VICTORIA Optometrists Association Victoria will contribute to the development of, and participate in, research programs aimed at better understanding the prevalence of vision problems in children across Victoria. This research should focus on the use, reach and effectiveness of current surveillance programs and approaches. Partners in this research could include: general practitioners, specialist ophthalmologists, the Australian College of Optometry, the optometry research community, the children’s eye health research community, the Department of Education and Early Childhood Development, or other organisations that may be providing screening programs, working with children with eye problems, or collecting data.
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