051618 #VisionScreening, #upmedwebinars
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Webinar lecture on vision screening May 16, 2018, #upmedwebinars series
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051618 #VisionScreening, #upmedwebinars
- 5. Ophthalmologic Exam 5 • Vision assessment • Pupils • Gross abnormalities • Refraction • Sensorimotor evaluation • Slit lamp evaluation • Posterior Pole Evaluation: retina, optic nerve, vessels http://premiereyes-wi.com
- 9. Revised 2013 PGH Basic Course +/- Role of Providers in Vision Screening PAO Sight Preservation Committee 2013 by M Rondaris
- 11. • 1.4M children blind • 1M in Asia • Prevalence in 0-15 years: 0.3-1.5/1000 • Number of blind children low, but a lifetime ahead • 75 million blind years (number blind x length of life) • 600-6000/10M population • 40% preventable or treatable http://www.who.int/blindness/Vision2020_report.pdf World Health Organization (WHO) & International Agency for the Prevention of Blindness (IAPB), 1999
- 13. Causes of Avoidable Childhood Blindness • Corneal Scarring • Cataract • Glaucoma • Retinopathy of Prematurity • Refractive errors • Low Vision from untreatable causes http://www.who.int/blindness/Vision2020_report.pdf World Health Organization (WHO) & International Agency for the Prevention of Blindness (IAPB), 1999
- 14. Uniform guidelines for reporting: Amblyogenic factors detected by Preschool Vision Screening • Anisometropia (sph or cyl) >1.5D • Any manifest strabismus • Hyperopia >3.5D in any meridian • Myopia > 3.0D in any meridian • Any media opacity >1mm size • Astigmatism – >1.5D at 90, 180 - >1.0 D at oblique axis (>10deg of 90, 180) • Ptosis </= 1 mm MRD • VA per age appropriate standards Donahue et al, Preschool vision screening: what should we be detecting and how should we report it? Uniform guidelines for reporting results of preschool vision screening studies. J AAPOS. 2003 Oct;7(5):314-6 •Refractive Error •Strabismus •Media Opacity •Ptosis •Poor vision from other reasons
- 15. AAPOS Amblyopia Risk Detected by Automated Preschool Screening Refractive Risk Factor Targets Age, Months Astigmatism Hyperopia Anisometropia Myopia 12-30 > 2.0 D > 4.5 D >2.5 D >- 3.5 D 31-48 > 2.0 D > 4.0 D > 2.0 D > -3.0 D >48 >1.5 D > 3.5 D > 1.5 D > -1.5 D Non Refractive Risk Factors All ages manifest strabismus > 8PD in primary position Media opacity > 1 mm Donahue SP, et al. AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013; 17:4–8. [PubMed: 23360915]
- 16. Target Diseases for Vision Screening • Refractive errors 22.8% • Amblyopia 0.74-6% • Eye misalignment 2.5-3.55% • Media opacities < 1% 1. Xiao et al. Elflein HM et al. Prevalence of amblyopia in school- aged children and variations by age, gender, and ethinicity in a multi-country refractive error study. Ophthalmology 2015; 122: 1924-31. 2. McKean-Cowdin R, eta al. Prevalence of amblyopia in Asian and noHispanic white preschool children: multiethnic pediatric eye disease study. Ophthalmology 2013; 120: 2117-24. 3. Arnold RW. Amblyopia risk factor prevalence. J Pediatr Ophthalmol Strabismus 2013; 50: 213-7. 4. Elflein HM et al. The prevalence of amblyopia in Germany: data from the prospective population based Gutenberg Health Study. Dtsch Arztebl Int 2015; 112: 338-44. 5. Hashemi H, et al. The prevalence of amblyopia in 7-year old school children in Iran. Strabismus. 2014; 22: 152-157. 6. Kerr NC, Arnold RWl. Vision Screening for children: current trends, technology and legislative issues. Curr Opin Ophthalmol 2004; 15: 454-9. 7. Snowden SK, Stewart-Brown SL. Preschool vision screen. Health Technol Assess. 1997; 1: 1-4.
- 23. Objectives • To identify children with visual impairment or eye conditions that can be picked up by screening • To outline the tools used in vision screening • To plan a cost efficient method of performing vision screening in the community
- 24. Vision Screening: For children <6y • LEA Symbols • HOTV • iScreen Ophthalmic Camera • SPOT, Plusoptix, Welch-Allyn Sure Sight • EyeSpy 20/20 Washington County Public Health. www.washph.com/Home.aspx Accessed April 12, 2018
- 33. WA Spot Screener Referral Threshold Refractive Error Gaze, Degrees Age, mos Anisom etropia, D Astigma tism, D Myopia, D Hypero pia, D Anisoco ria, mm Vertical Nasal Tempor al Asymm etry 6-12 1.5 2.25 2 3.5 1 8 5 8 8 12-36 1 2 2 3 1 8 5 8 8 36-72 1 1.75 1.25 2.5 1 8 5 8 8 240- 1200 1 1.5 0.75 0.75 1 8 5 8 8 1. Peterseim et al. The effectiveness of the Spot Vision Screener in detecting amblyopia risk factors. J AAPOS 2014; 18(6): 539-542.
- 35. Annual School Usage License • unlimited installations of EyeSpy 20/20 vision screening software within each licensed school. TOTAL verified enrollment: 0-249 students - $1,500 250-499 students - $2,000 500+ students - $2,500 https://www.good-lite.com
- 38. Tools for children over 6 years • SLOAN • HOTV • LEA Numbers • Snellen (Outdated) Washington County Public Health. www.washph.com/Home.aspx Accessed April 12, 2018
- 39. VISUAL ACUITY CHARTS https://clinicalposters.com/anatomy/options/303.jpg SNELLEN CHART SLOAN LETTERS HOTV CHART Copyright PERI 2017
- 41. Additional Tools for Vision Screening Plus • Penlight • Cover paddle • Tests for EOM Movements • Tests of binocular functions • Color vision test From Rosenbaum & Santiago, Clinical Strabismus Management http://www.color-blindness.com/wp- content/images/Ishihara-Plate-07-38.jpg
- 42. 2005 Sensory Tests & Visual Acuity Circles Seconds of Arc Visual Acuity 9 40 20/25 8 50 20/30 7 60 20/40 6 80 20/50 5 100 20/60 4 140 20/70 3 200 20/80 2 400 20/100 1 800 20/200 Donzis PB et al. Effect of binocular variations of Snellen’s visual acuity on Titmus Stereoacuity, 1983, 101: 930-932.
- 47. July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 47 • Age: Birth to 5 years of age • Purpose: To observe for the red reflex in both eyes • Facilities: Darkened or low-light room • Equipment: Ophthalmoscope • Procedure: – Set ophthalmoscope lens power to “0” – Position self 18 to 30 inches (45-75 centimeters) away from patient. – Move the light beam across pupil of both eyes – Observe the orange or red glow that reflects from the fundus through the pupil • Pass: A symmetric, normal red reflex observed from both eyes • Fail: A markedly diminished red reflex, the presence of white or yellow reflex, or asymmetry of the reflexes. • A White Pupil Warrants Immediate Referral Revised 2013 PGH Basic Course Brückner Test (red orange reflex) PAO Sight Preservation Committee 2013 by M Rondaris
- 48. July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 48 • Age: Birth to 5 years of age • Purpose: To assess the eyelids, eyelashes, lacrimal apparatus, and orbit. • Facilities: Well-lighted room • Equipment: None • Procedure: Observe patient for any structural abnormalities. • Pass: Symmetry of facial features, absence of any masses, ocular discharge or redness. • Fail: Presence of any oculo-facial and congenital anomalies or structural abnormalities. Revised 2013 PGH Basic Course External Inspection PAO Sight Preservation Committee 2013 by M Rondaris
- 49. July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 49 • Age: Birth to 5 years of age • Purpose: To test will assess size, symmetry and shape of pupils; for their direct and consensual responses to light; and for presence of a relative afferent defect. • Facilities: Darkened or low-light room • Equipment: Penlight, flashlight or ophthalmoscope • Procedure: – Ask patient to fixate at a distant object if possible. – Direct a penlight into the child’s eyes from approximately 12-16 inches away and notice whether the pupils constrict or remain unaffected. • Pass: Both pupils should react by constricting when light is presented and dilating when light is removed. • Fail: If one/both do not respond to bright light. Irregular shape pupils Revised 2013 PGH Basic Course Pupillary Examination PAO Sight Preservation Committee 2013 by M Rondaris
- 50. July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 50 • Age: 6 months to 5 years of age • Purpose: To detect eye deviations • Facilities: Normal or lowered light level in room • Equipment: Bright penlight, flashlight or ophthalmoscope • Procedure: – Encourage child to fixate on a light source from a distance of 12 inches (30 cm – Observe the position of the two corneal reflexes • Pass: Normal corneal light reflection, symmetric reflexes are centered or slightly displaced nasally. • Fail: The temporal or nasal displacement of the corneal light reflex in one or both eyes is abnormal. An upward or downward displacement of the corneal light reflex in one or both eyes is abnormal. Revised 2013 PGH Basic Course Hirschberg’s Corneal Light Reflex PAO Sight Preservation Committee 2013 by M Rondaris
- 51. July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 51 • Age: 6 months to 3 years old • Purpose: To determine gross visual acuity • Equipment: Penlight, flashlight or brightly colored object • Procedure: – Engage child’s attention using a developmentally appropriate target. – Move target horizontally and vertically. Observe that child’s ability to follow target. • Pass: Child follows target steadily and completely to right and left, and above and below. • Fail: Failure to fix and follow and presence of “jiggly” eyes. Revised 2013 PGH Basic Course Tracking (Fixation and Following) PAO Sight Preservation Committee 2013 by M Rondaris
- 58. Objectives http://2.bp.blog spot.com/- ANF8YWBBJ88/ VhPfR_JEnHI/AA AAAAAATZc/6nL zIGB- kf4/s1600/274C- Image%2BMan %2BQuestion%2 BMark.jpg • To outline the tools used in vision screening • To identify children with visual impairment or eye conditions that can be picked up by screening • To plan a cost efficient method of performing vision screening in the community
- 59. Mass vision screening • Cost efficient • Quick to perform – Critical Line vs Threshold Acuity – Photoscreeners • Sensitivity and specificity • Provide intervention / eyeglasses
- 61. LEGISLATION https://www.senate.gov.ph/lis/bill_res.aspx?congr ess=16&q=SBN-2948 http://www.congress.gov.ph/legisdocs/basic_16/H B06459.pdf http://news.mb.com.ph/2016/12/10/house-panel-okays- eye-screening-program-for-preschoolers-nationwide/ ESTABLISHING A NATIONAL SCREENING PROGRAM FOR KINDERGARTEN PUPILS AND APPROPRIATING FUNDS THEREFOR Copyright PERI 2017
- 62. • Participation of local eye health care experts and planners in Vision 2020 • Vision 2020 Committees – Assess local needs – Develop national action plan – Facilitate implementation – Monitoring and assessment • Society made aware of known, well-tested, cost-effective intervention • Prevent avoidable visual loss http://www.who.int/blindness/Vision2020_report.pdf World Health Organization (WHO) & International Agency for the Prevention of Blindness (IAPB), 1999
- 63. Timing of Screening • Age 4-5 at school entry • Cost efficient, most beneficial • Clinically effective • Younger more False Positives • Child more cooperative • Older poorer outcome 1. Tailor V et al. Childhood amblyopia: current management and new treads. Br Med J 2016; 119: 75-86. 2. Solebo AL, Cumberland PM, Rahi JS. Whole population vision screening in children aged 4- 5 years to detect amblyopia. Lancet 2015; 385: 2308-19.
- 64. TIMING OF VISION SCREENING • 0-6 months • Preschool age (before 3 years) • School entry (4-6 years) • Annual eye exam • Others: vaccination campaigns Copyright PERI 2017
- 65. VISION SCREENING Philippines Recommendation • Vision screening for amblyopia and strabismus is recommended for all children at least once using an age appropriate chart. 2014 Updated Recommendations for Vision Screening: Guidelines for Filipino Children Entering the Philippine Public School System http://paojournal.com/vol39no2/downloads/0042.pdf Copyright PERI 2017
- 66. Screening for visual impairment Philippine Guidelines on Periodic Health Examination (PHEX) 2004 Effective Screening for Diseases among Apparently Healthy Filipinos • Vision screening for amblyopia and strabismus is recommended for all children at least once before entering school using Snellen chart and/or stereoacuity testing (level 2). • Screening infants at 6 months of age for ocular problems, and at age 2-3 years, at 5 years, and every 1-2 years thereafter for visual acuity and ocular alignment may or may not be done (level 4) July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren
- 67. Screening for visual impairment 2014 Updated Recommendations for Vision Screening: Guidelines for Filipino Children Entering the Philippine Public School System http://paojournal.com/vol39no 2/downloads/0042.pdf • Vision screening for amblyopia and strabismus is recommended for all children at least once using an age appropriate chart (level 2). • Screening infants at 6 months of age for ocular problems, and at age 2-3 years, at 5 years, and every 1-2 years thereafter for visual acuity and ocular alignment may or may not be done (level 4) July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren
- 69. Visual Acuity Ranges and Visual Acuity Notations Lea Symbols Decimal US UK 4m ETDRS MAR logMAR VAS (letter count) 10/10 1 20/20 6/6 4/4 1 0 100 0.8 20/25 6/7.5 4/5 1.25 0.1 95 10/15 0.63 20/32 6/9.5 4/6.3 1.6 0.2 90 10/20 0.5 20/40 6/12 4/8 2 0.3 85 10/25 0.4 20/50 6/15 4/10 2.5 0.4 80 0.32 20/63 6/19 4/12.5 3.2 0.5 75 10/40 0.25 20/80 6/24 4/16 4 0.6 70 10/50 0.2 20/100 6/30 4/20 5 0.7 65 0.16 20/125 6/38 4/25 6.3 0.8 60 0.125 20/160 6/48 4/32 8 0.9 55 10/100 0.1 20/200 6/60 4/40 10 1 50
- 71. How to screen & Warning Sign • Cannot read 20/40 line • Or Age 3: – cannot read 20/40 – Above red line • 4 or older – Cannot read 20/30 – Below the red line July 5, 2017 © AP Santiago 2017 #VisionscreeningforChildren 71 From PERI Vision Screening kit
- 72. Strategy to Prevent Avoidable Childhood Blindness • Promote school eye-health programs – For diagnosis and management of common conditions (e.g., refractive error) – Promote a healthy environment – Educate children in looking after their eyes as part of curriculum • In areas where >2% of 11-15 have EOR, – ensure that children undergo a simple vision screening examination – Ideally as part of school health program – Provision of spectacles http://www.who.int/blindness/Vision2020_report.pdf
- 73. Suggestions to School Health Physicians, LGUs, RHUs • Regular vision screening does not have to be complicated • Consider critical line vision screening: Pass or Fail • Do annually http://cliparting.com/free-doctor-clip-art- 31294/
- 74. Adult Vision Screening • Visual acuity testing during driving tests • Preemployment screening • Color Deficiency Screening • Diabetic Retinopathy Screening • Cataract Screening
- 76. Diabetic retinopathy screening • Direct Ophthalmoscopy • Indirect ophthalmoscopy • Fundus Photos • Optical Coherence Tomography
- 80. Seeing the world through the eyes of a child, Is the purest joy that anyone can experience. -Constance Zimmer https://expertbeacon.com/sites/default/files/how_e arly_and_often_children_should_have_a_comprehen sive_eye_exam.jpg