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Concerns over behavioural optometry school screenings

08/08/2018By Matthew Woodley
A number of paediatric ophthalmologists have raised fears about optometrists, in particular behavioural optometrists, performing vision screenings in schools.

Dr Alan Hilton, from Brisbane North Eye Centre, said he was concerned after seeing leaflets advertising school vision screening services for optometrists and behavioural optometrists, as well as seemingly asymptomatic patients who had been referred to him following such screenings. As well as saying there was a lack of evidence to support certain therapies related to behavioural optometry, Hilton told Insight there were questions over potential conflicts of interest.

“Optometrists should not be able to take part in any school screening procedure involving children as there is a potential financial advantage to that person or group, for example, by way of selling glasses,” he said. 

“Similarly, behavioural optometrists should not partake in screening children’s vision in schools as there is a potential financial advantage to them of not only selling glasses, but selling the use of exercises. This is especially concerning when there are no evidence-based studies to support such practices.”

“There is no evidence to support the value in re-screening healthy and asymptomatic children.”
Maree Flaherty, paediatric ophthalmologist

Research by Insight revealed examples of privately run behavioural optometry clinics offering school screening services across Australia, as well as government-run schools pointing to services offered by behavioural optometrists on their websites.

According to Dr Maree Flaherty, a member of the RANZCO Paediatrics Special Interest Group, schools that promote the services of behavioural optometrists or support the use of on-campus vision screenings outside of official programs, often do so in contravention of state education department guidelines that emphasise the importance of evidence-based resources.

“There is no evidence to support the value in re-screening healthy and asymptomatic children. Where ‘free’ eye screenings in schools, outside of an official screening program, are being bulk billed to Medicare, this equates to over servicing and is a waste of limited funding,” she said.

“In respect to a diagnosis of ‘tracking’, ‘eye-teaming’ or ‘focusing’ problems by behavioural optometrists or other practitioners, when a paediatric ophthalmologist sees these children for a second opinion, the overwhelming majority of them have an entirely normal eye exam – including refraction, dynamic retinoscopy, cover test, eye movements, convergence and stereoacuity. This indicates major flaws in the diagnostic process, leading to overtreatment at significant expense to the parent.”

Flaherty was one of 14 ophthalmologists who last year sent a letter to NSW education minister Mr Rob Stokes in relation to the issue of behavioural optometry in schools. The letter listed concerns about teachers frequently referring children with reading problems to behavioural optometrists and pointed to a Macquarie University Special Education Centre (MUSEC) briefing that stated behavioural optometry should not be recommended to help alleviate such difficulties.

“It would seem that behavioural optometrists are now directly engaging with local schools and offering to test or screen children for reading problems. Not surprisingly, they find a high percentage of children with ‘visual processing’ difficulties and refer back to themselves for the inevitable glasses and vision therapy,” the letter stated.

“We would urge you to make the teachers aware of the lack of scientific evidence when they are referring children (albeit with the best of intentions) to behavioural optometrists. In addition, behavioural optometrists certainly should not be visiting and accessing children on school grounds.”

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Insight approached the Australasian College of Behavioural Optometrists (ACBO) for comment in relation to these concerns, and while it said school screenings were not arranged by or associated directly with the college, it strongly supported the provision of screening and vision examinations for all children.

“School screenings and vision examinations are routine optometry services provided by registered and qualified optometrists in the relevant circumstances. Behavioural vision care is not a consideration,” a spokesperson said.

“All health professionals consult and diagnose patients and offer therapy or treatment, and are paid for the consultation and therapy/treatment. This is not a conflict of interest. School screenings are provided by optometrists as an unpaid community service and are a part of accepted standards for general optometry practice.

“If the ophthalmologists referred to in this story have examples of any optometrists who have behaved inappropriately or unprofessionally, they should present this evidence to AHPRA for investigation or refrain from inappropriate public comment.”

ACBO also said the suggestion that behavioural optometry lacked evidence was false.

“There is a vast body of evidence for the many concepts and principles that make up the extensive scope of practice referred to as ‘behavioural optometry’. Some is without question. Other evidence is significant and is under discussion,” the spokesperson said.

“A few areas of practice are evolving, and evidence is accumulating. ACBO supports and mandates evidence-based practice principles and informed consent for members.”

Meanwhile, Optometry Australia (OA) also defended the value of school screenings in certain circumstances.

“Optometry Australia believes all children should have timely access to an eye examination from an optometrist and that working with schools can support better access to needed eyecare,” the spokesperson said.

“School screenings and vision examinations are routine optometry services ... Behavioural vision care is not a consideration.”
ACBO spokesperson

“We focus our efforts on trying to raise community awareness via our Good Vision For Life campaign, to repeatedly promote the need for children to have a comprehensive eye examination with an optometrist before starting school, and then at regular intervals throughout life.”

Dr Flaherty agreed that it was important for all children to receive timely eyecare, but said official programs were the ideal way to ensure children received an appropriate eye test.

“If there are no significant signs of vision problems earlier, then around four years old is an appropriate time for eye screening,” Flaherty said.

“Screening in schools should be performed as part of an official screening program, such as the NSW StEPS (Statewide Eyesight Preschooler Screening) Program, by practitioners who have no financial interest in the outcome of the screening process.”

More reading:

RANZCO challenges evidence behind behavioural optometry

RANZCO condemns behavioural optometry media coverage

Behavioural optometrists barred by children’s hospital

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