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OAW: The crucial role of orthoptists in paediatric vision screening

Orthoptics Awareness Week is taking place between 1-5 June with the theme ‘Seeing the future’. To kick off the five-part series, LOUSIE BRENNAN discusses the important role of orthoptists in paediatric vision screenings and the success of the New South Wales StEPs program. 

Louise Brennan.

The primary goal of paediatric vision screening is to detect disorders of vision that can lead to amblyopia.

Orthoptists can play a key role in amblyopia detection and management thanks to university training programs, workplace experience and continuing education opportunities. The orthoptist skillset means they can competently assess vision from birth into adulthood with specialised testing and adaptive techniques.

The techniques of play, distraction, adaptability and a ‘never give up’ attitude are key in paediatrics. These allow orthoptists to gain accurate vision assessment, enabling timely diagnosis and appropriate intervention.

Universal vision screening involves thorough planning and accessibility through all stages, including implementation, detection and timely treatment. In New South Wales, StEPS (State-wide Eyesight Preschooler Screening) is one such program, which offers all four-year-old children free vision screening before they reach school.

The success of the program has been evidenced in an external evaluation in 2018 that showed that the program “was working well and that there were many benefits for families and children that participated in the program”.

The Children’s Hospital at Westmead (CHW) has now been involved in StEPs for 12 years. It sees high priority referrals of four year olds that have undergone primary community-based screening with a vision fail of 6/18 or worse. They are managed within the tertiary level clinics by paediatric orthoptists and ophthalmologists.

On a personal note, orthoptists working within the high priority referral clinic at CHW have a great sense of achievement. Families have anecdotally shown their gratitude; firstly to the community-based screeners for detecting their child’s vision problem; and secondly to the paediatric orthoptists and ophthalmologists involved in their care.

Orthoptists working in this clinic feel privileged to deliver first-class care to NSW children and gain good visual outcome for the child by the time they are eight years old. The program adopts a holistic approach and is accessible for all. Those with a disability or additional needs can also be assessed via secondary and tertiary screening to ensure no child is missed.

The four year old test is crucial because at this age children have the cognitive function to perform gold standard crowded acuity letter matching tests. It’s also an ideal window of opportunity for treatment during the critical period of vision development.

The vast majority of children referred to the CHW high priority clinic with a visual acuity of 6/18 or less have a diagnosis of refractive error with amblyopia.

A small proportion are children who were unable to be screened at the community-based screening, while another small proportion have other ocular disorders or pathology.

The most common refractive errors are hypermetropic astigmatism, myopic astigmatism and anisometropia. It’s no surprise, particularly with the high anisometropic cases, that children in this age group do not complain of vision problems; due to having one ‘good’ eye, their poor monocular vision goes unnoticed by parents and care givers too.

This demonstrates the importance of a universal vision screening program.

The main form of management is to correct the refractive error with glasses that are worn fulltime for all activities.

A glasses adaptation period of 12 weeks is allowed and, if sub normal vision persists in one eye, then amblyopia is diagnosed and part-time occlusion therapy of the better eye is commenced.

In some cases of high anisometropic amblyopia with poor visual acuity and assumed dense amblyopia, part-time occlusion therapy is commenced immediately at the same time as the glasses are commenced.

With close monitoring and support from orthoptists in regard to occlusion therapy, outcomes in this age group are excellent. The majority achieve a final best corrected visual outcome in their worse eye of 6/7.6 or better.

Between the ages of eight to 10 children, who can demonstrate their vision has stabilised after active occlusion therapy and can competently perform a subjective refraction, are discharged to their local eyecare provider.

Paediatric orthoptists possess great communication and counselling skills, allowing rapport to be built with children and families. This facilitates the provision of accurate information to reassure to families, while ultimately contributing to the best outcome for the child.

ABOUT THE AUTHOR: Louise Brennan is a Senior Paediatric Orthoptist who has worked at The Children’s Hospital at Westmead for the past 25 years.

More reading: Orthoptics Awareness Week spotlights paediatric eye health