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A B S T R A C T
The Vision First Check Program was
developed in consultation with ophthalmology and optometry representatives on the
provincial Vision Advisory Committee and
piloted by participating optometrists in four
communities in BC between January and
June 1998. This preschool vision screening
program provides for one vision screening for
children aged two and three at no cost to the
family or the Medical Services Plan of BC.
The screening is by optometrists, the marketing of the program is coordinated through
public health, and the data collection is coordinated through the Medical Services Plan as
a no-fee item.
A
B
R
É
G
É
Le Vision First Check Program a été
élaboré de concert avec les responsables de
l’ophtalmologie et de l’optométrie du comité
consultatif provincial sur la vision et dirigé
par les optométristes participants au sein de
quatre collectivités de Colombie-Britannique
entre janvier et juin 1998. Ce programme
préscolaire de dépistage des troubles de la vue
permet d’effectuer un dépistage chez les
enfants de deux ou trois ans sans frais pour la
famille ou pour le régime de santé de la C.-B.
Le dépistage est effectué par des
optométristes, le marketing du programme
est coordonné au moyen de la santé publique
et la collecte de donnée est coordonnée au
moyen du régime de santé à titre d’examen
gratuit.
The Vision First Check Program in
British Columbia: A Preschool Vision
Screening Program for Children Age
Two and Age Three
Lorie J. Bradley, OD, Mary Lou Riederer, OD, MA
The visual conditions usually targeted
for identification in children’s vision
screening programs are amblyopia, strabismus, and refractive error.1-3
Amblyopia is a reduction in visual acuity
caused by a suppression of function usually
in one eye. It can result from strabismus,
unequal acuity due to differences in refractive status, or visual deprivation. Untreated
amblyopia is the leading cause of blindness
in one eye in children.4-6 Amblyopia usually develops before 5 years of age. Estimates
of the prevalence of amblyopia in children
ages 4-6 years vary from 1-5%. Early
detection of amblyopia is necessary to
achieve acceptable visual acuity. The
younger the child, the shorter the duration
of treatment required, and the better the
prognosis for treatment.7,8
Strabismus, an abnormal alignment of
the eyes, can result in a loss of binocular
vision required for fine depth perception.
It can also cause a loss of visual acuity in
the turning eye (amblyopia). Strabismus
affects about 2% of the preschool population and usually develops before 5 years of
age.4-6,9 Early detection and treatment of
strabismus is essential to the development
of binocular vision.
Refractive errors are the most common
visual disorder. About 3-6% of children
aged 5 to 12 years are significantly farsighted to the extent that they cannot maintain
clear and comfortable vision when reading;
3% have significant amounts of astigmatism. Myopia becomes more prevalent as
children grow. It affects 1-3% of children
ages 5 to 9 years, and 17% of teenagers.4-6,10
While most binocularly balanced refractive
Correspondence and reprint requests: Dr. Mary Lou
Riederer, 10-2630 Bourquin Cr. West, Abbotsford,
BC, V2S 5N7, Tel: 604-859-2015, Fax: 604-8592065, E-mail: [email protected]
252
REVUE CANADIENNE DE SANTÉ PUBLIQUE
errors can be corrected effectively with
lenses at any age, earlier treatment will
allow the child to partake more fully in
their environmental learning experiences,
thus contributing to their social, physical
and intellectual development.11
Due to the unreliability of the standard
subjective based vision screening tests (i.e.,
visual and stereo acuity charts) with
preschoolers, most BC health units do not
have preschool vision screening programs.
Furthermore, as regional health units in
BC face growing demands for their limited
resources, even kindergarten vision screening by public health units has been discontinued in a number of communities.
Recent Medical Services Plan data indicate
that, on average, only 8% of three year
olds in BC are receiving eye examinations
by either an optometrist or ophthalmologist.12 The B.C. Ministry for Children and
Families’ Vision Advisory Committee
believes that this is due to lack of awareness on the part of the public as well as
among the general health practitioners
usually interacting with this age group.
In response to this unmet need for earlier childhood vision assessment, the Vision
First Check Program was launched by the
Ministry for Children and Families in partnership with the British Columbia
Association of Optometrists, after consultation with optometry and ophthalmology
representatives on the provincial Vision
Advisory Committee. Four pilot sites in
different-sized communities were selected
for the purpose of further refining the program elements, including reporting and
follow-up procedures as well as marketing
strategies. The purpose of the pilot was to
determine whether the Vision First Check
program would result in a substantially
higher number of 2 and 3 year olds receivVOLUME 91, NO. 4
VISION FIRST CHECK PROGRAM IN BRITISH COLUMBIA
ing a thorough vision assessment than currently indicated by provincial government
data.
METHODS
Cranbrook, Prince George, Powell River
and Sooke were chosen as pilot sites after
discussion with both public health administrators and local optometrists. The sixmonth duration of the project was the
minimum felt necessary to allow for the
anticipated lag between when a parent was
first informed of the availability of the program and when they would arrange for the
actual visit to the participating
optometrist.
The optometrists in each community
volunteered to do a Modified Clinical
Technique vision screening on two and
three year olds at no charge to the parent
or the Medical Services Plan (MSP) of BC.
In addition, a local advisory committee
consisting of health unit and optometric
representation and other community
providers (e.g., physicians, child care
licensing officers) was established.
Vision screening of the preschool-aged
child is particularly challenging because
the traditional subjective tests used in
screening are unreliable due to the young
child’s inherent shyness, short attention
span, or inability to understand what is
expected of them. In fact, of all the vision
screening tests in existence, the only one
that has a satisfactory specificity and sensitivity, regardless of the age of the child,
is the Modified Clinical Technique
(MCT). The MCT is distinctive in that it
relies on objective measures and achieves
a correct referral rate of around 98%.4-6 It
is also a superior vision screening method
in that it targets the identification of all
visual anomalies threatening children, i.e.,
ocular disease, refractive error, amblyopia
and strabismus. The MCT requires the
skills of an ophthalmologist or
optometrist, hence the need for their participation.
The ophthalmology and optometry representatives on the provincial Vision
Advisory Committee established the criteria for failure of the Modified Clinical
Technique screening program for this age
group (see Appendix 1). Previous studies
JULY – AUGUST 2000
TABLE I
Breakdown of Screening Results
January 1, 1998 to June 30, 1998
Number
383
331
52
21
10
7
7
4
2
1
Result
Screenings
Passed
Failed
Hyperopia (≥ +2.00 D)
Astigmatism ( > 1.50 D )
External Ocular Pathology
Strabismus
Amblyopia
Phoria
Internal Ocular Pathology
Percentage
100.0
86.4
13.6
5.5
2.6
1.8
1.8
1.0
0.5
0.3
TABLE II
Vision First Check Pilot Project Statistics
January 1, 1998 to March 31, 1998
Children Screened as a Percentage of Age Cohort
Age
Cranbrook
2 years
4.1%
3 years
6.4%
Total number screened 33
Prince George Powell River
0.6%
1.0%
1.2%
10.8%
32
29
Sooke
1.3%
4.2%
9
Total
1.2%
3.7%
103
January 1, 1998 to June 30, 1998
Children Screened as a Percentage of Age Cohort
Age
Cranbrook
2 years
10.7 %
3 years
25.0%
Total number screened 113
Prince George Powell River
4.4%
2.0%
9.1%
21.7%
184
58
Sooke
5.3%
11.9%
28
Total
5.2%
13.2%
383
During the full year of 1995/1996, 1.1% of British Columbia’s 2 year olds and 4.7% of its 3 year
olds had an optometric exam. The Vision First Check Pilot Program, which lasted for only half a
year, screened 2 year olds at 4.7 times the 1995/96 full-year rate and 3 year olds at 2.8 times.
using this screening technique focussed on
school-age children so some of the criteria
were changed to accommodate the visual
characteristics of the preschool population.
If a child failed the screening, a recommendation was made for a full examination
with the family’s optometrist or ophthalmologist. Reports on children who failed
the screening were sent to the health unit
if the child did not receive a subsequent
full examination from the screening
optometrist. Health unit staff would then
contact the parents in question to ensure
that they pursued appropriate follow-up
from another eye care practitioner.
To monitor the program, a series of
non-remunerative MSP codes were developed. This allowed for the tracking of the
number of children seen as well as the
number of children who failed to meet the
screening criteria, and linking through
indicator codes to the probable condition
associated with the failure. A reporting
mechanism was developed to allow for the
statistical analysis of the pilot project.
Program information packages
In order to inform all the participants
and ensure the pilot project was understood clearly, the following information
packages were developed:
• an initial package for optometrists which
requested their support for the program,
particularly since participation involved
providing free office services;
• subsequent information on the specifics
of the pilot project for the optometrists,
for instance, outlining the nonremunerative billing codes and the criteria for failure of the MCT;
• an information package for those participating on the local advisory committee
and to outline details of the pilot project
to health unit staff.
Marketing materials
Marketing materials were developed in
conjunction with the Communications
Division of the Ministry for Children and
Families. Each community received copies
of:
CANADIAN JOURNAL OF PUBLIC HEALTH 253
VISION FIRST CHECK PROGRAM IN BRITISH COLUMBIA
Appendix 1
The Modified Clinical Technique
The Modified Clinical Technique (MCT) consists of the following tests performed under nondilated
conditions by an ophthalmologist or optometrist:
1. Distance Visual Acuity (Stycar or other illiterate optotypes)
2. Cover test at distance and near
3. Retinoscopy for determination of refractive error
4. Ophthalmoscopy and external inspection for the presence of organic anomalies
The Clinical Criteria for Referral for the Pilot was:
Visual Acuity
Refractive Error
1. Hyperopia
2. Myopia
3. Astigmatism
4. Anisometropia
+2.00 D.S. or more
-1.00 D.S. or more
over 1.50 cylinder
1.00 D. or more
C.
Coordination Problems
1. At Distance (20 feet)
a. Tropia
b. Esophoria
c. Exophoria
d. Hyperphoria
any tropia
5∆ or more
5∆ or more
2∆ or more
2.
D.
At Near (16 inches)
a. Tropia
b. Esophoria
c. Exophoria
d. Hyperphoria
Organic Problems
• Vision First Check desk card with parent/child coupons providing information about the importance of early
assessment. These were displayed in the
offices of optometrists, family physicians, health units as well as libraries,
etc.;
• a pamphlet entitled, “Your Child’s
Vision: A Parent’s Guide”;
• a Vision Screening Report to be given to
the parent with a copy sent to the health
unit if follow-up is required;
• letters explaining the project that were
sent to licensed daycare operators, family
physicians and First Nations
Communities;
• newspaper advertisements and a press
release for use as desired.
Additional activities
After the information packages and marketing materials were completed, a small
group of optometrists and a separate small
group of public health nursing administrators were brought together to critique and
review the materials for clarity and completeness before they were sent out to the
pilot communities.
Surveys were developed by the Ministry
for Children and Families for optometrists,
254
“Correct Referral”
20/40 or less, either eye
A.
B.
any tropia
6∆ or more
10∆ or more
2∆ or more
Any verified pathology or medical
anomaly of the eye or adnexa.
health unit staff, family doctors, licensed
day cares and the advisory committee
members. These were used to canvass the
participants’ overall impressions.
RESULTS
Table II indicates the number of children
screened in each pilot area as a percentage of
their age cohort. During the full year of
1995/96, 1.1% of British Columbia’s 2 year
olds and 4.7% of 3 year olds had an optometric exam. The Vision First Check Pilot
Program, which lasted for only half a year,
screened 2 year olds at 4.7 times the
1995/96 full-year rate and 3 year olds at 2.8
times. As optometrists provide 80% of primary eye care in BC, these utilization rates
were felt to present a fairly accurate picture
of preschool eye care delivery in BC. Indeed,
MSP statistics for 1995/96 show that ophthalmologists only saw 2.7% of children age
3, most of whom would have been seen first
by an optometrist, then referred and therefore counted twice. Results of the breakdown of screening results for those children
who failed the MCT screening indicate that
the incidence of visual anomalies was in
agreement with the numbers reported in the
literature for this age group.4,10
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DISCUSSION
The results showed that the Vision First
Check program significantly increased the
percentage of preschool children receiving
professional eye care. Table II also shows
that during the second half of the pilot,
twice the number of children were
screened as in the first three months of the
program. This reflects the fact that it
requires time to develop utilization of any
new program in a community.
The variance among the four pilot communities was thought to be the result of
more intensive media coverage of the program in Cranbrook and Powell River.
Also, news probably travels faster in smaller communities like these two. The smallest community of Sooke, however, had
only one health nurse who was away for a
large portion of the pilot, which contributed to its relatively lower utilization.
Discussions with the public health personnel and participating optometrists during the pilots indicated a high level of satisfaction with the program. The input from
nurses led to minor changes in the poster
(e.g., a brighter border was added and a
smaller version was published for dissemination to community centres, etc.) as well
as further simplification of the language
used in the pamphlet.
CONCLUSION
Results from the pilot studies indicate
that the Vision First Check Program was
successful in increasing the number of
preschoolers receiving vision care. The program has been received so favourably by
the public and the professionals involved
that it has been expanded within each of
the initial pilot communities to cover their
entire public health region. The Capitol
Regional Health District, including the
city of Victoria, was added in November
1998. In Fall 1999, the rest of Vancouver
Island implemented the program along
with North and West Vancouver, the
Kootenays, North West BC and the
Cariboo region. The rest of the province is
anticipated to come into the program during the year 2000.
This program is a unique collaborative
effort to address the need for earlier vision
VOLUME 91, NO. 4
VISION FIRST CHECK PROGRAM IN BRITISH COLUMBIA
assessment. The funding for the promotional materials is provided by the Ministry
for Children and Families; the screening is
provided voluntarily by optometrists; the
follow-up is by Public Health personnel.
Utilization of the Vision First Check
program is expected to increase as public
awareness grows. One of the key opportunities for nurses to promote preschool
screening is at the time a parent brings
their child in for the 18-month vaccination. Another is via a Vision First Check
coupon in the BC Health Passport book
currently given to parents of newborns.
These two avenues for marketing the program could be expected to increase significantly the numbers of children seen.
The Vision First Check program, with
monitoring by MSP, will contribute to further exploration of vision screening issues
such as optimum public education strategies in different communities and incidence of vision anomalies. As further
research funds become available, more
detailed analysis will be made of samples of
children who participate in the screening
to confirm the reputed effectivity of the
MCT. Similarly, a controlled study of children who require treatment intervention
could provide insights into the issues of
optimum age for treatment and its effects
on quality of life.
Éditorial de la page 247
« Nous ne devrions pas avoir à désigner
avec exactitude et précision la manière
dont un pesticide neurotoxique nuit au
développement du cerveau et le degré de
cette réaction avant de parvenir à la conclusion que la santé publique n’est pas protégée, sachant que l’urine de presque tous
les enfants de ce pays contient des résidus
de ces produits chimiques. Nous pouvons
faire plus attention aux pesticides que nous
utilisons à la maison et modifier les systèmes agricoles afin que l’on dépende
moins des pesticides qui sont toxiques et
qui sont très répandus dans l’environnement.
« Il est à notre portée de protéger les
enfants des expositions nocives aux produits
chimiques de l’environnement. Les incertitudes concernant les résidus ne peuvent
constituer une excuse pour la passivité alors
que les preuves démontrent qu’elles engendrent probablement des souffrances. »
Les stratégies de promotion de la santé
ont permis d’aborder de manière efficace
les enjeux qui nous touchent tous que ce
Directeur du Center for Children’s Health
and the Environment du Mount Sinai
School of Medicine, situé à New York,
« nous assistons apparemment à une augmentation des conséquences sur la santé se
traduisant par des troubles notables du
développement. Il existe des mécanismes
biologiques qui lient probablement les produits toxiques de l’environnement à certaines conséquences sur la santé, comme
cela a été prouvé sur des animaux de laboratoire. Nous accumulons des preuves des
dégâts neurotoxiques infligés aux enfants
par les agents environnementaux, comme
le plomb et les BPC. Nous devons améliorer notre compréhension de la neurotoxicité
des produits chimiques qui se trouvent
dans l’environnement à l’heure actuelle, et
nous devons adopter des politiques en
matière de santé publique qui réduisent
l’exposition des fœtus et des enfants aux
produits chimiques qui se trouvent dans
l’environnement.
JULY – AUGUST 2000
ACKNOWLEDGEMENT
We acknowledge the invaluable support
of Ann Little, Chair of the Vision Advisory
Committee and Public Health Consultant,
Child, Youth and Family Support
Division, Ministry for Children and
Families.
REFERENCES
1. Schmidt PP, Cinder E, Dobson V. A survey of
vision screening policy of preschool children in
the United States. Survey of Ophthalmology
1999;43(5):445-57.
2. Bobier W, Robinson B. Measurement of the
validity of a preschool vision screening program.
Am J Public Health 1999;89:193-98.
3. Lydick E, Yawn B, Epstein R, Jacobsen S. Is
school vision screening effective? J School Health
1996;66(5):171-75.
4. Rosenbloom A, Morgan M (Eds.). Principles and
Practice of Pediatric Optometry. New York:
Lippincott Company, 1990.
5. Peters HB, Blum HL, Bettman JW, et al. The
Orinda Study. Am J Optometry 1959;36:455-69.
6. Schmidt PP. Screening for the vision problems of
young children. In: Moore B (Ed.), Eye Care for
Infants and Young Children. Boston:
Butterworth-Heinemann, 1997;175-89.
7. Bassett K. Vision Screening for Strabismus and
Amblyopia: A Critical Appraisal of the Evidence.
BC Office of Health Technology Assessment
Discussion Paper Series. 1995.
8. Beauchamp R. Lazy eye. Issues in Vision
Physiology 1987;1(4):9-23.
9. Anke S, Atkinson J, Bobier W, et al. Infant
Vision Screening Programme: Can Early
Detection of Refractive Errors in Infants with a
Family History of Strabismus Predict Later
Visual Problems?, presented at the 7th international Orthoptic Congress, Nuremberg, 1991.
10. Woodruff M. Vision and refractive status among
Grade 1 children of the province of New
Brunswick. Am J Optometry and Physiological
Optics 1986;63(7):545-52.
11. Canadian Association of Optometrists. The
Canadian Association of Optometrists brief to
the House of Commons Standing Committee on
Health and Welfare, Social Affairs, Seniors and
the Status of Women, April 10, 1990.
12. B.C. Statistics, B.C. Ministry of Finance and
Corporate Relations, population data as of
September 1996.
Received: April 13, 1999
Accepted: February 15, 2000
soit dans notre quotidien ou en tant que
population, enjeux que nous tenons souvent pour acquis. Les programmes de promotion de la santé, tout d’abord de
manière individuelle, puis dans leur ensemble, ont changé la situation dans laquelle
nous nous trouvons, au quotidien, dans
bon nombre de nos collectivités. Cette
situation a beaucoup changé au cours des
vingt dernières années, les stratégies portant maintenant sur la prévention des
blessures, l’amélioration des conséquences
de l’accouchement, les modes de vie sains
et le développement des jeunes enfants,
pour n’en nommer que quelques-uns.
Imaginez les occasions que nous auront au
cours des vingt prochaines années au cours
desquelles nous allons aborder la question
de l’inégalité du revenu, de l’inclusion de
toutes les populations et de la réduction de
l’exposition à la pollution environnementale au sein du monde dans lequel nous
vivons et dans lequel vivront nos enfants et
nos petits-enfants.
CANADIAN JOURNAL OF PUBLIC HEALTH 255