2019 vision screen peds postgrad
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Lecture for September 5, 2019, UP-PGH Department of Pediatrics Postgraduate Course
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Mais de Alvina Pauline Santiago, MD
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2019 vision screen peds postgrad
- 1. Raised to the Max: Preventive and Proactive Pediatrics for Optimal Health VISION SCREENING Alvina Pauline D. Santiago, MD #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 2. Online links Slideshare: https://www.slideshare.net/AlvinaPaulineSantiag/0516 18-visionscreening-upmedwebinars Upmedwebinars 2018: https://youtu.be/1AmNY62XXKQ?t=90 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 3. Financial Disclosure Affiliations: • No financial interests #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 4. Objectives To discuss updated recommendations for vision screening for school-aged children. To discuss preventive strategies for vision problems in school-aged children#visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 5. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 6. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 7. Vision Screening = Eye Examination https://brighteyevision.files.wordpress.com http://premiereyes-wi.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 8. Ophthalmologic Exam 8 • Vision assessment • Pupils • Gross abnormalities • Refraction • Sensorimotor evaluation (includes EOM) • Slit lamp evaluation • Posterior Pole Evaluation: retina, optic nerve, vessels http://premiereyes-wi.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 9. Vision Screening 9 • Vision assessment https://brighteyevision.files.wordpress.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 10. Vision Screening [plus] for NonEYEMD EOM VISION PUPIL GROSS EXAM RED REFLEX Vision Screening Child may/not complain! HISTORY #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 11. Vision Screening [plus] for the EYEMD EOM PUPIL GROSS EXAM RED REFLEX Vision Screening Child may/not complain! Refraction Color Binocular Test HISTORY VISION #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 12. Revised 2013 PGH Basic Course +/- Role of Providers in Vision Screening PAO Sight Preservation Committee 2013 by M Rondaris #visionscreening, #uppghpediapostgrad ©APSantiago2019 September5,2019
- 14. Hirschberg’s Corneal Reflex From Rosenbaum & Santiago, Clinical Strabismus Management, 1999 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 15. Bruckner (Red Orange Reflex) From Rosenbaum & Santiago, Clinical Strabismus Management #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 16. ALTERNATE COVER TEST Courtesy of R Pena, MD #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 17. 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 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 18. Color Deficiency Screening • Occupational requirements • Optic nerve functional assessment http://www.color-blindness.com/wp- content/images/Ishihara-Plate-07-38.jpg #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 19. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening and state the rationale for performing vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 20. http://www.who.int/blindness/Vision2020_report.pdf World Health Organization (WHO) & International Agency for the Prevention of Blindness (IAPB), 1999 • Eliminate avoidable blindness by 2020 • Prevent projected doubling of avoidable visual impairment from 1990- 2020
- 21. Target Diseases for Vision Screening • Refractive errors 22.8% • Amblyopia 0.74-6% • Eye misalignment 2.5-3.55% • Media opacities < 1% • Ptosis • Other causes 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. #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 22. Refractive Errors http://www.clarkeeye.com #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 23. Refractive Error https://www.epainassist.comhttps://www.mycupcaketoppers.co.uk https://www.dickssportinggoods.com #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 24. http://slideplayer.com #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 25. http://slideplayer.com #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 26. Eye Misalignment or Strabismus #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 27. Media Opacities Cataract Retinoblastoma http://todossv.comhttps://www.indiamart.com #visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 28. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening and state the rationale for performing vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children#visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 29. Levels of Evidence 1. All met 2. A only 3. B, C, D only 4. None met PHEX Task Force Criteria A. Treatment for asymptomatic condition evaluated by RCTs that observed clinical outcomes B. Burden of illness measured in local community-based studies. C. Accuracy of screening test validated in the community D. Cost effectiveness of test and treatment evaluated locally in properly conducted economic analysis
- 30. 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)
- 31. Snellen Chart Stereoacuity Test https://upload.wikimedia.org From: Rosenbaum & Santiago. Clinical Strabismus Management, 1999
- 32. 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. #visionscreening, #upmedwebinar © AP Santiago 2018 May 16, 2018 http://www.snapily.com/blog/ overcoming-strabismus/
- 33. 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)
- 34. VISION SCREENING Philippines Recommendation • Vision screening for amblyopia and strabismus is recommended for all children at least once using an age appropriate chart. (Level 2) 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
- 35. http://slideplayer.com #visionscreening © AP Santiago 2019
- 36. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening and state the rationale for performing vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children#visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 37. Legislation: School Entry • One year of preschool education • Children enter the public school system at age 5 years http://www.officialgazette.gov.ph/2012/01/20/republic-act-no-10157/ #visionscreening © AP Santiago 2019
- 38. Legislation: http://www.officialgazette.gov.ph/2012/01/20/republic-act-no-10157/ #visionscreening © AP Santiago 2019 Signed, July 31, 2019
- 39. RA 11358 • Sec 3: Establish a national vision screening program NVSP under DepEd • Objectives of NVSP: 1. Conduct simple vision screening on kindergarten pupils through teachers and health personal and identify pupils with visual problems
- 40. NVSP Objectives 1. Conduct vision screening and ID pupils with visual problems 2. ID early childhood visual problems 3. Provide immediate attention to visually impaired pupils 4. Develop vision screening database 5. Conduct research
- 41. NVSP Program Implementation • Department of Education (lead) • Department of Health • Philippine Eye Research Institute
- 42. Private schools • Funding for school’s vision screening program assumed by private schools
- 43. RA 11358 • Approved/Signed July 31, 2019 • Published in Official Gazette August 2, 2019 • Shall take effect 15 days after publication: August 17, 2019 • IRR given 90 days from approval date: October 31, 2019
- 44. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening and state the rationale for performing vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children#visionscreening, #upmedwebinars © AP Santiago 2018 May 16, 2018
- 45. 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 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 46. Philippine Eye Research Institute Vision Screening Kit #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 47. Philippine Eye Research Institute Vision Screening Kit #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 48. HOTV / HOTEX https://www.good-lite.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 49. http://slideplayer.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 50. 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 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 51. VISUAL ACUITY CHARTS https://clinicalposters.com/anatomy/options/303.jpg SNELLEN CHART SLOAN LETTERS HOTV CHART Copyright PERI 2017 Outdated! #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 52. Philippine Eye Research Institute Vision Screening Kit #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 53. 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]
- 55. Digital Photoscreeners #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 56. MTI Photoscreener http://slideplayer.com/slide/5285177/17/images/34/Photoscreeners.jpg Sensitivity: 65% Specificity: 87% Sensitivity strabismus: 95% Tong PY, et al. Screening for amblyopia in preverbal children with photoscrening photographs: II. Sensitivity and specificity of the MTI photoscreener. Ophthalmology 2000; 107: 1623-9.
- 57. Autorefractors 2005 http://briotweco.ca https://www.welchallyn.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 58. Welch-Allyn Spot Screener https://www.welchallyn.com Sensitivity: 89.6% Specificity: 80.3% Peterseim et al. The effectiveness of the Spot Vision Screener in detecting amblyopia risk factors. J AAPOS 2014; 18(6): 539-542. #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 59. Outcomes Differentiate vision screening from comprehensive eye examination Identify target diseases for vision screening and state the rationale for performing vision screening Be knowledgeable on the updated recommendations for vision screening for school-aged children Be aware of RA 11358: An Act Creating a National Vision Screening Program for Kindergarten Pupils Perform a simple vision screening test especially for kindergarten pupils Enumerate strategies for screening vision problems in school-aged children Enumerate preventive strategies for vision problems in school-aged children
- 60. Preventive Strategies • Timing of screening and repeat exams • Tools to Use 1. Threshold vs Critical Line 2. Machine Screeners • What to do after a child fails vision screening #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 61. 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. #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 62. http://slideplayer.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 63. http://slideplayer.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 64. http://slideplayer.com #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 65. 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
- 67. Mass vision screening • Cost efficient • Quick to perform – Critical Line better than Threshold Acuity – Photoscreeners: risk factors • Sensitivity and specificity • Provide intervention / eyeglasses #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 68. How to screen & Warning Sign • Less than age 5: – cannot read 20/40 – Above red line • 5 or older – Cannot read 20/30 – Below the red line for the PERI Lea Symbols FromPERIVisionScreeningkit #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 69. 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 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 70. Barriers to Follow-Up Care after Failed Vision Screening • Parent had other priorities – Income generation – Other kids – Home management • ”fear of the eyedrops” • Proximity of eye care professional • Government subsidy for consult and intervention • Hassle if children normal • Absence of legislation • Misconceptions Santiago AP, Garces G, Cubillan LDP. Barriers to implementing a kindergarten vision screening program, lessons learned from the Cecilio Apostol Vision Screening Project 2014-2015. Unpublished. #visionscreening,#uppghpediapostgrad ©APSantiago2019 September5,2019
- 71. Parental unawareness of a failed visual acuity screening #visionscreening,#uppghpediapostgrad ©APSantiago2019 September5,2019
- 72. • Not knowing how to access eye test/eye care professional • Concerned that child be given glasses that are not needed #visionscreening,#uppghpediapostgrad ©APSantiago2019 September5,2019
- 73. J of AAPOS 2006: 476-478 • Lack of insurance coverage • Inconvenience of follow-up • Lack of knowledge about benefits of early intervention #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 74. J of School Health 1999: 69 (1): 35-38 • Lack of time • Lack of financial resources • Children would not wear glasses #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 75. Improving compliance to follow-up eye care • Education: drops, early intervention • Performing follow-up eye care where convenient • Incentives • Provision for glasses #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019
- 76. 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 #visionscreening, #uppghpediapostgrad © AP Santiago 2019 September 5, 2019