Children’s vision screening pathway Nicola Turner Orthoptist Aneurin Bevan University Health Board September 2017

Introduction Orthoptists are autonomous practitioners. Diagnose, manage and treat a variety of binocular vision defects and eye movement disorders including amblyopia. Work as part of Ophthalmology team. Orthoptists experts in vision screening. Current NSC recommendations supported by RCOphth recommend Orthoptic led screening for children aged 4-5 years. WG requested development of All Wales Pathway. Introduce etc

WHY A SCREENING PATHWAY ? Discrepancies between vision screening service provided by Orthoptic Departments across Wales. To provide a flexible and auditable pathway for vision screening. To provide a service that is both equitable and effective. One that is accessible to all. Reasons why screening pathway was necessary

HOW WAS THE PATHWAY DEVELOPED? Meetings involving: Orthoptists and Optometrists from each Health Board in Wales. WG. All Orthoptic Departments across Wales were involved and consulted. British and Irish Orthoptic Society including Special Interest Group (School Screening). Consultation with Child Health. Development of pathway

tIMESCALE Objective By When By Who Resources Needed/ Evidence Outcome Measure 1 To scope current provision of vision screening of children aged 4 – 5 years and identify development requirements to achieve equitable provision across Wales Sept 2013 All Wales Orthoptic Advisory Committee (AWOAC) and Welsh British & Irish Orthoptic Society (BIOS) Consultation via AWOAC and Welsh BIOS Current documentation Evaluate cost implications Production of updated AWOAC document Summary of development requirements to achieve equitable provision of vision screening across Wales 2 To agree the logMAR test to be used for vision screening AWOAC and Welsh BIOS Evaluate tests available Funding to purchase equipment Equipment purchased 3 To review the “All Wales Vision Screening Pathway” Dec 2013 Representative/s for Orthoptists/Optometrists/ Ophthalmologists/HCSW/School Nurse (SN) Manager Evidence from existing pathways, e.g. audits of effectiveness and costs Evaluate cost implications / cost analysis Production of updated pathway Time scale, initially scoping exercise, agreement on test to be used , review of pathway developed by Children's Vision Wales Group, (as it was known at that time )

Training, Engagement of SN’s , HCSW, Objective By When By Who Resources Needed/ Evidence Outcome Measure 4 To plan and To To Provide training and development to designated Healthcare Support Workers (HCSWs) & School Nurses who undertake the vision screening. July 2014 AWOAC and Welsh BIOS with support from CVSAG and SN Manager Scope current training Produce training package Cost implication of implementing training across Wales Funding to deliver training Training package with competencies Designated staff trained Database of trained staff 5 To develop system of annual audit, that enables accountability and continuous improvement within open governance structures Sept 2014 Orthoptists/Optometrists/HCSW/SNs and support from appropriate advisory group/s on audit design and implementation and CVSAG Evaluate current audit systems Identify system that enables consistent monitoring, evaluation and review Evaluate cost implications Agreed audit system 6 To implement equitable provision of vision screening of children aged 4 - 5 years across Wales Orthoptists/Optometrists/HCSW / SNs Funding as identified in objectives 1, and 3 Vision screening standardised across Wales Audit of screening services and outcomes reported annually Training, Engagement of SN’s , HCSW, Development of auditable system KPI’s Implemented September 2014 Became WG Policy in February 2015

THE PATHWAY All Reception Children in Mainstream school opt-out consent. Pathway Pass or Fail . Strict Criteria. Pass on left hand side.- advised to attend own Optician in community on routine basis Fail- Referred to Orthoptics , either seen for a combined Orthoptic + Optometry appointment or initially Orthoptics only, depending on clinic capacity/ availability. Child is assessed for ocular motility defect at Orthoptic assessment also. Some children who are referred when retested reach the 0.2 criteria and are discharged at this visit to care of Optician. Those who fail either have a refraction same day or are booked for next available appointment. Following on from refraction , children are then seen again in Orthoptics if Vision has improved to 0.200 or better at this stage then they are discharged to c/o Optician. If there is a concern regarding the level of visual acuity or other reason then they are seen by Consultant Ophthalmologist.

Special schools Children attending Special Schools in ABUHB Area are not included in the screening programme as they are unable to follow the WG Pathway. Many of these children are seen in HES from birth. Pilot study by Optometrists undertaken to provide this service.

VISION TEST

VISION SCREENING PROCESS All Wales Screening Pathway Agreed. WG Policy (February 2015). All Wales KPIs identified (2016). Worked in partnership Child health team to implement / further improve Pathway / Referrals. ABUHB Orthoptic / Optometry processes reviewed and implemented in line with All Wales Pathway. Data collection.

KEY PERFORMANCE INDICATORS 2016 Performance Indicators for Vision Screening Pathway (by Health Board)   Action detail Structure – staff in place/leadership/staff trained 1 Named Orthoptist as screening programme lead: Y Named Lead School nurse Named Ophthalmologist Named Optometrist 2 Proportion of school nurses and HCSW with up to date competencies in vision screening 99% 3 A quality assurance system in place for maintaining competency of staff administering screening Process- pathway compliance with standards, satisfaction, failsafe 4 WG recommended children's vision screening pathway in use for all children 5 Crowded logMAR test used to screen Screening programme outputs and outcomes 6 Total number of children in cohort (Age 4-5 years) ordinarily resident in the health board area 7138 7 Total number of children screened (Age 4-5 years) ordinarily resident in the health board area 7065 8 Number of children screened in cohort (age 4-5 years) referred to Hospital Eye Service 897 9 Proportion of children screened in cohort (age 4-5 years) referred to Hospital Eye Service 12.70% 10 Number of children screened referred for full sight test in primary care 24 11 Proportion of children screened referred for full sight test in primary care 0.34% 12 Number of children referred to HES seen in HES 877 13 Number of children referred to primary care seen in primary care unknown

OUTCOMES 2016 All Wales Screening Pathway Implemented. 99% of children aged 4-5 years (7065)underwent Vision Screen. Achieved RTT of 12 weeks in 84.2 % of cohort. KPI’s Audited and results returned to WG. (August 2016). 897 referrals were received by Orthoptic Department. Improved Communication between Child Health, GP and Parents. Orthoptic led competency training package introduced for SN and HCSW. Completion and update of database.

KEY PERFORMANCE INDICATORS 2017

OUTCOMES 2017 ABUHB Interim Figures 97 % (6598) underwent vision screening Achieved RTT (12 weeks) in 91.5 % (Orthoptic + Refraction) Achieved RTT (12 weeks) in 97.8 % (Orthoptics only) To date 878 referrals received by Orthoptic Department. Use of E screening form for data collection.

WHY IS VISION SCREENING IMPORTANT This is the only vision test child will receive. Parents are often unaware of defect in vision. Impact on visual requirement later in life. Small window of opportunity when treatment is effective.

CONCLUSIONS Vision Screening is now in place in 5 out of 6 HB’s in Wales. Data collection for audit purposes to WG. Orthoptic led screening provides a robust and auditable screening service.

REFERENCES National Screening Committee. Wales Vision Strategy Plan. Welsh Health Circular ( Children’s Vision Pathway). British and Irish Orthoptic Society.