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

2. 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

3. 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

4. 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

5. 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 )

6. 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 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

7. 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 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.

8. 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.

9. VISION TEST

10. 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.

11. 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

12. 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.

13. KEY PERFORMANCE INDICATORS 2017

14. OUTCOMES 2017 ABUHB Interim Figures
97 % (6598) underwent vision screening
Achieved RTT (12 weeks) in % (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.

15. 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.

16. 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.

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