Page 74 - DISINVESTMENT AND IMPLEMENTATION OF VISION SCREENING TESTS BASED ON THEIR EFFECTIVENESS

CHAPTER 4
ABSTRACT
BACKGROUND In the Netherlands, child healthcare physicians screen children seven times for vision disorders between the ages of 1 and 60 months. Examination consists of inspection of the external structures of the eye, fundus red reflex, Hirschberg test, pupillary reflexes, cover-uncover test, alternating-cover test, eye motility, monocular pursuit, and, from 36 months onwards, visual acuity. We observed how well these tests are done.
METHODS Screening test performance was assessed with semi-structured observations. Two orthoptic students developed a semi-structured observation form. In addition to extensive instructions form an orthoptist and child healthcare physicians instructor, they attended two one-day courses for child healthcare physicians. Tests were assessed using criteria based on the Dutch Child Vision Screening Guideline version 2010 and the Dutch Manual for Orthoptic Examination. Type of chart, testing distance, and starting eye were recorded for the visual acuity measurements. The observations in the first week were done simultaneously by the two observers and checked for concordance.
RESULTS Concordance between the two observers was good. Twenty-five child healthcare physicians were observed during 100 days in total. Two physicians were excluded because they examined few children. The remaining 23 physicians examined 329 children, of whom 82 were 1-4 months, 157 aged 6-24 months, and 90 aged 36- 45 months. Fundus red reflex was performed in 89% of children, Hirschberg test in 88%, pupillary reflexes in 14%, cover-uncover test in 65%, alternating-cover test in 62%, eye motility in 68% monocular pursuit in 23%, and visual acuity at 36-45 months in 94%. Forty-eight percent of cover-uncover tests, 36% of alternating-cover tests and 7% of eye motility tests were performed correctly. Visual acuity testing was measured at three meters in 2%, others at five meters in accordance with the guideline. A picture chart was used instead of the Landolt-C at the age of 45 months in 23%. Visual acuity measurements were performed correctly in 89%, fundus red reflex in 89% and Hirschberg test in 87%.
CONCLUSIONS Hirschberg test, fundus red reflex and visual acuity were adequately tested in most cases. Cover-uncover test, alternating-cover test and eye motility were often performed inadequately. Pupillary reflexes were skipped often as room lights could not be dimmed.
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