- Email: [email protected]
The UCLA preschool vision program, 2012-2013
The UCLA preschool vision program, 2012-2013 Shiva Mehravaran, MD, MIH,a Pamela B. Duarte, BS,a Stuart I. Brown, MD,b Bartly J. Mondino, MD,a Karen Hendler, MD,a and Anne L. Coleman, MD, PhDa PURPOSE
METHODS
RESULTS
CONCLUSIONS
To introduce the University of California Los Angeles (UCLA) Preschool Vision Program (UPVP) and describe the utilization pattern and challenges of the first year of implementation. The UPVP aims to improve vision in 3- to 5-year-old preschoolers of Los Angeles County. On the first visit, trained personnel use a handheld autorefractometer (Retinomax 3; Righton, Japan) for initial screening and identify those who would benefit from a complete eye examination. On the second visit, the UCLA Mobile Eye Clinic staff and ophthalmologists provide follow-up examinations. Prescribed eyeglasses are fit and provided by program personnel on the school site on a separate visit. Follow-up calls are made to ensure compliance. From a population of 12,088 children in 215 preschools, 11,260 preschoolers (mean age, 4.3 years; 49.2% females) were screened successfully. In this sample, 86% were Latino, and almost all (97%) spoke either Spanish or English. About 65% of referred preschoolers underwent a complete eye examination. Prescription eye glasses were provided for 850 preschoolers (7.5%); 95 children (0.8%) were newly diagnosed with amblyopia. A large proportion of Los Angeles County preschoolers with refractive errors have unmet needs in terms of refractive correction. Further studies are recommended to understand barriers to eye care for children and to devise initiatives for Los Angeles’s large, densely populated, and complex community to increase awareness and willingness. ( J AAPOS 2016;20:63-67)
P
eriodic vision assessments and eye examinations are especially important in childhood, because undetected visual disorders can limit a child’s range of experiences and information they are exposed to and thus affect their cognitive, social, and emotional development.1,2 Some visual problems, if left untreated, can lead to permanent vision loss.1,3 In the United States, it is estimated that 1 out of 20 preschool-age children and 1 in 4 school-age children are affected by common causes of visual impairment in childhood such as refractive errors, amblyopia, and strabismus.3 The American Academy of Ophthalmology, the American Academy of Pediatrics, and the American Association for Pediatric Ophthalmology and Strabismus recommend timely screening for the early detection and treatment of
Author affiliations: aDepartment of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; b Department of Ophthalmology, Shiley Eye Center, School of Medicine, University of California–San Diego, La Jolla, California Material in this paper was presented as a paper at the 40th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Palm Springs, California, April 2-6, 2014. Submitted February 10, 2015. Revision accepted October 29, 2015. Correspondence: Anne L. Coleman, MD, PhD, Stein Eye Institute, 100 Stein Plaza, #2118, Los Angeles, CA 90095-7000 (email: [email protected]). Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.10.018
Journal of AAPOS
eye and vision problems.4 For this purpose, a variety of vision screening programs are administered by primary care providers, community programs, and schools. When performed effectively, vision screening can maximize the rate of problem detection and minimize the cost of referrals. However, screening is only the first step; treatment depends on many other factors, including availability, accessibility, and affordability of eye care services providing comprehensive eye examinations as well as parent awareness and willingness to seek care for their children. To ensure that children receive the appropriate treatment after a failed vision screening, the University of California Los Angeles (UCLA) Center for Community Outreach and Policy has created a strategic partnership with, and is funded by, the First 5 LA Children’s Vision Care Program to improve the vision and school readiness of 3- to 5-year-old preschoolers in Los Angeles County. The purpose of this report is to introduce the UCLA Preschool Vision Program (UPVP) and describe the challenges and results after the first year of implementation in Los Angeles County Preschools.
Subjects and Methods This study was approved by the UCLA Institutional Review Board and conformed to the requirements of the US Health Insurance Portability and Accountability Act of 1996. The UPVP is modeled after the University of California San Diego “EyeMobile for Children” program.5 The target population of the
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FIG 1. Flowchart of the UCLA Preschool Vision Program. program is 3- to 5-year-old preschoolers attending subsidized preschools within Los Angeles County. These include children participating in child development programs such as the Los Angeles Unified Preschool (LAUP), the Head Start, or the California State Preschool Program (CSPP). After enrolling eligible preschools, parent consent forms for vision screening by UPVP are completed when applicable, and appointments are made for screeners to test all available preschoolers on site during normal school hours. This study used UPVP data from the 2012-2013 school year. The flowchart in Figure 1 represents the basic program. In the first part of the program, noncycloplegic screening testing is performed using a handheld autorefractometer (Retinomax 3; Righton, Japan) set for reporting the cylinder component with a minus sign. Screeners are ophthalmic technicians trained by the program manager and/or lead ophthalmic technician on the UCLA Mobile Eye Clinic. Referral criteria include a spherical refractive error of $ 11.75 D or # 3.25D in either eye, a cylinder refractive error of # 1.50D in either eye, or an interocular difference of .2.00 D in spherical error (.1.5 D if antimetropic) or .1.00 D cylinder error.6 When communicating screening results to parents, the UPVP staff provide consent forms for a free eye examination offered by the UPVP ophthalmologist or pediatric ophthalmologist if a child meets the referral criteria. Uncooperative children and those with unreliable autorefractometer readings are also referred for a repeat screening test. For children who already have glasses, UPVP offers a free pair of eyeglasses based on a prescription that is no more than 1 year old. In the second part of the program, the UCLA Mobile Eye Clinic visits preschool sites to rescreen and examine referred children. The staff ophthalmic technician records demographics and the ocular and medical history and tests visual acuity and color
vision before referring a child to the examination room; cycloplegic autorefraction with the Retinomax 3 is performed as needed. New enrollees or children who were absent on the first session may also be screened during this visit. The ophthalmologist conducts a comprehensive eye examination, including slit-lamp examination, ocular alignment and motility, cycloplegic refraction, and indirect ophthalmoscopy. Children who need correction for their refractive errors receive a prescription for eyeglasses and choose their preferred frame from the selection available on the bus. Prescribed eyeglasses are manufactured and provided to the teachers to give to children and their parents. Preschoolers who have an eye condition that requires treatment other than eyeglasses are referred to the appropriate eye care professional. In the last step of the program, follow-up calls are made to parents and teachers of preschoolers who are provided eyeglasses by the UPVP. The objective is to assess the rate of compliance with prescribed spectacle wear and to remind caregivers of the importance of vision correction and adherence to treatment as well as to offer possible solutions to challenging situations. For children who report lost or broken glasses, UPVP offers a free replacement pair. In this study, amblyopia was defined as unilateral if there was 2 or more lines difference in the best-corrected visual acuity, and bilateral if best-corrected visual acuity was worse than 20/50 for children \4 years of age and worse than 20/40 for children $4 years of age.
Results During the 2012-2013 school year, 23 school districts and agencies in the Los Angeles County participated in the
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Table 1. The racial and language profile of the preschooler population screened by the UCLA Preschool Vision Program in the 2012-2013 school year Profile Race Latino Asian Black/African American White Multiracial Other Race/Ethnicity Unknown Race/Ethnicity Pacific Islander Alaska Native/American Indian Total Language Spanish English Cantonese Other Vietnamese Mandarin Korean Tagalog Total
n
%
9,640 626 444 302 93 92 39 23 1 11,260 n
85.61 5.56 3.94 2.68 0.83 0.82 0.35 0.20 0.01 %
5,560 5,335 158 102 70 28 6 1 11,260
49.38 47.38 1.40 0.91 0.62 0.25 0.05 0.01 -
program, and 215 preschools were enrolled. Of these preschools, 49 (23%) were LAUP, 131 (61%) were Head Start, 20 (9%) were CSPP, and the remaining were independent public schools under Los Angeles Unified School District. According to school rosters, a total of 12,088 preschoolers 3- to 5-years of age were enrolled in participating preschools; of these, 11,076 were screened by UPVP screeners on the first session, and an additional 184 were screened by UCLA Mobile Eye Clinic staff on the examination day. A total of 11,260 were screened in this population; the remaining children were either absent or did not have a signed parent consent form on either visit. The mean age of the screened population was 4.3 years; 5,541 (49%) were girls. Table 1 summarizes the demographics of the screened children in terms of their ethnicity and language most often spoken at home: 9,640 of children (86%) were Latino, and 10,895 (96.8%) spoke either Spanish or English. Based on the referral criteria, 9,342 of the 11,260 preschoolers passed the screening test the first time, and 157 passed the criteria when they were rescreened. Also, 207 of the preschoolers already had eyeglasses or were receiving care from an eye care provider. Of the remaining 1,554 children who met the referral criteria, 1,005 were scheduled an examination by the UCLA Mobile Eye Clinic in their own preschools, and 549 were invited to go to a different site (Table 2). The average time elapsed between the screening and examination days was 68 days (range, 6-237 days). Table 2 summarizes the frequency of examinations and reasons for not receiving an examination. The overall examination rate was 64.8%; the rate was 70.8% for those
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Table 2. Frequency of eye examinations and reasons for no eye examination by referral site Referral site for eye exam
Examineda Comprehensive exam Comprehensive exam and glasses Not examined No show No consent Other Unspecified Total
At same preschool n (%)
Elsewhere n (%)
Total n (%)
711 (70.8) 203 (20.2) 508 (50.6)
296 (53.9) 64 (11.7) 232 (42.3)
1007 (64.8) 267 (17.2) 740 (47.6)
294 (29.3) 97 (9.7) 161 (16.0) 23 (2.3) 13 (1.3) 1005 (100)
253 (46.1) 81 (14.8) 93 (16.9) 7 (1.3) 72 (13.1) 549 (100)
547 (35.2) 178 (11.5) 254 (16.3) 30 (1.9) 85 (5.5) 1554 (100)
a P value (c2 test) on the effect of referral site on receiving an eye examination of \0.001.
who had an appointment in their own school and 53.9% if they had to go to a different one (P\0.001 [c2 test]). Of the 1,007 preschoolers examined by the UCLA Mobile Eye Clinic, 740 received their first prescription eyeglasses. A total of 95 children (0.8% of the screened population; 95% CI, 0.7%-1.0%) were newly diagnosed with amblyopia, of whom 22 (0.2% of the screened population) were identified with bilateral amblyopia. Of the referred preschoolers who did not receive an eye examination, 78% did not have parental consent or were no-shows (Table 2). Other reasons for failure to participate included leaving before the dilated examination, dropping out of school, arriving too late, and refusing dilation despite signing the consent form. The reason was not specified in 85 cases. Table 3 summarizes the results of follow-up calls made at least 1 month after distributing the prescribed eyeglasses. UPVP screeners contacted about 489 of the 740 children through their parents, caregivers, or teachers; of these, 429 (87.7%) stated that their children complied with treatment.
Discussion In the United States, school entry vision screening examination requirements and guidelines vary by state.7 For preschools in Los Angeles County, these requirements vary by type of preschool. The Los Angeles County Office of Education (LACOE) is one of the largest education agencies of its kind in the nation and provides services for the 80 school districts in Los Angeles County as an intermediate organization between school districts and the California Department of Education.8 Any child enrolled in a LACOE program may have physical examinations including sight, hearing, and scoliosis testing unless parents or legal guardians withhold consent by filing a signed written statement.9 Also, preschoolers enrolled in Head Start programs are required to complete children’s vision
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Table 3. Results of follow-up calls made at least 1 month after distributing prescribed eyeglasses Result of inquiry Able to contact Wearing glasses as prescribed Not wearing glasses as prescribed Subtotal Not able to contact No number/wrong number/disconnected No answer/answering machine Subtotal Grand total
n
% of grand total
429 60 489
58.0 8.1 66.1
89 162 251 740
12.0 21.9 33.9 -
screenings within 45 days of the child’s enrollment.10 Of the 215 preschools enrolled in the first year of UPVP, more than 60% were LACOE and/or Head Start programs that had acquired screening consents as part of school enrollment. Obtaining signed parent consent forms for screening was only needed for the remaining schools. This explains the relatively high screening participation rate, and the ability to surpass our screening goal by more than 3,000 preschoolers. Retinomax performance and accuracy for preschool vision screening has been verified by the Vision in Preschoolers (VIP) study.11-13 Retinomax has been ranked among the top 3 tests in terms of sensitivity for identifying preschool children with VIP-targeted vision conditions when overall specificity was set at either 90% or 94%. Some studies have also reported good inter- and intratester agreement for Retinomax.14,15 In a retrospective cohort of preschoolers however, Lowry and colleagues16 found that 25% of preschoolers who presented for a follow-up examination passed the second screening that was performed an average 96 days later. The fail rate in their cohort was 17.11% (1,303/7,614), and the authors believe that Retinomax variability is clinically significant and may cause unnecessary referral that can be avoided by repeat autorefraction. Their conclusion was not supported by UPVP results. On the first UPVP visit for screening, 1,798 of the 11,076 (16%) screened preschoolers met one or more of these criteria, and thus failed the screening test. Of these, 1,100 were rescreened on the examination day and only 112 (10%) of them passed the second screening with Retinomax and visual acuity tests. Another issue in designing an effective screening program is selection of appropriate referral criteria and cutoff values. For the UPVP, the VIP criteria were chosen because the criteria had been tested, validated, and published in the literature when the screening protocol was established. Alterations in referral criteria result in an inverse relationship between sensitivity and specificity; although a high sensitivity is more likely to detect at-risk children, it also risks excessive overreferrals. On the other hand, minimizing overreferrals through high specificity reduces sensitivity and some children will go undetected. Results of comprehensive examinations by the UPVP showed that about 6.5% of 3- to 5-year-olds in our popu-
lation needed and received prescription eyeglasses. The percentage requiring correction increases to 8.1% (95% CI, 7.9%-8.6%) of the screened population when the 174 children who already had eyeglasses are added. This could be an underestimation, because 547 of the children referred to the UCLA Mobile Eye Clinic (4.9% of the screened population) did not follow-up and were not examined. Multiple barriers to childhood vision care have been identified.17-20 Studies suggest that social/family and perceptual barriers need be addressed before financial and logistical assistance can be fully effective. One of the important issues to address is parent/guardian understanding of the importance of vision care, and there is need for research concerning the impact of education to promote acceptance of spectacle wear.21 For the Hispanic immigrant population studied by Frazier and colleagues,22 cost, lack of interest, and the absence of signs, symptoms, or a family history of eye problems were the most frequently mentioned barriers. The UPVP eliminates financial barriers by offering free services. Furthermore, the 87.7% compliance rate is self-reported and could be an overestimate. Therefore, there is also need to understand the causes of non-compliance among children who receive free eyeglasses but do not wear them as prescribed (Table 3). In most cases, conversations implied that there is an ongoing need for parent awareness programs. Using the UCLA Mobile Eye Clinic for follow-up examinations brings some limitations and challenges to the UPVP. The clinic is the size of a school bus and many smaller preschools lack sufficient parking space and/or sufficient staff to offer assistance. The bus only makes trips to preschools with 6 or more referrals. For these two preschool categories, parents were invited to bring their children to an alternate site (most often a nearby preschool) for follow-up; this seems to have affected the percentage of children who came to their follow-up examinations. Nonetheless, we feel that the compliance for examinations at both sites were more than acceptable, especially considering that this was UPVP’s first year. We expect to see better collaboration, participation, and results as the program matures. Better parent and teacher education about the importance of glasses may also improve our examination rate in the future as school personnel become more enthusiastic and engaged.23
Acknowledgments The authors wish to thank Mrs Faye Oelrich for her long dedication to the UCLA Mobile Eye Clinic as Program Manager and her valuable suggestions in the preparation of this manuscript. References 1. Our Vision for Children’s Vision. A National Call to Action for the Advancement of Children’s Vision and Eye Health. http://www. preventblindness.net/site/DocServer/08-045_OVFCV_small.pdf?doc ID51601. Accessed June 5, 2014. 2. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol 2008;126:252-8.
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Volume 20 Number 1 / February 2016 3. Prevent Blindness America. Quick Facts: Children’s Eye Problems. http://www.preventblindness.org/sites/default/files/ national/documents/fact_sheets/MK03_QuickFactsChildren.pdf. Accessed June 5, 2014. 4. American Academy of Ophthalmology. Joint Policy Statement: Vision Screening for Infants and Children. http://one.aao.org/Assets/ 902411d9-f839-4c9f-b5eb-8822f7c097a7/635209988330700000/ vision-screening-for-infants-and-children-2013-pdf. Accessed June 5, 2014. 5. University of California, Sandiego, Siheley Eye Center. UCSD EyeMobile: Our Program. Website: http://eyemobile.ucsd.edu. Accessed June 5, 2014. 6. Kulp MT. Vision in Preschoolers Study Group. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci 2009;86:619-23. 7. American Association for Pediatric Ophthalmology and Strabismus. State-by-State Vision Screening Requirements. http://www.aapos. org/resources/state_by_state_vision_screening_requirements. Accessed June 5, 2014. 8. Education Pioneers. Partner: Los Angeles County Office of Education - Head Start and State Preschool. Website: http://www. educationpioneers.org/becoming-a-partner/partner?cid50014000 000Go3kgAAB. Accessed June 5, 2014. 9. Los Angeles County Office of Education. Annual Notification. http://www.lacoe.edu/Portals/0/LACOE/Annual%20Notification %202013-14.pdf. Accessed June 5, 2014. 10. Early Childhood Learning and Knowledge Center. Head Start Program Performance and Standards and Other Regulations: 45 CFR 1304. http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps/1304/1304. 20%20child%20health%20and%20developmental%20services.htm. Accessed June 5, 2014. 11. Ying GS, Maguire M, Quinn G, Kulp MT, Cyert L, Vision in Preschoolers (VIP) Study Group. ROC analysis of the accuracy of Noncycloplegic ret1inoscopy, Retinomax Autorefractor, and SureSight Vision Screener for preschool vision screening. Invest Ophthalmol Vis Sci 2011;52:9658-64. 12. Ying GS, Kulp MT, Maguire M, Ciner E, Cyert L, Schmidt P, Vision in Preschoolers Study Group. Sensitivity of screening tests for detect-
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13.
14.
15.
16.
17.
18. 19.
20.
21.
22.
23.
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ing vision in preschoolers-targeted vision disorders when specificity is 94%. Optom Vis Sci 2005;82:432-8. Schmidt P, Maguire M, Dobson V, et al., Vision in Preschoolers Study Group. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision in Preschoolers Study. Ophthalmology 2004;111:637-50. Huang J, Maguire MG, Ciner E, et al., Vision in Preschoolers (VIP) Study Group. Intertester agreement in refractive error measurements. Optom Vis Sci 2013;90:1128-37. Harvey EM, Miller JM, Wagner LK, Dobson V. Reproducibility and accuracy of measurements with a hand held autorefractor in children. Br J Ophthalmol 1997;81:941-8. Lowry EA, Lui R, Enanoria W, Keenan J, de Alba Campomanes AG. Repeat Retinomax screening changes positive predictive value. J AAPOS 2014;18:45-9. Kodjebacheva G, Brown ER, Estrada L, Yu F, Coleman AL. Uncorrected refractive error among first-grade students of different racial/ethnic groups in southern California: results a year after school-mandated vision screening. J Public Health Manag Pract 2011;17:499-505. Kimel LS. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nurs 2006;22:156-62. Castanes MS. Major review: The underutilization of vision screening (for amblyopia, optical anomalies and strabismus) among preschool age children. Binocul Vis Strabismus Q 2003;18:217-32. Yawn BP, Kurland M, Butterfield L, Johnson B. Barriers to seeking care following school vision screening in Rochester, Minnesota. J Sch Health 1998;68:319-24. Sharma A, Congdon N, Patel M, Gilbert C. School-based approaches to the correction of refractive error in children. Surv Ophthalmol 2012;57:272-3. Frazier M, Garces I, Scarinci I, Marsh-Tootle W. Seeking eye care for children: perceptions among Hispanic immigrant parents. J Immigr Minor Health 2009;11:215-21. Kodjebacheva GD, Maliski S, Coleman AL. Use of eyeglasses among children in elementary school: perceptions, behaviors, and interventions discussed by parents, school nurses, and teachers during focus groups. Am J Health Promot 2015;29:324-31.
METHODS
RESULTS
CONCLUSIONS
To introduce the University of California Los Angeles (UCLA) Preschool Vision Program (UPVP) and describe the utilization pattern and challenges of the first year of implementation. The UPVP aims to improve vision in 3- to 5-year-old preschoolers of Los Angeles County. On the first visit, trained personnel use a handheld autorefractometer (Retinomax 3; Righton, Japan) for initial screening and identify those who would benefit from a complete eye examination. On the second visit, the UCLA Mobile Eye Clinic staff and ophthalmologists provide follow-up examinations. Prescribed eyeglasses are fit and provided by program personnel on the school site on a separate visit. Follow-up calls are made to ensure compliance. From a population of 12,088 children in 215 preschools, 11,260 preschoolers (mean age, 4.3 years; 49.2% females) were screened successfully. In this sample, 86% were Latino, and almost all (97%) spoke either Spanish or English. About 65% of referred preschoolers underwent a complete eye examination. Prescription eye glasses were provided for 850 preschoolers (7.5%); 95 children (0.8%) were newly diagnosed with amblyopia. A large proportion of Los Angeles County preschoolers with refractive errors have unmet needs in terms of refractive correction. Further studies are recommended to understand barriers to eye care for children and to devise initiatives for Los Angeles’s large, densely populated, and complex community to increase awareness and willingness. ( J AAPOS 2016;20:63-67)
P
eriodic vision assessments and eye examinations are especially important in childhood, because undetected visual disorders can limit a child’s range of experiences and information they are exposed to and thus affect their cognitive, social, and emotional development.1,2 Some visual problems, if left untreated, can lead to permanent vision loss.1,3 In the United States, it is estimated that 1 out of 20 preschool-age children and 1 in 4 school-age children are affected by common causes of visual impairment in childhood such as refractive errors, amblyopia, and strabismus.3 The American Academy of Ophthalmology, the American Academy of Pediatrics, and the American Association for Pediatric Ophthalmology and Strabismus recommend timely screening for the early detection and treatment of
Author affiliations: aDepartment of Ophthalmology, Stein Eye Institute, David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California; b Department of Ophthalmology, Shiley Eye Center, School of Medicine, University of California–San Diego, La Jolla, California Material in this paper was presented as a paper at the 40th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Palm Springs, California, April 2-6, 2014. Submitted February 10, 2015. Revision accepted October 29, 2015. Correspondence: Anne L. Coleman, MD, PhD, Stein Eye Institute, 100 Stein Plaza, #2118, Los Angeles, CA 90095-7000 (email: [email protected]). Copyright Ó 2016 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.10.018
Journal of AAPOS
eye and vision problems.4 For this purpose, a variety of vision screening programs are administered by primary care providers, community programs, and schools. When performed effectively, vision screening can maximize the rate of problem detection and minimize the cost of referrals. However, screening is only the first step; treatment depends on many other factors, including availability, accessibility, and affordability of eye care services providing comprehensive eye examinations as well as parent awareness and willingness to seek care for their children. To ensure that children receive the appropriate treatment after a failed vision screening, the University of California Los Angeles (UCLA) Center for Community Outreach and Policy has created a strategic partnership with, and is funded by, the First 5 LA Children’s Vision Care Program to improve the vision and school readiness of 3- to 5-year-old preschoolers in Los Angeles County. The purpose of this report is to introduce the UCLA Preschool Vision Program (UPVP) and describe the challenges and results after the first year of implementation in Los Angeles County Preschools.
Subjects and Methods This study was approved by the UCLA Institutional Review Board and conformed to the requirements of the US Health Insurance Portability and Accountability Act of 1996. The UPVP is modeled after the University of California San Diego “EyeMobile for Children” program.5 The target population of the
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FIG 1. Flowchart of the UCLA Preschool Vision Program. program is 3- to 5-year-old preschoolers attending subsidized preschools within Los Angeles County. These include children participating in child development programs such as the Los Angeles Unified Preschool (LAUP), the Head Start, or the California State Preschool Program (CSPP). After enrolling eligible preschools, parent consent forms for vision screening by UPVP are completed when applicable, and appointments are made for screeners to test all available preschoolers on site during normal school hours. This study used UPVP data from the 2012-2013 school year. The flowchart in Figure 1 represents the basic program. In the first part of the program, noncycloplegic screening testing is performed using a handheld autorefractometer (Retinomax 3; Righton, Japan) set for reporting the cylinder component with a minus sign. Screeners are ophthalmic technicians trained by the program manager and/or lead ophthalmic technician on the UCLA Mobile Eye Clinic. Referral criteria include a spherical refractive error of $ 11.75 D or # 3.25D in either eye, a cylinder refractive error of # 1.50D in either eye, or an interocular difference of .2.00 D in spherical error (.1.5 D if antimetropic) or .1.00 D cylinder error.6 When communicating screening results to parents, the UPVP staff provide consent forms for a free eye examination offered by the UPVP ophthalmologist or pediatric ophthalmologist if a child meets the referral criteria. Uncooperative children and those with unreliable autorefractometer readings are also referred for a repeat screening test. For children who already have glasses, UPVP offers a free pair of eyeglasses based on a prescription that is no more than 1 year old. In the second part of the program, the UCLA Mobile Eye Clinic visits preschool sites to rescreen and examine referred children. The staff ophthalmic technician records demographics and the ocular and medical history and tests visual acuity and color
vision before referring a child to the examination room; cycloplegic autorefraction with the Retinomax 3 is performed as needed. New enrollees or children who were absent on the first session may also be screened during this visit. The ophthalmologist conducts a comprehensive eye examination, including slit-lamp examination, ocular alignment and motility, cycloplegic refraction, and indirect ophthalmoscopy. Children who need correction for their refractive errors receive a prescription for eyeglasses and choose their preferred frame from the selection available on the bus. Prescribed eyeglasses are manufactured and provided to the teachers to give to children and their parents. Preschoolers who have an eye condition that requires treatment other than eyeglasses are referred to the appropriate eye care professional. In the last step of the program, follow-up calls are made to parents and teachers of preschoolers who are provided eyeglasses by the UPVP. The objective is to assess the rate of compliance with prescribed spectacle wear and to remind caregivers of the importance of vision correction and adherence to treatment as well as to offer possible solutions to challenging situations. For children who report lost or broken glasses, UPVP offers a free replacement pair. In this study, amblyopia was defined as unilateral if there was 2 or more lines difference in the best-corrected visual acuity, and bilateral if best-corrected visual acuity was worse than 20/50 for children \4 years of age and worse than 20/40 for children $4 years of age.
Results During the 2012-2013 school year, 23 school districts and agencies in the Los Angeles County participated in the
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Table 1. The racial and language profile of the preschooler population screened by the UCLA Preschool Vision Program in the 2012-2013 school year Profile Race Latino Asian Black/African American White Multiracial Other Race/Ethnicity Unknown Race/Ethnicity Pacific Islander Alaska Native/American Indian Total Language Spanish English Cantonese Other Vietnamese Mandarin Korean Tagalog Total
n
%
9,640 626 444 302 93 92 39 23 1 11,260 n
85.61 5.56 3.94 2.68 0.83 0.82 0.35 0.20 0.01 %
5,560 5,335 158 102 70 28 6 1 11,260
49.38 47.38 1.40 0.91 0.62 0.25 0.05 0.01 -
program, and 215 preschools were enrolled. Of these preschools, 49 (23%) were LAUP, 131 (61%) were Head Start, 20 (9%) were CSPP, and the remaining were independent public schools under Los Angeles Unified School District. According to school rosters, a total of 12,088 preschoolers 3- to 5-years of age were enrolled in participating preschools; of these, 11,076 were screened by UPVP screeners on the first session, and an additional 184 were screened by UCLA Mobile Eye Clinic staff on the examination day. A total of 11,260 were screened in this population; the remaining children were either absent or did not have a signed parent consent form on either visit. The mean age of the screened population was 4.3 years; 5,541 (49%) were girls. Table 1 summarizes the demographics of the screened children in terms of their ethnicity and language most often spoken at home: 9,640 of children (86%) were Latino, and 10,895 (96.8%) spoke either Spanish or English. Based on the referral criteria, 9,342 of the 11,260 preschoolers passed the screening test the first time, and 157 passed the criteria when they were rescreened. Also, 207 of the preschoolers already had eyeglasses or were receiving care from an eye care provider. Of the remaining 1,554 children who met the referral criteria, 1,005 were scheduled an examination by the UCLA Mobile Eye Clinic in their own preschools, and 549 were invited to go to a different site (Table 2). The average time elapsed between the screening and examination days was 68 days (range, 6-237 days). Table 2 summarizes the frequency of examinations and reasons for not receiving an examination. The overall examination rate was 64.8%; the rate was 70.8% for those
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Table 2. Frequency of eye examinations and reasons for no eye examination by referral site Referral site for eye exam
Examineda Comprehensive exam Comprehensive exam and glasses Not examined No show No consent Other Unspecified Total
At same preschool n (%)
Elsewhere n (%)
Total n (%)
711 (70.8) 203 (20.2) 508 (50.6)
296 (53.9) 64 (11.7) 232 (42.3)
1007 (64.8) 267 (17.2) 740 (47.6)
294 (29.3) 97 (9.7) 161 (16.0) 23 (2.3) 13 (1.3) 1005 (100)
253 (46.1) 81 (14.8) 93 (16.9) 7 (1.3) 72 (13.1) 549 (100)
547 (35.2) 178 (11.5) 254 (16.3) 30 (1.9) 85 (5.5) 1554 (100)
a P value (c2 test) on the effect of referral site on receiving an eye examination of \0.001.
who had an appointment in their own school and 53.9% if they had to go to a different one (P\0.001 [c2 test]). Of the 1,007 preschoolers examined by the UCLA Mobile Eye Clinic, 740 received their first prescription eyeglasses. A total of 95 children (0.8% of the screened population; 95% CI, 0.7%-1.0%) were newly diagnosed with amblyopia, of whom 22 (0.2% of the screened population) were identified with bilateral amblyopia. Of the referred preschoolers who did not receive an eye examination, 78% did not have parental consent or were no-shows (Table 2). Other reasons for failure to participate included leaving before the dilated examination, dropping out of school, arriving too late, and refusing dilation despite signing the consent form. The reason was not specified in 85 cases. Table 3 summarizes the results of follow-up calls made at least 1 month after distributing the prescribed eyeglasses. UPVP screeners contacted about 489 of the 740 children through their parents, caregivers, or teachers; of these, 429 (87.7%) stated that their children complied with treatment.
Discussion In the United States, school entry vision screening examination requirements and guidelines vary by state.7 For preschools in Los Angeles County, these requirements vary by type of preschool. The Los Angeles County Office of Education (LACOE) is one of the largest education agencies of its kind in the nation and provides services for the 80 school districts in Los Angeles County as an intermediate organization between school districts and the California Department of Education.8 Any child enrolled in a LACOE program may have physical examinations including sight, hearing, and scoliosis testing unless parents or legal guardians withhold consent by filing a signed written statement.9 Also, preschoolers enrolled in Head Start programs are required to complete children’s vision
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Table 3. Results of follow-up calls made at least 1 month after distributing prescribed eyeglasses Result of inquiry Able to contact Wearing glasses as prescribed Not wearing glasses as prescribed Subtotal Not able to contact No number/wrong number/disconnected No answer/answering machine Subtotal Grand total
n
% of grand total
429 60 489
58.0 8.1 66.1
89 162 251 740
12.0 21.9 33.9 -
screenings within 45 days of the child’s enrollment.10 Of the 215 preschools enrolled in the first year of UPVP, more than 60% were LACOE and/or Head Start programs that had acquired screening consents as part of school enrollment. Obtaining signed parent consent forms for screening was only needed for the remaining schools. This explains the relatively high screening participation rate, and the ability to surpass our screening goal by more than 3,000 preschoolers. Retinomax performance and accuracy for preschool vision screening has been verified by the Vision in Preschoolers (VIP) study.11-13 Retinomax has been ranked among the top 3 tests in terms of sensitivity for identifying preschool children with VIP-targeted vision conditions when overall specificity was set at either 90% or 94%. Some studies have also reported good inter- and intratester agreement for Retinomax.14,15 In a retrospective cohort of preschoolers however, Lowry and colleagues16 found that 25% of preschoolers who presented for a follow-up examination passed the second screening that was performed an average 96 days later. The fail rate in their cohort was 17.11% (1,303/7,614), and the authors believe that Retinomax variability is clinically significant and may cause unnecessary referral that can be avoided by repeat autorefraction. Their conclusion was not supported by UPVP results. On the first UPVP visit for screening, 1,798 of the 11,076 (16%) screened preschoolers met one or more of these criteria, and thus failed the screening test. Of these, 1,100 were rescreened on the examination day and only 112 (10%) of them passed the second screening with Retinomax and visual acuity tests. Another issue in designing an effective screening program is selection of appropriate referral criteria and cutoff values. For the UPVP, the VIP criteria were chosen because the criteria had been tested, validated, and published in the literature when the screening protocol was established. Alterations in referral criteria result in an inverse relationship between sensitivity and specificity; although a high sensitivity is more likely to detect at-risk children, it also risks excessive overreferrals. On the other hand, minimizing overreferrals through high specificity reduces sensitivity and some children will go undetected. Results of comprehensive examinations by the UPVP showed that about 6.5% of 3- to 5-year-olds in our popu-
lation needed and received prescription eyeglasses. The percentage requiring correction increases to 8.1% (95% CI, 7.9%-8.6%) of the screened population when the 174 children who already had eyeglasses are added. This could be an underestimation, because 547 of the children referred to the UCLA Mobile Eye Clinic (4.9% of the screened population) did not follow-up and were not examined. Multiple barriers to childhood vision care have been identified.17-20 Studies suggest that social/family and perceptual barriers need be addressed before financial and logistical assistance can be fully effective. One of the important issues to address is parent/guardian understanding of the importance of vision care, and there is need for research concerning the impact of education to promote acceptance of spectacle wear.21 For the Hispanic immigrant population studied by Frazier and colleagues,22 cost, lack of interest, and the absence of signs, symptoms, or a family history of eye problems were the most frequently mentioned barriers. The UPVP eliminates financial barriers by offering free services. Furthermore, the 87.7% compliance rate is self-reported and could be an overestimate. Therefore, there is also need to understand the causes of non-compliance among children who receive free eyeglasses but do not wear them as prescribed (Table 3). In most cases, conversations implied that there is an ongoing need for parent awareness programs. Using the UCLA Mobile Eye Clinic for follow-up examinations brings some limitations and challenges to the UPVP. The clinic is the size of a school bus and many smaller preschools lack sufficient parking space and/or sufficient staff to offer assistance. The bus only makes trips to preschools with 6 or more referrals. For these two preschool categories, parents were invited to bring their children to an alternate site (most often a nearby preschool) for follow-up; this seems to have affected the percentage of children who came to their follow-up examinations. Nonetheless, we feel that the compliance for examinations at both sites were more than acceptable, especially considering that this was UPVP’s first year. We expect to see better collaboration, participation, and results as the program matures. Better parent and teacher education about the importance of glasses may also improve our examination rate in the future as school personnel become more enthusiastic and engaged.23
Acknowledgments The authors wish to thank Mrs Faye Oelrich for her long dedication to the UCLA Mobile Eye Clinic as Program Manager and her valuable suggestions in the preparation of this manuscript. References 1. Our Vision for Children’s Vision. A National Call to Action for the Advancement of Children’s Vision and Eye Health. http://www. preventblindness.net/site/DocServer/08-045_OVFCV_small.pdf?doc ID51601. Accessed June 5, 2014. 2. Roch-Levecq AC, Brody BL, Thomas RG, Brown SI. Ametropia, preschoolers’ cognitive abilities, and effects of spectacle correction. Arch Ophthalmol 2008;126:252-8.
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Volume 20 Number 1 / February 2016 3. Prevent Blindness America. Quick Facts: Children’s Eye Problems. http://www.preventblindness.org/sites/default/files/ national/documents/fact_sheets/MK03_QuickFactsChildren.pdf. Accessed June 5, 2014. 4. American Academy of Ophthalmology. Joint Policy Statement: Vision Screening for Infants and Children. http://one.aao.org/Assets/ 902411d9-f839-4c9f-b5eb-8822f7c097a7/635209988330700000/ vision-screening-for-infants-and-children-2013-pdf. Accessed June 5, 2014. 5. University of California, Sandiego, Siheley Eye Center. UCSD EyeMobile: Our Program. Website: http://eyemobile.ucsd.edu. Accessed June 5, 2014. 6. Kulp MT. Vision in Preschoolers Study Group. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci 2009;86:619-23. 7. American Association for Pediatric Ophthalmology and Strabismus. State-by-State Vision Screening Requirements. http://www.aapos. org/resources/state_by_state_vision_screening_requirements. Accessed June 5, 2014. 8. Education Pioneers. Partner: Los Angeles County Office of Education - Head Start and State Preschool. Website: http://www. educationpioneers.org/becoming-a-partner/partner?cid50014000 000Go3kgAAB. Accessed June 5, 2014. 9. Los Angeles County Office of Education. Annual Notification. http://www.lacoe.edu/Portals/0/LACOE/Annual%20Notification %202013-14.pdf. Accessed June 5, 2014. 10. Early Childhood Learning and Knowledge Center. Head Start Program Performance and Standards and Other Regulations: 45 CFR 1304. http://eclkc.ohs.acf.hhs.gov/hslc/standards/hspps/1304/1304. 20%20child%20health%20and%20developmental%20services.htm. Accessed June 5, 2014. 11. Ying GS, Maguire M, Quinn G, Kulp MT, Cyert L, Vision in Preschoolers (VIP) Study Group. ROC analysis of the accuracy of Noncycloplegic ret1inoscopy, Retinomax Autorefractor, and SureSight Vision Screener for preschool vision screening. Invest Ophthalmol Vis Sci 2011;52:9658-64. 12. Ying GS, Kulp MT, Maguire M, Ciner E, Cyert L, Schmidt P, Vision in Preschoolers Study Group. Sensitivity of screening tests for detect-
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