SeeAbility response to Child Vision Screening resources consultation
SeeAbility is the national charity that supports people with sight loss and multiple disabilities.
SeeAbility’s concern is that children with learning disabilities are 28 times more likely to be at risk of serious sight problems than other children, but may be unable to report sight problems, often because they may have other difficulties with communication or their learning disability is ‘overshadowing’ any obvious problems with their vision.
Children with autism (which can often co-present with a learning disability) are also known to have a particular problem in accessing community sight tests and may have difficulty coping with the experience and unfamiliar environments.
This information is available from SeeAbility’s work in special schools, more of which can be found at and we are just about to publish our third annual report which provides data on 905 children we have tested over the course of our service using a multidisciplinary model of optometrists, orthoptists and a dispensing optician. Data analysis is by Dr Maggie Woodhouse of Cardiff University’s School of Optometry and Vision Science.
We hope the following information is of use to Public Health England and we would like to invite a meeting with PHE to discuss our findings and brief on the work needed to establish a programme that provides a specialist sight test at school entry and annually throughout a child’s time at their special school.
Screening is not a recommended tool for children in special schools: this needs to be explicit throughout the documentation
Clinical recommendations on children’s health are set out in the Hall Report ‘Health for all Children’.[1] This recommends that children of any age with suspected visual deficits, a significant family history or any neurological or disabling condition, should be routinely referred for a visual assessment. More targeted clinical surveillance of children with neurodevelopmental impairments is also endorsed by the Royal College of Ophthalmologists.[2]
Indications from SeeAbility’s soon to be published analysis are that over 90% of children attending special school in the 4–7.9 years age group would either be unable to perform or would fail the vision screening test as set out in National Screening Committee guidelines, which is why this is not a test suitable for these children. Dr Woodhouse has looked at the data for the 264 pupils in this age group and only 25 would pass vision screening. In fact across the entire school age range only 160 of 719 pupils who we tested for the first time would pass vision screening.
In the SeeAbility service, various acuity tests were used by our optometrists or orthoptists, including Kay Pictures and Cardiff Acuity Test. In general, more child-friendly tests such as these are considered likely to over-estimate acuity, and some screening services have more stringent pass criteria for these tests; in this case, even more of the pupils in special schools would fail screening.
In many cases, a fail would also necessitate onward referral for further investigation, most likely to secondary care due to a lack of community optometry alternatives for children with learning disabilities. In our data over 50% of children are under hospital eye care services, or have been seen and discharged. These are additional appointments out of school.
Public Health England endorsement and support for a special schools programme is needed as the ‘alternative pathway’ sometimes alluded to in the documentation.
Later the service specification goes on to recommend that that children who are developmentally unable to perform crowded LogMAR acuity tests undergo vision screening delivered by an orthoptist using a test appropriate for their developmental stage (the ‘alternate’ screening pathway).
Nowhere else in the literature does it explain what this ‘alternate’ pathway might be and where the tests should take place, other than a mention in the competencies that children attending special schools should be ‘screened’ by an orthoptist.
For the reasons outlined above, ‘screening’ is not a suitable test or phrase to be used in the special schools context. It is also worth noting that in SeeAbility’s service, ability-appropriate tests are used either by an optometrist or an orthoptist and it would be under these circumstances that there would still be an over 90% ‘failure’ rate, which again helps emphasise why more specific and comprehensive examinations are needed.
In addition the draft service specification in one place recommends referral to hospital eye services for children unable to complete the screening test but does not mention that there may be alternatives in the community (or support the case for the development of these).Again, our data indicates that of the 719 pupils seen for the first time, 60.8% did not co-operate either for any acuity test or withocclusion, and would therefore have failed screening.
We are concerned about avoidable use of hospital eye clinics, along with Royal College of Ophthalmologists, and tariffs for first appointments make this an expensive setting to refer into simply if a child hasn’t been able to comply.
This is another reason the materials need to ensure that the programme ‘fits’ with any current commissioned pathways for children in special schools and the learning disability community, as well as community optometry services more generally, to ensure there are no inappropriate referrals to under pressure hospital eye care services.
In some areas secondary care has been supplementing the vision screening programme, with visiting orthoptists, optometrists and ophthalmologists providing additional checks in school at school entry age and beyond. Through ‘outreach’ it ensures that a child is not having to have yet more medical appointments in hospital for routine eye care.
Proposals are being developed by NHS England for more comprehensive and targeted surveillance of children’s vision in special schools in England including at school entry age and ongoing as clinically required throughout their school life.
There is also a proposal for a community sight testing pathway for children and adults with learning disabilities, which would support children in mainstream schools in getting access to their right to a sight test in the community with accredited optometrists, again ensuring that should there be a ‘screen’ at mainstream school which a child fails there are accredited services which a child can attend.
Public Health England’s support for this programme of work is essential. The diagnostic pathway for children in special schools would complement the mainstream schools vision screening programme. A framework document, agreed with the Royal College of Ophthalmologists, British and Irish Orthoptic Society and other optical bodies has been published and is forming the basis of discussions with NHS England. This can be found here:
A copy was sent on to Public Health England in 2016.
As can be seen the diagnostic pathway involves delivering as much eye care and support within the school environment from school entry onwards, including spectacles dispensing in the child’s special school and onward referrals to community and secondary care only when necessary.
A next step would be for Public Health England to endorse these recommendations.
General comments
In the absence of a current programme of eye care in special schools, in the interim, the production of resources and materials to support the child vision screening programme is of course welcome. The information for teachers, children and parents is much needed, especially to ensure follow up. Equally the service specification will be very useful for commissioners to clarify how the NSC screening guidelines can be practically and effectively implemented.
1)It would be helpful if the materials highlight that children with learning disabilities are at more risk of having a sight problem. For example, this should be highlighted in parental information and in the knowledge competencies.
2)The materials need to more fully recognise the needs of children with learning disabilities and/or autism and encourage reasonable adjustments and the right testing materials to support current services, as well as ensuring that diagnostic information is recorded in a child’s Education, Health and Care Plan as well as the Child Health Record. For example, while the service specification has a focus on equality and health inequalities, the accompanying materials generally do not complement this message and there is no recommendation to collect equalities data. Public Health England’s learning disability observatory, Improving Health and Lives, would be able to advise further on these issues.
3)Throughout the consultation literature there is a message to go to the GP or an optometrist about concerns about eyesight. That message is adding appointments for eye care to already overburdened GPs who will only refer on to an optometrist. It would be better to describe what an optometrist does as in many circumstances they will be better placed than the GP. If an optometrist feels a child needs to see a GP they will make a referral and are obliged to do so under the General Ophthalmic Services contract. Certainly, if there were more national consistency and certainty for children with learning disabilities through new national optometric programmes, there would be less need to include the GP as a ‘failsafe’ for areas lacking the right support.
4)It is very important that the materials, particularly those being developed for parents and teachers, do not give the wrong impression that a vision screen equates to a full sight test. It needs to be more explicit that screening (where only distance visual acuity is tested) does not check for all eye or vision problems (hyperopia, convergence problems, some strabismus, pathologies).[3] This is an opportunity to reiterate and educate parents about sight tests and there could be more in the materials that children’s sight tests are free and glasses vouchers are free too. This might reassure parents who are worried about costs.
5)The risks need to be more clearly outlined in information for parents and teachers ie. that a child’s visual pathways are still developing up until the ages of 7 – 8 years old, but their sight will continue to mature and develop into teenage years. Some serious sight conditions can develop as a child gets older (for example, keratoconus is highly associated with some conditions that cause learning disabilities) and the importance of problems being picked up and treated successfully even if the child is showing no obvious signs of a problem with their vision.
6)Sometimes this is made plain but in other communications it is not. Fuller explanations and simplification of language is needed in some of the materials, for those who are not familiar with clinical terminology eg‘reduced vision’.
7)Commissioners are being encouraged to reduce pressure on GPs and secondary care and the materials could benefit from some ‘big picture’ messages to commissioners on the importance of the screening programme, the collection of data, and appropriate referral pathways. Although this is not mandated, it has been part of national policy to promote the screening as part of the “school entry health check” under the Healthy Child Programme for children from 0-19 years.[4] Is there an opportunity for Public Health England to ensure the data is collected nationally under the National Child Measurement Programme as presently only data on height and weight is collected? A national repository of information is needed and a question tabled on behalf of SeeAbility in parliament and answered on 18 March 2015 confirmed that this information is not being collected centrally.[5]
We also offer some specific comments on the materials below.
Vision screening pathway
Some simplification/explanation of some of the terminology and testing protocols would be helpful here.
The pathway should highlight, as it has done on page 1 of the introduction, that children under recent care of hospital eye services or an optometrist might be excluded (although recent needs to be defined)
There may also be children under the care of paediatricians and it would be helpful if there could be some clarity as to how information will be shared appropriately.
Information for teaching staff
It would be helpful to reiterate why the programme is important in this literature.
There is reference to ' green and orange glasses' would be better described as 'glasses that cover one eye then the other or similar- this is too prescriptive to using a very specific model / brand for which there is no clinical justification.
On the information for children, we could see no reason why a child could not be reassured that they can read pictures, as well as letters. This would help children with learning disabilities and would be a much more inclusive approach, ensuring all children develop the habit of good eye care from the start.
Invitation letter to parents
Page 1 bottom of page - should also include the option
“My child has just had a sight test at a local opticians”
Page 2.Vision screening. It is important that parents realise their child’s sight is still developing at this age which is why the screening tests happen now. This needs to be emphasised sooner.
It is important to say that vision screening is not the same as a sight test and doesn’t replace the need for a child to get regular sight tests throughout their school life. This can be a misconception.
This is an opportunity to reiterate public health messages on eye care and that every child has the right to a free NHS sight test annually.
Page 3. At the top of the page it would be helpful to say what the treatment is to reassure parents.
Information post screening
Under ‘Result’ we wonder if the last sentence ‘if only one eye is affected the other eye can compensate and the child adapts’ might be interpreted as a reassuring message, rather than one which encourages action.
Under ‘Letter to inform of no testing due to absence for vision screening’ it mistakenly refers to the child having missed the ‘eye test’. For the reasons outlined above it is important that vision screening is not confused with eye/sight tests.
Service specification
Under section 2.2 exclusion criteria should also include children who have recently had a sight test with an optometrist (this is information set out in earlier materials, but not reflected in the service specification). Again ‘recent’ would need to be defined.
Under 2.2 it should be noted that there are other useful and clinically validated logMAR vision tests (e.g. Sonsken Silver logMAR/ Digital testseg Thomson screener/Kays) but the advice is designed only to allow the use of the Keeler logMAR vision test.
We note that in the competencies it is recommended that vision screening ages 4 – 5 in special schools will normally be undertaken by an orthoptist which is welcome but there is nothing in the service specification to this effect. This should tie in with the statement in paragraph 3.4 that children who are developmentally unable to perform crowded LogMAR acuity tests undergo vision screening delivered by an orthoptist using a test appropriate for their developmental stage (the ‘alternate’ screening pathway).
There is nothing in the service specification about reasonable adjustments for children with disabilities in mainstream schools. For example Kay Picture Cards may be a better test for children with learning disabilities in mainstream schools.
The service specification has nothing about equalities data to be collected. It is absolutely essential that commissioners understand the groups who are failing or unable to comply with vision screening programmes, including those with learning disabilities who are 28 times more likely to have a sight problem.
Competencies
In this document there is a need under K2 to recognise the risks associated with having a learning disability.
Missing from the competencies are an ability to make reasonable adjustments for children with disabilities and use appropriate materials.
[1]Hall and Elliman (2008). Health for all children: Revised fourth edition. Oxford, Oxford University Press.
[2] Clarke M (2012). Ophthalmic Services for Children. The Royal College of Ophthalmologists: Ophthalmic Services Guidance.
[3]Eg.O’Donaghue et al Visual acuity measures do not reliably detect childhood refractive error- an epidemiological study. PLoS One. 2012;7(3):e34441.
[4]See Healthy Child Programme
[5] See