Screening, VA and falls assessments in 2020

The Orthoptics Australia online weekend conference in mid-November was the second virtual conference I attended in 2020. Not having to fund transport and accommodation makes these international meetings and speakers much more accessible to those of us in far-flung parts of the country. An added bonus, especially for those in different time zones, was the talks remained available on demand for delegates until January 2021, so we could refer back to them.


The screening conundrum


Anna Horwood, professor of orthoptics and visual development at Reading University in the UK, started us off with a discussion about the multinational EUscreen cost-effectiveness study. Running from 2017 to 2019, the study compared the cost effectiveness of childhood vision and hearing screening programmes (VAHSPs) across Europe to produce a toolkit to assist international healthcare providers and policy makers improve their screening models. The study highlighted the enormous differences that occur in decision-making around the world, such as whether to screen, how, when, the costs, and how and if the resulting knowledge should be shared.


Prof Horwood’s part of the project looked at photo-screening and found that while there are plenty of papers on the equipment, its sensitivity and specificity, only 56 of them mentioned implementation cost, compared photo-screening to other tests, or analysed its use within a population and long-term results. She suggested it’s not ethical to screen the whole population if only half can afford the subsequent treatment.


Orthoptics and Covid-19


Another highlight was the session focusing on Covid-19’s impact and the adaptations made by orthoptic clinical practitioners under lockdown. Groups including the British and Irish Orthoptic Society, the Royal Australian and New Zealand College of Ophthalmologists,


Orthoptics Australia and the Royal College of Ophthalmologists were all quick to release guidelines for us to use here in March/April of this year, which aided the New Zealand Orthoptic Society’s adaptations to its own clinical practice guidelines.


A take-home from the UK, with its extended lockdowns, was that it ceased atropine penalisation and instead titrated the occlusion therapy to the patient themselves. Moorfields also used photos and video links to triage new patients and screen referrals, focusing on symptoms for adults’ treatment decisions. The well-known London-based eye hospital also used the 9 Gaze app, designed to document eye motility and strabismus in the nine cardinal positions of gaze, for monitoring patients, finding it provided an ‘excellent’ pictorial ocular movement record. A link to an instructional YouTube video sent to the patient helped them accurately complete the test, which was then reviewed by the clinician, said Leena Patel, Moorfields consultant orthoptist and clinical lecturer at City University and UCL in London. The team at Moorfields were so impressed when they used this in their Botox clinics, she said, that they are now using it in place of the 1/52 face-to-face post-op visit and are reviewing it for pre- and post-strabismus surgery.


Professor David Mackey, managing director of the Lions Eye Institute and director of the Centre for Ophthalmology and Visual Science at the University of Western Australia, underlined the importance of vaccinations due to the high incidence of ocular manifestations of common diseases for unimmunised patients. It reminded us all to advise families about the importance of accepting vaccination protocols to protect their children. This was especially pertinent given the new Covid-19 vaccinations, which may also make families more open to having standard disease vaccines.


Visual function assessment developments


Dr Anna O’Connor, a senior lecturer at the University of Liverpool, focused on the assessment of visual function and the newly updated Kay Picture Test Single Crowded Book. For younger patients, from about 2½-years-old, this is an easier paediatric development test. Although it is known that a lower/better visual acuity (VA) can be achieved with pictures compared to letters, this doesn’t mean using letters is a more accurate method, only that verified age-group norms are needed on the test of choice and against verified age groups. It has also been validated with the letter LogMAR test to give an accurate vision reading for the different age groups.


The discussion then moved to the Kay iSight Test Professional app. Designed for professional, clinic-based use the app studies have found it compared favourably with conventional printed methods. A new study is now awaiting acceptance to evaluate its use as an at-home testing tool, which will be interesting given this was one of the biggest barriers for continuing treatment during lockdowns.


Also from Liverpool University, orthoptics lecturer Dr Jignasa Mehta’s research highlighted a huge unmet need here in New Zealand as it demonstrated the role VA, contrast sensitivity (CS) and stereoacuity (SA) have on falls. An individual with an SA of less than 85 arcsec on the Frisby stereotest has triple the risk of falling, compared to those scoring higher. While if a CS of 18 cycles per degree (cpd) improves by 1 log unit, the chance of falling decreases by a massive 89%. Thus, the impact on CS and SA should be considered in delaying first-eye or only-eye cataract surgery.


Liverpool University’s free Visual Impairment Screening Assessment (VISA) tool is now used by the UK’s National Health Service. To reduce the risk of missed steps and trips further, a standardised visual assessment of VA, CS and SA is essential in the fall-management pathway, said Dr Mehta, who left us in no doubt that we need to increase vision screening among our elderly population and ensure our falls assessment clinics include a visual assessment.


Sally-Anne Herring is a UK-trained orthoptist with more than 30 years’ experience in orthoptics, paediatrics and neurophthalmolgy, now working in New Zealand’s Hawke’s Bay.


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