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| School Eye Screening | |
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Hans Limburg MD DCEH
Of all causes of low vision or 'blindness', refractive errors are the easiest to diagnose and cure. Yet, in India, refractive errors are still the second cause of 'blindness', the second cause of low vision and the most common reason why patients consult ophthalmologists and ophthalmic assistants. 1 This in itself indicates that access to eye care services, awareness amongst the public and availability of spectacles has not yet reached adequate levels.
 Analysing which part of the population requires spectacles, we can distinguish three main groups: children with refractive errors, the middle age group with presbyopia and the older age group to correct aphakia after intracapsular cataract surgery. In our programme we decided to focus initially on refractive errors in children. Poor vision in childhood will affect the performance in school and have a strong negative influence on the future life of the child. Poor vision may be one of the main reasons for a high drop-out rate from schools in India. In rural districts of India, eye care services are provided by paramedical ophthalmic assistants (PMOAs) and ophthalmologists. They may be working in the government sector, in non-governmental organisations or in the pn.vate sector. An average rural district may have a population of 2.0 million, 2 ophthalmologists in the government sector, 3 in the private sector, and sometimes one or two ophthalmologists in the voluntary sector. In addition, PMOAs are working at primary health centre level in the rural areas. Ideally, there should be one PMOA per 100,000 people. On average in India, 25% of the population is in the age group 6-14 years, the school-going age. That means that in the ideal situation, one PMOA has to examine 25,000 children. That is impossible. Secondly, of all these children only an estimated 5-10% have refractive errors. So, a PMOA could waste 90-95% of his/her time by examining children with normal vision. In order to save precious time for the PMOA we tried to introduce a screening system through the school teachers. In the initial phase, our projects decided to concentrate on Middle Schools, grades 6-8, with children between 10 and 14 years. The reasons were that the number of children in Middle Schools was not too high, they would be able to cooperate well in the vision screening and lastly, they would be able to learn themselves how to test vision and take this procedure back home to their villages. After gaining experience with the procedure, it may be expanded in a later phase to Primary Schools as well. The next step was to identify all the Middle Schools in the Block (a cluster of villages) and the number of students enrolled. In the Districts where we work the enrolment rate was in the range of 15% to 25%. This shows clearly that by doing eye screening at these schools, we are only covering a small part of the entire group at risk. For this reason the Child-to-Child approach to spread the message to the entire community is essential. After listing all Middle Schools, their headmasters were approached and the School Eye Screening (SES) Programme was explained to them. They were requested to nominate one teacher to come for one day of training. Preference was given to female teachers with spectacles. Then a one-day training session was organised in the Block for a maximum of 20-40 teachers. During training the objectives of the SES programme were explained and the important role teachers can play. A little theoretical information on vision and the functioning of our eyes was given, the cards used and the methodology followed were explained and teachers were informed how children suspected of having poor vision would be examined by the PMOA and provided with spectacles. All materials required for screening all the children at one particular Middle School were provided in kit form, in an attractive bag. The kit contains a 6 metre long tape, a screening card for the teacher, referral cards for children with suspected poor vision and educational materials.  In the afternoon, practical sessions were held to acquire the practical skills required for screening. Children were screened by the trainee-teachers and they were also instructed how to teach children to carry out this screening. In the actual procedure, the teachers check whether the child can point in the direction of the open end of the 'E', the size of which conforms to 6/9 of the Snellen chart. There are 4 'E's on the chart and by rotating the chart, memorising of the sequence by other children will be difficult. There are only two possibilities: the child can see the 'E' or cannot see it. If the child cannot see it, he or she is referred to the PMOA. Our experience has shown that it may not always be necessary for ophthalmologists to conduct these training sessions. In few instances, it has been conducted by PMOAs and they were very well able to do this. Full involvement of the Education Department in the entire exercise is essential. After training, teachers go back to their respective schools and conduct the screening programme. Good coordination with the PMOA is very important at this stage, because he has to provide the service of examining the eyes and prescribing spectacles. Firm appointments have to be made when and where the PMOA will examine referred children from a certain school. For this reason, it may be necessary for the PMOA to have regular out patient sessions at more than one Primary Health Centre in the Block. Teachers have shown excellent co-operation in this work, without any monetary incentive. They have indicated that this screening adds to their own efforts to improve the study performance of their students. The programme has provided a new status for these teachers. Some have trained one of their colleagues in their school to provide additional help in the implementation of this SES programme. As the entire procedure is very simple this has been possible. When the teacher identifies a child who cannot indicate the direction of the open ends of the 'E' on the card with one or both eyes, she fills the referral card and sends the child to the PMOA. The PMOA does a complete refraction and prescribes spectacles where indicated. Ifhe feels that further examination by the ophthalmologist is needed, he refers. If not, the child goes to the local optical shop for spectacles. The provision of spectacles is arranged through local commercial opticians. We made an agreement with one or more opticians for the supply of good quality spectacles (acetate frames and white English glass) to all children referred to them under the programme for a standard cheap rate (Rs 60.- = $2). Payment is made against the referral card. If spectacl~s. are not according to the specifications, or the service is poor, the agreement can be terminated and another optician can be engaged. The contract is renewed on a yearly basis.  For the opticians it is attractive, because the SES programme brings them clients and publicity. Ultimately, we hope that through the increase of business for the opticians, competition in prices as well as in quality will increase and lead to better service. It must be emphasized that a SES programme should only be started when adequate services can be provided. If there is nobody to do a refraction or no system to provide spectacles, it is better not to start such a screening programme at all, since it will only lead to frustration amongst the students and their parents. By the end of 1991, more than 46,000 students from grades 6 to 8 in 10 Blocks of 4 Districts had been examined. Of all children attending Middle Schools 93% in these Blocks were covered. In 9 out of the 10 Blocks, all identified schools and all teachers were involved, indicating the cooperation and appreciation by teachers and headmasters. Only in one block was there less response. On average, 4.6% of the children examined by the teachers were suspected of having poor eyesight. These were only new cases: those children already having spectacles were not included in this screening. Of all referred children, 65% reported to the PMOA and were examined. In some cases, the referral system was not well organised. In other places, parents preferred to take their child directly to a private ophthalmologist for a check-up. Out of all children referred by teachers, 43% were confinned as having refractive errors. At first sight, it may appear that the teachers were not very accurate in their screening procedures, but if it is realised that through this screening teachers have reduced the workload of the PMOA from around 6,000 children per Block to something like 300 children, it can be appreciated that the programme has significant impact. Secondly, it saves the PMOA time in travelling, since he does not have to visit every school. The entire procedure, from the listing of schools to the provision of spectacles by the optician, took 3 months. On average, 16% of the children examined by the PMOA were referred to the ophthalmologist. This figure could be reduced even more through in-service training of the PMOAs. Ninety-five percent of the children with prescription have collected their spectacles; 96% of these are actually wearing the spectacles in school. Of the spectacles prescribed, over 60% of the corrections were in the range of less than -1.00 dioptre. But we also see that there are children who need corrections of 3.00 dioptres or more. For the smaller corrections, it is always emphasized that it remains the responsibility of the PMOA or the ophthalmologist to decide whether a child actually needs spectacles or not. Summary In summary, what was gained from this programme?
National Survey of Blindness, India, National Programme for Control, of Blindness-WHO. Madan Mohan, 1989. |
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