Barbara Ryan, Aideen McAvinchey, Andrew Millington, Nathan Davies

1. Vision care programme for children and young people in special schools in Wales J. Margaret WoodhouseSchool of Optometry & Vision Sciences Barbara Ryan, Aideen McAvinchey, Andrew Millington, Nathan Davies

2. Background • From published literature, we know that visual deficits are more common amongst children with disabilities • The Hall report on vision screening recommends that children with ‘any neurological or disabling condition should be routinely referred for visual assessment’ • Are pupils of special schools receiving adequate eye care?

3. Recent literature • Eye examinations conducted with 228 pupils in special schools in Glasgow found • 12% had low vision (WHO criterion) • 46% needed refractive correction Das, Spowart, Crossley, Dutton Arch Dis Child 2010; 95: 888-892

4. Survey • All 44 special schools in Wales were sent a questionnaire, aimed at determining current eye care provision and numbers of pupils with known visual impairment • Telephone interviews were conducted with the schools that failed to return questionnaire • Overall, data from 39 (89%) schools were received, representing 3298 pupils

5. Current status • Screening takes place in 53% schools • 47% by orthoptists • 36.8% by school nurses • Screening usually limited to • One age group (most commonly school entry) • In some schools, only when concerns arise

6. Current status • Visual impairment recorded as primary or secondary SEN for 6% of pupils • Glasses currently worn by 22% pupils • Most (92%) schools reported that some pupils were reluctant to wear glasses • Name calling, not cool • Poor fit, uncomfortable • Glasses broken • Lack of parental support in maintaining eye care

7. Eye examinations • Five schools were selected • No screening at present • Geographic spread • Generic special schools • Information packs and consent forms sent to all parents and returned to class teacher • School nurse was most suitable coordinator within the school • Parents invited to attend their child’s examination • Room which could be blacked out was allocated

8. Eye examinations • Two highly experienced optometrists conducted the tests • Appropriate equipment available (choice of tests suitable for pupils of all abilities) • An accompanying adult (usually TA) was essential for successful examination • Parents had indicated whether team could choose glasses if needed, or preferred prescription to be sent home

9. Results • To date 156 pupils have completed eye examination • Total time taken was under-estimated • Non-attendance of pupils, non-attendance of parents • Phone calls to parents for additional information • Report-writing, problem solving • Delivery and adjustment of glasses • Four pupils withdrew consent for data to be used, so analysis of data for 152 pupils

10. Previous eye tests • Parents reported that: • 40.8% had been seen previously by hospital clinic or optometrist • 28.9% (44 of 152 pupils) had been prescribed glasses • 38.2% had never had an eye examination

11. Glasses • Parents reported that 44 pupils had been prescribed glasses • Only 22 pupils had them for the eye examination

12. Habitual visual acuity(i.e. with glasses if the child had them on the day) • WHO definition of low vision or blindness is LogMAR 0.5 (Snellen 6/19) or poorer in better eye • 14.6% had low vision • Including 3 children who had never had an eye test • WHO definition of blindness is acuity poorer than LogMAR 1.3 (Snellen 6/120) in better eye • 4% were classified blind • Acuity of 0.3 (6/12) or poorer in better eye is generally accepted as an impediment to learning, termed ‘visual impairment’ • 19.7% were visually impaired

13. Prescribing glasses • Glasses were prescribed for 52.6% (80 pupils, compared with 44 who had glasses previously) • These comprised: • 17 pupils who had never had an eye test (including the 3 with low vision) • 19 pupils who had previous eye test but no glasses • 23 pupils who had glasses but needed new prescription • 21 pupils who had no change in prescription but ‘fair wear and tear’

14. Final acuity • After refraction, available for only 114 pupils • Of the pupils with low vision or blindness at the outset, only 5 provided a final acuity • 1 improved to ‘visually impaired’ • 4 improved to normal vision • Thus at least 5 pupils (3.3% of the total) had low vision by virtue of uncorrected refractive error

15. Refractive errors

16. Refractive errors Compared to typical school pupils: • The distribution of long and short sight is wider for pupils in special schools • Fewer pupils lie within the ‘emmetropic’ region • Prevalence of astigmatism is higher • 3.4% among typical school pupils • 34% among special school pupils McClelland J: Accommodative dysfunction and refractive anomalies in children with cerebral palsy, Faculty of Life and Health Sciences. University of Ulster, Coleraine, 2004

17. Other disorders Prevalence of: • Squint 24.5% • Nystagmus 10.5% • Other forms of abnormal eye movement: 17.8% • Blepharitis 69.5% • Hazy / scarred cornea 12.5% • Cataract or hazy lens 8% • Optic atrophy 2.1% • Other 22.6%

18. The next step • Current status is unacceptable • Screening is inappropriate • Standard criterion of 6/12 in either eye would mean referral of 36.8% of pupils • Over half of pupils required new glasses • Wales needs a service, providing full eye care for pupils in special schools

19. Case studies D, pupil with nystagmus, wheelchair user The school has been struggling to get an appropriate head rest for D but unfortunately due to lack of communication between the different disciplines i.e. optometrist to school or school to occupational therapy, his nystagmus had never been considered. The head rests in question were placed at a point maximising the nystagmus; therefore D tried to pull his head in the opposite direction. His head had been strapped in place to hold him and this may have induced oscillopsia (perception that the world is moving).

20. Case studies F, very strong child with little communication, highly destructive. Mum attempted to take F into a high street optometric practice after being discharged from HES only to be told “we regret that due to her demonstrative acts we are unable to take F into the testing room”. Mum states that she was in the practice for less than 2 minutes. F is only physical when frightened but is calmed and soothed by those closest to her. Our research optometrist spent 15 mins prior to the sight test simply talking to F about things familiar to her to win her trust. The sight test was then carried out at a pace that didn’t frighten or upset F. It had been some years since F had an eyetest. F proved to have a considerable refractive error., The first time F wore her new glasses she didn’t pull them off, she said “ I can see” and “I look pretty?”.

21. Case studies C, a child discharged by the HES C had been seen at the HES 5 years previously, where it was decided that glasses were not required. Cyclo refraction revealed a Rx of over +7.00D R+L (high hypermetropia, long-sight). C has very complex needs and the majority of his care at school was carried out one-on-one at a close proximity. Staff wondered why he got so “tired and upset” after relatively short periods of time. C now wears his glasses full time and a review has shown him to be improving significantly in core skills at school.

22. The service • Trained and accredited optometrists • Trained optical assistant? • Appropriate fee structure • Admin support • Eye examination in school or practice? Parental choice? • Second pair of glasses? • Full reports to parents and schools • Education for schools • Address the issue of reluctance to wear glasses

23. The service Your suggestions are very welcome! woodhouse@cardiff.ac.uk