Pre/School Vision Screening in Nicaragua

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Pre/School Vision Screening in Nicaragua

• A Pilot Project
• in cooperation with the
• UNESCO Chair in Visual Health and Development
• VERAS
• (Vision, Education, Achievement, Learning, and
  Sustainability) project.

Drs. Patti Fuhr, Wendy Marsh-Tootle, Marcela
Frazier of VOSH Int and the VERAS Working Group
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International ParticipantsEl Salvador,
Guatemala, Nicaragua

• UNESCO Chair in Visual Health and Development
• Opt. Anna Rius
• Lic. Astrid Villalobos
• Janet Leasher, OD
• Maria Cilleros
• VOSH/UAB, NECO/UES/U. GALILEO/ MINSA/MECD
• Wendy Marsh-Tootle, OD
• Marcela Frazier, OD
• Patti Fuhr, OD, PhD
• Bruce Moore, OD
• Erik Weissberg, OD
• Lic. Natalia Colome
• Nelson Rivera, OD
• John Gehrig, JD
• Miguel Silva, OD

• Ing. Sergio Romero
• Elise Harb,OD
• Kayla Smith
• Kimberly ChanKate Moore
• Marsha Feist-Moore
• Carolina Toledo
• Jose Salinas A.
• Vilma Chavez de Pop, MD
• Milago del C. Meduia
• Rosa Elana Alfaro
• Samuel Alanso, OD
• Jose Salinas Andreade
• Juan Carlos Aresti, OD
• Rommel Izaquirre, MD
• Milton Eugarrios Najlis, MD
• Jacqueline Castellon R, MD
• Johanna Ramirez Villalobo, MD

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Central America

• Belize
• Guatemala
• Honduras
• El Salvador
• Nicaragua
• Costa Rica
• Panama

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Central America lt 2/Day

• Belize -
• Guatemala -37.4
• Honduras 44.4
• El Salvador 45
• Costa Rica 14.3
• Panama 17.9
• Nicaragua 94.5 lt 2/Day
• 33 lt 1/Day

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Nicaragua

• Nicaragua (and Haiti)
• poorest nations in Western Hemisphere
• Population 5 million
• 1 million in Managua
• Literacy rate 66
• 800,000 without access to health services
• Human Poverty Index - ¼ are fully deprived of
  decent standard of living (drinkable water, etc)

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Nicaragua Visual Health

• Opticians or optometrists without specialized
  training 35 (CR50)
• Opticians or optometrists with university
  training 15 (CR350)
• Ophthalmologists with university training 55,
  CR 100
• No optometry school
• Optometry laws exist only in Panama, Guatemala
  and Costa Rica

• UNESCO CHAIR IN VISUAL HEALTH AND DEVELOPMENT
• REPORT ON VISUAL HEALTH IN CENTRAL AMERICA

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VERASVision Education Achievement Learning
Sustainability Vision, Educacion, Rendimiento,
Aprendizaje y Sostenibilidad

• Cooperative project
• UNESCO Chair in Visual Health and Development
• VOSH
• MINSA and MECD
• Guatemala, El Salvador, Nicaragua
• Universities in Spain, El Salvador, Guatemala,
  US
• NGO - FOR Nicaraguan Health
• Planning meeting in El Salvador September 2005

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Role of Volunteer Optometric Service to Humanity
(VOSH)

• Enlist support of Nicaraguan Minister of Health
  and Minister of Education
• Expert advisors to help develop vision screening
  and examination protocols
• Help to train local persons to follow the
  protocol
• Ministers identify screeners
• Examine and treat the children in Nicaragua

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VERAS

• September 2005
• Planning Meeting
• Protocols developed
• January 2006 Summit
• Introduced protocols
• Trained and certified
• participants from
• El Salvador
• Guatemala
• Nicaragua
• superscreeners

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VERAS in Central America

• Goals
• Detect, diagnose and treat vision problems in
  preschool and first grade children
• Increase awareness of children's vision problems
  among health care providers, teachers and parents
• Design a feasible system that is culturally
  appropriate and sustainable in the local
  community

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VERAS Pilot Project in Nica

• Goals
• Test the screening and examination protocols
• Training screeners / super-screeners
• Initial training of supervisors
• Follow-up training
• MECD 20 volunteer teachers
• MINSA 5 volunteer nurses
• On site observation of initial screenings (1000)

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School-based screening
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VERAS

• Screening protocol
• Target population preschool and first grade
• VERAS visual acuity test 20/40 targets
• Screening acuity at 5 feet

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VERAS

• Standardization of Vision Screening
• Present cards 1-12 at 5 ft
• both eyes together (cards 1-4)
• right eye alone (cards 5-8)
• left eye alone (cards 9-12)
• Communication
• teach child to name or match symbols
• do not answer for child
• Test conditions
• ambient lighting
• hold test straight
• keep 5 foot string tight

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Screening Form
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VERAS

• Screening criteria
• Fail at least 2 symbols in any condition
• (eyes together, right eye alone or left eye
  alone)
• Protocol testing
• All children failing and equal number who passed
  to be examined

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VERAS

• Examination Acuities
• Test targets from 20/100 to 20/20 size
• Monocular
• 10 feet

Acuity tests donated by GoodLite
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Examination Acuity Form
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Pilot Project

• Goal of Examiner training
• Standardized form
• Standardization of Methods
• Cycloplegic
• Standardized approach to correction of refractive
  errors in children

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Examination

• Cover test
• detect strabismus
• detects latent strabismus
• with prism measure

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Examination

• External inspection
• determine safety for dilation
• detect external eye disease
• detect media opacification

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Examination

• Cycloplegia
• proparacaine
• 2 drops 1 cyclopentolate
• 1 drop 1 Tropicamide
• 45 minute wait

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Internal Examination
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Retinoscopy and Rx
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Treatment Plan

• Spectacle Treatment
• Exact prescription
• Retinoscopy
• New frames
• New lenses
• Fabricated in Nicaragua

Frames donated by AA Optical, Texas
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Treatment Plan

• Surgical Evaluations
• Corneal specialist
• EOM surgeon
• Low vision care not available in community
• Coordination of care with local MDs

Frames donated by AA Optical, Texas
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Pilot Study Results

• 5673 Children Screened!
• 350 Failed the screening (6 referral rate)
• Examination
• 365 Children in protocol examined
• 211 who had passed the screening
• 154 who had failed the screening
• Masked to examiners

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Pilot Study Results

• True Positives
• Failed the screening and needed glasses 53
• False Positives
• Failed the screening and did not need glasses
  101
• True Negatives
• Passed the screening and did not need glasses
  195
• False Negatives
• Passed the screening and did need glasses 16

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Pilot Study Results
Sensitivity 0.77 Specificity 0.66
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Efforts to Decrease False Positive Rate

• High false positive rate can destroy a screening
  program
• Increase cost
• Decrease confidence in screening program

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Efforts to Decrease False Positive Rate

• What can we do?
• Require re-screening by a supervisor of those who
  failed screening initially
• Or increase training of first screeners
• Continue monitoring program for outcome until
  improvements are documented

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Pilot Study Results

• Quality control
• Track and compare results per individual screener
• Individuals beliefs about medical care may
  influence referral rates
• Teachers appeared more committed to finding
  children with vision problems
• They see the day-to-day problems
• Some individuals get better cooperation from
  pre-schoolers

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Pilot Study Results

• Lessons Learned
• Our test is inexpensive and well accepted in the
  community
• Process is labor intensive requiring training
• Tracking of results
• Re-training
• Re-testing before examination
• Lay people can be excellent screeners

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Pilot Study Results

• Parents were very interested
• Teachers are the key
• Sustainability occurs when local providers can
  continue the protocols and the care

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Vision Screening in NicaraguaAcknowledgements

• First VOSH cooperative project with UNESCO Chair
  in Visual Health and Development
• Very productive partnership
• Pilot phase completed in 8 months!
• Grant from VOSH International
• UAB School of Optometry
• Department of Veterans Affairs
• GoodLite
• AA Optical of Texas
• All planning, implementation, and evaluation
  participants

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Its the glasses!
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Its the vision!
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Its the children!