学前 Screening 筛选 of Children Worthwhile?

Transcription

1 Is Pre-school 学前 Screening 筛选 of Children Worthwhile? Dr. Dorothy FAN Consultant Ophthalmologist Department of Ophthalmology Hong Kong Sanatorium & Hospital

2 Amblyopia ( 弱视 ) Amblyopia results from degradation of the retinal image during a sensitive period of visual development historically to be thought to occur during the first 7 years of life Papakostopoulos WC. Br J Ophthalmol 1995:79: Von Noorden GK et al. Trans Ophthalmol Soc.UK 1979; 99: Davis AR et al. Invest Ophthalmol Vis Sci 2003: 44:610-17

3 Screening for Amblyopia ( 弱视筛查 ) The American Academy of Pediatrics states that vision screening at birth (red reflex test 紅光反射 ) and infants should be evaluated for fixation preference 固定偏好, ocular alignment 眼軸對準 and eye disease by 6 months of age; formal testing by 3 years of age

4 Screening for Amblyopia ( 弱视筛查 ) Many screening programs measure visual acuity 视敏度 and rely on detection of amblyopiogenic factors 弱视因素 Photoscreening Automated refraction 自动验光

5 VIP Study Vision in preschoolers study (Schmidt P et al. Ophthalmology 2004; 111:637-50) Various screening methods (N=11) were compared with each other and with gold standard eye exams in children 3-5 yrs Autorefractor 自动验光 methods higher sensitivity than vision test (HOTV, Lea) Vision testing was better than photoscreening & stereoacuity 立体视锐度 testing Testing VA 视敏度 took longer than automated refractor 自动验光 The Retinomax: sensitivity of specificity of 90% None of the tested devices or protocols are adequate for costeffective screening of entire populations for amblyopia risk

6 When to screen 筛选? The controversy is based in the belief regarding the sensitive period of development 发育 and amblyopia 弱视 should be treated by age 7, the earlier the better Emerging data from randomized clinical trials 随机临床试验 raised the question whether earlier treatment yielded better outcomes More studies are needed to address what strategies are to be used PEDIG. Arch Ophththalmol 2002;120: PEDIG. Arch Ophthalmol 2003; 121: Clarke et al. BMJ 2003; 327:1251-6

7 Screening for Amblyopia 弱视筛查 Better visual prognosis is associated with early detection and treatment of amblyopia Cost-effectiveness 成本效益 of screening 筛选 and treatment 治疗 may potentially place demands on current and already limited health resources 卫生资源

8 Screening for Amblyopia 弱视筛查 Several factors play into determining cost effectiveness 成本效益 : screening accuracy 准确性 and participation compliance 遵从 with treatment efficacy 疗效 at long-term follow-up 长期跟进 functional significance 功能性意义 of amblyopia

9 Hong Kong 香港

10 Vision screening 视力篩筛查 in MCHCs 母婴健康院 :Comprehensive Observation Scheme vision screening at 3 years by nurses Transition to screening by optometrist 验光师 / orthoptist 视觉矫正师 at 4 years

11 Components related to Vision in Child Health Program MCHC target population : newborn to 5y or preschool Newborn 新生儿 physical examination red reflex Developmental surveillance 发育监察 parental concern on child s vision Vision screening 视力筛查 at preschool years Health education 健康教育 video, pamphlet

12 Aim: To prevent visual loss 视力丧失 in children affected by amblyopia 弱视 Objectives: To identify children with amblyopia and amblyogenic conditions early To arrange for early referral for assessment 评估 and treatment 治疗

13 Screening protocol Level 1 Tests History External eye examination Eye movements Cover test Convergence Mono-ocular visual acuity at 3m Red reflex Criteria for level 2 Structural eye abnormalities Strabismus Impaired visual acuity < 6/12 (0.3), 2 line difference Repeat examination Repeat examination Border visual acuity <6/9.5

14 Screening protocol Level 1 Tests History External eye examination Eye movements Cover test Convergence Mono-ocular visual acuity at 3m Red reflex Criteria for level 2 Structural eye abnormalities Strabismus Impaired visual acuity < 6/12 (0.3), 2 line difference Repeat examination Repeat examination Border visual acuity <6/9.5

15 Screening protocol Level 2 Ophthalmologist Assessment Tests Non-cycloplegic retinoscopy Direct ophthalmoscopy Stereo-acuity test Visual acuity with pin-hoe Structural eye abnormalities Strabismus Refractive errors of amblyogenic potential Hyperopia 2.75D Myopia 2.75D Astigmatism >1.5D Anisometropia 1.5D Visual acuity <6/15 <5 y, <6/12 at >5y Community optometrists Other refractive errors, VA 6/12 Repeat screening

16 Screening protocol Level 2 Ophthalmologist Assessment Tests Non-cycloplegic retinoscopy Direct ophthalmoscopy Stereo-acuity test Visual acuity with pin-hoe Structural eye abnormalities Strabismus Refractive errors of amblyogenic potential Hyperopia 2.75 D Myopia 2.75 D Astigmatism >1.5 D Anisometropia 1.5 D Visual acuity <6/15 <5 y, <6/12 at >5y Community optometrists Other refractive errors, VA 6/12 Repeat screening

17 Objective: To evaluate the performance 表现 (sensitivity 灵敏度 and specificity 特异性 ) of visual screening 视觉筛查 tests for 4 years old preschoolers in Hong Kong Cross-sectional study 横断面研究 to evaluate the performance of detecting amblyopia 弱视 / amblyogenic factors 弱视因素 by different vision tests in children of 4 to 5 years

18 Subject Recruitment Part of the surveillance programme 发育监察 of MCHCs Performed by optometrists 验光师 and orthoptists 视觉矫正师 at 3 years 9 months to 5 years MCHCs 母婴健康院 in Kowloon Central region East Kowloon Hung Hom Robert Black West Kowloon Yaumatei

19 Criteria Test Fail Pass Mono-ocular visual acuity Worse eye : 6/12 or worse Between eye difference 2 lines or more (except when one eye =6/6) Worse eye: 6/9.5 or better Between eye difference <2 line Cover test Eye Alignment Refractive errors Structural abnormalities Manifested squint Hyperopia +2.0 D Myopia -1.0 D Astigmatism 1.0 D Anisometropia 1.25 D Abnormalities that affect vision, for example: cataract, ptosis No squint Phoria with good recovery Hyperopia < +2.0 D Myopia < -1.0 D Astigmatism < 1.0 D Anisometropia < 1.25 D Nil

20 Results 結果 Subjects: 160 children in Dec 2010

21 Results Visual Acuity 视敏度 Screening 筛选 6/7.5: 16 (5.0%) 6/9.5: 86 (26.9%) 6/12: 52 (16.2%) 6/15: 92 (28.8%) 6/19: 22(6.9%) 6/24: 20(6.2%) 6/30: 2(0.6%) <6/30: 18(5.6%) Missing: 12(3.8%) Examination 检查 6/6: 2(0.6%) 6/7.5: 32(10.0%) 6/9.5: 70(21.9%) 6/12: 62(19.4%) 6/15: 58(18.1%) 6/19: 52(16.2%) 6/24: - 6/30: 18(5.6%) <6/30: 18(5.6%) Missing: 8(2.5%)

22 Results Visual Acuity 视敏度

23 Results Amblyopia 弱视 Screening 筛选 No amblyopia Amblyopia Examination 检查 No amblyopia Amblyopia 2 46

24 Results Strabismus 斜视 Screening 筛选 No Strabismus Strabismus Examination 检查 No Strabismus Strabismus 2 12

25 Kindergarten Study 幼稚园研究 Part 1 done 1996, Part 2 completed kindergartens 幼稚园 in Hong Kong (random selection) Screening done in school Monocular visual acuity (single optotype SG at 6 m) Cover test at near and distance fixation Ocular motility Convergence Cycloplegic refraction with auto-refractor Children with VA <20/40 were referred to eye clinics for further exam

26 Kindergarten Study Part A 601 children that were surveyed VA 20/40: 3.8% Strabismus: 1.8% Refractive error:. Astigmatism ( 2.00 D): 6.3% Hypermetropia ( D): 5.8% Myopia ( D): 2.3%

27 Kindergarten Study Part B 823 children that were surveyed VA 20/40: 2.7% Strabismus: 1.7% Refractive error:. Myopia ( D): 6.3% (p = 0.001) Astigmatism ( 2.00 D): 5.7% Hypermetropia ( D): 5.1%

28 Comparison with other countries He Mingguang et al Robaei D et al Gronlund MA et al Donnelly UM et al Matsuo T et al Goh PP et al Year Published Our study Place of Study China Australia Sweden Ireland Japan Malaysia Hong Kong Age of children screened Total no. of children Visual Acuity Strabismus (mean 4.6) <20/40: 22.3% 1.9% - 3.0% <0.3logMAR: 0% 6% <6/18: 1.13% 3.98% Questionnaire: 0.14% 1.28% <20/40:1.4% <20/40: 2.7% 1.7% Refractive error Hypermetropia Myopia Astigmatism Anisometropia >2.0D 16.7% >-0.5D 3.3% >0.75D 33.6% >2.0D 1.5% 34.4% in amblypopes 2.0D 10% -0.5D 1% 0.75D 23% 1.5D 2.2% -0.75D 1.3% 1.0D 2.3% 1.5D 1.2% 2.0D 3.8% -0.5D 9.8% 0.75D 15.7% 2.5D 5.1% -1.0D 6.3% -2.0D 5.7% 1.0D 1.6% Total 17.6% D Fan et al.

29 Summary 總結 Visual screening 视觉筛查 programs may need to be tailored to correspond to the local population 地区性 and from time to time 时间性

30 Thanks!