Join a powerful, unprecedented alliance for better eye health for all.
Join IAPBDetailed examination should be done by a recognised cadre within the health system, with the necessary competencies in refracting children and examination of other non-refractive conditions (for example, optometrists, optometry students, ophthalmologists).
Retinoscopy only or instrument-based autorefraction is not sufficient to prescribe glasses for school-aged children. Subjective refraction must follow objective refraction. There are two alternatives for providing subjective refraction:
Disadvantages:
Disadvantages
*Referral to optical centres which are not actively involved in the program is not recommended as the quality of the refraction and the spectacles dispensed cannot be monitored.
Referral to the local eye care provider should be made for:
No child with severe vision impairment (VA <6/60; 1.0) or who is blind (VA <3/60; 1.3) should be referred directly to low vision services, special education or rehabilitation without first being assessed by an primary or secondary eye care professional.
If done on site, cycloplegia should be done by a trained eye care professional.
Indications:
In children over the age of 5 years, 2 drops of cyclopentolate 1% should be administered per eye with 5 minutes separation between instillations. Parental consent is mandatory. Children, parents and teachers should be aware of side effects (blurriness, dilated pupils, sensitivity to light, dizziness etc.)
To be included in protocol if personnel is qualified
For more information on these tests: AAO Paediatric eye evaluations PPP 2022
Provision of quality spectacles can improve a child’s vision, reduce discomfort, and even lead to better educational outcomes. The following indications for correction provide a way to objectively prioritize refractive care in situations of limited resources, but should not override individual needs where resources permit. Some studies showed that spectacle wear is associated with poorer uncorrected VA and higher levels of refractive error, so prescription of spectacles should be made only when there is a significant improvement in VA 11,41.
| Myopia | Hyperopia | Astigmatism | Anisometropia |
|---|---|---|---|
| improvement of VA by 2 or more logMAR/Snellen lines | improvement of VA by 2 or more logMAR/Snellen lines | improvement of VA by 2 or more logMAR/Snellen lines | significant anisometropia i.e. ≥ 2D AND one or more of the following: correctly balanced lenses improve vision of the most affected eye by 2 or more logMAR/Snellen VA lines, and/or noticeably improve eye comfort |
| presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable | presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable | presence of amblyopia and the child’s age suggests the amblyopia is potentially treatable | |
| esotropia or large esophoria | noticeably improved eye comfort |
Spectacle wear rates can be very low after school screenings. The main reasons cited for non-compliance are:
| Main reasons for non-compliance | Possible solutions to improve compliance |
|---|---|
| Broken/lost frames | Dispensing quality frames suitable for children
Ongoing partnerships with local eye care providers for repair/replacement of spectacles |
| Discomfort when wearing spectacles | Provision of quality frames adapted to children
Thorough adjustment when delivering the spectacles Regular screenings to prevent children growing out of their frames |
| Social stigma (teasing, family disapproval, negative perceptions) & misconceptions towards spectacle wear | In-class health promotion activities
Integration of eye health in the school curriculum ‘Vision champions’ in schools Community-based eye health education Parents’ involvement in screenings |
| No perceived benefits | Prescription of spectacles only to those with significant VA improvement |
Gathering context-specific data on reasons for non-compliance can be very useful in developing locally-relevant material 11.
Each child requiring correction should get a suitable, comfortable and adapted pair of spectacles.
While best practice is to provide a custom-made pair with exact prescription and PD, it can get very expensive for programmes. Approximately 85% of children who need correction should be eligible for ready-made or ready-to-clip glasses. These are acceptable and cost-effective solutions for providing quality eyewear to children when custom-made spectacles are not available or affordable42,43.
They are available in powers from −6.00 D to +6.00 D and can be dispensed on site. However, powers above 3.50 D are not recommended as there could be induced prism if there is a mismatch in pupillary distance. Frames should be selected based on the children’s preference. Ready-made spectacles should be supplied under the guidance of a qualified practitioner and should be adjusted to suit the wearer by a trained person. Children who are not eligible should have their spectacles made at a local eye center44.
| Ready-made spectacles | Custom-made | |
|---|---|---|
| Improvement in vision with spherical equivalent lenses | Same or only one line less than full correction | VA with full correction is two lines or more than spherical equivalent |
| Difference in the spherical equivalent in RE/LE | < 1.00D (<2.00D for ready-to-clip) | >1.00D |
| Astigmatism | max. of 0.75 cylinder in both eyes | >0.75D cylinder in at least one eye |
| Maximum spherical equivalent* | +/- 3.50D | No limit |
| Inter-pupillary distance between the eyes and the frames available | Not more than +/- 2mm | Can be adapted to any PD |
| Comfort of spectacles frames | As comfortable as custom spectacles |
* Delivery of custom-made spectacles back to outreach sites can be difficult, therefore a wider range of ready-made spectacles may be needed for such programmes. Full quality assurance checks should be carried out where possible.
