PAEDIATRIC VISION SCREENING IN AUSTRALIA StEPS towards national

The pursuit of an Australia-wide early childhood vision screening program has been a passion project for Professor Frank Martin throughout his career, and one that has endured many false starts.

But this goal may finally be realised by 2030, with the potential nationwide roll out of the successful NSW Statewide Eyesight Preschooler Screening (StEPS) program – with modifications – thanks to a major push from the eye health sector and an appetite from the Federal Government.

Martin, a Sydney-based paediatric ophthalmologist, presented on this topic to close out the RANZCO Congress in Brisbane in The Council Lecture where he reviewed the status of pre-schooler vision screening in Australia and charted a path towards a national program.

Martin – whose various roles include visiting ophthalmologist at The Sydney Children’s Hospitals Network at Westmead and Randwick, Sydney Eye Hospital and his private practice at Sydney Ophthalmic Specialists – became interested in this topic in the 1960s when working alongside Professor Fred Hollows before later accompanying him in western NSW in 1978 for the National Trachoma and Eye Health Program.

Years later in 1982, he provided a paper on the epidemiology of strabismus that discovered amblyopia was significantly more common in the non-Aboriginal population than Aboriginal, and concluded the need for an early childhood screening program.

Despite this, it would take several decades for a breakthrough.

This came when Martin met Associate Professor Elizabeth Murphy, senior advisor for child and family health in NSW Ministry of Health who advocated for hearing screening of newborns. The pair had discussions about a similar approach for vision. Eventually, the NSW Government granted funding for a preschool vision screening program in 2007, with Murphy chair of an implementation reference group, and Martin the ophthalmology representative.

StEPS was born: a program that commenced in 2008 and continues today. At its core, it provides an outreach vision screening service to 4-year-olds at their preschools, childcare centres and community health centres.

“I thought things were moving along nicely, because in 2009 the Commonwealth commissioned the Murdoch Children’s Research Institute in Melbourne to prepare a report on early childhood vision screening.

“I represented RANZCO and all eyecare stakeholders were represented – and the report came to the recommendation there was a need for vision screening for all children, but the government ultimately didn’t implement the recommendation," Martin said.

Nsw Model To Become National Blueprint

With the absence of a national program still 13 years later, in The Council Lecture Martin broke down the siloed nature of child vision screening programs across Australia in 2022.

These vary from no formal vision screening program in the Northern Territory, and screening of 5- to 7-years-olds in Queensland and 3.5to 4.5-year-olds in Victoria, through to the NSW StEPS program for 4-year-olds. While there are differences in the age of testing, they can also vary significantly in terms of testing settings, the types of tests conducted and overall participation rates, which were not known in Western Australia and as low as 60% in Victoria.

In essence, Martin said the NSW StEPS program is the only established pre-schooler vision screening program in Australia. Today, the program operates in 15 NSW Local Health Districts (eight in metro Sydney and seven in regional NSW), visiting early childhood care centres, with nurses and lay-screeners preforming testing with the HOTV logMAR vision chart.

Since 2009, 96.4% of 4-year-old children have been offered screening through what constitutes a universal program.

StEPS was born out of an election commitment in 2007 of $14.2 million over four years. An implementation group was formed comprising NSW Health, the state education department, rural and metropolitan nurses, early childhood nurses, ophthalmology, optometry, orthoptics. They debated:

- How StEPS should be administered

- Who should perform the screening

- Where should screening be performed

- Age at which screening occurs

- What ocular problems should be screened for

- What vision tests should be used

- Referral criteria and the pathway

“Having such a diverse group led to quite acrimonious discussion at times, but with good final outcomes,” Martin said.

While NSW Health administered the program, a unique feature allowed each Local Health District (LDH) the autonomy to run StEPS as suited to their area.

Screeners underwent rigorous training that was orthoptist-led, and included two training modules through the Higher Education Training Institute, four hours minimum of onsite practical training, assessment for competency after three months, and reassessment annually.

Martin said: “The evidence showed you could test most 4-year-olds’ vision accurately using quality testing. Also at that age, the conditions that threaten vision can’t be detected by surveillance or the child’s behaviour – children can have extremely poor vision and not complain, so it goes unnoticed by their parents. At this age, children are also young enough for treatment to commence during a critical period of brain development.

“But it was what type of vision tests that should be used that generated the most discussion. Some wanted colour vison testing and convergence testing, but we agreed on visual acuity because if this is affected, there’s got to be a reason. It could be amblyopia, a refractive problem, or another issue. There was rapid agreement that the HOTV logMAR chart should be used at 6m, but where not possible, at 3m.”

When it comes to screening results and referral criteria, the StEPS program follows international guidelines whereby 6/9 (right and left) is considered a ‘pass’, and 6/9-1 or 6/9-2 in either eye is a ‘borderline pass’ where parents are informed vision is within normal limits but will require reassessment after one year. A result of 6/9-3 or worse in either eye but better than 6/18 is referred to an eye health professional. 6/18 or worse in either eye is deemed a high priority referral and children are also referred if vision is within normal limits but there are other findings or they’re unable to do the test. In these cases, children can be referred to one of eight StEPS Paediatric Ophthalmic Outpatient Clinics (POOCs) located in metro hospitals, a GP, optometrist, ophthalmologist, or community orthoptist.

The dedicated POOCs are unique to the program, in addition to ‘catch up clinics’ for children who might have been away when the screeners visited their care centre. There are also StEPS coordinators who have the major responsibility of following up with families to ensure high priority referrals are seen within a timely manner.

Proven Value

As expected, the NSW Government was keen to understand the ROI with StEPS. University of Technology (UTS) Sydney won the tender to conduct an independent evaluation, which assessed the program’s appropriateness, effectiveness, efficiency, cost-effectiveness and whether it was implemented as intended.

“The evaluation report [published in 2018] came to the conclusion the model is unique to Australia and internationally, and is one of the largest, most systematically implemented and evidence-based vision screening programs available,” Martin said.

Specifically, the report said that use of an age-appropriate gold standard visual acuity test (HOVT logMAR) and ‘catch up clinics’ were appropriate. It also found that, despite local implementation variation, this was not associated with a difference in referral or outcome patterns. In terms of effectiveness, Martin said the report was favourable, achieving a high rate of vision screening in the target population; between 2009 and 2016, 96.4% of NSW 4-year-olds were offered the program, with 75.6% uptake. The availability of ‘catch up clinics’ had the greatest impact on screening rates at 19.3%.

With an overall referral rate of 9.4%, StEPS was also found to have a negligible number of false positive referrals and, according to Martin, an additional unforeseen advantage was previously undetected autism spectrum disorder and/or developmental delays in some children.

The annual cost of the program is $3.9 million, based on 2016/17 data.

“This translates to less than $50 for every child, and if screening was increased to 100% would be round $38 per child. The independent evaluation concluded StEPS was similarly cost effective to other prevention programs and represented good value for money," Martin said.

Progress To A National Vision Screening Program

How the Australian ophthalmic sector can implement the StEPS model country-wide is currently the focus of peak eye health body Vision 2020 Australia, whose member organisations include RANZCO, Optometry Australia and Orthoptics Australia.

Martin said Vision 2020 had established a child screening working group, with many of the same arguments emerging as per StEPS in 2009.

“They came to the conclusion there’s a need for a program and developed a national screening framework for 3.5- to 5-year-olds,” Martin said.“It will have universal access, there will be minimum standards for vision screening, they have addressed the issue of post-screening pathways and the model is to be based on StEPS.”

Momentum has been gathering in the literature too, with at least two studies published on how to deploy StEPS nationally. RANZCO has also been active. Outgoing president Professor Nitin Verma met with previous Federal Health Minister Mr Greg Hunt last year who tasked the college to develop a plan to eliminate avoidable blindness by 2030. RANZCO subsequently launched Vision 2030 and beyond, highlighting the need for a national paediatric vision screening program.

“So how do we achieve this? We need to consider the NSW StEPS model to be the national model with some modifications. It needs to be a collaborative effort with all stakeholders involved,” Martin concluded.

“It will depend on advocacy and implementation in each state and territory. With advocacy, Vision 2020 have a very good record and are committed to seeing this through. Implementation will be the role for RANZCO as the leader in collaborative eyecare.

“The minster and college have set the goal of 2030, and let’s hope by then a national pre-schooler vision screening program will be available to all Australian children.”