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1. 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.

2. 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

3. Central America Belize Guatemala Honduras El Salvador Nicaragua Costa Rica Panama

4. Central America < $2/Day Belize - Guatemala -37.4% Honduras – 44.4% El Salvador – 45% Costa Rica – 14.3% Panama – 17.9% Nicaragua – 94.5% < $2/Day 33%$ < $1/Day

5. 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)

6. Nicaragua – Visual Health Opticians or optometrists without specialized training = 35 (CR=50) Opticians or optometrists with university training = 15 (CR=350) 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

7. 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

8. 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

9. VERAS September 2005 Planning Meeting Protocols developed January 2006 Summit Introduced protocols Trained and certified participants from El Salvador Guatemala Nicaragua “superscreeners”

11. 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

12. 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)

13. School-based screening

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

15. 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

16. Screening Form

17. 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

18. VERAS Examination Acuities Test targets from 20/100 to 20/20 size Monocular 10 feet

19. Examination Acuity Form

20. Pilot Project Goal of Examiner training: Standardized form Standardization of Methods Cycloplegic Standardized approach to correction of refractive errors in children

21. Examination Cover test detect strabismus detects latent strabismus with prism measure

22. Examination External inspection determine safety for dilation detect external eye disease detect media opacification

23. Examination Cycloplegia proparacaine 2 drops 1% cyclopentolate 1 drop 1% Tropicamide 45 minute wait

24. Internal Examination

25. Retinoscopy and Rx

26. Treatment Plan Spectacle Treatment Exact prescription Retinoscopy New frames New lenses Fabricated in Nicaragua

27. Treatment Plan Surgical Evaluations Corneal specialist EOM surgeon Low vision care not available in community Coordination of care with local MDs

28. 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

29. 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

30. Pilot Study Results

31. Efforts to Decrease False Positive Rate High false positive rate can destroy a screening program Increase cost Decrease confidence in screening program

32. 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

33. 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

34. 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

35. Pilot Study Results  Parents were very interested Teachers are the key Sustainability occurs when local providers can continue the protocols and the care

36. 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 A&A Optical of Texas All planning, implementation, and evaluation participants

37. It’s the glasses!

38. It’s the vision!

39. It’s the children!