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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 (Vi s ion, Education, Achievement, Learning, and Sustainability) project. Drs. Patti Fuhr, Wendy Marsh-Tootle, & Marcela Frazier of VOSH Int

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pre school vision screening in nicaragua
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

international participants el 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

International ParticipantsEl Salvador, Guatemala, Nicaragua
central america
Central America
  • Belize
  • Guatemala
  • Honduras
  • El Salvador
  • Nicaragua
  • Costa Rica
  • Panama
central america 2 day
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
nicaragua
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)
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

Nicaragua – Visual Health
slide7
VERASVision Education Achievement Learning SustainabilityVision, 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
role of volunteer optometric service to humanity vosh
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
veras
September 2005

Planning Meeting

Protocols developed

January 2006 Summit

Introduced protocols

Trained and certified

participants from

El Salvador

Guatemala

Nicaragua

“superscreeners”

VERAS
veras in central america
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
veras pilot project in nica
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)
veras14
VERAS
  • Screening protocol
    • Target population preschool and first grade
    • VERAS visual acuity test 20/40 targets
    • Screening acuity at 5 feet
veras15
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

veras17
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
veras18
Examination Acuities

Test targets from 20/100 to 20/20 size

Monocular

10 feet

VERAS

Acuity tests donated by GoodLite

pilot project
Pilot Project
  • Goal of Examiner training:
    • Standardized form
    • Standardization of Methods
      • Cycloplegic
    • Standardized approach to correction of refractive errors in children
examination
Cover test

detect strabismus

detects latent strabismus

with prism measure

Examination
examination22
External inspection

determine safety for dilation

detect external eye disease

detect media opacification

Examination
examination23
Cycloplegia

proparacaine

2 drops 1% cyclopentolate

1 drop 1% Tropicamide

45 minute wait

Examination
treatment plan
Spectacle Treatment

Exact prescription

Retinoscopy

New frames

New lenses

Fabricated in Nicaragua

Treatment Plan

Frames donated by A&A Optical, Texas

treatment plan27
Treatment Plan
  • Surgical Evaluations
    • Corneal specialist
    • EOM surgeon
  • Low vision care not available in community
  • Coordination of care with local MDs

Frames donated by A&A Optical, Texas

pilot study results
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
pilot study results29
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
pilot study results30
Pilot Study Results

Sensitivity 0.77

Specificity 0.66

efforts to decrease false positive rate
Efforts to Decrease False Positive Rate

High false positive rate can destroy a screening program

Increase cost

Decrease confidence in screening program

efforts to decrease false positive rate32
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
pilot study results33
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

pilot study results34
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
pilot study results35
Pilot Study Results

Parents were very interested

Teachers are the key

Sustainability occurs when local providers can continue the protocols and the care

vision screening in nicaragua acknowledgements
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