Acknowledgements
The Department of Health wishes to thank all those persons who were involved in the development of the national guidelines: Refractive errors screening for persons 60 years and older National and Provincial colleagues of the Department of Health South African Optometric Association Private Optometrists Universities
Contents
The Refractive Errors Screening Guidelines for Older Persons, which 1 have pleasure in presenting, will be of benefit in terms of screening for refractive errors and the provision of refraction, together with screening for major ocular disease and referral.
With age, the lens of the eye becomes more rigid. Refractive errors and the related visual disability are detrimental to the successful performance of many of the activities of daily living and pastimes, such as reading, playing cards, cooking, sewing, knitting and beadwork.
The correction of refractive errors forms a significant part of the World Health Organisation's Vision 2020 initiative to eliminate avoidable blindness.
I would like to thank all those who participated in the development of these guidelines.
Correction of refractive errors is a significant component of the WHO campaign to eliminate preventable blindness by the year 2020. While the provision of spectacles is a cost effective intervention, in South Africa little has been accomplished in this aspect. The vast majority of the population do not have access to refractive services. The lack of these services and the inadequate provision of spectacles impact tremendously on educational and employment opportunities for the disadvantaged in our society.
Any strategy to deal with the refractive errors challenge has to recognise the enormity of the challenge ahead and therefore target priority groups with visual disability due to uncorrected refractive errors. Service provision to these under-served communities will improve the quality of vision; create greater acceptance of eye care by the population; and be used to identify individuals with other treatable causes of poor vision.
To deliver refraction services as an integral part of general health care and comprehensive eye care systems
To identify, refer and provide services for the targeted adults who would benefit from refractive correction by:
There is a severe lack of epidemiological data on the magnitude of uncorrected visually disabling refractive errors. A few studies have focussed on convenience or clinic samples. The lack of population-based studies renders much of this information less useful. There is therefore a need for epidemiological studies as these are essential to the planning and allocation of resources.
The target group will be adults aged 60 years and above.
Screening and Referral criteria
Visual impairment will be defined as less than 6/12.
The main target for screening should be primary health care clinics. Patients presenting to clinics should be screened for distance and near refractive errors.
Provision of refractive services
Clinical refractive services will be delivered at District health care level. Refractions should be performed by eye care personnel (ECP) only, who have the appropriate skills in objective and subjective refraction, ocular motility, basic eye examination, ability to detect potentially blinding diseases and communication skills.
Aphakic/ Pseudophakic Patients
Post-cataract patients may require spectacles. It is recommended that nurses be made aware of this fact and that if there are no spectacles available, then the patient should be referred to a secondary level centre. If patients do not experience difficulty with distance vision and have 6/6 with a pinhole, they can be provided with reading glasses at the clinic.
Provision of Spectacles (will be in accordance with the UPFS) Affordable and/or fully subsidised spectacles should be provided to those in need, preferably at the site of the screening or refraction. The spectacles should be of acceptable optical and safety quality.
Ready-mades, in accordance with the recommendations by the WHO, should be available to patients with:
Made-to-order spectacles to be provided to all patients not falling within the above criteria.
Human resources for Refractive Services
Trained and equipped personnel are needed to implement refractive services at the community level.
Clinic nurses/Ophthalmic nurses should be trained to provide appropriate screening services.
Possible cadres for each level include:
Community level: Clinic nurses, outreach Ophthalmic nurses service Secondary Level: Ophthalmic nurses, Optometrists Tertiary level: Optometrists, Ophthalmologists.
Health Education:
Refractive services need to be advertised so that older persons are able to access them appropriately.
Eye care personnel should be able to educate the patient about the risk of other diseases and the appropriate action to be taken e.g. Diabetic Retinopathy.
Ophthalmic nurses - To be trained in basic refraction
Clinic Nurses - To be trained in screening techniques and/or the prescription of reading glasses and health education.
Optometrists
It is necessary for optometrists to be involved in other eye care work such as pre- and post-operative cataract management, diagnostics and management of common eye diseases, health promotion and the training of other eye care personnel.
Programme Evaluation
The success of the programme will be the number of needed referrals that are made, and not the number of reading spectacles prescribed.
It is important that the outcome of providing refractive services is monitored through appropriate indicators and that operational research be utilised to evaluate the most cost-effective interventions.
Specific Refraction Indicators
Public/Private Partnerships - Should be fostered.
Research
There is a need for operational research into various aspects of assessment, cost-effectiveness of interventions and outcome measurement. Universities should be encouraged to research these aspects.
Costs of a Refractive Errors Programme
Human Resources: Optometrists
Ophthalmic nurses
Equipment (refraction only):
Spectacles: Ready-mades
Made-to-Order (frame and lenses)
Cost Recovery: Refer UPFS
November 2004
Department Of Health
Directorate: Chronic Diseases,Disabilities and Geriatrics