National Guide

Chapter 9 | Eye health and vision

Visual acuity







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      1. Visual acuity

The health of young people | Visual acuity

Dr Natalie Williamson 

Key messages

  • Aboriginal and Torres Strait Islander children have better vision and less visual impairment than non-Indigenous Australian children. However, Aboriginal and Torres Strait Islander adults aged >40 years are three-fold more likely to have visual impairment than non-Indigenous people in Australia.1,2
  • Ask all people about vision and complete assessment of visual acuity in those with symptoms and/or who request it.
  • There has been a significant improvement in funding and the availability of eye health services, and it is imperative that clinicians are aware of the services available in their region to optimise patient care.3
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children Conduct regular reviews of all infants and children and recommend vaccination As per the NIP schedule and relevant state and territory immunisation schedules for Aboriginal and Torres Strait Islander children Strong National schedule9
National guideline10		 As per the NIP and Australian immunisation handbook
Infants Conduct a general eye examination:
  • red reflex (reflection from the retina)
  • corneal light reflex (reflection from the cornea)
  • cover test (covering and uncovering each eye)
Refer to an ophthalmologist if the red reflex is absent or any other abnormality is found		 Before 3 months of age and again between 3 and 6 months of age Good practice point National guidelines4–6 Risk factors for reduced visual acuity include birth weight <1500 g, prematurity, developmental delay or disability
Children aged 3–5 years Assess visual acuity using Lea and Tumbling E charts depending on age and maturity of child
Refer if visual acuity is less than 6/12 in either eye		 As part of a routine health assessment at or before school entry Strong National and international guidelines4–7 Early identification of vision abnormalities can prevent the development of permanent vision loss (amblyopia)
All people Ask about vision

Test visual acuity if any problems are identified
Include testing for near visual acuity from age 40 years onwards		 Opportunistically Good practice point National guidelines8–10 As per existing national guidelines
People with diabetes Undertake visual acuity and retinal assessment by a trained assessor

This includes dilated fundus examination and/or the use of retinal photography by trained primary healthcare staff combined with external review by an ophthalmologist		 At diagnosis then annually Strong National guideline11 Permanent vision loss caused by DR can be prevented with early detection
Pregnant women with diabetes Conduct a dilated fundus examination and counsel clients about the risks of diabetic retinopathy (DR) Preconception Strong National and international guidelines12–15 DR can progress in pregnancy for women with pre-existing diabetes
Pregnant women with diabetes Conduct an eye examination by dilated fundus examination or retinal digital imaging First trimester Strong National guidelines13,14,16,17  
Pregnant women with diabetes The need for further retinal examinations should be guided by results of earlier examinations Second and third trimesters Conditional National guidelines13,14,16–18  
Pregnant women with diabetes Provide ongoing ophthalmic follow-up in the post-partum period with retinal digital photography or dilated fundus examination 6–12 months postpartum Strong National and international guidelines12–15  
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All children Conduct regular reviews of all infants and children and recommend vaccination As per the NIP schedule and relevant state and territory immunisation schedules for Aboriginal and Torres Strait Islander children Strong National schedule9
National guideline10		 As per the NIP and Australian immunisation handbook
Current smokers Advise smoking cessation to reduce the risk of developing cataracts (see Chapter 2: Healthy living and health risks, Smoking) Opportunistic Conditional Narrative review19
Single study20		 Smoking is a risk factor for poor eye health
All people Recommend reduced ocular exposure to ultraviolet B light to reduce the risk of cataract (ie wearing a hat and sunglasses when outdoors) Opportunistic Conditional Narrative review21
Single studies22,23
Systematic review24		 Exposure to ultraviolet B light is a risk factor for poor eye health
All people Recommend a balanced diet high in fruit and vegetables to help promote good eye health and reduce the risk of developing diabetes and age-related macular degeneration Opportunistic Conditional Position statement25
Narrative study26		 A healthy diet promotes good eye health
  • Include eye health in chronic disease management plans and consider in team care arrangements.
  • Establish recall and reminder systems for annual eye reviews in high-risk patients.
  • Provide regular staff training and updates in the assessment of eye health, including visual acuity and retinal photography.
  • Consider the location of the Snellen chart within the clinic space. Ensure good natural light or illumination (without reflection) on the Snellen chart to assess visual acuity.
  • When assessing visual acuity, it is best to use an occluder to cover the eye that is not being tested; where an occluder is not available, use the patient’s cupped hand to cover the eye.
  • Vision charts are standardised for size and contrast; do not photocopy or make your own charts.

Clinical guidelines

General

Other resources for health professionals

Tools

Background

Healthy eyes are important to overall health and wellbeing. Vision impairment can limit opportunities in education, employment and social engagement, as well as increase the risk of injury and be a reason for loss of independence. These effects are felt not only by the affected individual, but also their family and community.27 Among older people, visual impairment is a risk factor for falls, hip fractures, depression, social and functional decline and increased mortality.28–31 

The age-adjusted prevalence of vision impairment and blindness in Aboriginal and Torres Strait Islander adults is threefold higher than in non-Indigenous Australians.32 Vision impairment is diagnosed as a loss of visual acuity <6/12. Blindness is the loss of visual acuity to a level <6/60.32,33 Approximately 90% of vision impairment and blindness among Aboriginal and Torres Strait Islander peoples is preventable or treatable.32 

The leading causes of vision impairment and blindness in Aboriginal and Torres Strait Islander peoples are uncorrected refractory error, cataract and DR.1 Thus, most vision impairment is preventable, treatable and/or reversible with spectacle correction or cataract surgery.32 The course of DR can be ameliorated with optimal diabetic control, early detection of retinopathy and a range of treatments.34–36 Trachoma is still a significant contributor to blindness in Aboriginal people, particularly in Central Australia1,3,33,37,38 (see Chapter 9: Eye health and vision, Trachoma and trichiasis). 

Factors contributing to poor eye health include age, injury, ultraviolet light exposure, repeated infection, hypertension, obesity, low birth weight, diabetes, alcohol and tobacco use.1,27,39 The modifiable nature of these risk factors emphasises the opportunities for prevention.1 Addressing the prevalence of risk factors could substantially improve eye health in Aboriginal and Torres Strait Islander people.1 

There have been significant improvements in service availability since the first National Indigenous Eye Health Survey in 2008.40 Increased funding for programs, including the Visiting Optometrist Scheme, Medical Outreach Indigenous Chronic Disease Program and the Rural Health Outreach Fund, have seen outreach optometry and ophthalmology service provision more than double, with a 17% increase in eye examinations between 2012 and 2018.19 The provision of a Medicare item number41 for screening for DR in Aboriginal and Torres Strait Islander people without the need of a dilated pupil has increased access to screening for DR.42 The highest uptake of this item has been in rural and remote areas, and further studies are exploring the possibilities of artificial intelligence to interpret these photographs, as well as the role of telehealth ophthalmology consultation.43–45

Testing vision

The standard (Snellen) eye chart, HOTV (using letters H, O, T and V), tumbling E chart and the Lea Symbols charts are the most suitable tools to assess visual acuity.8,32,33 The need to test near or ‘reading’ vision is of equal importance when caring for people aged over 40 years. Near vision test cards, or any printed matter, can be used to test near vision for people who can read, and E-tests for near vision can be used for those who cannot read.8 

Vision screening in children

Vision assessment in children varies across Australian states. Clinical guidelines recommend a check for congenital eye conditions within the first three months of life.6 The project advisory group from the National Children’s Vision Screening Project in 2009 recommended vision assessments for children between the ages of three and six months.4,5 Routine visual assessment in infants includes assessment for the presence of a red reflex (reflection from the retina), corneal light reflex (reflection from the cornea) and cover test (covering and uncovering each eye), and focuses on the detection of retinoblastoma, amblyopia and strabismus refractive error. However, there is little evidence to support these practices.4,5,7,46
 
Aboriginal and Torres Strait Islander children have been found to have better vision than non-Indigenous Australian children.3,20,32 The risk of visual impairment increases with advancing age and other risk factors, including prematurity, birth weight less than 1500 g and developmental delay or disability.4 In addition to routine vision screening, Aboriginal and Torres Strait Islander children living in rural and remote areas should be screened for trachoma when there is increased risk (see Chapter 9: Eye health and vision, Trachoma and trichiasis). 

For older children, Australian consensus and the US Preventive Services Task Force recommend vision screening at least once between the ages of three and five years.4–7 Screening should aim to detect impaired visual acuity and those at higher risk of developing visual impairment. Further assessment and treatment should be provided for those who require it. Referral criteria depend on the age of the child and include a visual acuity less than 6/9 in either eye for a child aged three years and 6/9 or less in either eye for a child aged 4–6 years.6

Vision screening in adults

Although there is insufficient evidence to fully assess the benefits and harms of population-based screening for visual acuity in otherwise well adults,25 visual acuity screening is advocated in older people because refractive errors are correctable with eyeglasses and have good outcomes with refractive surgery, if available, and the challenges of falls and loss of independence related to visual impairment are well documented.9,25,47,48 The Royal Australian College of General Practitioners’ Guidelines for preventive activities in general practice (Red Book) recommends assessment of visual acuity in Australians from the age of 65 years if requested or symptomatic.9 

The substantially higher prevalence and underdiagnosis of vision impairment in Aboriginal and Torres Strait Islander people, along with poorer access to treatment services, supports routine visual acuity screening in all age groups. An eye examination is recommended in Aboriginal and Torres Strait Islander annual health checks (eg MBS Item 715; see Useful resources),49 the CARPA standard treatment manual (8th edn) and Queensland’s The chronic conditions manual.8,10 

Cataract

Cataract is the second leading cause of visual impairment and the single largest cause of blindness in Aboriginal and Torres Strait Islander people.20,50 The causes/risk factors for cataract are advancing age, smoking, low socioeconomic status, ultraviolet light exposure, alcohol intake and chronic diseases such as diabetes, hypertension, obesity, chronic kidney disease and autoimmune disease. Aboriginal and Torres Strait Islander people are more likely to visit their GPs for the management of cataract, but are less likely to receive cataract surgery, than non-Indigenous Australians.37
 
Surgical correction of cataracts occurs in a younger Aboriginal and Torres Strait Islander population than among non-Indigenous Australians. Specifically, Aboriginal and Torres Strait Islander people aged 50–59 years have equivalent rates of cataract surgery to non-Indigenous Australians aged 70–79 years.20 Despite notable improvements in the number of eye examinations, as well as both outreach optometry and ophthalmology services,3,19 there are often long delays to surgery, with Aboriginal and Torres Strait Islander people waiting 63% longer for cataract surgery than non-Indigenous Australians. This effect is most prominent in rural and remote areas.3,19
 
The importance of early detection of cataract through regular screening leads to earlier treatment and better postoperative outcomes.3,37 Prevention and protective behaviours are key and include the reduction of modifiable risk factors, such as tobacco smoking and exposure to ultraviolet B light, and optimising diabetic control.3,37

Diabetic retinopathy

DR is the most common microvascular complication of diabetes. It is a silent disease, usually affecting both eyes, and rarely causes any symptoms until the late stage of disease, when vision loss has occurred. This means screening and early DR is the most common microvascular complication of diabetes. It is a silent disease, usually affecting both eyes, and rarely causes any symptoms until the late stage of disease, when vision loss has occurred. This means screening and early detection provide real opportunity to prevent loss of vision and are therefore imperative. The prevalence of diabetes is three-fold higher among Aboriginal and Torres Strait Islander peoples than among non-Indigenous Australians,3,51 and thus the proportion of Aboriginal and Torres Strait Islander people at risk of DR is also higher.3,52

The strongest factor determining DR prevalence is the duration of diabetes.11,17,51 People at higher risk include those with poor glycaemic control, hypertension, dyslipidaemia and renal impairment.11,17,36 Vision loss in DR is caused by diabetic macular oedema (DMO), which can occur at any stage of DR. Aboriginal and Torres Strait Islander people experience a high incidence of DMO and sight-threatening proliferative retinopathy.53 
For women with pre-existing diabetes, pregnancy is an independent risk factor for worsening of DR due to hormonal and metabolic changes associated with pregnancy. Progression of retinopathy occurs at approximately double the rate in pregnant compared with non-pregnant women and is a leading cause of blindness in women who have pre-existing diabetes during their childbearing years.

Current recommendations are:

  • an eye examination in the first trimester, either by dilated fundus examination or retinal digital imaging13,14,17,18
  • retinal examinations in the second and third trimesters, depending on findings in earlier examinations13,14,17,18
  • ophthalmic follow-up at 6–12 months postpartum.12–14

Many guidelines also recommend preconception counselling about the risks of DR and eye examination for women with pre-existing diabetes who are planning pregnancy.12–14 

Gestational diabetes does not increase the risk of DR because of the recent onset of diabetes, and therefore DR is not present. Thus, women with gestational diabetes do not require screening. 

Current Australian recommendations are that all Aboriginal and Torres Strait Islander people with diabetes have visual acuity and retinal assessment, either by dilated fundus examination or retinal photography, on diagnosis of diabetes and then annually.11,17 As described previously, this has been facilitated by an MBS primary care item number41 for assessment of visual acuity, and retinal photography with a non-mydriatic retinal camera for Aboriginal and Torres Strait Islander people with diabetes exists as an alternative to dilated fundus examination.10,11,34,35,41 Retinal screening for children and adolescents with type 2 diabetes should be conducted at diagnosis and annually thereafter.54 

Good glycaemic,8,12,14,17,55,56 lipid14,57,58 and blood pressure8,12,14,17,57,58 control, together with regular eye examinations and early treatment of any DR, remain the cornerstones of primary prevention and delay of progression of DR.8,17,58 These measures also increase life expectancy and so do not reduce the lifetime risk of developing retinopathy. Regular follow-up with early detection and timely treatment of vision-threatening retinopathy enables the prevention of up to 98% of visual loss.14,16,17 

Assessment of DR should be incorporated into all GP management plan reviews and regular care for diabetes. Any new visual symptoms should prompt consultation with local ophthalmology services.8,17 Urgent ophthalmology referral (within four weeks) is recommended if DMO or proliferative DR are suspected or there is an unexplained reduction in visual acuity.17

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