Guidelines for preventive activities in general practice

Miscellaneous

Vision

      1. Vision

Miscellaneous | Vision

Screening age bar

0-9* 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80

*Between 3 and 5 years.

It is estimated that over 13 million Australians had one or more chronic (long-term) eye conditions in 2017–18, with chronic eye conditions affecting 93% of people aged ≥65 years.1 Conditions such as cataracts, macular degeneration, glaucoma and diabetic retinopathy can lead to blindness if left untreated.1 Declining vision impacts the everyday quality of life of the patient2 and contributes to injury and morbidity.3 Open-angle glaucoma prevalence increases with age after age 40 years and is more common in people of Caucasian, Asian and African ethnicity.

Aboriginal and Torres Strait Islander peoples aged >40 years have nearly three times the rate of vision loss of other Australians.4,5

Screening

Recommendation Grade How often References
Vision screening in children to detect amblyopia, or its risk factors, is recommended.

Risk factors include:
  • strabismus
  • uncorrected refractive errors (eg myopia, hyperopia and astigmatism)
  • anisometropia
  • media opacity.
Additional risk factors include:
  • family history in a first-degree relative
  • prematurity
  • low birth weight
  • maternal substance abuse
  • maternal smoking during pregnancy
  • low levels of parental education.
 
Conditionally recommended Once, between the ages of 3 and 5 years 6
Visual acuity screening in the general population is not recommended, because of insufficient evidence.  Generally not recommended N/A 7,8
Glaucoma screening in the general population (without increased risk factors) is not recommended, because of insufficient evidence.  Generally not recommended N/A 9
Vision screening in children aged <3 years is not recommended, because of insufficient evidence. Generally not recommended N/A 6
Screening for primary open-angle glaucoma in the general population aged ≥40 years is not recommended, because of insufficient evidence. Generally not recommended N/A 7

Case finding

Recommendation Grade How often References
Identify people aged >50 years at high risk of glaucoma and refer to an optometrist/ophthalmologist for further assessment.
 
People at higher risk of glaucoma include patients aged >50 years with:
  • diabetes
  • myopia
  • long-term steroid use
  • migraine and peripheral vasospasm
  • abnormal blood pressure
  • history of eye trauma.
 
Conditionally recommended Frequency of follow up determined by the individual patient’s eye assessment. 9,10

Preventive activities and advice

Recommendation Grade How often References
Advise good eye care to help prevent eye strain and vision problems:
  • reduce ocular exposure to ultraviolet B light to reduce risk of cataracts (e.g., wearing a hat and sunglasses when outdoors),
  • wear any prescribed glasses or contact lenses,
  • wearing eye protection (particularly for people with occupations or hobbies who may be at risk of getting objects or chemicals in their eyes),
  • rest eyes if using screens for long periods of time to reduce eye strain,
  • quit smoking,
  • eat plenty of fruits and vegetables.
 
 
Practice point N/A 11

Vision screening: Children aged <3 years

Newborn vision screening in Australia is typically undertaken in hospitals, soon after the baby is born. However, there is insufficient evidence to recommend routine vision screening in primary care in children aged <3 years. Children aged <3 years are often unable to cooperate with some of the clinical screening tests performed in general practice, such as visual acuity testing, and therefore may lead to false positive results.6

Vision screening: Children aged 3–5 years

The purpose of vision screening between the ages of 3 and 5 years is to detect any vision problems, but primarily to detect amblyopia. Amblyopia is more commonly known as ‘lazy eye’. It typically only occurs in one eye, but occasionally occurs in both.

Optometry Australia guidelines recommend the following techniques to measure acuity in children aged 3–5 years. The Broken Wheel Test is a possible alternative if the below tests cannot be conducted:12

  • Patti Pics or Lea Chart at 3 metres or 6 metres
  • Snellen chart at 6 metres – use multiple-line presentation or crowding bars to increase sensitivity of detection of amblyopia. Single-line presentations with crowding bars can also be considered.

Glaucoma

Glaucomas are a group of relatively common optic neuropathies in which there is pathological loss of retinal ganglion cells, progressive loss of sight and associated alteration in the retinal nerve fibre layer and optic nerve head. While there is no evidence for population screening for primary open-angle glaucoma,9 GPs have an important role in identifying those at increased risk for glaucoma and advising them to attend regular, fully comprehensive eye examinations with an optometrist. Open-angle glaucoma can be identified with optimal coherence tonography (high sensitivity), automated visual field testing (high sensitivity), tonometry (lower sensitivity) and visualisation of the optic disc (lower sensitivity). Management to reduce intraoccular pressure slows progression of glaucoma. However, there are currently no tools available that can identify patients’ individual risk, or for whom screening may be more beneficial.9

Assessing fitness to drive

The Austroads Assessing Fitness to Drive guidelines include a subsection on Vision and eye disorders. This provides information on the effects of vision and eye disorders on driving, assessment and management guidelines, and medical standards for licensing.
 
 

For specific recommendations for Aboriginal and Torres Strait Islander people, please refer to the following sections from Chapter 6: Eye health of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people:

People at greater risk of visual impairment and loss include:8

  • older people
  • people with diabetes
  • people with family history of vision impairment
  • smokers (current or previous).

Older people

It should be determined whether the patient is wearing up-to-date prescription spectacles. Also assess whether there is a possibility of falls, or if the patient is no longer capable of managing a bifocal, trifocal or multifocal prescription.

Guidelines for screening and preventive care in Aboriginal and Torres Strait Islander people:
Visual acuity, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people | RACGP
Trachoma and trichiasis, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people | RACGP

Screening guidelines for diabetes-related eye disease, such as diabetic retinopathy:
Microvascular complications: Diabetes-related eye disease, Management of type 2 diabetes: A handbook for general practice | RACGP
 
Guidelines for assessing fitness to drive:
Assessing fitness to drive | Austroads
 
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) referral pathways for age-related macular degeneration, diabetic retinopathy and glaucoma management:
Collaborative care | RANZCO

  1. Australian Institute of Health and Welfare. Eye health. Cat. no. PHE 260. Canberra: AIHW, 2021. Available at: [Accessed 27 April 2023].
  2. Purola P, Koskinen S, Uusitalo H. Impact of vision on generic health-related quality of life – A systematic review. Acta Ophthalmol 2023;101(7):717–28. doi: 10.1111/aos.15676.
  3. National Aboriginal Community Controlled Health Organisation; The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd edn. RACGP, 2018.
  4. Australian Institute of Health and Welfare. Eye health measures for Aboriginal and Torres Strait Islander people 2022: Interactive data. AIHW, 2023 [Accessed 27 April 2023].
  5. Foreman J, Xie J, Keel S, et al. The prevalence and causes of vision loss in Indigenous and non-Indigenous Australians: The National Eye Health Survey. Ophthalmology 2017;124(12):1743–52. doi: 10.1016/j.ophtha.2017.06.001.
  6. Jonas DE, Amick HR, Wallace IF, et al. Vision screening in children ages 6 months to 5 years: A systematic review for the US Preventive Services Task Force. JAMA 2017;318(9):845–58. doi: 10.1001/jama.2017.9900. PMID: 28873167.
  7. Clarke EL, Evans JR, Smeeth L. Community screening for visual impairment in older people. Cochrane Database Syst Rev 2018;2(2):CD001054. doi: 10.1002/14651858.CD001054.pub3.
  8. Chou R, Bougatsos C, Jungbauer R, et al. Screening for impaired visual acuity in older adults: A systematic review for the US Preventive Services Task Force. Evidence Synthesis, No. 213. Agency for Healthcare Research and Quality (US), 2022 [Accessed 8 April 2024].
  9. US Preventive Services Task Force; Mangione C, Barry M, et al. Screening for primary open-angle glaucoma: US Preventive Services Task Force Recommendation Statement. JAMA 2022;327(20):1992–97. doi: 10.1001/jama.2022.7013.
  10. Patient. Primary open-angle glaucoma: Symptoms, assessment and management. Patient, 2022 [Accessed 8 April 2024].
  11. Vision Australia. Maintaining eye health. Vision Australia, 2023 [Accessed 27 April 2023].
  12. Optometry Australia. Clinical practice guide: Paediatric eye health and vision care. Optometry Australia, 2016 [Accessed 27 April 2023].
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