Developing an integrated paediatric low visionservice*

Gillian Rudduck1, Helen Corcoran2 and Kay Davies2

1Optometry Department, Wirral NHS Trust, Wirral, and 2Vision Support Service, Wirral Education

and Cultural Services Department, Solar Campus, Wirral, UK

Abstract

A survey of usage of low vision aids (LVAs) by 56 children with visual impairment, who were

attending mainstream schools in Wirral, was undertaken. A total of 25% of children owned an LVA

and 5% were using these on a regular basis. These low levels of ownership and usage led to the

development of a low vision service involving the collaboration of education and health care. This

paper describes the development of that service, its elements and implementation. The results from

the new service show that of the 29 children issued with an LVA, 82.7% are using them on a regular

basis. Having an integrated service is shown to significantly improve LVA usage in the group of

children seen so far. The service results are discussed with suggestions for future service

development.

Keywords: low vision aids, multi-disciplinary, paediatric, visual impairment

Introduction

The benefit of low vision aids (LVAs) for the visuallyimpaired (VI) is well known, but anecdotal evidencewould suggest that VI children in mainstream schoolsdo not generally use LVAs. Mason and Mason (1998)showed that VI children in mainstream schools arereluctant to use LVAs for a variety of reasons. Thelimitations, difficulties and logistics of using LVAs,discomfort due to failure to address the ergonomicissues, and inadequate training, all lead to a reluctanceto use as does the unwanted attention, teasing andbullying that can be associated. The results of aninvestigation of LVA usage amongst VI childrenattending schools on the Wirral and the developmentof a paediatric low vision service are detailed.

Method

Patients

Wirral has a population of approximately 330 000people. In common with most local education author-ities, Wirral Metropolitan Borough Education andCultural Services Department has a vision supportservice (VSS) which works with children with visualimpairment (aged 0–19 years). At the time of thisstudy, this service monitored the progress of 131 youngpeople ranging from Reception year to sixth form(16+) (Table 1). The monitoring of these childreninvolves regular contact with a specialist teacher of theVI and annual multi-disciplinary review of progresswith input from health and education. Depending onneed, some children would have full or part time one-to-one support with a teacher of the VI. These childrenfell into one of three groups; those educated inmainstream school (n ¼ 57) those educated in main-stream schools with a vision support base (n ¼ 23),those educated in special school (n ¼ 44) and thoseeducated out of the area (n ¼ 7) and it is the group of80 children attending mainstream schools that thecurrent study included.

Of the 80 children attending mainstream schools, 23attend a school with a vision support base. A vision

Received: 22 December 2003

Revised: 27 March 2004

Accepted: 5 April 2004

*This paper was presented at the UK Multi-disciplinary Low Vision

Rehabilitation and Research Conference held at Aston University,

December 2003.

Correspondence and reprint requests to: Gillian Rudduck, Optometry

Department, Arrowe Park Hospital, Upton, Wirral CH49 5PE, UK.

Tel.: +44 (0) 151 604 7237; Fax: + 44 (0) 151 604 7172.

E-mail address: gillian.rudduck@whnt.nhs.uk

Ophthal. Physiol. Opt. 2004 24: 323–326

ª 2004 The College of Optometrists 323

support base within a mainstream school is a centrewhere VI pupils can access electronic vision aids, e.g.CCTV; modification of materials, e.g. enlargement;and receive one-to-one support. As a general rule, thepupils who attend one of the schools with a visionsupport base are those children who are considered tohave the greatest need in terms of curriculum support/modification. In a minority of cases, young peoplewith significant vision needs, as identified in theirStatement of Special Educational Need, have chosen toattend a school without a vision support base. Of the57 children attending schools without a vision supportbase 33 children had been reported by the VSS ashaving difficulty accessing near and/or distance mater-ial in the classroom. This gave a total sample of 56children for whom LVAs may potentially give somesupport. The range of visual impairment among thegroup of 80 monitored children in mainstream schoolsis wide as is demonstrated by the number of childrenwho were not included in the sample. Many of thesechildren will have visual field loss whilst still main-taining a good level of visual acuity and hence maynot require magnification.

An audit of these children and their LVA ownershipand usage was undertaken by the VSS. The childrenwere asked directly whether they owned or used anLVA. This information was also gathered from theirsupport teacher. Ownership was examined in terms ofstage in education and LVA type and source.

Results

Of the sample of 56 VI children, 14 (25%) were found toown an LVA with some owning up to three. Thesechildren were most likely to be in the 16+ age groupwith no child in Key stage 1 or 4 owning an LVA(Figure 1) The LVAs came from a variety of sources(Figure 2) with the local education authority being thegreatest provider. Three of the group (5%) were usingLVAs on a regular basis. The most common LVA to beissued was a stand magnifier and was as likely to be usedon a regular basis as was a hand magnifier (Figure 3).Regular use was defined as daily use in school.Telescopes were rarely issued (n ¼ 3) and least likelyto be used.

Summary of findings and service development

The above results show a low level of ownership andusage of LVAs by children in mainstream schools. Asdetailed earlier, this can be for a variety of reasons. In

Table 1. Educational stages

Key stage School year Age range (years)

KS1 Reception, years 1 and 2 4–7

KS2 Years 3 to 6 7–11

KS3 Years 7 to 9 11–14

KS4 Years 10 and 11 14–16

POST 16 Years 12 and 13 16–18

0

5

10

15

20

25

30

KS1 KS2 KS3 KS4 16+

Educational stage

Num

ber

of p

upils

Monitored children Monitored children using LVA

Figure 1. Educational level of children with visual impairment

monitored by VSS, showing LVA ownership.

0

1

2

3

4

5

6

Hand Stand CCTV TelescopeType of LVA issued

Num

ber

of p

upils

HES LEA Family

Figure 2. Sources of LVAs owned by pupils with visual impairment.

0

1

2

3

4

5

Hand Stand CCTV Telescope

Type of LVA issued

Num

ber

of p

upils

Not used Occasional use Regular use

Figure 3. Frequency of usage of LVAs owned by pupils, according

to type of LVA.

324 Ophthal. Physiol. Opt. 2004 24: No. 4

ª 2004 The College of Optometrists

order to address some of these issues the hospital eyeservice (HES) and VSS established an integrated lowvision service. To maximise the potential benefits of theservice to the service user it was essential to engage allthe major stakeholders in the provision of this service.Wirral has a well-established paediatric eyecare groupwith representatives of education, and primary andsecondary health care providers. This group meetsquarterly to discuss paediatric eyecare issues and itwas within this forum that the following recommenda-tions were made:• All paediatric low vision assessments should be multi-disciplinary, linking the work of education and health.• Pupils with visual impairment should undergo regularassessment and re-evaluation of their visual needs.• Ergonomic requirements of the pupils in the work andhome environments should be assessed and addressed.• Structured and monitored training in use of LVAsshould be part of the service.• The provision of LVAs to begin in primary educationor earlier.• Awareness training for staff and pupils should beprovided in the local schools.• Awareness training for parents/carers to be provided.Figure 4 details the flow chart or patient pathway

through the new service. All stakeholders in educationand health care agreed the protocol for referral to theclinic. In order to ensure appropriate sharing of infor-mation, any reports generated are copied to parents,general practitioners and consultant ophthalmologists(where the child remained under their care).

Pupils could be referred to the service at the request ofthe parent or school. A qualified rehabilitation officer(HC) working for the education department would carryout an assessment of the child’s LVA needs followingreferral. A comprehensive written report would then besent to the low vision optometrist (GR) based in thelocal HES (Table 2). A low vision assessment wouldthen be carried out. HC would be in attendance at thatconsultation. These close links ensured a smooth trans-fer of information between the different parts of theservice. Any interested party was welcome to attend anypart of the low vision assessment. This was particularlybeneficial at the hospital session as LVAs would beprescribed and it was felt important that ownership ofthese aids by the child would be encouraged if parentsand teachers were involved at this stage.

A summary report (Table 3) would then be returnedto the education department and follow-up training withHC in use of the LVAs would be arranged. This trainingcould take place in the school, home or leisure environ-ments. By not restricting the training environment,pupils were encouraged to appreciate that the LVA wasnot solely for educational use.

Pupils could return to the low vision service at anytime as their needs changed. This change in need is

Initial referral

Rehabilitation assessment

Referral to hospital eye service

Hospital low-vision assessment

Follow-up by rehabilitation officer

Post-clinic report

Figure 4. Flow chart illustrating elements of integrated paediatric

low vision service.

Table 2. Summary of referral report sent to HES following VSS low

vision assessment

• Demographics

• Known ophthalmic history

• Diagnosis, previous treatment, ongoing treatment

• Spectacle wear

• Reason for referral to low vision service

• Distance vision, observations, specific tasks, aids tried

• Near vision, observations, specific tasks, aids tried

• Desired outcomes

• Environment, ergonomic issues

• Effects of different lighting, colours

Table 3. Summary of clinical report sent to VSS following HES low

vision assessment

• Demographics

• Known ophthalmic history

• Diagnosis and its possible effects in real terms

• Refraction results and advice on spectacle wear

• Best distance acuity

• Best near vision and advice re print size with respect to threshold

• Contrast sensitivity and advice re print contrast with respect to

threshold

• Aids trialed, issued, acuities, uses

• Visual fields

• Colour vision

• Advice re environment, lighting

• Agreed outcomes and follow-up arrangements

Integrated paediatric low vision service: G. Rudduck et al. 325

ª 2004 The College of Optometrists

particularly evident as a child passes through the schoolsystem and it was necessary to look at different forms ofmagnification for different tasks. It was important tokeep the service as accessible as possible.

Results from new service

Since the service commenced in 2000 there have been 22designated clinics held at the hospital eye department.Each child is given a 1-h consultation at the first visit.Thirty-two children have been through at least onecomplete cycle of the service. Some children have beenseen by the VSS and not proceeded to the HES. Somereferrals did not receive parental consent (N ¼ 2) and insome cases the VSS did not feel LVAs were appropriateat that time (N ¼ 10).

Ownership and usage

Of the 56 children previously identified, 32 children wereseen in the new service. Three children required aspectacle correction alone and the remaining 29 wereprescribed an LVA. LVAs issued were predominantlybrightfields and hand magnifiers for near with binocu-lars or telescopes issued for distance tasks. Manychildren were issued with more than one LVA allowingfor a range of tasks. The service does not provideCCTVs or electronic LVAs. On review, 25 (82.7%)children are known to be using their LVA on a regularbasis in the school and at home. Four children havestopped using the prescribed LVA. The reported reasonsfor this have been investigated and tend to rest mostfirmly with the denial of need by the child. It isinteresting to note that this group of four pupils fallswithin the secondary school age group. Peer pressurehad already been identified as, and may still be, a factorin non-use of LVAs (Mason and Mason, 1998). Thisissue needs to be revisited and ongoing awarenesstraining implemented.

Access to the service is an important element and ninechildren have been seen on more than one occasion inthe HES as their needs have changed. These childrenhave all been issued additional or alternative LVAs.

Conclusion

Providing elements of training, follow-up and supportthroughout a paediatric low vision service has led to amarked increase in the use of LVAs for children with avisual impairment. By working in collaboration withother professionals who provide support to childrenwith a visual impairment, but who do not traditionallyfall within the area of health care, it has been demon-strated that it is possible to provide an integratedservice.

On reflection, the service has not to date received asmany referrals as the original audit would have indica-ted. Introducing a new service sometimes requires acultural change especially where there has been a heavyreliance on enlarged materials and other classroomsupport. It has been important to improve awareness ofthe benefits of LVA usage within the education service.

Discussion

There are arguments to suggest that children who firstreceive low vision support at school age may actually bereceiving services too late (Leat, 2002). Many cases ofvisual impairment are congenital and can affect otherareas of general development. Ritchie et al. (1989)reported that children of cognitive age 3 or older maybenefit from a simple magnifier and it is proposed thatthe service should expand into pre-school. It is alsoimportant that all children with a visual impairment areincluded, not just those educated in a mainstreamsetting, and the service will be further developed toinclude children with multiple disabilities.

Developing a multi-disciplinary service helps toaddress some of the issues presented in the report�Fragmented Vision� (Ryan and Culham, 1999). TheDepartment of Education and Skills have recentlypublished quality standards in education (Departmentfor Education and Skills, 2002) to provide markers forlocal education authorities when reviewing services andthese support the general principle of collaborativeworking with other agencies. This kind of servicedevelopment shows benefits for all concerned but mostof all for the patient or service user. All professionalsworking within the service gain from the informationand expertise of their collaborators. The success of theservice can be measured by the increase in usage ofLVAs in the subject group.

References

Department for Education and Skills (2002) Quality Standards

in Education Support Services for Children and Young Peoplewith Visual Impairment. DFeS Publications, London (CrownCopyright).

Leat, S. J. (2002) Paediatric low vision management.CE Optom. 5, 22–25.

Mason, H. L. and Mason, B. F. (1998) The use of low visionaids in mainstream schools by pupils with a visual impairment.

Report to Viscount Nuffield Auxiliary fund, University ofBirmingham.

Ritchie, J. P., Sonksen, P. M. and Gould, E. (1989) Low vision

aids for preschool children. Dev. Med. Child Neurol. 31,

509–519.Ryan, B. and Culham, L. (1999) Fragmented Vision: Survey of

Low Vision Services in the UK. Royal National Institute forthe Blind, Peterborough.

326 Ophthal. Physiol. Opt. 2004 24: No. 4

ª 2004 The College of Optometrists