An ordinary day in the life of an Orthoptist…Preschool Vision Screening

Sophie Tsang, NHS Lothian

A day in the life of an Orthoptist is variable, challenging and yet, very rewarding. No two days are exactly the same. Even if you are working in the same environment and in the same clinic, you meet different people everyday and each case will not be the same as the previous.

Today my job was to complete Preschool Orthoptic Vision Screening at a local nursery. It can be very difficult for parents to tell if their child has a problem with their eyes so that is why the Scottish Government recommends that all children have their eyes checked before they begin school. The test involves checking their vision and if they have a squint or any eye muscle problems and generally takes around 5-10 minutes to complete. It is a non-invasive test and involves matching shapes and looking at fixation pictures and lights.

Today my job was to complete Preschool Orthoptic Vision Screening at a local nursery. It can be very difficult for parents to tell if their child has a problem with their eyes so that is why the Scottish Government recommends that all children have their eyes checked before they begin school. The test involves checking their vision and if they have a squint or any eye muscle problems and generally takes around 5-10 minutes to complete. It is a non-invasive test and involves matching shapes and looking at fixation pictures and lights.

I arrived at the nursery at around 8.45am, set up an area for testing, sorted out the paperwork and then began my day of testing. Today, three children required referring for further examination.

Child with a head posture

A cheerful, energetic boy happily entered the room and told me that his name was Sam and that he was 4 years old before sitting down on the testing chair, eager to find out what the ‘eye games’ would be.

His vision was good and equal in both eyes. However, he constantly tilted his head significantly to the right throughout the whole test. I was informed that he had been treated for torticollis (abnormal head or neck position, which can due to a range of different causes) since he was very young and after many sessions of physiotherapy there had been some improvement, but he still preferred tilting his head to the right. With this head posture he did not have a squint and was able to demonstrate signs of 3D vision. Yet, as soon as his head was straightened, his left eye would drift upwards and he would lose his ability to see in 3D. Upon testing his eye movements, the eye muscle that would move his left eye downwards was found to be weak which was resulting in his left eye drifting upwards. This eye muscle imbalance was compensated by him tilting his head.  ,

He was subsequently referred to the Eye Hospital for further examination by an Ophthalmologist and Orthoptist.

Child with an intermittent inward turning squint

Ellie was a shy, quiet child who, at first would not allow me to test her eyes as she was afraid that it might hurt or that it might involve needles. After much reassurance and persuasion, I was finally able to examine her eyes with the help of Ellie’s teacher who encouraged her throughout the process. She barely met the level of vision required and was very hesitant during the vision test, which I thought was maybe partly due to her timid nature. However, upon examining her eye movements, her eyes would intermittently drift inwards whenever she focussed on anything close to her.  

I therefore referred her for further examination at the Eye Hospital by an Orthoptist and Optometrist.

Child with ‘wobbly eyes’

Alice had been seen at the Eye Hospital when she was a baby, due to ‘wobbly eye movements’. She was found to have an inward turning squint and nystagmus, which is a condition that is defined by involuntary, repetitive eye movements. She was also found to be longsighted with astigmatism in both eyes and was given glasses to wear. Unfortunately due to various reasons and missed appointments she was lost to follow-up and had not attended the Eye Hospital for more than a year.

Upon meeting her today, I was told that she was struggling to wear her glasses and that her inward turning squint and nystagmus were becoming more noticeable. She was also beginning to turn her head to the right to see things and her teachers reported that Alice would bump into things and fall over quite easily. Her vision was very poor upon testing so I immediately referred her back into the Eye Hospital.

Follow-up after referral

Sam

After consultation with the Ophthalmologist and detailed measurements of his eye movements by an Orthoptist, Sam had two operations on his eye muscles and his head posture was greatly improved. His parents were very happy with the results and he was left with only a very minimal occasional head tilt. He was discharged from the Eye Hospital, two years after the initial referral with excellent vision and eye alignment.

Ellie

She was seen by the Hospital Optometrist for a glasses check and was found to be moderately longsighted in both eyes. She was issued with glasses to wear full time and was monitored in the Orthoptics Department. At her review appointment, her parents reported that she had been wearing her glasses well and that a positive change in her behaviour had been noticed by her nursery teacher. Upon examination her intermittent inward turning squint was controlled with her glasses and she managed to demonstrate a good level of vision with ease. She was discharged from the Eye Hospital after 2 years of follow-up and monitoring but was advised to attend her local opticians annually so that they could ensure that her glasses prescription was up-to-date.

Alice

Her glasses were updated and eventually her compliance with glasses wear improved vastly, but unfortunately her vision remained poor in both eyes. After discussion with her parents, the Ophthalmologist registered her as partially sighted on the VINCYP (Visual Impairment Network for Children and Young People) database. This meant that Alice and her parents would receive the support required for her education and needs in the future. She was also referred to the Functional Vision Clinic (which involves a consultation and assessment by a Community Paediatrician, Orthoptist and visiting teacher) and a multi-agency support plan was set up for her as well as arranging for a visiting teacher and vision support officer to support her at school. 

If you would like to find out more about the Preschool Orthoptic Vision screening programme ‘See4School’ please visit please visit: https://www.nhsinform.scot/campaigns/see4school

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