Comparing paediatric optometric vision care in Canada over a 14-year period

Abstract

Purpose

In Canada, teaching in paediatric eye care has increased in the past decade both within the optometry curriculum and as continuing education to optometrists. Paediatric vision care guidelines have also been established by North American optometric associations. This study examined whether this exposure was associated with changes in paediatric eye care in Canada over a 14-year period.

Methods

Canadian optometrists were invited to participate in an anonymous 35-item survey in 2007 and 2021. The surveys sought to investigate optometrist's recommendations for first eye examinations, the number of paediatric patients seen in a typical week and preparedness to provide eye examinations to children. Response frequencies were determined for each survey item.

Results

Across Canada, 133/1000 (13.3%) and 261/~6419 (~4.1%) optometrists responded to the survey in 2007 and 2021, respectively. No significant difference was found in the number of years practicing, days per week in practice and total number of patients seen per week. The modal age optometrists recommended children be seen for their first eye examination changed from 3–4 years in 2007 (53%) to 6–12 months in 2021 (61%). In 2007, 87% of respondents provided eye examinations to children <2 years, increasing to 94% in 2021 (p = 0.02). Despite a reduction in the recommended age between the two survey years, the most frequent age children were seen for their first eye examination was 3-4 years (30% in both surveys) and the most common age seen in a typical week remained unchanged (4–6 years—56% 2007; 66% 2021).

Conclusion

Although optometrists' willingness to provide paediatric eye care increased over the past 14 years, the number of children seen in a typical week did not change. Barriers to determine why more children are not being seen at an earlier age need to be investigated.

Supplementary Information

The online version of this article (doi:10.1111/opo.13281) contains supplementary material, which is available to authorized users.

Key points

• Canadian optometrists are more comfortable and better prepared to recommend and provide eye examinations to younger children in 2021 compared to 2014.

• The number of children receiving their first eye examination at age 6–12 months has not changed over 14 years, despite noted improvements in optometrist comfort and attitude towards paediatric eye care.

• Optometrists surveyed reported the same number of children receiving an eye examination each week in 2021 compared to 2007.

INTRODUCTION

Childhood vision disorders, such as amblyopia and congenital cataracts, may arrest visual development if not detected and treated at an early age,^1–3 and a delay in diagnosis and treatment may result in poor prognosis for these conditions.^4,5 Vision also plays a vital role in a child's development from gross to fine motor skills, visual perceptual development and academic success.^6,7 Conditions, such as uncorrected refractive error, strabismus, amblyopia and binocular vision anomalies, can be a barrier to maximising a child's potential in school. Timely intervention is important since moderate uncorrected hyperopia and reduced near visual acuity (VA) are associated with delayed literacy, while reduced distance VA is associated with poorer reading performance and academic achievement.^8–10 In addition, slower reading speed has been linked with amblyopia¹¹; challenges with learning to read are associated with uncorrected clinically significant refractive errors^12–14 and learning difficulties are more common among children with refractive and binocular vision disorders.¹⁵ Studies by Nishimura et al.¹⁶ and Drover et al.¹⁷ reported approximately one in five children aged 3–6 years have visual problems such as amblyopia or clinically significant refractive errors in Canada. In addition to the negative consequences on education, if left untreated, correctable childhood vision problems may also have lifelong impacts on employability and overall quality of life.^18–20 To identify and provide appropriate treatment for vision disorders that can impact general, visual or educational development, it is important that vision screenings or eye examinations are part of a child's health care routine.

VA, oculomotor skills, binocularity and accuracy of accommodation all develop rapidly from birth.²¹ Developmentally, by 6 months of age, a typically developing child has reached several critical visual milestones,^7,22 making 6–9 months an appropriate age for their first eye and vision examination⁸ as supported by the Canadian Association of Optometrists (CAO) and the American Optometric Association (AOA).^23–26 Although much evidence has been documented over the past decade regarding the prevalence of eye and vision disorders in children^2,27–29 and the effect of uncorrected hyperopia on early literacy,⁹ the number of children examined before the age of 6 years appears to have remained unchanged.^30,31 More specifically, despite examinations being paid for by the provincial government, in 2007 the National Coalition for Visual Health reported that only 14% of Canadian children received a comprehensive vision examination before the age of 6 years³⁰ and similar statistics were reported for the province of Ontario in 2015.³¹ The reasons why few children receive professional eye care is unclear. Possible explanations include reliance on optometrists or primary care physicians to inform parents of the appropriate age to bring their child for an eye examination, parents' lack of knowledge regarding the need for routine eye care in children, parents' reliance on paediatric vision screenings to detect eye and vision problems³² and/or optometrists' lack of willingness or readiness to undertake paediatric eye examinations.

The scope of practice of optometrists in Canada covers children of any age and includes the ability to diagnose and manage paediatric eye conditions such as amblyopia and refractive error. Optometric education is based on this scope of practice with professional students being taught that the recommended age for children to receive their first eye examination is 6–9 months. Over the past decade, paediatric eye health has been promoted by optometric associations throughout Canada. Programmes such as the Eye See…Eye Learn® programme (Alberta, Saskatchewan and Ontario) encourage optometrists to raise public awareness about the importance of eye examinations at an early age.³³ Optometric associations also provide continuing education in the areas of paediatrics and binocular vision. There has been an increase in the learner's exposure to Paediatric optometry in the University of Waterloo Optometry clinic, and paediatric and binocular vision residencies (three per year) have been created during this time period. With increased education on and awareness of eye conditions in children, the purpose of this study was to investigate Canadian optometrists' attitudes and practice of paediatric eye care. More specifically, this study compared whether changes in paediatric optometric vision care were evident in Canada between 2007 and 2021, and whether there were changes in adherence to paediatric vision assessment guidelines.

METHODS

The study adhered to the Declaration of Helsinki and was reviewed and received ethics clearance from University of Waterloo Research Ethics Board. A survey was developed to explore the paediatric treatment and management preferences and practices of Canadian optometrists (Appendix S1). In 2007, 1000 members of the CAO received a printed copy of the survey by mail and were invited to participate. In 2021, 5456 registered optometrists in Canada who were CAO members were sent an electronic survey created in REDCap® (projectredcap.org) and invited to participate through the CAO monthly newsletter (CAO membership encompasses ~85% of optometrists in Canada which indicates approximately 6419 total optometrists in Canada in 2021). The invitation was also sent through the Canadian Optometry Group Forum (email group) and the University of Waterloo, School of Optometry and Vision Science (UWOVS) webpage and social media pages (Twitter, Facebook) to capture optometrists who were not CAO members. While all CAO members were sent an invitation to participate, it was difficult to know how many non-CAO members (remaining 15% of optometrists in Canada) received the invitation through these sources.

The 2021 survey included similar questions to the 2007 survey with a few edits to the original version for clarity and to reflect a change in the available equipment (Appendix S1). The cover letter was similar for both surveys and no incentives were offered for participants to respond. The 2007 survey was sent only once, while survey reminders were sent via the CAO and UWOV Twitter and Facebook page for the 2021 survey with a closing date. The 2007 survey was offered in English only, while the 2021 survey was offered in both English and French. Surveys for both years were sent to all provinces across Canada.

Analysis

Descriptive statistics were used to describe the populations and the optometrists' responses, and the chisquare test of independence was used to compare the two surveys. A p-value < 0.05 was considered significant.

RESULTS

A total of 394 optometrists (133 in 2007 and 261 in 2021) responded to the survey, which gave a response rate of 13.3% to the postal survey in 2007 and a response rate of between 4.8% (based on CAO membership) and 4.1% (based on total number of optometrists in Canada) to the electronic invitations in 2021.

Practice demographics

The practice demographics of the 2007 and 2021 surveys were very similar with no significant differences (p > 0.05) found in the following areas: number of years respondents had practiced optometry (mode = 23.9% for 2007; 30.2% for 2021), the number of days per week they practiced at their primary practice location (mode = 4), the total number of patients seen per week in the practice (mode ≥ 60) and the age distribution of the patients seen in the practice.

However, significant differences were found between the two surveys in the population size of practice location (p ≤ 0.0001), group versus solo practice (p < 0.0001) and scheduling of patient appointments (p = 0.0003). Specifically, in 2021, there was an increase in the proportion of optometrists who worked in large towns or cities, worked in a group practice and saw patients by appointment, rather than a mixture of drop-in and appointments.

In both survey years, most respondents (49.1% in 2007 and 44.0% in 2021) reported that in a typical week, 60%–79% of the patients in their primary office location were seen for a primary care examination. This can be compared with all other optometric services for which most optometrists reported 0%–19% of patients for these services: contact lenses, low vision, ocular disease and vision therapy. However, there was a significant increase in the 2021 survey for the proportion of patients presenting for ocular disease (p = 0.02) and vision therapy services (p = 0.02) and a decrease in patients for contact lenses (p = 0.02).

Finally, the majority of patients seen in a typical week in their office were 41 years of age and over (84.8% in 2007 and 93.6% in 2021) with a significant shift towards a greater percentage of patients in the >60-year-old age group in the 2021 survey (p = 0.0003). Interestingly, there was no significant change in the total percentage of paediatric patients (age 0–10 years) seen in 2007 compared to 2021 each week (p = 0.32), with most practices reporting 0%–19% of their total patient population in this age group. Similarly, no change was seen in the total percentage (0%–19%) of older children (age 11–20 years) seen between the two survey years.

Paediatric eye examination

Survey respondents' recommendations for paediatric eye examinations

In 2021, there was a shift towards a lower age when optometrists recommended a child receive their first routine eye examination. Specifically, in 2007, most optometrists (53.4%) recommended the first eye examination at 3 years of age, while age 6 months was recommended by the majority (61.3%) of the respondents in 2021 (p = 0.0001, Figure 1). For those optometrists in group practices in both surveys, the respondent's recommendation corresponded to the practice recommendation for a child's first eye examination—86.4% in 2007 and 78.8% in 2021 (p = 0.19). Some respondents (9.9% in 2007; 15.1% in 2021) reported their practice did not have any age recommendations for paediatric eye examinations.

FIGURE 1.

Age optometrists recommended children receive their first eye examination.

Primary reason for eye examination

Table 1 highlights that the main reason a parent brought a child for their first eye examination differed between the 2007 and 2021 surveys (p = 0.0002). In both surveys, the most frequent reason was ‘the parent did not notice a vision or eye problem but felt the child should get his or her eyes examined’. The next two most frequent reasons were the school made a recommendation (higher in 2007 at 23.9%; 11.1% in 2021) and parents had noticed an eye or vision problem (lower in 2007 at 17.1%; 26.2% in 2021). The survey also showed more children were seen for their first eye examination on recommendation of their family doctor in 2021 (10.7%) compared to 2007 (2.2%).

TABLE 1.

Chief complaint for child's first eye examination.

Chief complaint	% Respondents		p Value
	2007 (n = 134)	2021 (n = 244)
Noticed an eye problem	17.1	26.2	0.02
Felt child should have eyes examined	33.6	38.1	0.19
Recommended by an optometrist	14.9	20.5	0.08
Recommended by a family doctor	2.2	10.7	0.0002
Recommended by school	23.9	11.1	0.001
Family history of an eye or vision problem	3.0	6.1	n/a
Child complained of an eye or vision problem	0.7	2.9	n/a
Other reason	0.7	2.5	n/a
No reason	3.7	0.8	n/a

Note: Bold text shows those which were significantly different. n/a = not applicable; those with insufficient power due to small percentages.

Preparedness (to see paediatric patients)

Corresponding to the age at which optometrists recommended children be seen for their first eye examination, the age that optometrists stated that they saw paediatric patients for their first eye examination also decreased significantly between 2007 and 2021 (p < 0.0001). The modal age in 2007 was 4–5 years (30.8%), followed by 3–4 years (30.1%). In 2021, there was a change in the distribution towards seeing children at a younger age; 3–4 years (30.4%), followed by 6 months to 1 year (21.5%; Figure 2).

FIGURE 2.

Typical age optometrists state that they see children for their first eye examination.

When asked whether they (the optometrist) felt comfortable seeing children below the age of 2 years, a significant difference (p = 0.02) was noted between the two surveys, with more respondents in 2021 prepared to see children below the age of 2 years (94.2%) compared to 2007 (87.1%). Considering the respondents who reported they do not see children below the age of 2 years, the most common reasons for not doing so were similar in 2007 and 2021. This included lack of equipment and lack of experience in providing paediatric eye care (Figure 3). Other reasons were infrequently mentioned, but included lack of knowledge, paediatric eye care being perceived as time consuming, medico-legal reasons in paediatric care and difficulty in handling paediatric patients due to lack of co-operation.

FIGURE 3.

Reasons why optometrists do not feel comfortable providing eye examinations to children less than 2 years (*no equipment = optometrist felt they do not have adequate equipment to perform a reliable paediatric examination).

Paediatric patient profile

No difference was found between the two surveys regarding the age profile of paediatric patients. In a typical week, most respondents examined two or fewer children between 0 and 6 months (99.2% in 2007 and 96.7% in 2021; p = 0.76), 6 months–1 year (95.5% and 93.8% respectively; p = 0.94), 1–2 years (93.2% and 89.5%, p = 0.74) and 2–3 years (74.2% and 73.1%, p = 0.97). At the ages of 4–6 years, most optometrists saw three to five patients per week (56.1% and 66.4%; p = 0.24).

Regarding diagnosis, more than 50% of optometrists diagnosed anisometropic amblyopia (for the first time) in patients aged 0–6 years at least once per month (61.6% in 2007 and 51.5% in 2021). These rates were similar for strabismus (61.2% and 49.1%) and have not changed significantly between the two surveys. Questions regarding congenital cataracts and the diagnosis of congenital glaucoma were included in the 2007 survey, with 0% of respondents diagnosing patients aged 0–6 years with either condition in a typical month. Due to the low percentage of diagnoses, this question was not asked in 2021 and was replaced with how many children between the ages of 0 and 6 years were diagnosed with a refractive error that would benefit from correction for the first time, see Table 2.

TABLE 2.

Number of children aged 0–6 years diagnosed with specific disorders for the first time in a typical month (2021 data).

Number of children aged 0–6 years diagnosed in a typical month	Refractive error that would benefit from correction (%)	Strabismus (%)	Anisometropic amblyopia (%)
0	28.8	47.5	45.6
1	22.2	37.7	36.7
2	15.7	5.9	7.2
3	8.5	3.4	5.9
4	9.3	0.4	0.8
≥5	12.7	1.7	0.8
No response	3.0	3.4	3.0

Equipment

When asked about paediatric testing equipment in the practice, there was a significant difference in the availability of distance VA tests in practices between 2007 and 2021 (p < 0.00001; Figure 4a; note: Patti Pics matching tests, Patti Pics/LEA paddles and HOTV were listed in the 2021 survey but not in the 2007 survey). In both surveys, most respondents had the Allen test which included those in a projector or digital VA charts (84.2% in 2007 and 68.2% in 2021). In 2007, this was followed by Optokinetic Nystagmus (OKN) drum (16.5%) and the Kay Picture test (13.5%). However, in the 2021 survey, the second most common VA test was HOTV (46.2%) followed by the Lea-Uncrowded test (37.7%).

FIGURE 4.

(a) Paediatric visual acuity tests available in respondents' offices. C, crowded; UC, uncrowded (b) Tests for stereopsis available in respondents' offices. (c) Colour vision tests available in respondents' offices. CV, colour vision (d) Contrast sensitivity charts available in respondents' offices; CST, constrast senstivity test (e) Equipment available in respondents' offices to examine ocular health. bino, binocular; BIO, binocular indirect ophthalmoscope; DO, direct ophthalmoscope; HH, handheld; MIO, monocular indirect ophthalmoscope; mono, monocular; OKN, Optokinetic Nystagmus; WA, Welch Allyn.

There was no significant difference (p = 0.08) in the types of tests available to measure stereopsis. In both surveys, the Randot (stereooptical.com/products/stereotests-color-tests/randot/; 76.0% in 2007 and 85.6% in 2021) was the most common stereopsis test followed by the Titmus test (stereooptical.com/products/stereotests-color-tests/original-stereo-fly/) (45.1% in 2007 and 31.8% in 2021; Figure 4b).

Regarding the availability of colour vision tests, most practices had pseudo-isochromatic plate tests (95.4% in 2007 and 96.1 in 2021) followed by the D-15 colour test (color-blind-test.com/d15-color-blind-test-more) (72.9% and 75.4%; p = 0.15; Figure 4c).

Finally, a significant increase in the percentage of respondents who had a contrast sensitivity chart was seen in 2021 (5.3% in 2007 vs. 41.5% in 2021; p < 0.0001; Figure 4d) while no significant difference in the type of ocular health testing equipment (e.g., direct ophthalmoscope and binocular indirect ophthalmoscope) was found between the 2007 and 2021 surveys (p = 0.11; Figure 4e).

DISCUSSION

In this study, both the 2007 and 2021 surveys found the most common reason parents brought their child to see an optometrist was for a routine eye examination (no visual and/or ocular concerns) followed by recommended by school (2007) and an eye or vision problem noticed (2021). More specifically, when a child was suspected to have an eye problem, 17.1% of respondents reported parents brought their child to an optometrist in 2007, which increased to 26.2% in 2021. This finding demonstrates the public's awareness of optometrists as primary eye care providers increased over the 14-year study period.

The preparedness of optometrists to provide vision care for children at an earlier age also improved from 2007 to 2021. The modal age optometrists recommended children be seen for their first eye examination reduced from 4–5 years (2007) to 3–4 years (2021), with the largest difference seen in children aged 6–12 months (1.5%, 2007; 22%, 2021; p < 0.05). This change may be the result of the considerable amount of research in the last 15 years on the development, prevalence and risk factors for ocular disorders in children which should help clinicians in their understanding and management of paediatric eye care.^9,13,16,29 This knowledge has been included in the clinical education of optometrists and in continuing education lectures and workshops. There has been an increased emphasis on paediatric eye care within the optometry curriculum in Canada, and increased offerings of paediatric workshops and continuing education lectures to promote programmes such as Eye See…Eye Learn®.³³ Increased paediatric education and more knowledge may have influenced Canadian optometrists to be more prepared to provide eye care at a younger age. In addition, interprofessional collaborations with paediatric ophthalmologists co-managing conditions such as amblyopia and refractive error may have also increased preparedness and confidence in providing vision care to infants and young children. However, there are still barriers, with lack of equipment and lack of experience being the most common in both surveys. Continued promotion about the importance of routine eye examinations before 1 year of age, coupled with increased hands-on educational opportunities for optometrists, may help to improve knowledge and preparedness in delivering paediatric vision care.

However, despite the findings showing that optometrists recommended that children receive their first eye examination at a younger age and that parents recognise the role optometrists play when eye or vision problems arise, the number of paediatric patients examined each week remained the same in both survey years, with an average per respondent of only 0–2 children being seen per week before the age of 4. The under-utilisation of routine eye care in this age group has previously been reported by Ng et al.³⁴ and Poe.³⁵ In 2006, Ng et al.³⁴ explored the barriers and reasons why children were not receiving eye care. Parents with children between the ages of 4 and 6 years were surveyed regarding their children's current vision care and their opinions on the role vision plays in the learning process. Results of their study revealed that most parents (73%) took their children for an eye examination before 6 years of age, but few parents (5%) took their children by the CAO recommended age of 6 months. As noted by Ng et al.,³⁴ although parents appeared to have a good awareness of the need for their child to receive a vision assessment by the time they started school, they may have less awareness about the benefits of an eye examination at an earlier age. Wilson et al.³⁶ using focus groups found time and money, knowledge, skills and confidence, awareness and communication, range of attitudes and clinical setting to be the barriers to children receiving eye examinations by optometrists. The authors also reported that practice context and office policy affected optometric paediatric eye examination rates. Additional investigation regarding factors that influences optometrist's recommendations for first eye examinations in children is needed.

The barriers for the under-utilisation of eye care were not evaluated in this study, but one reason may be the lack of public understanding about eye conditions often seen in children. For example, Spafford et al.³⁷ reported that only 14% of respondents in their survey understood the key feature of amblyopia is blurred vision. Also, Wilson et al.³⁶ found lack of awareness to be a barrier and raising awareness to be an enabler to children receiving eye examinations. This demonstrates a stronger need for the profession to educate the public on the importance of paediatric vision care and to encourage parents to bring their child for their first eye examination within their first year of life.³⁸

Other survey findings

Respondent demographics and type of practice were also explored in this study. The results revealed no difference in respondent demographics between the two survey years, but a shift towards specialty eye care for ocular diseases and vision therapy was seen in 2021 compared to 2007. However, the majority of optometrists still see most patients for primary care (which includes paediatric optometry). Similar to the reasons noted above for the increases in optometrists' preparedness for paediatric vision care (increased awareness and education), this shift may also reflect the profession's preparedness and interest in providing care in specialist areas or a shift based on patient demographics. In this study, the only patient age group which changed between the two survey years was an increase in patients ≥60 years of age. While this finding is likely a reflection of an aging population,²⁴ it may also indicate more respondents practiced in areas with older populations versus young families. Another finding was a change in the location of practices, with more optometrists practicing in larger urban settings in 2021. Finally, there was a move towards group practices (two or more optometrists) in 2021, with more solo practices in 2007. The advantage of group practices would be the opportunity for an individual optometrist to concentrate on a specific area(s) of optometry.

Strengths/Limitations

A limitation of the survey was the low response rate in both survey years and the potential for bias in those who chose to participate (optometrists with more interest and involvement in paediatrics may be more likely to respond). If this is true, then the actual numbers of young children being seen for routine eye examinations may be lower than what this survey indicates. In addition, both surveys were based on self-reporting rather than objective data, possibly leading to either a higher or a lower reported number of paediatric patients being seen and the type of conditions diagnosed. The effect of self-reporting may be expected to be similar in both surveys. Despite the limited response rate, the findings remain important to understanding the changes in paediatric optometric vision care. It was not possible to compare if there was a change as to whether the respondents had additional training in paediatric vision care or had a practice that focused on paediatric vision care, since these questions were not included. Finally, how participants were recruited differed in the two survey years. In 2007, CAO member optometrists were invited by mail while the invitation was sent electronically in 2021 to most registered optometrists in Canada though CAO and UWOVS channels. This may have resulted in differences in those receiving and completing each survey.

CONCLUSION

This study shows that Canadian optometrists are recommending eye examinations at an earlier age in 2021 compared to 2007 and are also prepared to examine children at a younger age. However, this has not yet resulted in a higher proportion of younger children receiving an eye examination. A substantial change is needed to reach the CAO²² and AOA¹ Evidence-based Clinical Practice Guidelines on Paediatric Eye and Vision Examination. Further investigation is needed to determine why a change in optometrists' attitude and preparedness has not translated into children presenting for their first eye examination at an earlier age. Understanding and tackling these factors and encouraging parents to bring their child to an optometrist starting at the CAO and AOA recommended age of 6–9 months^1,23 would likely result in more children being diagnosed and treated.

AUTHOR CONTRIBUTIONS

Lisa W. Christian: Conceptualization (lead); data curation (equal); formal analysis (equal); funding acquisition (supporting); investigation (lead); methodology (lead); project administration (lead); visualization (equal); writing – original draft (lead); writing – review and editing (equal). Victor Opoku-Yamoah: Data curation (supporting); formal analysis (supporting); visualization (supporting); writing – original draft (supporting); writing – review and editing (supporting). Kalpana Rose: Investigation (supporting); methodology (equal); writing – review and editing (supporting). Deborah A. Jones: Conceptualization (supporting); formal analysis (supporting); funding acquisition (supporting); methodology (supporting); writing – review and editing (supporting). Daphne McCulloch: Formal analysis (supporting); funding acquisition (supporting); methodology (supporting); writing – review and editing (supporting). Elizabeth L. Irving: Formal analysis (equal); funding acquisition (equal); methodology (supporting); writing – review and editing (supporting). Susan J. Leat: Conceptualization (equal); data curation (equal); formal analysis (lead); funding acquisition (lead); investigation (equal); methodology (equal); project administration (supporting); supervision (lead); visualization (equal); writing – original draft (equal); writing – review and editing (supporting).

CONFLICT OF INTEREST STATEMENT

The authors report no conflicts of interest and have no proprietary interest in any of the materials mentioned in this article.