Vision Screening of Ophthalmic Nursing Staff in a Tertiary Eye Care Hospital Outcomes and ocular healthcare-seeking behaviours

OBJECTIVES
This study aimed to evaluate ocular healthcare-seeking behaviours and vision screening outcomes of nursing staff at a tertiary eye care hospital.


METHODS
This study was conducted between April and September 2016 among all 500 nurses employed at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Data were collected on age, gender, use of visual aids, the presence of diabetes, a history of refractive surgery and date of last ocular health check-up. Participants were tested using a handheld Spot™ Vision Screener (Welch Allyn Inc., Skaneateles Falls, New York, USA).


RESULTS
A total of 150 nurses participated in the study (response rate: 30.0%). The mean age was 41.2 ± 8.9 years old. Distance spectacles, reading spectacles and both types of spectacles were used by 37 (24.7%), 32 (21.3%) and 10 (6.7%) nurses, respectively. A total of 58 nurses (38.7%) failed the vision screening test. Visual defects were detected for the first time in 13 nurses (8.7%). With regards to regular eye checkups, 77 participants (51.3%) reported acceptable ocular healthcare-seeking behaviours; this factor was significantly associated with age and the use of visual aids (P <0.01 each).


CONCLUSION
A high proportion of participants failed the vision screening tests and only half displayed good ocular healthcare-seeking behaviours. This is concerning as ophthalmic nurses are likely to face fewer barriers to eye care services than the general population.

2][3] In many countries, vision screening is a component of comprehensive physical assessments which prospective employees undergo during job recruitment. 4In addition, the increasing number of senior citizens who continue to drive past 65 years of age has compelled many licensing agencies to incorporate vision screening into their relicensing requirements. 5Some professions also have specialised visual needs with regards to their employees; the role of eye testing in relation to altered refractive status has been highlighted previously in a cohort of pilots. 6 However, healthy asymptomatic individuals rarely present for regular vision tests.
For young adults, the visual demands of precise near work has increased significantly due to the extensive use of smartphones and computers for communication, entertainment and work-related tasks. 7This constant strain on the visual system can cause symptoms of asthenopia and changes in the refractive status of the eyes. 8For healthcare staff, untreated or undiagnosed defective vision could compromise the quality of patient care and potentially result in early retirement. 9Hence, even asymptomatic healthcare workers should ensure any visual issues are appropriately addressed in order to function effectively within the patient care environment and in daily life activities.
In 2016, the World Health Organization initiated a worldwide campaign to increase public awareness of important health issues for healthcare workers, as well as the general population. 10This study consequently aimed to determine the refractive status and ocular healthcare-seeking behaviours of ophthalmic nurses at a tertiary eye care hospital in central Saudi Arabia.

Methods
This study was conducted between April and September 2016 at the King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.Using a convenience sampling method, all 500 ophthalmic nurses working in different departments of the hospital were invited to participate in a three-day refractive error screening campaign via a personalised email sent by the head of the Nursing Department.The demographic data of the participants was collected, including age, gender, use of visual aids such as spectacles or contact lenses, a previous history of refractive surgery and the presence/absence of diabetes.Participants were considered diabetic based on their fasting blood sugar and glycated haemoglobin levels over the previous year and a confirmed diagnosis by a physician.Nurses following medical advice to use distance or reading spectacles or both were considered to be regular users of visual aids.If they used visual aids sparingly or not at all, they were considered to be irregular users.
For each participant, the Spot ™ Vision Screener (Welch Allyn Inc., Skaneateles Falls, New York, USA) was used to determine the refractive status of each eye without visual aids.The instrument was held 1 m from the eyes during measurement; if a message was displayed stating that the eyes were too far or too close, the distance was adjusted accordingly until a successful measurement was acquired.At the end of the measurement, the screening instrument displayed a message within 10 seconds indicating if the subject had passed or failed the test.Failure indicated the presence of a substantial visual defect requiring assessment by an ophthalmologist or optometrist, either due to refractive error, corneal opacity, lenticular opacity, nystagmus or miotic pupils.A pass indicated that the participant was bilaterally emmetropic, either had no or marginal refractive errors and that their vision was probably >20/40.If the display indicated that the pupils were too miotic, the ambient room lighting was reduced and the test was repeated.The average time taken to perform the screening test was one minute.
Refractive errors were documented as spherical, cylindrical or axial.If the cylindrical error was <1 D, the spherical equivalent of the refractive error was calculated using the following equation: 11 where sph is the spherical value and cyl is the cylindrical value as determined by the screening instrument.The eye with the greatest refractive error was used to determine the refractive status of the participant.The nurses were diagnosed as anisometropic if there was a >1 D difference in the refractive error between each eye. 12Mild and moderate myopia was defined as -0.5 D to -3 D and -3 D to -6 D in the worse eye, respectively.Severe myopia was defined as >-6 D in the worse eye. 13ular healthcare-seeking behaviours were determined using a questionnaire and confirmed via ophthalmic or optometric health records.Healthcareseeking behaviour was deemed acceptable if the participants reported having undergone an eye/vision assessment in the preceding two years.Participants who had not undergone an ocular examination since being recruited or those who had undergone an examination more than two years prior to their sph + (cyl/2) participation in the study were considered to have poor ocular healthcare-seeking behaviour.
Data were collected using an Excel spreadsheet, Version 2003 (Microsoft Corp., Redmond, Washington, USA).The Statistical Package for the Social Sciences (SPSS), Version 22 (IBM Corp., Chicago, Illinois, USA), was used to analyse the data.For qualitative data, frequencies and percentages were calculated.If quantitative data were normally distributed, means and standard deviation were calculated for each variable.Associations between the outcome variables and determinants were assessed using odds ratios, 95% confidence intervals and two-sided P values.A P value of <0.05 was considered statistically significant.
This study was approved by the Institutional Research & Ethics Board of the King Khaled Eye Specialist Hospital (local project #1641-R).Verbal informed consent to use their data for research purposes was obtained from all participating nurses.Participants who failed the screening test were advised to consult an optometrist and/or ophthalmologist for further management.

Results
A total of 150 nurses participated in the study (response rate: 30.0%).Most participants were over 40 years old (n = 78; 52.0%) and just over half were using visual aids on the day of the screening (n = 81; 54.0%).In addition, 36 nurses (24.0%) had never undergone vision testing after being recruited to their current place of employment.None of the participants had previously undergone refractive surgery and two were irregular users of contact lenses for optical and cosmetic purposes [  participants under 30 years old failed the test (n = 5; 22.7%).While more than half of the participants had refractive errors, no participants were found to have severe myopia or anisometropia [Figure 1].The ocular healthcare-seeking behaviour of the nurses and associations with different variables is presented in Table 3.An acceptable level of healthcare-seeking behaviour was noted in 77 participants (51.3%).Age and the use of visual aids were significantly associated with a higher rate of acceptable healthcareseeking behaviour in terms of more frequent vision check-ups (P <0.01 each).

Discussion
Due to the increased visual demands of the modern digital era, universal vision and refractive error screening is not recommended as individuals are more motivated to actively seek out an eye care professional to maintain optimal vision.Hence, recommendations for vision screening in adults remain debatable. 145][16] Kumah et al. reported that 68.1% of Ghanaian teachers who underwent vision screening were presbyopic; 29.6% of these individuals did not wear corrective aids. 15tudies from Zanzibar and Kenya also indicated that while 89.2% and 85.4% of adults were presbyopic, only 17.6% and 5.4% of these individuals wore spectacles, respectively. 16,17though the current study was performed in a country with a rapidly evolving economy, the vision screening of nurses working at a tertiary eye care hospital indicated that several participants were unaware that they had a refractive error requiring an optical aid for optimal vision.Moreover, just under half of the ophthalmic nursing staff demonstrated poor healthcare-seeking behaviours in that they had not undergone an ocular assessment in the previous two years.These results indicate that proactive vision and refractive error screening is needed even for individuals with fewer barriers to adequate eye care, such as cost, distance and lack of access.Public health and education initiatives are therefore necessary to ensure the provision of rapid vision screening services to healthcare professionals in Saudi Arabia.
In the present study, none of the participants had previously undergone refractive surgery and just over half regularly wore distance or reading spectacles at the time of screening.This may be due to the fact that just over half of the participants were over 40 years old; at this age, hyperopia can manifest due to a loss of ciliary muscle tone. 18Initially, hyperopic individuals may compensate for the refractive error by decreasing the distance of far objects to view them more clearly or simply ignoring the effect of the error.For near-sighted  individuals, a reading distance of >25 cm should be ensured.However, female nurses may avoid or delay wearing spectacles for aesthetic reasons. 19ontact lens use was also found to be very low among participants of the current study; this is surprising as the prevalence of contact lens use has been noted to be as high as 70.2% in Saudi Arabia. 20his low rate of use might be due to the hot, dry and dusty climate and the widespread use of air conditioners in Saudi Arabia, which can cause tears or film abnormalities in contact lenses. 21In the current study, the prevalence of diabetes was appreciably higher than that reported among Danish nurses (7.3% versus 4.4%). 22A high prevalence of diabetes has been previously reported among Saudi Arabian adults (12.1%). 23A high prevalence of risk factors for diabetes-such as obesity, poor diet and a sedentary lifestyle-could be the underlying cause of the high prevalence of diabetes in Riyadh. 24apid vision screening methods have previously been proposed for adults. 25However, such methods often involve computer-assisted tools and are not portable.In contrast, the Spot ™ Vision Screener (Welch Allyn Inc.) is a handheld unit that provides rapid measurements and has been validated in the detection of risk factors for amblyopia and uncorrected refractive errors in children. 26,27In the clinical experience of the authors, significant uncorrected refractive errors are regularly identified in adults using the Spot ™ Vision Screener (Welch Allyn Inc.); moreover, individuals with distance spectacles often fail the screening test and their prescriptions are outdated.However, in the majority of patients, the outcomes of the screening test using the Spot ™ Vision Screener (Welch Allyn Inc.) are similar to that of their current prescriptions.
The current study is subject to some limitations.Vision screening was performed on a voluntary basis; as such, the findings of the current sample may differ from those who opted not to undergo screening and cannot be extrapolated for all nurses working at this tertiary eye care hospital.Moreover, to the best of the authors' knowledge, the Spot ™ Vision Screener (Welch Allyn Inc.) has not been validated for use in adults.Further studies are recommended to validate this instrument for adult vision screening in comparison with other conventional tests or instruments.Lastly, the grading of refractive errors was not confirmed by other methods.

Conclusion
A high proportion of ophthalmic nurses failed the vision screening tests; furthermore, only half reported adequate ocular healthcare-seeking behaviours.As nurses working at a tertiary eye care hospital are less likely to face barriers to eye care, the detection of uncorrected refractive errors among these individuals is concerning.These findings indicate the need for enhanced public health and education initiatives in Saudi Arabia to ensure the provision of rapid vision screening services to healthcare professionals.

Figure 1 :
Figure 1: Distribution of refractive status* among ophthalmic nurses at a tertiary eye care hospital in Saudi Arabia (N = 150).*Usingdata from the worst eye.
Vision Screening of Ophthalmic Nursing Staff in a Tertiary Eye Care Hospital Outcomes and ocular healthcare-seeking behaviours e76 | SQU Medical Journal, February 2017, Volume 17, Issue 1

Table 1 ]
.The outcomes of the vision screening tests are shown in Table2.A total of 58 nurses (38.7%) failed the test; of these, 13 (8.7%) with distance vision defects were unaware that they required visual aids.Very few

Table 1 :
Demographic characteristics and ocular healthcare-seeking behaviours among ophthalmic nurses at a tertiary eye care hospital in Saudi Arabia (N = 150) *After being recruited to their current place of employment.

Table 2 :
Vision screening outcomes and ocular healthcareseeking behaviours among ophthalmic nurses at a tertiary eye care hospital in Saudi Arabia (N = 150) *After being recruited to their current place of employment.

Table 3 :
Determinants of acceptable ocular healthcareseeking behaviours* among ophthalmic nurses at a tertiary eye care hospital in Saudi Arabia (N = 150)