Critical appraisal of Australian and New Zealand paediatric vision screening clinical practice guidelines using the AGREE II tool

Figures & data

Table 1. Criteria used for systematic search and selection of the clinical practice guidelines (CPGs) and exclusion criteria.

Inclusion criteria
Clinical Practice Guideline (CPG)	Clinical practice guidelines (‘guidelines’) are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances
Type of participants	Children from 0–18 years of age, or guidelines that included vision screening for both adults and children (but only the paediatric section was addressed)
Type of intervention	Only vision screening guidelines with a screening or testing protocol and referral criteria were included. Guidelines that were designed to provide guidance on comprehensive eye and vision examinations in children were excluded.
Date of Publication	From January 2008 – January 2023
Exclusion criteria
Title and Abstract Screening	Identified literature did not include the words ‘guideline’ or ‘protocol’ The guideline was not published in the last 15 years The guideline was not in English
Full Text Retrieved	The guideline was not developed for vision screening The target population did not include patients between the ages of 0–18 years The CPGs were not developed for use in Australia or New Zealand
Full Text Screening	The guideline described comprehensive vision examinations and not a vision screening protocol Did not specifically screen for refractive error, strabismus, amblyopia risk factors or reduced visual acuity in the specified age group Guidelines that screened for other visual conditions such as retinopathy of prematurity (ROP), retinoblastoma, diabetes, juvenile arthritis etc.

Figure 1. Preferred reporting items for systematic literature search, search through guideline databases and professional association websites, and Google search.

Table 2. Characteristics of the seven clinical practice guidelines (CPGs) selected for quality appraisal using the AGREE II tool.

Guideline Name	CPG Name	Institution/Guideline Development Group	Year	Country	Screeners
WA Clinical Nursing Manual, Vision and Eye Health^Citation16	WA Clinical Nursing Manual	Government of Western Australia, Child and Adolescent Health Service^Citation16	2021	Australia	Nurse Practitioners
Victorian Maternal and Child Health Service, Practical Guidelines Supplementary material: Melbourne Initial Screening test (MIST) booklet^Citation17,Citation18	Melbourne Initial Screening Test	Victorian Maternal and Child Health Service^Citation17,Citation18	2009	Australia	Nurse Practitioners and screeners
Vision 2020 National Framework for Vision Screening^Citation24	Vision 2020	Vision 2020^Citation24	2020	Australia	Anyone conducting vision screening
Lions Eye Health Program, Children’s Vision Screening Screener Manual^Citation19	Lions Eye Health	Lions Club^Citation19	2022	Australia	Trained Layperson
New Zealand Well Child Tamariki Ora Programme Supplementary material: Brief Evidence Reviews for the Well Child Tamariki Ora Programme^Citation20,Citation21	New Zealand Well Child	Ministry of Health, Manatu Hauora^Citation20,Citation21	2014/2019	New Zealand	Nurse Practitioners and Trained Layperson Vision Hearing Technician
The B4 School Check^Citation22	B4 School Check	Ministry of Health, Manatu Hauora^Citation22	2008	New Zealand	Registered nurses, vision technicians
National Vision and Hearing Screening Protocols^Citation23	New Zealand National Protocols	Ministry of Health, Manatu Hauora^Citation23	2021	New Zealand	Vision Hearing Technicians

Figure 2. Radar Chart showing individual AGREE II domain scores (%) for the seven selected clinical practice guidelines (CPGs).

Table 3. Individual AGREE II domain scores (%) for the seven selected clinical practice guidelines (CPGs). Percentage scores for each domain were calculated by summing individual item scores and by reporting the total as a percentage of the maximum possible score for that domain.

Guideline name	Scope and Purpose Domain (%)	Stakeholder Involvement Domain (%)	Rigour of Development Domain (%)	Clarity of Presentation Domain (%)	Applicability Domain (%)	Editorial Independence Domain (%)	Overall Score (%)
WA Clinical Nursing Manual, Vision and Eye Health^Citation16	86.1	33.3	19.1	64.8	22.9	0.0	69.4
Victorian Maternal and Child Health Service, Practical Guidelines Supplementary material: Melbourne Initial Screening test (MIST) booklet^Citation17,Citation18	93.3	50.0	20.0	65.6	32.5	3.3	66.7
Vision 2020 National Framework for Vision Screening^Citation24	91.1	60.0	21.7	83.3	72.5	18.3	66.3
Lions Eye Health Program, Children’s Vision Screening Screener Manual^Citation19	68.9	25.6	2.9	42.2	22.5	0.0	43.3
New Zealand Well Child, Tamariki Ora Programme Supplementary material: Brief Evidence Reviews for the Well Child Tamariki Ora Programme^Citation20,Citation21	95.8	63.9	83.3	87.5	47.9	60.4	95.8
The B4 School Check^Citation22	97.2	44.4	22.4	84.7	63.5	0.0	70.8
National Vision and Hearing Screening Protocols^Citation23	95.8	33.3	8.9	86.1	29.2	0.0	70.8
Average	89.8	44.4	25.5	73.5	41.6	11.7	69.0
Standard deviation	9.9	14.5	26.5	16.8	20.1	22.5	15.3

Table 4. Clinical recommendations from the selected clinical practice guidelines (CPGs).

Clinical Guideline	Age of Screening	Recommended VA test	VA Referral Criteria (for one or both eyes)	Who performed screening	Supplementary tests	Referral Pathway
WA Clinical Nursing Manual, Vision and Eye Health^Citation16	4 years	Lea Symbols Chart 3 m^39	6/12 refer 6/19 Urgent refer	Nurses	Red reflex, cover test, corneal light reflex	Non-urgent referrals are re-checked within 3 months. Urgent referrals to ‘medical practitioner’
Victorian Maternal and Child Health Service, Practical Guidelines/Melbourne Initial Screening test (MIST) booklet^Citation17,Citation18	3–5 years	MIST Letter matching chart 3 m^Citation17,Citation18	3/5 (Snellen equivalent approx. 6/9.5)	Nurses	n/a	Ophthalmologist, eye clinic at a public hospital, optometrist, orthoptist
Vision 2020 National Framework for Vision Screening^Citation24	3.5–5 years	Crowded or linear optotypes e.g., HOTV, Lea^Citation26	6/15 refer 6/18 urgent refer	Lay screeners, nurses and teachers	n/a	Ophthalmologists, optometrists, orthoptists
Lions Eye Health Program, Children’s Vision Screening Screener Manual^Citation19	Pre-school and school-aged children	Lea symptoms chart 3 m^39	6/12 refer	Lay-person who has completed a screening course	‘Quick 6’- Basic colour vision screening, Stereo Fly, Spot Vision Screener	Optometrist or Ophthalmologist
New Zealand Well Child Tamariki Ora Programme/Brief Evidence Reviews for the Well Child Tamariki Ora Programme^Citation20,Citation21	4–5 year-old 11–12 year-old	Parr 4 m letter-matching with confusion bars (or equivalent Sheridan Gardner)^Citation27	6/9 + 6/6 Re-screen 6/12 Refer	Vision and Hearing Technicians, or other competent health practitioner	None	Ophthalmologist or Optometrist
The B4 School Check^Citation22	4 year-old	Snellen chart, or single-letter charts with crowding bars at 4 m^39	6/9 + 6/6 re-screen 6/12 refer	Registered nurses, vision and hearing technicians	None	Orthoptist
National Vision and Hearing Screening Protocols^Citation23	4 year-old	Parr 4 m letter matching, Snellen chart^Citation27	6/9 + 6/6 rescreen 6/12 refer	Vision and Hearing Technician	Ishihara	Optometrist

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