Quality of Rural Refractionists

We tested the quality and accuracy of eye exams performed by rural clinicians as part of our efforts to provide vision care to students throughout China.

Chinese children have one of the highest rates of myopia in the world. However, we knew little about the accuracy of the vision care services available to rural Chinese students.

Partnering with a team of doctors from the Zhongshan Ophthalmic Center (ZOC), we tested the quality of autorefraction performed by rural clinicians.

In September and October 2012, local teams of one nurse and one assistant conducted visual acuity screenings for students in the Shaanxi and Gansu provinces. In total, they screened 10,309 students (grades 4-6) in 253 primary schools. One week later, a refractionist from a local private optical shop, accompanied by the local nurse and assistant, returned to the schools and conducted autorefraction examinations to prescribe eyeglasses to the students.

After one month, a team of optometrists and ophthalmologists from the ZOC performed quality checks at 1/3 of the schools screened. At each school, the team performed visual acuity testing and automated refraction on five students with vision problems correctable by glasses and on all of the children with problems that the local clinicians could not treat.

We compared the treatment from the rural clinicians to the treatment from the ZOC doctors.


Overall, we found that local clinicians are undertrained in how to use autorefractors and how to treat children with severe vision problems.

Rural clinicians did not have much education: only 28.6% attended college. They lack adequate training in how to use the autorefraction machine. While the measurements for the majority of children were accurate, particularly for those with simple myopia, certain conditions were associated with relatively poor accuracy, including astigmatism, far-sightedness (hyperopia) and vision uncorrectable by glasses.

The rural clinicians lack the knowledge to treat severe vision problems. Rural clinicians were unable to correct over 1/5 of children with poor vision using glasses. Of the children that rural clinicians were unable to treat, ZOC doctors were able to improve the vision of 54.1%. Thus, 11% of all children with poor vision are missing out on the opportunity to improve their vision, and therefore losing the chance to improve their academic success and quality of life.


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