Vision Screening Procedures

For Infancy, Childhood and

School Age Children

Revised 2009

Minnesota Department of Health (MDH) Community and Family Health Division

Child and Adolescent Health Unit

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Work Group

This 2007 edition was developed with the advice of 14 vision screening experts and key stakeholders who were selected by their respective professional organizations or agencies because of their knowledge and interest in vision screening for children. Following a comprehensive Minnesota Department Health (MDH) literature review of vision screening research and practice, the work group addressed issues that were either unclear in the literature or were conflicting between professional organizations. The time and effort provided by the members is gratefully acknowledged by the Minnesota Department of Health (MDH).

Group Member

Organization

Erick Bothun MD Minnesota Academy of Ophthalmology

Linda Chous OD. Minnesota Optometric Association

Diane Madlon-Kay MD, MS. Minnesota Academy of Family Practice

Mike Severson MD American Academy of Pediatrics, Minnesota Chapter

Jane Shaw Minnesota Dept. of Human Services (DHS),

Child and Teen Check-ups (EPSDT)

DebbyKay Peterson Minnesota Department of Education (MDE), Early Childhood Education

Mary Vanderwert Minnesota Department of Education (MDE), Head Start

Karen Klevar Sight & Hearing Association

Dawn Willson RN, LSN Bloomington Schools

Cindy Hiltz RN, LSN, MS School Nurse Organization of Minnesota

Mary Retzlaff RN, PHN o Local Public Health Association, Dakota County Public Health Dept

Marcia Hesse Child and Teen Checkups (EPSDT),

Pope, Stevens, Traverse & Grant Public Health Agencies

Steve Robak, CPNP MDH, Child and Teen Checkups (EPSDT)

Karen Jorgensen-Royce RN, PHN, MSN

MDH, Minnesota Early Childhood Comprehensive Screening System

Cheryl Smoot RN, MPH MDH, Minnesota School Nurse Consultant

MDH Staff Supporting the Process

Rebecca Weber, RN, MS MDH Vision Screening Coordinator

Aaron Norman, BS University of Minnesota MPH Candidate, Epidemiology

Janice Stenger BA MDH Hearing and Vision Consultant

Cynthia Ahler PHN, MA, CPNP MDH Hearing and Vision Consultant

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For more information, contact:

Minnesota Department of Health Division of Community and Family Health

Child and Adolescent Health Unit 85 East Seventh Place, Suite 220

PO Box 64882 St. Paul, MN 55164-0882

Phone (651) 201-3760 Fax: (651) 201-3590

http://www.health.state.mn.us

Website: www.health.state.mn.us/divs/fh/mch/hlth-vis/index.html

Upon request, this publication can be made available in alternative formats such as large print, Braille or cassette tape

Printed on recycled paper

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Section

TABLE OF CONTENTS

Description

Page

I Introduction Cover Page 1

Minnesota Vision Screening Committee 2

MDH Identification and Contact Information 3

Table of Contents 4-5

Background and Overview 6

Pediatric Eye Screening or Evaluation 7

MDH Recommendations for Screening 7-8

II Vision Screening Preparation 9

General Considerations for Vision Screening (C&TC) 10

Preparing for Mass Screening (Schools) 11-12

Mass Screening Program Planning and Organization (Schools) 13-14

Re-screen, Referrals, Follow-up and Evaluation (schools) 15

Infection Control and Care of Vision Equipment 16

III Vision Screening Procedures 17

Child & Family History Taking 18

External Inspection 19

Pupillary Light Response 20

Retinal (Red Light) Reflex 21

Monocular Fix & Follow (EOM) (4m to 3 yrs) 22

Binocular Fix & Follow (EOM) (4m to 3 yrs) 23

Ophthalmoscope Directions 24

Observation 25

Corneal Light Reflex 26

Cross Cover (4m to Gr 3 or 8yrs) 27

Stereoacuity Random Dot E (optional) 28

Stereoacuity Butterfly (optional) 29

Color Vision (Gr 1 Males, Schools only) 30

Visual Acuity Explanation 31

Visual Acuity Minnesota Early Childhood Visual Acuity Test – LEA/HOTV Flip Chart 32

Visual Acuity HOTV 33-34

Visual Acuity LEA Symbols 35

Visual Acuity Snellen and Sloan 36

Visual Acuity – Near - Plus Lens 37

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IV Screening With Technology 38

Keystone, Optec, Titmus Vision Screeners; MTI Photoscreener 39

SureSight™ Vision Screener 40

V Resources on the Web 41

www websites 42

VI Glossary 43

Terms 44-47

VII Addendums 48

Teacher & Child Vision Worksheet 49

Parent Version – Child & Family Vision & Health History – Side 1 50

Parent Version – Child & Family Vision & Health History – Side 2 51

Parent Version - Child Vision Developmental Checklist 52

Vision Screening Worksheet 53

Vision Referral Letter 54

Color Vision Advisory Letter 55

C&TC Clinic H&P Form 56

C&TC Periodicity Schedule Page 1 57

Vision Screening Practice Sheet - LEA Symbols 58

Vision Screening Practice Sheet – HOTV 59

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Background and Overview

Purpose and Rationale

Vision screening is a procedure performed by properly trained persons for the purpose of early

identification of children who may have vision problems and referral to appropriate medical professionals

for further evaluation. Minnesota’s vision screening procedures are based on sound epidemiologic

findings and principles.

Impaired vision in children can contribute to the development of learning problems which may be

prevented or alleviated through early identification and intervention. Children with impaired vision often

are not aware of their impairment; therefore, they do not complain or seek help. If they have always

seen things in a blurred or distorted way, they accept the imperfect image without question. It is up to

adults responsible for children’s health care and education to assure that children have their vision

screened on a regular basis.

Minnesota’s Vision Screening Program

This vision screening training manual provides the screener with instructional information to conduct

vision screenings in schools or clinics. The screening procedures herein serve as guidelines for Child

and Teen Check-ups (C&TC), Head Start, Early Childhood Screening, and school programs.

Child and Teen Checkups [federally titled Early Periodic Screening Diagnosis and Treatment

(EPSDT)] is a program administered by the Minnesota Department of Human Services for children and

teens enrolled in Medical Assistance and MinnesotaCare under Minnesota Statute MS 256B.04-

256B.0625. The Minnesota Department of Health provides health recommendations to the program. For

more information see the Minnesota Child and Teen Checkups provider guide at:

http://edocs.dhs.state.mn.us/lfserver/legacy/DHS-4212-ENG

Head Start- Head Start and Early Head Start are comprehensive child development programs

which serve children from birth to age 5. They are child-focused programs and have the overall goal of

increasing the school readiness of young children in low-income families. Minnesota Head Start follows

Child and Teen Checkup guidelines. For more information see the Minnesota Head Start page at:

http://education.state.mn.us/mde/Learning_Support/Early_Learning_Services/Early_Childhood_Program

s/Head_Start/index.html

Early Childhood- Early Childhood Screening or evidence of a comparable screening by a non-

school provider (e.g., Head Start, Child and Teen Checkups/EPSDT or a health care provider) is required

for entrance in Minnesota’s public schools or within 30 days of enrollment into kindergarten (MS

121A.16-121A.17). Early Childhood Screening is offered throughout the year by local school districts.

For more information see the Minnesota Early Childhood Screening page at:

http://education.state.mn.us/mde/Learning_Support/Early_Learning_Services/Early_Childhood_Program

s/Early_Childhood_Screening/index.html

.

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Pediatric Eye Screening or Evaluation

Professional Academy Recommendations

The American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, the American Academy of Pediatrics, the American Academy of Family Physicians and the American Association of Certified Orthoptists all recommend early vision screening. A pediatrician, family physician, nurse practitioner, or physician assistant should examine a newborn's eyes for general eye health including a red reflex test in the nursery. An ophthalmologist should be asked to examine all high risk infants.

While there may be minor differences to each association’s periodicity tables, they all agree with the basic principles of pediatric vision care. After much review and discussion, the professional representatives from the “Work Group” and from the Minnesota Department of Health arrived at a consensus with regard to the vision screening recommendations contained in this manual.

Minnesota Department of Health Recommendations for Vision Screening

According to Minnesota Department of Health (MDH) guidelines, a child's vision should be

screened at the following intervals:

Child and Teen Checkups (C&TC):

Screening is done according to the Schedule of Age Related Screening Standards:

a. Subjective screening: child and family history should be taken and updated at every well child exam following the usual schedule for C&TC even when other objective tests are administered.

b. Objective screening: All other objective screenings and procedures should be

administered at every well child exam for children ages 3 through 12 years following

the usual C&TC schedule (located online at:

http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3379-ENG) . For ages 14-20,

every other year testing is recommended. Acuity screening is in addition to the

physical assessment of ocular health performed by the C&TC provider.

Head Start Schedule:

a. Early Head Start and Head Start- the vision screening schedule for the state’s

EPSDT program (in Minnesota, this is C&TC) is followed. C&TC Periodicity

Schedule: http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3379-ENG

Early Childhood:

a. Minnesota school districts are required to offer Early Childhood Screening to young

children before kindergarten entrance, targeting children 3 to 4 years of age. Children

must be screened at least once before kindergarten entry.

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School setting:

a. Children in grades 1, 3, 5, 7, and 10 should be screened.

b. In addition, a screening should be administered to students where there are

parent or teacher concerns and any new students.

c. Any child with a diagnosed eye condition should be screened in accordance with

the doctor's recommendations.

d. Prior to placement in a special education program, a child’s risk factors should be

reviewed to determine if there is a need for an exam by an eye specialist.

When a shortage of time, space, or personnel does not permit implementation of the full

frequency of screening in a school, emphasis should be placed on the lower grades.

Facility The room selected for vision screening should be properly lighted and at least five feet longer

than the distance required for each visual acuity screening. Additionally, it should be free from

direct sun glare and distractions. When more than one visual acuity screening station is being

used, they should be separated by a minimum distance of 8-10 feet. Muscle balance stations

must be arranged to avoid interfering with each other.

Equipment

For Required Procedures:

Occluder: 3” square of paper or plastic occluder Penlight Toy (1/2 inch in size) as a target object HOTV and/or Lea Vision Chart (50% rectangle), response card, and conditioning flashcards LEA Symbols Puzzle may be useful for children who are autistic or have ADHD Snellen or Sloan Alphabet Chart Ishihara, Good Light Color Vision Plates, or Waggoner Color Vision Made Easy Vision Screening Worksheet Antimicrobial hand gel and appropriate antimicrobial cleaner for occluder

For Optional Procedures:

Random Dot E Test Kit or Stereobutterfly Stereopsis tests

Plus Lens: +2.25 lenses, +1.75 lenses

Care of Equipment:

• The equipment should be kept clean and in good repair. • Color vision books should be kept closed when not in use to prevent fading. • Glasses (Random Dot E & Plus Lenses) should be cased when not in use and routinely

cleaned. • Visual acuity charts and response cards may be washed with warm, soapy water. • Replace chipped or torn charts as they can be distracting to the child. • Replacement flashlight bulbs and batteries should be readily available.

For More Information: The Minnesota Department of Health (MDH) Maternal Child Health

Section provides training and consultations to C&TC, Head Start and School providers.

http://www.health.state.mn.us/divs/fh/mch/hlth-vis/trainings.html 651-201-3760

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Vision Screening Preparation

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GENERAL CONSIDERATIONS: C&TC SETTING

Frequency: See Child & Teen Checkup (C&TC) Periodicity Schedule

http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-3379-ENG

Facility The room selected for vision screening should be at least five feet longer than the distance

required for each procedure, well-lighted and free of distractions and direct sunlight glare

screening.

Provider Roles in C&TC Clinics

Primary Care Provider: Usually updates history and performs the ophthalmoscope evaluation

and tests muscle balance (Extra Ocular Movements (EOM), Cross Cover test and corneal light

reflex) as part of the physical exam.

Certified Medical Assistant or Nurse: Usually screens with visual acuity charts.

Equipment for Visual Acuity Screening

Provide the parent or guardian with the HOTV or LEA practice sheets prior to screening so they

are familiar with the symbols if desired. (See page 58-59).

• Occluders: 3 inch square of paper or plastic occluder.

• Penlights

• HOTV or LEA vision 10 foot wall chart (Age 3-5 years), or the Minnesota Early Childhood

Visual Acuity flip chart, response card, and conditioning flashcards or LEA Symbols

Puzzle alternative which may be useful for children with Autism or ADHD

• Snellen or Sloan alphabet chart (age 6 years +)

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PREPARING FOR MASS VISION SCREENING:

Head Start, Early Childhood and School Screenings

Planning Meeting:

• Arrange a planning meeting for those persons who will be involved in the technical and

administrative aspects of the screening process; determine the number of students to be

screened and the number of staff and volunteers needed.

• Reserve appropriate space for the screening site. Size determination should be based

on which visual acuity charts will be used and how many stations will be necessary for

the screening.

• Identify the organization or schools’ policies & procedures to address data privacy in a

mass screening in order to maintain compliance with FERPA/HIPAA regulations

• Set calendar for volunteer recruitment and training dates and screening and re-screening

dates.

Notification letter to parents:

• Prior to the screening date send out an informational letter with the details of the

screening event including date, time, location and what to expect plus a copy of the

parent version of the child vision questionnaire for parents to fill out and return to school.

• Advise them there will be a second screening for children who have difficulty with any

part of the first screening.

• If after the second screening a child continues to be unable to meet passing criteria,

parents will be notified with a referral and strongly encouraged to bring their child in for

further evaluation by an eye professional.

• Any parent/guardian who does not want their child screened should be advised as to the

importance of the screening but when desired, the procedure they should follow so that

their child will be excluded from the screening.

• ESC students may be given sample HOTV or LEA symbols for practice opportunities

prior to screening if desired. There is also a LEA symbols puzzle to assist the child in

preparation for the LEA chart.

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PREPARING FOR MASS VISION SCREENING:

Head Start, Early Childhood and School Screenings (page 2)

Designate a Vision Screening Coordinator

Duties:

• Attend the MDH Training on vision and hearing

• Serve as primary person responsible for the smooth operation of the screening.

• Recruit, schedule and orient volunteers.

• Train volunteers using resources available from MDH.

• Assign volunteer tasks. It is best to make a volunteer an expert at one area instead of

rotating that volunteer to different screening stations.

• Provide on-site supervision.

• Arrange for and maintain needed equipment and supplies.

• Carry out or designate a person(s) to work in collaboration with the referral professional

and be responsible for sending out referral letters, follow-up and record keeping.

Referral/Follow-up Professional: A currently licensed (in Minnesota) professional

nurse with MDH training in vision screening

Responsibilities:

1. Determine which children need further professional evaluation based on MDH criteria.

2. Contact parents or guardian if follow-up information about the referral is not received

and explain the screening results as needed.

2. Communicate with appropriate staff regarding referrals and follow-up information.

3. Monitor child's vision and treatment as appropriate. 4. Maintain screening and follow-up information on the child's health record.

5. Evaluate the screening program.

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Mass Screening Program Planning and Organization

Head Start, Early Childhood Screening, School Screening

Prescreening Activities: 2 weeks prior to the intended screening date

• Determine the number of children to be screened and their ages or grade level

• Determine the number of staff needed to provide mass screening (see page 14 for

example)

• Recruit volunteers and schedule dates and times for volunteer training and orientation,

and the screening and re-screening sessions.

• Screening facilities should be examined and reserved for the screening dates.

• Copies should be made of the vision screening worksheet (see pages 49-51) and

distributed to classroom teachers and parents to be filled out with the child’s

name/age/grade and comments, if any

• Copies should be made of the referral (see page 54) and follow-up letters (pages 54-55).

• Determine the amount and type of the equipment needed and that it is in working order

Screening Clinics organized into “Stations”

An efficient ratio for the stations is:

3:1 (3)-visual acuity to (1)-muscle balance (i.e, corneal light, cross cover) station.

When the color vision procedures are included the ratio is:

3:2 (3)-visual acuity stations to (2)-muscle balance/color vision stations.

Number of staff per station is determined by the age of the children

Pre-school through first grade:

Visual acuity screening may require two persons per station

Older Children:

Muscle balance/color vision screening requires one person per station.

Visual Acuity Station: Approximately 20 children per hour can be screened

A few additional volunteers will be needed to help with traffic flow.

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Example based on the above guide:

To screen 300 children in 1-1 1/2 days, including color vision:

4 – (Two muscle balance/color vision stations using two volunteers each (2X2))

6 - (Three acuity stations using two volunteers each (3X2))

1 - (One volunteer to bring the children to the clinic from the classroom, direct traffic flow to and

from the various stations and to sort worksheets and record the results)

__

11 Volunteers Total

Screening Day Activities

• The vision screening coordinator will set up the vision stations in the screening area.

o The stations should be arranged so children cannot hear and repeat the answers

of other children being screened.

o Visual acuity stations should be at least eight to ten feet apart from one another.

• Volunteer training is done immediately prior to the screening on the clinic day.

� A minimum of one hour should be scheduled for this training.

� Each volunteer is assigned his/her specific task

� Each volunteer must have an opportunity to practice before screening begins

• Children should have their pre-filled out vision screening worksheets with them

• Children with a diagnosed visual condition should be included in the screening activities

to determine if there are any changes in their vision and if changes are found, a referral

back to the child’s eye care provider should be made.

Post Screening Activities

1. The Screening Worksheets are sorted into pass/re-screen groups to determine number of

children to be re-screened

2. The above guidelines for organizing the screening and determining numbers of

volunteers, vision stations, etc., can also be used in planning and preparing for the re-

screening to take place 10-14 days after the initial screening.

3. Screening results should be reviewed and documented on the child's individual

permanent health record by the Referral/Follow-up Professional.

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Re-Screening, Referral, Follow-Up, and Program Evaluation

Head Start, Early Childhood Screening, School Screening

Re-screening

� Re-screening is indicated for the child who failed any part of the initial screening.

� A second screening is performed to eliminate those children who failed the initial

screening because of such factors as illness, anxiety, misunderstanding, etc.

� The number of students re-screened will be typically about 20% of the initial number

screened.

� Re-screening is performed 10-14 days after the initial screening

� Re-screening procedures are the same as those followed for the initial screening.

Referral

• A referral is indicated if the child fails any portion of the re-screening except the color

vision test.

• The referral should be made by mailing a Referral Letter (see pages 54-55) to the

parent/caregiver within one week after the re-screening.

• The Referral Letter should not be hand carried by the child

• A phone call to the parent/caregiver soon after the referral is mailed usually improves

follow-up results

Follow-up and Tracking

• A tracking system is essential to follow-up those who are referred so as to assure the

identified child receives the appropriate treatment and other services.

• If the information about the referral is not received in 3-4 weeks, a phone call should be

made to the child’s home. In some cases a home visit might be appropriate.

• All pertinent information regarding the screening results, referral, parent/caregiver

comments, and results of the professional evaluation and recommendations must be

documented in the child’s health record

• It may be determined by the professional examiner that a child doesn't presently need

glasses or other specific treatment, but this would not invalidate the referral if a problem

were confirmed.

• Following professional diagnosis and treatment, further planning may be needed for the

child whose vision status cannot be brought to within normal limits. In this case, the

special education director should be notified so special programming can be

implemented as needed.

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Infection Control Considerations for Vision Screening

General Principles:

1. Wash hands with soap and water before the screening session begins. If a sink is not

available use antimicrobial hand gel.

2. Wash occluders and plus lenses with soap and water, rinse and wipe dry before starting the

screening program.

3. Ideally, the occuluders and plus lenses should be disinfected after each student is screened.

This can be done by using an appropriate anti-microbial agent. Additionally, the cloth covers

used to cover the ear phones on headsets for audiometers may be used to cover the occluder-

head that comes in contact with the child’s eye. If neither of these cloths is available, an alcohol

wipe may be used.

4. Children whose eyes are red or draining should not be screened but instead referred

immediately to their primary care provider.

Care of Vision Equipment

Color vision books should be kept closed when not in use to prevent fading.

Do not touch the color plates with your fingers as the oil on your skin can damage the plates.

Clean visual acuity charts periodically with mild warm, soapy water to prevent distortion of chart

letters from dirty smudges

A much more frequent cleaning will be necessary for the child’s HOTV or LEA response card

since the children handle them.

Discard chipped or torn charts.

The charts should be laid flat and away from heat when stored to prevent curling.

Any flashlights used in screening should be stored with batteries removed.

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Vision Screening Procedures

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Child and Family Vision History Taking

Grades/Ages: Perform at birth to 5 years or at any age if family history is unknown.

Continue to update ocular history at each subsequent well child visit.

Purpose: Identify a child/family history of any medical conditions that may be

associated with eye disorders.

Description: Elicit information of selected medical conditions and syndromes from the parents that may indicate the need for referral even if other screening procedures are passed.

Additionally the parents are asked to identify any complaints or unusual visual behavior their child may have exhibited

Forms: Teacher and Child Vision Prescreening Worksheet (see page 49)

Child Vision History Questionaire for Parents/Caregivers (see pages 50-51)

Procedure: Parent/caregiver are given the forms to fill-out and their answers are

reviewed and flagged if significant history of conditions/syndromes or

behaviors are identified.

If parents have any questions regarding the form, a contact number for the

Referral/Follow-up professional nurse should be given

Pass: No family history of associated conditions or syndromes or vision behaviors

are identified.

Refer: Family history of associated conditions or syndromes or visual behaviors

are reported.

EYE ANATOMY

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External Inspection

Ages: Birth through 20 years (C&TC) or birth through all grades (Early Childhood and school screenings).

Purpose: To check for signs of external eye disease or abnormalities.

Description: A systematic inspection of observable parts of the eye and surrounding tissue.

Equipment: None.

Facilities: Well-lit area.

Procedure: If the child is wearing glasses, they may be removed in order to give the screener an unobstructed view of the area around the eyes.

The area around the eyes should be checked for swelling and/or discoloration or excessive tearing.

The eyes themselves should be checked in the order suggested by the acronym "WIPL."

W - Whites: The sclera should be white. There should be no discoloration or growths.

I - Iris: The iris should be a complete circle. Both should be the same color.

P - Pupil: The pupils should be clear and dark. There should be no cloudiness or white discoloration. The pupils should be of equal size and circular shape.

L - Lids and Lashes: The lids in their natural, open position should give a full view of the pupil. The lids should be free of lumps (chalazia). There should not be redness or crustiness along the margin or signs of a stye. The margin of the lid should be flush against the surface of the eye. The child should show normal blinking during observation period. Lashes should be present on the top and bottom lids of both eyes. Lashes should not turn in causing them to come in contact with the conjunctiva.

Pass: Normal appearance of all parts of the eye.

Re-screen/Refer: Any abnormality noted. If a white pupil (leukocoria) is noted, an immediate referral to an Ophthalmologist is necessary.

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Pupillary Light Response

Ages: Birth to age 3 years (or until visual acuity can be measured).

Purpose: To check for the pupils' reaction to changes in illumination.

Description: Observing the child's pupils for symmetrical reaction to light.

Equipment: Penlight

Facilities: Normal or lower light level.

Procedure:

• First observe the child's eyes noting if the pupils are of equal size.

• Approaching from the side, at eye level, shine the light into the right

eye- the pupil should quickly constrict.

• Observe the left eye to see if it has equally constricted (consensual

response).

• Remove the light- both eyes should dilate.

• Repeat the procedure on the left eye.

Pass: Pupils constrict quickly and equally when light is introduced and almost as

quickly and equally dilate when light is removed.

Re-screen/Refer: Sluggish or no response upon the introduction or removal of the light or the

pupils become unequal in size.

NOTE: The screener may observe the pupils dilate and constrict several

times after illumination. This is a normal occurrence called Hippus.

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Retinal (Red Light) Reflex

Ages: Birth to age 3 years (or when visual acuity can be measured)

Purpose: To check for abnormalities that block light flow within the eye by observing

the reflected light from the retina which is red in color.

Description: Observing symmetrical and equal intensity reflexes from the retinae.

Equipment: Ophthalmoscope.

Facilities: Normal to lower light level- minimum number of light sources (windows,

overhead lights, etc.).

Procedure:

• Position the child so the circle of light from the ophthalmoscope falls

just to the outside of both eyes.

• Looking through the ophthalmoscope you should observe a glow in

both pupils simultaneously.

Pass: Reflexes are equal in symmetry of pattern, color and intensity.

Re-screen/Refer: A reflex that is altered in symmetry. In the presence of a leukocoria, one or

both pupils may appear white instead of the normal red color expected and

immediate referral is required.

For More Info: American Academy of Pediatrics. Policy Statement. Red Reflex

Examination in Neonates, Infants, and Children. December 2008.

Available online at:

http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;122/6/14

01

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Monocular Fix and Follow / Extra Ocular Movements (EOM)

Ages: 4 months to when visual acuity can be measured.

Purpose: To check for vision and the movement of the eye when it is following a

continuously moving target with the other eye covered.

Description: Target is moved horizontally then vertically in relation to a center point on a

visual axis of each eye. Make sure the child’s head doesn’t move, the

parent can help.

Equipment: Penlight or interesting target.

Procedure: Test the Right Eye

Horizontal -

• Cover the Left Eye and attract the child's attention to a target 14-16

inches away, centered in front of the child's right eye.

• Slowly move the target horizontally to your right until the child's eye

is in its extreme left viewing position.

• Slowly move the target to your left, crossing the center point and

continuing until the eye is in the extreme right viewing position.

• Return target to center point.

Vertical -

• Starting at the center point, raise the target until the eye reaches the

extreme up viewing position.

• Lower the target through the center point until the eye reaches the

extreme down view position.

• Return target to center point.

Test the Left Eye: Cover the Right Eye & repeat the procedure above

Pass: Each eye follows the target easily and smoothly, without head movement.

Re-screen/Refer: The child does not attend to the target; either eye shows jerky movements,

or the child objects to one eye being covered but not the other.

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Binocular Fix and Follow / Extra Ocular Movement (EOM)

Ages: 4 months to when visual acuity can be measured.

Purpose: To check for symmetrical eye movements when following a moving target.

Description: The child's head is stabilized while a target is moved in horizontal, vertical

and oblique patterns in relation to a center point on a visual axis. The

target is also moved from the center point toward the child.

Equipment: Penlight or interesting target.

Procedure: Horizontal-

• Hold the target 14-16 inches away, centered in front of the child's

eyes (center point) and slowly move the target horizontally to your

right until the child's eyes are in their extreme left viewing position.

• Slowly move the target to your left, crossing the center point and

continuing until the eyes are in the extreme right viewing position

• Return target to center point.

Vertical-

• Start at the center point, raise the target until the eyes reach the

extreme up viewing position.

• Lower the target through the center point until the eyes reach the

extreme down viewing position.

Oblique-

• Start at the center point, raise the target until the eyes reach the

extreme upper right viewing position.

• Lower the target through the center point until the eyes reach the

extreme lower left viewing position.

• Repeat this procedure for the upper left to the lower right viewing

position.

Convergence–

• It is the simultaneous inward movement of both eyes to maintain

binocular vision

• Starting at the center point, move the target slowly toward the child

to a distance of 4 inches.

Pass: Both eyes follow the target easily and smoothly.

Re-screen/Refer: Eyes do not follow in unison or movements are jerky, uneven, or "break"

further than 4 inches from the bridge of the nose, or child uses head

movements. Eye crossing is fixed and/or intermittent

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Ophthalmoscope Directions

Here are the steps to using the ophthalmoscope correctly:

1. To screw the head onto the power base:

a. Match the notches in the Ophthalmoscope head

with those on the power base (see illustration)

b. Press down until notches mesh

c. Twist clockwise

d. Pull gently to see if head is secure

2. To turn the ophthalmoscope on:

a. Press colored button on the top rim of the power

base handle in a downward direction

b. Twist the button clockwise around the rim

You should be able to see the light in the palm

of your hand when you point the narrow end

toward your palm.

3. View the eye with the ophthalmoscope

a. Turn the vertical dial with your thumb until it is

on the “0” setting (see illustration)

b. Find the “large circle of light” by turning the

horizontal dial with your thumb (see illustration)

c. View both eyes at same time through the scope’s

sight to visualize a symmetrical reflex

25

Observation

Ages: 4 months through 8 years (C&TC) or 3rd grade (Early Childhood and school screenings).

Purpose: To check for constant strabismus.

Description: Observing the child's eyes to see if they are properly aligned.

Equipment: None.

Facilities: Well-lit room.

Procedure: The screener observes the child's eyes to see if one eye appears to turn in, out, up, or down in relation to the other. The position of the head for tilt (chin up or down) should also be noted.

Pass: Eyes are properly aligned and head position normal.

Re-screen/Refer: One eye appears to turn in, out, up, or down in relation to the other, eyes cross or abnormal head position*

*A child with an abnormal head position should also be referred as it may be indicative of an eye disorder leading the child to tilt his/her head to improve their view.

26

Corneal Light Reflex

Ages: 2 months through 8 years (C&TC) or 3rd grade (Early Childhood and school screenings).

Purpose: To check for milder degrees on constant strabismus. To differentiate pseudo-strabismus on children with large epicanthal folds.

Description: By noting the position of light being reflected in the pupils, the observer is able to check for a constant strabismus.

Equipment: Penlight and target object

Facilities: Normal or lower light level. Minimize, if possible, the number of light sources (i.e. windows, overhead lights, etc.)

Procedure: 1) Position the child so that the target, the light source and the examiner's line of vision is at the midline in front of the child's eyes at a distance of 14-16 inches. 2) Try to have the child sit with his/her back to any ceiling lights. 3) Shine the penlight at the center of the child's forehead directly above and between the child's eyes. 4) Make sure the child is focused on the target. 5) The screener then observes the reflected light in each pupil. 6) It is very important that good light is used. Ceiling lights are not sufficient. Pass: The reflection of the light appears to be in a symmetrical position in the

pupil of each eye.

Re-screen/Refer: The reflections of light appear to be asymmetrical.

Note: This test is very helpful to detect pseudostrabismus, the false appearance of strabismus. Sometimes a child’s eyes may appear crossed when they actually are not. This is often due to the wide bridge of the nose or the epicanthal fold

27

Cross Cover

Ages: 4 months through 8 years (C&TC) or 3rd grade (Early Childhood and school screenings).

Purpose: To check for tendency of the eyes to misalign when fusion is interrupted.

Description: Observing the eye being uncovered for movement when the occluder is shifted to the other eye.

Equipment: Small, interesting target object and occluder

Procedure:

1. Have the child focus on a target object held steady 14-16 inches in front of their eyes.

1. Cover the right eye with the occluder, hold for a count of three (3).

2. Pass the occluder quickly over the bridge of the nose to cover the left eye. Watch the right eye as it becomes uncovered for any movement.

3. Hold the occluder over the left eye for a count of three (3).

4. Pass the occluder quickly back over the bridge of the nose to cover the right eye again. Watch the left eye as it becomes uncovered for any movement.

5. This procedure should be repeated two or three more times.

Pass: No observable movement of the eye being uncovered.

Re-screen/Refer: Repeatable movement or resistance by the child to having one eye covered but not the other or uncovered eye moves out, in, up, or down.

28

Stereo Acuity Test: Random Dot E (Optional)

IF YOU HAVE THE EQUIPMENT, WE RECOMMEND IT

Stereopsis measurement should be performed before the eyes are dissociated by tests such as the cover test.

Ages: 3 years through 8 years (C&TC) or 3rd grade (Early Childhood and school screenings).

Purpose: To check for problems with stereo acuity or depth perception.

Description: Note if the child is able to see the raised “E” while wearing special glasses.

Equipment: Random Dot E stereo card, blank stereo card, model E card, and polarized glasses.

Facilities: A well-lit, glare free location

Procedure:

1. Place the polarized glasses on the child. Do not remove prescription glasses if the child

wears them

2. If the polarized glasses are too large for the child, put a short piece of masking tape on

the top of the glasses and use the other end of the tape to hold the glasses on the child’s

forehead.

3. When showing the child the test targets, be sure he/she keeps his/her head straight up,

as tilting to one side or allowing the glasses to tilt on his nose, will interfere with the test.

4. At 20 inches away from the child, hold the sample model E card with the long sides on

the top and bottom. Ask the child what the figure is. If the child cannot name it or has

difficulty, point at the E figure on the card and say “that’s an E.

5. With the polarized glasses still on, practice using the sample card and blank together by

mixing up the cards behind your back and presenting the cards to the child. Have the

child point to the card with the ‘E” on it. Do this 4-5 times.

6. Substitute the model E care with the stereo E card. Tell the child that, “sometimes, while

wearing the magic glasses, he may see a “picture” appear on the card.” Mix the blank

card and stereo E card behind your back and present the cards to the child. Have the

child identify the card they see a picture in. Do this 5 times.

7. Move back to 40 inches from the child and repeat step 4.

Note: Slightly move cards up and down (don’t tilt) to give optimal viewing of the stereo

image.

Pass: Student is able to point to the correct stereo E card at least 4 times at 20 inches and 40 inches.

Re-screen/Refer: The child cannot distinguish the E figure in the stereo E card at all, or can

only see it when the card is approximately 20 inches or closer.

29

Stereo Acuity Test: Stereo Butterfly (Optional)

IF YOU HAVE THE EQUIPMENT, WE RECOMMEND IT

Stereopsis measurement should be performed before the eyes are dissociated by tests such as the cover test.

Ages: 3 years through 8 years (C&TC) or 3rd grade (Early Childhood and school screenings).

Purpose: To check for problems with stereo acuity or depth perception

Description: By noting if the child is able to see the raised “butterfly” while wearing special glasses, the observer is able to check for stereo acuity problems.

Equipment: Stereo butterfly card and polarized glasses.

Facilities: A well-lit, glare free location

Procedure:

1) Place the polarized glasses on the child. Do not remove prescription glasses if

the child wears them.

• If the polarized glasses are too large for the child, put a short piece of

masking tape on the top of the glasses and use the other end of the

tape to hold the glasses on the child’s forehead.

• When showing the child the test targets, be sure he/she keeps his/her

head straight up, as tilting to one side or allowing the glasses to tilt on

his nose, will interfere with the test.

2) At normal reading distance from the child, hold the stereo butterfly page

upright. Ask the child what the figure is that they see. If the child cannot name

it or has difficulty, point at the butterfly figure on the page and say “that’s a

butterfly”. Ask the child to touch the butterfly wings.

Note: Slightly move the book up and down (don’t tilt) to give optimal viewing of the

stereo image.

Pass: Student is able to point to the butterfly wings above the page.

Re-screen/Refer: The child cannot distinguish the butterfly figure in the stereo butterfly card,

or touches the page when trying to touch the wings.

30

Color Vision

Ages: 1st grade (age 6 years) boys, others optional.

Purpose: To check for color vision deficiency.

Description: Color vision deficiency is checked by having the child read numbers or follow lines on specially designed color plates.

Equipment: Ishihara PseudoIsochromatic Plates, Color Vision Testing Made Easy or Good-Lite Book of Color Plates. Fluorescent desk lamp - if enough natural daylight is not available.

Facilities: Room well-lit by daylight

Procedure: The test book should be positioned to eliminate glare and at a normal

reading distance from the child's eyes. It should never be in direct sunlight.

Instruct the child to read the numbers or trace the image on each page

carefully. Follow each manufacturer’s instructions.

Pass: Follow each manufacturer’s instructions. Generally, able to correctly

identify numbers or follow lines on testing plates.

Re-screen/Refer: Follow each manufacturer’s instructions. Generally, inability to identify

a number on any one or more plates or inability to follow the line on any one

or more plates (See referral letter on page 55)

Considerations for screening special populations:

• If the person being tested does not know numbers, the plates with lines can

be used.

• Do not use a pointer, such as a pencil, eraser, or finger that would mark up

or deface the color plates. A clean, dry, watercolor brush works best for

tracing, if needed

Pass: Follows all lines correctly on all plates.

Re-screen/Refer: Unable to follow the line on any one plate.

Note: Children, other than 1st grade males, should be screened on request.

31

Visual Acuity

Definition:

Visual acuity is the sharpness or clarity of a person’s vision.

Visual acuity is written as a fraction:

Numerator= The number of feet at which screening is done (e.g., 10 feet, 20 feet)

Denominator= The smallest line on which the majority of the symbols are correctly

identified. (Line size is indicated on the chart as 10, 15, 20, 30, 40, 50, 70, 100, 200)

For example:

If one’s vision is “20/70” means:

• at 20 feet, the smallest line that person can see is the 20/70 line

• and a person with 20/20 vision could read that same line at 70 feet away

If one’s vision is “ 20/20”

• at 20 feet, the smallest line that person can see is the 20/20 line

Results of testing done at 20 feet distance are written: 20/20, 20/25, 20/30, 20/40, 20/50, etc.

Results of testing done at 10 feet distance are written: 10/10, 10/15, 10/20, 10/30, 10/40, etc.

32

Visual Acuity – LEA/HOTV Flip Chart

Minnesota Early Childhood Visual Acuity Test

Ages: Preschool (Age 3 years and difficult-to-screen children)

Purpose: To check the visual acuity of children who do not know the alphabet or

have difficulty with the LEA or HOTV 50% spaced rectangle chart.

Description: The Minnesota Early Childhood Visual Acuity Test Flip Chart is a

variant of the line test for children who find it distracting to look at a

chart.

Equipment: LEA or HOTV Minnesota Early Childhood Visual Acuity Test Flip Chart

LEA/HOTV Response Key Card and LEA/HOTV Flash Cards

Facilities: Room well-lit, without glare and free of distractions.

Test Procedure: 1) The child must be standing or sitting at a table with the response card

in front, eyes at a ten foot distance from the flip chart.

2) The child must be conditioned to match letters by pointing to the

same letter on his response card as is being shown with a flash card or

pointed to on the chart.

3) Test the right eye first. Start with the 10/25 page and proceed to the

10/20, 10/16, 10/12.5 and 10/10 page as long as the child is able to

match 4 of the 5 letters or symbols on each page.

4) Record the visual acuity as the last page that the child can correctly

identify four of the five symbols.

Age 3-4 Pass: 10/20 or better in each eye without a 2 line difference in the pass range.

Age 3-4 Rescreen 10/25 or worse in either eye or a 2 line difference in the pass range.

Age 5 Pass: 10/15 or better in each eye without a 2 line difference in the pass range.

Age 5 Rescreen: 10/20 in either eye or a 2 line difference in the pass range.

Considerations for screening special populations:

The matching of the HOTVor LEA symbols should be practiced before the screening. A practice

sheet that may be duplicated is in the Addendum (oages 58-59). For some children with special

needs, it may be useful to reproduce the response card, cut and space them so that larger

movements can be used when indicating the matching symbol.

NOTE: At recheck, the poorer eye should be screened first

33

Visual Acuity - HOTV Chart

Ages: Preschool through age 5 years.

Purpose: To check for visual acuity of children who do not know the alphabet.

Description: Visual acuity is screened at a distance of 10 feet using the symbols HOTV. The

child need not know these symbols, but must be able to match the indicated

symbols on a wall chart with those on the response card.

Equipment:

• 10' HOTV Vision Chart (with 50% spaced rectangle)

• Student Response Card and Flashcards

• Table and chair

• Occluder with lip

Facilities: Room approximately 15 feet long or greater, well–lit and without glare.

Procedure: Testing the Right Eye

1) The child must be standing or sitting at a table with the response card in

front, eyes at a 10-foot distance from the chart.

2) The child must be conditioned to match letters by pointing to the same letter

on the response card as is being shown with a flash card or pointed to on the

chart.

3) Begin screening with one person holding an occluder horizontally (with the lip

nasally) over the child's left eye.

4) Another person points to the letters on the HOTV wall chart using caution not

to cover the rectangle line with their finger or pointer.

5) The child should point to the corresponding letter on the response card. Start

with the top line and continue downward showing one letter per line. If the child

reaches the bottom line, show the remaining three (3) letters.

6) If the child misses, go to the line above and show four different letters in that

line. If the child matches them correctly, proceed downward.

7) To receive credit for a line, the child must correctly match each of the four

different letters on the line.

8) The number recorded as the visual acuity is the smallest line the child can

read correctly.

Testing the Left Eye: Cover the Right Eye and repeat the procedure

34

Visual Acuity - HOTV Chart (page 2)

Kindergarten-Gr 1: Pass: 10/15 or better in each eye without a two-line difference.

Re-screen/Refer: 10/20 or worse in either eye or a two-line difference in the pass range

Preschool Pass: 10/20 or better in each eye without a two-line difference

Re-screen/Refer: 10/25 or worse in either eye or a two-line difference in the pass range.

Considerations for screening special populations:

The matching of the HOTV symbols may be practiced before the screening. A practice

sheet that can be duplicated is in the Addendum (page 59). For some children with special

needs, it may be useful to reproduce the response card, cut and space them so that larger

movements can be used when indicating the matching symbol.

NOTE: At recheck, the poorer eye should be screened first.

Tips: No peeking, watch for memorization, watch for head tilt.

Children unable to perform the HOTV should be given the procedures designed for younger children.

Occluders should be cleaned between children.

35

Visual Acuity-LEA Symbols

Ages: Preschool through age 5 years

Purpose: To check for visual acuity of children who do not know the alphabet

Description: Visual acuity is screened at a distance of 10 feet using the Lea symbols.

The child need not know these symbols, but must be able to match the

indicated symbols on a wall chart with those on the response card.

Equipment: 10' Lea Vision Chart Student Response Card Flashcards

Table and chair Occluder with lip

Facilities: Room approximately 15 feet long or greater, well–lit and without glare.

Procedure:

Testing the Right Eye:

1. The child must be standing or sitting at a table with the response card in front, eyes at a

10-foot distance from the chart.

2. The child must be conditioned to match symbols by pointing to the same symbol on the

response card as is being shown with a flash card or pointed to on the chart.

3. Begin screening with one person holding an occluder over the child's Left Eye.

4. Another person points to the symbols on the Lea wall chart using caution not to cover the

rectangle line with their finger or pointer.

5. The child should point to the corresponding symbol on the response card.

6. Start with the top line and continue downward showing one letter per line. If the child reaches

the bottom line, show the remaining three (3) symbols.

7. If the child misses, go to the line above and show four different symbols in that line. If the

child matches them correctly, proceed downward.

8. To receive credit for a line, the child must correctly match each of the four different symbols

on the line.

9. The number recorded as the visual acuity is the smallest line the child can read correctly.

Testing the Left Eye: Cover the Right Eye and repeat the procedure

Kindergarten-1st: Pass: 10/15 or better in each eye without a two-line difference.

Re-screen/Refer: 10/20 or worse in either eye or a two-line difference in the pass range

Preschool Pass: 10/20 or better in each eye without a two-line difference

Re-screen/Refer: 10/25 or worse in either eye or a two-line difference in the pass range.

Considerations for screening special populations:

The matching of the Lea symbols may be practiced before the screening. A practice sheet that

can be duplicated is in the addendum (page 58). For some children with special needs it may

be useful to reproduce the response card, cut and space them so that larger movements can be

used when indicating the matching symbol.

NOTE: At recheck, the poorer eye should be screened first. Children unable to perform the Lea chart should be given the procedures designed for younger children. Occluders should be cleaned between children.

36

Visual Acuity Snellen or Sloan Alphabet Chart

Ages: 1st grade (6 years) and older

Purpose: To check visual acuity.

Description: Visual acuity is checked at 20 feet with letters presented in a linear fashion.

Equipment: Snellen or Sloan Alphabet Chart (20 Ft)

Occluder (held horizontally with lip of occluder at nose)

Facilities: Room at least 25 feet long, well-lit, without glare.

Procedure:

• Vision is screened in the right eye first, with the left eye occluded.

• Have the child start reading the letters on the 20/50 line and proceed downward. If the

child misses one on the 20/50 line, go up to the 20/70 line.

• If the child misses one on the 20/70 line, proceed to the 20/100 line.

• To receive credit for a line, all the letters must be read correctly on the line labeled 20/40

and those above it.

• On the 20/20, 20/25 and 20/30 lines, the child may miss two letters on each line and still

get credit for the line.

• The number recorded for the visual acuity on the screening record is the smallest line the

child reads correctly.

• For screening purposes, you do not need to go lower than the 20/20 line.

• Screen the left eye.

Pass: 20/30 or better in each eye without a two-line difference

Re-screen/Refer: 20/40 or worse in either eye or a two-line difference in the passing range.

Considerations for children with cognitive impairments:

If a child does not know the alphabet or is developmentally unable to perform the Snellen or

Sloan chart, then screen with the HOTV or LEA symbols chart at 10 feet instead.

NOTE: For re-screen, check the poorer eye first. A 10-foot Sloan chart may be used if space is an issue.

37

Plus Lens (OPTIONAL)

Ages: Optional one time screening between ages 6 years (grade 1) up to grade 5

Purpose: To check for hyperopia (farsightedness).

Description: With plus lenses on and one eye covered, the child attempts to read the

smallest line on the visual acuity chart.

Equipment: +2.25 lenses for grades 1-3.

+1.75 lenses for grades 4 and 5.

Occluder

Visual Acuity Chart

Facilities: As appropriate for visual acuity screening.

Procedure: Omit when wearing glasses or has failed visual acuity.

• After the child has been checked for visual acuity, the plus lens procedure is done at the same distance.

• Place the appropriate size plus lenses on the child. Let the child’s eyes adjust by having the glasses on at least 30 seconds before attempting the test.

• With the left eye occluded, the child should attempt to read the chart for at least 15 seconds. Repeat the process with the right eye occluded.

Pass: Inability to read six or more letters on the 20/20 line (or one of each of the

four symbols on 10/10 line with HOTV) with either eye.

Re-screen/Refer: Ability to read six or more letters on the 20/20 line (or one of each of the

four symbols on 10/10 line with HOTV) with either eye.

Note: Any child referred to the health office for vision symptoms such as those

listed in the Addendum (pages 49-51) should be screened with the plus

lens.

38

Screening

With

Technology

Keystone SureSight

39

Technology for Vision Screening

Keystone, Optec, Titmus Titmus

1. These are brand names of vision screening machines whose main advantage is that

they do not require 10 or 20 feet and they have a consistent light source.

2. However, while they test for visual acuity fairly accurately, both for distance and near

vision, they do not have as good a record for accuracy in testing muscle imbalances.

3. The problem occurs because younger children’s head size is small creating an

opportunity to “peek” and therefore skew the results. It is essential to monitor for this.

4. It should be noted, that some manufacturers have updated their equipment in 2005 to

ergonomically accommodate a smaller size head.

5. Depending on the package purchased, this technology can also screen for color

screening deficiency.

6. It is recommended that the color vision tests recommended in this manual be used

instead of the color slides in this technology.

MTI Photo Screener

Not recommended because of its high cost and also because it is quite complicated to operate

and requires considerable training.

40

Welch Allyn® SureSight Vision Screener

MDH does not officially recommend this technology because it is currently being studied by the

National Institute of Health for its usefulness in preschool settings and also because of its high

cost. If you have the “SureSight 2.22”, the following information may be useful.

Ages: Can be used in children ages 3 through all grades.

Purpose: To detect refractive error in a short span of time in any population

Description: A device that can be used to screen for visual acuity

Equipment: SureSight Vision Screener, stand, printer.

Facilities: Natural lighting.

Procedure:

Position the unit straight and level with the patient and at a distance of 14” away from their eyes.

Look through the viewer at the patient’s right eye first and try to point the crosshair (target) at

the pupil. You may have to scan around the pupil a little to get a reading. You will start to hear

sounds:

Test the Right Eye

When the unit is too far away, you will hear slow, low-pitched beeps.

Slowly move closer. At the correct distance (14”), you will hear a steady, low tone.

When the unit is too close, you will hear quick, high-pitched beeps.

The cross-hair will flash in sync with the tones.

When the test is over for the eye, you will hear a “tah-dah” sound.

Test the Left Eye

Scan over to the patient’s left eye and point at pupil.

Repeat same procedures as on right eye.

After you hear the “tah-dah” sound for the left eye, you’re finished.

Referral Criteria:

Please follow manufacturer’s criteria for referral.

Please note: This procedure only replaces visual acuity testing. Other screening procedures still

need to be completed.

41

RESOURCES

ON THE

WORLD WIDE WEB

42

RESOURCES ON THE WORLD WIDE WEB

Vision Resources

Websites

American Academy of Ophthalmology aao.org

Minnesota Academy of Ophthalmology www.mneyemd.org

American Association for Pediatric

Ophthalmology & Strabismus

www.aapos.org

American Optometric Association www.aoa.org

American Academy of Pediatrics www.aap.org

American Academy of Family Physicians www.aafp.org

Canadian Ophthalmology Association www.eyesite.ca

Sight & Hearing Association www.sightandhearing.org

Vision In Preschoolers (VIP) Study

Home Page

http://optometry.osu.edu/research/vip/

National Guideline Clearinghouse www.guideline.gov

Welch Allyn SureSight Auto Refractor http://www.welchallyn.com/medical/products/c

atalog/detail.asp?ID=29372

Visual Development http://home.earthlink.net/~toddwolly/vision/

Minnesota Department of Health (MDH)

-Vision screening documents

-Online Vision Screening Module

-C&TC and school vision screening tips

www.health.state.mn.us/divs/fh/mch/hlth-

vis/index.html

Minnesota Department of Education

Early Childhood Screening

http://education.state.mn.us/MDE/Learning_S

upport/Early_Learning_Services/Early_Childh

ood_Programs/Early_Childhood_Screening/in

dex.html

Minnesota Department of Human Services

C&TC Periodicity schedule

http://edocs.dhs.state.mn.us/lfserver/Legacy/

DHS-3379-ENG

Minnesota Parents Know http://www.parentsknow.state.mn.us/

National Eye Institute http://www.nei.nih.gov/

43

Glossary

of Vision Screening Terms

44

GLOSSARY

Accommodation- the adjustment of the lens

to focus at different distances through action of

the ciliary muscle.

Amblyopia- poor vision in one or both eyes

not due to organic defect.

Anisometropia- inequality in the refractive

power of the two eyes of considerable degree.

Anterior chamber- the space between the

cornea and the iris.

Aqueous humor- the clear fluid which fills the

anterior and posterior chambers of the eye.

Astigmatism- a refractive error in which a

defect of curvature on one of the refractive

surfaces of the eye prevents a clear image

from being focused on the retina.

Binocular vision- the ability to use both eyes

simultaneously to focus on the same object

and fuse the two images into one with the

correct interpretation of solidity and position in

space.

Blepharitis- inflammation of the glands and

lash follicles along the margin of the eyelids.

Blindness- legal blindness is a visual acuity of

20/200 and or the ability to see only 20% or

less of the visual field after best correction in

the better eye.

Blind spot- area where retinal nerve fibers

converge (optic disc) to form the optic nerve.

Corresponds to the area of non-vision in the

visual field

Cataract- a defect in the transparency or

opacity of the lens or its capsule.

Chalazion- a lump on the eyelid that results

from chronic inflammation of meibomian gland.

Choroid- the vascular layer located between

the sclera and the retina.

Cilia- of the eye refers to eyelashes

Ciliary body- the portion of the uveal tract

between the iris and the choroid that contains

the muscles of accommodation and secretes

aqueous.

Coloboma- absence or defect of some ocular

tissue, usually a congenital fissure of any part

of the eye, such as an incomplete iris.

Color deficiency- inability to perceive

differences in color, usually for red-green,

rarely for blue-yellow. It can range from mild to

severe in degree. It is more common in males

than females.

Concave lens- a lens having the power to

diverge parallel rays of light. It is used to

correct myopia.

Cones- one of two types of light-sensitive cells

on the retina. Cones are more numerous in

the area of the macula and are responsible for

seeing color and fine detail.

45

Conjunctiva- delicate membrane that lines the

eyelids and the exposed part of the sclera.

Conjunctivitis- inflammation of the

conjunctiva.

Convergence- simultaneous turning of the

eyes toward each other.

Convex lens- a lens having the power to

converge parallel light rays to bring an image

to focus. It is used to correct hyperopia or

presbyopia.

Cornea- the clear transparent membrane that

covers the iris and pupil and joins the

conjunctiva.

Crystalline lens- a transparent colorless body

suspended in the anterior portion of the eyeball

between the aqueous and vitreous chambers.

Its function is to help bring light rays into focus.

Dacryocystitis- inflammation of the tear sac,

usually due to blockage.

Depth perception- the ability to perceive the

solidity of objects and their relative position in

space. Stereopsis.

Diopter- unit of measurement expressing the

strength or refractive power of a lens at one

meter.

Diplopia- double vision.

Divergence- simultaneous turning of the eyes

away from each other.

Emmetropia- absence of refractive error.

Epicanthus- congenital skin fold overlying the

inner portion of the upper lid and the inner

canthus; simulates the appearance of

esotropia. Tends to recede as the bridge of

the nose narrows in early childhood.

Esophoria- a latent tendency of the eye to turn

inward.

Esotropia- a manifest inward deviation of the

eye.

Exophoria- a latent tendency of the eye to turn

outward.

Exotropia- a manifest outward deviation of the

eye.

Farsightedness- a lay term for hyperopia.

Field of Vision- the entire area which can be

seen at one time without shifting the head or

eyes.

Floaters- opacities within the vitreous space

that cast moving shadows on the retina.

Focus- adjustment of the lens to produce a

clear picture.

Fovea- small depression in the retina at the

back of the eye; part of the macula adapted for

the most acute vision.

Fusion- the integration of two separate images

into a single mental picture.

Glaucoma- a disease marked by increased

intra-ocular which can cause blindness if not

treated.

Hyperopia- the refractive condition of the eye

at rest such that light rays from a distant object

are focused behind the retina.

Hypertropia- a tendency of one eye to deviate

upward.

46

Iris- the colored circular membrane

surrounding the pupil.

Iritis- inflammation of the iris.

Lacrimal apparatus- the system responsible

for the formation, secretion and drainage of

tears.

Lazy eye- lay term for amblyopia.

Lens- the transparent body, convex on both

surfaces, lying directly behind the iris and

serves to focus light rays on the retina.

Lids- the outermost covering of the eye.

Macula- a small depressed area in the retina

where sharpest vision occurs.

Monocular- pertaining to or having one eye.

Myopia- a refractive error in which the eyeball

is too long from front to back or the refractive

power so strong so that parallel rays of light

are focused in front of the retina.

Near point of accommodation- the nearest

point at which the eye can see an object

distinctly. It varies according to the power of

accommodation in the individual.

Near point of convergence- the nearest point

at which two eyes can direct their gaze

simultaneously, normally about three inches

from the nose.

Nearsighted- lay term for myopia.

Night blindness- a condition in which the sight

is good by day by deficient at night or in faint

light.

Nystagmus- an involuntary rapid movement of

the eyeball; it may be lateral, vertical, rotary or

mixed.

Occluder- a device used to cover one eye

during vision screening.

Oculus dexter (O.D.)- right eye.

Oculus sinister (O.S.)- left eye.

Oculi uterque (O.U.)- both eyes.

Ophthalmologist- an MD. who specializes in

medical and surgical diagnosis and treatment

of defects and diseases of the eye, prescribes

drugs, eyeglasses, contact lenses and optical

aids.

Ophthalmoscope- an instrument used in

examining the interior of the eye.

Optic nerve- nerve by which visual impulses

are transmitted from the retina to the brain.

Optician- a person who grinds lenses, fits

them into frames and adjusts the frames to the

wearer.

Optometrist (OD)- a doctor of optometry who

specializes in the diagnosis and treatment of

functional vision problem, prescribes

correctives lenses, contact lenses, or visual

therapy and examines for eye disease or

ocular signs of systemic disease.

Orthophoria- straight eyes.

Peripheral vision- ability to perceive

presence, motion or color of objects to the

side.

Phoria- a root word denoting a latent tendency

of one eye to deviate up, down, left or right.

47

Photophobia- eyes having an abnormal

sensitivity or discomfort in light.

Plus lens- a convex lens used for screening

farsightedness by checking the eyes’ ability to

accommodate at distance.

Posterior chamber- space between the

posterior surface of the iris and anterior

surface of the lens filled with aqueous fluid.

Presbyopia- physiological change in the eye

characterized by the lens becoming less elastic

and therefore not able to focus up close.

Ptosis- drooping of the upper eyelid.

Pupil- the opening at the center of the iris that

adjusts to allow light to enter the eye.

Refraction- determination of refractive errors

of the eye and correction by glasses.

Retina- the innermost light sensitive layer of

the eye and contains the rods and cones.

Rods- vision cells that are not color sensitive

used for perception of motion, in low

illumination, and in night vision.

Sclera– the white part of the eye, which with

the cornea forms the external protective coat of

the eye.

Stereopsis– binocular depth perception.

Strabismus– eyes that are out of alignment.

Sty– infection of a gland in the margin of the

eyelid.

Suppression- a condition in which the image

from one eye is ignored (suppressed) by the

brain. Supression that exists for a period of

time could lead to amblyopia.

Tropia– a root word denoting a manifest

turning in, out, up or down of one eye in

relation the other.

Uvea– vascular and pigmented layer of the

eye, includes the choroid, ciliary body and the

iris.

Visual acuity– the ability of the eye to

distinguish detail as an object is placed farther

away or as it becomes smaller in size.

Vitreous humor– transparent gelatinous

substance that fills the space behind the lens

and keeps the eyeball expanded and in shape.

48

Addendums

Forms, Questionnaires, and

Practice Sheets

49

Teacher and Child Vision Pre-Screening Worksheet

Purpose: To identify eye or vision problems throughout the year. Procedure: Child is asked to report any complaint about his/her eyes. Teachers are

asked to report any abnormal visual behaviors or any visual complaints as expressed by the child whenever they occur and give report prior to screening.

Child’s Name

Grade: DOB/Age:

Teacher Name and Date Completed Other Comments

Yes

No

Description: Teacher Observations

Do you suspect anything is wrong with the child's eye/vision

Has the child ever been diagnosed with an eye condition that you are aware of

Have you observed any problems or change in the whites, pupils, lids, lashes or the area around the eyes

Has the child shown any signs of abnormal sensitivity to light or dizziness

Abnormally short attention span

Turning of one eye (in, out, up or down)

Poking at the eyes or frequent rubbing

Excessive blinking

Unusual watering or discharge of the eye

Poor eye contact or eye-hand coordination

Covering or closing an eye when looking at an item of interest

Abnormal head posture such as tilting the head to one side or moving forward or

backward when viewing an item of interest

Squinting

Placing the head close to an item of interest

Inaccuracy in reaching for an item of interest

Avoiding close work

Frowning or scowl when reading

Using finger or other device to keep place while reading

Child’s performance in school is less than expected

Yes No Description: Child’s Complaints

Light Sensitivity

Burning or itching of eyes or lids

Blurred vision or seeing double images

Words or lines running together

Words or pictures jumping

Headache

Nausea or dizziness

50

Child Vision History Questionnaire for Parent/Caregiver (Side 1 of 2) Child’s Name:________________________________________Age/DOB______________ Parent/Caregiver Name:______________________________________________________ Date Filled Out:_____________________________________________________________ CHILD’S HISTORY: Place an “X” in the appropriate box as it applies to your child Yes No Description

Do you suspect anything is wrong with your child's eye/vision

Has your child ever been diagnosed with an eye condition

Have you observed any problems or change in the whites, pupils, lids, lashes or the area around the eyes

Has your child shown any signs ofabnormal sensitivity to light or dizziness

Has your child had any complaints of nausea or headaches

Turning of one eye (in, out, up or down)

Poking at the eyes or frequent rubbing

Excessive blinking

Unusual watering or discharge of the eye

Poor eye contact

Covering or closing an eye when looking at an item of interest

Abnormal head posture such as tilting the head to one side or moving forward or

backward when viewing an item of interest

Squinting

Placing the head close to an item of interest

Inaccuracy in reaching for an item of interest

Has any immediate family member(s) had eye/vision problems that required treatment at an early age before entering school? If yes, explain _________________________________________________________________

Do you have any concerns about your child’s health in general or his/her ability to see clearly? If yes, explain_________________________________________________________________

51

Child Vision History Questionnaire for Parent/Caregiver (Side 2 of 2) Has your child/ family member ever been diagnosed with any of the following conditions? (Family member is defined as blood relatives: “siblings/parents/grandparents/aunts/uncles”)

Yes No Condition If Yes, who Albinism Amblyopia Aniridia/Ankylosing Spondylitis Best Disease Coloboma Congenital cataract Congenital Glaucoma Diabetes Melitus Trisomy 21 (also known as Down Syndrome) Fetal Alcohol Syndrome Juvenile Muscular Dystrophy Marfan Syndrome Myotonic Dystrophy Neurofibromatosis Optic Atophy Pierre Robin Syndrome Prader-Willi Syndrome Retinoblastoma Retinitis Pigmentosa Rubella Sickle Cell Anemia Strabismus Sturge-Weber Disease Toxoplasmosis Turner Syndrome Usher Syndrome Wilson Disease Spondylo-Epiphyseal Dysplasia (SED) Congenita Kniest Syndrome (osteodysplasia) Bardet-Biedl Syndrome Idiopathic Carpotarsal Osteolysis, (Francois Type)

also known as “Dystrophia Dermo-Chondro-Cornealis Familiaris”

Hallermann-Streiff-Francois Syndrome also known as “Francois Dyscephalic Syndrome” or

“Oculo-Mandibulo Dyscrania with Hypotrichosis”

CHARGE Syndrome Rubinstein-Taybi Syndrome

Stickler Syndrome

Nystagmus

Vision loss/blindness

52

Child Vision Development Checklist for Parents/Caregivers

During the first month of life, does your child?

� Look towards the face of the person holding them?

� Closes eyes to sudden bright light?

When your child is 2 months, does your child?

� Follow a moving object? Follow light past midline?

� Look at the eyes of the person holding them?

� Switch gaze between two people or objects?

When your child is 4 months, does your child?

� Reach towards an object and grasp it?

� Fixate on a close object with eyes not crossing?

� Respond to the full range of colors?

� Show visual interest to near and distant objects?

When your child is 6 months, does your child?

� Enjoy looking in a mirror?

� Sustain visual interest at near and distant objects?

� Maintain fixation on stationary object, even in the presence of competing moving stimuli?

� Begin to demonstrate hand-eye coordination?

When your child is 7-12 months, does your child?

� Notice small objects such as breadcrumbs?

� Smile back at another person?

� Recognize objects that are partially hidden?

� Scan eyes around the room to see what is happening?

When your child is 18 months, does your child?

� Point to objects or people using words “look or see”?

� Look for and identify pictures in books?

� Play with simple puzzles?

When your child is 24-36 months, does your child?

� See small pictures well with both eyes?

� Show ability to arrange similar pictures in groups?

� Watch and imitate other children (30-36 months)?

Source: CDC, AAP

Child’s Name_________________________________________ DOB/AGE_______________

Parent/Caregiver Name_________________________________________________________

53

VISION SCREENING WORKSHEET

Child’s Name: DOB: Age:

____Yrs____Mo

Name of Initial Screener:

Name of Re-Screener:

Date:

Initial Screening

Date:

Re-Screening

Screening Test Ages Pass ReScreen Pass Referral

External Inspection WIPL all ages

Pupillary Light Response birth to ~3y

Retinal (Red Lt) Reflex birth to ~3y

Observations 4mo to Gr 3(8y)

Corneal Light Reflection 2mo to Gr 3( 8y)

Cross Cover Test 4mo to Gr 3 (8y)

EOM/Fix & Follow Monocular 4mo to ~3y +

EOM/Fix & Follow Binocular 4mo to ~3y +

Color vision Male (6y)Grade 1

Visual Acuity Ages Pass ReScreen Pass Referral

Right Eye Left Eye

10/ 10/ ~3 to 5yr

10/ 10/ ~3 to 5yr

20/ 20/ 6yr +

20/ 20/ 6yr +

Optional Tests Pass ReScreen Pass Referral

Plus Lens ( 6y (Gr 1) to 11y Gr 5)

Stereopsis Test (3yr-Gr 3 or 8yrs)

Comments:

Initial Screening ReScreening

Do you question the validity of the test today?

Is the behavior today typical for this child?

Legend: ~ (approximately) + (and older) Gr (Grade)

54

Vision Referral Letter for (Child’s Name)_______________________________

Dear Parent:

In keeping with the recommendations of the Minnesota Department of Health, your child was screened

____/____/____ and re-screened ____/____/____.

You are urged to take your child for a professional eye examination for the reason(s) checked below:

Your child has had complaints about his/her vision

Child/Family history of eye conditions

External eye problems

Possible eye muscle problems (noted by observation, corneal light reflex, EOMs or cross cover)

Abnormal Retinal (Red Light) Reflex

Possible stereopsis problems

Possible farsightedness problems

Your child was unable to read lines on the chart appropriate for age group OR the difference

between vision in each eye was greater than one line (with) (without) corrective lenses

Right 10/______ Left 10/______ or Right 20/______ Left 20 / ______

Please have your eye care professional complete this form

Dear Eye Care Provider:

Please complete this portion of the form and send it at your earliest convenience to:

(School Nurse) ____________________________________________________________

____________________________________________________________

I have examined________________________________DOB__________on _______/_____/________

My findings are: Right: _____/_____ Left: _____/_____ without corrective lenses

Insufficient to require treatment Muscular Condition:

Fully Correctible Myopia

Partially Correctible Hyperopia

Not Correctible Astigmatism

Corrective lenses prescribed Supression

Best Correction: R ____/____ L _____/_____ Fusion Condition

Change in corrective lens External Eye Condition

Best Correction: R ____/____ L _____/_____ Other:

No significant visual handicap to interfere with

learning

A visual handicap that may interfere with

learning

Child should return for follow-up examination______________________________________________

Recommendations including any accommodation that the school should make for the student:

___________________________________________________________________________________

Print Name ____________________________ Signature_____________________________________

55

Color Vision Advisory Letter

Child Name___________________________________________ Grade _____ Room _____

Dear Parent/Guardian,

During the recent vision screening conducted at your child’s school, your child displayed some

difficulty meeting passing criteria in distinguishing colors. This screening is not diagnostic but

suggests your child may have some color vision deficiency. The following information may be

helpful to you.

Color Vision Deficiency:

���� Current literature suggests there is no significant difference in school achievement between students with normal color vision and those with color deficiencies.

���� Children use different clues to identify colors so the condition generally is

not problematic. ���� Referrals for professional evaluation of this condition are usually not made

since there is no widely accepted treatment for color vision problems at this time.

A professional examination may be beneficial to determine if the problem exists and to

accurately diagnose it.

• During the early years of school, the use of colors in conjunction with learning concepts in

arithmatic and other materials is sometimes employed and may be a problem for children

with vision color deficiency.

• Accommodations for this can easily be made and schools are required to do so by

federal law if there is a properly documented diagnosis.

• Additionally, as your child gets older, informed decisions about career choices can be

made when the exact nature and scope of the visual problem is known since some

occupations require the ability to distinguish colors.

56

Child and Teen Checkups Online Resources

1) Child and Teen Checkups Documentation Templates: (Available Online)

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&Revision

SelectionMethod=LatestReleased&dDocName=id_048044

Figure 1. Example of Vision and Hearing Documentation from Child and Teen Checkups Documentation Templates

2) Child and Teen Checkups- Vision Screening FACT Sheet for Primary Care Providers:

http://www.health.state.mn.us/divs/fh/mch/ctc/factsheets/vision.pdf

3) Child and Teen Checkups Online Vision Screening Module

http://www.health.state.mn.us/divs/fh/mch/webcourse/index.html

4) Child and Teen Checkups Trainings

http://www.health.state.mn.us/divs/fh/mch/ctc/trainings/index.html

57

58

PRESCREENING PRACTICE SHEET

In order fo

r us to ch

eck

you

r ch

ild’s vision he/she m

ust be able to play

a m

atch

ing ga

me.

1. Cut the pap

er alon

g th

e dotted lines.

2. Place the fou

r large letters (Chart 1) in fron

t of

you

r ch

ild.

3. Po

int to a letter on

Chart 2 and

have you

r ch

ild tou

ch the letter th

at loo

ks the sam

e on Chart 1.

Start with the large

r letters and

move dow

nward to th

e smaller.

4. Play

the gam

e until you

r ch

ild respon

ds co

rrectly and

con

sistently.

59

PRESCREENING PRACTICE SHEET

In order fo

r us to ch

eck

you

r ch

ild’s vision he/she m

ust be able to play

a m

atch

ing ga

me.

1. Cut the pap

er alon

g th

e dotted lines.

2. Place the fou

r large letters (Chart 1) in fron

t of

you

r ch

ild.

3. Po

int to a letter on

Chart 2 and

have you

r ch

ild tou

ch the letter th

at loo

ks the sam

e on Chart 1.

Start with the large

r letters and

move dow

nward to th

e smaller.

4. Play

the gam

e until you

r ch

ild respon

ds co

rrectly and

con

sistently.

O V

H V

O

T

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H

O

V

H

V

O

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O H