Vision Screening Basics Vision Screening Basics for Health Assistantsfor Health Assistants
Charlotte Branch-Briggs, BSN, RNNMDOH NE Region School Health Advocate505-476-2714 [email protected]
Vision DevelopmentVision DevelopmentBy about 4-6
months of age, a child should be using both eyes together (binocular vision). At 7 ½ to 8 years of age, the eye reaches optimum size for seeing and the brain has learned to interpret the information that the eye gives it.
NM School Health Manual, NM School Health Manual, Section IIISection III
Recommended Screening Equipment
Room Set Up and Screening Environment
Recommended grades to screen
Recommended tests to perform
Who can do vision Who can do vision screening?screening?
A school nurse trained in vision screening assessment
A Primary Care Health ProviderSchool nurse designee or lay
eye screener trained in vision screening techniques
New Mexico LawNew Mexico LawHouse Bill 1283 and Senate Bill
1149 passed into law in 2007Defines who can perform vision
screening Targets screening for pre-
kindergarten, kindergarten, first grade, third grade and for all transfer and new students unless a parent prohibits vision screening.
New Mexico Law con’t…New Mexico Law con’t…Created the “Save Our Children’s
Sight Fund” for expenditures related to vision exams and glasses regardless of family income
Designated the Department of Health as responsible for the development and implementation of screening practice guidelines for children ages pre-k through 12th grade
EARLY DETECTIONEARLY DETECTIONThe purpose of a vision screening
program is early detection of common vision disorders such as refractive errors, amblyopia and strabismus.
Parent Permission for ScreeningAlways get parent permission or
notify parents that their child will be screened.
Parents may request that child not be screened.
Vision Screening GuidelinesVision Screening Guidelines
Grade levels to be screened yearly are:◦ Pre-kindergarten◦ Kindergarten◦ 1st grade◦ 3rd grade◦ All students new to
the district ◦ Sp Ed. Students with
IEP evaluations◦ SHM recommends 8th
grade screening
Tests to be performed at screening:◦ Far Vision – any
grade level◦ Random Dot E or
Stereopsis – only required once in target populations
◦ Color Vision – only required once in target populations
Creating a Screening Creating a Screening EnvironmentEnvironment
Screening Room Set UpScreening Room Set Up
Make sure the room has adequate lightThe wall behind the chart should be plain
white or a neutral color - a busy pattern behind the chart can distract the child while testing
Keep other students quiet while waiting to be screened to minimize distractibility of children being screened
Clearly mark where student should stand or sit for testing – 10 feet from a 10 foot chart
The chart’s passing line should be placed at eye level
Equipment to Use for Equipment to Use for ScreeningScreening Pre-kindergarten and Kindergarten can use an
HOTV or Lea symbol chart. 1st grade can use letter chart or HOTV chart
depending on their ability to accurately identify the letters.
All other grades should use letter charts.
Distance Charts“For testing at 10 feet”
Equivalent 20 foot
Actual 10 foot
Equipment to use con’t….Equipment to use con’t….Random Dot
EButterfly or
fly stereopsisEye
occluders
Before testing begins.....Note if the child is
wearing glassesAre their eyes equal
in appearanceAre their eyes clear
– are they red? Crusty discharge?Swollen/puffy
eyelids?
Droopy eyelids?Keyhole pupils?Do the eyes move
together?Excessive tearing? Jerky eye
movements?Pupil constricted or
dilated?
Notify your school nurse if you see any of these visual signs so that additional assessment can be done!
Distance ScreeningDistance ScreeningThe child stands or sits 10 feet from the chart
– the child’s heels should be on the 10 ft mark if standing, the back of chair should be at 10 ft line if sitting
For younger children, functional acuity should be done using both eyes to review testing procedures with the child
Ask the child if they wear glasses or contacts to help with distance or near vision – test them with their glasses ON. Be sure to mark on the testing sheet that the child was tested WITH CORRECTION if wearing glasses
Start at the top of the chart and work your way down the chart – you may skip lines if the child is moving along and understanding the directions.
Distance screeningDistance screeningOnce you get to the passing line, move all the
way across the line Passing is when the child can correctly identify
one more than half the letters on the lineTest one eye at a time by securing a cover
over the left eye first using an occluder, disposable eye patch, small Dixie cup or paper cut out.
ALWAYS praise their response with “great job” , “good” or “yes”
Do not let them know they missed a letter or ask them to try again
If they fail a line, move back up the chart until they can identify one more than have the line correctly.
What to look for in What to look for in distance testingdistance testing
Is the child turning their head or trying to look around the occluder?
Are they squinting? Do they become easily distracted, anxious or
fidgety when testing? Are their eyes watery or tearing during
testing? Are they rubbing their eyes?
THESE ARE SIGNS THE CHILD IS STRUGGLING TO SEE AND YOU SHOULD MOVE BACK UP THE CHART UNTIL THE CHILD CAN PASS THE LINE WITHOUT SHOWING
THESE SIGNS.
IsolatorsUsing linear isolators is OK if the
child is having difficulty focusing on the vision chart during screening
Letter isolators are not recommended as this increases the chance of missing amblyopia
SEE EXAMPLE NEXT SLIDE
Isolators
Random Dot E or StereopsisFor children 3years to 3rd gradeUsed to check for problems with depth
perception – indication of strabimusUse Random Dot E when availablePlace polarized glasses on child – do not
remove any prescription glasses if the child wears them, place to polarized glasses over the prescription glasses
Make sure the location is well lit and glare free
Be sure the child keeps their head straight – no tilting to one side or allowing polarized glasses to tilt.
Random Dot E con’tAt 20 inches away from the child, hold up the
sample model E and ask child to identify object. If they can not identify letter, point at the figure and say “that’s an E”
With the glasses still on, practice using the sample card and the blank card – mixing up the cards behind your back, and present to the child 4-5 times, asking them to identify the E each time.
Then replace the sample card with the stereo E card, repeat the steps above (you may need to rotate the cards up and down to pick up the light to give optimal viewing of the stereo image)
Move back 40 inches from the child and repeat last step.
Random Dot E con’tPass if the child is able to point to
the correct stereo E card at least 4 times at 20 inches and 40 inches
Rescreen/Refer is the child can not distinguish the E figure in the RDE card at all, or can only see it when the card is approximately 20 inches or closer
ANY rescreens should be performed by the school nurse
Stereo Butterfly or FlyFor children 3 years to 3rd gradePlace polarized glasses on child –
over prescription glasses if applicableMake sure child keeps head straight
when viewing test plate.Present the plate at a normal reading
distance.Ask the child what the figure is, if
they can not identify the figure, ask the child to touch the butterfly’s wings
Stereo Butterfly or Fly con’tPass – the student is able to point
to the butterfly wings above the page
Rescreen/Refer – The child can not distinguish the butterfly figure in the stereo butterfly card or touches the page when trying to touch the wings
ANY rescreens should be performed by the school nurse
Test for Red/Green deficiencies, Blue/Yellow deficiencies more rare
Full test consists of 39 plates, but deficiency become apparent after just a few
No treatment for color blindness Adequately lit room using day light Hold about 30 inches from subject Answers within 3 seconds With both eyes uncovered, ask the
student to identify the numbers or trace them with the Q-tip (Ishihara).
With the double numbers and small children, you may need to cover one and identify only one at a time.
Passing is a correct response on each slide.
McDowell is matching block colors in sequence.
Creamer color charts present 2 figures (star and circle) which may be easier for preschool or preliterate kids to identify.
Color Vision – Ishihara Plates
Additional thoughts on Vision ScreeningIf a kindergartener fails vision screening
at mass screening, bring child back to health office 2 weeks later to rescreen privately
If any child fails the vision screen – do not tell them “YOU FAILED” your vision test, instead say, “I’m going to have the nurse check my results” and send them to the rescreening station, or call them back down to the health office at a later date.
Investigate whether or not the child is currently supposed to be wearing prescription glasses and where they are if the child did not bring them to screening.
Passing GuidelinesPassing Guidelines – Vision* If vision in either eye is WORSE that the limits below OR if the student has a 2 line difference or greater - then REFER for vision exam.
Grade Distance Other Testing
PK 20/40 •Random Dot E and Color Vision – required only once in any of the target population grades.K 20/30
1 20/30
3 20/30
Passing Guidelines - Hearing
1000 Hz20 dB
2000 Hz20 dB
4000 Hz20 dB
RRPS Screening Worksheet Student Name:____________________ Date of Screening:__________________ Grade:_______________
Teacher:_______________
School:_______________
Wears Glasses: _____Yes _____No _____Reading _____Distance If Yes, glasses are worn at screening: □Yes □ No □ Broken/ Lost HEIGHT _______________ WEIGHT________________ Vision Screening 1st Screening 2nd Screening BY SCHOOL NURSE Screened by:_______________________
Screened by:_______________________
Distance: □ 10 ft. Right Eye 20/ ________ □ 20 ft. Left Eye 20/ _______ Functional Acuity (both eyes) 20/ _________ Chart Used: □ Letter □ PASS □ “E” □ FAIL □ HOTV □ Symbol/ Picture
Distance: □ 10 ft. Right Eye 20/ ________ □ 20 ft. Left Eye 20/ _______ Chart Used: □ Letter □ PASS □ “E” □ FAIL □ HOTV □ Symbol/ Picture
Near: Right Eye 20/ ________ Left Eye 20/ ________ □ PASS □ FAIL
Stereo/ Depth: □ PASS □ FAIL
Stereo/ Depth: □ PASS □ FAIL Color: □ Color Blocks □ PASS □ Ishihara □ FAIL □ Did Not Test Motility: Tracking/ Convergence: □ PASS □ FAIL
Screening Notes
Cover/ Uncover: Near: 12-13 inches □ No Eye Movement – PASS □ Eye Movement – FAIL □ Could not Test/ Did not Test
Hearing Screening 1st Screening Date: 2nd Screening Date: Right
500 (25 dB)
1000 (20 dB)
2000 (20 dB)
4000 (20 dB)
Right
500 (25 dB)
1000 (20 dB)
2000 (20 dB)
4000 (20 dB)
Left
500 (25 dB)
1000 (20 dB)
2000 (20 dB)
4000 (20 dB)
Left
500 (25 dB)
1000 (20 dB)
2000 (20 dB)
4000 (20 dB)
Otoscopic Exam (by school nurse): □ Clear □ Possible Ear Infection □ Possible Wax Impaction □ Refer □ Re-Check by Audiologist __________(date) □ PASS □ Watch
Recheck and ReferralsA school nurse should recheck all vision
“fails”If the child has glasses that are broken or
lost, there is no need for a second screening – just have the nurse refer the student
Follow up with referrals after 4 weeks and again in 8 weeks
The school nurse may need to provide parent education and vision resources if they are non-compliant in taking their child for an exam.
RESOURCES for GlassesSave Our Children’s Sight Fund – thru
DOHMedicaid – will pay for one eye exam
and one pair of glasses per yearChildren’s Medical Services – for
children w/o Medicaid and meet certain criteria
New Mexico Lion’s Operation KidSight – active in certain communities and has limited resources for exams and glasses or uninsured or needy students.
RESOURCES con’tNew Mexico School for the Blind and Visually
Impaired – fund for eyeglasses for children who are diagnosed with a visual impairment. This funding must be approved by legislature each year.
Pasty Irene Bennett Memorial Endowment Vision Care Program Fund – only for APS students, pays for exams and glasses for APS students.
Sight for Students – gift certificates through the NASN for exams and glasses. Only school nurse with current membership in NASN can receive gift certificates. There are financial qualifiers to use certificates.
Follow-up to ReferralsTHE most
important part of process.
THE most difficult part of process.
Make at least 2 phone calls.
Offer resources.Document.
QUESTIONS?
Dental Screening
Section XIII of NM School Health Manual
Optional (as directed by district)
Dental Caries looks like......
Gum Disease looks like......
Oral Herpes (Cold Sore)
Canker Sore
Avulsed Tooth
Mouth lesions from chewing tobacco
Height and Weight Screening
Section XII of NM School Health Manual
Optional (as directed by district)
Growth ChartsIf measuring, be consistent
(remove shoes, hats, coats, sweatshirts, etc) and provide privacy.
When looking at heights and weights – compare percentiles on the growth charts.
Use CDC growth charts which can be found at:◦www.cdc.gov/growthcharts/
CDC BMI Charts
Referrals for Elevated BMIDoes your district have a policy
regarding BMI referrals?Follow district guidelines.
