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Vision ScreeningGuidelines for theSchool NurseAugust 2014

Objectives Discuss the purpose and evaluation of anyscreening program State the purpose of vision screening in theschool Identify the recommended vision screeningprocedures and equipment Explain the importance of follow up andtracking of vision referrals

Purpose of AScreening ProgramTo identify or detect .1. Commonly occurring diseases/entities/healthproblems or conditions in order to facilitate 2. Early intervention that will be 3. Significantly beneficial to the client Proctor, 2005

Characteristics ofScreening Programs Brief or limited evaluation of a group of individualspresumed to be normal Results must be communicated Follow-up on referrals for those “at risk” keycomponent of screening Follow-up continued until problem is resolved

Referral Process Parents– Notify by phone/visit any student who meets thereferral criteria following the screening and therescreening Parental understanding Elicit need for additional resources/assistance Provide information on community resources

Referral Results Follow with written referral communicating results ofthe screening– Request written report withresults/recommendations Contact parent periodically and provide assistance asneeded Track referrals made Notify classroom teacher

Evaluation ofScreening ProgramTo determine the effectiveness of any screeningprogram, careful evaluation of the planning,implementation, referral process, and referraloutcomes must be completed with each screening.

EvaluationEvaluate in terms of:––––––Validity—ability to identify those who have conditionReliability—consistency of resultsYield—number of persons identifiedCost—personnel and equipmentAcceptance—informed parents agree to valueFollow up—communicating results to parents whorespond with appropriate actions to get necessarydiagnosis and treatment if indicated

Vision ScreeningGuidelines

Purpose and Objectiveof A VisionScreening Program Ability to see impacts on student’s ability to learn– Estimated 80% of learning occurs through visualsenses– Influences student’s performance andadjustment in school, society, as well as overallhealth and behavior

Purpose and Objectiveof A VisionScreening Program Identify children with possible visual defects atearliest possible stage allowing time to refer fordiagnosis and treatment Earlier identification results in improvedoutcomes

Screening ProgramScheduleGradeScreenType ofScreeningAll students new todistrictRecommendedAge AppropriateKRecommendedNear & DistanceAcuity, Random Dot ERecommendedNear & DistanceAcuity, Random Dot E2ndRecommendedNear & DistanceAcuity, Random Dot E3rdRecommendedNear & DistanceAcuity, Random Dot EEvery other year after3rd gradeRecommended astime permits1stNear & Distance Acuity

Visual Acuity Visual acuity refers to the sharpness of one’seyesight. Acuity is reported in a fraction.– Numerator – distance from the subject to the chart– Denominator – size of the symbol the person cansee at 20 feet– Example – 20/40, at 20 feet the eye sees at a 20foot distance what a normal eye sees at 40 feet

Childhood VisionDisordersConditionNegative ImpactInterventionMyopiaBlurry distance visionPoor school performanceGlassesContact LensesHyperopiaBlurry near visionEye strainDifficulty readingPoor school performanceGlassesContact LensesAstigmatismBlur at distance and nearEye strainGlassesContact Lenses

Myopia The most common of therefractive errors.Formerly called“nearsightedness”.Unable to see clearly atdistance.

Hyperopia A refractive error in which the light rays from anincoming visual image have not converged by thetime they reach the retina. Formerly called“farsightedness”. Near vision is blurry.

Strabismus A manifest deviation of oneor both eyes from the visualaxis of the other so they arenot simultaneously directedto the same object. Alsoreferred to as heterotropia,or tropia.

Amblyopia An ocular condition in an otherwise healthy eye, inwhich there is an abnormality of corticol response inthe occipital lobe of the brain due to insufficient orinadequate stimulation of the fovea, neuralpathway, and cortex that may result in unilateralvision loss if untreated.

AmblyopiaGood eyeAmblyopic eye

Distance VisualAcuity Screening Purpose– Screen for clearness of vision when looking in the distance– Detect Myopia (nearsightedness) Amblyopia (weakness of sight, lazy eye) Astigmatism (blurred vision)

Distance VisualAcuity Screening Equipment– Distance chart for 10 or 20 feet (should include 20/25 line) Choose according to student’s developmental level HOTV, Snellen, Sloan, Tumbling E, LEA Symbol, Lighthouse– Occluder (e.g., paper cup, paper patch, palm of hand withtissue)– Antibacterial wipes

Examples of VisionCharts

Distance VisualAcuity Screening Location Quiet with no distractions Well lit and free from glare Suggestionso Room 5 feet longer than distance for screening toolo Minimum of 8-10 feet between stations if multiplestations

Distance VisualAcuity Screening Setup Chart at student’s eye levelo May be seated or standing Mark off a 10-20 feet distance with tapeo Position heels or back legs of chair on tapeo Eyes should be in direct line above tape

Distance VisualAcuity Screening Procedure– Orient student to the screening– Demonstrate use of occluder– Ask if student wears glasses. If yes, screening should bedone with glasses on (be sure to mark the form)– Watch carefully that student is not peeking, tilting head,squinting or leaning head or torso forward– Begin by screening right eye with left eye occluded– Instruct to keep both eyes open and read the selectedletter or line of letters with the uncovered eye.– Begin at 20/50 line and move down to 20/20 line

Distance VisualAcuity Screening (cont.) Procedure (cont.)– Move upward if student unable to read 20/50 line– Do not use marking device as pointer to avoid leavingdistracting marks on chart– Student must identify or match one more than half ofthe letters/symbols on a line– Record results including the line number for the lastline read correctly with each eye– Repeat procedure for left eye– If student is unsuccessful, he or she should berescreened within 14-21 days

Distance Visual AcuityReferral CriteriaA failed screening followed by afailed rescreening should be referred for further evaluationGradeCriteriaKindergartenEach eye must see at least the20/40 line.1st – 12th gradeEach eye must see at least the20/30 line.

Distance Visual AcuityReferral Criteria –Important ExceptionRefer if there is a two-line differenceOne EyeOther ss20/2020/25Pass20/2020/30Refer – 2 linedifference

Near VisualAcuity Screening Purpose– Screen for near visual acuity– Detect excessive hyperopia (farsightedness) Equipment– Near vision chart chosen according to student’sdevelopmental level (should include 20/25 line)– Occluder (e.g., paper cup, paper patch, palm ofhand with tissue)– Antibacterial wipes

Near VisualAcuity Screening Location Quiet and no distractions Well lit and free from glare Suggest--minimum of 8-10” between stations ifmultiple stations

Near VisualAcuity Screening Procedure– Orient student to the screening– Demonstrate use of occluder– Ask if student wears glasses. If yes, screening should bedone with glasses on (be sure to mark the form)– Watch carefully that student is not peeking, tilting head,squinting or leaning head or torso forward

Near VisualAcuity Screening Procedure (cont.)– Begin by screening right eye with left eye occluded– Instruct to keep both eyes open and read the selectedletter or line of letters with the uncovered eye.– Begin at 20/50 line and move down to 20/20 line– Ask the student to name or read the letter or symbolson each line as directed.

Near VisualAcuity Screening Procedure (cont.)– Move upward if student unable to read 20/50 line– Do not use marking device as pointer to avoid leavingdistracting marks on chart– Student must identify or match one more than half ofthe letters/symbols on a line

NearVisual Acuity Procedure (cont.)– Record results including the line number for the lastline read correctly with each eye– Repeat procedure for left eye– If student is unsuccessful, he or she should berescreened within 14-21 days

Near Visual AcuityReferral CriteriaA failed screening followed by afailed rescreening should be referred for further evaluationGradeCriteriaKindergartenEach eye must see at least the20/40 line.1st – 12th gradeEach eye must see at least the20/30 line.

Near Visual AcuityReferral Criteria –Important ExceptionRefer if there is a two-line differenceOne EyeOther ss20/2020/25Pass20/2020/30Refer – 2 linedifference

Binocularity/StereoscopicVision Screening What is Binocular Vision– Includes ocular alignment and stereo acuity– Screening determines how well eyes functiontogether

Binocularity/StereoscopicVision Screening Purpose of Screening– to determine if student has adequatebinocularity Equipment– Random Dot (RDE) Stereotest Kit– Antibacterial wipes

Random Dot E KitEquipment

Random Dot E Constructed ofcardboard with alarge raised,embossed “E” Used only fortraining purposesas it is easy forthe student to seeModel E Slide

Random Dot E Presents an array ofdots that appear to berandomly oriented. When viewed throughpolarized glasses, an Eappears in the test plateif the student has normalbinocular vision.Raised/Recessed E Slide Used for screeningpurposes only

Random Dot EWith the glasses inplace, children withgood alignment andnormal binocularvision will be ableto see the stereo “E”in 3-dimensions.

Random Dot E Presents a randomarray of dots. No“E” appears evenwith the polarizedglasses in place. Used for trainingpurposesStereo Blank Slide

Random Dot E Is also used forscreening purposeswhen paired with theRaised/Recessed E SlideStereo Blank Slide

Random Dot E Location and Setup– Make sure that the test distance between thestudent and the cards is carefully measured at40 inches.– Make sure that there is bright room lighting.

Random Dot E Procedure– Have student put on stereo glasses.– If the student wears glasses, the stereo glassesshould be placed over the student’s own glasses.(Indicate on form)– Be sure the student keeps head straight whenviewing slides

Random Dot E Hold model Edemonstration plateat a distance of a 40inches in front ofstudent.

Random Dot E Point to the “E” andsay to the student,“Tell me what yousee.”

Random Dot E Pick up the blank testplate and hold it next tothe demonstration plate. Ask the student to pointto the plate with theraised, embossed “E”.

Random Dot E Shuffle the plates behindyour back and repeat theprocedure 4 more times,holding the plates sideby side or above andbelow each other. Varythe position.

Random Dot E Replace the Model E slide with theRaised/Recessed Stereo slide when you determinethat the student understands the procedure Repeat the procedure Student passes the stereo screening if he/shecorrectly identifies the location of the stereo E onat least 4 of the 5 presentations.

Random Dot E Be careful to hold the stereo test plate with the Eupright. Tilting the top of the stereo test plate maybe helpful. It takes a few seconds to see the stereo “E”, --encourage the student to “keep looking”. You can tell the student that the “E” is hiding andthat they need to look hard to find it.

Random Dot E Do not let the student see the plateswithout the stereo glasses. The student should be referred if he or sherefuses to wear the glasses, even afterwatching another student being screened.

Random Dot EScreening Results Let the parents know the results of the screening,include type of screening and date. The eye careprofessional wants to know the screening methods.