Kenneth Royall Children’s Vision Screening Improvement

www.pbnc.org

Kenneth Royall Children’s Vision Screening Improvement Program Participant Guide

PARTICIPANT NAME

DATE

Table of ContentsCOURSE OVERVIEW

Course Objectives 3

Children’s Screening Described 4

Summary of State Laws Pertaining to Vision Screenings 6

SECTION 1: NATURE AND SCOPE OF CHILDREN’S EYE PROBLEMS

1.1 Common Eye Problems 8

1.2 ABCs of Potential Vision Problems 10

SECTION 2: CHILDREN’S SCREENING MATERIALS

2.1 General Supplies 11

2.2 Acuity Screening Supplies 11

2.3 Space Requirements 12

SECTION 3: SCREENER ROLES AND RESPONSIBILITIES

3.1 Roles 13

3.2 Responsibilities 13

SECTION 4: DISTANCE VISUAL ACUITY SCREENING

4.1 Definition 14

4.2 Measurements and Recording 14

4.3 PBNC–Recommended Distance Acuity Charts 14

4.4 Visual Acuity Screening Steps 15

4.5 Practice Worksheet 20

SECTION 5: SPECIALIZED VISUAL TESTS

5.1 Near Vision Acuity Testing 21

5.2 Stereopsis Testing 23

SECTION 6: REFERRAL, DOCUMENTATION, AND FOLLOW-UP PROCEDURES

6.1 PBNC Referral Criteria Summary 25

6.2 Documenting Screening Results 25

6.3 Screening Follow-Up 26

6.4 Resources 27

Course OverviewCOURSE OBJECTIVES

Upon completing this course participants will be able to successfully conduct a children’s vision screening program. You will learn to:

• Recognize signs of vision difficulties and potential eye problems

• Conduct a children’s vision screening

• Interpret acuity screening results

• Understand follow-up procedures

PREVENT BLINDNESS NORTH CAROLINA’S ROLE IN SCREENING

Founded in 1967, Prevent Blindness North Carolina is the state’s leading volunteer eye health and safety organization dedicated to preventing blindness and preserving sight. Focused on promoting a continuum of vision care, Prevent Blindness North Carolina touches the lives of thousands of people each year through public and professional education, certified vision screening training, community service programs, advocacy, and research. These services are made possible through the generous support of the North Carolina Department of Health and Human Services, corporate, and private funding. Together with the support of a national office and a network of affiliates, divisions and chapters, Prevent Blindness remains committed to eliminating preventable blindness in North Carolina. For more information, or to make a financial contribution to programs and services, call 1.800.543.7839 or visit the website www.pbnc.org.

COURSE OVERVIEW

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CHILDREN’S SCREENING DESCRIBED

The purpose of a screening is to test asymptomatic people for eye diseases and refer those who are suspect, for eye disease or refractive error, to eye care professionals.

WHAT IS CHILDREN’S VISION SCREENING?

Children’s vision screening is a systematic approach to identifying children with potential vision problems.

WHAT IS THE PURPOSE OF THE CHILDREN’S VISION SCREENING PROGRAM?

The purpose is to identify and refer children with potential vision problems to an eye care professional or primary care provider for further examination, diagnosis, and if necessary, treatment and follow-up. Prevent Blindness NC provides training in support of mass screening to test all public school children for vision problems and refer those who are suspect to eye care professionals.

WHAT IS THE DIFFERENCE BETWEEN A SCREENING AND AN EXAMINATION?

A Screening • Identifies children with possible

vision problems

• Raises school personnel’s awareness of childhood vision problems

• Alerts parents to possible vision problems

• May result in a referral to an eye care professional

SCREENING COMPONENTS

The components listed below comprise a minimum or baseline for effective children’s vision

screening programs.

• Observation (ABCs)

• Distance visual acuity screening

• Stereopsis screening for children entering Kindergarten

• Referral and follow-up

An Examination • Examines child for eye disorders

and diseases

• Diagnoses eye disorders and diseases

• Prescribes treatment and follow-up visits

COURSE OVERVIEW

IMPORTANCE OF SCREENING

If not detected and treated early, vision problems in children can lead to a variety of problems. Since children often do not realize they are not seeing as they should and may not complain about signs of a problem even when aware of a difficulty, screening takes on a critical role for preventing serious problems. Untreated vision problems can lead to:

• Loss of vision

• Learning difficulties

• Delayed sensory, motor, cognitive or social-emotional development

• Without help, children may not be able to “catch-up” later, even if the vision problem is corrected and their vision is normal. As adults, they may have trouble learning job skills. That is why it is very important to screen the vision of young children to identify vision problems or potential vision problems as early as possible and to help assure children with vision impairments get the special help they need.

Some children are at higher risk for vision disorders and may be referred directly to an eye doctor for an eye examination. Note that, unless the vision screening is being conducted in the child’s medical home, the screener is not likely to have access to a child’s medical history and will not be in a position to refer based on the following conditions:

• A diagnosis of a neurodevelopmental disorder

• Systemic diseases known to have associated eye disorders

• A family history of a first-degree relative with strabismus, amblyopia, or high refractive error

• A history of premature birth and low birthweight who has not already had a normal comprehensive eye examination

• Parents who believe their child has a vision-related problem or have concerns regarding their child’s reaching age-appropriate developmental or academic milestones

COURSE OVERVIEW

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SUMMARY OF STATE LAWS PERTAINING TO VISION SCREENINGS

The following is an overview of laws pertaining to vision screenings in North Carolina. It does not include the complete legislative language or all directives.

130A-440. (APPLICABLE TO CHILDREN ENROLLING IN THE PUBLIC SCHOOLS FOR THE FIRST TIME BEFORE THE 2016–2017 SCHOOL YEAR) HEALTH ASSESSMENT REQUIRED.

https://www4.ncleg.net/enactedlegislation/statutes/pdf/bysection/chapter_130a/gs_130a-440.pdf

Every child in this State entering kindergarten in the public schools shall receive a health assessment. The health assessment shall be made no more than 12 months prior to the date of school entry. No child shall attend kindergarten unless a health assessment transmittal form, developed pursuant to G.S. 130A-441, indicating that the child has received the health assessment required by this section, is presented to the school principal. A health assessment shall include a medical history and physical examination with screening for vision and hearing and, if appropriate, testing for anemia and tuberculosis. Vision screening shall be conducted in accordance with G.S. 130A-440.1.

130A-440.1. EARLY CHILDHOOD VISION CARE.

https://www4.ncleg.net/enactedlegislation/statutes/pdf/bysection/chapter_130a/gs_130a-440.1.pdf

Requires vision screening for every child entering kindergarten or enrolling in the public school for the first time in the public schools in accordance with vision screening standards adopted by the Governor’s Commission on Early Childhood Vision Care. Within 180 days of the start of the school year, the parent of the child shall present to the school principal or the principal’s designee certification that the child has, within the past 12 months, obtained vision screening conducted by a licensed physician, optometrist, physician assistant, nurse practitioner, registered nurse, orthoptist, or a vision screener certified by Prevent Blindness North Carolina, or a comprehensive eye examination performed by an ophthalmologist or optometrist. All providers conducting vision screening shall provide each parent in writing the results of the vision screening. The provider shall also orally communicate this information to the parent and shall take reasonable steps to ensure that the parent understands the information communicated. For children who receive and fail to pass a vision screening, a comprehensive eye examination is required. The comprehensive eye examination shall be conducted by a duly licensed optometrist or ophthalmologist. No child shall be excluded from attending school for a parent’s failure to obtain a comprehensive eye examination required under this section.


130A-441. (APPLICABLE TO CHILDREN ENROLLING IN THE PUBLIC SCHOOLS FOR THE FIRST TIME BEFORE THE 2016-2017 SCHOOL YEAR) REPORTING.

https://www4.ncleg.net/enactedlegislation/statutes/pdf/bysection/chapter_130a/gs_130a-441.pdf

Health assessment results shall be submitted on the statewide standardized health assessment transmittal form developed by the Department and the Department of Public Instruction and submitted to the school principal. With regard to vision, the health assessment transmittal form shall only include information on whether the student passed a vision screening and any concerns related to the student’s vision.


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Section 1: Nature and Scope of Children’s Eye ProblemsFor a person to see normally, all parts of this visual system must work. The visual system is not fully developed at birth. An infant with normal vision will not be able to see things as clearly as an adult with normal vision. The baby’s eyes do not work together all the time until about four months of age. Pathways carrying signals to the brain, and the brain itself, continue to develop during the early years of life.

As the eye and the visual cortex of the brain develop, a child’s ability to see detail improves. As the eyes begin to work together, the brain learns to combine the images from the two eyes into a single image. The child learns how to use the signals in the brain to recognize things, such as faces and toys, and to tell the difference between things that look similar.

1.1 COMMON EYE PROBLEMS

REFRACTIVE ERROR Refractive error is a defect in the optics of the eye that results in a lack of precise focus of the

light rays on the retina causing a blurred image. Light rays entering the eye cannot be brought to a single focus. Instead they may focus in front of, in back of, or irregularly on the retina.

Nearsightedness (Myopia)Light focuses in front of the retina resulting in blurry distant objects while objects at close range are seen with more clarity. Myopia occurs when the eye is elongated and often develops in the rapidly growing school-aged child. This condition will progress during the growth years and will likely require frequent changes in prescriptive lenses. Children with a family history of myopia are predisposed to the condition and the corrective lenses are needed to bring the light to a focus point so the child can see distant objects clearly. Children typically do not outgrow this condition. Nearsightedness affects approximately one percent of 6-year-olds; that percentage increases to twenty percent for 16-year-olds.


Farsightedness (Hyperopia) Light focuses behind the retina because the eye is too short. This results in blurry near vision while distant objects are seen with more clarity. Hyperopia usually exists in infancy, but most children will outgrow the problem by their teen years. Approximately three percent of children ages 6–16 are farsighted, which is why near vision screening is not generally recommended for mass screenings.

AstigmatismThe curvature of the cornea and/or lens prevents light rays from focusing on a single point on the retina, resulting in a blurred image. Visual acuity is poor for objects both near and far.

Strabismus (Crossed Eye) Strabismus refers to eyes that are not straight or properly aligned. As a result of eye muscles not working together, one or both eyes may turn in (crossed eye), turn out (wall eye), turn up or turn down. The deviation, or eye turn, may be constant, or it may come and go. In some instances, it alternates eyes, first one eye turns and then the other.

Strabismus affects approximately two percent of the nation’s children, half of whom are born with the condition. It is critical that the problem be diagnosed and corrected at an early age since children with uncorrected strabismus may go on to develop amblyopia.

Amblyopia (Lazy Eye) Amblyopia is reduced vision in an eye that has not received adequate use during early childhood. An estimated two to three percent of the general population suffers from this visual impairment. If not treated early enough, an amblyopic eye may never develop good vision and may even become functionally blind. A condition that causes amblyopia and is left untreated until about the age of 6 will most often result in some permanent visual impairment. Amblyopia may be caused by several conditions such as strabismus, unequal refractive error, cataract or a drooping eyelid.


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1.2 ABCs OF POTENTIAL VISION PROBLEMS

Children may experience the following signs of a possible vision problem. Unfortunately, children, especially very young children may not sense or complain about discomfort or visual difficulties associated with some of the following signs. Parents and classroom teachers may have picked up on various signs or have noted comments from a child to indicate a possible problem. Observation of any one of the following signs is sufficient reason to refer a child for an examination.

Appearance Signs

• Cloudiness/haze

• Crossed eyes

• Unequal pupil size

• Presence of white pupil

• Possible eye injury. Watch for eyes that are reddened, bloodshot, blackened, bruised or swollen, or show evidence of lacerations or abrasions.

• Eyes in constant motion

BEHAVIOR SIGNS

• Body rigid when looking at distant objects

• Thrusting head forward or backward while looking at distant objects

• Tilting head to one side

• Squinting or frowning

• Excessive blinking or rubbing of the eyes

• Closing or covering one eye

• Clumsiness or decreased coordination

COMPLAINT SIGNS

• Headaches, nausea, dizziness or eye pain

• Blurred, double vision or spots floating across field of vision

• Sees blur when looking up after close work

• Unusual sensitivity to light

The following can be symptoms of a possible eye problem that may need attention but are not indicative of a vision problem. Therefore, they should not be used as part of the screening referral process

• Watering or discharge from the eyes

• Red-rimmed, encrusted, swollen or drooping eyelids

• Styes or infections on eyelids

• Burning, scratchy or itchy eye


Section 2: Children’s Screening MaterialsThe following are basic materials required for most screenings. Some items may not be required at each screening, while the unique circumstances of other screenings may require other items.

2.1 GENERAL SUPPLIES

• Vision screening recording forms

• Measuring tape or yardstick

• Masking tape to mark testing line on the floor, secure happy/magic feet, hang chart, etc.

• Pencils, paper clips and stapler

• Plain paper to tape behind wall chart, if necessary, to provide uncluttered background, or for covering windows to reduce glare

• One small table for screening materials

• Two chairs for screener and chart attendant

• Wastebasket/trash bags

• Name tags for screeners

• One or more lamps, if needed, to properly light the chart

• Extension cords for lamps

• Tissues

• Rewards such as stickers, coloring pages and ribbons

2.2 ACUITY SCREENING SUPPLIES

• Distance visual acuity chart/matching card

• Pointer. A red-tipped pointer, such as a red marker or small wood dowel with painted tip, draws the child’s attention to the target.

• Happy/magic feet

• Acceptable occluders include adhesive patches, 2-inch surgical tape, or occluder glasses with opaque or frosted lenses. Paddle occluders and hand-held “Mardi Gras mask” for 10 years and older are acceptable. Paper fish-shaped occluders, tissues, cups, and hands should not be used because children can easily circumvent these types of occlusion.

• Sanitation practices are an important part of the screening process. Be sure to take appropriate measures to minimize the spread of infection and disease. Wash hands with soap and water before beginning screening. Antimicrobial hand gel may also be used.


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2.3 SPACE REQUIREMENTS

The following space requirements apply to all children’s vision screenings:

• Quiet area, as free from distractions as the environment permits

• Room with sufficient space to permit viewing the acuity chart without obstruction

» Approximately 12 feet of space for a 10 foot chart

• Uncluttered, non-patterned, light colored wall

• Appropriate lighting without shadows or glare


Section 3: Screener Roles and Responsibilities3.1 ROLES

In the ideal screening, the team consists of two certified screeners; however, each team requires the presence of one certified screener. Volunteers may assist; but, the responsibility of observation and screening lies with the certified screener. If both team members are certified, it is easy to switch roles from time to time. It normally takes 3 to 5 minutes to screen a child. The roles are:

• Screener (must be certified)

• Chart Attendant or Pointer

3.2 RESPONSIBILITIES

Screener’s Responsibilities • Manage the overall screening by giving verbal directions to the child and chart

attendant

• Assist in setting up the screening area

• Greet children; establish rapport with them

• Observe signs of potential vision problems

• Determine the pass and referral criteria for testing

• Screen the children for distance vision (and near vision, if required)

• Watch for proper occlusion

Chart-related Responsibilities • Assist in setting up screening area

• Point to the proper symbol or letter on the appropriate line

• Watch for proper occlusion

• Assist the certified screener in observing signs of potential vision problems

Maintaining confidentiality regarding screening results is the responsibility of both the Screener and the Chart Attendant.

SECTION 3: SCREENER ROLES AND RESPONSIBILITIES

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Section 4: Distance Visual Acuity Screening 4.1 DEFINITION

Visual acuity is defined as sharpness of vision; the standard measurement is 20/20.

4.2 MEASUREMENTS AND RECORDING

Visual acuity is typically determined by having a person “read” an eye chart at a standardized distance. 10 foot charts are strongly recommended for childhood distance vision screenings.

Visual acuity is determined to be the smallest line a child is able to pass and is recorded as a fraction. The larger the bottom number, the worse the vision.

4.3 PBNC-RECOMMENDED DISTANCE ACUITY CHARTS

Charts should be chosen based on the child’s ability. The most challenging chart a child is able to accomplish should be used when screening.

The following distance acuity charts are recommended by Prevent Blindness North Carolina. Each chart is calibrated for a 10 foot testing distance, presented in a crowded format, and includes a 20/25 acuity line, which is recommended by eye care professionals. Some school nurses, health departments, and other screening organizations may have access to other charts or machines. It is always important to verify the appropriate testing distance is marked off for the chart being used.

• Lea Symbol Chart: for very young, EC, or non-English speaking children kindergarten and 1st grade

• Sloan Letter Chart: 2nd grade and up

The 20 foot “equivalent” of the visual acuity is found on the right side of the chart and should be used when recording results on data collection form.


4.4 VISUAL ACUITY SCREENING STEPS

Acuity screening involves the following five steps:

• Setup acuity screening area

• Greet child and observe for signs of potential vision/eye problems

• Conduct acuity screening practice

• Conduct acuity screening

• Interpret acuity screening results

STEP 1: SET UP ACUITY SCREENING AREA

• A 3’ x 3’ piece of plain paper may be used as a background when it is necessary to hang the chart on a patterned or cluttered wall.

• Select a wall for the chart that ensures an unobstructed view for the children.

• Place the chart on a wall away from windows that may cause glare or shadows. If necessary place plain paper over windows to reduce glare.

• The passing or critical line should be approximately at eye level with the child to be screened. This is generally 40 inches from the floor to midway between the 20/30 and 20/40 lines.

• Ensure that the chart is adequately illuminated. Normal room lighting is usually sufficient. When additional lighting is necessary, a gooseneck lamp or other portable light may be directed on the chart.

• Once the chart is hung, make certain it is clearly visible and there is no glare or shadow cast on the chart.

• Measure off and mark 10 feet.

• Mark floor with masking tape to indicate the testing line or tape down “happy feet”, placing the back of the heels of the feet on the line.

• Place a chair and pointer near the chart for the chart attendant.

• Place a table, chair, recording forms, occluders, and wastebasket near testing line where child will stand.


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STEP 2: GREET THE CHILD AND OBSERVE FOR SIGNS OF POTENTIAL VISION/EYE PROBLEMS

Purpose

Though greeting the child requires little time, it serves two important functions:

1. Ensures the child is comfortable and at ease

2. Provides an opportunity to observe potential eye problems

Tips for Greeting the Child: • Pay the child a compliment to help her/him feel comfortable with you.

• Ask his/her name and age to establish rapport.

• Answer any questions the child might have to help him/her feel at ease.

• Avoid questions that can be answered “yes” or “no.” For example, avoid asking “do you want to play the game?” Instead say, “Now we’re going to play a game.”

• Avoid offering options. For example, don’t ask “would you like to play a matching game?” or “would you like to name the symbols?” Tell the child gently but clearly what you expect him/her to do.

• Look for any of the ABC’s of vision problems. Volunteers and certified screeners all watch for signs of potential vision problems. The decision to refer based on observation is made by a certified screener.

STEP 3: ACUITY SCREENING PRACTICE

• Have the child stand at the 10-foot line with heels on the line.

• Children who use a wheelchair or other chair due to a physical limitation should be seated with the back of the chair on the 10-foot line.

• Make sure the child is wearing glasses or contacts if he or she normally does so. Note the use of prescription eyewear on the recording form.

• Explain the characters to be used and make sure the child understands how to respond.

• Confirm the child is able to identify the symbols correctly by asking them to read the matching card prior to screening.

• If the child is unable to name the symbols, use the matching card to “match” that symbol on the card. This process may involve a little more time but ensures the screening has a reliable result.

• Respond to the child in a positive manner using such words as “good”, “fine”, “okay”, “next”…

• If the child cannot be encouraged to participate in the screening, refer the child to the nurse for individual screening.


Step 4: Screening Procedure

Age of child: Passing line:

4 years old 20/40 (Lea)

5 years and older 20/30 (Lea) or 20/32 (Sloan)

• Begin screening on the top line of the chart.

• Occlude the left eye and have the child read the first character on each line until a character is missed.

• Return to the line above the missed character and ask the child to identify each character on that line.

• Continue asking the child to identify each character on each lower line until the child misses 3 on one line.

• If the child is able to continue moving down the chart, screening should end after reading the 20/20 line.

• If the child is unable to correctly identify at least 3 of the 5 characters on a line, move up the chart until you find the lowest line at which a child is able to identify 3 out of 5.

• Visual acuity is recorded as the smallest line on which the child can correctly identify at least 3 of the 5 characters.

• Occlude the right eye; repeat the process to screen the left eye.

• Note: The bottom portion of the Sloan chart divides into two charts; one for screening the right eye and one for screening the left eye.


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Threshold Screening Referral for Two Line Difference

Refer any child with a visual acuity difference of two or more lines between the eyes, even within the passing range, to a professional for a complete eye exam.

Example for a 4-year-old child using the LEA Chart:

• Pass: 20/30 acuity in the right eye 20/40 in the left eye

• Refer: 20/20 acuity in the right eye 20/30 in the left eye

Example for an 8-year-old child using the Sloan Chart:

• Pass: 20/20 acuity in the right eye 20/25 in the left eye

• Refer: 20/20 acuity in the right eye 20/32 in the left eye

In each of these scenarios, the child has passed the screening for individual eyes according to the passing criteria. However, due to the difference in visual acuity between the eyes, this child should be referred.

The two-line difference between the eyes is an indication of possible amblyopia. The stronger eye may be controlling the child’s binocular vision and the weaker eye may continue to deteriorate without recognition by the student, parent, or teacher.


STEP 5: INTERPRET ACUITY SCREENING RESULTS

Referral Criteria for Distance Acuity Screening

Children ages 4: The passing line for children four years old is the 20/40 line. They are referred at 20/50 or more for either eye when re-screened.

Children age 5 and older: The passing line for children five years old and older is the 20/30 line (on charts without a 20/30

line, the passing line is 20/32). They are referred at 20/40 or more for either eye when re-screened.

Initial Acuity Screening Outcomes

After completing the distance acuity screening, the child either:

• Passes or

• Returns for re-screening by the school nurse or other screener

Re-screening Outcomes

Re-screening within two weeks is suggested, or as soon as possible.

After completing the re-screening, the child either:

• Passes or

• Is referred to an eye care professional or primary care provider.

The following graph may be helpful.

DETERMINE THE CHART: BASED ON EDUCATIONAL LEVEL OR ABILITY

Grade Chart

K and 1st grade Lea Symbols

2nd grade and up Sloan

DETERMINE PASSING LINE AND REFERRAL CRITERIA: BASED ON AGE

Age Passing Refer If

4 20/40 20/50 or worse in either eye

5 and up 20/30 or 20/32 20/40 or worse in either eye

CHECK FOR A TWO-LINE DIFFERENCE: Refer children with a visual acuity difference of two or more lines between eyes.

Chart Refer If:

20/20 in one eye 20/30 or worse in the other eye

20/25 in one eye 20/40 or worse in the other eye

Sloan 20/20 in one eye 20/32 or worse in the other eye


LeaSymbols

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REFER A CHILD FOR ANY ONE OF THE FOLLOWING REASONS:1. The child demonstrates one of the observable signs (ABC’s).

2. The child has a failing acuity score in either eye.

3. The child has a two-line difference in visual acuity between the two eyes.

4.5 PRACTICE WORKSHEET

Use the Lea Symbols and Sloan distance acuity charts and the Chart Selection and Referral Criteria on page 19 as you work this practice. Determine the appropriate chart to use and place a check in the Pass or Refer column for the following visual acuities:

Kindergarten and First Grade: Which Chart? __________________________

Age Right Eye Left Eye Pass Refer If Refer, Why?

4 20/20 20/25

5 20/50 20/30

5 20/30 20/25

6 20/30 20/20

4 20/40 20/20

6 20/30 20/40

Grades 2 and Up: Which Chart? __________________________

Age Right Eye Left Eye Pass Refer If Refer, Why?

9 20/25 20/32

8 20/32 20/40

7 20/63 20/20

10 20/32 20/40

9 20/20 20/32

7 20/20 20/25


Section 5: Specialized Visual Tests5.1 NEAR VISION ACUITY TESTING

The current scientific literature has little to no evidence to support near visual acuity screening and most vision experts do not believe near visual acuity screening is necessary as a part of a mass screening. It is the consensus of the Prevent Blindness expert workgroup that adding near acuity testing will increase the amount of time required for a vision screening and will result in a low yield for near visual acuity problems relative to the amount of effort required. Should you need to conduct a near vision screening on a referral basis, the following process should be used.

Choosing a chart

• The LEA Symbols chart is appropriate for young, EC, or non-English speaking children.

• The LEA Numbers chart is appropriate for children who know their numbers.

• If the child does not want to or cannot talk, choose pointing at the large numbers on the card or the symbols at the lower edge of the card as a matching game.

• Either side of the chart may be used.

Set up Screening Area:

• Select area with good lighting and free of distractions.

• Use a 16 inch cord to measure between chart and temple close to child’s eyes.

• Children should be screened with their glasses on if they have them.

• Have eye occluders available.

Referral Criteria:

• Passing lines are determined by age.

Age of Child Passing Line

4 years 20/40

5 years and older 20/32

• To pass a line, the child must correctly identify 3 of 5 characters.

• The last, (or smallest line) a child can pass is the visual acuity for that eye.

• Refer if either eye is not within the passing range based on the child’s age.

• OR if there is a two-line difference between the eye acuities.

Screening Process:

• Occlude the left eye.

• Starting at the top line, ask child to identify the first character on each line until a character is missed.

• Return to the line above the missed character and ask child to identify each character on that line.


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• Continue asking the child to identify each character on each lower line until the child misses 3 on one line.

• If the child is able to continue moving down the chart, screening should end after reading the 20/20 line.

• If the child is unable to correctly identify at least 3 of the 5 characters on a line, move up the chart until you find the lowest line at which a child is able to identify 3 out of 5.

• Visual acuity is the value of the smallest line on which the child correctly reads at least 3 out of 5 of the characters.

• Occlude the right eye and repeat the process.


** Charts should not be copied and used for screening purposes.

5.2 STEREOPSIS TESTING

Stereopsis is the simultaneous visual perception of three-dimensional space resulting from the blending of the images from each eye. Testing for stereopsis is one of the requirements of the North Carolina Early Childhood Vision Care Program and is required for children entering Kindergarten.

Stereopsis screening is conducted to determine if the eyes are working together. When the eyes are not working together, the brain is unable to blend the separate images from each eye. The child who fails the stereopsis screening is at great risk for amblyopia or loss of vision in one eye.

There are several tests for stereopsis. The Early Childhood Vision Care Program (ECVCP) recommends three tests: Titmus Butterfly, Titmus Fly, or the Lang-Stereotest II. Prevent Blindness North Carolina recommends the Lang-Stereotest II because it does not require stereo glasses, is simple to administer, and affordable.

THERE ARE FOUR FIGURES ON THE LANG-STEREOTEST II CARD (SHOWN BELOW). THE STAR IS VISIBLE TO ALL CHILDREN, EVEN IF THEY DO NOT HAVE BINOCULAR VISION. THE OTHER FIGURES (MOON, ELEPHANT AND JEEP/TRUCK) REQUIRE BINOCULAR VISION TO SEE.


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Testing Procedure:

• Ask child to name or point to figures on card

• If the child is able to see the figures or tries to point to or grasp the figures, this is evidence of stereo vision

• Touching the card does not alter its effectiveness

• Screen children with glasses, if applicable

• Test binocularly

• Screener should hold card

• Card should be displayed 16” inches from the child’s eyes and at a right angle

• To prevent monocular clues, avoid moving the card in flip-flop movements

Initial Lang-Stereotest II outcomes:

When screening young children for stereopsis, two outcomes are possible:

• Pass:

» Child identifies the star and at least one other figure

• Refer:

» Child identifies only the star and no other figure


Section 6: Referral, Documentation and Follow-up Procedures6.1 PBNC REFERRAL CRITERIA SUMMARY

Children unable to complete or pass the screening on the first attempt should be scheduled for re-screening at a later date. If the child is unable to complete or pass the screening on the second attempt, referring the child to an eye care professional is the best course of action.

6.2 DOCUMENTING SCREENING RESULTS

SUGGESTIONS FOR COMPLETING THE RECORDING FORM

THE SCHOOL OR OTHER DESIGNEE COMPLETES THE FOLLOWING INFORMATION ON THE RECORDING FORM:

• School, school phone, county, teacher, grade level, and number of students (top section)

• Name, age, and sex of each child

THE SCREENER COMPLETES THE FOLLOWING:

• Screener’s name

• Date of screening

• Observation – Pass or Refer

• Remarks – Any observed signs of possible vision problems, child screened with glasses, etc.

• Distance Visual Acuity – Acuity results (i.e. 20/40, 20/30 for initial screening of each eye); note if a rescreening is needed

• Near Visual Acuity result, if applicable

The school nurse completes the following:

• Distance acuity results determined from rescreening

• Near visual acuity determined from rescreening

• Stereopsis screening results, if applicable

• Note if the child will be referred to an eye care professional

SECTION 6: REFERRAL, DOCUMENTATION AND FOLLOW-UP PROCEDURES

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6.3 SCREENING FOLLOW-UP

The purpose of children’s vision screening follow-up is to encourage the parent or guardian to schedule an eye examination for any child who fails the vision screening. Contact with the parent or guardian can be made by the school nurse, social worker, or other school authority. Whether or not a vision problem exists will be conclusively determined by an eye care professional. Vision screening is not diagnostic; it is a tool to discover a possible vision problem.

Follow-up Practices (For School Nurses Only)

It is typically the practice of school personnel or screening teams to follow up with the parents of referred children. Follow-up results are then reported to the training agency.

Tips or suggestions for effective follow-up are:

• Establish a systematic approach to use time and resources efficiently.

• Referral letters personally handed to the parent from the teacher may result in better compliance.

• Within a day or two of the screening, call parents of referred children to field questions, explain the results, and offer encouragement to comply with the referral.

• Consider establishing a time limit to motivate those doing follow-up to complete the task in a timely fashion. Three to six months works well for some.

• Provide a letter or fact sheet explaining the importance of compliance with referral and timely follow-up to each group or individual conducting screening follow-up.

• Provide a list of local eye care offices that provide services for children not covered by insurance.

• Offer access to financial assistance.

• Establish a minimum/maximum number of follow-up attempts to ensure “secured care”.


6.4 RESOURCES

Resources are available to assist families without insurance or financial means to take their child to an eye care professional for an exam and possible eyeglasses. The school nurse or social worker is usually responsible for the follow-up and helping the family secure assistance from various resources. The school nurse or social worker can contact Prevent Blindness North Carolina by calling 800.543.7839 or 919.755.5044 to secure a copy of the current Vision Resource Guide and Vision Resources Application.

Applications are also available on our website at www.pbnc.org. There are informationresources for children’s eye safety available through the Prevent Blindness website: www.preventblindness.org/safety.


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The information and recommendations contained in this publication have been compiled from sources considered to be accurate. The course manual is a training tool and reference guide for children’s vision screener certification candidates. The publication does not serve as a complete resource for eye health or eye care. Vision screening does not take the place of a complete eye examination; only an eye care professional can provide an eye examination.

CVS01 5/19 © Prevent Blindness North Carolina® All rights reserved.

Founded in 1967, Prevent Blindness North Carolina is the state’s leading volunteer eye health and safety organization dedicated to preventing blindness and preserving sight. Focused on promoting a continuum of vision care, Prevent Blindness North Carolina touches the lives of thousands of people each year through public and professional education, certified vision screening training, community service programs, advocacy, and research. These services are made possible through the generous support of the North Carolina Department of Health and Human Services, corporate, and private funding. Together with the support of a national office and a network of affiliates, divisions and chapters, Prevent Blindness remains committed to eliminating preventable blindness in North Carolina. For more information, or to make a financial contribution to programs and services, call 1.800.543.7839 or visit the website www.pbnc.org.

PREVENT BLINDNESS NORTH CAROLINA’S ROLE IN SCREENING

Documents

Kenneth Royall Children’s Vision Screening Improvement