Vision Screening Basics Vision Screening Basics for Health Assistantsfor Health AssistantsBy Laura Case, RN, MSN, NCSNNursing CoordinatorAlbuquerque Public Schools505.855.9834Laura.Case@aps.edu

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 IIIRecommended

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 unless the parent provides a written excluding their child from screening.

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◦ Stereopsis – Pre-K,

K, 1st ◦ 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 students quite 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 must use an

HOTV chart or Lea Symbols. 1st grade can use HOTV or Sloan letter chart

depending on their ability to accurately identify the letters.

All other grades should use Sloan letter charts.

Lea Symbols ChartLea Symbols Chart

Distance Charts“For testing at 10 feet”

Equivalent 20 foot

Actual 10 foot

Equipment to use con’t….Equipment to use con’t….Butterfly

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 distractible, 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

StereopsisFor children 3years to 3rd gradeUsed to check for problems with depth

perception – indication of strabismusUse Butterfly stereo Place 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.

Stereo Butterfly For 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, tell him it is a butterfly. Have them touch the wings.

Stereo Butterfly 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

First at 20”5 times;Then at 40” repeat the test.

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.

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 – not

operating yetMedicaid – will pay for 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

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

Growth ChartsWhen 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.