Vision Screening Basics for Health Assistants

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Vision Screening Basics for Health Assistants

• By Laura Case, RN, MSN, NCSN
• Nursing Coordinator
• Albuquerque Public Schools
• 505.855.9834
• Laura.Case_at_aps.edu

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Vision Development

• By 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.

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NM School Health Manual, Section III

• Recommended Screening Equipment
• Room Set Up and Screening Environment
• Recommended grades to screen
• Recommended tests to perform

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Who can do vision screening?

• A school nurse trained in vision screening
  assessment
• A Primary Care Health Provider
• School nurse designee or lay eye screener trained
  in vision screening techniques

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New Mexico Law

• House Bill 1283 and Senate Bill 1149 passed into
  law in 2007
• Defines 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.

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New Mexico Law cont

• Created the Save Our Childrens 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

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EARLY DETECTION

• The purpose of a vision screening program is
  early detection of common vision disorders such
  as refractive errors, amblyopia and strabismus.

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Parent Permission for Screening

• Always get parent permission or notify parents
  that their child will be screened unless the
  parent provides a written excluding their child
  from screening.

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Vision 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

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Creating a Screening Environment
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Screening Room Set Up

• Make sure the room has adequate light
• The 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 charts passing line should be placed at eye
  level

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Equipment to Use for Screening

• 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.

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Lea Symbols Chart
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Distance Charts
For testing at 10 feet
Actual 10 foot
Equivalent 20 foot
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Equipment to use cont.

• Butterfly stereopsis
• Eye occluders

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Before testing begins.....

• Note if the child is wearing glasses
• Are their eyes equal in appearance
• Are 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!
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Distance Screening

• The child stands or sits 10 feet from the chart
  the childs 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.

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Distance screening

• Once 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 line
• Test 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.

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What to look for in distance 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.
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Isolators

• Using 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

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Isolators
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Stereopsis

• For children 3years to 3rd grade
• Used to check for problems with depth perception
  indication of strabismus
• Use 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.

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Stereo Butterfly

• For children 3 years to 3rd grade
• Place polarized glasses on child over
  prescription glasses if applicable
• Make 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.

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Stereo Butterfly cont

• Pass 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

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First at 20 5 times Then at 40 repeat the test.
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Color Vision Ishihara Plates

• 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.

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Additional thoughts on Vision Screening

• If 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, Im 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.

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Passing Guidelines
Passing 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. Passing 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. Passing 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. Passing 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. Passing 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 Distance Other Testing Other Testing
PK 20/40 20/40 Random Dot E and Color Vision required only once in any of the target population grades. Random Dot E and Color Vision required only once in any of the target population grades.
K 20/30 20/30 Random Dot E and Color Vision required only once in any of the target population grades. Random Dot E and Color Vision required only once in any of the target population grades.
1 20/30 20/30 Random Dot E and Color Vision required only once in any of the target population grades. Random Dot E and Color Vision required only once in any of the target population grades.
3 20/30 20/30 Random Dot E and Color Vision required only once in any of the target population grades. Random Dot E and Color Vision required only once in any of the target population grades.
Passing Guidelines - Hearing Passing Guidelines - Hearing Passing Guidelines - Hearing Passing Guidelines - Hearing Passing Guidelines - Hearing
1000 Hz 20 dB 1000 Hz 20 dB 2000 Hz 20 dB 2000 Hz 20 dB 4000 Hz 20 dB
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Recheck and Referrals

• A 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.

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RESOURCES for Glasses

• Save Our Childrens Sight Fund not operating
  yet
• Medicaid will pay for one pair of glasses per
  year
• Childrens Medical Services for children w/o
  Medicaid and meet certain criteria
• New Mexico Lions Operation KidSight active in
  certain communities and has limited resources for
  exams and glasses or uninsured or needy students.

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RESOURCES cont

• New 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.

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Follow-up to Referrals

• THE most important part of process.
• THE most difficult part of process.
• Make at least 2 phone calls.
• Offer resources.
• Document.

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QUESTIONS?
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Dental Screening

• Section XIII of NM School Health Manual

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Dental Caries looks like......
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Gum Disease looks like......
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Oral Herpes (Cold Sore)
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Canker Sore
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Avulsed Tooth
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Mouth lesions from chewing tobacco
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Height and Weight Screening

• Section XII of NM School Health Manual

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Growth Charts

• 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/

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CDC BMI Charts
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Referrals for Elevated BMI

• Does your district have a policy regarding BMI
  referrals?
• Follow district guidelines.