Vision Screening of Young Children, Including Those with Additional Disabilities

1. Vision Screening of Young Children, Including Those with Additional Disabilities By Tanni L. Anthony, Ph.D. November 6, 2009 .

2. Training Objectives • Provide vision screening that is developmentally appropriate. • Establish best practices across the state for system consistency.

3. Colorado School Laws 2008 22-1-115 School Children – sight and hearing The sight and hearing of all children in K, 1st, 2nd, 3rd, 5th, 7th, and 9th grades, or children in comparable age groups referred for testing, shall be tested during the school year by the teacher, principal, or other qualified person authorized by the school district.

4. Colorado School Laws 2008 22-1-116 School Children – sight and hearing Each school in the district shall make a record of all sight and hearing tests given during the school yea and record the individual results of each test on each child’s records. The parents or guardian shall be informed when a deficiency is found. The provisions of this section shall not apply to any child whose parents or guardian objects on religious or personal grounds.

5. ECEA Rules (December 2007) 4.02 (2) (c) (iii) Screening procedures for identifying from the total population of children ages 3 to 21 years those may need ore in-depth evaluation in order to determine eligibility for special education and related services.

6. ECEA Rules (December 2007) 4.02 (2) (c) (iii) Follow up to vision and hearing screening shall interface with the vision and hearing screenings which occur for all children in public preschool, K, grades 1, 2, 3, 5, 7and 9 year accordance with Section 22-1-116 C.R.S. Appropriate educational referral shall be made if the child is suspected of having an educationally significant vision or hearing loss and parents shall be informed of any need for further medical evaluation.

7. Why Do Vision Screening? Vision problems are not uncommon in young children. One out of every fifth child may have some type of vision concern. Vision screening may ID concerns in time for medical correction. Vision problems can have a major impact on the development of a young child. Early ID and intervention minimize the effects of a vision loss on a child’s development.

8. Vision Screening Should • Be economical • Be easy to complete by trained personnel • Answer the simple question of whether there is or not a vision concern. • Proceed any other developmental evaluation of the child.

9. Vision Screening Should NOT Be used as an opportunity to infer any type of medical diagnosis. The role of the screener is to simply determine whether a next step evaluation is needed for more information.

10. Vision Screening Manual 0-5 • http://www.cde.state.co.us/early/downloads/early_vision_manual.pdf • The manual and the protocol forms can be downloaded (the latter in word format so they can be customized for administrative unit use). • The manual was finalized in January 2005.

11. Vision Screening Tips Prior to the screening, be sure that you have gathered the correct forms and materials. Take a few moments to build rapport with the child. Greet and talk to the child before beginning of the screening activities. The order of the screening tasks does not affect outcome. Perform the least invasive and most fun tasks first.

12. Vision Screening Tips • Ensure the child is in a supported posture. • Hips support = trunk support = head support. • Focus should be on looking and not maintaining balance.

13. Vision Screening Tips Advise the parent not to cue the child in any way during the vision screening activities, if the child is sitting in his or her parent’s lap. Use toys, lights, and objects that do NOT make sounds. You want the child to respond to visual stimulation only.

14. Vision Screening Tips Use a screening room environment that is quiet and free of unnecessary visual distractions such as people moving around the room. Be sure to monitor the lighting in the screening room. Light should not be overly dim or bright. Any sunlight coming in through a window should fall behind the child. Children who wear glasses should be screened with their glasses on unless the directions specifically indicate they should be removed.

15. Components of 0-5 Visual Screening • Reviewing Intake History For High Risk Info • Visual Inspection of the Eyelids/ Eyes • Pupillary Constriction • Alternate Cover and/or Corneal Light Test • Fixation / Tracking / Convergence • Visual Acuity • Compensatory Visual Behaviors

16. Family Interview Is there a family history of eye crossing, color vision problems, and/or other types of congenital (at birth) visual impairments. Any concerns about child’s vision and/or development. Has the child ever been seen by an eye doctor (optometrist or ophthalmologist?) What were the results? Does the child have a medical history that includes any of the following conditions: (see next slide)

17. High Risk Indicators of Vision Problems / Visual Impairment • Prematurity • TORCH Infections (40,000 newborns annually) • FAS / FAE or other prenatal toxins • Cerebral Palsy • Syndromes (e.g., Down, Goldenhar) • Deaf/Hard of Hearing • Pre and Postnatal Viruses • Traumatic Brain Injury / Neurological Insult

18. Anticonvulsants and Side Effects • Phenobarbital: photophobia, constriction/convergence problems • Dilantin: convergence problems, focus problems, esotropia • Clonopin: abnormal eye movement, diplopia, nystagmus, glassy eyed appearance • Tegretol: photosensitivity, blurred vision, visual hallucinations, oculomotor disturbances, nystagmus, conjunctivitis

19. Quick Review: Visible Parts of the Eye

20. Appearance of Eyelids / Eyes MANY VISUAL PROBLEMS ARE VISIBLE. • Look at the child’s face and eyes. • Is there any evidence of asymmetry, unusual irritation, tearing, eye crossing, etc.

21. Misalignment of Eyes

22. Eye Deviation

23. Eye Deviation

24. Drooping Eyelid

25. Cloudiness of Eye

26. Cloudiness of Eye

27. Usual Shape / Size of Pupil

28. Unusual Pupil / Iris Shape

29. Appearance of Eyes Right EyeLeft EyeAll are grounds for referral: □ □ unusually red or irritated. □ □ unusually teary. □ □ are cloudy in appearance. □ □ not aligned (turned in, out, etc.) □ □ have involuntary jerky movements □ □ do not appear to move together □ □ Eyelid(s) is drooping.

30. Pupillary Constriction • Practice with your penlight. • Do not direct the beam into the child’s eyes. Center the beam at forehead level. • Look for brisk and bilateral constriction with light. Dilation with light removal.

31. Pupillary Constriction Seizure medications, neurological problems, and other medications can inhibit this response. If abnormal responses are noted, ask the parent about medications the child is taking. Regardless, an abnormal pupillary response would warrant failure of the vision screening.

32. Pupillary Constriction Right eye: □ brisk □ absent / sluggish Left eye: □ brisk □ absent / sluggish Results: Pass: Both eyes respond quickly. Fail: Absent or sluggish response

33. Alternate Cover Test • Equipment: a fixation toy and the occluder. • Instructions:Limit distractions in the room. Do not touch the child’s face with the occluder at any time during the test. The target object (e.g., penlight with monster cap, small toy) may need to be manipulated or changed to maintain a young child’s attention.

34. Hold the target about 12 inches away directly in front of the child. Secure fixation. Cover the right eye, watching the left eye for any movement. Leave covered for 2-3 seconds. Quickly move the occluder across the bridge of the nose to cover the left eye, watching the right eye for any movement. Wait 2-3 seconds after the cover is moved to permit fixation of the now uncovered eye. Move the cover from the left eye back to the right eye, across the bridge of the nose, watching the left eye for any movement. Allow 2-3 seconds for fixation. Repeat procedure several times to be assured of observations.

35. Alternate Cover Test Right eye: Pass: No Movement Refer: Obvious Movement Left eye: Pass: No Movement Refer: Obvious Movement Results: If there is no redress movement in either eye, the child will pass this screening indicator. If there is redress movement in either eye, the child will fail this indicator and should be referred for further evaluation.

36. Corneal Light Reflex Test Equipment: penlight Instructions:Hold a penlight 12-13 inches away from the child’s face directly in front of the eyes. Direct the light from the penlight at the hairline in the center of the child’s forehead. The child needs to fixate either on the penlight or an object that may be held near the light. Observe the reflection of the penlight in the pupils of both eyes – the reflection should be centered or equally centered slightly toward the nose (nasal).

37. Corneal Light Reflex Test Look at where the light is reflected in each eye.

38. Corneal Light Reflex Test Pass: reflection is symmetrical Fail: reflection isnot symmetrical Results: If the reflection is symmetrical and centered in both eyes, the child will pass this screening indicator. The child does not pass this screening indicator if the reflection of the penlight does not appear to be in a centered position in the pupil of each eye. Sensitivity to light, rapid eye movement, and poor fixation observed during this test are also reasons for referral for further evaluation.

39. Eye Teaming Tasks • Near fixation with cake decoration pellet and black foam sheet. • Horizontal and vertical tracking with penlight/monster caps or frog finger puppet. • Convergence with fixation stick, frog finger puppet, and/or penlight with monster caps.

40. Near Fixation (at 8-18 inches) 1-inch object (4 months) Pass: Sustained Fail: Fleeting/ Absent Fruit Loop™ or ¼ inch cake decoration pellet (6 months) Pass: Sustained Fail: Fleeting / Absent Results: If a child of six months or older fixates on the one inch object and a small cake decoration pellet or piece of cereal, this is recorded as a pass. If the child does not fixate on either item or fixates with one eye only, the result is a fail.

41. Tracking Horizontal Pass: smooth/together Refer: jerky/segmented Vertical Pass: smooth/together Refer: jerky/segmented Results:If tracking is smooth and demonstrated with both eyes moving together as they follow the target, the child will pass the tracking indicators. If one eye lags behind another eye or tracking movements are jerky and incomplete, the child will fail this indicator and should be referred for further evaluation.

42. Convergence Pass Both eyes follow to at least 4-6 inches from the nose. Refer: One eye deviates or child looks away when object is more than 4-6 inches from nose. Results: If both eyes maintain their gaze on the oncoming object at least 4-6 inches from the nose – pass. If one or both eyes break gaze farther than 4-6 inches from nose – fail.

43. Lea Symbol Cards • For 2.5 years and older (if able) • Practice with set of cards • Remember to double the denominator, if you screen from 10 feet.

44. Right EyePass at 20/40 level (3 symbols correctly IDed) Fail child cannot correctly identify 3 symbols at the 20/40 level Left EyePass at 20/40 level (3 symbols correctly IDed) Fail child cannot correctly identify 3 symbols at the 20/40 level Results:The visual acuity threshold is defined as the level (smallest symbol size)at which the child can correctly identify at least three out of five symbols. If the child only identifies two of the five symbols, report the visual acuity of the previous large size.

45. 1.1.5.T1

46. Compensatory Behaviors • Complete after screening. • Notice any unusual body posturing and/or eye behaviors (squinting, blinking, eye rubbing, etc.)

47. □ Rubs eye(s) / presses hands into eye(s) frequently. □ Squints, blinks, closes an eye(s) when looking at something.□ Squints, blinks, closes an eye(s) to changes in lighting.□ Turns or tilts head when looking at something.□ Appears overly interested in gazing at overhead lights. □ Looks away from visual targets, shows gaze aversion.□ Inattentive to a visual target unless it is has an accompanying sound.□ Takes longer than usual to focus on an object or face.□ Views objects at an unusually close distance from eyes.□ Over or under reaches for an object.

48. Scoring the Screening Tool Three Outcomes. Pass = no problems observed / reported Re-screen= screener would like another chance to screen the child on another day. Fail = refer to the next step medical specialist (based on family’s insurance etc.)

49. ?s and Future Comments Let us know how this is working for you! Tanni Anthony 303 866-6681 Anthony_t@cde.state.co.us