Vision Screening Basics for Health Assistants

1. Vision Screening Basics for Health Assistants Charlotte Branch-Briggs, BSN, RN NMDOH NE Region School Health Advocate 505-476-2714 charlotte.branchbri@state.nm.us

2. 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.

3. NM School Health Manual, Section III • Recommended Screening Equipment • Room Set Up and Screening Environment • Recommended grades to screen • Recommended tests to perform

4. 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

5. 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.

6. 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

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

8. Parent Permission for Screening • Always get parent permission or notify parents that their child will be screened. • Parents may request that child not be screened.

9. 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 • Random Dot E or Stereopsis – only required once in target populations • Color Vision – only required once in target populations

10. Creating a Screening Environment

11. 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 other students quiet 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

12. Equipment to Use for Screening • Pre-kindergarten and Kindergarten can use an HOTV or Lea symbol chart. • 1st grade can use letter chart or HOTV chart depending on their ability to accurately identify the letters. • All other grades should use letter charts.

13. Distance Charts “For testing at 10 feet” Actual 10 foot Equivalent 20 foot

14. Equipment to use con’t…. • Random Dot E • Butterfly or fly stereopsis • Eye occluders

15. 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? Before testing begins..... Notify your school nurse if you see any of these visual signs so that additional assessment can be done!

16. Distance Screening • The 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.

17. 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.

18. 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 distracted, 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.

19. 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

20. Isolators

21. Random Dot E or Stereopsis For children 3years to 3rd grade Used to check for problems with depth perception – indication of strabimus Use Random Dot E when available 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.

22. Random Dot E con’t At 20 inches away from the child, hold up the sample model E and ask child to identify object. If they can not identify letter, point at the figure and say “that’s an E” With the glasses still on, practice using the sample card and the blank card – mixing up the cards behind your back, and present to the child 4-5 times, asking them to identify the E each time. Then replace the sample card with the stereo E card, repeat the steps above (you may need to rotate the cards up and down to pick up the light to give optimal viewing of the stereo image) Move back 40 inches from the child and repeat last step.

23. Random Dot E con’t Pass if the child is able to point to the correct stereo E card at least 4 times at 20 inches and 40 inches Rescreen/Refer is the child can not distinguish the E figure in the RDE card at all, or can only see it when the card is approximately 20 inches or closer ANY rescreens should be performed by the school nurse

24. Stereo Butterfly or Fly 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, ask the child to touch the butterfly’s wings

25. Stereo Butterfly or Fly con’t 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

26. 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. Creamer color charts present 2 figures (star and circle) which may be easier for preschool or preliterate kids to identify. Color Vision – Ishihara Plates

27. 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, “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.

28. Passing Guidelines

30. 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.

31. RESOURCES for Glasses Save Our Children’s Sight Fund – thru DOH Medicaid – will pay for one eye exam and one pair of glasses per year Children’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.

32. RESOURCES con’t 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.

33. 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.

34. QUESTIONS?

35. Dental Screening Section XIII of NM School Health Manual Optional (as directed by district)

36. Dental Caries looks like......

38. Gum Disease looks like......

40. Oral Herpes (Cold Sore)

41. Canker Sore

42. Avulsed Tooth

43. Mouth lesions from chewing tobacco

44. Height and Weight Screening Section XII of NM School Health Manual Optional (as directed by district)

45. Growth Charts If measuring, be consistent (remove shoes, hats, coats, sweatshirts, etc) and provide privacy. 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/

46. CDC BMI Charts

48. Referrals for Elevated BMI Does your district have a policy regarding BMI referrals? Follow district guidelines.