Vision Screening: Pediatric Eye Screening or Evaluation

Pediatric Eye Screening or Evaluation

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Professional Academy Recommendations

The American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, the American Academy of Pediatrics, the American Academy of Family Physicians and the American Association of Certified Orthoptists all recommend early vision screening. A pediatrician, family physician, nurse practitioner, or physician assistant should examine a newborn's eyes for general eye health including a red reflex test in the nursery. An ophthalmologist or other appropriate eye care professional should be asked to examine all high risk infants.

Minnesota Department of Health Recommendations

According to Minnesota Department of Health (MDH) guidelines, a child's vision should be screened at the following program specific intervals:

Child and Teen Checkups (C&TC):

Screening is done according to the C&TC Periodicity Schedule:

Subjective screening: Take the child and family history and/or update at every well child visit following the usual schedule for C&TC even when other objective tests are administered.

Objective screening: All other objective screenings and procedures are done at every well child visit for children ages 3 through 12 years. For ages 14-20, every other year screening is recommended. Acuity screening is in addition to the physical assessment of ocular health performed by the C&TC provider.

Head Start schedule:

Early Head Start and Head Start - Follow the vision screening schedule for the state's EPSDT program (in Minnesota, this is C&TC) is followed; go to the C&TC Periodicity Schedule.

Early Childhood:

Minnesota school districts are required to offer Early Childhood Screening to young children before kindergarten entrance, targeting children 3 to 4 years of age. Children must be screened at least once before kindergarten entry.

School setting:

Children in grades Kindergarten (males screened for color blindness) 1, 3, 5, 7, and 10 should be screened for distance visual acuity. Kindergarten males should be screened for color vision deficiency. In addition, a screening should be done when there are parent or teacher concerns and for any new students.

Any child with a diagnosed eye condition should be screened in accordance with the doctor's recommendations. Prior to placement in a special education program, a child’s risk factors should be reviewed to determine if there is a need for an exam by an eye specialist. When a shortage of time, space, or personnel does not permit implementation of the full frequency of screening in a school, emphasis should be placed on the lower grades.

Facility

The room selected for mass vision screenings should be well-lit and at least 12 feet long for each visual acuity screening. Additionally, rooms should be free from direct sun glare and distractions. When more than one visual acuity screening station is being used, they should be separated by a minimum distance of 8-10 feet. Muscle balance stations must be arranged to avoid interfering with each other.

Equipment

Equipment for required procedures:

for images and more information about vision screening equipment see MDH recommended equipment for distance visual acuity screening.

  • Occluder: Specially purchased or constructed sunglasses, adhesive temporary occlusion eye patches, 2 inch Micro-pore adhesive paper tape, and for children 10 years and older, plastic or spectacle occluders.
  • Penlight
  • Toy (1/2 inch in size) as a target object
  • LEA SYMBOLS ® and/or HOTV wall chart (50% rectangle) or MASS Vat LEA SYMBOLS ® and/or HOTV flip charts (including lines from 10/40 to 10/8), response card, and conditioning flashcards
  • LEA SYMBOLS ® Puzzle may be useful for children who have a hard time focusing
  • Sloan Alphabet Chart
  • Plus Lens: +2.50 lenses
  • Ishihara, Good Light Color Vision Plates, or Waggoner Color Vision Made Easy
  • Vision Screening Worksheet
  • Antimicrobial hand gel and appropriate antimicrobial cleaner for occluder

Equipment for optional procedure:

  • Random Dot E Test Kit or Stereo Butterfly Stereopsis test

Vision screening occlusion equipment

Occlusion equipment temporarily obstructs vision in the eye not being screened during vision screening. It is never recommended at any age to use a hand to cover the eye. Kids peek. Peeking can be a factor for children who PASS when they can't see, known as a false negative. The ability of a child to peek is impressive, even with constant vigilance.

Specially constructed occluder glasses

One pair of glasses for the right eye and one for the left eye is recommended for visual acuity screening for children younger than 10 years of age.

  • Occluder glasses can be purchased online.
  • An alternate cost-effective way to make occluder glasses is to use inexpensive child-sized wraparound sunglasses.
    • Pop the right lens out and occlude the left lens with duct tape or a large sticker making sure there are no gaps left open.
    • Do the same with the other pair, but pop the left lens out and occlude the right lens.
    • Because children come in all shapes and sizes, it is recommended that various sizes of children’s sunglasses are purchased to ensure a proper fit.
  • Plastic occluders with lips can be purchased online.
    • They are to be used during the Unilateral Cover Tests and monocular Visual Acuity.
    • They can be used for screening children 10 years of age and older.
    • Plastic occluders can also be used to cover an eye for other tests where a child is unable to wear occluder glasses (e.g., already wearing glasses, refuses to wear them, etc.). Be sure the child is not peeking around the occluder and that it is held in the proper position. The small raised area should be positioned to the inside of the child’s eye and aligned with the bridge of the nose and under prescription glasses. It may be helpful in these situations to have one person holding the occluder over the eye and monitoring the child for peeking and ability to tolerate the occluder while another person administers the test. Kids peek.
  • Adhesive temporary occlusion eye patches or 2 inch micro-pore paper tape can be helpful for children who will not wear occluder glasses. They can be used in cases where other forms of occlusion are not effective. These patches and tape may be purchased online or at medical supply stores.

Care of vision equipment

  • The equipment should be kept clean and in good repair.
  • Occluder glasses, stereo acuity glasses and plus lenses should be routinely cleaned and cased when not in use.
  • Color vision books should be kept closed when not in use to prevent fading.
  • Do not touch the color plates with fingers as the oil on the skin can damage the plates.>
  • Clean visual acuity charts periodically with mild warm, soapy water to prevent distortion of chart letters from dirty smudges.
  • A much more frequent cleaning will be necessary for the child’s HOTV or LEA SYMBOLS ® response cards since the children handle them.
  • Discard chipped or torn charts.
  • The charts should be laid flat and away from heat when stored to prevent curling.
  • Any flashlights used in screening should be stored with batteries removed.
  • Replacement flashlight bulbs and batteries should be readily available.

Infection control considerations for vision screening

  1. Wash hands with soap and water before the screening session begins. If a sink is not available use antimicrobial hand gel.
  2. Wash occluders and plus lenses with soap and water, rinse and wipe dry before starting the screening program.
  3. Ideally, the occluders and plus lenses should be disinfected after each student is screened. This can be done by using an appropriate anti-microbial agent. Additionally, the cloth covers used to cover the ear phones on headsets for audiometers may be used to cover the occluder-head that comes in contact with the child's eye. If neither of these cloths is available, an alcohol wipe may be used.
  4. Children whose eyes are red or draining should not be screened but instead referred immediately to their primary care provider.

For more information: The Minnesota Department of Health (MDH) Maternal Child Health Section provides training and consultations to C&TC, Head Start and School provider.

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