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-- [ Page 1 ] --

Revised 2002

Reprinted 5/02






Robert S. Zimmerman, Jr., M.P.H.

Secretary of Health












Far Visual Acuity Test

Near Visual Acuity Test

Convex Lens Test – (Plus Lens)

Color Vision – Color Discrimination Test

Stereo/Depth Perception Test








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The Division of School Health, Pennsylvania Department of Health gratefully acknowledges the assistance of the members of the 2000-01 Advisory Task Force on School Vision Screening in the revision of this manual.

Maggie Beall, MA, BS, RN,C, School Nurse, Moniteau School District; President, School Nurse Section, Department of Pupil Services, Pennsylvania State Education Association Deborah S. Blanchard, Pennsylvania Optometric Association, Director of Communications/Staff Contact Mark B. Boas, OD, MS, Pennsylvania Optometric Association, Pediatric Vision Care Task Force Elise B. Ciner, OD, FAAO, Pennsylvania Optometric Association, Pediatric Vision Care Task Force Lorraine Crum, BSN, RN, School Nurse, Conneaut School District Jon Dale, MS, Director, Division of School Health, Pennsylvania Department of Health Sharon Daly, RN,C, School Health Consultant, Southeast District, Pennsylvania Department of Health Linda D. Deeter, BSN, RN, School Health Consultant, Northwest District, Pennsylvania Department of Health Michelle Ficca, DNSc, RN, Assistant Professor, Department of Nursing, Bloomsburg University Deborah Fontaine, BSN, RN, School Health Consultant, Northcentral District, Pennsylvania Department of Health Judith Gardner, CRNP, BSN, School Health Consultant, Southcentral District, Pennsylvania Department of Health Debra Gilbert, MSN, BSN, RN, School Nurse, Bloomsburg School District Douglas J. Goepfert, OD, Pennsylvania Optometric Association, Pediatric Vision Care Task Force Judith Lavrich, MD, Total Eye Care Centers Letitia Leitzel, MA, BSN, RN,C, School Health Consultant, Central Office, Pennsylvania Department of Health Robert Lloyd, OD, Optometrist, Bradford, Pennsylvania Linda McGrath, BSN, RN, School Nurse, Grove City School District James W. McManaway III, M.D., Pennsylvania Academy of Ophthalmology David R. McPhillips, OD, FAAO, President, Pennsylvania Optometric Association, Pediatric Vision Care Task Force Patricia Montalbano, RN,C, School Health Consultant, Northeast District, Pennsylvania Department of Health Marla L. Moon, OD, FAAO, Pennsylvania Optometric Association, Pediatric Vision Care Task Force Ann Murray, BSN, RN, School Nurse, Midd-West School District George William Orren, III, OD, Orren Eye Associates Rita Schmitt, BSN, RN, School Nurse Coordinator, City of Erie School District James S. Spangler, OD, Pennsylvania Optometric Association; Chairman, Pediatric Vision Care Task Force Karolyn Stone, BSN, RN, MEd., Retired School Nurse Charles V. Stuckey, Jr., OD, FAAO, Executive Director, Pennsylvania Optometric Association Cynthia Thomas, BSN, RN, School Health Consultant, Southwest District, Pennsylvania Department of Health Rita Verma, OD, Betz Ophthalmology Associates, Lewisburg, Pennsylvania Denise T. Wilcox, OD, Pennsylvania Optometric Association, Pediatric Vision Care Task Force i Special acknowledgement is given to the following: Mark Boas, OD, MS, Pennsylvania Optometric Association for contributing many hours to the clinical review of this manual and the writing of Appendix G, Near Point of Convergence; Doris Luckenbill, MSN, CSNP for the original writing of the Students with Special Health Care Needs section; and Charles J. Stuckey, Jr., OD, FAAO, Pennsylvania Optometric Association for his contribution to the Contact Lens section.

Review and comment of the manual prior to publication was also provided by the following

individuals or organizations:

Robert S. Muscalus, D.O., Physician General of Pennsylvania Pennsylvania Academy of Ophthalmology Pennsylvania Association of School Nurses and Practitioners Pennsylvania Optometric Association The previous document, Guidelines for the School Vision Screening Program for Pennsylvania’s School-Age Children and Adolescents, was developed by members of the Vision Screening Task Force and the School Nurse Advisory Committee in 1989.

–  –  –

The purpose of a school vision screening program is to identify students with visual impairments. “Vision problems affect one in 20 preschoolers and one in four school-age children” (Prevent Blindness America, 2000). Visual problems can and do affect the educational, social and emotional development of children. Early detection of vision problems assures the child of the opportunity of taking the best advantage of his/her educational opportunities.

Ninety percent of all information is transferred to the brain via the eyes. Most vision problems are correctable, at least to some degree. Impaired vision is most damaging in primary grades because it is at these grade levels that the foundations for learning are taught. Those children with vision loss severe enough to require special educational opportunities must be identified early if they are to be helped.

It is routine for infants to have their ocular health screened at birth, and vision authorities agree that children should have a more thorough eye examination very early in life. The American Optometric Association (AOA) recommends an eye examination by six months of age, at three years of age, before first grade, and every two years thereafter. According to the American Academy of Ophthalmology (1996), “Two to four percent of America’s children develop strabismus and/or amblyopia. Early detection and treatment of these disorders during childhood are essential for preventing permanent vision loss.” Although it is recommended that every child have an eye examination very early in life, vision screenings continue to provide an important tool in the early detection of vision disorders in the pediatric population. However, the opportunity for vision screenings is not always afforded to every child in the early years of life. As attendance at school is mandated for all children in Pennsylvania, the school setting provides an accessible place where children may have their vision screened. It is possible for children in Pennsylvania as young as four to have their vision screened if they attend kindergarten.

Recognizing the above statements, vision screening has been rightly mandated for Pennsylvania school age children since 1957. The purpose of this procedure manual is to provide standards for the school vision screening program throughout the Commonwealth of Pennsylvania. This manual replaces the “Guidelines for the School Vision Screening Program for Pennsylvania’s School-Aged Children and Adolescents”, H514.032P, revised 9/89.

Disclaimer: Any reference to trade names or products does not represent an endorsement by the Pennsylvania Department of Health. Resources and references do not represent an all inclusive listing.

–  –  –

I. INTRODUCTION “Vision screening is not diagnostic, but is a practical approach to identifying children needing professional eye services. It is an efficient, economical, and efficacious manner of detecting possible vision problems in the pre-school and school age populations. By definition, screening is the process by which a large number of persons are tested by a fast, efficient method in order to separate them into different groups. The purpose of the vision screening test is to separate those children who probably have no vision problems from those who should be examined by an eye doctor for potential problems and possible treatment” (National Association of School Nurses, 1995).

According to the American Academy of Pediatrics Policy Statement (1996), “Vision screening and eye examination are vital for the detection of conditions that distort or suppress the normal visual image, which may lead to inadequate school performance or, at worst, blindness in children”. “A screening program of early identification, diagnosis and correction of children’s vision disorders is an essential part of all child health programs. The early detection and treatment of vision disorders gives children a better opportunity to develop educationally, socially, emotionally and physically” (Ohio Vision Manual, Rev. 1998).

The frequency of vision disorders increases with age, therefore it is important to have a clear understanding of critical periods in human visual development. For example, studies show that the greatest proportions of these are errors in refraction.

Approximately five percent of pupils in the first grade may have errors of refraction, while “nearly 20% of the pediatric population require the use of eyeglasses for refractive errors before the late teenage years” (American Academy of Pediatrics, 1996).

Because vision screening is not diagnostic, children who fail the test must be referred to an eye specialist for a diagnostic examination. Screening will not identify every child who needs eye care, nor will every child who is referred require treatment. But the criteria for referral have been set to keep both the overreferrals (those with no problem on examination) and the under-referrals (those who are missed) at a minimum.

In addition to detecting vision problems, vision screening programs are valuable in raising the awareness of parents, teachers and the community to the importance of eye care. Another screening benefit is the identification of children who may need special education services because of a visual impairment.

The most important aspect of the screening program is referral with follow-up. The child who fails the screening should receive a comprehensive eye examination by an eye care specialist. If the child does not receive attention by an eye care specialist, then the screening program has not accomplished its goal.


The Public School Code of 1949, Section 1402(a) (Act 404 of 1957) requires that “Each child of school age shall be given by methods established by the Advisory Health Board, a vision test...”. The vision test shall be administered by a certified school nurse, medical technician (health room aide) or teacher. 28 Pa. Code § 23.4 (Regulations) of the Department of Health requires vision screening tests to be given annually. The regulations specify that the Snellen chart or other screening devices approved by the Department of Health shall be utilized for vision screening.

–  –  –


A. When planning for vision screening it is imperative to select a room or area that is quiet and free from interruptions (ideally, the health office). Be sure that other students can not see the chart.

B. If a wall mounted visual acuity chart is used, the room should be large enough to allow for a physical distance of 10 ft for a 10 ft chart or 20 ft for a 20 ft chart from the student being tested.

C. If a wall mounted visual acuity chart is used, it should be placed against a background, the brightness of which should not be in great contrast with the chart itself. The background should be free of distractions (posters, toys, pictures and other children).

D. The room should be well lighted and free from glare. If there is insufficient light on the chart, position gooseneck lamps on the floor in front of the chart.

The illumination in the room should be the same or slightly less than the illumination of the chart.

E. The chart should be hung so that the chart’s “20 feet” line is level with the student’s eyes.


All students should be educated so that they understand the purpose of vision screening and their role in the activity.

A. Education of the student should emphasize the following:

1. The value of early and periodic screening tests;

2. The relationship of correct health and safety practices to the prevention of eye diseases;

3. The prompt medical treatment of eye injuries and preservation of sight.

B. The individual who will be doing the screening should plan time with the Primary grade teacher to demonstrate the screening procedures to the


1. When the tumbling “E” chart is to be used, a large letter “E” can be turned in various positions to show the students how to use their arms to indicate the direction of the shafts. Other names can be substituted for the term “vision test”, such as “E game” or “Table leg game” since the word “test” may imply to the student the “need to pass.”

2. Related health education appropriate to the student’s grade level and maturity should be offered concurrently. Health education should emphasize: (1) the importance of early and periodic screening tests; (2) the relationship of correct health and safety practices to the prevention of eye diseases, eye injuries and preservation of sight; (3) prompt medical treatment of correctable and/or reversible eye health conditions, and (4) environmental factors which are conducive to the maintenance of eye health and safety. If well planned, the screening procedure will then become a laboratory experience in health, which enriches the instructional program for the child.


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