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GD-100-PHS-WCH: Vision Screening Guidelines for Children



AGES 3 and Older









Effective: December 2010

GD-100-PHS-WCH: Vision Screening Guidelines for Children Acknowledgments The Arizona Department of Health Services would like to thank the following people for

their contributions to these guidelines:

ADHS Vision Screening Guidelines Task Force Denise Allen, R.N., B.S.N., Tempe Schools Panfilo Contreras, Arizona School Board Association Robin Daviet, Lions Club of Laveen Kim Elliott, Ph.D., Arizona Health Care Cost Containment System Felipe Flores, T3 Trainer Gretchen Fuller, VisionQuest 20/20 Miranda Graves, Arizona Department of Education Virginia James, Arizona Department of Health Services Laurel Kruger, R.N., B.S.N., M.Ed., N.C.S.N., Tucson Unified School District Karen Kuhfuss, Arizona Department of Health Services Lynn Ladd, Arizona Department of Education Carol Lamoureaux, VisionQuest 20/20 Lorraine McCabe, Navajo Head Start Patty Merk, Ph.D., University of Arizona Cooperative Extension-Maricopa County Kelley Murphy, First Things First Dr.

James O’Neil, M.D., VisionQuest 20/20 Alison Rapping, VisionQuest 20/20 Maggie Rodriguez, R.N., Tucson Unified School District Shirley Rodriguez, R.N., B.S.N, C.S.N.P., School Nurse Organization of Arizona Jeanette Shea, Arizona Department of Health Services Sheila Sjolander, Arizona Department of Health Services Angela Soliz, VisionQuest 20/20 Dr. Peggy Stemmler, M.D., M.B.A., Arizona Academy of Pediatrics B.J. Tatro, Ph.D., Consultant Dr. Roy Teramoto, M.D., Indian Health Service Richard Tirendi, VisionQuest 20/20 Detza Van Bogaert, M.S.W., University of Arizona Cooperative Extension-Maricopa County GD-100-PHS-WCH: Vision Screening Guidelines for Children


Arizona Department of Health Services Bureau of Women’s and Children’s Health Sensory Program 150 North 18th Avenue, Suite 320 Phoenix, Arizona 85007 Phone: 602-364-1400 www.azdhs.gov GD-100-PHS-WCH: Vision Screening Guidelines for Children Table of Contents Section I: Introduction Children’s Vision Screening 7 Section II: Vision Basics Section III: Common Vision Problems Refractive Errors 11 Strabismus-Crossed Eyes 13 Amblyopia-Lazy Eye 13 Color Deficiency

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GD-100-PHS-WCH: Vision Screening Guidelines for Children Section I: Introduction The Arizona Department of Health Services (ADHS) works to improve health outcomes of all children in Arizona.

As the state agency charged with responsibility for overseeing children’s health issues, the Department supports actions for the benefit of children’s health by setting programmatic policy and making procedural recommendations.

These guidelines were developed with the advice and contributions of the ADHS Vision Screening Guidelines Task Force. A facilitated process of reviewing professional recommendations and related literature was conducted over three meetings in 2009 and 2010. A final review was conducted by a panel of stakeholders with interest and experience in vision screening of children.

Vision screening of children, unlike hearing screening, is not currently mandated by Arizona state law. However, vision screening can be a positive and worthwhile undertaking in helping to identify children who may require further evaluation of their eyesight. The vision screening process can lead to early detection and correction of vision problems which positively impacts a child’s opportunity for academic success and learning potential. Therefore, ADHS has an interest in ensuring that vision screening of children is accomplished in as reliable, valid and consistent manner as possible.

These guidelines apply to vision screening programs occurring in school and community settings.

Sensory screening also occurs during well-child care visits in a medical setting where vision problems may be detected. Not all children have access to primary care. School and community screenings may be the only avenue for some children to have vision screening completed. When vision problems are identified during school and community screenings and a child has a primary care provider (PCP), communication and coordination with the child’s PCP is the key to follow-up, diagnosis and treatment.

When a child has no primary care, linking the family to a community resource for follow-up, diagnosis and treatment is essential.

The purpose of this document is to provide information, guidance and recommendations for implementing a vision screening program for children ages 3 and older in school and community settings. Vision screenings are becoming more common in child care settings and at community events such as health fairs. Regardless of the setting, there are standards of practice that make vision screening a viable and cost-effective community health strategy. This document provides guidance and practical information on the screening process, appropriate screening tools, referral criteria and follow-up procedures. The guidelines are not intended to serve as a complete resource for eye health or eye care.

The sources and references used for the guidelines are research-based.

GD-100-PHS-WCH: Vision Screening Guidelines for Children

Children’s Vision Screening

What is children’s vision screening?

Children’s vision screening is a systematic approach to identifying children with potential vision problems. The focus is on detecting conditions that are commonly occurring and can be easily corrected.

Typically, traditional vision screening of children assesses distance vision of both eyes (binocular vision) and one eye at a time (monocular vision). Near vision and color vision are additional parameters which may be included as part of a traditional vision screening program. Alternatively, newer technologies may be employed which can evaluate for focusing problems, eye alignment, and opacities within the eye. Vision screening does not take the place of a complete or comprehensive eye examination which only an eye care professional can provide.

Why screen children’s vision?

The development of a child’s sense of sight occurs over a period of years and is most sensitive to correction during the first seven to eight years of life (Eliot, 1997). As children age, there may be changes in their vision that may impact their learning. Many vision problems in children go undetected by parents, teachers and the children themselves without a formal vision assessment. Vision screening can help detect or identify a problem with a child’s eyesight so it can be caught early when treatment can be most effective.

If a problem is detected, the child’s parent or guardian is notified and the child is referred for further evaluation and treatment if necessary. A well-developed vision screening program may help identify children ages 3 and older who may require additional follow-up with an eye care professional for a professional examination.

What is the difference between a vision screening and an eye examination?

A screening for the purposes here “involves the appraisal of only those conditions that are commonplace and amenable to easy and early intervention” (Proctor, 2005, p.


Screenings described in these guidelines do not involve examination of eye structures such as the retina to determine eye disease.

There are several important differences between vision screening and a vision examination. These

are outlined in the table below:

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What is the importance of vision screening?

Children are often unaware that they are seeing “less” than they should and often do not complain of visual difficulties.

Identifying children who may have issues with vision “appears to have substantial benefits in simpler, more effective, and less costly treatment, improvement of developmental outcomes, and enhancement of quality of life” (AAPOS, 2001 as cited in Proctor, 2005).

If not detected and treated early, vision problems in children can lead to a variety of long-term

consequences. Untreated vision problems can lead to:

Permanent loss of vision Difficulty learning Delayed sensory and social-emotional development An understanding of the importance of vision screening by administrators, teachers, school nurses, other school personnel and parents is critical to the outcome of a child’s academic success.

Vision deficits are a common problem in the preschool and school age population. Early detection and treatment of these deficits will lessen the possibility of any damaging long-term effects and may have a direct impact on each child’s academic performance.

The focus of these guidelines is on providing quality screenings as consistently as possible.

Although the optimal situation is for screenings to be performed and/or supervised by nurses, the guidelines recognize that other health care and non-health care professionals, teachers and/or volunteers may be involved in the vision screening process. Therefore, it is even more important that these recommended guidelines be followed when conducting vision screening of children.

GD-100-PHS-WCH: Vision Screening Guidelines for Children The ability to screen young children is dependent upon several criteria including the child’s capacity to understand directions and having developed the cognitive ability to perform the screening successfully. Those conducting vision screenings with preschoolers will need to determine whether or not the child has met the above criteria.

For children birth through age 2, vision screening should be conducted by a health professional or by other specially-trained individuals. The guidelines contained in this document do not necessarily apply to vision screening for this population. The attachment section includes Age-Appropriate Pediatric Vision Screening Guidelines recommended by The American Academy of Pediatrics (AAP) combined with the American Academy of Ophthalmology (AAO) and the American Association of Pediatric Ophthalmology and Strabismus (AAPOS).

An effective vision screening program includes the following components:

Periodic scheduled screenings Re-screening, as necessary Notification of results to parents or guardians and others Referrals to appropriate professionals Follow-up of referral outcomes Continual program evaluation These guidelines address each of these elements. Utilization of the recommended guidelines will promote implementation of a quality, reliable and effective vision screening program.

GD-100-PHS-WCH: Vision Screening Guidelines for Children

Section II: Vision Basics Our eyes receive messages from the outside world and transmit them to our brain. All images we see are the result of reflected or emitted light from the surfaces of objects that we view.

The vision process begins when light rays enter the eye through the transparent, curved cornea. The cornea directs the light through the pupil. The pupil is an opening that can be expanded or constricted by the iris to control light entering the eye. The light is then focused toward the retina by a transparent lens. An upside-down image is formed on the retina in the back of the eye.

Cells on the retina called rods and cones can sense light and color. Rods detect black and white, while cones detect colors. The cells on the retina turn the picture into electrical signals (nerve impulses) that travel along the optic nerve to the brain. The images from both eyes are combined and are “seen” by the brain as right side up.

Some parts of the eye are protective. The eyelids, cornea and sclera all protect the eye from injury.

The sclera is the outer “white part” of the eye.

The outer wall is tough and gives protection to the delicate inner structures. Figure 1 is an illustration of the major eye structures. Defects in any part of the eye may cause visual deficits.

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Section III: Common Vision Problems The goal of screening is to detect commonplace possible or potential visual anomalies and refer for examination and treatment. This section outlines and describes some of these anomalies.

Refractive Errors Refractive errors are caused by a defect in the shape of the cornea or the shape of the eye. All refractive errors may occur in one eye and not in the other or in both eyes equally or in differing degrees in each eye. The result is blurred vision for near and/or distant objects. The following are common

refractive errors:

Distance Vision-Myopia - Nearsightedness Myopia is the most common vision problem seen in children. Myopic eyes are too long from the front to the back. The images of distant objects are focused in the front of the retina and appear blurred.

This is commonly known as nearsightedness because near things are seen more clearly than distant objects.

Near Vision-Hyperopia – Farsightedness Hyperopia is the result of an eyeball that is shorter than normal from the front to the back. The image of near objects is focused behind the retina resulting in blurred near vision. It is commonly called farsightedness because distant images are seen more clearly.

Astigmatism Astigmatism is caused by an uneven surface of the eye that prevents light rays from falling on a single point on the retina. The normal cornea is round like a basketball while the astigmatic cornea is irregular and elliptical, like a football.

GD-100-PHS-WCH: Vision Screening Guidelines for Children

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GD-100-PHS-WCH: Vision Screening Guidelines for Children Strabismus–Crossed Eyes Strabismus is a misalignment of the eyes that prevents them from looking at the same object together. One eye may be directed inward, outward, or rarely, up or down in relation to the other eye.

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