Vision Screening Basics for
Health Assistants
By Laura Case, RN, MSN, NCSN
Nursing Coordinator
Albuquerque Public Schools
505.855.9834
Laura.Case@aps.edu
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.
NM School Health Manual, Section
III




Recommended
Screening Equipment
Room Set Up and
Screening Environment
Recommended grades
to screen
Recommended tests
to perform
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
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.

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

EARLY DETECTION

The purpose of a vision screening
program is early detection of common
vision disorders such as refractive errors,
amblyopia and strabismus.
Parent Permission for Screening

Always get parent permission or notify
parents that their child will be screened
unless the parent provides a written
excluding their child from screening.
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
◦ Stereopsis – Pre-K, K, 1st
◦ Color Vision – only
required once in target
populations
Creating a Screening Environment
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 students quite 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
Equipment to Use for Screening



Pre-kindergarten and Kindergarten must use an HOTV chart
or Lea Symbols.
1st grade can use HOTV or Sloan letter chart depending on
their ability to accurately identify the letters.
All other grades should use Sloan letter charts.
Lea Symbols Chart
Distance Charts
Actual 10
foot
“For testing at 10 feet”
Equivalent 20 foot
Equipment to use con’t….
Butterfly
stereopsis
 Eye occluders

Before testing begins.....





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?
Notify your school nurse
if you see any of these
visual signs so that
additional assessment
can be done!
Droopy eyelids?
 Keyhole pupils?
 Do the eyes move
together?
 Excessive tearing?
 Jerky eye movements?
 Pupil constricted or
dilated?

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.

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.
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 distractible, 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.
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

Isolators
Stereopsis






For children 3years to 3rd grade
Used to check for problems with depth
perception – indication of strabismus
Use Butterfly stereo
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.
Stereo Butterfly
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, tell him it is a
butterfly. Have them touch the wings.

Stereo Butterfly 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

First at 20”
5 times;
Then at 40”
repeat the
test.
Color Vision – Ishihara Plates










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 Qtip (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.
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.

Passing Guidelines
Passing Guidelines – Vision
* If vision in either eye is WORSE that the limits below OR if the student has a 2 line difference or greater - then REFER
for vision exam.
Grade
Distance
PK
20/40
K
20/30
1
20/30
3
20/30
Other Testing
•Random Dot E and Color Vision – required
only once in any of the target population
grades.
Passing Guidelines - Hearing
1000 Hz
20 dB
2000 Hz
20 dB
4000 Hz
20 dB
RRPS Screening Worksheet
Student Name:____________________
Date of Screening:__________________
Grade:_______________
Teacher:_______________
School:_______________
Wears Glasses: _____Yes
_____No
_____Reading
_____Distance
If Yes, glasses are worn at screening: □Yes
□ No
□ Broken/Lost
HEIGHT _______________
Vision Screening
WEIGHT________________
1st Screening
2nd Screening BY SCHOOL NURSE
Screened by:_______________________
Distance:
□ 10 ft.
Right Eye 20/________
□ 20 ft.
Left Eye
20/_______
Screened by:_______________________
Distance:
□ 10 ft.
Right Eye 20/________
□ 20 ft.
Left Eye
20/_______
Chart Used:
□ Letter
□ PASS
□ “E”
□ FAIL
□ HOTV
□ Symbol/Picture
Functional Acuity (both eyes) 20/_________
Chart Used:
□ Letter
□ “E”
□ HOTV
□ Symbol/Picture
Stereo/Depth: □ PASS
□ PASS
□ FAIL
□ FAIL
Near:
Right Eye 20/________
Left Eye 20/________
□ PASS
□ FAIL
Stereo/Depth: □ PASS
Color:
□ Color Blocks
□ Ishihara
Screening Notes
□ FAIL
□ PASS
□ FAIL
□ Did Not Test
Motility:
Tracking/Convergence: □ PASS
Cover/Uncover:
Near: 12-13 inches
□ No Eye Movement – PASS
□ Eye Movement – FAIL
□ Could not Test/Did not Test
□ FAIL
Hearing Screening
1st Screening Date:
Right
Left
Otoscopic
□ Clear
□ Possible
□ Possible
□ Refer □
2nd Screening Date:
500
1000
2000
4000
(25 dB)
(20 dB)
(20 dB)
(20 dB)
500
1000
2000
4000
(25 dB)
(20 dB)
(20 dB)
(20 dB)
Right
Left
500
1000
2000
4000
(25 dB)
(20 dB)
(20 dB)
(20 dB)
500
1000
2000
4000
(25 dB)
(20 dB)
(20 dB)
(20 dB)
Exam (by school nurse):
Ear Infection
Wax Impaction
Re-Check by Audiologist __________(date)
□ PASS □ Watch
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 noncompliant in taking their child for an exam.

RESOURCES for Glasses
Save Our Children’s Sight Fund – not
operating yet
 Medicaid – will pay for 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.

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.
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.

QUESTIONS?
Dental Screening
Section XIII of NM School Health
Manual
Dental Caries looks like......
Gum Disease looks like......
Oral Herpes (Cold Sore)
Canker Sore
Avulsed Tooth
Mouth lesions from chewing
tobacco
Height and Weight Screening
Section XII of NM School Health
Manual
Growth Charts
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/
CDC BMI Charts
Referrals for Elevated BMI
Does your district have a policy regarding
BMI referrals?
 Follow district guidelines.
