Vision Screening
Procedures
For Infancy, Childhood
and
School Age Children
Minnesota Department of Health (MDH)
Community and Family Health Division
Child and Adolescent Health Unit
Vision Screening
Procedures
For Infancy, Childhood
and
School Age Children
Revised 6/2014
For more information, contact:
Minnesota Department of Health
Maternal and Child Health Section
Child and Adolescent Health Unit
PO Box 64882
St. Paul, MN 55164-0882
MDH C&TC website
http://www.health.state.mn.us/divs/fh/mch/ctc/
CONTENTS
Background and Overview .................................................................................................... 1
Pediatric eye screening or evaluation................................................................................... 3
MDH recommendations for vision screening ....................................................................... 3
Vision Screening Preparation.................................................................................................... 2
General considerations for vision screening (C&TC) ............................................................ 4
Preparing for mass vision screening ..................................................................................... 5
Head Start, Early Childhood and School Screenings (page 2) ............................................... 6
Mass screening program planning and organization ........................................................... 7
Re-Screening, referral, follow-Up, and evaluation ............................................................... 9
Infection control and care of vision equipment ................................................................. 10
Vision Screening Procedures................................................................................................... 12
Child and family history taking ........................................................................................... 14
External inspection ............................................................................................................. 15
Pupillary light response....................................................................................................... 17
Retinal (red light) reflex ...................................................................................................... 18
Monocular fix and follow / extra ocular movements (EOM) .............................................. 19
Binocular fix and follow / extra ocular movement (EOM) .................................................. 20
Ophthalmoscope directions................................................................................................ 22
Observation......................................................................................................................... 23
Corneal light reflex .............................................................................................................. 24
Cross Cover ......................................................................................................................... 26
Stereo acuity test: random dot E (Optional)....................................................................... 27
Stereo acuity test: stereo butterfly (optional) .................................................................... 29
Color vision.......................................................................................................................... 31
Visual acuity ........................................................................................................................ 33
Visual acuity – LEA/HOTV flip chart .................................................................................... 34
Visual acuity - HOTV chart .................................................................................................. 36
Visual acuity-LEA symbols ................................................................................................... 38
Visual acuity - Snellen or Sloan Alphabet Chart .................................................................. 40
Plus Lens (OPTIONAL) ......................................................................................................... 42
Screening with Technology ..................................................................................................... 44
Keystone, Optec, Titmus Vision Screeners; MTI Photoscreener ........................................ 46
Welch Allyn® SureSight Vision Screener .......................................................................... 47
Resources and Glossary .......................................................................................................... 50
Online vision resources ....................................................................................................... 52
Glossary ............................................................................................................................... 54
Addendums ............................................................................................................................. 60
Teacher and Child Vision Pre-Screening Worksheet ......................................................... 62
Child Vision History Questionnaire for Parent/Caregiver ................................................... 64
Child Vision Development Checklist for Parents/Caregivers .............................................. 68
Vision Screening Worksheet ............................................................................................... 70
Vision Referral Letter for (Child’s Name) ........................................................................... 72
Color Vision Advisory Letter................................................................................................ 74
Child and Teen Checkups Online Resources ....................................................................... 76
Prescreening Practice Sheet - LEA Symbols ........................................................................ 78
Prescreening Practice Sheet - HOTV ................................................................................... 80
Background and Overview
Purpose and rationale
Vision screening is a procedure performed by properly trained persons for the purpose of
early identification of children who may have vision problems and referral to appropriate
medical professionals for further evaluation. Minnesota’s vision screening procedures are
based on sound epidemiologic findings and principles.
Impaired vision in children can contribute to the development of learning problems which
may be prevented or alleviated through early identification and intervention. Children with
impaired vision often are not aware of their impairment; therefore, they do not complain or
seek help. If they have always seen things in a blurred or distorted way, they accept the
imperfect image without question. It is up to adults responsible for children’s health care
and education to assure that children have their vision screened on a regular basis.
Minnesota’s vision screening program
This vision screening training manual provides the screener with instructional information
to conduct vision screenings in schools or clinics. The screening procedures herein serve as
guidelines for Child and Teen Check-ups (C&TC), Head Start, Early Childhood Screening, and
school programs.
Child and Teen Checkups [federally titled Early Periodic Screening Diagnosis and Treatment
(EPSDT)] is a program administered by the Minnesota Department of Human Services for
children and teens enrolled in Medical Assistance and Minnesota Care under Minnesota
Statute MS 256B.04-256B.0625. The Minnesota Department of Health provides health
recommendations to the program. For more information see the Minnesota Child and Teen
Checkups provider guide at http://edocs.dhs.state.mn.us/lfserver/legacy/DHS-4212-ENG.
1
Head Start- Head Start and Early Head Start are comprehensive child development
programs which serve children from birth to age 5. They are child-focused programs and
have the overall goal of increasing the school readiness of young children in low-income
families. Minnesota Head Start follows Child and Teen Checkup guidelines. For more
information see the Minnesota Head Start page at http://www.mnheadstart.org/.
Early Childhood- Early Childhood Screening or evidence of a comparable screening by a
non-school provider (e.g., Head Start, Child and Teen Checkups/EPSDT or a health care
provider) is required for entrance in Minnesota’s public schools or within 30 days of
enrollment into kindergarten (MS 121A.16-121A.17). Early Childhood Screening is offered
throughout the year by local school districts. For more information see the Minnesota Early
Childhood Screening page at
http://education.state.mn.us/MDE/StuSuc/EarlyLearn/EarlyChildScreen/.
2
Pediatric eye screening or evaluation
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 should be asked to examine all high risk infants.
While there may be minor differences to each association’s periodicity tables, they all agree
with the basic principles of pediatric vision care. After much review and discussion, the
professional representatives from the “Work Group” and from the Minnesota Department
of Health arrived at a consensus with regard to the vision screening recommendations
contained in this manual.
Minnesota Department of Health recommendations for vision screening
According to Minnesota Department of Health (MDH) guidelines, a child's vision should be
screened at the following intervals:
Child and Teen Checkups (C&TC):
Screening is done according to the Schedule of Age Related Screening Standards:
Subjective screening: Take the child and family history and/or update at every well child
exam following the usual schedule for C&TC even when other objective tests
areadministered.
Objective screening: All other objective screenings and procedures are done at every well
child exam for children ages 3 through 12 years following the usual C&TC Periodicity
Schedule (https://edocs.dhs.state.mn.us/lfserver/Public/DHS-3379-ENG). For ages 14-20,
every other year testing 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 - the vision screening schedule for the state’s EPSDT
program (in Minnesota, this is C&TC) is followed. C&TC Periodicity Schedule
(https://edocs.dhs.state.mn.us/lfserver/Public/DHS-3379-ENG).
3
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 1, 3, 5, 7, and 10 should be screened. 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 vision screening should be properly lighted and at least five feet
longer than the distance required for each visual acuity screening. Additionally, it 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
For Required Procedures:
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Occluder: 3” square of paper or plastic occluder
Penlight
Toy (1/2 inch in size) as a target object
HOTV and/or Lea Vision Chart (50% rectangle), response card, and conditioning
flashcards
LEA Symbols Puzzle may be useful for children who are autistic or have ADHD
Snellen or Sloan Alphabet Chart
Ishihara, Good Light Color Vision Plates, or Waggoner Color Vision Made Easy
Vision Screening Worksheet
Antimicrobial hand gel and appropriate antimicrobial cleaner for occluder
For optional procedures:
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Random Dot E Test Kit or Stereobutterfly Stereopsis tests
Plus Lens: +2.25 lenses, +1.75 lenses
4
Care of equipment:
The equipment should be kept clean and in good repair.
Color vision books should be kept closed when not in use to prevent fading.
Glasses (Random Dot E & Plus Lenses) should be cased when not in use and routinely
cleaned.
Visual acuity charts and response cards may be washed with warm, soapy water.
Replace chipped or torn charts as they can be distracting to the child.
Replacement flashlight bulbs and batteries should be readily available.
For More Information: The Minnesota Department of Health (MDH) Maternal Child Health
Section provides training and consultations to C&TC, Head Start and School providers.
http://www.health.state.mn.us/divs/fh/mch/hlth-vis/trainings.html.
5
1
Vision Screening
Preparation
2
3
General considerations: C&TC setting
Frequency: See Child & Teen Checkup (C&TC) Periodicity Schedule
(https://edocs.dhs.state.mn.us/lfserver/Public/DHS-3379-ENG).
Facility
The room selected for vision screening should be at least five feet longer than the distance
required for each procedure, well-lighted and free of distractions and direct sunlight glare
screening.
Provider roles in C&TC clinics
Primary care provider: Usually updates history and performs the ophthalmoscope
evaluation and tests muscle balance (Extra Ocular Movements (EOM), Cross Cover test and
corneal light reflex) as part of the physical exam.
Certified Medical Assistant or Nurse: Usually screens with visual acuity charts.
Equipment for Visual Acuity Screening
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Provide the parent or guardian with the HOTV or LEA practice sheets prior to
screening so they are familiar with the symbols if desired.
Occluders: 3 inch square of paper or plastic occluder.
Penlights
HOTV or LEA vision 10 foot wall chart (Age 3-5 years), or the Minnesota Early
Childhood Visual Acuity flip chart, response card, and conditioning flashcards or LEA
Symbols Puzzle alternative which may be useful for children with Autism or ADHD
Snellen or Sloan alphabet chart (age 6 years +)
4
Preparing for mass vision screening
Head Start, Early Childhood and School Screenings
Planning meeting:
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Arrange a planning meeting for those persons who will be involved in the technical
and administrative aspects of the screening process; determine the number of
students to be screened and the number of staff and volunteers needed.
Reserve appropriate space for the screening site. Size determination should be
based on which visual acuity charts will be used and how many stations will be
necessary for the screening.
Identify the organization or schools’ policies & procedures to address data privacy in
a mass screening in order to maintain compliance with FERPA/HIPAA regulations
Set calendar for volunteer recruitment and training dates and screening and rescreening dates.
Notification letter to parents:
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Prior to the screening date send out an informational letter with the details of the
screening event including date, time, location and what to expect plus a copy of the
parent version of the child vision questionnaire for parents to fill out and return to
school.
Advise them there will be a second screening for children who have difficulty with
any part of the first screening.
If after the second screening a child continues to be unable to meet passing criteria,
parents will be notified with a referral and strongly encouraged to bring their child in
for further evaluation by an eye professional.
Any parent/guardian who does not want their child screened should be advised as to
the importance of the screening but when desired, the procedure they should follow
so that their child will be excluded from the screening.
ESC students may be given sample HOTV or LEA symbols for practice opportunities
prior to screening if desired. There is also a LEA symbols puzzle to assist the child in
preparation for the LEA chart.
5
Preparing for mass vision screening
Head Start, Early Childhood and School Screenings
Designate a vision screening coordinator
Duties:
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Attend the MDH Training on vision and hearing
Serve as primary person responsible for the smooth operation of the screening.
Recruit, schedule and orient volunteers.
Train volunteers using resources available from MDH.
Assign volunteer tasks. It is best to make a volunteer an expert at one area instead
of rotating that volunteer to different screening stations.
Provide on-site supervision.
Arrange for and maintain needed equipment and supplies.
Carry out or designate a person(s) to work in collaboration with the referral
professional and be responsible for sending out referral letters, follow-up and record
keeping.
Referral/follow-up professional:
A currently licensed (in Minnesota) professional nurse with MDH training in vision
screening
Responsibilities:
1. Determine which children need further professional evaluation based on MDH
criteria.
2. Contact parents or guardian if follow-up information about the referral is not
received and explain the screening results as needed.
3. Communicate with appropriate staff regarding referrals and follow-up information.
4. Monitor child's vision and treatment as appropriate.
5. Maintain screening and follow-up information on the child's health record.
6. Evaluate the screening program.
6
Mass screening program planning and organization
Head Start, Early Childhood Screening, School Screening
Prescreening activities: two weeks prior to the intended screening date
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Determine the number of children to be screened and their ages or grade level
Determine the number of staff needed to provide mass screening
Recruit volunteers and schedule dates and times for volunteer training and
orientation, and the screening and re-screening sessions.
Screening facilities should be examined and reserved for the screening dates.
Copies should be made of the vision screening worksheet and distributed to
classroom teachers and parents to be filled out with the child’s name/age/grade and
comments, if any
Copies should be made of the referral and follow-up letter
Determine the amount and type of the equipment needed and that it is in working
order
Screening clinics organized into “stations”
An efficient ratio for the stations is:
3:1 (3)-visual acuity to (1)-muscle balance (i.e, corneal light, cross cover) station.
When the color vision procedures are included the ratio is:
3:2 (3)-visual acuity stations to (2)-muscle balance/color vision stations.
Number of staff per station is determined by the age of the children
Pre-school through first grade:
Visual acuity screening may require two persons per station
Older children:
Muscle balance/color vision screening requires one person per station.
Visual Acuity Station: Approximately 20 children per hour can be screened
A few additional volunteers will be needed to help with traffic flow.
Example based on the above guide:
To screen 300 children in 1-1 1/2 days, including color vision:
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4 - (Two muscle balance/color vision stations using two volunteers each (2X2))
6 - (Three acuity stations using two volunteers each (3X2))
7
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1 - (One volunteer to bring the children to the clinic from the classroom, direct
traffic flow to and from the various stations and to sort worksheets and record the
results)
11 Volunteers Total
Screening day activities
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The vision screening coordinator will set up the vision stations in the screening area.
The stations should be arranged so children cannot hear and repeat the answers of
other children being screened.
Visual acuity stations should be at least eight to ten feet apart from one another.
Volunteer training is done immediately prior to the screening on the clinic day.
A minimum of one hour should be scheduled for this training.
Each volunteer is assigned his/her specific task
Each volunteer must have an opportunity to practice before screening begins
Children should have their pre-filled out vision screening worksheets with them
Children with a diagnosed visual condition should be included in the screening
activities to determine if there are any changes in their vision and if changes are
found, a referral back to the child’s eye care provider should be made.
Post screening activities
1. The Screening Worksheets are sorted into pass/re-screen groups to determine
number of children to be re-screened
2. The above guidelines for organizing the screening and determining numbers of
volunteers, vision stations, etc., can also be used in planning and preparing for the
re-screening to take place 10-14 days after the initial screening.
3. Screening results should be reviewed and documented on the child's individual
permanent health record by the Referral/Follow-up Professional.
8
Re-Screening, referral, follow-Up, and program evaluation
Head Start, Early Childhood Screening, School Screening
Re-screening
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Re-screening is indicated for the child who failed any part of the initial screening.
A second screening is performed to eliminate those children who failed the initial
screening because of such factors as illness, anxiety, misunderstanding, etc.
The number of students re-screened will be typically about 20% of the initial number
screened.
Re-screening is performed 10-14 days after the initial screening
Re-screening procedures are the same as those followed for the initial screening.
Referral
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A referral is indicated if the child fails any portion of the re-screening except the
color vision test.
The referral should be made by mailing a referral letter to the parent/caregiver
within one week after the re-screening.
The Referral Letter should not be hand carried by the child
A phone call to the parent/caregiver soon after the referral is mailed usually
improves follow-up results
Follow-up and tracking
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A tracking system is essential to follow-up those who are referred so as to assure the
identified child receives the appropriate treatment and other services.
If the information about the referral is not received in 3-4 weeks, a phone call should
be made to the child’s home. In some cases a home visit might be appropriate.
All pertinent information regarding the screening results, referral, parent/caregiver
comments, and results of the professional evaluation and recommendations must
be documented in the child’s health record
It may be determined by the professional examiner that a child doesn't presently
need glasses or other specific treatment, but this would not invalidate the referral if
a problem were confirmed.
Following professional diagnosis and treatment, further planning may be needed for
the child whose vision status cannot be brought to within normal limits. In this case,
the special education director should be notified so special programming can be
implemented as needed.
9
Infection control considerations for vision screening
General principles:
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 occuluders 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.
Care of vision equipment
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Color vision books should be kept closed when not in use to prevent fading.
Do not touch the color plates with your fingers as the oil on your 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
response card 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.
10
11
Vision Screening
Procedures
12
13
Child and family vision history taking
Ages
Perform at birth to five years or at any age if family history is unknown. Continue to
update ocular history at each subsequent well child visit
Purpose
Identify a child/family history of any medical conditions that may be associated with
eye disorders.
Description
Elicit information of selected medical conditions and syndromes from the parents
that may indicate the need for referral even if other screening procedures are
passed.
Additionally, the parents are asked to identify any complaints or unusual visual
behavior their child may have exhibited.
Forms
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Teacher and Child Vision Prescreening Worksheet
Child Vision History Questionnaire for Parents/Caregivers
Procedure
Parent/caregiver are given the forms to fill-out and their answers are reviewed and
flagged if significant history of conditions/syndromes or behaviors are identified.
If parents have any questions regarding the form, a contact number for the
Referral/Follow-up professional nurse should be given.
PASS
No family history of associated conditions or syndromes or vision behaviors
are identified.
REFER
Family history of associated conditions or syndromes or visual behaviors
are reported.
14
External inspection
Ages
Birth through 20 years (C&TC) or birth through all grades (Early Childhood and
school screenings)
Purpose
To check for signs of external eye disease or abnormalities
Description
A systematic inspection of observable parts of the eye and surrounding tissue
Equipment:
None
Facilities
Well-lit area
Procedure
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If the child is wearing glasses, they may be removed in order to give the screener
an unobstructed view of the area around the eyes.
The area around the eyes should be checked for swelling and/or discoloration or
excessive tearing.
The eyes themselves should be checked in the order suggested by the acronym
"WIPL."
Whites: The sclera should be white. There should be no discoloration or growths.
Iris: The iris should be a complete circle. Both should be the same color.
Pupil: The pupils should be clear and dark. There should be no cloudiness or
white discoloration. The pupils should be of equal size and circular shape.
Lids and Lashes: The lids in their natural, open position should give a full view of
the pupil. The lids should be free of lumps (chalazia). There should not be
redness or crustiness along the margin or signs of a sty. The margin of the lid
should be flush against the surface of the eye. The child should show normal
blinking during observation period. Lashes should be present on the top and
bottom lids of both eyes. Lashes should not turn in causing them to come in
contact with the conjunctiva.
PASS
Normal appearance of all parts of the eye
15
Re-screen/REFER
Any abnormality noted. If a white pupil (leukocoria) is noted, an immediate referral
to an Ophthalmologist is necessary.
16
Pupillary light response
Ages
Birth to age three years (or until visual acuity can be measured)
Purpose
To check for the pupils' reaction to changes in illumination
Description
Observing the child's pupils for symmetrical reaction to light
Equipment
Penlight
Facilities
Normal or lower light level
Procedure
1. Observe the child's eyes noting if the pupils are of equal size.
2. Approaching from the side, at eye level, shine the light into the right eye- the
pupil should quickly constrict.
3. Observe the left eye to see if it has equally constricted (consensual response).
4. Remove the light- both eyes should dilate.
5. Repeat the procedure on the left eye.
PASS
Pupils constrict quickly and equally when light is introduced and almost as quickly
and equally dilate when light is removed.
Re-screen/REFER
Sluggish or no response upon the introduction or removal of the light or the pupils
become unequal in size.
Note: The screener may observe the pupils dilate and constrict several times after
illumination. This is a normal occurrence called Hippus.
17
Retinal (red light) reflex
Ages
Birth to age three years (or when visual acuity can be measured)
Purpose
To check for abnormalities that block light flow within the eye by observing the
reflected light from the retina which is red in color
Description
Observing symmetrical and equal intensity reflexes from the retinae
Equipment
Ophthalmoscope
Facilities
Normal to lower light level- minimum number of light sources (windows, overhead
lights, etc.)
Procedure
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Position the child so the circle of light from the ophthalmoscope falls just to the
outside of both eyes.
Looking through the ophthalmoscope, you should observe a glow in both pupils
simultaneously.
PASS
Reflexes are equal in symmetry of pattern, color and intensity
Re-screen/REFER
A reflex that is altered in symmetry. In the presence of a leukocoria, one or both
pupils may appear white instead of the normal red color expected and immediate
referral is required.
For More Info: American Academy of Pediatrics. Policy Statement. Red Reflex Examination
in Neonates, Infants, and Children. December 2008. Available online at:
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;122/6/1401
18
Monocular fix and follow /extra ocular movements (EOM)
Ages
Four months to when visual acuity can be measured
Purpose
To check for vision and the movement of the eye when it is following a continuously
moving target with the other eye covered
Description
Target is moved horizontally then vertically in relation to a center point on a visual
axis of each eye. Make sure the child’s head doesn’t move, the parent can help.
Equipment
Penlight or interesting target
Procedure
Test the Right Eye
Horizontal
•
Cover the Left Eye and attract the child's attention to a target 14-16 inches
away, centered in front of the child's right eye.
• Slowly move the target horizontally to your right until the child's eye is in its
extreme left viewing position.
• Slowly move the target to your left, crossing the center point and continuing
until the eye is in the extreme right viewing position.
• Return target to center point.
Vertical
•
Starting at the center point, raise the target until the eye reaches the
extreme up viewing position.
• Lower the target through the center point until the eye reaches the extreme
down view position.
• Return target to center point.
Test the Left Eye: Cover the Right Eye & repeat the procedure above
PASS
Each eye follows the target easily and smoothly, without head movement
Re-screen/REFER
The child does not attend to the target; either eye shows jerky movements, or the
child objects to one eye being covered but not the other.
19
Binocular fix and follow / extra ocular movement (EOM)
Ages
Four months to when visual acuity can be measured
Purpose
To check for symmetrical eye movements when following a moving target
Description
The child's head is stabilized while a target is moved in horizontal, vertical and
oblique patterns in relation to a center point on a visual axis. The target is also
moved from the center point toward the child.
Equipment
Penlight or interesting target
Procedure
Horizontal
•
Hold the target 14-16 inches away, centered in front of the child's eyes (center
point) and slowly move the target horizontally to your right until the child's eyes
are in their extreme left viewing position.
•
Slowly move the target to your left, crossing the center point and continuing
until the eyes are in the extreme right viewing position
•
Return target to center point.
Vertical
•
Start at the center point, raise the target until the eyes reach the extreme up
viewing position.
•
Lower the target through the center point until the eyes reach the extreme
down viewing position.
Oblique
•
Start at the center point, raise the target until the eyes reach the extreme upper
right viewing position.
•
Lower the target through the center point until the eyes reach the extreme
lower left viewing position.
•
Repeat this procedure for the upper left to the lower right viewing position.
Convergence
20
•
It is the simultaneous inward movement of both eyes to maintain binocular
vision
•
Starting at the center point, move the target slowly toward the child to a
distance of 4 inches.
PASS
Both eyes follow the target easily and smoothly
Re-screen/REFER
Eyes do not follow in unison or movements are jerky, uneven, or "break" further
than 4 inches from the bridge of the nose, or child uses head movements. Eye
crossing is fixed and/or intermittent.
21
Ophthalmoscope directions
Here are the steps to using the ophthalmoscope correctly:
1. To screw the head onto the power base
a. Match the notches in the Ophthalmoscope head
with those on the power base (see illustration)
Press down until notches mesh
c. Twist clockwise
d. Pull gently to see if head is secure
2. To turn the ophthalmoscope on
a. Press colored button on the top rim of the power
base handle in a downward direction
b. Twist the button clockwise around the rim
You should be able to see the light in the palm
of your hand when you point the narrow end
toward your palm.
3. View the eye with the ophthalmoscope
a. Turn the vertical dial with your thumb until it is
on the “0” setting (see illustration)
b. Find the “large circle of light” by turning the
horizontal dial with your thumb (see illustration)
c. View both eyes at same time through the scope’s
sight to visualize a symmetrical reflex
22
Observation
Ages
Four months through eight years (C&TC) or 3rd grade (Early Childhood and school
screenings)
Purpose:
To check for constant strabismus
Description:
Observing the child's eyes to see if they are properly aligned
Equipment:
None
Facilities
Well-lit room
Procedure:
The screener observes the child's eyes to see if one eye appears to turn in, out, up,
or down in relation to the other. The position of the head for tilt (chin up or down)
should also be noted.
PASS
Eyes are properly aligned and head position normal
Re-screen/REFER
One eye appears to turn in, out, up, or down in relation to the other, eyes cross or
abnormal head position*
*A child with an abnormal head position should also be referred as it may be
indicative of an eye disorder leading the child to tilt his/her head to improve their
view.
23
Corneal light reflex
Ages
Two months through eight years (C&TC) or 3rd grade (Early Childhood and school
screenings)
Purpose
To check for milder degrees on constant strabismus. To differentiate pseudostrabismus on children with large epicanthal folds
Description
By noting the position of light being reflected in the pupils, the observer is able to
check for a constant strabismus
Equipment
Penlight and target object
Facilities
Normal or lower light level. Minimize, if possible, the number of light sources (i.e.
windows, overhead lights, etc.)
Procedure
1. Position the child so that the target, the light source and the examiner's
line of vision is at the midline in front of the child's eyes at a distance of
14-16 inches.
2. Try to have the child sit with his/her back to any ceiling lights.
3. Shine the penlight at the center of the child's forehead directly above
and between the child's eyes.
4. Make sure the child is focused on the target.
5. The screener then observes the reflected light in each pupil.
6. It is very important that good light is used. Ceiling lights are not
sufficient.
PASS
The reflection of the light appears to be in a symmetrical position in the pupil of
each eye.
Re-screen/REFER
The reflections of light appear to be asymmetrical.
24
Note:This test is very helpful to detect pseudostrabismus, the false appearance of
strabismus. Sometimes a child’s eyes may appear crossed when they actually are not. This is
often due to the wide bridge of the nose or the epicanthal fold
25
Cross Cover
Ages
Four months through eight years (C&TC) or 3rd grade (Early Childhood and school
screenings)
Purpose
To check for tendency of the eyes to misalign when fusion is interrupted
Description
Observing the eye being uncovered for movement when the occluder is shifted to
the other eye
Equipment
Small, interesting target object and occluder
Procedure
1. Have the child focus on a target object held steady 14-16 inches in front of their
eyes.
2. Cover the right eye with the occluder, hold for a count of three.
3. Pass the occluder quickly over the bridge of the nose to cover the left eye. Watch
the right eye as it becomes uncovered for any movement.
4. Hold the occluder over the left eye for a count of three.
5. Pass the occluder quickly back over the bridge of the nose to cover the right eye
again. Watch the left eye as it becomes uncovered for any movement.
6. This procedure should be repeated two or three more times.
PASS
No observable movement of the eye being uncovered
Re-screen/REFER
Repeatable movement or resistance by the child to having one eye covered but not
the other or uncovered eye moves out, in, up, or down
26
Stereo acuity test: random dot E (Optional)
If you have the equipment, MDH recommends performing this screen.
Stereopsis measurement should be performed before the eyes are dissociated by tests
such as the cover test.
Ages
Three years through eight years (C&TC) or 3rd grade (Early Childhood and school
screenings)
Purpose
To check for problems with stereo acuity or depth perception
Description
Note if the child is able to see the raised “E” while wearing special glasses
Equipment
Random Dot E stereo card, blank stereo card, model E card, and polarized
glasses.
Facilities
A well-lit, glare free location
Procedure
1. Place the polarized glasses on the child. Do not remove prescription glasses if the
child wears them
2. If the polarized glasses are too large for the child, put a short piece of masking
tape on the top of the glasses and use the other end of the tape to hold the
glasses on the child’s forehead.
3. When showing the child the test targets, be sure he/she keeps his/her head
straight up, as tilting to one side or allowing the glasses to tilt on his nose, will
interfere with the test.
4. At 20 inches away from the child, hold the sample model E card with the long
sides on the top and bottom. Ask the child what the figure is. If the child cannot
name it or has difficulty, point at the E figure on the card and say “that’s an E.
5. With the polarized glasses still on, practice using the sample card and blank
together by mixing up the cards behind your back and presenting the cards to
the child. Have the child point to the card with the ‘E” on it. Do this four to five
times.
6. Substitute the model E care with the stereo E card. Tell the child that,
“sometimes, while wearing the magic glasses, he may see a “picture” appear on
27
the card.” Mix the blank card and stereo E card behind your back and present
the cards to the child. Have the child identify the card they see a picture in. Do
this five times.
7. Move back to 40 inches from the child and repeat step 4.
Note: Slightly move cards up and down (don’t tilt) to give optimal viewing of the
stereo image.
PASS
Student is able to point to the correct stereo E card at least 4 times at 20 inches and
40 inches.
Re-screen/REFER
The child cannot distinguish the E figure in the stereo E card at all, or can only see it
when the card is approximately 20 inches or closer.
28
Stereo acuity test: stereo butterfly (optional)
If you have the equipment, MDH recommends performing this screen.
Stereopsis measurement should be performed before the eyes are dissociated by tests
such as the cover test.
Ages
Three years through eigh years (C&TC) or 3rd grade (Early Childhood and school
screenings).
Purpose
To check for problems with stereo acuity or depth perception
Description
By noting if the child is able to see the raised “butterfly” while wearing special
glasses, the observer is able to check for stereo acuity problems.
Equipment
Stereo butterfly card and polarized glasses.
Facilities
A well-lit, glare free location
Procedure
1. Place the polarized glasses on the child. Do not remove prescription glasses if the
child wears them.
 If the polarized glasses are too large for the child, put a short piece of
masking tape on the top of the glasses and use the other end of thetape to
hold the glasses on the child’s forehead.
 When showing the child the test targets, be sure he/she keeps his/her head
straight up, as tilting to one side or allowing the glasses to tilt on his nose,
will interfere with the test.
2. At normal reading distance from the child, hold the stereo butterfly page
upright. Ask the child what the figure is that they see. If the child cannot name it
or has difficulty, point at the butterfly figure on the page and say “that’s a
butterfly”. Ask the child to touch the butterfly wings.
Note: Slightly move the book up and down (don’t tilt) to give optimal viewing of
the stereo image.
29
PASS
Student is able to point to the butterfly wings above the page
Re-screen/REFER
The child cannot distinguish the butterfly figure in the stereo butterfly card, or
touches the page when trying to touch the wings
30
Color vision
Ages
1st grade (age six years) boys, others optional
Purpose
To check for color vision deficiency
Description
Color vision deficiency is checked by having the child read numbers or follow lines
on specially designed color plates
Equipment
Ishihara Pseudo-Isochromatic Plates, Color Vision Testing Made Easy or Good-Lite
Book of Color Plates.
Fluorescent desk lamp - if enough natural daylight is not available
Facilities
Room well-lit by daylight
Procedure
The test book should be positioned to eliminate glare and at a normal reading
distance from the child's eyes. It should never be in direct sunlight. Instruct the child
to read the numbers or trace the image on each page carefully. Follow each
manufacturer’s instructions.
PASS
Follow each manufacturer’s instructions. Generally, able to correctly identify
numbers or follow lines on testing plates.
Re-screen/REFER
Follow each manufacturer’s instructions.Generally, inability to identify a number on
any one or more plates or inability to follow the line on any one or more plates. See
referral letter.
31
Considerations for screening special populations:
 If the person being tested does not know numbers, the plates with lines can be
used.
 Do not use a pointer, such as a pencil, eraser, or finger that would mark up or
deface the color plates. A clean, dry, watercolor brush works best for tracing, if
needed
Note: Children, other than 1st grade males, should be screened on request.
32
Visual acuity
Definition
Visual acuity is the sharpness or clarity of a person’s vision.
Visual acuity is written as a fraction:
Numerator= The number of feet at which screening is done (e.g., 10 feet, 20 feet)
Denominator= The smallest line on which the majority of the symbols are correctly
identified. (Line size is indicated on the chart as 10, 15, 20, 30, 40, 50, 70, 100, 200)
For example
If one’s vision is “20/70” it means:


at 20 feet, the smallest line that person can see is the 20/70 line
and a person with 20/20 vision could read that same line at 70 feet away
If one’s vision is “ 20/20”it means:

at 20 feet, the smallest line that person can see is the 20/20 line
Results of testing done at 20 feet distance are written: 20/20, 20/25, 20/30, 20/40, 20/50,
etc.
Results of testing done at 10 feet distance are written: 10/10, 10/15, 10/20, 10/30, 10/40,
etc.
33
Visual acuity – LEA/HOTV flip chart
Minnesota Early Childhood visual acuity test
Ages
Preschool (Age three years and difficult-to-screen children)
Purpose
To check the visual acuity of children who do not know the alphabet or have
difficulty with the LEA or HOTV 50% spaced rectangle chart.
Description
The Minnesota Early Childhood Visual Acuity Test Flip Chart is a variant of the line
test for children who find it distracting to look at a chart.
Equipment
LEA or HOTV Minnesota Early Childhood Visual Acuity Test Flip Chart
LEA/HOTV Response Key Card and LEA/HOTV Flash Cards
Facilities
Room well-lit, without glare and free of distractions.
Test Procedure:
1. The child must be standing or sitting at a table with the response card in front,
eyes at a ten foot distance from the flip chart.
2. The child must be conditioned to match letters by pointing to the same letter on
his response card as is being shown with a flash card or pointed to on the chart.
3. Test the right eye first. Start with the 10/25 page and proceed to the 10/20,
10/16, 10/12.5 and 10/10 page as long as the child is able to match 4 of the 5
letters or symbols on each page.
4. Record the visual acuity as the last page that the child can correctly identify four
of the five symbols.
Age three to four PASS
10/20 or better in each eye without a two line difference in the pass range
Age three to four rescreen
10/25 or worse in either eye or a two line difference in the pass range
Age five PASS
10/15 or better in each eye without a two line difference in the pass range.
34
Age five rescreen
10/20 in either eye or a two line difference in the pass range.
Considerations for screening special populations:
The matching of the HOTV or LEA symbols should be practiced before the screening. A
practice sheet that may be duplicated is in the Addendum. For some children with special
needs, it may be useful to reproduce the response card, cut and space them so that larger
movements can be used when indicating the matching symbol.
NOTE: At recheck, the poorer eye should be screened first
35
Visual acuity - HOTV chart
Ages
Preschool through age five years
Purpose
To check for visual acuity of children who do not know the alphabet
Description
Visual acuity is screened at a distance of 10 feet using the symbols HOTV. The child
need not know these symbols, but must be able to match the indicated symbols on a
wall chart with those on the response card.
Equipment:
10' HOTV Vision Chart (with 50% spaced rectangle)
Student Response Card and Flashcards
Table and chair
Occluder with lip
Facilities
Room approximately 15 feet long or greater, well–lit and without glare
Procedure
Testing the right eye
1. The child must be standing or sitting at a table with the response card in
front, eyes at a 10-foot distance from the chart.
2. The child must be conditioned to match letters by pointing to the same letter
on the response card as is being shown with a flash card or pointed to on the
chart.
3. Begin screening with one person holding an occluder horizontally (with the
lip nasally) over the child's left eye.
4. Another person points to the letters on the HOTV wall chart using caution
not to cover the rectangle line with their finger or pointer.
5. The child should point to the corresponding letter on the response card. Start
with the top line and continue downward showing one letter per line. If the
child reaches the bottom line, show the remaining three letters.
6. If the child misses, go to the line above and show four different letters in that
line. If the child matches them correctly, proceed downward.
36
7. To receive credit for a line, the child must correctly match each of the four
different letters on the line.
8. The number recorded as the visual acuity is the smallest line the child can
read correctly.
Testing the left eye: Cover the right eye and repeat the procedure
Age five PASS
10/15 or better in each eye without a two-line difference.
Re-screen/REFER
10/20 or worse in either eye or a two-line difference in the pass range
Age three to four PASS
10/20 or better in each eye without a two-line difference
Re-screen/REFER
10/25 or worse in either eye or a two-line difference in the pass range.
Considerations for screening special populations:
The matching of the HOTV symbols may be practiced before the screening. A practice sheet
that can be duplicated is in the Addendum. For some children with special needs, it may be
useful to reproduce the response card, cut and space them so that larger movements can
be used when indicating the matching symbol.
NOTE: At recheck, the poorer eye should be screened first.
Tips:



No peeking, watch for memorization, watch for head tilt.
Children unable to perform the HOTV should be given the procedures designed
for younger children.
Occluders should be cleaned between children.
37
Visual acuity-LEA symbols
Ages
Preschool through age five years
Purpose
To check for visual acuity of children who do not know the alphabet
Description
Visual acuity is screened at a distance of 10 feet using the Lea symbols.
The child need not know these symbols, but must be able to match the indicated
symbols on a wall chart with those on the response card.
Equipment
10' Lea Vision Chart Student Response Card Flashcards
Table and chair
Occluder with lip
Facilities
Room approximately 15 feet long or greater, well–lit and without glare.
Procedure
Testing the right eye:
1. The child must be standing or sitting at a table with the response card in
front, eyes at a 10-foot distance from the chart.
2. The child must be conditioned to match symbols by pointing to the same
symbol on the response card as is being shown with a flash card or pointed
to on the chart.
3. Begin screening with one person holding an occluder over the child's left eye.
4. Another person points to the symbols on the Lea wall chart using caution not
to cover the rectangle line with their finger or pointer.
5. The child should point to the corresponding symbol on the response card.
6. Start with the top line and continue downward showing one letter per line. If
the child reaches the bottom line, show the remaining three symbols.
7. If the child misses, go to the line above and show four different symbols in
that line. If the child matches them correctly, proceed downward.
8. To receive credit for a line, the child must correctly match each of the four
different symbols on the line.
38
9. The number recorded as the visual acuity is the smallest line the child can
read correctly.
Testing the left eye
Cover the right eye and repeat the procedure
Age five PASS
10/15 or better in each eye without a two-line difference.
Re-screen/REFER
10/20 or worse in either eye or a two-line difference in the pass range
Age three to four PASS
10/20 or better in each eye without a two-line difference
Re-screen/REFER
10/25 or worse in either eye or a two-line difference in the pass range.
Considerations for screening special populations:
The matching of the Lea symbols may be practiced before the screening. A practice
sheet that can be duplicated is in the Addendum. For some children with special
needs it may be useful to reproduce the response card, cut and space them so that
larger movements can be used when indicating the matching symbol.
NOTE: At recheck, the poorer eye should be screened first. Children unable to perform the
Lea chart should be given the procedures designed for younger children. Occluders should
be cleaned between children.
39
Visual acuity - Snellen or Sloan Alphabet Chart
Ages
1st grade (six years) and older
Purpose
To check visual acuity
Description
Visual acuity is checked at 20 feet with letters presented in a linear fashion
Equipment


Snellen or Sloan Alphabet Chart (20 Ft)
Occluder (held horizontally with lip of occluder at nose)
Facilities
Room at least 25 feet long, well-lit, without glare
Procedure

Vision is screened in the right eye first, with the left eye occluded.

Have the child start reading the letters on the 20/50 line and proceed
downward. If the child misses one on the 20/50 line, go up to the 20/70 line.

If the child misses one on the 20/70 line, proceed to the 20/100 line.

To receive credit for a line, all the letters must be read correctly on the line
labeled 20/40 and those above it.

On the 20/20, 20/25 and 20/30 lines, the child may miss two letters on each line
and still get credit for the line.

The number recorded for the visual acuity on the screening record is the smallest
line the child reads correctly.

For screening purposes, you do not need to go lower than the 20/20 line.

Screen the left eye.
PASS
20/30 or better in each eye without a two-line difference
Re-screen/REFER
20/40 or worse in either eye or a two-line difference in the passing range
40
Considerations for children with cognitive impairments
If a child does not know the alphabet or is developmentally unable to perform the
Snellen or Sloan chart, then screen with the HOTV or LEA symbols chart at 10 feet
instead.
NOTE: For re-screen, check the poorer eye first. A 10-foot Sloan chart may be used if space
is an issue.
41
Plus Lens (OPTIONAL)
Ages
Optional one time screening between ages six years (grade 1) up to grade 5
Purpose
To check for hyperopia (farsightedness)
Description
With plus lenses on and one eye covered, the child attempts to read the smallest
line on the visual acuity chart
Equipment
+2.25 lenses for grades 1-3
+1.75 lenses for grades 4 and 5
Occluder
Visual Acuity Chart
Facilities
As appropriate for visual acuity screening
Procedure
Omit when wearing glasses or has failed visual acuity



After the child has been checked for visual acuity, the plus lens procedure is
done at the same distance.
Place the appropriate size plus lenses on the child. Let the child’s eyes adjust
by having the glasses on at least 30 seconds before attempting the test.
With the left eye occluded, the child should attempt to read the chart for at
least 15 seconds. Repeat the process with the right eye occluded.
PASS
Inability to read six or more letters on the 20/20 line (or one of each of the four
symbols on 10/10 line with HOTV) with either eye
Re-screen/REFER
Ability to read six or more letters on the 20/20 line (or one of each of the four
symbols on 10/10 line with HOTV) with either eye
Note: Any child referred to the health office for vision symptoms such as those listed in the
Addendum (pages 49-51) should be screened with the plus lens.
42
43
Screening with
Technology
44
45
Technology for vision screening
Keystone, Optec, Titmus
1. These are brand names of vision screening machines whose main advantage is
that they do not require 10 or 20 feet and they have a consistent light source.
2. However, while they test for visual acuity fairly accurately, both for distance and
near vision, they do not have as good a record for accuracy in testing muscle
imbalances.
3. The problem occurs because younger children’s head size is small creating an
opportunity to “peek” and therefore skew the results. It is essential to monitor
for this.
4. It should be noted, that some manufacturers have updated their equipment in
2005 to ergonomically accommodate a smaller size head.
5. Depending on the package purchased, this technology can also screen for color
screening deficiency.
6. It is recommended that the color vision tests recommended in this manual be
used instead of the color slides in this technology.
MTI Photo Screener
Not recommended because of its high cost and also because it is quite complicated to
operate and requires considerable training.
46
Welch Allyn® SureSight Vision Screener
MDH does not officially recommend this technology because it is currently being studied by
the National Institute of Health for its usefulness in preschool settings and also because of
its high cost. If you have the “SureSight 2.22”, the following information may be useful.
Ages
Can be used in children ages three through all grades
Purpose
To detect refractive error in a short span of time in any population
Description
A device that can be used to screen for visual acuity
Equipment
SureSight Vision Screener, stand, printer
Facilities
Natural lighting.
Procedure
1. Position the unit straight and level with the patient and at a distance of 14” away
from their eyes.
2. Look through the viewer at the patient’s right eye first and try to point the
crosshair (target) at the pupil. You may have to scan around the pupil a little to
get a reading. You will start to hear sounds:
Test the right eye





When the unit is too far away, you will hear slow, low-pitched beeps.
Slowly move closer. At the correct distance (14”), you will hear a steady,
low tone.
When the unit is too close, you will hear quick, high-pitched beeps.
The cross-hair will flash in sync with the tones.
When the test is over for the eye, you will hear a “tah-dah” sound.
Test the left eye



Scan over to the patient’s left eye and point at pupil.
Repeat same procedures as on right eye.
After you hear the “tah-dah” sound for the left eye, you’re finished.
47
Referral criteria
Please follow manufacturer’s criteria for referral.
Please note: This procedure only replaces visual acuity testing. Other screening
procedures still need to be completed.
48
49
Resources and Glossary
50
51
Online vision resources












American Academy of Opthalmology (http://www.aao.org/)
Minnesota Academy of Ophthalmology (www.mneyemd.org)
American Association for Pediatric Ophthalmology & Strabismus
(http://www.aapos.org/)
American Optometric Association (www.aoa.org)
American Academy of Pediatrics (www.aap.org)
American Academy of Family Physicians (www.aafp.org)
Canadian Ophthalmology Association (www.eyesite.ca)
Sight & Hearing Association (www.sightandhearing.org)
Vision In Preschoolers (VIP) Study Home Page
(http://optometry.osu.edu/research/vip/)
National Guideline Clearinghouse (www.guideline.gov)
(http://www.welchallyn.com/apps/products/product.jsp?id=16-in-961181046616203)
Visual Development ( http://home.earthlink.net/~toddwolly/vision/)
Minnesota Department of Health (MDH)


C&TC Vision screening materials (http://www.health.state.mn.us/divs/fh/mch/hlthvis/vismaterials.html)
C&TC Online Vision Screening E-learning Module
(http://www.health.state.mn.us/divs/fh/mch/webcourse/)
Minnesota Department of Education


Early Childhood Screening
(http://education.state.mn.us/MDE/StuSuc/EarlyLearn/EarlyChildScreen/
index.html)
Minnesota Department of Human Services



C&TC Periodicity schedule (https://edocs.dhs.state.mn.us/lfserver/Public/DHS-3379ENG)
Minnesota Parents Know (http://www.parentsknow.state.mn.us/)
National Eye Institute (http://www.nei.nih.gov)
52
53
GLOSSARY
Accommodation - the adjustment of the lens to focus at different distances through action
of the ciliary muscle
Amblyopia - poor vision in one or both eyes not due to organic defect
Anisometropia - inequality in the refractive power of the two eyes of considerable degree
Anterior chamber - the space between the cornea and the iris
Aqueous humor - the clear fluid which fills the anterior and posterior chambers of the eye
Astigmatism - a refractive error in which a defect of curvature on one of the refractive
surfaces of the eye prevents a clear image from being focused on the retina
Binocular vision - the ability to use both eyes simultaneously to focus on the same object
and fuse the two images into one with the correct interpretation of solidity and position in
space
Blepharitis - inflammation of the glands and lash follicles along the margin of the eyelids
Blindness legal blindness is a visual acuity of 20/200 and or the ability to see only 20% or
less of the visual field after best correction in the better eye
Blind spot - area where retinal nerve fibers converge (optic disc) to form the optic nerve.
Corresponds to the area of non-vision in the visual field
Cataract - a defect in the transparency or opacity of the lens or its capsule
Chalazion - a lump on the eyelid that results from chronic inflammation of meibomian gland
Choroid - the vascular layer located between the sclera and the retina
Cilia - of the eye refers to eyelashes
Ciliary body - the portion of the uveal tract between the iris and the choroid that contains
the muscles of accommodation and secretes aqueous
Coloboma - absence or defect of some ocular tissue, usually a congenital fissure of any part
of the eye, such as an incomplete iris
Color deficiency - inability to perceive differences in color, usually for red-green, rarely for
blue-yellow. It can range from mild to severe in degree. It is more common in males than
females
Concave lens - a lens having the power to diverge parallel rays of light. It is used to correct
myopia
54
Cones - one of two types of light-sensitive cells on the retina. Cones are more numerous in
the area of the macula and are responsible for seeing color and fine detail
Conjunctiva - delicate membrane that lines the eyelids and the exposed part of the sclera
Conjunctivitis - inflammation of the conjunctiva
Convergence - simultaneous turning of the eyes toward each other
Convex lens - a lens having the power to converge parallel light rays to bring an image to
focus. It is used to correct hyperopia or presbyopia
Cornea the clear transparent membrane that covers the iris and pupil and joins the
conjunctiva
Crystalline lens - a transparent colorless body suspended in the anterior portion of the
eyeball between the aqueous and vitreous chambers. Its function is to help bring light rays
into focus.
Dacryocystitis - inflammation of the tear sac, usually due to blockage
Depth perception - the ability to perceive the solidity of objects and their relative position
in space. Stereopsis
Diopter - unit of measurement expressing the strength or refractive power of a lens at one
meter
Diplopia - double vision
Divergence - simultaneous turning of the eyes away from each other
Emmetropia - absence of refractive error
Epicanthus - congenital skin fold overlying the inner portion of the upper lid and the inner
canthus; simulates the appearance of esotropia. Tends to recede as the bridge of the nose
narrows in early childhood
Esophoria - a latent tendency of the eye to turn inward
Esotropia a manifest inward deviation of the eye
Exophoria - a latent tendency of the eye to turn outward
Exotropia - a manifest outward deviation of the eye
Farsightedness - a lay term for hyperopia
Field of Vision - the entire area which can be seen at one time without shifting the head or
eyes
Floaters - opacities within the vitreous space that cast moving shadows on the retina
55
Focus - adjustment of the lens to produce a clear picture
Fovea - small depression in the retina at the back of the eye; part of the macula adapted for
the most acute vision
Fusion - the integration of two separate images into a single mental picture
Glaucoma - a disease marked by increased intra-ocular which can cause blindness if not
treated
Hyperopia - the refractive condition of the eye at rest such that light rays from a distant
object are focused behind the retina
Hypertropia - a tendency of one eye to deviate upward
Iris - the colored circular membrane surrounding the pupil
Iritis - inflammation of the iris
Lacrimal apparatus - the system responsible for the formation, secretion and drainage of
tears
Lazy eye - lay term for amblyopia
Lens - the transparent body, convex on both surfaces, lying directly behind the iris and
serves to focus light rays on the retina
Lids - the outermost covering of the eye
Macula - a small depressed area in the retina where sharpest vision occurs
Monocular - pertaining to or having one eye
Myopia - a refractive error in which the eyeball is too long from front to back or the
refractive power so strong so that parallel rays of light are focused in front of the retina
Near point of accommodation - the nearest point at which the eye can see an object
distinctly. It varies according to the power of accommodation in the individual
Near point of convergence - the nearest point at which two eyes can direct their gaze
simultaneously, normally about three inches from the nose
Nearsighted - lay term for myopia
Night blindness - a condition in which the sight is good by day by deficient at night or in
faint light
Nystagmus - an involuntary rapid movement of the eyeball; it may be lateral, vertical,
rotary or mixed
Occluder - a device used to cover one eye during vision screening
56
Oculus dexter (O.D.) - right eye
Oculus sinister (O.S.) - left eye
Oculi uterque (O.U.) - both eyes
Ophthalmologist - an MD. who specializes in medical and surgical diagnosis and treatment
of defects and diseases of the eye, prescribes drugs, eyeglasses, contact lenses and optical
aids
Ophthalmoscope - an instrument used in examining the interior of the eye
Optic nerve - nerve by which visual impulses are transmitted from the retina to the brain
Optician - a person who grinds lenses, fits them into frames and adjusts the frames to the
wearer
Optometrist (OD) - a doctor of optometry who specializes in the diagnosis and treatment of
functional vision problem, prescribes correctives lenses, contact lenses, or visual therapy
and examines for eye disease or ocular signs of systemic disease
Orthophoria - straight eyes
Peripheral vision - ability to perceive presence, motion or color of objects to the side
Phoria - a root word denoting a latent tendency of one eye to deviate up, down, left or right
Photophobia - eyes having an abnormal sensitivity or discomfort in light
Plus lens - a convex lens used for screening farsightedness by checking the eyes’ ability to
accommodate at distance
Posterior chamber - space between the posterior surface of the iris and anterior surface of
the lens filled with aqueous fluid
Presbyopia - physiological change in the eye characterized by the lens becoming less elastic
and therefore not able to focus up close
Ptosis - drooping of the upper eyelid
Pupil - the opening at the center of the iris that adjusts to allow light to enter the eye
Refraction - determination of refractive errors of the eye and correction by glasses
Retina - the innermost light sensitive layer of the eye and contains the rods and cones
Rods - vision cells that are not color sensitive used for perception of motion, in low
illumination, and in night vision
Sclera - the white part of the eye, which with the cornea forms the external protective coat
of the eye
57
Stereopsis - binocular depth perception
Strabismus - eyes that are out of alignment
Sty - infection of a gland in the margin of the eyelid
Suppression - a condition in which the image from one eye is ignored (suppressed) by the
brain. Supression that exists for a period of time could lead to amblyopia
Tropia - a root word denoting a manifest turning in, out, up or down of one eye in relation
the other
Uvea - vascular and pigmented layer of the eye, includes the choroid, ciliary body and the
iris
Visual acuity - the ability of the eye to distinguish detail as an object is placed farther away
or as it becomes smaller in size
Vitreous humor - transparent gelatinous substance that fills the space behind the lens and
keeps the eyeball expanded and in shape
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59
Addendums
Forms, Questionnaires, and
Practice Sheets
60
61
Teacher and Child Vision Pre-Screening Worksheet
Purpose
To identify eye or vision problems throughout the year.
Procedure
Child is asked to report any complaint about his/her eyes. Teachers are asked to
report any abnormal visual behaviors or any visual complaints as expressed by the
child whenever they occur and give report prior to screening.
Description: Teacher Observations
(circle Yes or No as
indicated)
Do you suspect anything is wrong with the child's eye/vision
Yes
No
Has the child ever been diagnosed with an eye condition that you are
aware of
Yes
No
Have you observed any problems or change in the whites, pupils, lids,
lashes or the area around the eyes
Yes
No
Has the child shown any signs of abnormal sensitivity to light or
dizziness
Yes
No
Abnormally short attention span
Yes
No
Turning of one eye (in, out, up or down)
Yes
No
Poking at the eyes or frequent rubbing
Yes
No
Excessive blinking
Yes
No
Unusual watering or discharge of the eye
Yes
No
Poor eye contact or eye-hand coordination
Yes
No
Covering or closing an eye when looking at an item of interest
Yes
No
Abnormal head posture such as tilting the head to one side or moving
forward or backward when viewing an item of interest
Yes
No
Squinting
Yes
No
Placing the head close to an item of interest
Yes
No
Inaccuracy in reaching for an item of interest
Yes
No
Avoiding close work
Yes
No
Frowning or scowl when reading
Yes
No
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Using finger or other device to keep place while reading
Yes
No
Child’s performance in school is less than expected
Yes
No
Light Sensitivity
Yes
No
Burning or itching of eyes or lids
Yes
No
Blurred vision or seeing double images
Yes
No
Words or lines running together
Yes
No
Words or pictures jumping
Yes
No
Headache
Yes
No
Description: Child’s Complaints
Nausea or dizziness
Child’s Name
Grade:
Yes
DOB/Age:
No
Teacher Name and Date Completed
Other Comments
63
Child Vision History Questionnaire for Parent/Caregiver
Child’s Name:
Age/DOB
Parent/Caregiver Name:
Date Filled Out:
CHILD’S HISTORY: Place an “X” in the appropriate box as it applies to your child
Description
Do you suspect anything is wrong with your child's eye/vision
(circle Yes or No as
indicated)
Yes
No
Yes
No
Have you observed any problems or change in the whites, pupils, lids,
lashes or the area around the eyes
Yes
No
Has your child shown any signs ofabnormal sensitivity to light or
dizziness
Yes
No
Has your child had any complaints of nausea or headaches
Yes
No
Turning of one eye (in, out, up or down)
Yes
No
Yes
No
Excessive blinking
Yes
No
Unusual watering or discharge of the eye
Yes
No
Poor eye contact
Yes
No
Covering or closing an eye when looking at an item of interest
Yes
No
Abnormal head posture such as tilting the head to one side or moving
forward or backward when viewing an item of interest
Yes
No
Squinting
Yes
No
Placing the head close to an item of interest
Yes
No
Inaccuracy in reaching for an item of interest
Yes
No
Has your child ever been diagnosed with an eye condition
Poking at the eyes or frequent rubbing
64
Has any immediate family member(s) had eye/vision problems that required treatment at
an early age before entering school?
If yes, explain
Do you have any concerns about your child’s health in general or his/her ability to see
clearly?
If yes, explain
Has your child/ family member ever been diagnosed with any of the following conditions?
In the table below, circle yes or no for each condition as indicated. If yes, write in the family
member. Family member is defined as blood relatives: “siblings / parents / grandparents /
aunts / uncles.”
Condition
Yes
No
Albinism
Yes
No
Amblyopia
Yes
No
Aniridia/Ankylosing Spondylitis
Yes
No
Best Disease
Yes
No
Coloboma
Yes
No
Congenital cataract
Yes
No
Congenital Glaucoma
Yes
No
Diabetes Melitus
Yes
No
Trisomy 21 (also known as Down Syndrome)
Yes
No
Fetal Alcohol Syndrome
Yes
No
Juvenile Muscular Dystrophy
Yes
No
Marfan Syndrome
Yes
No
Myotonic Dystrophy
Yes
No
Neurofibromatosis
Yes
No
Optic Atophy
Yes
No
If Yes, Who
65
Pierre Robin Syndrome
Yes
No
Prader-Willi Syndrome
Yes
No
Retinoblastoma
Yes
No
Retinitis Pigmentosa
Yes
No
Rubella
Yes
No
Sickle Cell Anemia
Yes
No
Strabismus
Yes
No
Sturge-Weber Disease
Yes
No
Toxoplasmosis
Yes
No
Turner Syndrome
Yes
No
Usher Syndrome
Yes
No
Wilson Disease
Yes
No
Spondylo-Epiphyseal Dysplasia (SED)
Congenita
Yes
No
Kniest Syndrome (osteodysplasia)
Yes
No
Bardet-Biedl Syndrome
Yes
No
Idiopathic Carpotarsal Osteolysis, (Francois
Type)
Yes
No
Yes
No
CHARGE Syndrome
Yes
No
Rubinstein-Taybi Syndrome
Yes
No
Stickler Syndrome
Yes
No
Nystagmus
Yes
No
Vision loss/blindness
Yes
No
also known as “Dystrophia Dermo-Chondro-Cornealis
Familiaris”
Hallermann-Streiff-Francois Syndrome
also known as “Francois Dyscephalic Syndrome” or
“Oculo-Mandibulo Dyscrania with Hypotrichosis”
66
67
Child Vision Development Checklist for Parents/Caregivers
During the first month of life, does your child?
 Look towards the face of the person holding them?
 Closes eyes to sudden bright light?
When your child is 2 months, does your child?
 Follow a moving object? Follow light past midline?
 Look at the eyes of the person holding them?
 Switch gaze between two people or objects?
When your child is 4 months, does your child?
 Reach towards an object and grasp it?
 Fixate on a close object with eyes not crossing?
 Respond to the full range of colors?
 Show visual interest to near and distant objects?
When your child is 6 months, does your child?
 Enjoy looking in a mirror?
 Sustain visual interest at near and distant objects?
 Maintain fixation on stationary object, even in the presence of competing moving
stimuli?
 Begin to demonstrate hand-eye coordination?
When your child is 7-12 months, does your child?
 Notice small objects such as breadcrumbs?
 Smile back at another person?
 Recognize objects that are partially hidden?
 Scan eyes around the room to see what is happening?
When your child is 18 months, does your child?
 Point to objects or people using words “look or see”?
 Look for and identify pictures in books?
 Play with simple puzzles?
When your child is 24-36 months, does your child?
 See small pictures well with both eyes?
 Show ability to arrange similar pictures in groups?
 Watch and imitate other children (30-36 months)?
Source: CDC, AAP
Child’s Name
DOB/Age
Parent/Caregiver Name
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69
Vision Screening Worksheet
Child’s Name:
DOB:
Age (in months
and years):
Name of Initial Screener:
Date of Initial
Screening:
Date of ReScreening:
Name of Re-Screener:
Complete the following screenings and document the results. Legend: ~ (approximately), +
(and older), Gr (Grade).
Screening Test
External Inspection WIPL (all ages)
Pupillary Light Response (birth to ~3y)
Retinal (Red Lt) Reflex (birth to ~3y)
Observations (4mo to Grade 3(8y))
Corneal Light Reflection (2mo to Grade 3( 8y))
Cross Cover Test (4mo to Grade 3 (8y))
EOM/Fix & Follow Monocular (4mo to ~3y +)
EOM/Fix & Follow Binocular (4mo to ~3y +)
Color vision (Males Grade 1(6y))
Circle PASS or Rescreen for each test, as
indicated
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
If a rescreen is performed for any of the above screenings, document results in table below.
Screening Test
External Inspection WIPL (all ages)
Pupillary Light Response (birth to ~3y)
Retinal (Red Lt) Reflex (birth to ~3y)
Observations (4mo to Grade 3(8y))
Corneal Light Reflection (2mo to Grade 3( 8y))
Cross Cover Test (4mo to Grade 3 (8y))
EOM/Fix & Follow Monocular (4mo to ~3y +)
EOM/Fix & Follow Binocular (4mo to ~3y +)
Color vision (Males Grade 1(6y))
Circle PASS or REFER for each test, as
indicated
PASS
REFER
PASS
REFER
PASS
REFER
PASS
REFER
PASS
REFER
PASS
PASS
PASS
PASS
REFER
REFER
REFER
REFER
70
Visual Acuity Screen
Right Eye
Left Eye
Age
10/
10/
20/
20/
10/
10/
20/
20/
~3 to 5yr
~3 to 5yr
6yr +
6yr +
Write in results and circle PASS or
Rescreen, as indicated
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
PASS
Rescreen
Visual Acuity Re-screen (if indicated on initial screen)
Right Eye
Left Eye
Age
10/
10/
20/
20/
10/
10/
20/
20/
~3 to 5yr
~3 to 5yr
6yr +
6yr +
Write in results and circle PASS or REFER,
as indicated
PASS
REFER
PASS
REFER
PASS
REFER
PASS
REFER
Optional Tests (circle Pass, Rescreen or Refer as indicated)
Plus Lens ( 6y (Gr 1) to 11y Gr 5)
PASS
Rescreen
PASS
REFER
Stereopsis Test (3yr-Gr 3 or 8yrs)
PASS
Rescreen
PASS
REFER
Comments:
Write Yes or No in the empty boxes, as indicated
Initial Screening
Re-Screening
Do you question the validity of the test
today?
Is the behavior today typical for this
child?
71
Vision Referral Letter for (Child’s Name)
Dear Parent:
In keeping with the recommendations of the Minnesota Department of Health, your child
was screened ____/____/____ and re-screened ____/____/____.
You are urged to take your child for a professional eye examination for the reason(s)
checked below:
Your child has had complaints about his/her vision
Child/Family history of eye conditions
External eye problems
Possible eye muscle problems (noted by observation, corneal light reflex, EOMs or cross
cover)
Abnormal Retinal (Red Light) Reflex
Possible stereopsis problems
Possible farsightedness problems
Your child was unable to read lines on the chart appropriate for age group OR the
difference between vision in each eye was greater than one line (with) (without)
corrective lenses
Right 10/______ Left 10/______ or Right 20/______ Left 20 / ______
Please have your eye care professional complete this form
Dear Eye Care Provider:
Please complete this portion of the form and send it at your earliest convenience to:
(School Nurse)____________________________________________________________
____________________________________________________________
I have examined________________________________DOB__________on
_______/_____/________
72
My findings are: Right: _____/_____ Left: _____/_____ without corrective lenses
Insufficient to require treatment
Muscular Condition:
Fully Correctible
Myopia
Partially Correctible
Hyperopia
Not Correctible
Astigmatism
Corrective lenses prescribed
Supression
Best Correction: R ____/____ L
_____/_____
Fusion Condition
Change in corrective lens
External Eye Condition
Best Correction: R ____/____ L
_____/_____
Other:
No significant visual handicap to interfere
with learning
A visual handicap that may interfere
with learning
Child should return for follow-up
examination______________________________________________
Recommendations including any accommodation that the school should make for the
student:
Print Name ____________________________
Signature_____________________________________
73
Color Vision Advisory Letter
Child Name
Grade
Room
Dear Parent/Guardian,
During the recent vision screening conducted at your child’s school, your child displayed
some difficulty meeting passing criteria in distinguishing colors. This screening is not
diagnostic but suggests your child may have some color vision deficiency. The following
information may be helpful to you.
Color Vision Deficiency:

Current literature suggests there is no significant difference in school achievement
between students with normal color vision and those with color deficiencies.

Children use different clues to identify colors so the condition generally is not
problematic.

Referrals for professional evaluation of this condition are usually not made since
there is no widely accepted treatment for color vision problems at this time.
A professional examination may be beneficial to determine if the problem exists and to
accurately diagnose it.

During the early years of school, the use of colors in conjunction with learning
concepts in arithmatic and other materials is sometimes employed and may be a
problem for children with vision color deficiency.

Accommodations for this can easily be made and schools are required to do so by
federal law if there is a properly documented diagnosis.

Additionally, as your child gets older, informed decisions about career choices can
be made when the exact nature and scope of the visual problem is known since
some occupations require the ability to distinguish colors.
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75
Child and Teen Checkups Online Resources
1. Child and Teen Checkups Documentation Templates
(http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&Re
visionSelectionMethod=LatestReleased&dDocName=id_048044)
Figure 1. Example of Vision and Hearing Documentation from Child and Teen Checkups
Documentation Templates
2. Child and Teen Checkups- Vision Screening FACT Sheet for Primary Care Providers
(http://www.health.state.mn.us/divs/fh/mch/ctc/factsheets/vision12.pdf)
3. Child and Teen Checkups Online Vision Screening Module
(http://www.health.state.mn.us/divs/fh/mch/webcourse/index.html)
4. Child and Teen Checkups Trainings
http://www.health.state.mn.us/divs/fh/mch/ctc/training.html
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77
PRESCREENING PRACTICE SHEET
In order for us to check your child’s vision he/she must be able to play a matching game.
1. Cut the paper along the dotted lines.
2. Place the four large letters (Chart 1) in front of your child.
3. Point to a letter on Chart 2 and have your child touch the letter that looks the same on Chart 1. Start with the larger letters and
move downward to the smaller.
4. Play the game until your child responds correctly and consistently.
78
79
Prescreening Practice Sheet
In order for us to check your child’s vision he/she must be able to play a matching game.
1. Cut the paper along the dotted lines.
2. Place the four large letters (Chart 1) in front of your child.
3. Point to a letter on Chart 2 and have your child touch the letter that looks the same on Chart 1. Start with the larger letters and
move downward to the smaller.
4. Play the game until your child responds correctly and consistently.
Phone: (651) 201-3760
Fax: (651) 201-3590
If you require this document in another format,
such as large print, Braille, or audio recording, call (651) 201-3760.
Printed on recycled paper.
Rev. 6/2014