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Vision Screening of Young Children, Including Those with Additional Disabilities


Vision Screening of Young Children, Including Those with Additional Disabilities By Tanni L. Anthony, Ph.D. November 6, 2009. * * Hold the target about 12 inches away ... – PowerPoint PPT presentation

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Title: Vision Screening of Young Children, Including Those with Additional Disabilities

Vision Screening of Young Children, Including
Those with Additional Disabilities
  • By Tanni L. Anthony, Ph.D.
  • November 6, 2009
  • .

Training Objectives
  • Provide vision screening that is developmentally
  • Establish best practices across the state for
    system consistency.

Colorado School Laws 2008
  • 22-1-115 School Children sight and hearing
  • The sight and hearing of all children in K, 1st,
    2nd, 3rd, 5th, 7th, and 9th grades, or children
    in comparable age groups referred for testing,
    shall be tested during the school year by the
    teacher, principal, or other qualified person
    authorized by the school district.

Colorado School Laws 2008
  • 22-1-116 School Children sight and hearing
  • Each school in the district shall make a record
    of all sight and hearing tests given during the
    school yea and record the individual results of
    each test on each childs records. The parents or
    guardian shall be informed when a deficiency is
    found. The provisions of this section shall not
    apply to any child whose parents or guardian
    objects on religious or personal grounds.

ECEA Rules (December 2007)
  • 4.02 (2) (c) (iii)
  • Screening procedures for identifying from the
    total population of children ages 3 to 21 years
    those may need ore in-depth evaluation in order
    to determine eligibility for special education
    and related services.

ECEA Rules (December 2007)
  • 4.02 (2) (c) (iii)
  • Follow up to vision and hearing screening shall
    interface with the vision and hearing screenings
    which occur for all children in public preschool,
    K, grades 1, 2, 3, 5, 7 and 9 year accordance
    with Section 22-1-116 C.R.S. Appropriate
    educational referral shall be made if the child
    is suspected of having an educationally
    significant vision or hearing loss and parents
    shall be informed of any need for further medical

Why Do Vision Screening?
  • Vision problems are not uncommon in young
    children. One out of every fifth child may have
    some type of vision concern. Vision screening
    may ID concerns in time for medical correction.
  • Vision problems can have a major impact on the
    development of a young child.
  • Early ID and intervention minimize the effects of
    a vision loss on a childs development.

Vision Screening Should
  • Be economical
  • Be easy to complete by trained personnel
  • Answer the simple question of whether there is or
    not a vision concern.
  • Proceed any other developmental evaluation of the

Vision Screening Should NOT
  • Be used as an opportunity to infer any type of
    medical diagnosis.
  • The role of the screener is to simply determine
    whether a next step evaluation is needed for more

Vision Screening Manual 0-5
  • http//
  • The manual and the protocol forms can be
    downloaded (the latter in word format so they
    can be customized for administrative unit use).
  • The manual was finalized in January 2005.

Vision Screening Tips
  • Prior to the screening, be sure that you have
    gathered the correct forms and materials.
  • Take a few moments to build rapport with the
    child. Greet and talk to the child before
    beginning of the screening activities.
  • The order of the screening tasks does not affect
    outcome. Perform the least invasive and most fun
    tasks first.

Vision Screening Tips
  • Ensure the child is in a supported posture.
  • Hips support trunk support head support.
  • Focus should be on looking and not maintaining

Vision Screening Tips
  • Advise the parent not to cue the child in any way
    during the vision screening activities, if the
    child is sitting in his or her parents lap.
  • Use toys, lights, and objects that do NOT make
    sounds. You want the child to respond to visual
    stimulation only.

Vision Screening Tips
  • Use a screening room environment that is quiet
    and free of unnecessary visual distractions such
    as people moving around the room.
  • Be sure to monitor the lighting in the screening
    room. Light should not be overly dim or bright.
    Any sunlight coming in through a window should
    fall behind the child.
  • Children who wear glasses should be screened with
    their glasses on unless the directions
    specifically indicate they should be removed.

Components of 0-5 Visual Screening
  • Reviewing Intake History For High Risk Info
  • Visual Inspection of the Eyelids/ Eyes
  • Pupillary Constriction
  • Alternate Cover and/or Corneal Light Test
  • Fixation / Tracking / Convergence
  • Visual Acuity
  • Compensatory Visual Behaviors

Family Interview
  • Is there a family history of eye crossing, color
    vision problems, and/or other types of congenital
    (at birth) visual impairments.
  • Any concerns about childs vision and/or
  • Has the child ever been seen by an eye doctor
    (optometrist or ophthalmologist?) What were the
  • Does the child have a medical history that
    includes any of the following conditions (see
    next slide)

High Risk Indicators of Vision Problems / Visual
  • Prematurity
  • TORCH Infections (40,000 newborns annually)
  • FAS / FAE or other prenatal toxins
  • Cerebral Palsy
  • Syndromes (e.g., Down, Goldenhar)
  • Deaf/Hard of Hearing
  • Pre and Postnatal Viruses
  • Traumatic Brain Injury / Neurological Insult

Anticonvulsants and Side Effects
  • Phenobarbital photophobia, constriction/convergen
    ce problems
  • Dilantin convergence problems, focus problems,
  • Clonopin abnormal eye movement, diplopia,
    nystagmus, glassy eyed appearance
  • Tegretol photosensitivity, blurred vision,
    visual hallucinations, oculomotor disturbances,
    nystagmus, conjunctivitis

Quick Review Visible Parts of the Eye
Appearance of Eyelids / Eyes
  • Look at the childs face and eyes.
  • Is there any evidence of asymmetry, unusual
    irritation, tearing, eye crossing, etc.

Misalignment of Eyes
Eye Deviation
Eye Deviation
Drooping Eyelid
Cloudiness of Eye
Cloudiness of Eye
Usual Shape / Size of Pupil
Unusual Pupil / Iris Shape
Appearance of Eyes
  • Right Eye Left Eye All are grounds for
  • ? ? unusually red or irritated.
  • ? ? unusually teary.
  • ? ? are cloudy in appearance.
  • ? ? not aligned (turned in, out, etc.)
  • ? ? have involuntary jerky movements
  • ? ? do not appear to move together
  • ? ? Eyelid(s) is drooping.

Pupillary Constriction
  • Practice with your penlight.
  • Do not direct the beam into the childs eyes.
    Center the beam at forehead level.
  • Look for brisk and bilateral constriction with
    light. Dilation with light removal.

Pupillary Constriction
  • Seizure medications, neurological problems, and
    other medications can inhibit this response. If
    abnormal responses are noted, ask the parent
    about medications the child is taking.
  • Regardless, an abnormal pupillary response would
    warrant failure of the vision screening.

Pupillary Constriction
  • Right eye ? brisk ? absent / sluggish
  • Left eye ? brisk ? absent / sluggish
  • Results
  • Pass Both eyes respond quickly.
  • Fail Absent or sluggish response

Alternate Cover Test
  • Equipment a fixation toy and the occluder.
  • Instructions Limit distractions in the room. Do
    not touch the childs face with the occluder at
    any time during the test. The target object
    (e.g., penlight with monster cap, small toy) may
    need to be manipulated or changed to maintain a
    young childs attention.

  • Hold the target about 12 inches away directly in
    front of the child. Secure fixation.
  • Cover the right eye, watching the left eye for
    any movement. Leave covered for 2-3 seconds.
  • Quickly move the occluder across the bridge of
    the nose to cover the left eye, watching the
    right eye for any movement. Wait 2-3 seconds
    after the cover is moved to permit fixation of
    the now uncovered eye.
  • Move the cover from the left eye back to the
    right eye, across the bridge of the nose,
    watching the left eye for any movement. Allow
    2-3 seconds for fixation.
  • Repeat procedure several times to be assured of

Alternate Cover Test
  • Right eye Pass No Movement
  • Refer Obvious Movement
  • Left eye Pass No Movement
  • Refer Obvious Movement
  • Results If there is no redress movement in
    either eye, the child will pass this screening
    indicator. If there is redress movement in
    either eye, the child will fail this indicator
    and should be referred for further evaluation.

Corneal Light Reflex Test
  • Equipment penlight
  • Instructions Hold a penlight 12-13 inches away
    from the childs face directly in front of the
    eyes. Direct the light from the penlight at the
    hairline in the center of the childs forehead.
    The child needs to fixate either on the penlight
    or an object that may be held near the light.
    Observe the reflection of the penlight in the
    pupils of both eyes the reflection should be
    centered or equally centered slightly toward the
    nose (nasal).

Corneal Light Reflex Test
  • Look at where the light is reflected in each eye.

Corneal Light Reflex Test
  • Pass reflection is symmetrical
  • Fail reflection is not symmetrical
  • Results If the reflection is symmetrical and
    centered in both eyes, the child will pass this
    screening indicator. The child does not pass
    this screening indicator if the reflection of the
    penlight does not appear to be in a centered
    position in the pupil of each eye. Sensitivity
    to light, rapid eye movement, and poor fixation
    observed during this test are also reasons for
    referral for further evaluation.

Eye Teaming Tasks
  • Near fixation with cake decoration pellet and
    black foam sheet.
  • Horizontal and vertical tracking
  • with penlight/monster caps or frog
  • finger puppet.
  • Convergence with fixation stick, frog finger
    puppet, and/or penlight with monster caps.

Near Fixation (at 8-18 inches)
  • 1-inch object (4 months)
  • Pass Sustained Fail Fleeting/ Absent
  • Fruit Loop or ¼ inch cake decoration pellet (6
  • Pass Sustained Fail Fleeting / Absent
  • Results If a child of six months or older
    fixates on the one inch object and a small cake
    decoration pellet or piece of cereal, this is
    recorded as a pass. If the child does not fixate
    on either item or fixates with one eye only, the
    result is a fail.

  • Horizontal Pass smooth/together
  • Refer jerky/segmented
  • Vertical Pass smooth/together Refer
  • Results If tracking is smooth and demonstrated
    with both eyes moving together as they follow the
    target, the child will pass the tracking
    indicators. If one eye lags behind another eye
    or tracking movements are jerky and incomplete,
    the child will fail this indicator and should be
    referred for further evaluation.

  •  Pass Both eyes follow to at least 4-6 inches
    from the nose.
  • Refer One eye deviates or child looks away when
    object is more than 4-6 inches from nose.
  • Results If both eyes maintain their gaze on the
    oncoming object at least 4-6 inches from the nose
    pass. If one or both eyes break gaze farther
    than 4-6 inches from nose fail.

Lea Symbol Cards
  • For 2.5 years and older (if able)
  • Practice with set of cards
  • Remember to double the denominator, if you screen
  • from 10 feet.

  • Right Eye Pass at 20/40 level (3 symbols
    correctly IDed)
  •   Fail child cannot correctly identify 3
    symbols at the 20/40 level
  • Left Eye Pass at 20/40 level (3 symbols
    correctly IDed)
  •   Fail child cannot correctly identify 3
    symbols at the 20/40 level
  • Results The visual acuity threshold is defined
  • as the level (smallest symbol size)at which the
  • child can correctly identify at least three out
  • five symbols. If the child only identifies two
  • the five symbols, report the visual acuity of the
  • previous large size.

Compensatory Behaviors
  • Complete after screening.
  • Notice any unusual body posturing and/or eye
    behaviors (squinting, blinking, eye rubbing, etc.)

? Rubs eye(s) / presses hands into eye(s)
frequently. ? Squints, blinks, closes an
eye(s) when looking at something.? Squints,
blinks, closes an eye(s) to changes in
lighting.? Turns or tilts head when looking at
something.? Appears overly interested in gazing
at overhead lights. ? Looks away from visual
targets, shows gaze aversion.? Inattentive to a
visual target unless it is has an accompanying
sound.? Takes longer than usual to focus on an
object or face.? Views objects at an unusually
close distance from eyes.? Over or under
reaches for an object.
Scoring the Screening Tool
  • Three Outcomes.
  • Pass no problems observed / reported
  • Re-screen screener would like another chance to
    screen the child on another day.
  • Fail refer to the next step medical specialist
    (based on familys insurance etc.)

?s and Future Comments
  • Let us know how this is working for you!
  • Tanni Anthony
  • 303 866-6681
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