Vision Screening of Young Children, Including Those with Additional Disabilities

1
Vision Screening of Young Children, Including
Those with Additional Disabilities

• By Tanni L. Anthony, Ph.D.
• November 6, 2009
• .

2
Training Objectives

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

3
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.

4
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.

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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.

6
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
  evaluation.

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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.

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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
  child.

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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
  information.

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Vision Screening Manual 0-5

• http//www.cde.state.co.us/early/downloads/early_v
  ision_manual.pdf
• 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.

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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.

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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
  balance.

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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.
•  

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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.

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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

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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
  development.
• Has the child ever been seen by an eye doctor
  (optometrist or ophthalmologist?) What were the
  results?
• Does the child have a medical history that
  includes any of the following conditions (see
  next slide)

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High Risk Indicators of Vision Problems / Visual
Impairment

• 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

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Anticonvulsants and Side Effects

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

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Quick Review Visible Parts of the Eye
20
Appearance of Eyelids / Eyes

• MANY VISUAL PROBLEMS ARE VISIBLE.
• Look at the childs face and eyes.
• Is there any evidence of asymmetry, unusual
  irritation, tearing, eye crossing, etc.

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Misalignment of Eyes
22
Eye Deviation
23
Eye Deviation
24
Drooping Eyelid
25
Cloudiness of Eye
26
Cloudiness of Eye
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Usual Shape / Size of Pupil
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Unusual Pupil / Iris Shape
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Appearance of Eyes

• Right Eye Left Eye All are grounds for
  referral
• ? ? 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.

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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.

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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.

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Pupillary Constriction

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

33
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.

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• 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
  observations.

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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.

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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).

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Corneal Light Reflex Test

• Look at where the light is reflected in each eye.

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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.

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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.

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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
  months)
• 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.

41
Tracking

• Horizontal Pass smooth/together
• Refer jerky/segmented
• Vertical Pass smooth/together Refer
  jerky/segmented
• 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.

42
Convergence

•  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.

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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.

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• 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
  of
• five symbols. If the child only identifies two
  of
• the five symbols, report the visual acuity of the
  
• previous large size.

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1.1.5.T1
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Compensatory Behaviors

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

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? 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.
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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.)

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?s and Future Comments

• Let us know how this is working for you!
• Tanni Anthony
• 303 866-6681
• Anthony_t_at_cde.state.co.us