Vision screening may be performed by physicians, optometrists, ophthalmologist, nurses, and other professionals certified in vision screening in accordance with state laws.
All children should receive age-appropriate vision screening by 6 months to 1 year of age (Table 117-1).
From birth to 4 years of age, vision screening should occur at all routine healthcare visits and include ocular history, vision assessment, external inspection of the eyes and lids, ocular motility assessment, pupil examination, and red reflex.
From 3 years and older, screening includes all the above plus age-appropriate measurement of visual acuity and an attempt at ophthalmoscopy. Preschool-aged children, especially 3 to 4 year olds, should be screened for amblyopia and strabismus.
Photoscreening and handheld autorefraction may be effectively used in children 6 months to 5 years of age to assess for conditions that may lead to amblyopia.
Color deficiency screening is recommended to be performed before the child enters school. However, children aged 5 years and older are better at being able to follow instructions and complete the test.
Children with presumed or diagnosed learning disabilities (e.g., dyslexia) should receive a comprehensive visual examination to identify and treat any underlying visual impairments that may further impede their learning.
Functional assessments that should be performed are tests of visual acuity, ocular alignment, and ocular media clarity. Based on the child’s history and findings, additional tests may be performed depending on the cooperation by the child, such as stereoacuity testing, color vision testing, and visual fields (see Chapter 3).
If a child is uncooperative during vision screening, a second attempt to complete vision screening should be scheduled. If the child remains uncooperative, the child should be referred for comprehensive vision evaluation.
TABLE 117-1 Common Vision Screening Testsa | ||||||||||||||||||||
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Visual acuity chart, computer software, flash cards, or equivalent.
Select a vision-screening chart that match the developmental and cognitive level of the child being screened, are evidence-based, and meet national and international eye chart design guidelines.
Sloan letters or numbers for older school-age children.
Lea symbols or HOTV (with proportional spacing or crowding bars) for children ages 3, 4, and 5.
Tumbling E chart with Es in inverted pyramid shape (for ages 8 and older and non-English speakers, note that E at threshold can be guessed by children by looking at lighter side of letter).
Photoscreening device
Measuring tape, masking tape, or placement marker
Occluder, small paper cup, or cardboard (3 × 5-inch card or cut-out shapes)
Report sheet and/or documentation form
Pen
Plus lenses (+2.25 and +1.75 diopters) or hyperopia lens
Timer or watch with second hand
Ophthalmoscope or penlight
Small, interesting, or colorful objects (e.g., small stuffed animal, ceramic figure)
Polarized glasses
Pseudoisochromatic plates, such as the Ishihara plates or equivalent
Stereotests such as the fly, circle patterns, animals, or equivalent
Perform external assessment of the child’s eyes and lids. Use the ABC checklist for vision, as appropriate:
A = appearance: eyes turning in or out, ptosis, swelling, differently sized pupils
B = behavior: head tilting, squinting, excessive stumbling, fumbling, or awkwardness
C = child’s statement: headaches, blurry vision, cannot see the board, double vision
Any visual complaint or manifestation of vision problems from a child warrants referral to an eye specialist, regardless of test results. Another important referral criterion is family member observations.
Obtain ocular history:
Inquire about relevant familial eye disorders such as childhood cataracts or glaucoma, strabismus, amblyopia, and parental or sibling history of wearing glasses in preschool or early childhood.
Explain the procedure to the family and the child in an age-appropriate manner and in the primary language (see Table 117-1 for common vision screening tests and their purpose). Assure them that the procedures are painless.
PROCEDUREVisual Acuity: Distance
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KidKare Engage the child in the testing by allowing him or her to hold the occluder. It gives the child a sense of control during the testing.
KidKare When testing preschoolers, children with developmental delay, or children who do not speak the language, the letter chart may be substituted with the symbol chart such as the Lea symbols, the HOTV chart, or the tumbling Es. The Lea symbols and HOTV require object naming or object matching, whereas the tumbling Es requires the child to demonstrate with his or her fingers which direction the E is pointing. When using any of the symbol charts, orient the child to the objects up close and practice with the larger prints before testing the child at a distance.
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