Download Functional Vision Screening Test

Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Regulations – North Carolina Statutes
Vision screening is required as part of the Health Appraisal Transmittal Form for every student entering
Kindergarten and all students in grades 1-12, if attending public school in North Carolina for the first time. This
screening is to be completed by a licensed physician, optometrist, physician assistant, nurse practitioner,
registered nurse, orthoptist, or a vision screener certified by Prevent Blindness North Carolina, or a
comprehensive eye examination performed by an ophthalmologist or optometrist. North Carolina also requires a
vision screening for all preschool age children.
§ 130A-440.1 Early Childhood Vision Care and § 130A-440 Health Assessments for Children in the Public Schools
Overview
Young children and their parents are often unaware of reduced visual functioning. Childhood and adolescent
vision problems vary in nature and severity, ranging from mild refractive errors to permanent vision impairment
and blindness. Vision problems have a direct relationship to learning; untreated, severe adverse effects on
educational achievement can occur. Poor vision can also affect the entire adjustment to school and compromise
a child’s development. Early detection and treatment are vital in children with eye problems.
Common Eye Problems
 Refractive Errors - the most common vision problems that impair visual acuity:
o Myopia/ nearsightedness – visual acuity impaired at far distance; or,
o Hyperopia/ farsightedness) – visual acuity impaired at a near distance.
o These problems are often correctable with eyeglasses.
 Other vision problems include:
o Astigmatism (irregular curvature of the cornea causing distorted images);
o Strabismus (muscle imbalance, crossed or misaligned eyes);
o Amblyopia (lazy eye);
o Problems with binocular coordination of eye movements;
o Problems with the integration of visual sensory perception and the brain.
o These problems can typically be addressed with eyeglasses, medication, or vision therapy. B
 Both amblyopia and strabismus can cause a child to visually ignore one eye and rely on the other.
o The ignored eye becomes inefficient through lack of use; and,
o If the condition is not treated before the age of 6 or 7, permanent vision impairment in the
unused eye can be the result.
Signs of Possible Vision Problems (ABC’s)
Children observed to have any of the following signs, by the teacher or parent, should be referred to the school
nurse for a vision screening regardless of age or grade placement:
 Appearance Signs
o Cloudiness/haze.
o Crossed eyes.
o Unequal pupil size.
o Presence of white pupil.
o Possible eye injury - reddened, bloodshot, blackened, bruised or swollen, or show evidence of
lacerations or abrasions.
 Behavior Signs
o Body rigid when looking at distant objects.
o Thrusting head forward or backward while looking at distant objects.
o Tilting head to one side.
o Squinting or frowning.
o Excessive blinking or rubbing eyes.
o Closing or covering one eye.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
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o Clumsiness or decreased coordination.
o Short attention span when reading, copying, or board-work.
o Overactive or lethargic in class.
Compliant Signs
o Headaches, nausea, or dizziness.
o Blurred or double vision.
o Sees blur when looking up after close work.
o Unusual sensitivity to light.
Other signs
o Loses place when reading; repeats or skips lines, or stops reading after a brief period.
o Writes with irregular size and spacing.
o Holds materials too closely, too far from face, or frequently changes the holding distance of book
when reading.
o Tends to reverse or confuse words, letters, or syllables.
o Experience learning problems or scholastic failure.
Vision Screening
 Is effective with the population of children who have a minor vision problem, who are verbal and
responsive, and who know their letters or symbols.
 Is not diagnostic.
 Will not identify every child who needs eye care nor will every child who is referred require treatment.
 Screening for distance visual acuity is considered by authorities to be the most important single test of
visual ability. This test will identify most of the vision problems listed above, and other conditions such as
cataracts.
 The preferred method of screening is linear and is recommended for children of all ages.
 Children who fail the screening test must be referred to an eye specialist for a diagnostic examination.
 Follow-up is the most important aspect of the screening program.
o Any possible problem identified by vision screening must be followed up with a
comprehensive eye examination.
o If the children referred do not receive professional attention, the vision-screening program has
failed to achieve its goal.
 Required Components
o Assessment by the screener of signs and symptoms of eye disease.
 Eye redness without pain (with or without discharge) may be referred to the primary care
physician or to an eye care professional (ophthalmologist or optometrist).
 The following signs or symptoms require referral to an eye care professional unless the
child is already under the care of an eye care professional for the condition:
 Eye pain, with or without redness.
 Nystagmus (jiggling eyes).
 Proptosis (protrusion of an eye).
 Light sensitivity.
 Marked swelling of eyelid(s).
 Drooping eyelid(s).
 Constant head tilt or face turn.
 Non-round pupil(s).
 Obvious strabismus (eye misalignment).
o Distance visual acuity.
o Stereopsis - Kindergarten.
Mass Screening and Individual Referrals for Vision Testing
 Students in K, 3, and 5 – mass vision screening.
 Students referred for signs/symptoms of possible vision problems.
 Students referred for EC programs.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
School Nurse Vision Screening Guidelines
Source: Guiding Practices for Early Childhood Vision Screening in NC
Mass Screening
Purpose: Early detection of a health problem that
may impact the educational process.
Set calendar dates.
Reserve appropriate space.
Completed by school nurse/school nurse teams.
Assure sufficient equipment for event.
Notify parents as per district policy (List in local
handbook the grades for mass screenings); and,
school policy (Connect Ed. calls, letters, notes in
student agendas, etc.).
Plan logistics and flow for dates.
Conduct screening event.
Plan make-up day for absent students.
Refer failures to school nurse for re-screen.
Record results in PowerSchool (required); Orange
Permanent Health Record (optional).
School nurse makes referrals for re-screen
failures.
School nurse follows up for secured care.
Individual Screening
Purpose for students referred by teachers based on their
observations: To determine if observations are related to a
health problem that may impact the educational process.
Purpose for students referred as part of an eligibility
process: To verify that student educational issues are not
related to an unidentified health problem.
Completed year-round upon referral.
Pre-standardized location, usually health room.
Completed by school nurse.
Equipment that has been assigned to school nurse is used.
Individual screenings that are not part of a mass event
require parental consent. May be part of a larger consent,
such as for Exceptional Children eligibility evaluation.
NA
Obtain student from class when referral is made.
NA
Refer failures to school nurse for re-screen.
Record results in PowerSchool (required); EC/other Referral
Form; and, orange Permanent Health Record (optional).
School nurse makes referrals for re-screen failure.
School nurse follows up for secured care.
Distance Visual Acuity Screening
 The screening environment:
o If a patterned or cluttered wall is used to hang the chart, use a 3’ x 3’ piece of plain paper as
background for the chart.
o Select a wall for the chart that ensures an unobstructed view for the student.
o Place the chart on a wall away from windows that may cause glare or shadows. If necessary,
place plain paper over windows to reduce glare.
o Make certain there is no glare or shadow on the chart.
o Ensure that the chart is adequately illuminated. Normal room lighting is usually sufficient.
 Select chart, following guidelines below.
o The 10’ charts presented in a crowded format and includes a 20/25 acuity line are strongly
recommended/preferred for childhood distance vision screenings.
o The most challenging chart a child is able to accomplish should be used.
o Determine the chart (based on educational level or ability):
o Lea Symbols → Very young, EC, or non-English speaking; K, and 1st grade.
o Sloan Letter Chart → 2nd grade & up.
 From the chart, measure and draw the designated line or place masking tape on the floor.
 Prepare student for the screening.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
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Pretest the child by walking him up to the eye chart to make sure he knows the symbols, or by
having him identify the figures on a handheld sheet on which the wall chart figures are
reproduced (so large that they can be seen even by children whose vision is poor).
o Explain the characters to be used and make sure the child understands how to respond.
o A child who is unable to name the symbols/cannot or will not talk can still be screened
successfully by having him/her match the figures he/she sees on the chart with the figures on a
handheld sheet/card.
o The entire line must be displayed at once, as opposed to masking all but one letter at a time.
 However, the performance of a shy or fidgety child can often be improved considerably if
the screener points to one letter or figure at a time on the line being tested.
 If a child has difficulty with the linear chart method, then the isolated method of
presenting letters or symbols singly may be used.
Have student place heels on the line. If a student is in a wheelchair or other chair due to physical
limitation, place seat with the back of the chair on the line.
Children who wear glasses or contact lenses:
o Wear the glasses or contacts for vision screening.
o Noted on the vision record (e.g., 20/40 with glasses).
o If known, also record for these children: date of the last professional eye examination, date of the
last correction, and date for the next examination.
A red-tipped pointer (e.g., red marker or small wood dowel with painted tip) may be used to indicate, by
pointing from below, which letter or symbol the child is to read.
Use an acceptable occluder (e.g., adhesive patch, occlude glasses with opaque or frosted lenses. Paddle
occluders and hand-held “Mardi Gras mask” are acceptable for ages 10 and older. Although not the most
ideal, a paper cup may be used.
Respond to the child in a positive manner using such words as “good”, “fine”, “okay”, “next”, etc.
Recording Vision Screening Results
o Visual acuity is recorded as a fraction. The numerator represents the distance, and the
denominator represents the line read. Examples for screening at a distance of 20 feet:
 If the child was able to read the 20-foot line, the visual acuity is 20/20.
 If the child could only read the 40-foot line at this same distance, the visual acuity is
20/40.
Vision Screening Steps
 Begin screening on the top line of the chart.
 Occlude the left eye and have the child read the first character on each line until a character is
missed.
 Return to the line above the missed character and ask the child to identify each character on that
line.
 Continue asking the child to identify each character on each lower line until the child misses 3 on
one line.
 If the child is able to continue moving down the chart, screening should end after reading the
20/20 line.
 If the child is unable to correctly identify at least 3 of the 5 characters on a line, move up the chart
until you find the lowest line at which a child is able to identify 3 out of 5.
 Visual acuity is recorded as the smallest line on which the child can correctly identify at least 3 of
the 5 characters.
 Occlude the right eye; repeat the process to screen the left eye.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
 Note: the bottom portion of the Sloan chart divides into 2 charts; one for screening the right eye
and one for screening the left eye.
Initial & Re-Screening Outcomes
 After completing the screening, the child either passes or returns for re-screening.
 Re-screening within 2 weeks is suggested, or as soon as possible.
 After completing the re-screening, the child either passes or is referred to an eye care
professional or primary care provider.
Passing and Referral Criteria (based on age):
 Ages 3, 4, & 5 → Passing = 20/40
→ Refer if 20/50 or more for either eye when re-screened.
 Age 5
→ Refer if fail stereopsis screening.
 Age 6 & older → Passing = 20/30 (LEA) or 20/32 (Sloan/chart without a 20/30 line).
→ Refer if 20/40 or more for either eye when re-screened.
Check for a 2-line difference.
 Refer children with a visual acuity difference of 2 or more lines between the eyes.
 The 2-line difference between the eyes is an indication of possible amblyopia.
 The stronger eye may be controlling the child’s binocular vision and the weaker eye may continue
to deteriorate with recognition by the student parent, or teacher.
LEA Symbols
 Refer if 20/20 in one eye or if 20/30 or worse in the other eye.
 Refer if 20/25 in one eye or if 20/40 or worse in the other eye.
Sloan Letter Chart
 Refer if 20/20 in one eye or if 20/32 or worse in the other eye.
Referral Criteria – Refer a child for any one of the following criteria:
 The child demonstrates one of the observable signs (ABC’s).
 The child has a failing acuity score in either eye.
 The child has a two-line difference in visual acuity between the two eyes.
Referral considerations for children wearing glasses or contact lenses
The need for referral of children who fail the visual acuity test (with their present correction) should be
based on the date of the last examination; observation by parent, teacher, and screener; and the schedule
of re-examinations recommended by the eye care specialist.
Direct Referral to an Eye Care Professional – Children at high risk of vision disorders should bypass
screening and be referred directly to an eye care professional, including:
 Children with a neurodevelopmental disorders.
 Children with systemic diseases associated with vision problems.
 Children with noticeable abnormalities such as crossed eyes (strabismus) or droopy eyelids
(ptosis).
Stereopsis
 The simultaneous visual perception of 3-dimensional space resulting from the blending of the images
from each eye.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
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Starting the school year 2008-2009, stereopsis vision screening has been required by the NC Early
Childhood Vision Care Program for students entering Kindergarten for the first time.
Conducted to determine if the eyes are working together.
When the eyes are not working together, the brain is unable to blend the separate images from each eye.
The child who fails the stereopsis screening is at great risk for amblyopia or loss of vision in one eye.
The Lang-Stereotest II shall be used as the testing device, as recommended by PBNC.
o There are 4 figures on the Lang-Stereotest II card.
o The star is visible to all children even if they do not have binocular vision.
o The other figures (moon, elephant, and jeep/truck) require binocular vision to see.
Testing procedure:
o Ask child to name or point to figures on card.
o If the child is able to see the figures or tries to point to or grasp the figures, this is evidence of
stereo vision.
o Touching the card does not alter its effectiveness.
o Screen children with glasses, if applicable.
o Test binocularly (both eyes open).
o Screener should hold card.
o Card should be displayed 16” from the child’s eyes and at a right angle.
o To prevent monocular clues, avoid moving the card in flip-flop movements.
Initial Lang-Stereotest II outcomes:
o Pass – child identifies the star and at least one other figure.
o Fail – child identifies only the star and no other figure.
Near Vision Acuity Screening
 Conducted on a referral basis. PBNC does not recommend to include in mass screening.
 Select chart, following guidelines below.
o The LEA Symbols chart is appropriate for young, EC, or non-English speaking children.
o The LEA numbers chart is appropriate for children who know their numbers.
o If the child does not want to or cannot talk, choose pointing at the large numbers on the card or
the symbols at the lower edge of the card as a matching game.
o Either side of the chart may be used.
 Set up screening area.
o Select area with good lighting and free of distractions.
o Use a 16” cord to measure between chart and temple close to child’s eyes.
o Children should be screened with their glasses on if they wear them.
o Have eye occluders available.
 Referral criteria:
o Passing lines are determined by age.
Age of Child
4-5 years
6 and older
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Passing Line
20/40
20/33
o To pass a line, the child must correctly identify 3 of 5 characters.
o The last, (or smallest line) a child can pass is the visual acuity for that eye.
o Refer if either eye is not within the passing range based on the child’s age.
o OR if there is a 2-line difference between the eye acuities.
Screening Process:
o Occlude the left eye.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
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Stating at the top line, ask child to identify the first character on each line until a character is
missed.
Return to the line above the missed character and ask child to identify each character on that line.
If the child is able to continue moving down the chard, screening should end after reading the
20/20 line.
If the child in unable to correctly identify at least 3 of the 5 characters on a line, move up the
chart until you find the lowest line at which a child is able to identify 3 out of 5.
Visual acuity is the value of the smallest line on which the child correctly reads at least 3 out of 5
of the characters.
Occlude the right eye and repeat the process.
Referral, Documentation, and Follow-up Procedures
 Referral criteria summary:
o Children unable to complete or pass the screening on the first attempt should be scheduled for
re-screening at a later date (2-week period recommended).
o If the child is unable to complete or pass the screening on the 2nd attempt, referring the child to
an eye care professional is the best course of action.
o Complete the vision referral form letter and send to parent/guardian.
 Documenting screening results
o School nurse’s signature/title.
o Date of screening.
o Observation – pass or refer.
o Remarks – Any observed signs of possible vision problems, child screened with glasses, etc.
o Distance visual acuity – acuity results (i.e., 20/40, 20/30 for initial screening or each eye); note if
rescreening is needed.
o Near visual acuity result, if applicable.
o Stereopsis screening results (pass or fail), if applicable
o Rescreening distance/near vision acuity results, if applicable.
o Note if the child will be referred to an eye care professional.
 Screening follow-up
o Purpose is to encourage the parent/guardian to schedule an eye examination for any child who
fails the vision screening.
o For students referred – within a few days of the screening, contact parent/guardian to field
questions, explain the results, and offer encouragement to comply with the referral.
o Establish a time limit of 3-6 months to complete follow-up.
o Assist families in accessing vision care resources and financial resources (i.e., vouchers), if needed.
o Establish a minimum/maximum number of follow-up attempts to ensure “secured care”.
Understanding and Managing Behavior in Young Children
Prevent Blindness North Carolina
A basic understanding of normal behavior can also be helpful to successfully screen children. The following
addresses only four and five-year olds whose ability to participate is not as well developed as the older school-age
child. Keep in mind that these generalities will not describe every young child.
4-Year Olds
 Four-year olds have a vocabulary of about 1500 words and use sentences of four to five words.
 They may exaggerate and ask questions.
 They can understand words such as “under, on top of, beside, in back of, in front of.”
 They may be very independent and impatient. Despite their desire to hold their own occluder, the
screener should hold the occluder.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
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They may rebel if they feel too much is expected of them. Such children may act out, cry, or stop
cooperating if unable to see the chart because of a vision problem.
They may be physically or verbally aggressive. Children who are waiting may become unruly. Keeping
the waiting area to no more than five or six children makes it easier to keep children calm and quiet.
They like to show off and may enjoy entertaining others. They will obey instruction when adults set
limits. Explain simply exactly what is expected.
5-Year Olds
 They have a vocabulary of about 2100 words and use sentences of six to eight words.
 They may talk a lot and ask questions. They are generally curious about factual information. Listen for
a brief period and then explain what needs to be done.
 Generally, they are more settled and eager to get down to business than they were at age four.
 They usually have very few fears.
 They most often try to please. They may try to peek around the occluder to get the right answer.
 They may be very industrious, trying to accomplish a goal and feel pride and satisfaction when the
goal is reached. They also sense when they have not succeeded. Use neutral words that encourage
effort. Avoid using words that convey right or wrong responses.
Handling Difficult Behavior
Despite efforts to understand normal behavior and work with each child’s unique qualities, sometimes a child’s
behavior makes it difficult to complete the screening. Remember to remain patient.
Hyperactive
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Check with the child’s teacher about strategies that have worked in the past.
Get close to the child.
Silly
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Laugh with the child for a moment.
Engage the child and then slowly move into “how important the task is”.
Can’t Follow Directions
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Demonstrate using minimal words.
Using the matching card while testing simplifies the response.
Break the task down into smaller parts; give only one direction at a time.
Uneasy or Afraid
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Allow the child to first watch others complete the screening.
Go slow. Remember to get on the child’s level.
Give the child time to explore the test materials to reduce anxiety.
Pair the child with a friend or familiar staff person.
Defiant/Seriously Uncooperative
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Say “I’m sorry you don’t want to…”
Promise something silly: “If you can play the matching game, I’ll show you my fish face!”
Crying
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Sympathize. Reassure the child he might have fun playing your games.
Gain the child’s attention; invite them to do something with you.
Excuse the child along with the group and attempt to screen at another time.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Assessment of Non-Responsive or Very Young Children
Visual functioning relates to how well a child is able to use his or her vision to perform everyday tasks. Visual
functioning is a learned behavior and is developmental. The more visual experiences the child has the more the
pathways to the brain are stimulated which leads to a greater accumulation of a variety of visual images and
memories. Experts estimate that 75% of everything a child learns in his or her first five years of life is learned
visually.
When a child cannot or does not respond to traditional screening tests, an alternate way of getting the needed
information is through the Functional Vision Assessment form. A vision screening form, Functional Vision
Screening Test, is attached. This form is used for the nonresponsive or very young child.
In addition to functional screening, other helpful information includes observation of the child performing
everyday tasks such as eating, playing, and/or moving about in the child’s own environment. Information provided
by the parents or those living with the child is most helpful (suggested questions follow).
Permission has been granted by the Alabama State Department of Education to use the assessment tool below.
[Resource]
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Functional Vision Assessment
Name
 Yes
DOB
 No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Pupillary reaction
Blinks at shadow of hand
Orients peripherally
a. Right
b. Left
Fixates on 4 inch object
a. At 12 to 18 inches
b. At 10 feet
Shifts gaze
Reaches on visual cue
Tracks horizontally
a. Light
b. Object
Tracks vertically
a. Light
b. Object
Tracks circularly
a. Light
b. Object
Converges
Picks up or tracks 3 objects less than 1 inch in size, listed below:
1.
2.
3.
No eye preference
Eye Preference:
Right
Left
Action Taken:
Observations:
Screened by:
Date:
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Functional Vision Screening Test
What:
The Functional Vision Screening Test is a short form version of the Functional Vision Screening
Inventory. The items were selected because they proved effective in detecting visual
abnormalities.
Purpose:
The Screening Test should be used to discriminate children who exhibit visual problems so severe
that they interfere with the child’s learning processes. This screening instrument was designed
only for the purpose of deciding whether a severe problem exits.
Administration: The administration procedures for each item are the same as the procedures outlined in the
manual for the Functional Vision Inventory. The only difference will be in the scoring procedure.
Scoring:
Each behavior assessed is scored on either being present or absent. If the visual behavior being
assessed is not within the normal limits, the NO column should be checked. If no visual problem
is suggested, the YES column should be checked.
Four or more checks in the NO column indicate that a visual problem severe enough to interfere
with learning does exist. The child should benefit from educational programs into which a vision
training program has been incorporated.
Administrative Procedures
1. Pupillary Response to Light
Materials:
Penlight
Procedure:
a.
b.
Notes:
Observe the child’s eyes before shining the light; blind children’s pupils may manifest a
continual constricting and dilating process, regardless of the presentation of light.
Observe the pupils as the child moves from one environment to another in which the
room is lighter or darker. Also, observe whether the pupils are equal in size.
Score:
The child’s pupils should immediately constrict with the presentation of light and almost
as rapidly readjust when the light is removed. If this behavior is observed, place a check
mark in the YES column. If this behavior is not observed, place a check mark in the NO
column.
Direct the light into the child’s eyes from 12 inches away.
Observe whether the child’s pupils constrict with the introduction of light; then
dilate when the light is removed; and the speed with which they do so: briskly,
sluggishly, or no response at all.
2. Blinks at Shadow of Hand
Materials:
None
Procedure:
a.
b.
c.
Slowly pass your hand with fingers spread horizontally across the child’s line of
vision.
Repeat several times.
If the child is non-ambulatory, place the child on his or her back or side and kneel
behind the child’s head.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
d.
e.
Score:
Be careful that the child is not responding to the wind created by your hand,
rather than to the oncoming movement of the hand itself; and that the blinking is
in response to the hand, not simply a coincidental response.
Observe whether the child blinks purposefully as the hand passes over the child’s
eyes.
The child should blink reflexively to the oncoming hand across his line of vision. If this
behavior is observed, place a check mark in the YES column. If this behavior is not
observed, place a check mark in the NO column.
3. Orients Peripherally:
Materials:
Penlight or small colorful toy.
Procedure:
a.
b.
c.
d.
Score:
Sit behind the child and in front of a mirror, bring the toy or light from behind the
child at eye level.
Slowly move it from the periphery and toward the center of the child’s vision,
holding the toy or light approximately 12 to 15 inches away.
Move the toy around the left, as well as the right side, of the child’s head.
Observe the point at which the child turns to look at the toy or light, and any spot
at which the child seems to lose sight of it.
The child should turn his or her eyes to each side when the toy or light is at an angle of 30
inches or more from the midline. If this behavior is observed, place a check mark in the
YES column. If this behavior is not observed, place a check mark in the NO column.
4. Fixates on 4-inch Object:
Materials:
Baby Speilzeug, bright orange squeak toy, toy car, yarn ball, nerf ball, cup, etc., all of
which are approximately 4 inches in size.
Procedure:
a.
b.
c.
d.
e.
f.
g.
Score:
5. Shifts Gaze:
Attract the child’s attention to the object at 12 to 18 inches by wiggling the toy or
activating a sound component if possible.
Position the object at various places within a 180° radius around the child, then
move back five feet, wiggle, or activate the object.
Again, position the toy at various places within a 3-foot radius of the child.
Move back to 10 feet, then repeat.
Observe whether the child fixates (looks at) his or her gaze for 3 seconds on the
object in any position within 12 to 18 inches of the child.
At 5-10 feet, observe whether the child turns his or her head, or eyes, to fixate or
look at the object for 3 seconds or more in any position.
If the child can sign or is verbal, teach the sign or label for the toys and ask the
child to name them at 10 feet away.
The child should look at the object for 3 seconds at 12 to 18 inches and at 10 feet. If this
behavior is not observed, a check mark should be placed in the NO column.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Materials:
Two toys from 2-4 inches in size identical in interest appeal Weebles, puppets, spinner
toys, plastic animals, etc.
Procedure:
a.
b.
c.
d.
Score:
Hold the two objects before the child 10 inches from his or her eyes with
approximately 6 inches between the objects.
Attract the child’s interest to one object and allow the child to attend several
seconds before attracting his or her attention to the other.
Repeat several times. If the toys differ, alternate the position of the toys several
times.
Observe for shift of gaze from one toy to the other attending to only one side, or
for difficulty in shifting to or locating the other toy.
The child should be able to shift his gaze easily and quickly from one toy to the other, 4 or
5 times in 5 seconds. If this behavior is observed, place a check mark in the YES column. If
this behavior is not observed, place a check mark in the NO column.
6. Reaches on Visual Cue (Reaches for Stationary Toy):
Materials:
Any bright object, toy, or cup filled with juice.
Procedure:
a.
b.
c.
d.
e.
Score:
Throughout the assessment, leave different size objects in various areas in a
circumference around the child.
Be alert to any attempt during the observation of the child, to reach for, or follow,
or gaze at different types of objects.
Be sure to record these observations, even if they are made while returning the
child to the classroom.
Observe whether the child reaches for objects on only one side.
Switch the positions of the objects that the child does reach for to see whether
the child prefers that object or whether the child does not see in that field.
A child of 5 months (chronologically or older) should reach for objects within his or her
visual field. When propped upright or sitting on the floor, the child of 10 months or older
should pick up small objects within 18 inches. If this behavior is observed, place a check
mark in the YES column. If this behavior is not observed, place a check mark in the NO
column.
7-9. Tracks Horizontally, Vertically, and Circularly.
Materials:
Penlight or a light covered with plastic figures that allow light to shine through: Big Bird
puppet, Baby Spielzeug, slinky, Redheaded Rattle, a cup, spoon, bottle, patterned box, or
face.
Procedure:
a.
b.
c.
d.
Hold the light source 12 inches from the child’s eyes and blink it several times to
attract the child’s attention.
Slowly move the blinking light in an arc to the far left, then to the far right
(horizontally).
From the center point (directly before the nose), move the light in an arc to
several inches above the child’s chin (vertically).
Next, move the light in a circular pattern (circumference should be no larger than
12 inches).
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
e.
f.
g.
h.
i.
j.
k.
l.
Score:
The circular motion should be conducted vertically around the child’s face, pause,
then, repeat.
Follow the same sequence with a toy or object.
If the child does not attend to a stationary toy, wiggle it to create another form of
motion as it is being moved across the child’s visual field.
Observe whether the child follows the light or the object, the direction in which
the child follows, and how the child follows.
Does the child follow with both eyes together, or with only one eye, which?
Does the child’s eyes follow smoothly or jerkily?
Does the child cross his midline or look only from the midpoint to one direction?
Can the child follow with only his or her eyes or does the child also move his or
her head?
The child should be able to follow both light and object smoothly in all directions. If this
behavior is observed, place a check mark in the YES column. If this behavior is not
observed, place a check mark in the NO column.
10. Convergence:
Materials:
Penlight, small puppet, flint sparkler, slinky, or Weeble.
Procedure:
a.
b.
c.
d.
e.
Score:
Sit before the child with the toy or light and attract the child’s attention to it.
When the child attends, move the toy or light slowly in toward the bridge of the
child’s nose from about 12 to 16 inches away.
Observe the child’s eyes as the toy or light moves toward the child, paying
particular attention to the distance at which the eyes turn in or out, or if the child
looks away, turns his or her head, or closes his or her eyes.
The eyes should continue to converge on the toy or light until it is 4 inches from
the child’s nose.
Note also, whether both eyes turn in simultaneously or whether one eye turns in
or out.
The child should follow the light or object with both eyes until the stimulus is
approximately 4 inches from the child’s eyes. If this behavior is observed, place a check
mark in the YES column. If this behavior is not observed, place a check mark in the NO
column.
11. Picks up or Tracks 3 Objects less than 1-inch in Size:
Bead/Thread Test:
Materials:
Cake decorations, (1) silver beads 3mm in size, and (2) colored beads 1mm in size, and
2-inch lengths of red sewing thread.
Procedure:
a.
b.
c.
Position the child over a bolster or wedge, on the floor, or at a table.
Be sure that there is a high contrast between the materials and the table or
surface on which they rest.
Scatter the large beads first, the smaller ones next, and the threads last.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Score:
12.
The child should be exposed to only one set of items at a time. Observe the child for any
focusing or attempts to pick up the objects. If this behavior is observed, place a check
mark in the YES column. If this behavior is not observed, place a check mark in the NO
column.
No eye preference:
Materials:
Objects administered during the assessment.
Procedure:
a.
b.
c.
d.
Observe during the administration of items whether the child closed either eye to
look from only one.
Does the child track with only one eye?
When either eye is covered, does the child resist?
When objects are brought into the left and then to the right visual fields (from
behind the child’s head), does the child turn to one side and then to the other?
Notes: Research shows a relationship between head posture and muscle imbalance.
Two of the most common defects associated with muscle imbalance are
described below:
1. Ocular posture — Eye turned in.
Usual compensatory head posture — Face turned towards affected side, chin
lowered.
2. Ocular posture — Eye turned out.
Usual compensatory head posture —Face turned towards normal side, chin
may be raised.
Score:
The child should maintain his or her head in midline when focusing on objects. No
preference for one eye should be noted either during occlusion through head posture, or
when gathering acuity data. If this behavior is observed, place a check mark in the YES
column. If this behavior is not observed, place a check mark in the NO column.
Candy is a useful tool for color testing, determining size of object seen, and eye/hand coordination.
Vision Screening Protocol
Prevent Blindness North Carolina Guidelines
Questions to ask parents
Yes
No
1.
Are there any medical issues/problems?
If yes, describe:
Yes
No
2.
Is your child taking any medications?
Yes
No
3.
Does your child recognize people when they enter the room (without an auditory cue)?
4.
How far away does the person have to be before the child recognizes the person?
If yes, list:
Yes
No
5.
Will the child raise his or her arms to be picked up?
Yes
No
6.
Have you noticed your child squinting when in bright sunlight or when near bright lights?
Yes
No
7.
Does your child appear to tilt his or her head in an unusual way to look at things?
Yes
No
8.
Does your child hold his or her hand or objects near his or her eyes in an unusual manner?
Yes
No
9.
Does your child locate things he or she drops on the floor?
Yes
No
10.
Does the child use vision to locate lost objects? How?
Yes
No
11.
Does your child appear to notice if the room lights are on or off?
Yes
No
12.
Is your child interested in watching television?
13.
What pictures capture your child’s attention?
14.
What kinds of things do you think your child sees?
15.
What are your child’s favorite toys and color preference?
Additional Comments:
Name of parent(s):
Signature of School Nurse:
Date: