1. Going Green www.arkansascsh.org.
This educational offering is joining others in an effort to save our environment by making the handouts available on our website

2. To show respect for our speakers and participants, PLEASE place your cell phone on silent or vibrate.
Should you need to answer a call, PLEASE go outside to hold your phone conversation.

3. If it is that important, please step outside!!!!
Respect the speakers and other participants around you by refraining from side bar conversations during the session.
If it is that important, please step outside!!!!

4. The planning committee &
faculty attest that NO relevant financial, professional or
personal conflict of interest exists, nor was sponsorship of commercial support obtained,
in the preparation or presentation of this educational activity.

5. VISION SCREENING CERTIFICATION

6. Importance of Vision Screening
One in 20 preschoolers has a vision problem.
One in 5-10 school-aged children has a vision problem.
Impaired vision can seriously impede learning.
Early identification and treatment can prevent or at least alleviate many vision problems.
Review the points above….kids can’t learn if they have a hearing or vision deficit

7. Purpose of Vision Screening
To screen a large number of children in a short amount of time.
To separate those children likely to have vision problems from those not likely to.
To refer those children who do not pass the screening or who are suspect for vision problems.
Even though we are moving the students thru quickly, we must have a quality screening program and must follow the protocols that have been established….

8. Landmarks of Visual Development
4-12 wks
Binocular fixation
12-20 wks
20/200
44 wks-12 mo
20/ /100
Full binocular vision
Amblyopia may develop
6 -18 mo
Convergence developed
18 mo-2 yrs
Accommodation developed
20/40
2-3 yrs
20/30
5 yrs
Min. potential for amblyopia
6 yrs
Approaches 20/20
Point out the developmental red flag: amblyopia at approximately 12 months of age. The child may have intermittent problems with muscle balance and control but by 12 months this should not continue to happen. Amblyopia should be identified as early as possible (after 12 months of age) and referred ASAP; however, we have students that present in school with this problem and it needs to be addressed at that time.
Legal blindness is a term that describes central vision acuity that is 20/200 or less in good eye after correction. or VA of more than 20/200 if there is a field defect in which the wide diameter of the visual field subtends an angle distance no greater than 20°

9. Parts of the Eye Outer layer: sclera and cornea
Middle vascular layer: choroid (lines the eyeball and contains vascular system that nourishes retina, ciliary body (consists of muscle that suspends lens and facilitates accommodation), iris
Inner nervous layer: retina
Lens and cornea principal optical structures: bend and refract light to focus a clear image
Shape of the lens and cornea in addition to the length of the eyeball determine where light rays focus on the retina…accommodation
Six extra ocular muscles control eye movement in the bony orbit…muscles work together to supplement or limit one another’s movement (individual eye) and both eyes work together to create simultaneous movement

10. Common Ocular Abnormalities

11. Black Eye
Result of simple blunt force trauma

12. Conjunctivitis Conjunctivitis Pinkeye or red eye
Causes: acute…viral, bacterial, seasonal allergies, smoke, chemicals
chronic…exacerbations and remissions…due to the above or entropion, blepharitis, chronic dacryocystitis, chronic exposure to irritants…..etc.
Bacterial is usually unilateral…purulent discharge, eyelids stick together, spread by hand (rubbing at eye and touching drainage and then touching something else before washing) to hand contact….advise females using eye makeup to discard…. Emphasize hand washing, not touching affected eye to rub, etc….

13.                                                                                  
Blepharitis
Blepharitis is an inflammation of the eyelid typically affecting the hair follicles: scaling and crusting. Meibomian gland can become plugged….or much more commonly, the hair follicle can become plugged….warm compresses may dissolve greasy plug
Two types: ulcerative usually caused by staph and need medication to treat
nonulcerative caused by allergy, smoke, chemicals, or seborrheic (improve eyelid hygiene)
Ulcerative is raw appearing and looks like it is oozing and ready to bleed , pustules
Burning, itching, redness

14. Chalazion
Inflammation of the meibomian gland…similar to a sebaceous cyst….gland distends
This gland secretes a substance that keeps the lids from sticking together….can resolve on it’s on hot compresses sometimes help but usually refer, sometimes surgical I & D is indicated to relieve if still persists after about 6 weeks…
This is an internal gland and sags downward (or upwards) as opposed to a stye (external gland)

15. Stye
Acute infection, usually staph… in the gland of Moll or Zeis…superficial or external
Pain, redness, tenderness, small round area of induration; should rupture spontaneously but can suggest warm, moist compresses..

16. Of upper eyelid due to scarring
Entropion
May lead to corneal ulceration or scarring
Of upper eyelid due to scarring
Of lower eyelid

17. Dacryocystitis Infection of the lacrimal duct/sac
Inner canthus….along side the nose…red, hot, swollen
Warm compresses and gentle milking may relieve
Sometimes a probe is used to open the duct
May require I & D

18. Ptosis Unilateral or bilateral
                         
Ptosis
Unilateral or bilateral
Student may have problem when you first encounter or may develop a problem
Rule out Horner’s syndrome nerve injury, central lesions in brain stem; iris does not become pigmented
MG episodic muscle weakness…loss; dysfunction acetylcholine receptors…ocular muscles affected first….autoimmune attack

19. Coloboma Coloboma means fissure or cleft
Causes: congenital (in utero infection)
surgical
pathological
Can affect the eyelid (upper or lower), pupil, or iris

20. Coloboma Coloboma means fissure or cleft
Causes: congenital (in utero infection)
surgical
pathological
Can affect the eyelid (upper or lower), pupil, or iris

21. Cataract
Cataract is an opacity of the lens, it’s capsule or both resulting in consequent loss of visual acuity
Causes: congenital in utero infections…rubella; chromosomal defects, metabolic disorder such as galactosemia
infection uveitis DM
cigarette smoke
corticosteroids

22. Strabismus Types Tropia Phoria
Eyes which are always improperly aligned
Phoria
Eyes which have a tendency to misalign when fusion is interrupted
Tropia caused by unequal muscle tone…convergent (eso, turns in), divergent (exo, turns out) or vertical (hyper, hypo); deviation from parallelism does not vary with ocular movement ( if upward, always upward)…to fixate
Phoria is deviation of one eye from parallelism with the other…nonparalytic, muscle imbalance is overcome by the CNS tendency to fuse the images from each eye…becomes apparent when the CNS is unable to maintain fusion

23. Esotropia
Note right eye turns inward

24. Bilateral Esotropia
Both eyes turn inward

25. Exotropia
Right eye turns outward

26. Hypertropia
Left eye turns upward

27. Pseudostrabismus (also Pseudotropia or pseudoesotropia)
Corneal light reflex is symmetrical…intercanthal folds lead to the appearance of a problem

28. Refractive Errors Myopia (Nearsightedness) Hyperopia (Farsightedness)
Astigmatism
Three types of refractive errors
We will discuss each

29. Image focuses in front of the retina…or the refractive power of the eye is too strong
"minus" lens for correction
Note the distance from side to side is greater than the distance top to bottom

30. Nearsighted view
Geese are clear but buildings are blurry
Problem in classroom is reading the blackboard

31. Most common refractive error… image focuses behind retina or refractive power of eye is too weak…"plus" lens for correction
Note the distance from side to side is less than the distance top to bottom

32. Farsighted view
Geese are blurry but buildings are clear
Problem in classroom is reading the text or doing paperwork

33. Unequal refraction of light rays
Curve of the cornea is more acute, not smooth
Distorts both shape and size

34.                                                              
All images distorted….size and shape 34

35. Astigmatism Unequal refraction of light rays
Curve of the cornea is more acute, not smooth
Distorts both shape and size

36. Amblyopia: Definition
Vision that cannot be corrected to better than 20/40.
Unilateral or bilateral
Brain suppresses poor image
Normal appearance
Reversible if detected and treated early
Amblyopia is reduced visual acuity due to cortical suppression of the image in the deviating eye to avoid confusion and diplopia
Organic cause is usually not reversible

37. Amblyopia Predisposing Factors Poor clarity Poor focus Poor aim
Cataract
Poor focus
Nearsightedness
Farsightedness
Poor aim
Strabismus
Treatment
Clearing the media
Cataract removal
Focusing the image
Corrective lenses
Correcting aim
Occlusion therapy
Drops
Point out predisposing factor and matching treatment

38. Amblyopia Therapy
Type of patching

39. Usher’s Syndrome Hearing Loss and Retinitis Pigmentosa
Screen children with hearing loss
Leading genetic cause of deaf-blindness, gradual loss of vision, seen with children with sensorineural hearing loss, autosomal recessive
#11q13, #14q, #1q32
Decreased night vision, decreased peripheral vision,
Vertigo/ataxia, loss of smell, nystagmus, MR, epilepsy, cataracts
There is a handout in your packet on this syndrome and if you want to know more about this syndrome there is a 1.3 CE activity for Ushers.

40. Vision Screening

41. Screening Procedure
The following is the protocol that school nurses follow during vision screening

42. Observation Appearance Behavior Complaints
Do observations with and without glasses! Should be a certified person only!

43. Appearance Whites Iris Pupil Lids Lashes
Immediate referral if abnormal
Note pupil size/symmetry
Cornea/lens….oblique lighting can help identify opacities
Do you note any of the problems or diseases reviewed earlier???

44. Behavior Head tilt or turn Blinking or rubbing Avoiding close work
Squinting/frowning
Closing or covering eye
Reading problems
Frustration/poor attention
Has the classroom teacher reported any of these behaviors?

45. Complaints Headaches Nausea Dizziness Burning or itching Blurring
Has the student been in the health room with frequent complaints?

46. Visual Acuity-Far Screen one eye at a time.
If a child wears glasses, perform the screening with the child wearing the glasses.
Screen at 20 feet – Snellen Chart
Literate children
Screen at 10 feet – Age Appropriate Chart
Allen Chart/Tumbling E’s
Pre-literate children/non-English speaking
Any eye with vision poorer than 20/40 is a screen failure.
Begin with the right eye “lit” and have the student read the correct line then switch to the left eye…
Passing is 4 correct

47. Plus 2 (+2.00) Visual Acuity Test for farsightedness.
Perform exactly as the distance visual acuity except;
Hold a lens in front of the tested eye (fellow eye covered).
Any eye that improves 2 lines of vision with the lens is a screen failure.
When administering this test slide, be sure that the student understands that they have passed…correctly….when it IS blurred…you may wish to ask does this make it better or worse…when you insert the lens….students know you are testing their eye sight and can get very upset if they think they failed when this is blurry!!

48. Instrument Screenings
Titmus
Optec
Keystone

49. Lateral & Vertical Muscle Balance-Far (Titmus & Optec)
Right eye on; left eye off.
Give instructions:
“Here is a box. I will throw a red ball. Tell me where the ball lands.”
Turn left eye on.
Need immediate answer.
If not, repeat test.
To pass the child should report the ball landing ‘in the box’ or ‘on the line’.
Test for phoria
Machine needs to be set in far mode

50. Lateral & Vertical Muscle Balance-Far Titmus & Optec
Right Eye
Left Eye
Titmus OV7 & Optec
Machine is in far mode; right eye on. Give instructions to tell where the ball lands. You turn on left eye. Answer must be immediate, if not repeat test.
TITMUS: Top and bottom slides are both titmus slides depending on machine you have
If you have the slide with A & B, then the pass criteria is landing in the A box (titmus 2
If you have the table without letters, passing is landing on the table or inside the box
Red ball on the line is acceptable for both slides!
Optec- bottom slide
Right Eye
Left Eye

51. Lateral Muscle Balance-Near Titmus
At completion of Muscle Balance Far screening switch lever to ‘near’ setting.
Procedure is the same now as the Lateral Muscle Balance Far screening.
Test for phoria
Remember to switch to near mode 51

52. Lateral Muscle Balance-near Titmus & Optec
Right Eye
Left Eye
Titmus OV7 and Stereo Optec
Machine in near mode
Top slide- pass criteria for the top card is red ball in A or B for the titmus 2 screener
Pass criteria- the lower slide is ball in the box (on the table) for the titmus ov7 & Optec
Red ball on the line is acceptable for both slides
Bottom slide is for either titmus or optec
Right Eye
Left Eye

53. Lateral Muscle Balance –Near Optec
Note: The procedure is the same as for Titmus the only difference is Optec has two slides: one for near and one for far

54. Lateral Muscle Balance-Far Titmus & Optec
Titmus- you could use this with older students but I don’t advise using it with younger students
Pass criteria pass criteria-

55. Vertical muscle balance-far Titmus & Optec
Far mode you can use this instead of ball in the box
Not recommended for young children
Pass criteria-line must go through middle of notes

56. Lateral Muscle Balance-Far Keystone
Right eye on; left eye on.
Place slide ‘Lateral Phoria – use at far point’.
Give instructions
“Here is a row of numbers, 1 to 15, and an arrow/pointer. What numbers) does the arrow point most closely to?”
Need immediate answer
If not, repeat test.
To pass the child should report the arrow pointing to a number(s) between 8 and 11. Any other answer is a screen failure.
Test for phoria 56

57. Lateral Muscle Balance-Far Keystone
fail
fail
pass
Test for phoria
Passing is 8-11 57

58. Vertical Muscle Balance-Far
Performed at ‘far’.
Keystone
Right eye sees a column of figures with a central circle and 2 figures above and below.
Left eye sees a horizontal line.
To pass the child should see the line passing through the circle or just above or below the circle.

59. Vertical Muscle Balance
Keystone
Pass

60. Lateral Muscle Balance-Near Keystone
Use slide labeled ‘Lateral phoria – use at near point’ (place at the near point).
Again a row of numbers (2 -10) and an arrow are present.
A response of the arrow pointing between 4.5 and 6.5 is a screen pass – outside this is a screen failure.
Test for phoria 60

61. Lateral Muscle Balance-Near Keystone
fail
pass
Test for phoria 61

62. Binocularity (fusion) at far Optec/Titmus
Can use whichever of three slides you have—only need to use one.
Pass criteria depends on the slide.
Test in far position.
Test with both eyes ‘on’.
This test both eyes ability to work together…
Both eyes are on 62

63. Binocular Vision-Far Titmus OV7, Stereo Optec 2000
Pass criteria is correctly identifying the direction of all three Es….child should say the first E is (pointing left, or toward boy), the second E is (pointing up or toward bird) and the third E is (pointing right or toward the girl) 63

64. Binocular Vision-Far E Titmus OV7, Stereo Optec 2000
Both eyes open – screen pass
Pass criteria is correctly identifying the direction of all three Es….child should say the first E is (pointing left, or toward boy), the second E is (pointing up or toward bird) and the third E is (pointing right or toward the girl) 65

65. Binocular Vision - Far Titmus 2 (Optional)
Pass criteria is seeing three cubes
Cubes merge and superimpose white over white so that the picture is three cubes in vertical order ( red, white, blue) child does not have to identify colors….only three cubes not two or four
A correct response with this screen is for the child to see all 4 boxes/objects when both eyes are ‘on’. 66

66. Binocular

67. Binocular Vision - Far Keystone red white blue Right eye Left eye
Pass criteria is seeing three cubes
Cubes merge and superimpose white over white so that the picture is three cubes in vertical order ( red, white, blue) child does not have to identify colors….only three cubes not two or four
A correct response with this screen is for the child to see 3 circles with both eyes. The circles should be in a vertical line or only minimally separated (if minimally separated it is acceptable to see 4 circles).

68. Binocular Vision - Far Keystone red white blue pass
Pass criteria is seeing three cubes
Cubes merge and superimpose white over white so that the picture is three cubes in vertical order ( red, white, blue) child does not have to identify colors….only three cubes not two or four
A correct response with this screen is for the child to see 3 circles with both eyes. The circles should be in a vertical line or only minimally separated (if minimally separated it is acceptable to see 4 circles).

69. Four circles widely separated is a screen failure.
Binocular Vision - Far
Keystone
fail
Pass criteria is seeing three cubes
Cubes merge and superimpose white over white so that the picture is three cubes in vertical order ( red, white, blue) child does not have to identify colors….only three cubes not two or four
Four circles widely separated is a screen failure.

70. Binocularity (fusion) at Near
This screen is performed as was fusion at far except the instrument is switched to the ‘near’ setting. Or the ‘near’ slide is place in the instrument.
This test both eyes ability to work together…

71. Color Performed with both eyes open.
Use a standard instrument slide or a standard hand held red/green color testing card.
To pass the student should be able to read/recognize the numbers presented.

72. Color

73. Re-screening
Rescreen in 4-6 weeks

74. Why Rescreen? Cuts down on over-referral.
Adds validity and parent confidence
Improves follow-up.
Saves time by decreasing amount of follow-up needed.
This is current practice and needs to be emphasized!!!
Over referral is a major problem because a rescreen exam was not performed….some students do not perform well in mass screenings and need the opportunity to work with the nurse in a quiet atmosphere and with one on one attention, slower pace…
Rescreen all tests that the student failed on the initial screening

75. Referral Immediate referral if do not pass:
Observation (Appearance)
Re-screen in four to six weeks if do not pass:
Visual Acuity
+2.00 test
Instrument screenings
Refer if do not pass any part of re-screen
Color vision deficit does not require a referral.
This is the referral criteria….note rescreen in four to six weeks and additional tests are added during the rescreen…..

76. Tips Observation with glasses on and off.
Glasses on for machine screening.
Keep child’s head in place on machine—no peeking with “good” eye!
Adjust machine to child’s height.
May need to hold child’s head in place
May need to let child sit on your lap, use a step stool, kneel in chair, whatever it takes to get the child in good position to read the cards in the machine…

77. Data Entry

78. Data Entry Vision screening data is entered into APSCN
Data queries will be pulled on Nov. 15 and April 15.
Training for APSCN will be provided at your Ed. Cooperative.

79. Data Entry No forms needed except for screening form
Parent Notification/Doctor Report Form will be generated through APSCN
You may want to print the screening forms especially if you will be entering the data into APSCN at a later date.
If a students fails their screening a line will be automatically added in APSCN to enter their rescreen data.
The parent notification/doctor report form will be generated through APSCN also.
THIS WILL BE COVERED MORE WITH YOUR APSCN TRAINING.

80. Screening Form Grade 1, room A
Obs Va +2
LMBf
LMBn
VMB Ff Fn C
P/F ?
Stu.A p P
Stu.B F
Rescreen
Stu.C f
Stu.D
Refer

81. Paula Smith, State School Nurse Consultant
Arkansas Department of Education, Office of Coordinated School Health
2020 West 3rd St., Suite 320
Little Rock, AR.72205
On this form you will need to fill in all the information of the students that have failed a screening/rescreening and given a referral and DID NOT follow through with the exam within the 60 days time frame stated in the LAW. The parent will need to know that the school will be following the law by notifying the Department of Education. This form can be sent to: Paula Smith
State School Nurse Consultant
Arkansas Department of Education
Coordinated School Health
2020 West 3rd St., Suite 320
Little Rock, AR 72205

82. RESOURCES vicki@arkansasoptometric.org 501-661-7675
Examinations and Eye glasses
411 S. Victory, Suite 206, Little Rock, AR 72201
To borrow Titmus vision screeners

83. Vision Machine Repair BSI--Jack Stone --in Little Rock (501) 416-1232
2M Eye Instruments-- Mike Shivley-- in West Memphis (870)