1. Vision Screening Training
Child Health and Disability Prevention (CHDP) Program
State of California CMS/CHDP
Department of Health Care Services
Revised 7/8/2013

2. Acknowledgements
Vision Screening Training Workgroup – comprising Health Educators, Public Health Nurses, and CHDP Medical Consultants
Dr. Selim Koseoglu, Pediatric Ophthalmologist
Local CHDP Staff
Members of the vision screening training workgroup created this PowerPoint presentation and the accompanying handouts, based on their research of current recommendations and best practices
Dr. Selim Koseoglu, a pediatric ophthalmologist reviewed the presentation and handouts for medical accuracy and appropriate language for the target audience
The local CHDP staff reviewed the presentation and handouts and offered suggestions and recommendations for editing

3. Objectives By the end of the training, participants will be able to:
Understand the basic anatomy of the eye and the pathway of vision
Understand the importance of vision screening
Recognize common vision disorders in children
Identify the steps of vision screening
Describe and implement the CHDP guidelines for referral and follow-up
Properly document on the PM 160 vision screening results, referrals and follow-up

4. Importance of vision screening

5. Why Screen for Vision? Early diagnosis of:
Refractive Errors (Nearsightedness, Farsightedness)
Amblyopia (“lazy eye”)
Strabismus (“crossed eyes”)
Early intervention is the key to successful treatment
The goals of pediatric vision screening includes early diagnosis of eye problems and prompt treatment .
The examiner performs additional vision screening procedures during the check up to assess:
Eye focusing
Eye coordination
Eye teaming (binocular vision)
Eye movement
Visual perceptual skills
Passing a vision screening with the eye chart test does not mean the child has perfect vision. The 20/20 test does not test how you see at a reading distance. It also does not evaluate many other important measures of normal vision.
We go to the dentist 2x a year for a cleaning but many people do not go for an eye exam until they experience vision problems.
This is why vision screening in the primary care setting is important for detecting vision problems at an early stage when treatment is more effective
But, as important as vision screening is, it should not take the place of a comprehensive eye exam.

6. Why Screen for Vision? Vision problems often go undetected because:
Young children may not realize they cannot see properly
Many eye problems do not cause pain, therefore a child may not complain of discomfort
Many eye problems may not be obvious, especially among young children
The screening procedure may have been improperly performed
Vision is a complex process that involves over 20 visual abilities and more than 65% of all the pathways to the brain.
Early detection of vision problems and intervention is the key to minimizing vision loss.
Some reasons why vision problems in children often go undetected:
Children often do not recognize that they are having a problem with their vision because they have seen this way all their lives, they do not know they have poor vision.
Many eye problems do not cause pain or discomfort so again go unrecognized
Even parents often do not recognize when something is wrong with their child’s eyes
Children with a family history of vision problems and premature births may be at greater risk for vision problems

7. Screening vs. Diagnosis
Identifies children at risk for certain eye conditions or in need of a professional eye exam
Detects signs of vision disorders in an early, treatable stage
Does not diagnose!!
Diagnosis
Identifies the child’s eye condition
Allows the eye specialist to prescribe the appropriate treatment

8. Prevalence of Vision Disorders in Children
80% of learning during the first 12 years of life is visual or visually-initiated
1 in 20 preschool-age children have vision problems
1 in 4 school-age children have vision problems
2-3% of children have Amblyopia (“lazy eye”)
2-5% of children have Strabismus (“crossed eyes”)
Without early detection and treatment, children’s vision problems can lead to permanent vision loss and learning difficulties
It is estimated that 80% of children with a learning disability have an undiagnosed vision problem. (Vision Council America)
Vision problems can also influence personality and social adjustment in school.

9. Elements of vision

10. Eye Anatomy
When conducting an external inspection of the eye you want to examine the:
Sclera: The tough and dense outer coating of the eyeball that forms the white of the eye.
The sclera should be white with no discoloration or growths
Iris: The color portion of the eye; it helps control the amount of light let into the eye.
The iris should be a complete circle and be the same color in both eyes.
Cornea: The transparent anterior part of the external coat of the eye covering the iris and the pupil. Its clarity (translucence) permits light to pass into the eye, through the pupil and on to the retina at the back of the eye.)
The cornea should be clear with no discoloration check for infection, trauma, inflammation, or dry eye.
Pupil: The opening in the center of the iris through which light enters the eye.
The pupils should be clear and dark. There should be no cloudiness or white discoloration. The pupils should be of equal size and circular shape. If they are white (leukocoria) then an immediate referral to an ophthalmologist is required.
Lens: A biconvex transparent body situated behind the iris in the eye; its role (along with the cornea) is to focuses light on the retina.
Conjunctiva: The delicate membrane lining the eyelids and covering the eyeball.
The Conjunctiva should be clear and free of infection and/or discoloration. When the there is an infection present it is known as conjunctivitis or by its common name “Pink Eye”, which is caused by bacterium or virus. The child should be referred if an infection is suspected.
Reference: Definitions were provided by the free on-line dictionary and the “Glossary of Vision Screening Terms” found on the Minnesota Department of Health’s website, under “Vision Screening Materials”.

11. Pathway of Vision
Vision is the process by which images captured by the eye are interpreted by the brain, and the visible part of the eye is where the process of sight begins.
Behind the cornea is a watery fluid called the aqueous humor. The cornea and aqueous humor form an outer lens that refracts (bends) light on its way into the eye. This is where most of the eye's focusing work is done.
The iris controls the amount of light entering the eye through the pupil. Like a camera, which controls the amount of light coming in to prevent both overexposure and underexposure, the iris becomes wider and narrower, changing the size of the pupil to control the amount of light entering the eye. The pupil gets bigger when more light is needed to see better and smaller when there's plenty of light.
The retina is made up of millions of light receptors called rods and cones. Rods are much more sensitive to light than cones. Each eye has about 125 million rods that help us see in dim light and detect shades of gray, but they cannot distinguish colors.
When focused light is projected onto the retina, it stimulates the rods and cones. The retina then sends nerve signals. The signals are sent through the back of the eye to the optic nerve. The optic nerve carries these signals to the brain, which interprets them as visual images.
Resource: Kids Health,

12. Development of Vision
The visual pathway from the eye to the brain is still developing from birth to about age 9 – this is the critical time period to detect vision conditions
The brain needs input from the eye in order to develop normally during this period
It is estimated that 80% of learning comes through the visual senses [1]. Vision affects the performance of the whole child. Vision also influences the child’s performance and adjustment in school, society, and overall health [2]. Vision screening is important because it leads to the identification of children with vision abnormalities such as visual acuity and muscle balance problems.
Children with impaired vision often are not aware of their impairment; therefore, they do not complain or seek help. If they have always seen things in a blurred or distorted way, they accept the imperfect image without question. It is up to adults responsible for child’s health care and educational development to detect when children are experiencing vision problems.
References: American Academy of Ophthalmology. Pediatric Eye Evaluations. Preferred Practice Guidelines AAO
Murphy R. Proctor S.E. To See or Not To See. Screening the Vision of Children in School Access via world-wide web:

13. Common Vision Conditions
Refractive errors (nearsightedness, farsightedness - child needs glasses)
Amblyopia (vision loss because the brain and eyes are not working together)
Strabismus (eyes that are misaligned – may have double vision)
The method explained in this training is designed to screen young children for nearsightedness, farsightedness, Amblyopia and Strabismus. Each of these common vision conditions will be explained in detail in the next few slides.

14. Refractive Errors - Myopia
Normal Vision
Myopia
Myopia or nearsightedness occurs in about 9% of the pediatric population, ages 5-17 years. With Myopia, the light that enters the eye is bent in a way that is focuses in front of the retina, causing a blurry image of objects that are far away.
Typically the child can see objects close up with no difficulty.
Reference: Refractive Error and Ethnicity in Children, Arch Ophthalmol. 2003; 121:

15. Refractive Errors – Myopia
Myopia Corrected
Myopia is corrected with a convex lens that bends the light to focus directly on the retina, thus producing a clear image.

16. Refractive Errors – Hyperopia
Normal Vision
Hyperopia or farsightedness works in the opposite manner – the light is bent so it focuses behind the retina and close objects appear blurry. Approximately 13% of the pediatric population, ages 5-17 are hyperopic.
Typically a hyperopic child can see objects that are far away with no difficulty.
Reference: Refractive Error and Ethnicity in Children, Arch Ophthalmol. 2003; 121:
Hyperopia

17. Refractive Errors – Hyperopia
Hyperopia Corrected
Hyperopia is corrected with a concave lens that bends the light to focus directly on the retina, thus producing a clear image

18. Amblyopia
Amblyopia, or “lazy eye” can be difficult to detect, especially in children.
Amblyopia occurs when one of the eyes “sees” a blurred view while the other eye “sees” a normal view. The brain has difficulty fusing both of these views into one image and learns to simply ignore the blurry view. Vision in this eye deteriorates and without treatment can lead to permanent vision loss.
Reference: American Association for Pediatric Ophthalmology and Strabismus,

19. Amblyopia
This is what the zebra would look like through the eyes of a child with Amblyopia
Over time the eye that “sees” the blurry image will be completely ignored by the brain

20. Importance of Screening for Amblyopia
Eyes often look perfectly normal
Amblyopia can cause permanent loss of vision early in life which affects quality of life, and may limit career choice (e.g. pilot)
Amblyopia must be detected early in life for most effective treatment – the effectiveness of treatment drops dramatically after age 10
The eyes may look perfectly normal in children with Amblyopia, but early detection can prevent permanent vision loss.
When physical indications of amblyopia are absent or inconclusive, vision acuity screening is helpful in finding children at risk for amblyopia – since the brain tends to favor one eye, the muscles become stronger in that eye and the vision acuity of one eye will be significantly better than the other eye.
Treatment, which typically includes vision therapy, is most effective the earlier it is begun – after age 10, the visual pathway to the brain has almost completely developed – the brain has learned to ignore the vision signals from one eye for so long that it becomes very difficult to reverse the ill effects at this point

21. Causes of Amblyopia
Anisometropia – the eyes have unequal refractive powers
Stimulus Deprivation – anything that clouds the lens or blocks light from entering the eye
Strabismus – the eyes are misaligned
There are three main causes of Amblyopia:
Anisometropia – the eyes will almost always look perfectly normal, but because the brain has learned to other accept signals from one eye, that eye becomes much stronger than the other eye and a large refractive difference can be detected during vision acuity screening (this is why it is important to refer a child who has a two-line difference in refractive powers between the two eyes – this will be discussed in more detail later)
Stimulus Deprivation – this can be from cataracts or other conditions that cloud the lens – it can even be caused by objects outside of the eye that systematically block light from entering the eye (e.g. long bangs)
Strabismus – the eyes are misaligned and may send two different images to the brain, causing double vision – the brain learns to ignore the image from the strabismic eye and that eye becomes weaker and weaker with time
Reference: American Association for Pediatric Ophthalmology and Strabismus,

22. Strabismus
Strabismus is any misalignment of the eyes – in children, this can be very obvious or very subtle

23. Strabismus Normal Vision Strabismus
With normal vision, each eye sees an object from a different angle and both eyes send clear pictures to the brain. The brain fuses these pictures into one 3-D image. With strabismus, one eye is misaligned and thus sends a blurry picture to the brain. The brain has difficulty fuses the clear picture and blurry picture and learns to ignore the blurry picture. The non-strabismic eye tends to become much stronger and amblyopia occurs in the strabismic eye (leading to vision loss in the strabismic eye).
Reference: American Association for Pediatric Ophthalmology and Strabismus,

24. Types of Strabismus Hypotropia – eye turns down
Hypertropia – eye turns up
Exotropia – eye turns out
Esotropia – eye turns in
*Up to 5% of children have some type of Strabismus*
There are four types of strabismus – they are characterized by the direction in which the misaligned eye turns.
As you can see in this figure, hypotropia is when the eye turns down, hypertropia is when the eye turns up, exotropia is when the eye turns out and esotropia is when the eye turns in.
Treatment for Strabismus can include eye glasses, eye exercises and/or eye muscle surgery. Problems associated with Strabismus (including Amblyopia, Ptosis and Cataract) are usually treated prior to eye muscle surgery.

25. Other Vision Conditions
Conjunctivitis (pink eye)
Nystagmus (dancing eyes)
Aniridia (absence of part or most of iris)
Coloboma (keyhole pupil)
Trichiasis (eyelids and lashes that turn in)
These other vision conditions are less common, but could cause problems with the eye that make vision screening difficult, so be on the lookout for any kind of visible irritation or abnormality of the eye

26. Elements of vision screening

27. Clinical Observation Provided by the Medical Practitioner
The medical practitioner provides these elements of vision screening starting at the child’s first well- child visit:
Patient/family history
Inspection of the external eye
Ophthalmoscopic visualization of the lens (red reflex) and Fundoscopic examination
Pupillary reaction to light and accommodation
Cover-uncover test
Hirschberg’s test (corneal light reflex)
The medical practitioner performs these examinations in order to detect other vision conditions starting at the child’s first well-child check-up
These examination are performed periodically throughout childhood.

28. Vision Screening Provided by Other Medical Staff
Other medical staff provide vision acuity screening starting when the child is 3 years of age
The child should be screened at EVERY well-child visit using a standardized eye chart
Starting at age 3, other medical staff perform vision acuity testing or vision screening at every well-child check-up
The Preferred Practice Patterns for Pediatric Eye Evaluations, released by the American Academy of Ophthalmology, states that, “Vision screening should be performed periodically throughout childhood. The combined sensitivity of a series of screening encounters is much higher than that of a single screening test, particularly if different methods are used. In addition, eye problems can present at different stages throughout childhood.”
Additionally, parents or caregivers may be unaware of the consequences of delayed care – some vision conditions, such as Amblyopia, do not always present with signs or symptoms that are apparent to parents or caregivers – this is why consistent vision screening at well-child check-ups is so important
During this section of the training, we will discuss the proper tools, set-up and procedures for screening as well as some tips for promoting cooperation during vision screening.
Reference: American Academy of Ophthalmology. Pediatric Eye Evaluations. Preferred Practice Guidelines AAO

29. Eye Charts – Ages 3-5 years
HOTV Chart
LEA Symbols Chart
These eye charts are designed for preschool age, preliterate children.
Both charts can be used with pre-school age children (ages 3-5 years). Some studies have shown that the LEA symbols chart works better with 3-year old children compared to the HOTV chart, but no difference was seen among 4-5 year olds.
Both of these charts meet guidelines for standardized charts by the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) – including the spacing of the symbols, spacing between lines, legibility of all symbols and 20-foot equivalent measurements on the right side of the chart
Be aware that not all companies that produce HOTV and LEA Symbols charts follow the protocols to keep the chart standardized. If you are unsure about the charts you are using, feel free to contact Prevent Blindness Northern California at
Reference: Hered RW, Murphy S, Clancy M. Comparison of the HOTV and Lea Symbols charts for preschool vision screening. J Pediatr Ophthalmol Strabismus Jan-Feb;34(1):24-8.)

30. Eye Charts – Ages 6 years & Older
Sloan Letters Chart
For children ages 6 years and older, the Sloan Letters Chart is recommended since it meets national and international eye chart design guidelines that ensure the chart is standardized (it is accepted worldwide as today’s Gold Standard for accurate visual acuity testing).
The Snellen chart is not recommended since it does not meet these guidelines for standardization.
Although the American Association for Pediatric Ophthalmology and Strabismus does not recommend the Snellen chart, they do comment that the Snellen chart is still better than no vision testing.
References: Nottingham, P.K. and Bradford, G.E., (2011, July). A historical review of distance vision screening eye charts: what to toss, what to keep, and what to replace. NASN School Nurse.
AAPOS Training PowerPoint slides, 2013

31. Properly Using the Eye Chart
At the top of the chart, it specifies at which distance the chart should be used – either 10 feet or 20 feet
This is the referral line – if this is the smallest line where the child can identify the majority of symbols, they should be referred to an eye specialist
Now that you have the correct, standardized charts, it’s important to know how to properly use them. Some charts are intended for testing at 20 feet and some at 10 feet. Make sure you look at the top of the chart to know which measurement should be used.
About 2/3 the way down the chart, you will find the Referral Line – this may or may not be marked on the chart. The referral line lets you know at which point you should refer a child. If this line is the smallest line where the child can identify the majority of symbols, they should be referred to an eye specialist (we will touch on other reasons to refer a child later on)
The referral line is different for younger children and older children. Be familiar with these numbers as they are used frequently when setting up and conducting the vision screening.
Referral Line
Ages 3-5 years: 20/50
Ages 6 years and older: 20/40

32. Properly Using the Eye Chart
Let’s look at one of the standardized charts to identify the key elements of the chart and make sure we can use it properly.
At the top, we see the name of the chart and the distance that should be used – 10 feet
Since, the Sloan chart is mainly used with children ages 6 years and older, we will utilized the 20/40 referral line – you can see it about 2/3 the way down the chart
Also note that for 10-foot charts, the 20-foot equivalent measurements are marked on the right hand side
On 10-foot charts, the 20-foot equivalent measurements are written on the right side

33. Occluder DO NOT use the child’s hand to cover the eye
Use non-disposable occluder and properly clean with alcohol after each use OR
Use disposable occluder, such as Dixie cup, tongue blades with back-to-back stickers, etc. and discard after each use
Occlusion is a very important element of vision screening. If the child’s eye is not properly occluded, they can peak during the test and end up passing the test even when a vision condition exists
First off, never let the child use their hand to occlude the eye
Make sure to clean non-disposable occluders (such as paddles) after each use or use disposable occluders (such as a Dixie cup) since bacteria from one child’s eye can be easily spread to another child during vision screening

34. Occluder
For preschool children, occluder glasses, such as those below, work very well
Children who wear glasses should also be screened – they can be occluded with a non- disposable occluder or a post-it note attached to the glasses
Occlusion is especially difficult with preschool children – occluder glasses are highly recommended for this age group as they work better than other methods and the fun designs enhance the experience for the child, thus promoting cooperation during screening
Children who already wear eye glasses should still be screened – they should wear their eye glasses during the screening and can be occluded with a disposable (i.e. post-it note) or non-disposable (i.e. paddle) occluder

35. Screening Set-up
Screen in a quiet, well-lit area, free from traffic and distractions
The eye chart should be positioned so the referral line is at the eye level of the child
For preschool-age children, this is about 40 inches from the floor to the referral line
Ages 3-5 years, referral line is 20/50
Ages 6 years and older, referral line is 20/40
As much as possible, screen in an area of the office or clinic that is quiet, well-lit and free from traffic or other distractions. This is especially important for preschool age children who have difficulty paying attention during the screening as is.
Make sure the eye chart is positioned on the wall at proper height. The referral line should be at the eye level of the child – as a general rule, for preschool age children this will be about 40 inches from the ground to the referral line.

36. Screening Set-up
The “heel line” should be marked on the floor – either 10 feet or 20 feet from the chart
Refer to the specific chart to know which distance to use
The “heel” line – where the child will stand for the screening – should be marked on the floor.
Remember to make sure you are screening at the proper distance – if the chart says 20 feet, screen at 20 feet; if the chart says 10 feet, screen at 10 feet
If you only have enough room in the office or clinic to screen at 10 feet, make sure you have the proper charts to do so – NEVER screen at 10 feet using a 20 foot chart!

37. Observing the Child Before, During and After Screening
Appearance of the eye
Examples: red or watery eyes; swelling around eyelids; slow or unequal pupils
Behavior of the child
Examples: Rubs eyes frequently, shuts or covers one eye, squints eyes to see better, blinks excessively; the child may also thrust their head forward when trying to focus or move closer to objects to see
Complaints from the child
Examples: Headaches or pain
The examples listed below are just samples. This not an exhaustive list. When observing, you are looking and listening for anything that is a potential concern. Document any concerns so the provider can investigate further during the exam.

38. Useful Tips for Promoting Cooperation During Screening
Smile often. Be enthusiastic. Stay positive.
You are part of the environment. Make it fun and the child will be more cooperative.
Give only one direction at a time.
Give verbal praise after each answer.
Promise a sticker at the end of the matching game. Encourage the child throughout the game.
If able, screen the other eye of the child.
The first step in creating a welcoming, child-friendly environment is greeting each child and family with a warm, positive, and enthusiastic attitude. You have great influence over the child’s comfort and engagement. If you promote the screening as a “game” that you want to play with them, the child is more likely to participate appropriately.
Children can often pay attention and complete tasks correctly when only one direction is given at a time. Be mindful that you are not combining steps or directions. This can confuse a child.
Verbal praise is an effective tool in maintaining attention and engagement. Providing praise immediately after every response keeps the child motivated and bolsters his/her self-esteem.
Stickers are only a suggestion, not a requirement. Follow your office policy on incentives for patients. If you give stickers, put a sticker on either side of a tongue depressor and give to the child. Even without a sticker or physical incentive, it is important that you encourage and praise the child throughout the game. Consistent, enthusiastic praise can be a very effective motivator for a child.
If the child demonstrates resistance to being screened in one eye, try starting with the other eye. With ongoing praise while screening the second eye, the child may become more comfortable with the game and allow you to then screen the first eye.

39. Other Tips for Promoting Cooperation During Screening – Matching Game
Use the practice flash cards to condition the child to the LEA shapes
Lets the child get familiar with the game
Lets the screener learn what the child calls each shape
Ask the child to call out the shape that matches the shape on your chart.
Practicing with the flash cards decreases the chances of the child being uncooperative.

40. Matching Game If child is resistant to talk:
Option #1: Ask the child to point to the card that matches the shape on your eye chart.
Option #2: Place the individual flash cards on the floor in front of the child and ask the child to step on the shape that matches the shape on your eye chart.

41. Screening Procedure Select the eye chart based on the child’s age
For ages 3-5, use the HOTV or LEA Symbols chart
For age 6 and older, use the Sloan Letters chart
The child should stand with their heels on the “heel line”
If a child has an ability level below their age (ex. six year old with the abilities of 3-4 year old), you can use the HOTV or LEA Symbols chart.
Conversely, if a child is age 3-5 but can read, you can use the Sloan Letter chart.

42. Screening Procedure
Screen the right eye first by placing the occluder over the left eye
The child SHOULD NOT hold the occluder – a teacher, aide or a member of the medical staff should hold the occluder over the child’s eye
It is highly recommended that you use occluder glasses, especially with young children
Start one line above the referral line
Ages 3-5 years, start at the 20/60 or 20/63 line
Ages 6 years and older, start at the 20/50 line

43. Screening Procedure
To pass a line, the child must correctly identify one more than half of the figures on that line (3 out of 5 figures on most charts)
If the child fails on any critical line, repeat the line in reverse order
Continue to the smallest line of figures the child can pass and record the number on the PM and the child’s medical record
If the first three figures are identified correctly, move to the next line

44. Documentation and referral
In this section, we will go over the guidelines for referrals and proper vision screening documentation on the PM 160.

45. What does 20/20 mean?
The person can see from 20 feet what a person with normal vision can see from 20 feet
20/40 vision means the person can see from 20 feet what a person with normal vision would see from 40 feet

46. Documentation on the PM 160
Record the smallest line of figures the child can pass (refer to Screening Procedure), for example:
OD 20/20 (right eye)
OS 20/20 (left eye)
OU 20/20 (both eyes)
If the child does not pass, record the failed screening on the PM 160 and the child’s medical record
If child does not pass, the results will go in the “Comments/Problems” section of the PM160. No diagnosis is needed, only the results and “passed” or “failed” vision screen.

47. Failed Screening
Visual acuity of 20/50 or worse in either eye for children age 3 through 5 years
Visual acuity of 20/40 or worse in either eye for children age 6 years and older
A two line difference or more in visual acuity between the eyes (e.g. 20/25 in one eye and 20/40 in the other eye)
Even if both eyes “pass” the screening, a two line difference or more between the eyes means they failed the screening, and should be referred to an eye specialist
The two-line difference in visual acuity between the eyes is one of the ways we screen for Amblyopia.

48. PM 160: Failed Vision Screening
Please include appointment or referral information in the “Comments/Problems” section. If parent chooses to make their own referral or appointment, please note that on PM160 as well.

49. Reasons to Refer History or clinical observation Any abnormalities
All children who are not testable because of special medical problems
“High Risk” children
History or clinical observation:
This would include head tilting, squinting, nystagmus (repetitive, uncontrolled movements of the eye), injury to or around the eye, or other clinical findings consistent with possible vision problem.
Any abnormalities:
Some examples of abnormalities include: Abnormal alignment of the eyes, cataracts, eye muscle imbalances
Special medical conditions:
Children who are developmentally delayed.
High Risk:
Includes prematurity, family history of congenital cataracts, retinoblastoma, metabolic or genetic diseases, significant developmental delay or neurologic difficulties, and systemic disease associated with eye abnormalities.

50. Importance of Referrals
Younger children (under the age of 7 years) with vision problems should see an eye specialist as soon as possible – certain eye conditions can cause permanent vision loss if left untreated in young children
Younger children tend to present with vision conditions that require a referral to an ophthalmologist more often than older children (e.g. Amblyopia, Strabismus, etc.)
Many eye disorders and vision problems can be treated successfully if diagnosed early.
Children who are uncooperative may actually have vision problems that are not readily apparent. Remember to re-screen them at the appropriate time, and refer to optometrist if needed.

51. PM 160: Questionable Result
A screening result may be questionable, for example, with a child who has watery-itchy eyes and cannot see clearly. If the child was able to complete the screening, but the you are concerned about the validity of the results, a recheck can be scheduled for the child – this is indicated in the Comments/Problems sectioned of the PM 160
NOTE: if the screening was complete, but you are scheduling a recheck, you can still bill for the original screening
Reference: October 25, 2011 CHDP Provider Information Notice No.: 11-11, CHDP Health Assessment Guidelines (HAG) Revision: Section 61, Vision Screening

52. PM 160: Incomplete Screening
If the child is unable to complete the screening, a second attempt should be made 4 to 6 months later.
For children 4 years and older, the second attempt should be made in 1 month.
If child fails the recheck, refer appropriately to an ophthalmologist or optometrist.
NOTE: if the child does not complete the screening, you cannot bill for the screening
Reference: October 25, 2011 CHDP Provider Information Notice No.: 11-11, CHDP Health Assessment Guidelines (HAG) Revision: Section 61, Vision Screening

53. Incomplete Screening
If a child who is 3 years of age is unable to complete the screening, a second attempt should be made 4 to 6 months later
If a child who is 4 years or older is unable to complete the screening, a second attempt should be made in 1 month
Shyness, inattention or poor cooperation may be related to a vision problem

54. Pm 160: Vision Recheck
When performing a vision recheck, only the sections related to the recheck need to be completed. Refer to CHDP Provider Manual – Recheck of Screening Procedure.
For information on completing the PM160 step by step for the recheck.
When child returns for re-check and fails, refer appropriately to an ophthalmologist or optometrist.
Reference: CHDP Provider Manual – Confidential Screening/Billing Report (PM 160) Claim Form: Completion Instructions conf clm comp 24 CHDP June 2003

55. PM 160: Vision Recheck
Make sure to write in the date of the original examination and check the “Screening Procedure Recheck” box

56. Referrals Refer to appropriate specialty provider who accepts Medi-Cal
For children with Temporary Full-scope Medi-Cal (through CHDP Gateway) – stress the importance of seeing the specialty provider prior to expiration of temporary Medi-Cal
Check with your local CHDP program for available resources, for children without Full Scope Medi-Cal.
Copy 4 (pink) of PM 160 must be given to the parent/legal guardian or patient at the time of the examination with a complete explanation of the results of the assessment.
Reference: CHDP Provider Manual – Confidential Screening/Billing Report (PM 160) Claim Form - conf clm 3 CHDP 20 April 2006

57. Follow-up
It is the responsibility of the referring clinic or provider to:
Maintain a referral log to track the status of the referral
Follow-up with the parent/guardian as needed

58. Thank You!
Please complete the post-test and evaluation. Thank you!