II. Health Supervision

Screening Services and Assessments: Vision Screening

Vision screening is a mandatory EPSDT service to be provided at each HealthCheck preventive visit. Screening is critical for early detection and treatment of potentially blinding diseases and visual impairments.

Between 2% and 5% of young children develop strabismus (crossed eyes), a primary cause of amblyopia ("lazy eye"). If undetected and untreated, amblyopia can lead to irreversible visual impairment. Nationwide, by 16 years of age, 20% of all children have refractive errors, which typically require corrective treatment with eyeglasses.¹

Periodicity and Guidelines for Vision Screening

Vision screening includes both subjective methods (health history, risk assessment, physical exam), and objective vision tests.

HealthCheck requires vision screening as follows:

• Subjective screening at each preventive health visit from birth to 21 years
• Objective screening with approved test methods at key developmental ages:

Childhood:

• Screen at 3, 5, 6, 8, and 10 years

Adolescence:

• Screen at 12, 15, and 18 years

Comprehensive Vision Screening

Comprehensive vision screening includes these components:

• Health history and risk assessment (see screening questions below)
  • Family history of vision or eye problems
  • Neonatal conditions (premature birth or low birthweight)
  • Maternal conditions (history of HIV or other STDs, substance abuse, rubella during pregnancy)
  • Parental concerns about child’s visual function or eye problems
  • School performance (worsening grades, reading and/or learning difficulties)
• Physical exam
  • Examination of child's eyes (lids, orbit, conjunctiva, sclera, cornea, iris) and ability to see
  • Assessment of ocular alignment and clarity
    • Red reflex test
    • Corneal light reflex test
    • Cover/uncover test
    • Fixation (fix-and-follow test)
• Objective tests that are age-appropriate (see Screening Methods below)
• Early detection and prompt referral to a vision specialist for corrective treatment, including eyeglasses
• Documentation in the medical record of specific screening method(s) used, test results, and referral (if indicated)

Screening questions²:

• Do you think your child sees all right?
• Does your child hold objects close to his or her face when trying to focus?
• Do your child's eyes appear straight or do they seem to cross or drift or seem “lazy”?
• Do your child's eyelids droop or does one eyelid tend to close?
• Have your child's eyes ever been injured?

Screening Methods

Children younger than 3 years

Vision screening is part of the physical exam and should include these tests:

Red Reflex. Perform test in a darkened room with an ophthalmoscope or other light source. Hold the light source at arm’s length from the child, drawing the child’s attention to look directly at the light. Both retinal reflexes should be red to red-orange and of equal intensity. Corneal Light Reflex. Use an ophthalmoscope or other light source. Corneal light reflections should fall symmetrically on corresponding points of the child’s eyes. Improper alignment appears as asymmetric reflections. (Test helps detect strabismus.) Cover/uncover. Have the child look straight ahead at a fixed object. Gently cover one of the child's eyes, one at a time, while observing any movement in the other (uncovered) eye. Such movement is abnormal and may indicate strabismus. (Aversion to the occlusion is normal. This test generally gives false-positive results and is less accurate than corneal light reflex test for detecting strabismus.) Also look for movement in the covered eye as you uncover it. Such movement is abnormal and may indicate heterophoria. Fixation (fix and follow). Hold a light, toy, or small object in front of the child's eyes. Have the child fix on the object, then follow it as you move it into various positions. Test both eyes, then test each eye separately. Normally, the child’s eyes will be aligned in the same direction, without deviation. If the test indicates poor ability to fix and follow an object, refer the child to a vision specialist.

Children ages 3 years and older: Screening for visual acuity

Continue to screen for ocular alignment at each visit with these tests:
red reflex, corneal light reflex, cover/uncover, and fixation

Beginning at age 3, test for visual acuity* using the most difficult test the child can perform. If the child is uncooperative, rescreen within 6 months. Testing for distance visual acuity is an essential part of objective screening.

Screen children ages 3–5, with one or more of these methods:

• Tumbling E
• HOTV
• Allen Figures
• LH (Leah Hyvarinen) Symbols

Screen children ages 6 and older with one of the following:

• Snellen Letters
• Snellen Numbers

*Testing distance of 10 feet is recommended for all visual acuity tests. Assign a passing score for any line on which the child gives more than 50 percent correct responses.

Color Perception
Screen children 6 years and older for color perception at least once, using polychromatic plates.

Note: In addition to the vision history and physical exam, results of school vision testing may be used. Contact the school nurse for this information.

Early Detection and Prompt Referral

Children with an ocular abnormality or those who fail vision screening should be referred promptly to a vision care specialist.

If the child wears eyeglasses, assess the need to refer for optometric re-evaluation, based on vision screening results and the date of the last optometric evaluation.

¹ U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion. 1998. Clinician's Handbook of Preventive Services (2nd ed.). Washington, DC: Government Printing Office.

² Vision screening questions drawn primarily from the American Academy of Pediatrics. Eye Examination in Infants, Children, and Young Adults by Pediatricians [policy statement]. Pediatrics 111(4):902–907. Also available online at http://www.aap.org/policy/s0208.html.