Vision for the Massachusetts School Nurse

Transcription

1 Vision for the Massachusetts School Nurse Review: anatomy of the eye, visual acuity and common vision disturbances Overview of vision tools used in schools and hands on practice Best practices for documentation of screenings and referral process 2 M.G.L : Testing of Vision and Hearing (A) The school committee or board of health shall cause the vision and hearing of each child in the public schools to be tested annually. (B) The hearing of each child shall be tested by means of some form of discrete frequency hearing test such as the Massachusetts Hearing Test. (C) The vision of each child shall be tested by means of the Massachusetts Vision Test or other similar method approved by the Massachusetts setts Department of Public Health. (D) Tests of sight and hearing shall be performed by teachers, physicians, optometrists, nurses or others who are approved by the Massachusetts Department of Public Health for this purpose and in accordance with instructions set up by the Department. (Such personnel may request necessary training from the Massachusetts Department of Public Health. The Department s instructions regarding vision and hearing testing may be procured from the Division of Family Health Services, 39 Boylston Street, Boston.) 50 years and going strong! Massachusetts Preschool Vision Screening: Legislative Mandate, MGL c71 s57, signed July 15, 2004 An addition to the existing mandate! Upon entering kindergarten or within 30 days of the start of the school year, the parent or guardian of each child shall present to school health personnel certification that the child within the previous 12 months has passed a vision screening conducted by personnel approved by the department of public health and trained in vision screening techniques to be developed by the department of public health in consultation with the department of education

2 The School committee or board of health shall cause the vision and hearing of each student in the public schools to be screened: in the year of school entry annually through grade 5 (or by age 11 in ungraded classrooms) once in grades 6 through 8 (or ages 12 through age 14 in ungraded classrooms once in grades 9-12 (ages 15 through 18 in the case of ungraded classrooms) Definition: Visual acuity (VA) is acuteness or clearness of vision, especially form vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain. Source: Cline D; Hofstetter HW; Griffin JR. Dictionary of Visual Science. 4th ed. Butterworth-Heinemann, Boston ISBN Definition: imperfections in the focusing power of the eye, so that light rays are not brought into sharp focus on the retina, causing blurred vision that can usually be corrected with glasses or contact lenses. Types of refractive errors: Nearsightedness (myopia Farsightedness (hyperopia) Astigmatism Source: 8 2

3 For a farsighted person the focus of the eye is behind the retina. People who are farsighted can have trouble seeing at distance and near. Source: John A. Moran Eye Center 50 North Medical Drive Salt Lake City UT Source: John A. Moran Eye Center 50 North Medical Drive Salt Lake City UT Telephone Fax Telephone Fax In a nearsighted person the cornea is too steep or the eye is too long and the focal point is in front of the retina resulting in blurred distance vision. Source: John A. Moran Eye Center 50 North Medical Drive Salt Lake City UT Astigmatism occurs when the cornea is not completely round but shaped more like a football. Light that enters the eye focuses on more than one spot on the retina resulting in blurring of vision. Astigmatism can occur with nearsightedness or farsightedness. Source: John A. Moran Eye Center 50 North Medical Drive Salt Lake City UT Telephone Fax Telephone Fax

4 At 20 feet, the person with 20/20 vision sees the stop sign clearly. At 20 feet, the person with 20/40 vision sees the stop sign as if they were 40 feet away. Source: Cline D; Hofstetter HW; Griffin JR. Dictionary of Visual Science. 4th ed. Butterworth-Heinemann, Boston ISBN The newborn s visual acuity is approximately 20/400, developing to 20/20 by two years. Some birds, such as hawks, are believed to have an acuity of around 20/2 In the United States, 20/200 is the cutoff for legal blindness Poor vision in an eye that is otherwise normal and healthy Developmental disturbance, from birth to 8 or 9 years of age Can be treated only during these early years of life; otherwise, there is irreversible visual loss!! 6 million Americans have amblyopia (2-5% of the population). Amblyopia is responsible for visual loss in more people younger than 45 years than all other ocular diseases and trauma combined. Screening is a cost effective way to identify children with amblyopia. Screening in Sweden resulted in the complete elimination of severe amblyopia, and a 50% decrease in the prevalence of amblyopia in the population

5 Distance to see the AV s in each educational setting clearly Near reading Stereopsis To identify amblyopia at a young age, preventing functional blindness in one eye External Examination Far Vision Near Vision i Stereo Testing/Ocular Alignment Color Your Eyes What do you see???

6 Issue may be detected by the teacher, parent or nurse during an office visit or vision i screening, or the primary care physician Abnormal head position Strabismus (misaligned eyes) Ptosis (droopy eyelid) Redness Discharge Squinting Tearing Photophobia Nystagmus (eyes jiggle) Child rubbing eyes Don t forget to have the child wear his/her glasses! Linear Symbols HOTV symbols, Snellen Letters or Tumbling E s are lined up in a row, not individual letters on a line OTVHT T Far/Distance Screening Test Parameter Far vision screening at 20/30 (20/32) for age 48 months thru grade 12 (20/40 for months). Monocular one eye screened at a time

7 Eye Occluder For distance-monocular vision screening with wall chart or Mass VAT cards Tape Measure Mark 10 feet for wall chart and Mass VAT Mark 4 feet for Random Dot E Good lighting! When using Mass VAT type flip cards or a wall chart, must have mechanism to cover one eye at a time Vision Testers have built in eye occluder Reality kids will try to peak Solicit help for younger children an aide, parent volunteer, etc. to hold occluder New Mass VAT Distance Vision Screening Tool Vision Tester Machine Wall Chart Mass VAT type Flip cards VAT = Visual Acuity Testing

8 Child does not need to know his letters place sample card in front of child Play matching game with letters or symbols Do not have your finger cross the black border line of the linear letters/symbols-this causes a visual disturbance Practice close up with both eyes open Game too easy! Tell them you will make it harder by covering one eye and moving further away 29 Used for Far Vision Screening of preschool and kindergarten children, primarily Measure 10 feet from child to screening cards Place matching card in front of child Explain what you will be doing and practice with child at closer distance Cover left eye Child must identify 4 out of 5 symbols At 20/40 < 48 months At 20/30 > 48 months Repeat with right eye covered 30 Used for Far Vision Screening Procedure essentially the same as the Mass VAT Cards! Mark 20/30 line for quick identification! Developed in 1862 by Dutch Opthomologist, Herman Snellen Symbols (letters) are called optotypes Black block capitalized letters intended to be seen and read as letters Letters are placed linearly Ten Letters used: C, D, E, F, L, N, O, P, T, Z

9 Wall Chart Many Varieties HOTV Lea Tumbling E s Line (Snellen) Letters Description: An integrated eye care worker (IECW) in rural Ethiopia practices visual acuity assessments using a tumbling E eye chart. In the STAR Study, each patient s vision was evaluated prior to trichiasis surgery. conditions=trichiasis

10 Several vendors: Optec, Titmus, others Slides must have linear symbols May include HOTV, Snellen Letters, Tumbling E s, etc. Newer Testers can be used for near and far screening Built in eye occlusion for far vision screening Appropriate lighting Adjustable height Variety of Slide options In Massachusetts, kindergarteners and preschools are not to be screener on vision tester! Linear Symbols HOTV symbols, Snellen Letters or Tumbling E s are lined up in a row, not individual letters on a line Near Near vision screening at 20/30 (20/32) grade 1 thru 12 Binocular Read with both eyes!

11 Vendors offer a variety of types Some Near Cards have linear letters at graduated variety of distances like a far wall chart, 20/200, 20/100, 20/80, etc. If using a card with multiple rows, mark testing row at edges with possibly a red dot so child can zero in on the row you want him to read 20/30 Maintain designated testing distance (usually 16 ) On this card, you could use the HOTV or Snellen Letters Top row is for practice Middle row is near 20/30 distance for screening Bottom HOTV for matching with younger children String is appropriate length and should be held at temple Near screening binocular- both eyes! Near vision screening slides in most newer vision testers Appropriate lighting Adjustable height Variety of Slide options Student looks down, like reading a book, rather than straight ahead

12 Tools: Random Dot E a.k.a. the Magic Glasses Game! Random Dot E Kit Front Back Primarily used for Pre- Kindergarten/Kinderg arten/grade 1-3 Vision Screening Measure 4 foot distance Show child 3 dimensional E and practice having child identify the card with the picture (sample card) Move to appropriate 4 foot distance Shuffle tests cards behind back and present to child Child must identify 4 out of 5 cards with the picture Tell the child that sometimes, while wearing the magic glasses, he may see a picture appear on the card. Child does not need to know his letters or that the image is an E With the magic glasses on, practice using the sample card and blank, then substitute the card with image Suggest you will make game harder by moving further away

13 Tell the child that sometimes, while wearing the magic glasses, he may see a picture appear on the card. Child does not need to know his letters or that the image is an E With the magic glasses on, practice using the sample card and blank, then substitute the card with image Suggest you will make game harder by moving further away Cards should be held at eye level Word Raised must be at top of card back, other wise the picture will be Recessed, rather than sticking out! Slightly rotate card up and down to pick up the light Note: it takes a few seconds for the image to appear A child with misaligned eyes may pass the visual acuity test in each eye. He/she would not pass the stereo test and would be appropriately referred

14 Optional Screening program Most schools screen as needed Easy to use tools Massachusetts School Vision Screening Summary Effective Sept Screening Test Distance Monocular Linear Near Binocular Linear 20/30 Stereopsis/ Ocular Alignment 3 yr old Preschool Wall chart or 20/40 N/A 4 year old Preschool/ Kindergarten Wall chart or 20/30 N/A Grade 1-3 Machine or Wall 20/30 Near card or machine with Near slide Grade 4-12 Machine or Wall 20/30 Near card or machine with Near slide Random Dot E Random Dot E Random Dot E N/A

15 Update referral letters to reflect new guidelines Give your self credit for what you do! Educate the parent/physician in the letter

16 Massachusetts Preschool Vision Screening Project Coordinated by: Remember, the vision screening program is one of the most successful initiatives impacting kids Thank you for what you do for our kids! Jean E. Ramsey, MD Director, Pediatric Ophthalmology Boston Medical Center Assistant Professor of Ophthalmology and Pediatrics, Boston University School of Medicine Bruce Moore, OD Marcus Professor of Pediatric Studies Chair, Department of Specialty and Advanced Care, New England College of Optometry In summary, the Massachusetts Department of Public Health would like to thank the Massachusetts Legislature, the Massachusetts Medical Society, American Academy of Pediatrics, Massachusetts Chapter of the American Academy of Pediatrics, Massachusetts Chapter of Prevent Blindness, Massachusetts Society of Eye Physicians and Surgeons, the Massachusetts School Nurse Organization, New England College of Optometry, Boston University and the many other organizations and individuals, too numerous to mention, for their support of pre-school vision screening in the Commonwealth. Revised Dec