A lecture on Vision Screening given in Manila Doctors Hospital Pediatrics 8th Scientific Forum entitled School Health #Getskona July 5, 2017

1. Vision Screening for Children
#StopLookandListen
in School Health #Getskona
MDH Pediatrics 8th Scientific Forum
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

2. Disclosures
´No financial interest
´University Researcher II at the Philippine
Eye Research Institute (PERI)
´PERI Vision Screening Kit mentioned
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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3. Who does vision screening?
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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4. Objectives
´Discuss the appropriate time to do vision
screening for school-aged children
´Identify warning signs that require referral to a
specialist
´Provide suggestions to school health physicians
to improve vigilance in vision screening
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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5. July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://2.bp.blogspot.com/-
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Image%2BMan%2BQuestion%2BMark.jpg

6. Outline
´ Terminology:
´ Differentiate between vision screening and comprehensive eye
examination
´ Differentiate between vision screening and screening for visual
impairment
´ Identify target diseases of vision screening
´ Identify target diseases for screening for visual impairment
´ Background literature
´ How to do vision screening
´ Warning signs requiring referral
´ Suggestions to school health physicians
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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7. Vision Screening vs. Eye Examination
July 5, 2017
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© AP Santiago 2017 #VisionscreeningforChildren
https://brighteyevision.files.wordpress.com/2017/03/vision-
screening-pic.jpg?w=440
http://premiereyes-wi.com/wp-
content/uploads/sites/1565/2016/01/chloe-eye-exam.jpeg

8. Ophthalmologic Exam
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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´ Vision assessment
´ Pupils
´ Gross abnormalities
´ Refraction
´ Sensorimotor evaluation
´ Slit lamp evaluation
´ Posterior Pole Evaluation:
retina, optic nerve, vessels
http://premiereyes-wi.com/wp-
content/uploads/sites/1565/2016/01/chloe-eye-
exam.jpeg

9. Tools for Screening
Vision
´ Test of Visual Acuity
Visual Impairment
´ Test of Visual acuity
´ Photoscreeners
´ Penlight for pupils and gross
abnormality
´ Cover paddle to test
misalignment
´ EOM duction and version
´ Tests of binocular function (e.g.
Stereofly test)
´ Color Vision Test
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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10. Philippine Eye Research Institute
Vision Screening Kit
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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11. Other screening tests
´ MTI Photoscreeners
´ Welch Allyn Spot Screener
´ Computer autorefractors
(not reliable in most
children)
´ Color vision testing
(Ishihara)
´ Stereoacuity tests
´ Etcetera
2005
http://briotweco.ca/images/products
/ophthalmic-instruments/portable-
instruments/retinomax3/800px/retinom
ax-3-plus-portable-autorefractor-
keratometer.jpg

12. July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://slideplayer.com/slide/5285177/17/images/34/Photoscreeners.jpg
https://www.welchallyn.com/content/dam/welchallyn/images/P
roduct-Images/Physical-Exam/Eye-Exam/Vision-Screeners/Spot-
Vision-Screener/Spot-Vision-Screener_rt-front-angle.jpg

13. Other Tests
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.color-blindness.com/wp-
content/images/Ishihara-Plate-07-38.jpg
From Rosenbaum & Santiago, Clinical Strabismus
Management

14. 2005
Uniform guidelines for reporting:
Amblyogenic factors detected by Screening
´ Anisometropia (sph or cyl) >1.5D
´ Any manifest strabismus
´ Hyperopia >3.5D in any meridian
´ Myopia > 3.0D in any meridian
´ Any media opacity >1mm size
´ Astigmatism
´ >1.5D at 90, 180
- >1.0 D at oblique axis (>10deg of 90, 180)
´ Ptosis </= 1 mm MRD
´ VA per age appropriate standards
´ J AAPOS 2003
•Refractive Error
•Strabismus
•Media Opacity
•Ptosis
•Poor vision from other
reasons
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

15. Target diseases in ophthalmologic screening
´Amblyopia 1-5%
´Refractive Error up to 8%
´Strabismus 3-4%
´Media opacities < 1%
´Cataract
´Retinoblastoma
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

16. Target Diseases
Vision Screening
´ Refractive Error
´ Amblyopia
Screening for Visual Impairment
´ Refractive Error
´ Amblyopia
´ Strabismus
´ Media opacities
´ Cataract and retinoblastoma
´ Other causes of visual impairment
´ Anterior Segment Pathology
´ Glaucoma
´ Ptosis
´ Retina problems
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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17. Vision 2020: The Right to Sight
World Health Organization (WHO) & International Agency for the Prevention of Blindness (IAPB)
´Launched 1999
´Aims:
´Eliminate avoidable blindness by 2020
´Prevent projected doubling of avoidable visual
impairment from 1990-2020
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/Vision2020_report.pdf

18. VISION 2020:
The Right to Sight
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/V
ision2020_report.pdf

19. VISION 2020: The Right to Sight
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/Vision2020_report.pdf
´ Participation of local eye health care experts and planners in Vision
2020
´ Vision 2020 Committees
´ Assess local needs
´ Develop national action plan
´ Facilitate implementation
´ Monitoring and assessment
´ Society made aware of known, well-tested, cost-effective
intervention
´ Prevent avoidable visual loss

20. VISION 2020: The Right to Sight
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/Vision2020_report.pdf
´ 1.4M children blind
´ 1M in Asia
´ Prevalence in 0-15 years: 0.3-1.5/1000
´ Number of blind children low, but a lifetime ahead
´ 75 million blind years (number blind x length of life)
´ 600-6000/10M population
´ 40% preventable or treatable

21. VISION 2020: The Right to Sight
Causes of Avoidable Childhood Blindness
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/Vision2020_report.pdf
´ Corneal Scarring
´ Cataract
´ Glaucoma
´ Retinopathy of Prematurity
´ Refractive errors
´ Low Vision from untreatable causes

22. VISION 2020: The Right to Sight
Strategy to Prevent Avoidable Childhood Blindness
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.who.int/blindness/Vision2020_report.pdf
´ Promote school eye-health programs
´ For diagnosis and management of common conditions (e.g., refractive error)
´ Promote a healthy environment
´ Educate children in looking after their eyes as part of curriculum
´ In areas where >2% of 11-15 have EOR,
´ ensure that children undergo a simple vision screening examination
´ Ideally as part of school health program
´ Provision of spectacles

23. Timing of vision screening
´0-6 months
´Preschool age (before 3 years)
´Before school entry (4-6 years)
´Annual eye exam
´Others: vaccination campaigns
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

24. Screening for
visual
impairment
Philippine Guidelines on Periodic
Health Examination (PHEX) 2004
Effective Screening for Diseases
among Apparently Healthy Filipinos
´ Vision screening for amblyopia and
strabismus is recommended for all
children at least once before
entering school using Snellen chart
and/or stereoacuity testing (level 2).
´ Screening infants at 6 months of age
for ocular problems, and at age 2-3
years, at 5 years, and every 1-2 years
thereafter for visual acuity and ocular
alignment may or may not be done
(level 4)
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

25. Snellen Chart
https://clinicalposters.com/anatomy/
options/303.jpg
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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26. Screening for
visual
impairment
2014 Updated
Recommendations for
Vision Screening:
Guidelines for Filipino
Children Entering the
Philippine Public School
System
http://paojournal.com/vol
39no2/downloads/0042.p
df
´ Vision screening for amblyopia and
strabismus is recommended for all
children at least once using an age
appropriate chart (level 2).
´ Screening infants at 6 months of age
for ocular problems, and at age 2-3
years, at 5 years, and every 1-2 years
thereafter for visual acuity and ocular
alignment may or may not be done
(level 4)
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

27. Age-appropriate Chart
Lea symbols
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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HOTV Chart
Lea numbers
Sloan Letters
C D H K N O R S V Z
https://www.good-
lite.com/cw3/assets/product_full/7
00530_lg.png
http://www.schoolnursesupplyinc.com/assets/imag
es/66062.jpg

28. Legislation: School Entry
´ One year of preschool education
´ Children enter the public school
system at age 5 years
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://www.officialgazette.gov.ph/2012/01/20/republic-
act-no-10157/

29. Legislation: Vision Screening
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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https://www.senate.gov.ph/lis/bill_res.aspx?con
gress=16&q=SBN-2948
http://www.congress.gov.ph/legisdocs/basic
_16/HB06459.pdf
17th Congress:
HB 2822: Suansing
HB 1387: Vargas
HB 3222: Cayetano
http://news.mb.com.ph/2016/12/10/house-panel-
okays-eye-screening-program-for-preschoolers-
nationwide/

30. July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://slideplayer.com/slide/5285177/17/images/19/T
hreshold+and+Critical+Line+Options.jpg

31. How to screen
& Warning Sign
´ Cannot read 20/40 line
´ Or Age 3:
´cannot read 20/40
´Above red line
´ 4 or older
´Cannot read 20/30
´Below the red line
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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FromPERIVisionScreeningkit

32. Screening for visual impairment for Non-EYEMD
EOM
VISION
PUPIL
GROSS
EXAM
RED
REFLEX
Child may/not complain!
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

33. Role of Providers in Vision Screening
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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34. Bruckner Test (Red Orange Reflex)
Simulates Photoscreener
From Rosenbaum & Santiago, Clinical Strabismus
Management
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

35. Bruckner Test (red orange reflex)
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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36. Gross Examination/External Inspection
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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37. Pupillary Examination
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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38. Hirschberg’s Corneal Light Reflex
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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39. Pseudostrabismus
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

40. Hirschberg’s
Corneal Reflex
From Rosenbaum & Santiago, Clinical
Strabismus Management
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren

41. Tracking (Fixation and Following)
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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42. Suggestions to School Health Physicians
´Regular vision screening
does not have to be
complicated
´Consider critical line vision
screening: Pass or Fail
´Do annually
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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http://cliparting.com/free-doctor-clip-
art-31294/

43. Role of Providers in Vision Screening
PAO Sight Preservation Committee 2013 by M Rondaris
July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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44. July 5, 2017© AP Santiago 2017 #VisionscreeningforChildren
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Seeing the world through
the eyes of a child,
Is the purest joy that
anyone can experience.
-Constance Zimmer
https://expertbeacon.com/sites/default/files/
how_early_and_often_children_should_have_
a_comprehensive_eye_exam.jpg