DR. MARLA MOON: This module will be on the Pennsylvania school vision screening guidelines that were adopted by the Pennsylvania Department of Health. Hi, my name is Dr. Marla Moon, I'm an optometrist
from State College, Pennsylvania. I'm a pediatric and low-vision rehabilitation specialist. I've been in practice there for over 25 years. The majority of the patients that I see are pediatric
patients, patients that have special needs, or patients that are in need of low-vision rehabilitation. And my contact information is, State College, Pennsylvania, that's my phone number. The best way
to get a hold of me if you have any questions with regard to this module is via email, at drmoon@nittanyeye.com. And I usually respond back to your emails within a 48-hour period of time. What we want
to do is break down different parts of the manual that is in place. That is the program that the school nurses in the state of Pennsylvania are performing. And the manual, actual manual itself, is
available at this website, at the Department of Health's Vision Guideline. So that's the website for your reference, that you can actually print out, the manual's about 78 pages. The Department of
Health moved from a guideline to an actual program with the adoption of this new manual. And the purpose was to identify students with visual impairments and to provide standards for school vision
screening programs throughout the Commonwealth. What had happened before this update was that screening programs could vary from school district to school district. So, this was the Department of
Health's direction to try to standardize and provide more detail in the school vision screening program that is administered to the students in Pennsylvania schools. I'm going to pull out different
parts of the manual of the pertinent information that is in this manual, and some of it is of some statistics that are worthy for us to keep in mind with regard to prevalence and incidence of visual
problems in students. Vision problems affect one in 20 preschoolers. And when we get to school age, it affects one out of every four school age children, so 25% of school age children have a visual
problem. And visual problems can and do affect the educational, social, and emotional development of children. The manual also states that early detection of vision problems assures the child of the
opportunity of taking the best advantage of his or her educational opportunities. Key part is early detection. The manual also states that 90% of all information that is transferred to the brain comes
through the eyes, the visual system. And most vision problems are correctible at least to some degree. So 90% of our learning comes through our visual system. The manual also states that impaired
vision is most damaging in primary grades because it is at these grade levels that the foundations for learning are taught. Those children with vision loss severe enough to require special education
opportunities must be identified early, if they are to be helped. So early identification is very, very important. The manual also states that the American Optometric Association recommends an eye
examination, not a screening, but a professional eye examination, by six months of age, again at three years of age, and before first grade. And then every two years thereafter, unless recommended
differently by the respective eye doctor. This manual also states that according to the American Academy of Ophthalmology, that two to four percent of children develop strabismus, that's an eye-turn,
and/or amblyopia, which is a lazy eye condition. And that early detection and treatment of those disorders during childhood are essential for preventing permanent vision loss. The manual also states
that although it is recommended that every child have an eye examination very early in life, vision screenings continue to provide an important tool and early detection of visual disorders in the
pediatric population. We actually need both. We actually need the periodic screenings, in addition to the comprehensive eye examinations. There's a place for both there. Kids grow very quickly,
various things can occur in their life that can cause changes to occur in their visual system. So the screening process that is done in the school is very, very important, as is comprehensive eye
examinations that will test some areas that the screenings do not. The manual also states that, however, the opportunity for vision screenings or professional exams are not always afforded to every
child in their early years of life. And this is an unfortunate circumstance that really needs to be changed. The manual also states that, as attendance at school was mandatory for all children in
Pennsylvania, the school setting provides an accessible place where children may have their vision screened. Manual also states that vision screening is not diagnostic, but is a practical approach to
identifying children needing professional eye services. So that many times it's the starting point. The manual also states that vision screening and eye examinations are vital for the detection of
conditions that distort or suppress the normal vision image which may lead to inadequate school performance and/or at worst, blindness in children, especially if there's an underlying eye health
problem that could possibly be missed or delayed in treatment. The manual also states that early detection and treatment of vision disorders give children a better opportunity to develop
educationally, socially, emotionally, and physically. The manual also states that the frequency of vision disorders increase with age. Therefore, it is important to have a clear understanding of
critical periods in a human development. The manual also states that studies show that the greatest proportions of these errors in refraction occur about five percent of pupils in first grade may have
refractive errors, that's near- sightedness, far-sightedness, and/or astigmatism, well nearly 20% of the pediatric population require eyeglasses before the late teens. This does tend to increase as a
child gets older. The average age for onset of refractive error needs, especially for near-sightedness, is about fifth grade or ten years of life. And the manual also states that because vision
screening is not diagnostic, children who fail the screening test must be referred to an eye care specialist for a diagnostic examination. This is basically a comprehensive eye examination. The manual
states that screening will not identify every child who needs eye care, nor will every child who is referred require treatment. Sometimes there are false positives and false negatives. There are
variables in a -- there are variable in raising the awareness of parents, teachers, and the community to the importance of eye care. The manual states that the most important aspect of the screening
program is referral with follow-up. It's one thing to make the referral and not to have follow-up to make sure that that referral and that child did have a professional eye examination. The child who
fails the screening should receive a comprehensive eye examination by an eye care specialist. If the child does not, then the program has not accomplished its goal. So follow through to make sure that
the child that failed the screening has had a professional eye examination is very important in the school vision screening guidelines. Now let's go over some basic anatomy review so we can understand
a few things here. This is a schematic, a cross-section of the eye. The basic parts that are involved with regard to vision, we look on the left side of this screen, we start out with the cornea,
which is the clear covering on the front part of the eye. It focuses images through a space of fluid, the anterior chamber where the aqueous is, it goes through the hole of the eye, the pupil. Images
then go back through the lens, the lens is our focusing mechanism that has muscles attached to it that allow us to look and see things clearly far away, and then the muscles flex the lens to zoom on
things to allow us to see things up close. And then the images go through the vitreous, the jelly part of the eye, in the middle. And then images are focused on the back part of the eye, the inner
lining is the retina, it's like the film of the camera, and then there are teeny-weeny little wires that are connected to photoreceptors that receive that information and then transfer it back to the
optic nerve that goes through the brain till we get to the back portion of the brain area, the visual cortex that receives that visual information. So there's a lot of structures that can be not
working properly or that we have an issue with that could impact upon visual functioning of our students. Let's talk about some indicators of possible vision problems in children. What thing should we
watch for? There actually is an ABC checklist, which is a very good checklist that can be completed by teachers in the classroom, and it's on page 11 and 12 of the Pennsylvania Department of Health
School Vision Screening manual. Such indicators may be structural in nature, if the shape of the pupil, the hole of the eye, has an irregular shape, or if the iris has some different coloration, that
it may indicate some neurological or some eye health issues. If there's a cloudy appearance on the clear surface of the eyeball, that's the cornea, that could also indicate an eye health issue.
Cataracts, a clouding to the lens tissue of the eye, it may look like a white dot in the pupil, those are all things that need to be looked at by an eye doctor to make sure that we do not have
something eye-health wise that needs to be treated or managed. Then we look at eye movement. How well the eye's working. Nystagmus is an involuntary oscillating eye movement that could be up and down,
vertical or horizontal or it could be in a circular pattern. Many times that does not appear until after about six to eight weeks of age. But that needs to be looked at to see if there's an underlying
visual impairment that may be causing that to occur. If there's any roving or drifting eye movements, if there's an eye-turn, either one eye or both eyes aren't working together, an eye may turn
outward, upward, downward, or inward. Does the child not make eye contact, do they tend to look off to the side or above or below. It can also indicate that there's an underlying eye pathology. There
may be a scar tissue in the retina that may cause them to have to look off that center spot to be able to pick up vision and move that blanked out spot out of the way. We're also looking at head
position. If there's a head tilt when we're focusing on objects. They may be titled to the side or tipping up or down. That can indicate that there's an eye muscle alignment or coordination problem,
they may be doing that to try to find a position where the eyes line up and double-vision goes away. If there's a field defect, they may have to view objects off to the side or objects in their field
of view may be missing. They may have several pieces of paper on their desk and they may only be able pick up two or three of them because one may be blanked out because of a visual field defect. This
is a young lady that demonstrates a very significant head tilt here. To her right. And as you look at the eyes, you look at the little images, the little reflexes that are bouncing off the front part
of her eye, and you see that they're pretty much lined up there. So, what happens to this young lady when her head is put into an upright position? You see that her left eye has an eye-turn, she has
strabismus. She has what's called hypertropia, where the eye deviates upward. And in this position, she sees double, she sees two images at one time. So, for her to compensate for that because
double-vision is confusing for the brain to process two pieces of information at one time, she demonstrates a head tilt, to get rid of the double-vision. So, anytime that we have a child that's
demonstrating a head tilt or a head turn if they've not undergone a comprehensive eye examination, that's necessary to occur. Now let's talk about the most common problems that we see in kids.
Refractive problems are the most common. The prevalence rate is about 15 to 30%, the younger the child, the lower the incidence. But as the child gets older, the incidence of a refractive problem
increases. And we talk about refractive problems, we're talking about near-sightedness, far-sightedness, and/or astigmatism. Sometimes known as myopia, hyperopia, and astigmatism. Refractive problems
come in various categories as we were talking about, and these are the incidences. Emmetropia means there is no need for glasses. Myopia's the near-sightedness, younger kids have about a 9.4%
incidence and as we get older, the incidence is about 20%. Far-sightedness, or hyperopia, tends to happen when -- more so when we're younger. About 85% of kid are born far-sighted, and as their
eyeball grows and elongates, the amount of far- sightedness reduces. And usually by about the time they're six years of age, it's reached a negligible amount that they may not need glasses for. As
they get older, the incidence reduces. Astigmatism is about the same, whether it's a younger child or an older child. A little over 22%. And then accommodative problems, that's a fancy name for
focusing, two muscles inside the eye attached to the lens, when we go to look at things up close, the muscles supposed to flex the lens to zoom in on things, to make things clear in our near world,
and then we look at things far away, like a chalkboard or a Smart Board, the eyes are supposed to relax focus to make things clear. And focusing problems are about one percent in the early population
preschool, and then about six percent in the school-age population. Focusing muscles don't reach full maturation of development usually until about seven year of age, or second grade. Let's talk about
some binocular vision problems. Basically, it is how well the eyes are working together. One of the categories of binocular vision problems is amblyopia, which is a fancy medical term for lazy eye condition.
It can involve both eyes, or it can involve just one eye. And we usually see this present before the age of three. We can see early signs or risk factors for this developing as young as between six
and 12 months of age. The general population affected is usually about two to three percent. Causes, there are various causes, which we'll talk about that, and the major impact if untreated is that
the eye does not see well. Visual acuities can be in the legally blind range, 2,200 or less. Let me go back to this slide just for a minute, I want to talk about some of the causes with regard to
amblyopia. Most common types of amblyopia are refractive in nature, either one eye did not grow fast enough, and that can cause an amblyopic condition to occur. If an individual had an eye-turn and
the brain began to ignore vision because we were seeing double, that can cause amblyopia to occur. And we can also have a pathology or an eye disease process that can cause a pathological form of
amblyopia. Those are our most common types. But let's talk about treatment with regard to amblyopia. Most common treatment with regard to it, is to do patching therapy. Patches come in various forms
now, they even have eye patch clubs for kids, they can pick whether they want a princess patch, if they want a Spiderman patch, so they try to make it fun with regard to kids. Sometimes we use a
conventional patch that's like a Band-Aid that goes over the eye. And that treatment is utilized over the better or the good eye to give it a break or a rest, to force the other eye to work. We give
it a vacation to make the weaker eye work. And patching philosophies have changed through the years. Moderate amounts of amblyopia usually only necessitate about two hours of patching a day. But the
frequency with regard to patching, how many days and how long, is based upon how severe the amblyopic condition is, and the age of the patient. If we have an individual that's three years of age,
that's undergoing patching therapy, their recovery time and the amount of time spent with patching is a lot less than say if a person is seven or eight years old. But that's something that's dictated
and prescribed by the doctor. If patching doesn't work or if some other things are needed, sometimes vision therapy, also known as orthoptics, can be used. There's a computer program that is out that
works very well with regard to amblyopia. Eye drops, if children are not cooperative with regard to patching, you put the patch on and they rip the patch off, eye drops can be used to blur vision in
the good eye for a couple of hours, and that will give the good eye a rest to force the other eye to work. Sometimes eyeglasses are needed. Sometimes even contacts, I've used contact lenses that blur
vision in an eye. But the big part with regard to this is, if these conditions go untreated, further vision loss, suppression of vision occurs, and there's a high -- much higher incidence of loss of
vision in the good eye. They're anywhere from three times to eight times greater risk for vision loss in the good eye. This is a patient that's wearing one of the conventional patches, the Orthoptic
Opticlude eye patch that looks like a Band-Aid, the patch goes over the better-seeing eye, the good eye, to force the other eye to have to work. And with regard to amblyopia, 75,000 three-year-olds
develop amblyopia each year, there's a lot of kids out there that have this condition. But this is the sad part, that only half of the children are diagnosed after five years of age. Remember what we
said before, that the earlier the intervention, the better. And we can turn these cases around much quicker as well too. The visual system is most pliable during the first 18 to 36 months of age. So
if we can start intervention at that point, we can turn them around and have a much better success of reaching 20/20 vision or near 20/20. Let's talk about strabismus. Strabismus is another binocular
vision problem, it's when the eyes don't work together. It's a fancy name for an eye-turn. Sometimes also referred to, if you look at reports, as tropia, t-r-o-p-i-a. The incidence of this occurs in
about one to four percent of the general population. It tends to be much more common to be noted in the preschool population of about 21% and then ten percent of the school-age population. About 25%
of these cases onset early, before six months of age. Heredity is big factor with regard to this, so if there's a family history of even cousins that have a history of strabismus, they need to undergo
examination at an early age. There's also some other factors that occur with regard to strabismus, if an individual's had a trauma during the pregnancy, especially during the delivery, especially if
forceps were used, sometimes it can damage the muscle. This is a young lady that has strabismus. If we look at her, her left eye, which we see on the right side of the screen. Her eye is turned
inward, it's crossed. And it's called esotropia. Now when an individual has strabismus, most commonly, they see two images, they have double-vision, diplopia. And because there's two images, their
depth perception can be off. Also, eye-hand coordination delays can occur. Because they're seeing two images, they go to reach out for an object and there's a fake one and a real one. This will also
impact upon writing skills. Sometimes the kid will write above or below the line because they're actually seeing two lines, and they don't know which one is the real one or the fake one. We can also
have the amblyopia developed, because the brain is confused by seeing two images at one time, so it would ignore or suppress vision in that turned eye, the eye then stops working and the vision
becomes lazy and the visual acuity is reduced. We also have a type of eye-turn that's related to our focusing mechanism, called accommodative esotropia, and we'll talk about that in a minute. And
we're also review a little bit of treatment options for this. This is a young lady that has an eye-turn, as you can see. Her right eye is turned in and up. She has right eso-inward-tropia, with a
hyper component. She has an accommodative esotropia, which I'll show you here in a minute. You see her right eye is lined up now. She did not have surgery. She did not have glasses here. But we have
glasses here. The glasses actually are assisting in keeping that right eye in alignment, and it's because she is far-sighted. So when she goes to look at things up close, she has to over flex her
focusing muscles to keep things clear. When that occurs, her eye tends to cross or turn in. Most common time to see this type of eye condition is between 18 and 36 months of age. This is a type of
eye-turn, that if we can catch these early, get them into glasses, we can prevent the need for surgery. Some milder forms may not pop up until about four to five years of age. But a lot of these kids,
probably about 75 to 80% of them, many times as their eye grows and continues to grow, by the time they reach about ten to 12 years of age, we can wean them out of glasses. Let's talk about the hidden
binocular vision problem. And it's called convergence insufficiency. Converging is inward and it's those muscles that aren't working properly or insufficient. It's not actually an eye-turn per se, we
don't see an eye wandering outward or crossing inward. Convergence insufficiencies are most commonly present in functioning problems between second and fifth grade. What happens at that time period
is, we're switching from learning to read to reading to learn. We also have a print size change that occurs during that period of time. Print size starts to get smaller. Another thing that occurs
during that time is we tend to have more crowding of print on a page. And we also will start to have an increase in the volume of reading that occurs. So these muscles may be working okay, but they
now begin to start to fatigue. And then they're not working as well. Studies estimate that about 20 to 25% of children that possess reading problems have a convergence insufficiency. It tends to
increase more in school-age population as opposed to preschool. They vary in severity with regard to their functioning problems and onset time. We may have kids that start out with a convergence
insufficiency in the morning, that their muscles are working okay, and later in morning or afternoon, then their performance may start to go down. There is a hereditary component. If a person has a
convergence insufficiency, somebody else in the family also has it as well. And we'll talk about an associated component with attention deficit. The attention deficit component, there was a study that
was done at Children's Eye Center at the University of San Diego. And we have a reference with this that was in the National Institutes of Health. They uncovered a relationship between convergence
insufficiency and attention deficit disorder. In fact, what they found was between ten and 15% of individuals in their study that they were initially diagnosed as attention deficit disorder actually
had an underlying convergence insufficiency problem. And when that was taken care of, the attention deficit disorder symptoms went away. So, basically their take on this from what they've found in their study,
which was a very good study of a multi-disciplinary team where you had eye doctors, you had pediatricians, you had diagnostic reading specialists and psychologists involved in this, that patients that
are diagnosed with attention deficit disorder should also undergo a professional eye examination to look at ruling out convergence insufficiency. And if it's present, have appropriate treatment. Let's
talk about some of those functioning issues that can indicate that there's a possible convergence insufficiency problem present. Words will tend to run together, will tend to have double- vision, they
may re-read meaning -- items, to try to get meaning out of it. Their performance is reduced over time. They may start out okay, performance is good, and as they sustain it, the activities, then their
performance gets worse. Headaches, especially in the sides or up at the front in their forehead area, usually occur after visual task. What happens in those situations is the muscles start to go into
spasms, and the headaches begin to radiate in those particular areas. This is not a type of headache that they traditionally will wake up with, this is a headache that's associated with doing up
close, near activities. This is a simulator of how the eyes are supposed to work together, a schematic when the eyes are converging at a proper place, they are -- the eyes are supposed to come
together at the plane of our near material, whether it's a book or whether it's a paper, and then the sentence is going to look appropriate. The letters will be clear, the letters aren't distorted.
But when we have a situation where the eyes aren't coordinating together, they're not converging at the right spot, then we have a breakdown of our eye teaming skills, and we can have distorted vision
or even doubling of vision, and I don't know about you, but if I had to look at print like that for any extended period of time, I'd sort of want to give up or not want to do it. Some other
functioning issues that are associated with convergence insufficiency is that performance shows minimal to no improvement with special education intervention. I'll have students that are referred in
for comprehensive eye examinations, asking to rule out a convergence insufficiency problem, with students that may have been involved in a title one remedial reading program for half the school year
and they're not showing any improvement. So that, many times, will spur on a referral to rule that out. There was an article that was printed in Dear Abby, of a mother who had a daughter that began to
start having academic problems at about second grade, she would have her daughter tested in school, she had gone to several different doctors and was not finding any problems, they weren't finding any
issues, but yet she continued to struggle in school. Mom happened to do some research on the Internet and found information on convergence insufficiency, took her daughter to Mayo Clinic, who happened
to be in one of the treatment study programs and said, can you test my daughter for convergence insufficiency? They did, they found she had a convergence insufficiency, remediated her problem, and her
academic problems went away. But the struggle was trying to find the answer for this mother from second grade until fifth grade. And so she wanted to tell her story and she wrote a letter to Dear
Abby. There's also a study that was done by the National Eye Institute, the convergence insufficiency treatment study, and that was done in 2008. It was printed out in October of 2008, this was a ten
center study, Mayo Clinic was involved in it, Bascom Palmer Eye Institute in Miami, and Children's Hospital in Philadelphia was involved in this as well. This was both optometrists and
ophthalmologists were involved, they looked at various treatment methods to find out what was the most effective in treating convergence insufficiency problems. What they found was the treatment
success rate is about 75% and it's a combination of in-office vision therapy program administered by a trained vision therapist, in addition to doing a home therapy program via a computer. Let's talk
about convergence insufficiency screenings. In the manual, in the school vision screening manual, it's actually an extra test, it's in appendix G of your manual. It's not one of the required tests,
but it is a very important test. And more and more, what's happening is diagnostic reading specialists or school psychologists, before they will do a formal examination with regard to a child, with
regard to learning issues, many times they will request this -- a test to be done. So, we'll talk a little bit more about this in detail. Now the screening tools that we use with regard to this is to
use a fixation stick, which is sometimes called an optistick, and I'll show you what that is. The manual requires that it, as you see, there's an object up at the top, the manual says to utilize a
target that's about 20/30 or 20/40 sized object, this one's actually a little bit bigger. We have one up here that's a little bit smaller. And what this is done is, it's held at about 16 to 18 inches
away from the individual's nose, it's slowly brought up to the nose, and you're looking for any eye to deviate outward. And I'll show you some images of individuals' eyes that deviate outward. So
that's the screening test that's in the manual. However, from a professional standpoint, not all individuals' convergence skills will break down by looking at this optistick. Because we have a
focusing component that sometimes helps the convergence skills, the eye teaming skills. And because it's a target that has form on it, we'll sometimes focus. So, if you look at my outline here on the
PowerPoint, you'll see a pen light and a pen light with a red lens. Now let me show you those. Just as we use the optistick starting at about 16 to 18 inches from the nose and bringing it up to the
nose, we'll do the same thing with a pen light. The pen light does not have any form that triggers the focusing accommodative system that can sometimes mask a convergence problem. But we're looking
for that same deviation. If they pass that, to challenge the visual system more, we'll use the red lens. Which is what you see on the left-hand side there. And you'll hold up a red lens in front of
the individual's eye, it doesn't make any difference which eye, and then again, you slowly start with the pen light at about 18 inches, 16, 18 inches, and you slowly bring it up towards the nose. A
failure rate on this test is if the eye deviates out of position, either eye, at five inches or greater from the nose. Five inches from the nose. And if they're not able to recover eye alignment,
seven inches or more from the nose. So five inches or more, the eye deviates outward, and then the eye alignment is not recovered seven inches or more. So a very important screening test to be done on
those students that may be struggling with regard to reading skills. Here's a young lady that we're looking at from a convergence standpoint. And she's working in a vision therapy program where we're
doing in-office therapy utilizing a procedure called Brock's string. And now it's not the procedure so much that we're looking at, but we're looking at her eye alignment. And this red bead would
simulate where the optistick target is, or the pen light, and her right eye, which you see on the left-hand side of the screen, is deviated a little bit outward. So she's not able to keep both eyes in
alignment within that five to seven inch zone. And we can see up close even more, that that right eye deviates outward. She's not able to hold her convergence. So that's what it looks like when we're
doing those screening tests that you're looking for an eye to deviate out of position. And they can alternate, it could be the right eye or the left eye. And here's the young lady after she's gone
through several session of vision therapy that that bead is within three inches now of her nose, and both eyes are able to converge and line up on that. This is what she looked like at the beginning
of therapy, and this is success as we've gone more into therapy. And it's not being able to do it for a split second, 'cause as we know, when kids are having to sustain with regard to reading, it's
not for a minute or two, it's for 30 minutes, it's for 40 minutes. So building and toning up those muscles are very, very important, it's a very important tool that our students are going to be using
for reading and writing. Here's an older patient of mine that's he's in his late teens. And he has some convergence issues and the bead isn't even in the screen. It's that far out, you can just see
the edge of it down at the left- hand of the screen, but his left eye on the right side of the screen is deviated outward, he cannot converge on it. And here, while he's a little blurry 'cause the
camera focused in on the bead, he's now starting to get some alignment if you look at the images while they're blurry of the light image that's coming off of his cornea. But this is still not an easy
task for him to do. That he still needs some work on it. Now, let's talk about the standard school vision screening tests. When the new revision was done, several tests were added to this in 2002. And
the tests include an ABC checklist of vision, where we're looking at appearance, behavior and complaint, as we had talked about before, this checklist is on pages 10 and 11 of the manual, and it's
something great to have the teachers fill out if there is a child that is suspicious for having some visual problems. The tests that are on the school vision screening manual is a distance visual
acuity test, and that's to be done annually. And that test has been there all along. The guidelines that got revised in 2001 and printed out in 2002 added a near visual acuity test, which is to be
done annually. What's interesting is up until that particular point in time, near visual acuity testing was not in the school vision screening guidelines which is interesting because the majority of
what children do in an academic day especially during the primary grades is up close work. But yet we weren't even screening for it. A plus lens test is included as well, and that has been in the
original guidelines, the manual. And what that does is that screens out for hidden far-sightedness. That's to be done in first grade or to be done if there's a new child entering that school. Color
vision tests are to be done at first grade or second grade, and we'll talk about that a little bit. And there's also a new test, a testing for stereo depth perception, it's to be done in first grade
or second grade, or if a child is new to that particular school. That's to help to screen out depth perception issues that may be the result of an amblyopic, a lazy eye condition, or strabismus.
However, some individuals that have intermittent strabismus, this -- they still may pass this test if it's not present at the time that's being screened. That means that the eyes aren't coordinating
some of the time, not all of the time. So the pass-fail requirements with regard to the visual acuities are more stringent for second grade and up then they are for kindergarten to first grade. And
it's if either eye visual acuity is less than 20/40, in kindergarten to first grade, or if either eye is less than 20/30 visual acuity for second grade and up. These are stiffer requirements than what
the original manual was. A failure also is if there's a two line difference or greater between the right eye and the left eye, and these are the requirements for both the distance and the near visual
acuities. The plus lens test which is also called a convex lens test is looking for hidden amounts of far-sightedness, a lens that's at 2.25 diopters of power is utilized for the younger children, and
1.75 diopters for kids that are older than eight years. And the failure is sort of an oxymoron, they fail the test if they are able to read the distance eye chart with the lens in place. That
indicates that there is some far-sightedness that's there. So if you put up the plus lenses and they cannot read the distance chart, then that's a normal situation, but if they can read it through the
lenses, that means that there is far-sightedness there that needs to be looked at because it may be impacting their up close near-vision functioning. Color vision discrimination, color vision issues
are a rare condition. It's much more common in males than in females. It's hereditary, it passes from mom is a carrier that passes it on to the son through the X chromosome. It occurs in about five to
eight percent of the population with regard to males. And it's about two to three percent of the population with females. You can test it through an autoscreener or through pseudo-isochromatic plates,
those are the plates that have the dots and they have numbers on them. But I'm also going to show you a test where you can test younger children that may not know their numbers or confuse their
numbers with a test called Color Made Easy, which is also part of the manual as far as a testing process. This is the Color Made Easy book, and what we'll do is we'll just go through some of these
test patterns. So you can familiarize yourself. This is the test pattern where we're looking at shapes. All they have to be able to do is to be able to see a square, a star, or a circle. I don't know
how the resolution with regard to that's coming up on the screen, but there's a square in a circle on that. And even if they can't verbalize a square or a circle, even if they trace over it with a
marker, we don't want to put our fingers on it because it -- the skin oils tend to take away the color perception on those. Let's skip over to a testing for even children that are younger that we
needs to get some color information on for color deficiencies that may not even know their shapes very well. So there is a picture form of this where they're looking at the shape of a dog, a boat, a
house, or a car. So as you see, that's pretty prevalent, that's the col -- that's the car that they would pick out of the background. And this one may be a little difficult with regard to the contrast
because of the lighting. But that's actually a boat. So this, again, was being brought up to show you that there are some tests out there when the question does come up with regard to color for these
younger children. Now, color deficiencies don't necessarily mean that there is a disease process with the screening that's done through the manual process, 'cause that only picks up red-green color
deficiencies, and that's the most common hereditary forms. But if an individual has a blue-yellow deficiency, that can indicate that there may be some eye health issues especially involving the nerve,
the optic nerve. But most screening tests don't have a blue- yellow component. But the big part with regard to being able to detect a color perception deficit is, from an educational standpoint,
having that awareness to teachers, and also in career guidance, 'cause some careers necessitate high levels of color discrimination and that would need to be known as early as possible. But if an
individual struggles and has difficulties with a color perception test, the first question to ask the child's mom, the biological mom, is did her father have any visual difficulties with color
perception. If the grandfather on the mother's side did, then there is a good possibility that the child, especially if it's a male, has a color perception deficit. But again, that can be tested.
Let's go on now and talk about another test requirement, the stereo depth perception test. This is one of the two new tests that were added to this manual. And it is using a random dot E, which looks
like an E going in various directions that will pop out of the test plate if an individual is able to perceive the depth perception using special polarized or 3D glasses. There is a plate that's also
available to be attached or included in the autoscreener machines. So you may want to check with the manufacturer of your specific autoscreener machine if your school is using those. The failure rate
for this is if they cannot identify four of the six plates that are presented. And again, the failure of a stereo depth perception test can indicate that we may have the presence of an amblyopic
and/or a strabismic eye condition. Now let's talk about the reporting of these results. There have been some changes in the manual with regard to reporting. A notification is to be sent to the parent
or guardian whether the student passes or fails the screening test. This is something new, before they just sent information with regard to failure. But now their requirements are that they be
notified if the child has been screened and even if they've passed. There are reporting forms in the appendix F1 and F2 of the manual. So those can just be printed off and utilized. One of the
statements that's in the screening reporting form and the reason why the pass is to be sent home as well, is there's a statement that says, screenings -- screening is not a substitute for a
professional eye examination. Some other things with regard to the results is every school shall submit to the Pennsylvania Department of Health. And aggregate information regarding the vision
screening program as specified in their instruction manual for the annual request for reimbursement and report of school health services, and these statistics are due to the Department of Health,
September 30th of every academic year. Now the vision screening tests for students with special health care needs is also included in this manual. Many times in the past when we had a child that was
nonverbal, or had some cognitive challenge level issues, and were not able to complete the standard vision screening for the general population, many times they were sort of forgotten or they were
just recorded as unable to test. So there has been a section that has been added to this manual on pages 28 to 31 that address this, that give you the tools to be able to screen some of these kids.
Also, don't forget, the near point of convergence screening test, it's not in the standard but it is an extra test, don't forget to consider that especially when kids are having reading problems. It's
in the appendix, on appendix G. Now let's talk a little bit about statistics and statements with regard to vision and vision and learning, and it further earmarks the importance of what you're doing
and the importance of periodic and regular screenings. As we had talked before, 80% of children, of what children learn, is acquired through the visual processing of information. Vision problems
affect one in 20 preschoolers and as we get older, school-age, it's one out of every four children. The National Society for the Prevention of Blindness states that an estimated 10 million children
below the age of ten have vision problems which affect their ability to learn. It is reported that children with reading problems exhibit a greater than 50% prevalence of visual deficiencies in
focusing or eye alignment, as compared to normal achieving peers. Among children who are reading disabled, as many as 80% show a deficiency in one or more of the basic visual skills that we talked
about. Children with vision related learning problems reveal that they were experiencing feelings such as a lack of direction, a sense of not belonging, inadequate sense of self assurance, and a
feeling of insecurity, inadequacy, and inferiority. These kids basically feel like they give up. The basic visual skills aren't there and they keep working harder and harder but they get no further.
They're very frustrated. The National PTA organization passed a resolution at their convention in 1999. That's over ten years ago, but they saw the importance of vision and vision functioning that
they wanted to make recommendations through a resolution and they adopted this at their national convention. And parts of it are well worth repeating here and so I have them stated here. Whereas it is
estimated that more than 10 million children between birth and ten years of age suffer from vision problems and whereas many visual skills are necessary for successful learning in the modern
classroom, and skill deficiencies may contribute to poor academic performance. And, whereas typical vision evaluations or screenings only test for a few of the necessary learning related visual
skills, like distance visual acuities, testing for 20/20 eyesight, stereo vision, and muscle balance, leaving most of the visual skill deficiencies undiagnosed. And whereas learning related vision
problems when accurately diagnosed can be treated successfully and permanently, and whereas knowledge regarding the relationship between poorly developed visual skills and poor academic performance is
not widely held among students, parents, teachers, administrators and public health officials, the awareness just isn't there, now therefore be it, resolve that the National PTA through its
constituent organizations provide information to educate members, educators, administrators, public health officials, and the public at large about learning related visual problems and the need for
more comprehensive visual skill testing in school vision screening programs and performed by qualified and trained personnel and be it further resolved that the National PTA through its constituent
organizations urge schools to include, in their vision screening programs, tests for learning related visual skills necessary for the success in the classroom. And the revisions in the Pennsylvania
guidelines made a great, great step towards that direction when those were made in 2001 and came out in 2002. And it was this National PTA resolution that really started the ball rolling with regard
to Pennsylvania. However, that convergence insufficiency part is also a part that needs to be included as well. So don't forget to use that even though that's in the appendix and it's not on the
required testing, 'cause that's a very important tool that can pick up some of these other visual skills. People at risk for learning related vision problems should receive comprehensive optometric
examinations. It should be conducted as part of a multi-disciplinary approach, in which all appropriate areas of functioning are evaluated and managed. Research has demonstrated that some people with
reading disabilities have deficits in the transmission of information to the brain through a defective visual pathway. Some of this information was done at Harvard University and MIT. This can create
confusion and disrupts the normal visual timing functions in reading. Individuals may have basic coding skills but their fluency may be affected because of binocular or eye teaming or visual tracking
problems. So, we have demonstrated that there are some problems out there that sometimes aren't being addressed or met or uncovered with regard to these kids, so what's being done to get more of an
awareness out there, to get these services to those kids that may be in need. Well, legislation is one thing. And let's review some of the legislation that has happened out there, and our neighboring
state of Ohio in 2003, they enact -- the passed a bill that began in 2004 and 2005 school years, that stated that within three months after a student has been identified with a disability under the
IEP process, that before IEP services are provided, they require that a student undergo a comprehensive eye examination. Nationally, there have been over 25 pieces of enacted legislation, with regard
to vision that have passed between 2000 and 2010. The first state that passed this was Kentucky in 2000, which required -- the requirements were that a comprehensive professional eye examination be
completed prior to entering school. And when the Kentucky bill first came into play some of the discussion was, do you have parents that cannot afford eye care services. What they found with regard to
this is that there were a very small number of individuals that couldn't afford it, that a lot already had insurances, especially eye care insurance, that would cover for these exams. But they did set
aside over a $100,000 to pay for student examinations whose parents couldn't afford it, and they used less than ten percent of that money during the first two years of that program. So, the abilities
are out there, we just need to get the kids serviced in the appropriate ways. Things to look for that could indicate a visual functioning problem, kids don't come with a neon sign saying I can't see
or that I have double-vision. So we need to observe them. And when to consider referring for an eye examination. Child seems bright but struggles to read. They fatigue quickly when reading and they
have frequent signs of frustration. These are kids that may start out great the first five, ten minutes, and then their performance goes dramatically downhill. They are unable to sit still, they
cannot stay on task for any length of time. If print looked like it was fuzzy and blurry or you saw two sets of it, I don't think that you would want to sustain at a near task for long periods of time
either. They frequently will lose their place. They'll tend to skip words, or whole lines. They have poor reading comprehension. They have difficulties copying from the chalkboard or a Smart Board
onto a paper or from a book onto a paper. They have sloppy handwriting. They can't stay on the line, they write above the line or below the line, if they have a binocular vision problem, they could be
seeing two lines. So that may be the reason why it looks like they're writing above or below the line. Medication has been tried, tutoring has been tried, and they're not successful in improving
school performance. You need to find out if there's an underlying visual problem that's there that may be blocking the individual from maximization of tutoring skills. They've been labeled with
learning disabilities, attention deficit problems, or dyslexia. There's frequent rubbing of the eyes or blinking or headaches. If the muscles go into spasms, we'll get headaches. Frequent rubbing or
blinking, they're trying to reset their focus because things have become blurry. Squinting, tilting of a head, we talked about that with eye-turns. Covering one eye because they're seeing double. An
actual eye-turn is even noted. It they tend to dislike or avoid close work, the blurred vision at any distance. So in summary, vision problems can and often do interfere with learning, and people at
risk for learning related vision problems should undergo examination. The goal of optometric intervention is to improve visual function and alleviate associated signs and symptoms. Prompt remediation
of learning related vision problems enhances the ability of children to perform to their full potential. I look upon this as providing our students and children with the best tools that we possibly
can to allow them to do their job, which is learning. And, it's like if you had a carpenter and you sent a carpenter out to build a house. And you have the two by fours there, you have the drywall,
you have the nails there, but you forgot to give him a hammer and a saw. I don't know how much of a house that they're going to be able to build. And that's what the visual skills are like. So people
with a learning problem require help from many disciplines to meet the learning challenges they face. An optometric involvement constitutes just one aspect of that multi-disciplinary management
approach required to prepare the individual for learning. We got to make sure that the tools are there and the tools are working properly. Here are some websites that I have that will provide you with
additional information from what we had talked about today, the American Optometric Association has an excellent part for parents and educators, the Parents Active for Vision Education website also
has a good piece for teachers and so does the Pennsylvania Optometric Association. Some other websites that are good for getting some additional resources is allaboutvision.com, childrensvision.com,
ADD ADHD organization and the Learning Disabilities Association of America. Thank you very much for allowing me to present this module to you. If you do have any questions, feel free to contact me,
the best way to get a hold of me is through my email address at drmoon@nittanyeye.com. Thank you.
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