Screening Services & Assessments: Vision
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
and Guidelines for Vision Screening
includes both subjective methods (health history, risk assessment,
physical exam), and objective vision tests.
requires vision screening as follows:
screening at each preventive health visit from birth to 21 years
screening with approved test methods at key developmental ages (See periodicity schedule), based on risk assessment.
Document visual acuity (for both left eye and right eye); [score 20/__] and indicate [corrected or uncorrected]; document if an unsuccessful attempt.
Remember to consult and follow the DC Medicaid HealthCheck Periodicity Schedules (pay particular attention for visits where a risk assessment is to be performed, with appropriate action to follow, if positive).
vision screening includes these components:
- Health history
and risk assessment (see screening questions below)
history of vision or eye problems
conditions (premature birth or low birthweight)
conditions (history of HIV or other STIs, substance abuse,
rubella during pregnancy)
concerns about childs visual function or eye problems
performance (worsening grades, reading and/or learning difficulties)
of child's eyes (lids, orbit, conjunctiva, sclera, cornea,
iris) and ability to see
of ocular alignment and clarity
light reflex test
Fixation (fix-and-follow test)
tests that are age-appropriate (see Screening Methods below)
- Early detection
and prompt referral to a vision specialist for corrective treatment,
in the medical record of specific screening method(s) used, test
results, and referral (if indicated)
- 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
- Do your child's
eyelids droop or does one eyelid tend to close?
- Have your
child's eyes ever been injured?
younger than 3 years
is part of the physical exam and should include these tests:
test in a darkened room with an ophthalmoscope or other
light source. Hold the light source at arms length
from the child, drawing the childs attention to look
directly at the light. Both retinal reflexes should be
red to red-orange and of equal intensity.
Light Reflex. Use
an ophthalmoscope or other light source. Corneal light reflections should
symmetrically on corresponding points of the childs 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.
(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.
both eyes, then test each eye separately. Normally, the childs 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.
ages 3 years and older: Screening for visual acuity
screen for ocular alignment at each visit with these tests:
red reflex, corneal light reflex, cover/uncover, and fixation
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.
ages 35, with one or more of these methods:
- Allen Figures
- LH (Leah
ages 6 and older with one of the following:
- Snellen Letters
- Snellen Numbers
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.
Screen children 6 years and older for color perception at least
once, using polychromatic plates.
In addition to the vision history and physical exam, results of
school vision testing may be used. Contact the school nurse for
and Prompt Referral
an ocular abnormality or those who fail vision screening should
be referred promptly to a vision care specialist.
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.