«National Vision and Hearing Screening Protocols Revised 2014 Citation: Ministry of Health. 2014. National Vision and Hearing Screening Protocols: ...»
7. Beginning with the largest letter, show the child progressively smaller letters from each level. Show the letters in a different order from that which you showed the child in step 3.
Encourage the child as much as possible. Continue until the child has difficulty identifying the letters.
8. Record the smallest letter size at which the child correctly matches two out of three letter shapes at any level. Use the conversion table on the back cover of the book.
Note: Record 6/6, 6/6 when you show all three 6/6 letters and the child can achieve two.
9. Parr letter-matching vision test (with confusion bars) is the recommended screening test for all children younger than seven years old. If the child has difficulty understanding the test, consider using the Parr letter-matching vision test without confusion bars.
Note: If this test is used, the child must achieve a result of 6/6 in both eyes at the B4 School Check (four years).
Children not achieving this should be rescreened (ie result is 6/9 both eyes) or referred (worse than 6/9 either eye) with a note to the referrer that the Parr chart without confusion bars was used.
Five to seven year olds screened without confusion bars who achieve a 6/6 result in both eyes, should be rescreened within 12 months. If their visual acuity is worse than 6/9 in either or both eyes, they should be referred with a note that Parr letter-matching vision test without confusion bars was used.
Screening outcome This screen has three possible outcomes: a pass, rescreen or refer. Rescreens should be notified to the preschool and the parents and done as scheduled.
Pass, rescreen and refer criteria for vision screening Vision is 6/9 or better in both eyes at the B4 School Check The child’s vision screening is considered a pass.
• Note the measurements of vision on the child’s records.
• Take no further action.
• Vision is 6/9 in one eye and 6/6 in the other at the B4 School Check or New Entrant Check test (5–7 years) Children aged four, five, and six years who have a visual acuity of 6/6 in one eye and 6/9 in the other should be rescreened within six months. This is because one eye may be improving or one eye getting worse. A rescreen will distinguish the two possible options.
Note the measurements of vision on the child’s record.
• Arrange a rescreen for within three to six months’ time.
• Vision is 6/12 or worse in either or both eyes at the B4 School Check or New Entrant test (5–7 years) Refer the child for further assessment according to the Ministry of Health’s referral • guidelines.
On rescreen If the child’s vision is 6/6 in both eyes, the rescreen is considered a pass and no further action is required. If there is no change in the child’s vision (ie, they are 6/9 in one eye and 6/6 in the other) or their vision has become worse in either eye (ie, they are 6/9 in both eyes, or 6/12 or worse in either eye), refer the child for further assessment according to the Ministry of Health referral guidelines (see Referral pathways below).
After the screening Notification to parents Parents will be notified of results following a screening test. Pass and refer brochures for use with all four- and five-year-olds screened are available online: www.health.govt.nz Children who are identified as requiring a referral should be given an Enable Spectacle Subsidy brochure.
Copies of the Spectacle Subsidy brochure can be ordered through Enable New Zealand (freephone 0800 17 1981). Copies of the subsidy for glasses and vision test brochures in a number of languages can be printed from the Ministry of Health’s website (www.health.govt.nz).
Subsidies for glasses/spectacles and eye exams Children with vision problems, aged 15 years and under, from low-income families may be able to get funding assistance for examinations, frames, lenses, eye patches and repairs. The child will need to have an assessment by a vision assessor who is registered as an assessor for this subsidy. The accredited vision assessor will assess a child’s vision needs and may recommend glasses or other vision equipment. An accredited assessor is usually an optometrist, eye specialist, or a service coordinator for the Royal New Zealand Foundation of the Blind. Not all optometrists and eye specialists are accredited vision assessors. The screener should have an up-to-date list of accredited assessors in their area.
There are brochures available for families to explain who is eligible for the subsidy. You can view this brochure and read further information at the Ministry of Health website (www.health.govt.nz).
If the child requires a referral and their parent has a Community Services Card, advise the parent to contact Enable New Zealand to find a vision assessor in their area (freephone 0800 17 1981).
Follow-up Local records must be kept of all children who have been screened including those who have passed, those requiring a rescreen, and those who have been referred. Parents, ophthalmologists, optometrists and orthoptists are asked to inform the referrer of the findings and proposed treatment. This information is recorded for future reference.
24 National Vision and Hearing Screening Protocols If feedback information has not been received from the referral, a follow-up letter or phone call to the family should be made to see if any action has been taken. If there is no response to this contact, then the case should be referred to the Public Health Nurse Services or Community Health Team. This information must be recorded for future reference.
Where a child has already been assessed and determined as needing glasses but is not wearing them, or where a child failed to attend an appointment with a hospital eye clinic, ophthalmologist or optometrist, the school’s nurse or the public health nurse should be informed. No further screening is required.
Preschool and school recording systems There is one main national database for recording vision results: the Ministry of Health’s B4 School Check Information System. Vision screening results must be entered to meet the national reporting requirements for vision screening, including the B4 School Check. The Ministry of Health and the Ministry of Education have developed a process for transferring vision screening data into the ENROL database. Results for Year 7 are recorded directly into ENROL.
Referral pathways Figure 3: Vision screening clinical pathway and referral at four years old
Figure 5: Vision screening clinical pathway and referral for Year 7 (and others) 26 National Vision and Hearing Screening Protocols Children failing a formal visual acuity screening A four-year-old or new entrant child who is referred from the vision screen with unequal visual acuity or has a result of 6/12 or worse should receive further professional investigation.
There are three possible referral scenarios.
1. A four-year-old or new entrant child who has distance vision that is equally reduced in each eye or with two or more lines difference in the vision between the eyes should be referred to either an ophthalmologist or an optometrist, depending on practitioner availability and parental preference.
NB: If a four-year-old or new entrant child with greater than two lines difference between the visual acuity in each eye is referred to an optometrist, referrers should consult with the New Zealand Association of Optometrists about optometrists available in their area who have appropriate training, experience and interest in seeing younger children.
2. A new entrant child who has a 6/9, 6/9 distance vision result should be rescreened within 12 months. If at rescreening the result is worse than a 6/6, 6/6, the child should be referred to an ophthalmologist or optometrist, depending on parental preference and practitioner availability.
3. A new entrant child with unequal vision of less than two lines difference should be rescreened at next visit.
The ophthalmologist at the hospital eye clinic or the optometrist to whom the child is referred should acknowledge receipt of the referral, and inform both the referrer and the child’s GP of the outcome of the referral.
Offer referral if concerns about child’s vision A child’s caregiver or teacher may occasionally have concerns about a child’s health, development, behaviour or learning and wonder whether a vision problem is causing these symptoms or difficulties.
Those requesting a vision test should be informed that screening is not a full diagnostic visual assessment, and a child should be referred to an optometrist or eye specialist if there are concerns. The results and outcomes must be recorded in the ENROL database.
It may be necessary to offer a referral of a comprehensive vision assessment for the child, as the screen does not test all aspects of vision.
Following a parent-initiated, teacher-initiated or self-referral, the health practitioner consulted must work within their scope of practice to ensure that the family receives a timely, high-quality service that addresses their concerns.
Resources Keeping an eye on your child’s vision (B4 school vision screening) (HE2278) is a Ministry of Health resource for parents/caregivers, available from its HealthEd website (www.healthed.govt.nz) in multiple languages.
National Vision and Hearing Screening Protocols Screening technique: Snellen eye chart The screen is conducted with the Snellen eye chart exactly 4 m from the child and at the same level as the child’s eyes. Measure 4 m from the child with the tape measure, and mark the floor at both ends with a piece of masking tape. Ensure that the Snellen chart has a matte finish to ensure the child cannot see reflections. Make sure the child is not facing a window or other bright light source that could make the chart difficult for them to see.
Preparing the child for Snellen vision screen
1. Stand the child behind the 4 mm mark, with their toes on the masking tape line.
2. Explain to the child that you will point to random letters on the chart and ask the child to identify each letter.
3. Ensure that the child knows the names of the letters.
4. Follow the procedure for the Snellen Vision screen.
Procedure for Snellen vision screen
1. Place the occluder in position with the child’s right eye visible. Explain that the child is to hold the occluder in place until asked to move it.
2. Turn the eye chart over. Beginning with the largest letter, point to progressively smaller letters (two or three letters from each level is sufficient). Select letters randomly.
Encourage the child as much as possible. Continue until the child has difficulty identifying the letters.
3. Record the smallest letter size at which the child identified all letters (ie, the whole line) correctly.
4. Ask the child to turn the occluder over, so their left eye is visible.
5. Turn the eye chart over. Beginning with the largest letter, point to progressively smaller letters (two or three letters from each level is sufficient). Select letters randomly and in a different order from that in step 2. Encourage the child as much as possible. Continue until the child has difficulty identifying the letters.
6. Record the smallest letter size at which the child identified all letters (ie, the whole line) correctly.
Referral pathways If the child is under the ongoing care of an ophthalmic practitioner (an ophthalmologist or
optometrist) and has been prescribed glasses:
the child should not be screened • if the child is screened, a referral is unnecessary no matter what the vision results are, but • contact the parent or caregiver to provide them with the results and to make sure the child has had a recent vision examination.
Offer referral if concerns about child’s vision If at any stage, a teacher, parent or caregiver thinks the child has any vision or developmentrelated problems, it may be necessary to refer the child for a comprehensive vision examination and assessment (see referral guidelines), as the screening test may not detect some visual conditions.
28 National Vision and Hearing Screening Protocols Caregivers presenting to a health practitioner with concerns about their child’s vision A child’s caregiver or teacher may occasionally have concerns about a child’s health, development, behaviour or learning and wonder whether a vision problem is causing these symptoms or difficulties. Sometimes an older child will complain of vision difficulties.
Depending on the child’s age, local services and caregiver preferences the initial presentation could be to a VHT, a nurse, an optometrist or a GP.
Following a parent, child or teacher initiated self-referral; the health practitioner consulted must work within their scope of practice to ensure that the family receives a timely high quality service as described below.
Health practitioner role The VHT should screen visual acuity in the appropriate manner for the child’s age and • development and refer onward if required with the results of the visual acuity screen and any relevant observations of the child.
A nurse or GP should measure and record visual acuities, undertake a clinical examination of • the eye with other appropriate examination of the child and make a referral or institute management if required.
An optometrist should obtain a history, measure and record visual acuities, examine the • external and internal structures of the eye, assess ocular motility, fusion, convergence, accommodation, pupil reactions, and conduct all other assessments necessary to determine a diagnosis. The optometrist should make a referral or institute management if required and appropriate.
Referrals In general infants and children under three years of age with visual acuity and other • problems should be referred to an ophthalmologist for further assessment.
In certain situations access issues and parental preferences may mean that an infant or child • under three years is referred to an optometrist. Referrers should regularly consult with the New Zealand Association of Optometrists (NZAO) about optometrists available in their area who have appropriate training, experience and interest in seeing younger children.