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Welcome to the page optometry created especially for School Nurse personnel

NASNClose your eyes and imagine that your vision screening equipment is age-appropriate and evidence-based. For information about which eye charts to toss, keep, and replace, refer to this article:

Nottingham Chaplin, P. K., & Bradford, G. E. (2011). A historical review of distance vision screening eye charts: What to toss, what to keep, and what to replace. NASN School Nurse, 26(4), 221-228.


Selecting an Eye Chart for Preschoolers

When selecting an eye chart for preschoolers, the National Academy of Sciences-National Research Council (1980) recommends choosing tests that:

LEA Symbols and HOTV ChartAppropriate eye charts for preschoolers from a joint Policy Statement of the American Academy of Pediatrics, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology include:

3 Common Early Childhood Vision Disorders

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Three common early childhood vision disorders that can lead to permanent vision disorders if not detected and treated early include:

1. Amblyopia

2. Strabismus

3. Abnormal refractive errors



Hyperopia Image

With hyperopia, distant objects are clear; close objects are blurred. This is also called farsighted vision.




Myopia Image

With myopia, near objects are clear; distant objects are blurred. This is also called nearsighted vision.




Astigmatism Image

A normal cornea is round, like a basketball. With astigmatism, the cornea is misshapen, resembling half a football, causing light rays to strike different parts of the retina. This causes blurred and distorted vision at both near and far distances.


5 Tips for Vision Screening5 Bits of Important Information to Share With Parents to Encourage Confirmatory Eye Exams

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  1. A failed vision screen indicates that your child may have a vision problem and the eye care professional will make that determination.
  2. You may see nothing in your child's behaviors that suggests your child has a vision problem.
  3. Children will not outgrow amblyopia (lazy eye) and strabismus (crossed eyes or lazy eye).
  4. Some undetected and untreated vision problems can lead to permanent vision loss.
  5. Children need to see well to learn well.

8 Tips for Screening the Vision of Reluctant Preschoolers

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  1. If you screen children with LEA SYMBOLS®, familiarize children with the symbols prior to vision screening day. For example, introduce the LEA 3-D PUZZLE™ in circle time or for play at the manipulatives table.
  2. LEA PuzzleSay you are going to play a game. Do not say, "I am going to test your eyes." This could frighten the child.
  3. Naming optotypes is a fast way of testing but requires a linguistic ability that we are not measuring. If you use naming, let the child choose the names for the optotypes. Accept the name the child suggests. It is a major error to suggest abstract names "circle" and "square" because they are not concepts of young children and may frighten the child so that answering stops. Matching is the best way of measuring just recognition. If you are screening children with disabilities or very young children and the child has difficulties with pointing or eye movements, see information on "Special use of the Puzzle board"
  4. Occluder GlassesIf a child will not name the optotypes and your eye chart includes response panels and individual flash cards, ask the child to play a matching game by pointing to the symbol on the response panel that matches the symbol on your chart. Another option is to place the individual flash cards on the floor in front of the child and ask the child to step on the symbol that matches the symbol on your eye chart.
  5. Refrain from giving young children responsibility for their own occlusion. Children are likely to peek, especially if one eye has amblyopia or blurred vision. Occluder glasses will increase testability in children who do not want to participate in vision screening.
  6. If a child strongly resists occluding one eye and does NOT resist occluding the other eye, the first eye may be preferred for vision and the second eye may have amblyopia. Try screening first with the second eye and then return to the first eye. If the child still resists, refer for a comprehensive, confirmatory eye exam.
  7. If you must direct a child's attention to optotypes, briefly use your finger or a pen to point above or below each symbol, but not directly on the symbol. Refrain from displaying one optotype at a time. Both can interfere with screening and result in an overestimation or underestimation of visual acuity.
  8. For untestable children, rescreen or refer for a comprehensive eye exam. Research from the Vision in Preschoolers Study suggests that untestable children are more likely to have vision disorders than children who passed vision screening. If you rescreen, the American Academy of Pediatrics suggests 4 to 6 mo. for children aged 3 and 1 mo. for children aged 4 and older.

1Maguire, M. G. (2007). Children unable to perform screening tests in vision in preschoolers study: Proportion with ocular conditions and impact on measures of test accuracy. Invest Ophthalmol Vis Sci, (48)1, 83-87.

33 Clinical Signs, Symptoms, or Family Member Observations
Suggestive of Eye/Vision Problems

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1. Defective ocular fixation or visual interactions
2. Abnormal light reflex (including both the corneal light reflections and the red fundus reflection)
3. Abnormal or irregular pupils
4. Large and/or cloudy eyes
5. Drooping eyelid
6. Lumps or swelling around the eyes
7. Ocular alignment or movement abnormality
8. Nystagmus (shaking of eyes)
9. Persistent tearing, ocular discharge
10. Persistent or recurrent redness
11. Persistent light sensitivity
12. Gazes at lights
13. Squinting/eye closure
14. Learning disabilities or dyslexia
15. Eyes that are red-rimmed, crusty looking, or swollen
16. Eyes that are frequently inflamed or watery
17. Styes that recur frequently


18. Pupils that look cloudy
19. Unable to make eye contact
20. Attempts to brush away a blur
21. Rubs eyes excessively
22. Frowns constantly
23. Shuts or covers one eye for visual tasks
24. Tilts or turns the head when looking at something
25. Leans forward to see better
26. Blinks excessively
27. Excessively irritable during close work
28. Stumbles or trips over objects
29. Clumsy in reaching
30. Dizziness, nausea, and headaches after close work
31. Statements such as "I can't see that."
32. Statements such as "I see two of them" (when only one object is present)
33. Complaint of pain in the eyes


Comprehensive Eye Examination: What Can I Expect To Have Done?

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The following may occur during your child's eye examination:

Visual Acuity:
Your child's vision will be checked to determine how well he/she can clearly see an object at a set distance. You will receive a visual acuity notation, such as 20/20. This test may involve identifying pictures on a chart.

Eye Alignment:
Various methods are used to determine how well your child's eyes work together. A light might be directed at your child's eyes to see if the light reflects from the same spot in both eyes. Your child's eyes might be covered, one at a time, to see if they move when focused on a target. If the light reflects at different points, or if your child's eye moves when covered, the eye muscles are not working properly.

Binocular Vision:
Tests are used to look at whether your child's eyes are working together and if the brain is seeing both images in order to have depth perception. Your child might be asked to find specific pictures while wearing 3-D glasses.

Tests will be done to see if your child is nearsighted, farsighted, or has astigmatism. A hand-held instrument, called a retinoscope, may be used to shine light into the pupil. The doctor may place various lenses in front of your child's eyes. If your child is nearsighted or farsighted, or has astigmatism, the light going through the pupil and reflecting off the retina in the back of the eye will look different. Using lenses of different powers will let the doctor determine what the glasses prescription should be.

Fundus (Retinal) Examination:
Drops may be placed in your child's eyes to dilate the pupils. It will take about 30 minutes for the drops to work and you may be asked to sit in the waiting room. Dilating the pupils allows the doctor to look into the back of your child's eyes with an instrument called an ophthalmoscope. This instrument is a special light that the doctor typically wears like a hat. The doctor is checking the blood vessels and nerves of the retina in each eye. The dilation drops may cause your child to have blurry vision and be sensitive to light. The dilation drops typically wear off in a few hours after the exam.

Depending on the results of the eye examination, your child may need glasses, an eye patch, surgery on the eye muscles, or your child's eyes may be working properly.


How Can I Get My Child to Wear Prescription Glasses?

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According to the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), "most young children who really need glasses will wear their glasses without a problem (happily) because they do make a difference in their vision." The AAPOS website has more helpful tips.

You may notice that your toddler chooses to wear the prescription glasses only when in a good mood.

What can you do to help your child wear the prescription eyeglasses?

For more information, visit the website of the American Association for Pediatric Ophthalmology and Strabismus

For a list of books about children wearing glasses, visit the website of the Vision Initiative for Children


Importance of Preschool Vision Screening: 6 Reasons

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Preschool vision screening is important for at least the following 6 reasons:

  1. Research suggests that 1 in 10 to 20 young children will have vision disorders that can lead to permanent vision impairments, including amblyopia (lazy eye), strabismus (lazy eye, misaligned eyes), and abnormal refractive errors, such as hyperopia, myopia, astigmatism, and anismetropia). If these disorders are detected and treated early, preferably before a child reaches age 5, many can be corrected. 2,5. 1,2
  2. Early detection and treatment increases a child's chances of achieving good treatment outcomes.2
  3. Professional experience indicates that oftentimes parents are unaware that their children have difficulty seeing clearly; thus, many vision problems are undetected by parents.3,4
  4. Young children are unaware of how they should see,4 typically cannot tell adults they have blurred vision, and must rely on adults to detect their vision problems. For example, a 5-year-old child who failed his Kindergarten vision screen in West Virginia, when asked by his mother why he did not tell her he could not see clearly, said, "I didn't know."
  5. Typically no pain is involved with vision problems.4
  6. Children do not "outgrow" amblyopia and strabismus.


1Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force (2004, May). Screening for visual impairment in children younger than age 5 years. Retrieved May 23, 2010, from

2Wasserman, R. C., Croft, C. A., & Brotherton, S. E. (1992). Preschool vision screening in pediatric practice: A study from the pediatric research in office settings (PROS) network. Pediatrics, 89(5). Retrieved May 23, 2010, from periodicsurvey/peds5_92.htm

3Brown, M. S. (1975). Vision screening of preschool children: How to check on visual acuity and heterophoria as part of a routine physical examination. Clinical Pediatrics, 14 (10), 968-973.

4Schmidt, P. P. (1997). Screening for the vision problems of young children. In B. Moore (Ed.), Eye care for infants and young children (pp. 175-189). Boston: Butterworth- Heinemann.


And The Answer Is . . .

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For a little fun, test your knowledge about vision and preschool vision screening.

1. Children know how they should see and should be able to tell us if they cannot see clearly.

True or False      -       Question 1: FalseGet the Answer

2. Many common eye/vision problems are detected by parents.

True or False?      -       Question 2: FalseGet the Answer

3. Watching television from less than 3 feet away will damage your eyes.

True or False?      -       Question 3: False, No damage will occur from sitting close to the television.Get the Answer

LEA Symbols Chart4. This eye chart to the right is recommended by the American Academy of Pediatrics.

True or False?      -       Question 4: True, LEA Symbols is a chart recommended by the American Academy of PediatricsGet the Answer

5. Holding a book close while reading damages your eyes.

True or False?      -       Question 5: False, Holding a book close does no damage. Holding a book close can be a sign of myopia (clear at near), but holding a book close will not cause myopia.Get the Answer

6. Reading in dim light is not harmful to your eyes.

True or False?      -       Question 6: True, A strong light may make reading easier because words are clearer to the visual system.Get the Answer

7. Preschool vision screening is important because we want to (select 2):

A. Help children make friends
B. Prepare children for kindergarten and learning
C. Protect vision as children grow into older adults who are likely to develop older adult eye disease
D. Help children run faster      -       Question 7: B and CGet the Answer

Kindergraten Chart8. The eye chart to the right is recommended by the American Academy of Pediatrics.

True or False      -       Question 8: FalseGet the Answer

9. The best distance to screen the vision of preschoolers is 20 feet:

True or False      -       Question 9: FalseGet the Answer

10. The eye care professional should dilate a child's eyes in a comprehensive eye exam:

True or False      -       Question 10: TrueGet the Answer

11. Three common early childhood vision disorders that we want to find through
preschool vision screening include (select 3):

A. Abnormal refractive errors
B. Amblyopia
C. Achromatopsia
D. Albinism
E. Cognitive delays
F. Communication delays
G. Strabismus      -       Question 11: A, B, and GGet the Answer

12. Preschool vision screening tests recommended by the American Academy of
Pediatrics include (select 2):

A. LEA Symbols
B. Blackbird
C. HOTV Letters
D. Kindergarten (Sailboat) Chart
E. "Hand" chart      -       Question 12: A and CGet the Answer

13. The best distance to screen the vision of preschoolers is 10 feet:

True or False      -       Question 13: True, 10 feet is recommended by the American Academy of PediatricsGet the Answer

14. Allowing children to use a hand to occlude their eyes during vision screening
is an appropriate occlusion method.

True or False      -       Question 14: False, Giving children responsibility for their own occlusion opens wide the door for peeking, especially if an eye has amblyopia or vision is blurred.Get the Answer

15. If a child fails preschool vision screening but does not act like he has a vision problem, it is ok to skip the follow-up eye exam:

True or False      -       Question 15: False, Many children do not exhibit behaviors suggesting they have a vision problem because oftentimes they have learned to compensate.Get the Answer

Typical Visual Development

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At birth:


Corneal reflex to touch; pupils react to light; rudimentary fixation; acuity estimated at about 20/400

1-3 months:

1 mo.

Regards faces

2 mo.

Eyes fixate, converge, and focus; follows vertical movements; prefers faces to complex patterns; attends to objects up to 6 feet away; becomes aware of bright lights (stares) and colors (yellow, orange red)

3 mo.

Eye movements become smoother; glances at 1" object; anticipates feeding via visual stimulus

3-5 months:

4 mo.

Hand regard (15 weeks); eyes begin to shift focus; recognizes familiar faces (smiles); visually
explores new environment; follows objects past midline; capable of horizontal, vertical,
circular eye movements, though may still be somewhat uncoordinated; unsuccessful
reach for dangling object; regards object in hand, and mouths

5 mo.

Eye-hand coordination developed and successful; gazes at objects close to eyes; can fixate
at 3' and then shift gaze to near point

5-7 months:

6 mo.

Eye movements coordinated and smooth; shifts visual attention easily; recognizes faces
up to 6' away; form discrimination emerges; transfers object from hand to hand with
visual monitoring; may anticipate position of falling object; fixates where object has disappeared;
acuity approximately 20/200

7 mo.

Manipulates objects; acuity near normal; depth perception developing

7-11 months:

7-8 mo.

Turns object in hand and explores visually

9-10 mo.

Can see tiny (2-3nim) objects nearby; observes facial expressions and tries to imitate;
looks for object seen hidden; visually alert to new objects, persons, places; vision monitors
hand and body movements

12 months:


Far and near acuity good; binocular vision stronger; has focus and accommodation; depth
perception good; discriminates geometric forms; scribbles spontaneously; vision monitors
movement in space

12-18 months:


Vertical orientation (walking; building block towers); matches identical objects; points to
pictures in a book; scribbles vertically, horizontally, and in circular motions; identifies

18-24 months:


Inspects objects visually (alone); imitates movements of others; increased visual memory;
all optical skills smooth; matches color and form

3 years:


Matches simple forms (form board); can do simple puzzles; can draw crude circle; places
1" peg in holes

4 years:


Discriminates size (matching); good depth perception (accurate); discriminates length of
lines; copies cross; discriminates most forms; eye-hand coordination precise

5 years:


Picks up and releases objects precisely; colors; cuts; pastes; gross motor control better
than fine; can draw a square; nests blocks with visual judgment; perceives detail in pictures

Child Classroom and Home Misbehaviors That May be Related to Vision

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"Our story is about 'Amelia', who seemed sort of spacey, as if she were in her own little world, usually a step behind the other students. She would often interrupt story time to come forward and peer at the pictures in the book. Her very astute teacher recommended that she be one of the first to participate in vision screening. And her teacher's instincts were quickly proven correct! Poor Amelia couldn't even see the practice panels with both eyes!

Amelia's mother immediately made an eye appointment and by the following week, Amelia was proudly wearing a new pair of glasses!

The cutest moment was when she and a friend were walking hand-in-hand around the playground. He was pointing out different things to her, and she would excitedly exclaim "I can see that now!" Amelia is now very aware and an active participant of everything that is happening in the classroom and will truly be ready for kindergarten!"
Head Start, Monongalia County, West Virginia

This Mom had concerns about the vision of her younger son and took him to a community health fair for vision screening, thinking if he failed the vision screen, she would schedule an eye exam. He failed his vision screening. A subsequent eye exam indicated that he required prescription glasses.

Those glasses have made an incredible difference for her son. Previously, she experienced difficulty trying to read to him because he would not sit still. Now, he sits in her lap while she reads a book from start to finish.

Previously he would run around the room instead of watching TV with his brother. Now, he watches cartoons with his brother without running around the room.

At age 4, he is achieving greater success at his daycare. Before the vision screening and eye glasses, he was "up and moving" during circle time. "He was kind of a loner before. He would get bored." Now he sits and participates in group activities.
Parent, Preston County, West Virginia

"After he received his glasses, he was like a different child. He seemed happier and less frustrated. Before his glasses, he would become frustrated trying to write his letters or draw. Now he likes to work on his letters."

The child shared that, before glasses, "things looked dusty".
Parent and Son, Marion County

"At XXXX Collaborative Preschool all the preschool children were vision screened mid-September. 'Sally' failed the screening with her left eye. Her mother called me to see if she should make an appointment with the doctor. I explained that this was a screening and that the children were still new in school. I would be rescreening in mid-October to see how they do.

When 'Sally' was rescreened, she again failed with her left eye. Being concerned, 'Sally's' mom immediately made an appointment for a full eye exam.

'Sally' returned to school with glasses to correct her vision and has done very well wearing them. 'Sally' does not have to squint when she is in circle and they are doing activities such as calendar time or weather chart. She wears them for class work and takes them off and stores them in her cute little pink case for recess, gym, and naps."
Head Start, Marion County, West Virginia

"I remember clearly one of the first vision screenings I completed. It was on a little girl who we had already realized was very clumsy. When I did the screening and she was referred I had no idea how that would affect her. She was prescribed very strong lenses and we immediately realized that her vision was the reason for her clumsiness. I have realized through these screenings that vision can affect a child's behavior, balance and academic performance."
Head Start, Nicholas County, West Virginia

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