Evaluation of the Visual System by the Primary Care Provider Following Concussion.

Concussion is a common injury in childhood and has the potential for substantial impact on quality of life. Visual issues have been increasingly recognized as a common problem after concussion. Many children initially seek care for concussion with their pediatrician, making it even more important for pediatricians to recognize, evaluate, and refer children with visual issues after concussion. This clinical report is intended to support the recommendations in the companion policy statement on vision and concussion and provides definitions of some of the physiologic aspects of the visual system as they relate to concussion. A description of clinically feasible testing methodologies is provided in more detail to aid the clinician in assessing the visual system in a focused fashion after concussion. This guidance helps direct clinical management, including support for return to school, sports, and other activities, as well as potential referral for subspecialty care for the subset of those with persistent symptoms.

Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment.

Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.

AAPOS uniform guidelines for instrument-based pediatric vision screen validation 2021.

BACKGROUND: As instrument-based pediatric vision screening technology has evolved, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) has developed uniform guidelines (2003, updated 2013) to inform the development of devices that can detect specified target levels of amblyopia risk factors (ARFs) and visually significant refractive error. Clinical experience with the established guidelines has revealed an apparent high level of over-referral for non-amblyopic, symmetric astigmatism, prompting the current revision. METHODS: The revised guidelines reflect the expert consensus of the AAPOS Vision Screening and Research Committees. RESULTS: For studies of automated screening devices, AAPOS in 2021 recommends that the gold-standard confirmatory comprehensive examination failure levels include anisometropia >1.25 D and hyperopia >4.0 D. Astigmatism >3.0 D in any meridian and myopia < -3 D should be detected in children <48 months, whereas astigmatism >1.75 D and myopia < -2 D should be detected after 48 months. Any media opacity >1 mm and manifest strabismus of >8Δ should also be identified. Along with performance in detecting ARFs and refractive error, validation studies should also report screening instrument performance with regard to presence or absence of amblyopia. Instrument receiver operating characteristic curves and Bland-Altman analysis are suggested to improve comparability of validation studies. CONCLUSIONS: Examination failure criteria have been simplified and the threshold for symmetric astigmatism raised compared to the 2013 guidelines, whereas the threshold for amblyogenic anisometropia has been decreased. After age 4 years, lower magnitudes of symmetric astigmatism and myopia are also targeted despite a low risk of amblyopia, because they can influence school performance and may warrant consideration of myopia prevention therapy.

12 Components of a Strong Vision Health System of Care: Part 3-Standardized Approach for Rescreening.

Strong school-based vision and eye health systems include 12 key components to be implemented before, during, and after the actual vision screening event. The National Center for Children's Vision and Eye Health (NCCVEH) at Prevent Blindness partnered with the National Association of School Nurses (NASN) to provide guidance for school nurses for each of the 12 key components via a Vision and Eye Health webpage on the NASN website ( https://www.nasn.org/nasn-resources/practice-topics/vision-health ). This online resource is designed to support school nurses accountable for vision screening and maintaining the eye health of preschool- and school-age children. This NCCVEH/NASN webpage addresses key activities that provide overall support for a child's vision and eye health-beginning with parent/caregiver education and ending with an annual evaluation of the school's vision and eye health system. NASN School Nurse is publishing information about each of these 12 components. The May 2019 installment provided details about the 12 Components approach as a whole and Components 1 and 2: Family Education and a Comprehensive Communication/Approval Process. The July 2019 edition described Components 3 and 4: Vision Screening Tools and Procedures and Vision Health for Children With Special Health Care Needs. This article describes Component 5: Standardized Approach for Rescreening.

12 Components of a Strong Vision Health System of Care: Components 1 and 2-Family Education and Comprehensive Communication/Approval Process.

The National Center for Children's Vision and Eye Health (NCCVEH) at Prevent Blindness partnered with the National Association of School Nurses (NASN) to provide guidance for school nurses responsible for screening the vision of preschool and K-12 students. Goals of this national partnership are to (1) standardize approaches to vision health, (2) facilitate follow up to eye care for students who do not pass vision screening, (3) provide family/caregiver friendly educational information, and (4) consult with leading pediatric eye care experts to promote evidence-based best practices. The NCCVEH/NASN partnership created a Vision and Eye Health page on the NASN website ( https://www.nasn.org/nasn-resources/practice-topics/vision-health ). This resource is organized according to the 12 Components of a Strong Vision Health System of Care. The 12 components emerged as the NCCVEH considered vision screening from a systems perspective. This systems perspective addresses key activities along the entire spectrum of care that supports a child's vision health-beginning with parent/caregiver education and ending with an annual evaluation of the school's vision health system. Each of these 12 components will be described in 4 installments of NASN School Nurse in 2019. This installment describes the first two components: Family Education and a Comprehensive Communication/Approval Process.

12 Components of a Strong Vision Health System of Care: Part 2-Vision Screening Tools and Procedures and Vision Health for Children With Special Health Care Needs.

Successful vision screening efforts require the implementation of 12 key components of a strong vision health system of care. The National Center for Children's Vision and Eye Health (NCCVEH) at Prevent Blindness partnered with the National Association of School Nurses (NASN) to provide guidance around these 12 components via a Vision and Eye Health webpage on the NASN website ( https://www.nasn.org/nasn-resources/practice-topics/vision-health ). This online resource is organized according to the 12 Components of a Strong Vison Health System of Care to support school nurses accountable for screening the vision of preschool and K-12 students. This NCCVEH/NASN webpage addresses key activities that support a child's vision health-beginning with parent/caregiver education and ending with an annual evaluation of the school's vision health system. Each of these 12 components will be described in NASN School Nurse. The May 2019 installment provided information about the 12 components approach as a whole and details on Family Education and a Comprehensive Communication/Approval Process. This installment describes Components 3 and 4: Vision Screening Tools and Procedures and Vision Health for Children with Special Health Care Needs.

An Eye on Vision: Five Questions About Vision Screening and Eye Health.

Current evidence-based and best-practice vision screening and eye health approaches, tools, and procedures are the result of revised national guidelines in the past 3 years and advances in research during the past 18 years. In providing answers to the five questions in this article, the National Center for Children's Vision and Eye Health at Prevent Blindness used published, peer-reviewed research; vision screening and eye health national guidelines; and consensus-based best practices from eye care professionals and public health experts. The answers may differ from your state or district vision screening guidelines and mandates. This is the second installment of the "An Eye on Vision" frequently asked questions section that will appear in future editions of NASN School Nurse. To review the first installment, see the March 2018 edition of NASN School Nurse. The authors encourage vision screeners to submit their vision screening and eye health questions to the email address that appears at the end of this article.

An Eye on Vision: Seven Questions About Vision Screening and Eye Health-Part 4.

Current evidence-based and best-practice vision screening and eye health approaches, tools, and procedures are the result of revised national guidelines in the past 3 years and advances in research during the past 18 years. To help the busy school nurse with little time to keep up with changes in children's vision practices and a growing body of literature, the National Center for Children's Vision and Eye Health at Prevent Blindness is providing answers to seven questions that are often received from the field. Topical areas are (1) instrument-based screening and stereopsis, (2) optotype-based screening if child is referred from instrument-based screening, (3) next steps if a student's glasses are scratched or broken, (4) critical line screening with a threshold eye chart, (5) full threshold screening if student does not pass critical line screening, (6) holding a ruler beneath line of optotypes to identify, and (7) convergence insufficiency screening in the school setting.

An Eye on Vision: Five Questions About Vision Screening and Eye Health-Part 3.

Current evidence-based and best practice vision screening and eye health approaches, tools, and procedures are the result of revised national guidelines in the past 3 years and advances in research during the past 18 years. To help the busy school nurse with little time to keep up with changes in children's vision practices and a growing body of literature, the National Center for Children's Vision and Eye Health at Prevent Blindness is providing answers to five questions that are often received from the field. Topical areas are: (1) instrument-based screening for children ages 6 years and older, (2) stereoacuity screening and Random Dot E, (3) binocular distance visual acuity screening, (4) a 2-line difference between the eyes as part of referral criteria, and (5) state vision screening guidelines excluding evidence-based tools.

An Eye on Vision: Five Questions About Vision Screening and Eye Health-Part 2.

Current evidence-based and best practice vision screening and eye health approaches, tools, and procedures are the result of revised national guidelines in the last 3 years and advances in research during the past 18 years. To help the busy school nurse, with little time to keep up with changes in children's vision practices and a growing body of literature, the National Center for Children's Vision and Eye Health at Prevent Blindness is providing answers to five questions that are often received from the field. Topical areas include (1) which numbers to record when using a 10-foot chart, (2) instrument-based screening and visual acuity, (3) screening children who wear glasses, (4) referring children who do not pass color vision deficiency screening, and (5) conducting near visual acuity screening monocularly or binocularly.

An Eye on Vision: 20 Questions About Vision Screening and Eye Health.

Current evidence-based and best practice vision screening and eye health approaches, tools, and procedures are the result of revised national guidelines in the past 3 years and advances in research during the last 16 years. To help the busy school nurse with little time to keep up with changes in children's vision practices and a growing body of literature, the National Center for Children's Vision and Eye Health at Prevent Blindness is providing answers to 20 questions received most often from the field. Question topics are: (1) arranging the screening environment, (2) occluders to cover the eyes during vision screening, (3) optotype-based screening at distance, (4) optotype-based screening at near, (5) instrument-based screening, (6) muscle imbalance screening, (7) referrals, and (8) vision screening certification.

A historical review of distance vision screening eye charts: what to toss, what to keep, and what to replace.

Vision screening protocol and equipment guidelines differ among schools across the United States. Budget cuts are forcing many school nurses to reevaluate their vision screening programs, as well as items in their vision screening toolboxes. School nurses tasked with inventorying those toolboxes to determine which items to toss, keep, or replace are oftentimes perplexed by the copious choices featured in vendor catalogs and websites. For school nurses who want their vision screening toolboxes to include eye charts, national and international eye chart design guidelines are available to help ensure selected eye charts are standardized. A national consensus policy exists that recommends specific eye charts. And, a large body of vision screening literature is available to help school nurses make informed decisions. Current documents suggest that LEA Symbols are appropriate for young children and Sloan Letters are a better choice than "Snellen" charts for older children.

Legislative issues facing pediatric ophthalmology in 2006.

PURPOSE OF REVIEW: There has been a surge in legislative activity concerning children's vision in recent years. This review will summarize and compare newly enacted state statutes and review legislation that has been introduced at both the state and federal level. Detailed reference sites are provided and may be a useful resource for those involved in legislative advocacy. RECENT FINDINGS: The legislative arena has often mirrored the disparate views of ophthalmology and optometry regarding the most appropriate methods for identifying vision problems in young children. While state legislation mandating comprehensive eye examinations for all asymptomatic and risk free children was passed in Kentucky in 2000, no other state since has successfully enacted and implemented similar legislation. In contrast, numerous states, have enacted mandatory preschool vision screening legislation. Federal legislation, introduced separately by ophthalmology and optometry, would provide funds for uninsured children's eye exams, but the two bills have important differences in eligibility requirements. Issues such as eye safety and retinoblastoma detection have also been addressed through the legislative process. SUMMARY: There has been a myriad of state and federal legislative activity in the area of children's vision. The momentum is likely to continue as additional states file new legislation.

Project Universal Preschool Vision Screening: a demonstration project.

OBJECTIVES: Visual disorders among preschool-aged children are common, yet screening is infrequent. The purpose of this project was to implement the vision screening recommendations proposed by the Maternal and Child Health Bureau and National Eye Institute Vision Screening in the Preschool Child Task Force: monocular visual acuity and stereopsis testing. METHODS: Four sites fully participated in the implementation of the task force recommendations with 3- and 4-year-old children. Two of the sites worked with primary care practices (testing performed by staff); 2 worked with community-based programs (testing performed by lay volunteers). Each site tracked number of children screened by age, as well as proportion testable, referred, and with documented follow-up evaluation. RESULTS: Variations in implementation of the recommendations were observed. Successful screening among 3-year-olds ranged from 70% to 93%; referral rates were 1% to 41%, and follow-up rates were 29% to 100%. Successful screening among 4-year-olds ranged from 88% to 98%; referral rates were 2% to 40%, and follow-up rates were 41% to 100%. The proportion of 3-year-olds who were treated was significantly different between the community-based sites (n = 20) and the primary care sites (n = 2). Similarly, the proportion of 4-year-olds who were treated was significantly different between the community-based sites (n = 36) and the primary care sites (n = 11). CONCLUSION: . The variability across pilot sites in numbers successfully screened and numbers referred suggests that all aspects of preschool vision screening need thorough review before the goal of universal preschool vision screening can be realized.