Children’s Vision Health Information for Staff and Families

Steve Shuman: Now we can get started. I'm so excited to introduce our colleagues from Prevent Blindness in the National Center for Children's Vision and Eye Health, Kira Baldonado and P. Kay Nottingham Chaplin. Kira?

Kira Baldonado: Thank you so much, Steve. We appreciate everyone taking time today to learn a little bit about children's vision health and we're going to provide information for staff and families. What we're going to talk about today is appropriate for both Head Start as well as Early Head Start staff. We will be providing a lot of information, and we want to thank the National Center for Health, Behavioral Health, and Safety for having us here for today's presentation. Next slide.

There we go. Thank you, Kay. She practiced it so much, everyone. We have two of us presenting today. As Steve mentioned, P. Kay Nottingham Chaplin. She works with our National Center for Children's Vision and Eye Health at Prevent Blindness and provides – as many of you out in the audience may have already received – technical assistance. She oversees our national online Prevent Blindness Children's Vision Screening Certification course.

Kay is well versed in vision, and she's been working with the topic of vision screening for 20 plus years, has co-authored many papers around vision screening, and presented at nearly 250 national webinars and presentations and conferences both at the state, local, and national level.

Then you also have myself, Kira Baldonado. I am vice president of Public Health and Policy for Prevent Blindness. I work to coordinate the mission driven programs that prevent blindness, including those of the National Center for Children's Vision and Eye Health.

I've worked in the area of vision for 18 plus years, specifically working in the areas of early detection, screening, eye health program improvement, and systems change. I have co-authored peer reviewed papers regarding vision screening and presented on the topic of children's vision and vision for adults as well at national conferences, webinars, and invited presentations at the state level. Kay?

About the National Center for Children's Vision and Eye Health at Prevent Blindness, just so you know where we're from. Prevent Blindness, the parent organization, was established in 1908 with a mission to prevent blindness and preserve sight. We worked this mission through public and professional education, advocacy for change, and empowering individuals and systems of care.

One of the ways that we work to empower systems of care is through our National Center for Children's Vision and Eye Health, which was established by Prevent Blindness in 2009. That center functions as a national resource center, working to find systematized, uniform approaches for children's vision for throughout the United States and beyond.

The way that our National Center works to elevate our approach is we work to promote uniform policies, evidence-based best practices, leadership training opportunities to support vision health. We provide guidance for improved follow-up to eye care, which is really critical after a vision screening referral for children who may be underserved or vulnerable populations, making sure they get connected to care.

Our work is advised by a committee of family advocates, as well as national experts, in Children's Vision, ophthalmology, optometry, pediatrics, nursing, family engagement, and public health, all to make sure that the work of the center is evidence-based and forward looking. We work to create resources, provide that technical assistance, and develop national partnerships to make sure our approach is advance for children's vision nationally.

Our work specifically with the National Center for Health, Behavioral Health, and Safety is around developing educational resources, developing and delivering professional education, such as today. We work to provide technical assistance to those programs of you out in the audience, should you have questions around children's vision or eye health programs. Next slide.

P. Kay Nottingham Chaplin: The newsletter.

Kira: Oh, thank you very much, Kay. Very important. Kay's advanced the sign up for our newsletter. Again, this is a link that's on the handout that's been placed in the chat. Be sure to look for that handout, the PDF with all of the links. You can sign up for the newsletter for the National Center for Children's Vision and Eye Health, so you'll be the first to know when we have new resources, information, highlighting research, and all things to be known about children's vision. Now you can advance.

Our presentation today is based in 12 components of a strong vision health system of care. There are several pieces that need to take place, be functioning well, in order for children's vision to work properly. Our presentation today is going to focus on two of those 12 components, the first one being that we want to make sure that parents and caregivers receive educational material, which respects their cultural and literacy needs about the importance of good vision for their child now and the future and scheduling and attending an eye exam when the child does not pass a vision screening. That's one of the 12 components. The link down there at the bottom will take you to an overview of all 12 components. Kay, if you can advance …

The second component that we'll be touching on today is looking at screening vision with appropriate and evidence-based tools and procedures, including both optotype-based tests, or a picture-based charts, and/or instruments. Our work follows national referral and rescreening guidelines, making sure that we include vision screening training for staff that leads to certification and evidence-based screening approaches and the other piece of that component is to ensure that any contracted screening organization also used evidence-based approaches and national referral and risk screening guidelines.

There is a link down there, again, on the slide and also on your handout, which will take you to our resource vision screening guidelines by age. This is a resource that helps you understand what to observe about a child's eyes as a part of the screening process. This will be appropriate for screening children of all ages seen in Head Start as well as Early Head Start, so children from birth to the first birthday, toddlers ages 1 and 2 years, and preschoolers ages 3, 4, and years old. This page that has the link here has a table of evidence-based tools that you can use for each of the different age groups. Please take a moment to check it out after today's webinar.

Our objectives today … There are three objectives. The first one is to identify materials in the toolkit that will help families have a better understanding of the importance of good vision for their child's ability to learn. We'll feature the small steps for children's vision to help you understand and learn about each of those materials.

The second objective, to identify materials and activities in the toolkit that will help families understand the importance of completing that follow-up to eye examination after a vision screening referral, adhering to treatment as prescribed and receiving ongoing vision care after the screening referral.

Then, our third is to empower adult family members with resources about the importance of caring for their own vision. We find that families who aren't taking care of their own vision as adult are less likely to take care of the children's vision. We're going to want to empower the adult family members as well.

Today we want to highlight the importance of vision screening and follow-up to eye examinations. Why is that important? Vision issues are very common in the age groups that you all are seeing. Approximately one in five preschool age children in the US, including those in Head Start, have a vision disorder that require monitoring and/or treatment by an eye care professional. It's very common. One child in every five. We need to make sure that we're screening regularly and making sure children are getting follow-up to care.

For the younger age group, for those in Early Head Start, the evidence is still emerging around that. We don't have the same kind of prevalence number for that age group, but certainly trying to improve surveillance systems so we do have a better idea of that number for Early Head Start infants and toddlers but still as important.

Why do vision screenings, follow-up eye examinations after vision screening referrals, monitoring, treatment by doctors, and ongoing vision care matter? Because children whose vision disorders are left undetected and untreated get more difficult to treat the longer that they're able to go. They lead to worsening and possibly permanent vision loss that will be carried on throughout the lifespan of that child and may impact learning if they're not treated early.

Oftentimes, around the age of seven is kind of considered the critical age that we try to have vision problems identified and treated. You can see you guys are playing a really important role at really critical ages to identify those problems and get them to treatment. These are the references for the previous slides.

Just to reiterate, for good vision a child needs to have straight eyes – two eyes that are looking in the same direction at the same time. The eyes and the vision system need to work correctly. All the different pieces and parts need to be working together in the way that they are supposed to be working. It's not just the eyes are straight, that the eyes and the brain are able to communicate together.

We need to make sure that the brain is receiving a focused and clear image from each of the eyes. We want to make sure the eyes are working like this, and not like this. That second picture could just be all blur, and a child with a vision disorder might not even know that those giraffes have eyes. That's a true story that we can draw from.

How is clear vision helpful for children? It's not just a matter of identifying and getting those vision problems treated early. You're actually going to impact a lot of other areas for children: healthy development, their ability to learn, a child's self-esteem and confidence, their athletic ability, improve behavior. All of those things are going to be impacted by healthy vision, but we can't see that kids can't see. By vision screening, helping families connect to eye care, making sure that they're keeping up with a treatment – that's an important role that you can play to make sure that children have their best vision possible. With that, I will pause and turn it over to Kay. Kay?

Kay: Hello, everyone. Thank you so much for joining us. I'm going to be starting here with our small steps for big vision. It has three key components. It does have a scripted PowerPoint presentation for staff with handouts and fun activities for parents to conduct a parent vision meeting, which can be conducted through Zoom. It has parent/caregiver resources and information to help parents care for their own vision and eye health as Kira alluded to earlier.

Let's talk about the pathway from vision screening referrals to an eye examination in a "ideal world." In this ideal world, a child would receive vision screening and referral for an eye examination if the child does not pass vision screening. The next step in the pathway is that parents, caregivers, grandparents – whomever – would schedule and take their child to an eye examination when their child receives a vision screening referral. The third step in this ideal pathway would be that the child attends an eye examination, receives treatment, and/or monitoring, and continues ongoing care – not just the one and done, but ongoing care.

Some misconceptions we have around this is that as vision screeners, we often think that parents, and caregivers, and family members will automatically follow this ideal pathway from receiving a vision screening referral, scheduling, and taking their children for an eye examination, receiving treatment, which may be just monitoring for a while, and continuing ongoing vision care. We may not always consider barriers, such as the level of knowledge that parents, caregivers have about vision and eye health, how they feel about their children wearing glasses, or other barriers and cultural beliefs related to the follow-up eye examination and ongoing vision and eye care.

What we've found that a breakdown in the ideal world pathway often happens at this step, where the parents schedule and take their child to an eye exam when their child receives a vision screening referral. This is often the breakdown.

We wanted to know why. What were all the reasons? We know transportation, it's always – not always – but typically a barrier. But we wanted to know what various barriers were, and we wanted to create an intervention to help reduce the gap between the vision screening, referral, and the eye examination treatment and/or monitoring, and ongoing care component. We started out in 2013 with a focus group with Head Start parents and among the items of great information they gave to us was to help parents get educated about eye and vision issues and to provide information about how children can be affected by poor vision or bad vision that has not been treated.

Then in 2013, we also ran a national survey on vision screening with Head Start staff. We found that lack of knowledge about the importance of vision was a strong barrier to the follow-up exam. Ninety-six percent of 131 respondents told us that informational materials and resources about vision screening for parents and caregivers would be useful. Then, we've conducted a literature review of barriers to our care, found multiple studies showing lack of knowledge about vision and eye health as a barrier to the eye exam. A strategy to improve follow-up was to provide more education about vision, and eye health, and timely follow-up.

Looking at all of that information, our intervention to help reduce the gap was to provide the education and information pieces through Small Steps for Big Vision and Eye Health Information Toolkit for Parents and Caregivers. This toolkit is online but for families who lack appropriate broad bandwidth, do not have internet, do not have smartphones. We also have paper packets, and all of this information is in English and Spanish.

How did we create the toolkit? We worked with focus groups with Head Start families, we developed a presentation, and we had five programs that were pilot programs. They pilot tested our program materials two times, and parents were involved. Then, we revised materials. All of this was made possible by our funding from Federal HRSA’s Maternal and Child Health Bureau. It was extremely helpful to have the five Head Start pilot programs to work with us and their parents so that the material would be what families needed.

The primary blocks in the Small Steps website, and link is at the bottom. As Kira said, you will be receiving – may have already received – links to the handouts that has links to all of the links on the PowerPoint. We have an introduction, which talks about Small Steps, how to run a vision meeting, parent resources. Then we have a block on what parents said about the meeting because we thought that might be helpful to hear their comments as well.

In the presenter information, we do have a presenter guide that explains how to run the meeting. It includes invitations – a sign in sheet includes handouts – experiential activities to help families get an idea of how their child may be viewing the world with the vision problem, and then again, the scripted PowerPoint. The scripted PowerPoint has notes and it even has embedded language. If some of you struggle with the words amblyopia and strabismus or an isometropia, those are embedded in the PowerPoint. You can just click on it, and it will say, “This word is pronounced amblyopia.” Again, The PowerPoint presentation is in either English or Spanish or a combination of both English and Spanish.

Now, I mentioned the experiential activities. There are four of them. One is a blurred vision simulation. Another is making their own simulator glasses and playing around with them looking at charts. Making their own occluder glasses – I think I just reversed those. Then, role play. But probably the favorite one would be the blurred vision simulation. Just to give you a quick idea, parents are given rolled sheets of plastic wrap, and then there's an eye chart 10 feet from them. They put the plastic wrap over their eyes and try to read the 2032 line of the chart, which is the line that they would read for their ages.

Then, they do that at distance and then for near, they either try to look – again, wearing the plastic wrap – at a cell phone, smartphone text message or a book. Then, they're asked questions such as, “Is it easy or difficult to see clearly? Were you comfortable or frustrated as you tried to see clearly? How would blurred vision impact your daily activities? How might blurred vision impact your children's learning and daily activities? What could you do as a parent or caregiver to help ensure your children can see clearly?” That's been successful with many parents. They get a better idea.

What do attendees say about the parent meeting and their evaluations? These are open-ended. They could write whatever they want, and we just pulled out a few: "My child may not be able to see even if I think they can," and "Parents usually don't know their child has a vision problem." This parent liked the explanation of how vision affects the child's ability to learn and to socialize with others. "Children don't know they have vision problems" … "I learned that vision problems may lead to permanent vision loss if not treated” … "Vision problems can even affect a child's behavior in the classroom." We just pulled a few, again, they were open-ended.

Now I want to show you this video – it’s around 40 seconds – from a parent who attended the session.

[Video begins]

Toneka Walker: The presentation today was very informative. It gave me a lot of information that I really had no clue about as far as vision care diagnosis that can be diagnosed on your child and ways to basically prevent those things and manage it if you do end up having some type of eye issue. Lots of information that I just had no clue about.

[Video ends]

Kay: This is a video that, again, is less than a minute from a Head Start director.

[Video begins]

Jessica Hollowell: First of all, from this meeting that we had with our parents, they took in a lot of great information. I think some stuff that they don't even think about. I had other things in the mind that thinking about and not necessarily thinking about the vision. We brought that to their attention. I think it opened up doors to think about, “Oh, what do I need to concentrate for my children” and how it helps them be able to see as they get into kindergarten. I think they got a lot of good information just to know what's going on. The parents that were not able to come, I think, the information would be shared with them too on a later day as far as the importance of vision and how to catch it at a very early age, so that they can be successful in learning, in the classrooms, and later on into adulthood.

[Video ends]

Kay: I liked what she said about the learning. How important good vision is to learning. Let's look now at the 10 top documents. There are several. I should have told you, when you download Small Steps, be patient. There is so much material on there that it takes about little less than a minute to download. Just be patient. Some of the documents, again, are in Spanish.

Did you know? I'll show you some of these: “10 Take-home Messages; Signs of Vision Problems in Children”; “The Association between Vision and Learning”; “Vision and Classroom Behaviors; the Difference between Vision Screening  and an Eye Examination,” which can sometimes be confusing; “The Importance of an Eye Examination”; “10 Steps from Vision Screening to the Eye Examination”; “How to Schedule an Eye Examination”; and then “Financial Assistance,” if that is needed.

Here is an example of the "Did you know?” … that children generally do not complain about problems with vision, parents and caregivers rarely know their child has a vision disorder, and uncorrected vision and eye problems can lead to a permanent vision loss. I'm not going to read the rest of this, but you see that includes steps for what parents can do around their children's vision.

Another popular document is a poster that lists “18 Milestones That Should Occur During The Child's First Year Of Life,” from birth to the first birthday. They can vary by 6 weeks, but this is just something as a leave behind or to give parents just so they can have this to monitor what's going on with their child's vision.

Then, the difference between a vision screening and an eye exam, again explaining that they are not the same procedures. Another document is the Importance of the “Follow-Up Eye Examination After the Vision Screening Referral.”

Then, 10 Steps From Vision Screening To Eye Examination, and it lists, again, the 10 steps to move from a vision screening referral to the eye examination. Then this document, “How To Schedule An Eye Examination?” … Literature shows that it's getting to the eye doctor is most successful if the eye examination appointment is made at the time of the vision screening but that cannot always occur.

This is a document that can be shared, and it even includes questions to ask the doctor during the eye examination because sometimes we all remember things after we get back at home that we wish we would have asked. It also explains how to prepare for the visit. There are links to videos about what will happen at the eye examination. It also includes financial assistance resources if needed for the eye exam or for glasses later.

Then this is an incredibly important one, the association between vision and learning. Finding lots of research emerging showing how poor vision can interfere with early literacy skills. I love this story of you can indulge me. She got an award because she is one of the highest-ranking children in her class and reading. I said, “Wow.” She said, “Yeah, mom. I put on the glasses, and I am reading.” That came out of a research article, and it gives me a chill bumps every time I read it.

This is a section for parents to help parents for family members to care for their own vision, that they want to be driving, seeing the way. This picture is depicted on the left versus the way it's driving. You look at the way you're driving with poor vision.

The small steps cool kit, tool kit – it is a cool toolkit – helps us to understand that children need good vision for learning and development. Children need an eye examination when they do not pass vision screening. Parents and caregivers should take care of their own vision and eye health, and it is our hope that through this toolkit that parents schedule and take their children to an examination when the children receive a vision screening referral, and children receive ongoing care, which again may just be monitoring. It may not always be glasses, but that is the conclusion of this part, and I will transition back to Kira.

Kira: Thank you, Kay. I think that term you just coined a cool kit is going to stick. I'm afraid all of you might have to hear that again someday, but stay tuned. Now, I just want to take a look at a few resources. It's a dozen resources that we have to offer to help you in your vision screening and eye health program, help children and family members get that follow-up to eye care when there is a vision screening or for referral or the parents need some help and taking care of their own vision. Let's explore some of those resources.

The first three, again, reiterate the 12 components. As we've discussed today, the parent education and vision screening with evidence-based tools … Those are just two components of the 12 components of a strong vision health system of care. The first resource is that whole link to the entire 12 components. I encourage you to check those out. Look at each of the different components, and identify ways that you can continue to build and grow your own vision and eye health program.

The next resource digs into those 12 components a bit and provide you with a way to evaluate your program, to go through and identify areas where you do have the resources, the skills, the practices in place or areas where you do not. It provides you with an opportunity to identify your top needs for your program, and ways to help improve those areas as a targeted approach.

Then third, just to reiterate the vision screening guidance by age. Again, the link is there and is available on the handouts from today's webinar. Those will provide you with your practices that are evidence-based and reviewed by experts for children of any age that you're seeing from Early Head Start through Head Start itself. Next slide, Kay.

Then, the next few resources … We've had the opportunity to produce a few of them in concert with the National Center for Health, Behavioral Health, and Safety. The first one is new. This year, “Screening Toddlers Ages One and Two Years Old” … really focusing on that young age group seen an Early Head Start. Then, we also worked with the National Center for Health, Behavioral Health, and Safety to develop the next resource, the “Vision Screening Fact Sheet.” Definitely refer to that for guidance on the overall policy, and approach, and practices related to vision screening as it relates to Head Start.

Then, the third resource here, “Promoting Family Vision And Eye Health” … We want to make sure that you really emphasize the importance that family members are seeing, well, they're the ones driving the children around to the Head Start Program, to the Early Head Start Program, to health appointments. We want to make sure they feel that they have healthy vision, they have opportunities to get that for themselves, and they're then a good example to the children that you may be referring for eye care.

Then, as we feature today, our “Family Vision and Eye Health Education: Resource Small Steps For Big Vision” ... Again, this is a cool kit. A cool toolkit that, really, Kay led the development of in concert with a lot of great partners, and I encourage you to check it out. Again, give it a moment or two to download depending on your internet speed, but there would be a lot of great resources that will help the families you serve.

Our next resource here is Children's Vision Digital Screen Tips. This has been a topic that I'm sure many of you have heard about. This really exploded. Importance, especially during the pandemic is the amount of time that we're all spending on digital screens – and especially children being exposed to digital screens … What does that mean for their vision? What are some signs of issues that we may need to take action on, that may need to connect the child to eye care if we see these signs? What are some things that families and centers can do to help make sure that kids vision remains healthy?

All of that is on this downloadable poster. It's in English and Spanish. There may still be some printable copies available through our partners, so we can connect you with that. It's just a great easy downloadable resource you can hang up or share with your families through your program.

Then again, I noticed in the chat some people mentioned that some families may be uninsured for vision, which unfortunately at this point in time is still true for many individuals. Our last resource here is the Financial Assistance Programs for Eye Care. It does provide eye care services for children and adults. There may be individuals who need help with different kinds of vision surgeries even or affording different kind of pharmaceutical drugs for their treatment, all of that is on this financial assistance document. That link is what you may want to bookmark because we do try to add new things to this. Every year, there are more opportunities for financial assistance, and we try to keep this document updated throughout the year. It's a really important one.

Then, a few other additional resources … Our professional development resource … There are a number of resources that are included on the website. These include reports, and white papers, and all kinds of documents that if you need to help make the case for children's vision, guidance on what to do with your vision and eye health program … All of that is at that link for the professional development resources. Check those out.

Then a timely one that was just updated within the last month or so is our guidance for vision and eye health programs as it relates to screening during COVID-19. If you have not already gotten that document and considered the guidance it contains for your vision and eye health programs, I do encourage you to check it out. If you had downloaded it several months ago, go back to this link and check it out. It has been updated just considering where we are currently in the COVID-19 pandemic.

Then, of course, there is opportunity for technical assistance. We coordinate that through the National Center for Health, Behavioral Health, and Safety. Connect with Steve, and he will reach out to us, and we can help provide that technical assistance around your program development, and proving your follow-up to eye care rates, communication with families about the importance of children's vision, and any other issues that you may need. As you're considering your own eye health program, and you have questions, I do encourage you to put your questions in the Q&A box down there. We'll have a few minutes to talk about those as we go through the end of today's webinar.

The call to action … Take time to educate parents and caregivers before the vision screening. You don't want the first time that a parent is thinking about their child's vision to be the point in time that they receive that letter for a vision or screening referral. They may have a lot of preconceived notions, concerns, frustrations, when they're receiving a letter. If they've been educated before that, then they'll know that there's resources out there, you're there to help them, and there's a lot of people that want to support them getting their child to an eye care provider and making sure that they have healthy vision for their lifetime. Take time to educate before.

Make sure that you conduct an evidence-based vision screening. When you are making that referral, it's based on procedures, practices, tools, devices that are meant to identify vision problems at the right age using the right kind of tool for where the child is developmentally … Follow those evidence-based vision screening procedures.

Help ensure that follow-up to eye care is available when children do not pass vision screening. There are many children who are able to be covered for vision care under Medicaid or a private insurance, but there are still many others who don't have those services in place as yet. There are a lot of programs out there that want to make sure that children get the care that they need. We have vouchers for free examinations, free eyeglasses for the child as well as the family. Don't let that thought of, “We can't afford eye care right now” be the reason that the child does not get follow-up to eye care.

Then, we want to make sure that children follow treatment plans. It's not enough just to go to the doctor, but if they're prescribed glasses, they should be wearing their glasses. If they're supposed to be patching because of possible amblyopia while they're in your care, make sure that they're patching. Help the parents understand the importance of that treatment so that if you have questions, or you need some support on your end, they're right there for you as a partner. Make sure that they're following up on the treatment plans. Also, if they’re prescribed to come back and get follow-up appointments, that they’re actually making those appointments. Be a partner with your families, and be a partner with your child's eye care provider to make sure that their vision is healthy.

Then finally, we can't say this enough, ensure that parents and caregivers are taking care of their own vision health. A lot of times – and I'm a mom; I do this too – you put your own health on the back burner to make sure that your family has what they need. I'm sure many of your parents and caregivers are doing the same. Just let them know that if they have a concern about their own vision. As you're teaching them about their child's vision, that you can be a partner in helping them meet that need as well. We'll certainly be a partner at Prevent Blindness and making sure they get donated care if they need it or connected to care if they need help with that. We're here for you as well. With that, I will pause and let Steve come in and help us answer some questions.

Steve: A cool kit indeed, Kira and Kay. That's wonderful. I know it's no coincidence because you work so closely with Head Start Programs and the National Head Start Association, but this kit and the materials you shared is so well aligned with Head Start and Early Head Start with parents as partners and working with parents from before we start screening children to all the way through follow-up and treatment. Cool indeed. Cool indeed.

We do have a number of questions, very exciting. The first one is if a child receives a referral using the vision screener, do we, the program, still have to wait two weeks and rescreen or can we use the initial referral and send it off right away?

Kay: Are they talking about … Do you have enough information to know if they're talking about an instrument?

Steve: That's not included in the question, Kay. But I think what happens is if the child doesn't pass the first screen, should they wait two weeks and rescreen before making a full referral?

Kay: OK. I'm going to answer that two ways, and Kira you chime in if you want. If they're using an optic-type base screening tool such as an art chart, our expert panel to the national center and our guidelines wrote to try to either rescreened … If you think you can get the kids back in, rescreen the same day if possible … Again, but no later than six months. If it is an instrument that does captures refractors or how the eyes look such as spot or plus optics, just go ahead and make the referral then unless you're – well, I ought not go down that road. Yeah, make a referral then. Kira, do you have anything to add?

Kira: I think just the consideration I would have put in there is here may be a guidance from the state that does require a rescreen in the case where you have state guidelines, where they say to rescreen, follow your state guidelines and doing so. But also, if you don't have state guidelines to follow, and you're concerned that I may not see this child again, go ahead and make the referral. It's better to get the child to eye care, get the treatment if need be earlier than losing the child.

It may be another three years before somebody checks on their vision, and there's a lot of time lost. Consider what your contact is with that child. If it's likely to be maintained, take the time to rescreen as Kay suggested. But if it's a very mobile community, you may not see the child again, get him referred and get him on that path to care.

Steve: Thank you both. A question about relatively newer technology: Do blue light vision glasses help? I'm assuming this with stress on the eyes that have been using screens.

Kay: Kira, I've seen mixed reviews on that in the literature, do you want to – I just took myself off video. Hello. Do you want to answer that one in more detail?

Kira: Well, I don't know if we'll call it more detail, but I'll say what I've heard from our expert advisory committee, especially as we were putting together the children's vision and digital devices poster, is that there's not a lot of evidence that show that the blue blocker glasses will provide a level of improvement, especially as it comes to children.

For children's vision, there are times when they should be exposed to some sunlight and get that, especially as we're trying to reduce the risk of myopia. They should be getting some outdoor time: one to two hours per day if possible, depending on the safety of their environment to get them exposed to a level blue light that helps with the proper formation of the shape of the eye. If you don't get enough blue light, then your eye elongates and that leads to myopia.

All of us staying inside, staying on devices, not getting that outdoor exposure … We're starting to see that we're causing a myopia epidemic in the US where it's already been seen in many other countries around the world. There are some positives for getting exposure to blue light, especially when it comes to young children's eye development, but the evidence is just not there to say consistently everybody should be wearing blue blocking lenses in a consistent way.

Kay: Kira, I would just like to add, during that one to two hours outdoors – because this may be even for families of older children – don't be looking at screens when you're outside during those one to two hours, that's –

[Laughter]

Steve: I think they call that counterproductive.

Kay: I think that's right.

Steve: Terrific. Thank you. That was more answer than I realized. That was great. What is the time frame for children to be rescreened for vision? I think you just touched on this, Kay. In Head Start, children have to get a vision screening within 45 days of enrollment. We are aware of that. If the child is uncooperative or doesn't pass their vision screening, when is the most appropriate time to be rescreened or do they get a referral after the first uncooperative or screening that the child doesn't pass?

Kay: Again, rescreened that same day if possible, and again, no later than the six months and that's way outside your 45-day timeline. But I do want to stress for those children who are untestable, and if you don't think you'll see them again, make a referral because the vision in preschoolers study group showed that children who were untestable were at least twice as likely to have a vision problem as children who passed. Don't lose those kids. Again, you can rescreen the same day if possible. If you can.

Steve: Thanks, Kay. Is there a recommendation to refer a child to an eye doctor or should the referral be to the pediatrician or other primary care provider? If it should be to an eye doctor and you live in a location with many eye doctors who take a variety of insurance providers, should you be referring to a specific provider or just to any eye doctor?

Kay: I'm going to start that, and Kira you can jump in. Ideally, in that ideal world, the child would go to an eye doctor, but some insurance programs or carriers recommend going to the child's medical provider first. In the paper that we wrote in conjunction with you guys, Steve, that Kira referenced earlier, we developed a list of questions to compile for eye doctors in the area – if you happen to be lucky enough to live in an area with multiple eye doctors – to collect information about each doctor and including the insurance that they take. Then, you want to make sure, first of all, that our doctor will see young children and then is taking new patients, likes kids, and takes that family's insurance. Anything you want to add, Kira, that I may have forgotten to say?

Kira: I just to reiterate that referring to a specific provider doesn't allow for that individual choice necessarily. At health care providers, everybody likes a different kind of person. As Kay recommended, if you want to put together a resource that helps individuals know what doctor options are in the area, those that are comfortable with children, and some of that detail around insurance – maybe languages spoken – that is a very helpful resource.

It's also an opportunity for your program to work with a student group, a parent advisory group member that may like to put that information together for you. This is a great way for your program to reach out and partner with another group to help collate and keep that information updated – because I know you all are very busy – and asking you to put together a list of doctors with all those questions is a lot to ask. It's a great opportunity to partner, get a resource developed that's local but also provide options that people can choose the right provider that's for them. You don't limit people accidentally by just pointing to one.

Kay: Those questions are in the document for screening toddlers ages one and two years.

Steve: That resource is on ECLKC and linked on the handout as well. Thank you. We have a few more questions and a few more minutes. This one, and a lot of the questions have been about screening, as you know … Does Plusoptix qualify as an evidence-based tool for vision screening? is that something on your list?

Kira: Yeah, you'll find that Plusoptix on our list of devices. Again, go to that vision screening guidelines by age. That link will connect you both to what's right for what age group and also point to the tools that are appropriate for that age group. You'll find Plusoptix on there along with Sport and others to consider. That would be fine.

Steve: Great. Here's a question I don't even know the answer to. If a child is playing outside, how long should they wait before you screen that child? In other words, their exposure to sunlight.

Kira: Children are very good at adapting from outside to inside – versus us adults that over time take a little bit longer. I would give them a few minutes, probably let them calm down, get a drink of water, and should be fine to go ahead and screen after that. They don't need half an hour or anything like that to accommodate from being outside to inside.

Steve: Thank you. Any tips for getting young children to sit still during a vision screening?

Kay: If you're talking about one and two-year-olds, of course the instruments make noises … That's to draw the children's attention. If they're looking at an art chart, you just want to make it a game, and do your sing song voice, and tell them that you're playing a game, and just try to make it fun. Anything to add, Kira?

Kira: Yeah. I think it's just maintain your energy. If you're into it and having fun, and say you're playing games versus tests, or let's get this done, or we have to do this, keeping any anxiety or pressure off the kids, then it should be engaging. Again, the instruments, if that's what you're using for the younger kiddos, it takes seconds to get your reading. You should be able to do that. If the child is not cooperative, maybe go let them have some downtime, and again if you can rescreen them after the rest of the group – you know, given another whirl at that point in time.

I know we only have a few minutes left, Steve. I just wanted to ask a question of the audience. If there is a vision related topic that they would like to have more information on or resource to put that suggestion in the chat because that's something that we as an organization can look at and make sure that we're providing the resources and the information that they need to help your vision and eye health programs. Add that to the chat for us if you could.

Steve: That'd be great because we're going to continue to partner with Kira and Kay and their colleagues at Prevent Blindness and the National Center for Children's Vision and Eye Health, and we'd love to know what kinds of materials would be helpful that you haven't seen yet. Kay, if you don't mind going to the next slide. Great. What will happen when the webinar ends, if you don't close it, the evaluation will pop up. This URL that you see on the screen is also on the handout … will also be in the email that you get in a few days.

If you miss it now, there'll be some other chances. If you had a question – and I know Kay and Kira answered many questions – but there were still some left unanswered. If you if you still need an answer, write to health@ecetta.info. That address has been in the chat, and that address is on the handout and is just our official address of the National Center on Health, Behavioral Health and Safety.

I want to thank Kira and Kay, what a great presentation. I told them when we were preparing for this webinar: Everything I know about vision I've learned from them. They are so incredibly knowledgeable, and they share the information so beautifully. This toolkit, this cool toolkit or a cool kit, is just so powerfully connected to our mission and work in Head Start. The National Center also has a mailing list, and we send out resources every month. That URL is something you can subscribe to and is on the handout as well. Next slide.

I want to thank everybody for their attention today and all the good questions. Kay, if you could bring us to the very last slide. This is our official address, our phone number, and our website on the ECLKC. Remember, don't close out because you'll miss the link to the evaluation that will pop up. Once again, thank you Livia and Kate, our wonderful interpreters, Martine and [Inaudible], and especially to Kira and Kay and to each of you that paid such close attention to today's presentation.

Thank you. We can close the platform and open the evaluation.

Kira: Thank you all. Appreciate it.

Kay: Thanks.

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