Vision Screening Webinars

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.

Vision Screening Tools for Very Young Children

April Powell: Welcome everyone, and thank you for standing by. My name is April Powell and I'm in the resource program manager for the National Center on Early Childhood Health and Wellness. And I'm pleased to welcome you to today's webinar, Vision Screening Tools for Very Young Children, which you could be listening to in English or in Spanish.

If you would like to listen to the webinar in Spanish, there is a phone number for you to dial into. It is 888-378-4398, passcode 576774, and we'll put that in the chat box a couple of times, just in case. So, there is a lot that we'll be covering today on the webinar.

But before we begin, I have just a couple of housekeeping announcements. First, all participants will be muted throughout the entire presentation portion of the webinar. There's a slide deck that's being shown in the webinar system, but only the webinar staff will have access to changing the slides. If you would like to look at the slides in English or in Spanish, check your email inbox. You got the slides in your inbox two hours ago in English and in Spanish. And the tool that we're going to be sharing, you got that in your inbox as well in English and in Spanish.

If you have any questions, go ahead and submit them in the bottom left-hand corner of your screen. Only the webinar staff and you will be able to see your questions. Some questions, we'll be able to answer right away, but other questions that we don't have time to answer, we'll email you back with an answer. Next, there will be videos that are going to be played on the webinar presentation. They're short, only about 30 seconds or so, and they do not have any sound. So, if you can't hear the sound coming from the video, that's correct, because there isn't any. So, immediately following the webinar, an online evaluation will pop up on your screen. At the end of the evaluation, there's a link that will contain your certificate. Please fill in your own name on your certificate and save it for your record. If the survey doesn't work for you, don't worry. You'll have another opportunity to take the survey.

We'll email you the link following the webinar also. So, there's a recorded version – excuse me. The webinar is being recorded, and the archived version, along with the slides in English and Spanish, will be posted to ECLKC, but they'll also be emailed to everyone that attended. So, I know that was a lot, and we'll be reminding you of all of those things throughout the webinar. But now I'm going to turn it over to our expert speakers. Kira?

Kira Baldonado: Thank you, April. And thanks to all of you for joining our webinar presentation today. We're very excited to be able to offer this in both English and Spanish as we talk today about vision screening tools for very young children. I am Kira Baldonado, Vice President of Public Health and Policy at Prevent Blindness and with the National Center for Children's Vision and Eye Health at Prevent Blindness, as well. Also joining me today will be Kay Nottingham Chaplin, who is director of Vision and Eye Health Initiatives for both Good-Lite and School Health, as well the Vision and Eye Health Education and Outreach coordinator for the National Center, and also a member of our Expert Advisory Committee. Also, Kay is a member of the Vision Screening Committee for the American Association for Pediatric Ophthalmology and Strabismus.

We do not have anything to disclose or interests to declare at this time. In our presentation today, we hope that you will take home four key learning objectives. We will describe the impact of uncorrected vision problems on a child's development, behavior, and learning readiness. We'll list 18 vision developmental milestones that should occur with the child in the first year of life. We will describe actions to take when those vision developmental milestones are not met. And we'll list two evidence-based approaches to vision screening and describe what each measures. When I mention the word evidence-based approach, what do we mean by that? The National Center for Early Childhood Health and Wellness defines evidence-based as an umbrella term that refers to the use of best research evidence, such as those found in health science literature, and clinical expertise, which is what our health care providers know based on their practice.

So, what does that mean for you? So, an example is a non-evidence-based approach would be simply stating that a tool was used to screen 10,000 children. That does not make the tool evidence-based. What we look for when we're talking about an evidence-based approach is a peer-reviewed publication stating that the tool was used to screen 10,000 children in a defined setting with a defined population, looking at those screening results compared with comprehensive eye examination, and making sure that the tool as used is referring a high percentage of children with the vision disorders and not necessarily referring children that do not have the vision disorders. We need to consider what the impact is of vision health on development, behavior, and learning readiness. And with this, I believe I will turn it over to Dr. Nottingham Chaplin. Kay?

Kay Nottingham Chaplin: Thank you, Kira. Hello everybody. Thank you for joining us. So, we're going to start this portion of the presentation with discussing the impact of vision health on development, on behavior, and on learning readiness. So, research currently is showing a link between health and a child's ability to perform to their best in school. And there are certain health barriers to learning, and those health barriers do include vision deficits. So, if left undetected and untreated, the vision deficit health barriers to learning can affect a child's ability to pay attention in class, to be motivated to learn, to maintain consistent attendance, to perform well academically, and even to graduate high school. So, here are just some examples. It's like we intuitively know that if a child has difficulty seeing, that that is going to impact their learning. And we now are starting to see emerging literature to support our intuition.

So, this first block is actually just a story that was shared to me by a Lions Club member in Indiana. And he was saying that he had a child who was in fifth grade making C's and D's. He was consistently unruly in class. But then, after he had vision screening, an eye exam, and glasses, his behaviors calmed almost immediately. And then three months later, his grades had improved to B's and he was even working on A's. And the student's aunt said to the Lions member, you saved my nephew by this vision screening. And then, looking at this block on the right, it was a 2015 study – it was actually published in 2015 – looking at low-income children ages three through five years. And I believe this was in South Carolina.

And what they found, that these children, after they had vision screening, an eye exam, and prescription glasses, they found an improvement in academic progress. They found an improvement in children's confidence and in their behavior. They also saw an increase in focus during lessons, an increase in classroom participation, and an increase in interaction. Then another ongoing study in Baltimore looked at, initially, for baseline, 317 second and third graders. And what they found, that children with uncorrected hyperopia, or farsightedness, did not perform as well on reading assessments when compared with children without hyperopia. And another study published in 2015 that is also ongoing looked at literacy test scores of children ages four and five years, and found that those children with farsightedness of at least 4 or more diopters – and I'll explain diopters in just a moment – that children with 4 or more diopters scored significantly worse on early literacy tests than children with normal vision. And if any of you are familiar with the research, you know that when you use the word significant that that does mean truly significant. The study also found that children who had less than 4 diopters of hyperopia did not perform as well but the difference was not considered significant. This slide provides the references if you want to look into those studies in more detail. This first picture on top gives you an example of how clearly you can see with full vision.

Then the bottom photo shows what we think you would see if you had 4 diopters of hyperopia. And you can imagine, if that's how you were seeing, how difficult it would be to see the words on a page. So, diopter refers to the strength of the lens in your prescription glasses that are required to give you, or a child, the clearest vision possible. The higher the number, the stronger the prescription lens. So, looking at the example from the study, a child requiring 4 diopters of correction to get clear vision, or to achieve clear vision, in their prescription glasses or in contact lenses would likely struggle with blurred vision. And you saw that example in the previous slide. They may have crossed eyes because they're trying to focus. They're really – you're strongly trying to focus, and that can draw the eyes in. Or they can have both blurred vision and crossed eyes, or strabismus, and would definitely see much better with prescription glasses.

So, this is another study, and although it was it's an older study conducted in 1997, it did follow children over a 10-year time. And what the results of this study were that first grade reading ability is found to be predictive of what will happen in the eleventh grade regarding reading comprehension, vocabulary, and general knowledge. So, this just helps to support the early vision screening. Because if a child has a vision disorder and it's not detected and treated early, and then they're having problems in first grade, now you can see what could happen when they're in 11th grade. And this block on the right-hand side was just a comment that I had pulled from a blog post that I just felt really supported this study. And excuse me as I read this to you, but the blog post writer said, "I always thought I was just sitting too far back from the blackboard to read the words and the numbers that the teachers were writing. It wasn't until my eighth-grade year, after repeating sixth grade, that I was vision tested. Jeez, what a difference it made when I went back to school as a freshman in high school. I could read everything and my learning was so much easier." So, again, support for doing early vision screening. And I'm going to turn this over to the moderator to see if we have any questions at this point before moving to the next section. I'm not seeing any questions. Does anybody else see questions? I think that they'll be some soon.

April: We do have one –

Kay: Fantastic. Okay.

April: So, –

Kay: Any concerns – go ahead, I'm sorry.

April: That's okay. In the questions tab, we have, please advise recommendations on screening children between 1 and 2 years old who are unable to use the screening device.

Kay: Stay tuned.

April: Okay. That's what I was thinking, that that would come up later. So, we'll pose that again at the end.

Kay: Okay. And I'm seeing a question about, any concerns or ages involving colorblindness? And there is a yes, and I am going to speak to that just very, very briefly. We really don't have any national guidelines speaking to color vision deficiency screening. However, just from stories that I've heard out in the field, it wouldn't hurt to do color vision deficiency screening as children enter a classroom setting with color-corroded – color-corroded – color-coded curriculum, just in case that child does have a color vision deficiency, because you don't want that child to get in trouble for sitting on the red circle instead of the brown circle because the differences are difficult to distinguish. But again, we don't have guidelines to support that. That's just my thought. So, I'm going to move ahead at this point. I think we do have another time, another option for questions. So, now we're going to look at the key Year 1 Vision Developmental Milestones. And then we will be talking about years 2 and 3.

So, this is a document I think that you did receive in your email today. This document, this tool, I believe we first posted it in 2015, around that time, and this is a newer version. And this version does have instructions for using the tool. It has updated guidance and examples. There is a data collection form. At the end of the tool, there is a screener signature section and child name and date on each page. And we now have this tool available in Spanish. So, this is what the first page looks like, and it does have – gives information about the tool and then instructions for using the tool. And one of the questions I typically receive and that we'll go ahead and answer at this point is, if you have a child coming into the program at 9 months of age, do you start at 9 months? And the answer is you start at the beginning, because you want to make sure that the child has reached all of those visual developmental milestones up until the point of the child's age. Then there's the Spanish version. The tool is also available in English and in Spanish at this website, so if you want to download extras for using. So, the time for reaching milestones can vary up to six weeks, because vision development is not set out here in a silo. It's all part of the overall child development.

So, there's only really one milestone that it's critical that if the child is not reaching that milestone that you make an immediate referral. So, the slides are showing when the baby should reach those milestones. And the processes is that you have the milestone and the age or the age range when that milestone should occur, the questions to ask or behaviors to monitor about those milestones, and then next steps, or what to do if those milestones are not met. So, as I stated earlier, many, most of the milestones are related to overall developmental milestones. It's just a different way of looking at those milestones from a perspective of vision, or how a baby's vision could impact reaching that developmental milestone. So, this is an example of the first milestone. You'll see you have the child's name, date of birth, age at the top. And the bottom, the signature of the person using the tool and the date. And I'm not going to go through each one of these because I want to allow time for questions.

But you'll see that, just to give you an example, that birth to the first month, baby is beginning to focus on lights, faces, and objects 8 to 15 inches, or 20, roughly 20.32, 38, 31 centimeters away from his or her face. And then the question is simply, is this happening? If not yet, then rescreen within six months and – I apologize for that if you heard that. I just had a Amazon package delivered. Sorry. So, if this developmental milestone is not yet happening, then you would check this box, put in a date for rescreen, then rescreen. If it's not happening after rescreen, then you move to the next steps. The first step is to refer to the baby's primary health care provider for further evaluation and to coordinate a referral for a comprehensive eye exam, referring to birth to three early intervention. And then we also provide activities that parents can be working on related to that milestone. And there is a Spanish version. And then, milestones 3, 4, 5, and 6 occur during the second and third months. And an important one here is that baby is making eye contact with the parent or caregiver. That's one of the critical milestones. And, again, you see the questions related to each milestone, opportunities for rescreening, next steps if this milestone is not occurring after rescreening. The Spanish version.

Now, here is an example of the video – and again, no sound – to look at what can be occurring that is causing the child to not maintain stable eye contact. So, we'll look at the first one, and I want you to watch what's going on with the baby, and to also look at the sibling and see if you see any red flags. And I'm not having the opportunity to play. Can someone hit play for me? Thank you. [Video clip begins] [Non-English Speech] So, you notice that no matter what mama is doing, baby is ignoring mama. [Non-English Speech] [Video clip ends] And this is the second video. OK, I think I did – can someone hit play for me? I left it down – here it is. [Video clip begins] [Non-English Speech] So, I don't know the reaction you all had, but every time I see this it gives me chill bumps. So, basically, what was going on here was baby's vision was so blurred that mama's face was just a blur and the baby couldn't really focus on mama's face. But then once these glasses were placed on the baby's face, then the baby could see mama for the first time and reacted with this smile. And then what I wanted you to notice about the sibling, he was also wearing glasses, and that's usually a red sign, or a sign that you definitely would need to check the other children. So, these are the milestones for months 3 and 4. They follow the same format – the milestones, questions, rescreening, and the next steps and items for parents to work on. The Spanish version.

Now, the fifth month. If the baby's eyes are not straight prior to age four months, you may see the baby's eyes turning because that's just natural. They may look crossed. But if they are not straight by the fifth month, that's an immediate referral note for an eye exam. So, that one is definitely critical. The eyes need to be straight with no turning whatsoever. Spanish version. Milestones for the sixth and seventh months. And you'll notice, down here too we give you a key that you don't have – you can stop here and don't move again until the baby is eight months. We would like to see this tool used throughout the entire year of the first year to make sure all these milestones are occurring. Spanish version.

And then we have months 8, 9, or 10. Spanish version. Then for the eleventh and twelfth months, there is a milestone to use if the child has been exposed to books in the home setting. There's the Spanish version. Or if not exposed to books, then this is the milestone that you can use. Spanish version. So, this one is an example of the pass, rescreen refer documentation at the end so that you don't have to flip through the pages. But we do encourage you to go through each page and not complete this section until you have completed going through the full document. Spanish version. This is a list of the expert contributors, or different individuals, PhDs, ophthalmologists, pediatric ophthalmologists, pediatric optometrists, who have reviewed this document. And these are the resources that we consulted in developing this tool. And you'll see it also includes a book from the American Academy of Pediatrics for children from birth up to age five years. So, Kira, I will turn this back to you at this moment.

Kira: All right. Thank you, Kay. This is going to be a bit of an interactive part of our presentation today. So, those of you who are listening to the webinar, I want you to take a moment and find your virtual hand raised tool. So, I'm going to ask you, as we go through these different scenarios and what we're finding with the children and how they are developmentally, I'm going to ask you to virtually raise your hand if you think that they pass or will be referred. So, I'm going to ask you to raise your hand if you think the child passes, just so we have one option, after we go through here. And then we'll see what the outcomes are for the different scenarios. So, let's dive in. So, here is our first case profile. And you can refer back to your document, if you need to, that were sent to you in your email. But we have a child here who is age five months old. Developmentally, they are maintaining stable eye contact with an adult, and they have a social smile. They're starting to explore their hands and putting them in their mouths, as well as watching the hand movements of others. But when the child is tired, their eye drifts and starts to cross.

So, raise your hand if you think this child passes the milestone developmental review. Give everyone a moment.

Okay. Let's see. I can – whoops.

Okay. So, it doesn't do my animation that we put in there. But had it done the animation, the pass or refer line would have gone away. This child would be referred. And I want to go back to something that Dr. Chaplin said. Around the age of five months, there's a critical guideline that you want to follow in the developmental tool, that the child's eyes, if they start to cross and drift, even if the child is tired, then that would be a referral.

So, that would be a moment of intermittent strabismus, that you would start to see the child's eyes cross when they're tired. It may occur when they're sick. But that would still lead to possible amblyopia and would be a reason for a referral. So, I'm going to have our administrator go ahead and lower the hands of those who have raised their hands. Thanks for playing along. And this would be a referral. So, let's go on to the next case profile. So, here we have a child that is nine months old, and they're also able to maintain stable eye contact. Social smile is present. They're exploring the hands and putting them in their mouth and watching the hand movements of others. There's one eye that turns in. They have goal-directed arm movements, and they do recognize parents, caregivers, and their grandpa. So, we've gone through. Raise your hand if the child passes the developmental screening in this case. Give it a moment for hands to be raised. Okay. And if the animation played along, this would also be a referral. A couple of things to consider here in this case. We have gone through with a child at nine months old and made sure that we checked all of the developmental assessments, even from the first month. So, we want to make sure those were present. In this case, the area of concern is that one eye is consistently turning in. So, that, again, is a case for possible strabismus.

And if that is left untreated, it can lead to possible amblyopia or loss of vision in one eye, because the brain is receiving two confusing vision messages and can't blend them into one consistent message. So, that one eye turning in is the area of concern and would be the reason for a referral in this second profile. Okay. Got all the hands down. Time to play along with case number 3. So, here we have a 9-month-old, as well. Maintains stable eye contact. We have a social smile. They're exploring their hands and putting them in their mouth. They're watching hand movements of others. The eyes are straight. They have goal-directed arm movements, and they recognize their parents, caregivers, and grandpa. So, raise your hand if you think this child passes the developmental screening. Giving a moment. There we go. I'm seeing a lot of hands being raised, and you guys are on target. So, this child does pass the developmental screening. There are no issues at this point in time that would cause a concern for referral to their pediatric provider or an eye care provider. So, this is a pass at this point in time. So, thanks for playing along with us. So, I will let you guys go ahead and put your hands back down. So, I want to talk a little bit also about vision screening approaches in the later early years, years 1 and 2. The tool that Kay reviewed does go through the first 12 months of a child's life. But as you know, in Head Start, Early Head Start programs, you do need to pay attention to the vision of children of all years, and so we want to talk about the approach for vision screening in years 1 and 2.

And there really are a couple of approaches, but they really are dependent on the environment that the child is in. The first approach would be vision screening conducted by their pediatric primary care provider, following the practice standards set by the American Academy of Pediatrics in their practice guidelines. And they have set clinical procedures that they'll do in that setting. But that may or may not happen. Children don't always see a pediatric primary care provider, so we need to make sure we have other approaches for the program setting that you guys can use as well. And right now, for children ages 1 and 2, the best approach that you can use is an instrument-based vision screening. Children at this young age are not able to match correctly to an optotype-based chart, whether t

hat's a shape-based or others. So, we need to have something that is not subjective and can be counted on to provide a clear referral or not for the child. So, an instrument-based vision screening is going to be the right approach for that. And I want to remind the group that an instrument-based vision screening assesses the eye structure. So, it's not going to provide you a visual acuity. It's assessing the structure of the eye, not how the brain would interpret the clearness of vision, which is what acuity is. What the instrument is analyzing are digital images of the eye, its length, its shape, to provide information about amblyogenic risk factors, so things that it thinks it sees in the structure of the eye that might indicate a possible lead to amblyopia. But that might include estimates of refractive error, hyperopia or farsightedness, and myopia, nearsightedness, astigmatism, which is a blurriness of vision at both near and far because of an uneven cornea surface. It also looks at estimates of anisometropia, which is a significant difference of refractive error between the two eyes.

And that could be one eye is slightly farsighted but the other is very much nearsighted, or one eye is nearsighted and one eye as farsighted. It's looking for that significant difference in refractive error. That can also be a possible cause of amblyopia if left untreated. It also looks for estimates of eye misalignment, not necessarily looking at the stereo acuity of the eye but how the eye is possibly misaligned, to see if there's an issue that needs to be further evaluated. Instrument-based vision screening, according to the policy statements from the American Academy of Pediatrics, is best used beginning at age 12 months. But, really, you get the best reading and more confidence with that at age 18 months, according to that policy statement. So, it is something that you can start after you've moved on from the vision developmental assessment tool with the children beginning after age 12 months. There are some instruments that we've had the opportunity to look at from the perspective of the National Center for Children's Vision and Eye Health. And we looked at the evidence around these tools based on their use in nonclinical settings, so how they performed in programs such as Head Start or Early Head Start, or other early education settings, as well as being used by individuals who are not medical providers or medical staff. And these have been shown to perform well for the age groups that we're looking at here. So, that's the Welch Allyn Spot Vision Screener, the Plusoptix Vision Screener, and Welch Allyn SureSight. Now, the Welch Allyn SureSight is no longer being produced but is still supported with repairs and technology. So, if you do have this instrument, you might have a year or two left in it if you're currently using it, but you may want to plan to update to other devices in your future budgeting purchase. There's a lot of resources available to help you consider how to implement your screening for very young children, as we've already talked about, as well as your vision screening and eye health program for children of all ages that you serve.

So, I'll work through some of those resources that are available. As we mentioned at the top of this webinar, the vision developmental milestones tool is available in English and Spanish on the National Center website in our publications, presentations, and videos section. So, you'll see there on the screen where to go to on that page and identify the vision developmental check-off tool. The website for the National Center is shown here. So, if you're not familiar with that website, please check it out in the near future. There's a lot of resources on there around professional development for your skill set in children's vision and eye health, provider education tools, family and parent or caregiver resources, a way to ask for technical assistance if you have a specific question, and lots of communication tools that you can engage into your social media or parent education newsletters. There's also a great vision screening fact sheet on the National Center for Early Childhood Health and Wellness. And again, this is one that's in English currently, and coming soon, very soon, in Spanish as well. So, that will be available to help guide your program. So, I encourage you to check that out. Additionally, there have been several publications that we've done in a variety of resources, whether it's Child Care Exchange magazine, NASN School Nurse journal, as well as other publications that we've explored how to establish a strong vision health system of care. So, here you see the article that was published a couple of years ago in Child Care Exchange on how to create a strong vision health system of care. And this really starts from the point of parent and caregiver education about the importance of vision.

So, this is important for parents of children of all ages, and it goes through vision screening approaches, supporting professional development, implementing the proper screening approach, and then setting up a way to monitor your success, whether that's comparing it to outcome from comprehensive eye exams, as well as performing a formal evaluation on your program annually. So, there are tools to support that as well. And here you see an example of one of the articles that we published in NASN School Nurse journal, which talks about vision screening with an instrument-based approach specifically. There have been several other articles published in NASN School Nurse more recently, and we do have an ongoing column in that journal as well that answers common questions for vision screenings. So, if you're able to access that, then I encourage you to check those out as well. We did an initiative with the National Head Start Association a few years ago called Year of Children's Vision, where we developed many resources, including our children's vision program evaluation document, and did several different webinars or conversations around children's vision. And those are all archived on this website specifically, and this is again a website within the National Center page.

So, I encourage you to check those out and see if there are resources to help you build your program. Within Prevent Blindness and our National Center website, we do have specific resources to support families and caregivers of children. One of our most popular ones is a financial assistance form, and this is also available in English and Spanish. And this financial assistance program provides access to eye exams, eyeglasses, even some pharmaceutical assistance if somebody needs some drugs for a vision problem. And this is addressing the vision needs of both children and adults. It's been found that parents or caregivers who don't have access to eye care are less likely to take their children to eye care. So, if you run into that issue with some of the families that you service in your programs, this may be one way for parents to overcome one of their barriers, which in turn will help make them more likely to take care of their children's vision as well. We also have a vision screening referral document listed here on the page, And this referral document provides an opportunity to capture vision screening outcomes on one side, and then on the other side is the referral letter to parents– again, available in English and Spanish– telling them what the vision screening was, what the next steps are for the parents laid out in a very clear way. And then also there is a section on that letter where the parent can sign and make sure that medical information, the outcomes from the eye exam, are shared back with your screening program. So, it does promote and improve communication between eye care providers and programs. And then on the far right, you just see an example of some of the other parent education pieces that we have.

This is a good way to kick off your year. It's just helping parents understand what kinds of vision problems you'll be looking for in your screening. And this is a document here shown in traditional Chinese, but again it's available in English and Spanish as well. Here's some more resources available to you to help your program. Once you have children who may be getting glasses for the first time, it's always helpful to help their families understand what to expect with eyeglasses, how to take good care of them. So, there's a free tips for wearing eyeglasses document that you can get downloaded or sent to you. The Eyes That Thrive program on that far right there shows a program that can be implemented in your classroom to help children continue wearing their glasses every day, or continue with their eye patching if they're being treated for amblyopia. And it reinforces the treatment in the classroom and also provides some parent education pieces. That particular program is available in seven different languages online. And then, finally, we do encourage you to have books related to wearing glasses or going to the eye doctor in your classroom.

So, this is just an example there in the middle of one of the more commonly used books for that purpose. For those of you that do provide vision screening for older children, we do have a national certification program for vision screening. That provides training both in person in our affiliate areas, as well as online for those individuals not in our affiliate areas. So, if you'd like more information, you can navigate to that link. And I just want to reiterate, all of the website links that I shared today are listed here on the page. So, each of these sites has special resources for you and your vision screening and eye health program, and I encourage you to check them out if you have not done so. I think we'll pause here and look and see what kind of questions we have. Steve or April?

April: Steve, do you want to take the question?

Steve: Do that. Thank you, Kira and Kay, for that great presentation. There are quite a few questions. The first one is about an uncooperative child between one and two years of age who won't sit still long enough for them to use the Spot screener. They started using the Spot in this program at 12 months of age. Do you have a recommendation? They have been just using the milestone checklist until that child becomes cooperative. Do you have any other recommendations?

Kira: Well, I'll jump in here. And then, Kay, if there's anything you want add to my response, please do so. But research has found that children who are uncooperative for vision screening approaches are more likely to have a vision problem than those children who are able to cooperate. So, I would recommend that, if the child is simply not cooperative with a screening device and you've tried it a couple of times, I would say that's a child that you definitely want to refer to an eye care provider, or coordination to their pediatric medical home to make sure that they are getting directed to see an eye care provider. I think it's really critical that you don't wait and see with children who are not cooperative with vision screening, because, especially around this critical age, their vision is really important for overall development, as we've discussed. And the sooner that a possible vision problem can be taken care of and treated, the easier and more likely that child will be to get back on track developmentally. Kay, anything else you want to add?

Kay: The only thing that I would add would be to – and this is just looking at logistics – would be to look at your screening environment. The instruments do make noise and so forth that capture a child's attention. So, you want to make sure that you are in a quiet area where the child would hear and see those cues to engage attention. And then, beyond that, I would support what Kira just suggested.

Steve: Thanks. So, this is a not dissimilar question. What are the recommendations for using this screening checklist for children with known physical disabilities who are not able to point or behave in a certain way?

Kay: Kira, you want to start that one also?

Kira: I will do so. So, if there are children who have known physical, or especially those with neurodevelopmental delays, those children should be automatically connected to an eye care provider, as many of those children are a much-increased risk for vision problems. There is additional information around the specific types of populations we have concerns with on the website for the National Center for Children's Vision and Eye Health. So, definitely refer to that for a more comprehensive list. There's a lot that we don't have the time to go through here specifically. But with developmental delays, neurodevelopmental delays, those children really should be connected to an eye care provider rather than going through screening processes again and again. And then after they are connected with an eye care provider, they should be seeing that provider based on the schedule and the periodicity that that provider set. So, that would be my recommendation. Kay, anything to add?

Kay: I don't have anything to add to that, other than if you want that list, you can also always email us. Any other questions? I'm seeing the question – if you don't mind if I jump in – about the ages to start vision screening with an instrument, and I'm going to touch on that. So, yes, you will see that instruments can start at age six months, but we are adhering to the national guidelines from American Academy of Pediatrics, the American Association of Certified Orthoptists, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology that were published in 2016. And as our slide showed, those guidelines say to start at age 12 months, again, with better success at 18 months. And so we're just following the national guidelines. So, any other questions?

April: Steve, if you're talking, we can't hear you.

Operator: The operator. It looks like we lost connection with Steve.

April: Okay. I'll go ahead and read some of the questions through. So, the Spot Vision Screener is advertised for ages 6 months through adult. Should it only be used for children ages 12 months and older?

Kay: According to the national guidelines, instruments are recommended for ages one and two years. And then at ages three, four, and five years, either instruments or optotype-based screening– meaning eye charts using either LEA symbols or HOTV – and a proportional-based distance are recommended. And then at age of 6 and older, which doesn't affect this group, but then it's back to eye charts, unless a child cannot do instrument-based screening, or the use of Spot. So, again, if you're talking Spot specifically, ages 12 months and older at ages 3, 4, and 5, you can either use Spot or an eye chart. At 3 to 5 years.

April: Okay. We've got lots of questions coming in, lots of good ones. Thank you, everyone. So, the next question, I believe you answered. This one specifically is on the tool. Which milestones would we be looking for or testing for in a 4-month-old child?

Kay: I saw some of the questions about that, and I appreciate those questions. So, when I say that you start at the beginning, that's with a new child. So, if you have a child that comes into the program who's four months of age, start at the first milestone. Now if you're con – yes, start at the first milestone, and then move forward up until and including that child's age. And then the bottom will say, use this next milestone when the child is whatever the next age is. Now, if you have a child entering the program at nine months of age, again start with the first milestone. But let's say you've used this tool multiple times with a child and you have a child who is nine months, who's just turned nine months, and you've been using the tool continuously at that point, and they met all the targets, met all the milestones, at that point there is no need to start back at the beginning, You would start at the child's age. So, you would only start at the beginning, no matter what the age of the child is, if it's the first time you have used that tool because that is a new child to your program.

April: Thank you for clarifying –

Kira: Can I add to that one item? I would just emphasize – and this is really emphasized in the tool itself, as well –   if at any point in time a child's eye crosses, whether intermittently or constantly – even after you have screened the child and they're now 9 months old – if that eye suddenly turns in, that is a reason for a referral. So, that is an urgent situation and I just want to reiterate that, that even if you've gone past that fifth month milestone, where you're checking that off, and then at 9 months the eye suddenly turns in, that is a concern. So, I just want to reiterate that, but the tool does as well.

Kay: Thanks for that clarification, Kira.

April: Thank you. Let's see. So, is there any adjustment for prematurity on the infant screening tool? And if so, what age should they be all caught up?

Kay: If you look at the instructions page up in the right-hand corner in a box, you will have the instructions on how to adjust for that child's age if the child is – up there. It's shaded in the right-hand corner to calculate corrected age. So, that will give you the instructions.

April: It's right there on your screen. Perfect. Thank you. So, here we've got a situation. So, this question is about follow-up. So, there's a child – this happened a few times – who has failed their vision screening and has fit with glasses. But once they receive their glasses, the parents refuse to put the glasses on the child on a regular basis. Do you have suggestions on how to sensitively talk to that parent about the importance of glasses and wearing them every day?

Kay: I'm going to start with this, Kira. And this is not part of the question but it's something to think about. If the child is not wearing the glasses, you always want to make sure that the glasses fit appropriately so that they're not too tight and hurting the ears, and that the glasses are the correct prescription. Now, if you have a situation where the glasses fit, you have the correct prescription, and the parent is not wanting to put the glasses on the child, then you need to dig a little deeper and look at cultural considerations. In some families, if a child is wearing glasses, the belief is that the child is considered to be less than or not as intelligent. In some families, cultures, if it's a female child wearing glasses, they won't be seen as marriageable. So, you need to dig a little bit deeper to determine, to help determine, why the glasses aren't being used. And then perhaps use an example from the slide, that 4 diopter vision example, and say this may be how your child is seeing the world and will have difficulty participating in learning. And those are the suggestions I would provide. Kira, do you have anything to add?

Kira: I will just add a couple of things there. If it does turn out to be a cultural issue, I think it is helpful if there's maybe another parent or caregiver that might be a part of your health advisory group, or willing to be a peer-to-peer mentor, that has the same cultural concerns, and maybe they will overcome this challenge. So, a peer-to-peer discussion is a great way to engage their parent health advisory committee membership if they can be helpful there, or other parents to be helpful in that situation. Additionally, as I mentioned in the resources, there's the Eyes That Thrive program. The Eyes That Thrive program does provide a parent education component to it, with some scripting– there's also a staff education component, as well – about different vision problems, and has some resources that you can give to the parents about vision conditions and what that means for the child. And, again, this is a great way to engage other members of the community, maybe some eye care providers in the community that can also help to explain the situation. If they're not sending the glasses to the program with the child, it's also been shown in many different studies and program interventions that having a second pair of glasses at school is one way to overcome that. So, those are some approaches that you might be willing to try.

April: Great. That was great information on that question. And overall, we are to the top of the hour now. Time has really gotten away from us. But there are a lot of questions that I see that we weren't able to get to, so we'll be answering those questions, both on MyPeers and via email. So, please be on the lookout for those questions. If there is a question that's burning and you would like answered immediately, please email it to our infoline – it's on your screen now, health at ecetta dot info – and we'll get an answer right over to you.

So, now this is the end of our webinar. So, when the meeting ends, a survey will pop up immediately. Please take the survey, and the very last question on the survey will contain your certificate. If, for some reason, the survey does not work for you, wait a couple of hours and another opportunity will present itself via email for you to take the survey. So, you'll get it immediately after the webinar, and you'll get it in a couple of hours in your inbox. So, I want to thank our speakers once again.

A wonderful job, a wealth of information. And we hope to hear from you all shortly via survey.

Thank you.

will be available to you after it ends. If they are colleagues of yours who were unable to attend this live version of the webinar, please let them know that they can still watch the webinar's archive, take the evaluation, and they, too, can get a certificate. So now, I'm going to introduce the speakers for today. First, we have Dr. Nottingham Chaplin. She has 16 years in the vision screening field and she's the former director and lead training for Vision Initiatives for Children at the West Virginia University Eye Institute. She's a member of the Advisory Committee to the National Center for Children's Vision and Eye Health at Prevent Blindness. And she's the current Education and Outreach Coordinator for the National Center for Children's Vision and Eye Health at Prevent Blindness. She's the Director of Vision and Eye Health Initiatives for Good-Lite and School Health Corporation. Our second presenter is Kira Baldonado. She has 14 years in children's vision screening and eye health. And she's the Director for the National Children's Vision and Eye Health at Prevent Blindness. She coordinates strategic and programmatic efforts for NCCVEH, including its national expert panel, advisory committee, federal-level relationships and state-level program initiatives. She has published, presented, and developed resources to support strong vision and eye health programs for children. And we have Janet Schultz, who will not be speaking today, but contributed to this presentation. She's a certified pediatric nurse practitioner. And she has 35 years of public health experience in the fields of pediatric and maternal child health bureau. And lastly, we've got Nancy Topping-Tailby, who is a part of the National Center on Early Childhood Health and Wellness. And she'll be fielding questions for us. So with that, I'm going to turn it over to our first speaker, Kira.
Kira Baldonado: Thank you, April. And on behalf of Kay and I, we would like to thank the National Center for Early Childhood Health and Wellness for the opportunity to speak about children's vision, its impact on learning, and ways that we can implement strong programs in Early Head Start and Head Start programs. On today's webinar, we'll learn the impact of vision problems on a child's school readiness, identify two evidence-based vision screening tools that can be used for vision screening of children in Early Head Start and Head Start programs, and also talk about one emerging practice for vision assessments in Early Head Start, and also provide you with access to free resources to help families obtain follow-up to eye care for their child. Vision is an important information for Early Head Start and Head Start programs. Out of the 1 million children enrolled in programs, 30,000 of those children, or 3 percent of all
the children in the programs, have some sort of diagnosed vision problem. So it's a big topic that we need to discuss and make sure that we have a strong national approach for. Vision in Early Head Start and Head Start is critical. Because we want to make sure that children are strong and school-ready as they enter into their later years. Some examples of the impact of vision on early education and education are seen in some current studies. One such study happened in 2015, which was the next step of the Vision in Preschoolers Study.
Some of you may be familiar with the Vision in Preschoolers Study, as it helped us to identify some evidence-based approaches for vision screening in children ages three through five. Their next study, the Hyperopia in Preschoolers Study, found that children ages four and five years old who have uncorrected hyperopia -- and so that's farsightedness at plus four diopters -- scored significantly worse on a test of early literacy than children with normal vision. Those children who also had hyperopia but at a lower level than plus 4 were also shown to have a difference on their performance of that test. But it was not statistically significant. That test that they analyzed with the children was the TOPEL test, the Test of Preschool Early Literacy. There's an example of it on your screen. Whoops. Too far. No. It's going to go through this again. Sorry, everybody. So the performance most affected on this test was the print knowledge subtest, which assesses the ability to identify letters and written words for the children. So those who had plus 4 hyperopia scored significantly worse on their ability to assess and identify different letters and written words. So here's an example on your screen of how a child with 4D of hyperopia sees in their world.
So, certainly not something that would help to aid them in identification of letters or trying to figure out words as they are young and early readers. Additional research shows us that there's also impact on behavior and outcomes in other large studies. So one of them is the BREDS Study, which is looking at the performance of reading and the impact of eyeglasses and eyeglass correction on children in second and third grades. And this study was conducted in several Baltimore city schools. Those children who were found to have a poor baseline visual acuity and hyperopia associated with reduced reading achievement and worse baseline reading scores. So those kids who had undiagnosed vision problems, uncorrected vision problems, had poorer baseline scores and reading achievement. Additional research has shown us that children within a specific school district, those ages three through five years, also had a significant change in their behavior after they received their eyeglasses. There was improvement in academic progress, increase in focus during lessons, increase in participation in classroom interactions, and an improvement in confidence and behavior of the children. So, correction of the vision problems made a big difference in how they interacted with their classroom and were able to learn.
And another research study has shown us that first graders, their reading ability in that first grade has been predictive of their reading ability and graduation rates as they approach their 11th grade. There is an understanding, from that first grade performance, of their reading comprehension, vocabulary, and general knowledge. So a strong early education platform in learning ability, reading literacy, language comprehension, is really important as you all are setting that baseline in Early Head Start and Head Start. It can continue to impact children through the rest of their educational career. Children who lag in first grade but catch up by third or fifth do have good prognosis for future reading level. So the sooner that we can identify vision problems in children and get them corrected, the better chance that we have for them to be performing well by the time they graduate. And then we look at the individual level. One such story that is near and dear to our heart is a story about Javier. Javier was considered a miracle baby according
to his parents. They had tried for a long time to have a child without much success, until Javier came along. When he was born, doctors were afraid that he might have a vision problem.
And so they sent him to an ophthalmologist to get an eye exam and see exactly what was going on. And unfortunately for him, they gave him a diagnosis of cortical vision impairment. And that really means that he was completely visually unaware of anything that was going on around him. So the doctors took the right step in helping to connect the family with an early intervention specialist so that they could help to prepare their household, their lives, and how to support the learning and development of a child who was basically considered blind. Fortunately, a collaboration of different stakeholders was going on in Massachusetts that allowed the early intervention specialist to become aware of a program that was going on to provide eye exams to very young children in a part of the state where there's not a lot of support for eye care. And so she encouraged Javier's parents to take him to see the doctors when they came to town, to see if they could provide any more support, or education, or information for these parents who were really unsure of what to do. So, remember, he had his first eye exam when he was born. At 12 months old, Javier had a second eye examination. And it was found that he really did not have CVI. He had high refractive error. And he was given a pair of glasses. So after 12 months, with his first pair of glasses, Javier was able to see the faces of his parents for the first time in his life.
And so he was able to get back on a path of normal development and learning baseline and good prognosis. And so on your screen is a picture of Javier. On the left is his mother. In the middle is his early intervention specialist, and then little Javier with his glasses on. So he's now able to connect with his world, the faces of his parents and the people around him, and really enjoy life. So what do these slides tell you? They tell you the importance of evidence-based vision screening. We have to make sure we're doing the right procedures, at the right age, at the right time, for the right population. We need to make sure that kids get those follow-up eye examinations and make sure that they have ongoing follow-up care if they are determined to have some kind of vision problem. And they receive their vision treatment, there aren't barriers to that treatment, and all of the related medical devices, materials, such as eyeglasses or eye patches in the case of amblyopia. And making sure that parents, families, and the children follow up on those treatment plans. And we'll offer you some resources to assist with that here later in the presentation. All of that leads to a good prognosis for education. And with that, I'll pause to see if there's a couple of questions that we need to answer. Nancy?
Nancy Topping-Tailby: So there is one that I think would be helpful to answer. And let me pull this one up. It relates to what you talked about. Can you please explain 4D and how that correlates to 20/20 vision? Okay. Or 4 diopters, you talked about, I think, Kira. And folks didn't know quite what that meant. That was unfamiliar terminology.
Kira: And Kay, this is typically from your slide set. So you may have a set response to this question already. I'll pause to see if you do.
Dr. Kay Nottingham Chaplin: Okay. A diopter is a way of measuring refractive error. And this is just to give you an example of how someone might see if they have 4 diopters of hyperopia. You can't equate a refractive error to a visual acuity value of 20 over x, because you're measuring two different aspects of vision. So if you're using an instrument, for example, and the results come up with hyperopia of 4.0, then this just gives you an example of what the child might be seeing. But again, you cannot equate that to a visual acuity value. And I'll get into this in a few moments. But refraction is basically looking at the eye.
And visual acuity is looking at how vision is interpreted at the brain level and the visual cortex and the full pathway from the eyes to the visual cortex.
Nancy: Thank you, Kay.
Kay: So that -- yes.
Nancy: So, why don't you move on. And we'll have a time for other questions later. Thank you.
Kay: Okay. And thanks. That was a great question. And thanks. That was a great question.
Kira: I will turn it over to Kay.
Kay: Okay. Sorry I talked on you, Kira. That was a great question. Thank you. So now, I'm going to be talking about vision screening to meet the new Head Start Program Performance Standard of ensuring that within 45 calendar days after the child first attends a program or the home-based program option that the program must either obtain or perform evidence-based screening. Now, hearing also, but we're talking about vision. And if the program operates for 90 days or less, then that changes from 45 days to 30 days. So we're talking about evidence-based today, for vision screening. So we're going to first look at what's currently available for Early Head Start, for infants. And we don't have a lot at this moment in time. But there is an infant vision milestones checklist that we'll be describing, and instrument-based screenings. So those are the two types of tools currently that would be evidence-based for Early Head Start. So, let's talk about the seven critical vision developmental milestones checklist to monitor from birth to nine months. Okay.
This is a slide of the child who -- one of the vision milestones is actually the very first one for the early weeks, up to about eight weeks, where baby is just basically ignoring mama, no stable eye contact. Notice the sibling there with the glasses. That's always a red sign.
But you see, this baby is totally ignoring mama. Now watch what happens in this one.
[Speaking in foreign language]
I get chill bumps every time I watch that. So baby was ignoring mama because baby couldn't see mama's face. And so with those plus lens glasses, that helped baby to see. So in this document that you will be seeing, the time to reach the milestones would be six weeks. And these milestones give you an idea of when baby should reach the milestones. And the process -- and this will make sense when you see a picture of it -- is that there are four fields. One shows the milestone and the age when that milestone should occur. Another field describes why that milestone is important to the development of vision. And then there's an example of what to do if the milestone is not met or next steps. And then the next steps describe what to do -- like if you're going to early intervention.
There's also slides for what to do with providers and, or steps for providers and family members. And when you look at the document, you will notice that many of the milestones are also related to just general overall developmental milestones. So you just kind of want to look at those from a perspective of vision. There's one, for example, for reaching. And sometimes, when a child doesn't reach, we might think that's motor. But we also need to think maybe it's vision, because maybe the baby can't see the object in order to reach. But this gives you an example, if you can see my mouse moving. So here is the milestone. Here is the importance of the milestone, the questions to ask or behaviors to monitor. And if answer is
no, then you move to the next steps. And then next steps are provided. So the ages would be over here on the left-hand side, if you can see my mouse. And this shows where you can find this checklist. And again, don't worry about writing down the URL, because you will have an opportunity to view the slides later.
And so just to give you an example of one, so the first vision milestone is at ages six weeks to no later than eight weeks. The milestone is maintains stable eye contact when awake and alert and initiated by the parent or caregiver. So think back to the video that you just saw that clearly was not stable eye contact or just maintaining that eye contact. So why is that important? A lack of stable eye contact can interfere with early emotional and general development. Think about the baby not developing bonding with the mama. So the question to ask or behavior to monitor would be, does the baby maintain stable contact when awake and alert and initiated by the parent or caregiver? If the answer is no, you go to next steps. And one is to refer to the child's medical home, medical doctor, to assess the need for a follow-up eye exam to see how well the baby can see.
And then for the family or the caregiver, a next step would be to talk close to baby's face while helping baby feel the parent's or caregiver's face. So we do try to provide next steps that aren't just refer to early intervention or refer to the medical home. There are some examples of appropriate eye contact and talking close to babies face. So we just showed you this. So we have time for a couple of questions on the birth to three component. Before we do that, though -- Okay. We didn't get into the instrument-based piece that can be used for ages one and two years in Early Head Start. But you'll see those when we look at the three to five. Three through five, you'll see the instrument-based then. So when I'm talking about instruments, I'm talking about Spot, Plusoptix, and -- here we go. So I must have missed that somehow.
Nancy: I pushed it out there, Kay. It skipped over it. So I got it back there for you.
Kay: Oh. Thank you. I was like, what happened? Okay. Let me -- Okay. So -- So after the checklist, then for ages one and two years, instruments can be used. And we'll talk about what instruments measure. But again, as I said earlier, the instruments are actually looking at the eyes and not visual acuity. So we do have -- this is the Spot, and this is the Plusoptix, and the Welch Allyn SureSight. Now, the SureSight is no longer manufactured. But if you're using them, it's okay to still use them. And these tools are just examples of vision screening tools for this age group. But these are approved by the National Center for Children's Vision and Eye Health at Prevent Blindness. So now, we have time for a couple questions, just in the Early Head Start piece. So there's a general question. If you could say a little bit about, what is evidence-based screening? Help people to understand, what does it mean to be evidence-based? Well, that is an excellent question and probably has several answers. But most often, when I'm talking about -- and Kira also -- when we're talking about evidence-based in our presentations, we're talking about tools that have a lot of research behind them, that have been published in a peer-reviewed journal and show that they are appropriate for that particular age group in that particular environment. So it will usually come from a peer-reviewed journal. Kira, do you want to add to that?
Kira: No. I just wanted to make sure that we touched on settings. And you did. So oftentimes, and this is a challenge with vision screening and assessment tools at this point in time, is there is some research. But a lot unfortunately comes from testing of tools in an ophthalmological clinic or a vision research clinic, and not necessarily the performance of that tool in non-clinical settings, so in Early Head Start, or a public health screening environment, or early education setting. We need to make sure that testing of that tool happens in these other settings by non-clinical personnel, to make sure they're just as equally effective
for that age group as they were in the other research environment. So that's something that the center really watches out carefully for.
Kay: Thank you.
Nancy: So there was a clarifying question. If you could just clarify, were you saying that the checklist should be used for children under one year and instruments for children between one and three? There was a little bit of confusion about that.
Kay: Okay. I apologize for that confusion.
Nancy: That's all right. It's complicated stuff.
Kay: At this moment, we would need to use checklists for birth to the first year. And then the tools, the instruments, would be appropriate for ages one year and two years. And then you're going to see in the next slides that instruments or eye charts, tests of visual acuity, can be used for ages three, four, and five years. So at this moment, it would be a checklist up until the first birthday, and then instruments for ages one and two years. Kira, would you agree with that?
Kira: Yeah. That's right. That's really the only evidence-based approaches that we have for this very young population.
Kay: Okay, do we have another question? Or are we ready to move on?
Nancy: Well, we have quite a few. So it's really about --
Kay: Okay. Nancy: -- if you -- we can do some now or we can circle back if there are other times to ask questions. So, whatever you think.
Kay: Let's go ahead and move forward. Because we have several slides. But we do want to answer as many questions as we can. And then there will be an opportunity for answering questions later. So now I'm going to move into evidence-based vision screening tools and procedures for children starting at age three years. So we have really two approaches to vision screening -- optotype-based screening, which would be eye charts, also known as tests of recognition visual acuity, or some software programs, or instrument-based screenings. So those are the two approaches. And I just got stuck here. Hold on. So I want to introduce you to a cast of characters that you will hear throughout this presentation. So when you see the initials NCCVEH or hear National Center, I am referring to the National Center for Children's Vision and Eye Health at Prevent Blindness. And the national expert panel to the National Center published guidelines, vision screening guidelines in 2015. Then, if you see AAP or AAP Joint Statement, that refers to the vision screening guidelines in 2016. And the groups involved in that would be the American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, the American Academy of Ophthalmology, and the American Association of Certified Orthoptists. So you will see it's much simpler for me to just say AAP instead of all those groups.
So, again, two approaches to vision screening. Optotype-based screening, this gives you an example in the right-hand side. This is a software program that is also considered optotype-based screening. Optotype-based screening are tests of visual acuity using optotypes. And optotype is the name of the picture, or the letter, or whatever it is that you're asking the child to identify. And that, by the way, is a Herman Snellen term. So, tests of visual acuity using optotypes to measure visual acuity as interpreted by the brain. And
a definition of visual acuity is -- and I'm going to read this to you -- quantifiable -- and that's where you get the 20 over x -- a quantifiable measure of the clearness of vision when identifying black optotypes on a white background using specific optotype sizes at a prescribed and standardized distance. Instrument-based screening, there's an example of Spot at the bottom. Instruments do not measure visual acuity. And that's very, very, very important to remember, that instruments do not measure visual acuity. And too often, our documentation to report vision screening results requires a visual acuity number, or a 20 over x, and don't provide the option of just a pass/fail, which is what you would have with instruments. So we don't want to have our documentation dictate the type of screening that you do.
So instruments do not measure visual acuity. Instruments analyze images of the eyes to provide information about amblyopia and reduced vision risk factors such as estimates of significant refractive error, hyperopia, myopia, astigmatism, farsightedness, near-sightedness, astigmatism. Estimates of anisometropia -- anisometropia is a difference of refraction between the two eyes. For example, I am near-sighted in one eye, farsighted in the other. Estimates of eye misalignment that may or may not be strabismus. And amblyopia -- and that's really what you're looking for when you're doing screening at these ages, the three, four, and five. And amblyopia is -- and I'm going to read this to you -- a loss of vision at the brain level. There is the visual cortex, where we actually have sight. A loss of vision at the brain level in one or both eyes, when the nerve cells in the visual cortex of the brain receive insufficient visual stimulation from the eyes while the sense of sight is developing. Primary causes are strabismus, or misaligned eyes, cataract, or refractive errors. So that's what amblyopia is. So let's look at some optotype-based screenings. So these charts that I'm going to show you now, or these tests of visual acuity, are not recommended by the National Center or AAP. That includes the sailboat chart; Allen pictures; the lighthouse chart, often called house, apple, umbrella; the Tumbling E; Snellen -- and I mention Snellen because I had seen some programs use Snellen with three-, four-, and five-year-olds, and kids typically don't know their letters -- and the Landolt C. So why are those not recommended? Because they haven't really been validated and standardized for this group. They don't meet standardization guidelines.
There are national and international guidelines around how eye charts should be designed. Children may not know their letters. And some of these require discrimination of direction, which is not sufficiently developed. For example, the tumbling E asks children to identify the direction of the legs on the table or whatever you're calling it. Orientation and direction are emerging cognitive skills. Up and down comes in first, followed by left and right. That all does not come together until around ages eight or ten years. So using that test prior to that age, you're actually just testing cognition and not vision. And they're not well validated in the screening environment. One of the national and international guidelines is that optotypes should be almost equal in discrimination, meaning one should not be any easier than another to identify. And that's not the case with the ones I just showed you. Although the E would be, in the sense that it's the same E, same letter.
But you have to think about the orientation and direction. Plus, when you get down to the threshold where you can no longer distinguish one from another, you can guess the direction of the E by looking at either the solid line or the broken lines. So the preferred optotypes for children ages three to seven -- and I realize that's outside your age group -- but according to the National Center, according to AAP, it recommends LEA Symbols and HOTV letters. So this would be LEA Symbols, HOTV. LEA Symbols, by the way, is the only pediatric optotype where the optotypes when you get to threshold, or the point when you can no longer distinguish one optotype from another, all the optotypes blur equally. And they typically look like circles. So there will be no guessing. Now, the preferred optotype format -- and this comes from
the National Center -- is a single LEA Symbol or HOTV letter surrounded with crowding bars for children ages three, four, and five years, at five feet. Not 20 feet, not 10 feet. So here are some examples.
So this is the vision in preschoolers. These are some eye checks. You see that it's a single optotype. And it has the crowding bars, which sort of gives you the same crowding as a full eye chart. Then an option would be a full line of optotypes in a crowding rectangle. And that's at 10 feet. And I'm not going to get into all the crowding here because we're a little bit limited. But adding bars around it, I will say it makes the optotypes easier to identify, which means you may under-refer children and miss a vision disorder. So, talking about screening distance, this is important. This is a procedure. Again, 5 or 10 feet from the chart to the child's eyes. All of the standardized charts will be at 10 feet. But when we're looking at the Stop -- in other words, you won't see 20-foot charts that are standardized. But we were looking at 5 feet and 10 feet for this age group. And if you happen to have an eye chart and it's a 10-foot -- and I get this question all the time -- there will be 10/xx on the left-hand side of the chart with 20/xx on the right hand side. The 10/xx is the actual screening distance. But the 20 number, like 20/20, is the equivalent, the 20-foot equivalent. And that would be the number that you actually report. Because we get real confused when we talk about 10/10. What is that?
That's 20/20. So when you think of that measurement, you want to think about toes on the line, or more appropriately, if you mark out your 10 feet between the chart and the child's eyes and you put a piece of tape on the floor, think of the arch of the foot. And that will be in line with the eyes. If the child is seated, you want to measure the 10 feet to the back of the chair and ask the child to sit with their back toward the back of the chair, if you can see my mouse here. And hopefully they won't be like this when they're sitting in their chair. So that's screening distance. Sometimes you will see -- and this is a screening tip -- sometimes, you'll see these cards with four optotypes on one that can be called a response panel or a lap card. And if a child doesn't want to talk to you, to actually verbalize what the optotype is, they can point to the optotype on the card as a matching game. An option to that would be these four individual cards. And this is a last option. You would keep these cards in your pocket until you need them. But if you have a child who's a little difficult to screen, you can place those cards in front of the child's feet and ask the child to step on the cards. But don't put them down as you're setting up your screening environment. Because it's been my experience that young kids want to help you.
And they'll think you dropped them. And they'll pick them up for you. So keep those until you need them. So now we're going to move on to occlusion, or what you use to cover the child's eyes during screening. When you give children responsibility for their own occlusion, they're going to try to peek. And that's just because if you're covering their better-seeing eye and they're having to look out of the eye that might have some vision problems, that's uncomfortable. So they will try to peek. So the appropriate occluders, according to the National Center and AAP, would be these adhesive eye patches, or two-inch surgical tape, or occluder glasses. And in the occluder glasses -- it's kind of difficult to see this. But this one's open. And this one's open. So there's one for each eye. And then there's also these little sunflowers for small or petite faces. So these are the recommended occluders. Unacceptable occluders for children ages three, four, and five years according to the National Center -- no hands, no tissues, no paper or plastic cups, no cover paddles, like the lollipop occluders. And why are these unacceptable?
Because children can easily peek around those occluders. So you don't want to use hand, tissue, paper or plastic cups, or cover paddles for children ages three, four, and five years. So I just wonder if this could be our future for vision screening. Text the third line. You never know. Okay. So we've talked about optotype-
based screening. Now we're going to look at instrument-based screening. Again, as a reminder, instruments do not measure visual acuity. Instruments analyze images of the eyes to provide information about amblyopia and reduced vision factors such as estimates of significant refractive error, estimates of anisometropia, estimates of eye misalignment. So the instruments that are currently approved by the National Center -- meaning they have sufficient research support -- include again the Welch Allyn Spot, the Plusoptix, and the Welch Allyn SureSight. So, instrument-based screening -- and I think I may have missed a slide here. Let me back up.
Okay. According to AAP, instrument-based screening can begin at 12 months, although you'll have better success at 18 months. And according to AAP, you can attempt visual acuity screening at age three years. Or you can use instruments. And for ages four and five years, and including three, you can use instruments or tests of visual acuity. So this is to give you an example, if you aren't familiar with instruments. This is a Spot. So this is what the children see. This is what you see. So this is when it's analyzing the eyes. And then you'll have a report that tells you whether the child passed or needs to be referred for an eye exam. If you use an instrument, you do not also need to do visual acuity screening. And if you cannot capture a pass or refer result, you would want to go ahead and refer the child. Because in the research information that I am receiving, the majority of times that you cannot receive a pass or refer result, the child does have a vision disorder. So there's a group of children who are at high risk for having vision disorders, and if they have strabismus -- misaligned eyes -- after the beginning of age five months; or if they have ptosis, which is a droopy eyelid; or hearing impairment; cerebral palsy as an example; Down syndrome with a cognitive impairment; some child on the autism spectrum disorder. Diabetes, although it may not be showing up now as a vision disorder, it will give the eye doctor a chance to follow that child. Juvenile arthritis; parents or siblings with a history of strabismus or amblyopia; a child with a history of prematurity less than 32 weeks completed gestation; or parents who actually my believe their child has something going on with their vision.
So in that case -- and these are the references for that group of children -- in that case, you would use the same screening tools you use with all children. And if the children are untestable, you refer to the child's medical provider for a referral for an eye exam. If the children pass, you still want parents to know that these kids are at a higher risk of having a vision disorder and should still have an eye exam, and that, yes, you still recommend an eye exam for these kids, even if they passed your vision screening. Now, if you want to add some specific text to your referral letters, these are just some suggestions. "We refer children for an eye exam when they do not pass vision screening. We also refer children who may pass a vision screening if they are at a higher risk of having a vision disorder because of a medical or a developmental reason." And that goes back to the slide showing all those medical or developmental reasons. Or you can say, "the reason for referral -- increased risk for vision disorder because of developmental or medical reason," and then describe that reason. Okay. I thought I had a link to that. But I don't. Okay. So, now we're ready for a couple questions in this section. That was a lot of information. But you will have the slides to review later.
Nancy: And we have a lot of questions for all the information. So if we don't get to all of them, which clearly we won't, the National Center on Early Childhood Health and Wellness with support from our wonderful presenters will do our best to do follow-up responses to as many of the questions as we're able. So I'm going to try and do a couple of clarifying questions. So here's one. Are those instrument-based screening tools only appropriate for age one and older? We use our Plusoptix screener on -- so, I didn't
get -- there's a number missing here. On children of a certain age. I'd like to clarify. Looks like April's answering.
Kay: Probably at six months.
Nancy: Six months. Okay. All right.
Kay: It could be six months.
Nancy: Then let me go -- Okay. Six months. Good to know.
Kay: Okay. I -- go ahead. I'm sorry.
Nancy: Go ahead. No, no. Go ahead, Kay. Please.
Kay: The manufacturers say six months. AAP, again, says starting at 12 months with maybe more success at 18 months. But I do have pediatricians tell me that they are successful at six months. So I guess it would -- that one's a difficult one to answer. If you're doing okay at six months, I guess continue. Would you agree, Kira?
Kira: Yeah. I think if you're getting something, and getting passes and failures, and it is giving you a result, go ahead and continue. Again, I think this is where you go back -- if you have a strong vision health program, you really are making sure you get follow-up on any referrals and comparing them to your screening results. Those successful outcomes, you really need to keep a close surveillance on that, if you are using instruments at an age younger than six months. I think leaning more on the developmental assessment is probably a more evidence-based approach at this point in time for that very young population.
Nancy: Thank you. So now I have a kind of a general, bigger picture question, and then a couple of specific questions about both the LEA images and the optotypes. So can you clarify, are you saying that we should do both optotype and instrument screenings for preschoolers, or either one is enough for evidence-based screening? So the question is, do you need to do both and, or just one?
Kay: Just one. You don't need to do both.
Nancy: Okay. All right. Thank you. And since our LEA images do not have the crowding bars or lines, is it not considered an evidence-based screening if they don't have the crowding bars or lines?
Kay: The crowding bars and the crowding rectangle, those are the preferred methods coming out of the National Center. And whether it's a LEA Symbols chart is going to depend on whether it's a linear or proportional spaced. And I don't want to get into that here because Kira still has a section. But we can go into more detail when we do a Q&A later. And I can explain that.
Nancy: Okay. Do you have time for one or two more? Or should we move on?
Kay: That's up to Kira.
Kira: Let us do one more.
Nancy: Okay. So, do we only do distance vision screening and not near vision?
Kay: That is going to depend on whether you are required to follow your state guidelines and whether your state guidelines call for near. Some states are picking up near, like California, Washington, some other states. So near is not recommended across the country at this moment. That may change as more research becomes available around hyperopia. But as of right now, that's really up to your program, and if you follow your state guidelines, what your state guidelines say. Yeah. Kira, do you want to add to that?
Kira: Yeah, I will add to that just a little bit. What we're doing with the vision screening program in Early Head Start and Head Start is a public health vision screening program. So to have another visual acuity test added to the number of tests that need to be provided for children on their intake does take a considerable addition of staff, and time, and resources. So it's not a small investment to add another test, depending on what the outcome is. And at this point in time, for kids in this age group, you're just not going to get enough outcomes on your referrals and prevention of eye disease to really qualify the addition of the staff, time, and resources it takes for that test. With the approach in some states where in school-age it's optional, that test is typically implemented when there are kids that are not reading at the same level as their peers. They're not meeting developmental guidelines. Then they may take a step to implement a near visual acuity test. In the case in Early Head Start and Head Start programs, where you have kids not performing to peers or not meeting developmental expectations, that's a point in time where you can refer for an eye exam to see if vision is one of the issues. So in this case, the addition of the cost and everything of the test, it's just not going to qualify what you get for an outcome where you may already make that referral.
Nancy: All righty. Thank you. Sure. Okay, I think --
Kay: And I will now --
Kira: -- I take over.
Kay: You do. And I may have advanced you too many slides.
Kira: Well, I have to go back. Because Lincoln is just so darn cute sitting on the shoulders of his mom there. So --
Kay: Aw. Kira: -- I like to show that picture. And so that's Lincoln. He's from Texas. He is a little fella who had a vision screening early. And they found that he had a vision problem and got him corrected. And now he's finally seeing the face of his mom as well. So we have to share these success stories and remind ourselves why we do what we do. But most importantly, we need to make sure that we are supporting the families of the children who have to help those kiddos get to the eye doctor, and adhere to treatment, which is not always an easy thing to ask of them. So we need to make sure that we support them. And the Head Start Performance Standards also state that a program needs to facilitate further diagnostic testing, evaluation, treatment, and follow-up as appropriate. So it is one of the expectations of programs as well. You also must have a system to track referrals, and services provider, and monitor the implementation of follow-up plans.
So I'll introduce a resource that will certainly help you to do so. And then also assist parents as needed in obtaining any prescribed medications, aids, or equipment for those health conditions identified. So what I want to talk about here in this section is many of the resources that we have on hand at the National Center and that we have developed through partnerships to really help with adhering to this performance standard. One of the things that we really like to elevate is just how helpful other parents and peers can
be to families. Many of you may have had the experience where a child failed a vision screening, was referred to follow-up eye care, and there's a feeling of guilt, or confusion, or I should have known this, that comes on the parts of the family. I think we hear that almost daily at our work, between Kay and I. And so, with that guilt and feeling that they should have known that comes, oftentimes, a lot of confusion, which can be compounded in the event that there are language barriers, access barriers, or other issues.
So there's a lot going on emotionally when a vision problem is identified. So we really do want to encourage you guys to have peers support other families, where there can be a conversation, one parent talking to another about the types of things they did to help their child with their treatment adherence, or a referral to an eye care provider that maybe they had a great outcome with. Sometimes peers can serve as personal advocates. For those families who get nervous when they go to a doctor's office -- maybe they had a bad medical experience in the past and they're nervous about going to any type of clinician -- having an advocate there to help understand what's happening and the expectations is always great to have on hand. Those peers may also be able to help provide translation. And this is important for those families who have access issues because they can't find a provider that speaks their native language. And you don't want them going in and not understanding what's happening with their child's vision. So to have other families offer to help provide translations is a huge help. Maybe just mobility is an issue.
And helping parents get access or getting their child to an appointment can be one way a peer helps another. We also encourage peers to help share their stories. In those cases where you've had families have positive outcomes for their child, where they've had treatment, it's improved the learning experience, encourage those families to share that experience, where you may have parent meetings, e-newsletters, or maybe a blog with your program, encourage those families to share their experience and encourage each family that gets their child referred to follow-up to an eye care provider. And then maybe you have families involved in your health committees. And so you want to help them set goals for the children's vision program in your center and make sure that they're helping to reduce any barriers that may come along for their child's eye care. And communication is key among anybody involved in this system. Whether it's the program staff, or the families, or the providers that you work with, you have to have good lines of communication. So for the families, see if you can identify different ways to get follow-up on the referral. So with the families, do you have phone numbers, and can you text them, or email, can you get permission from the families to get outcomes from the eye care provider back to your program? And I'll show you a resource that helps to facilitate that communication. Make sure that you promote engaging the medical home.
So if a child is referred from vision screening in your site to go to an eye exam or to their medical home, can you get permission to communicate with that child's medical home, so that they can do their proper function to help coordinate care for that child to other medical specialists? And if a child does have a diagnosed vision problem, support the treatment plan back in your center. Does the treatment plan provide you information that says maybe this child has a loss of vision, or a visual impairment. And maybe you need to engage other specialists, such as a teacher of the visually impaired, to help make sure they have a proper learning environment and they're getting as strong of a learning basis as they possibly can. And develop those relationships with people in your community. Healthy vision doesn't happen with just one person. It takes a lot of people working together and working in a coordinated way to make sure that it stays healthy.
So I wanted to show an example of a quality improvement project that's going on right now in Arizona, just to see what happens with parent engagement and follow-up to eye care. I thought this was kind of interesting for this audience. One of the projects I'm working with wanted to help parents understand what the child was experiencing when they had a vision problem. And so they have obtained some glasses with a vision condition sort of ground into them. So when they make a referral from their vision screening to the parents, and they're giving them the referral, and they talk with them verbally, to help reinforce the importance of that referral, they have the parents try on the glasses and try and do a task, so they can see really how difficult it can make the world for their child. And so right now, they're testing to see what the reactions are of the parents to the glasses and the number of referral follow-ups. So if you are engaged in quality improvement your program and you want to try out some new things, this is an example of a great approach that you can try to help with parent education and hopefully enhance your follow-up to eye care.
So there are some resources on the National Center website. And again, you will have the links after today's presentation. But we do have resources to facilitate access to eye care through many financial assistance programs that are out there. So we have a list on our website of programs that are not just for kids, but also for parents too. Oftentimes, we find that the parents are struggling to get access to eye care. And this resource will facilitate access for both kids and adults. There's also a vision screening data collection and referral document on the website that on one side is a letter to the family -- it's available in English and Spanish -- which allows for release of information from the care provider back to your educational site, as well as the medical home. And then on the other side, it helps to collect the vision screening information as well as eye exam information outcomes. So hopefully that will allow information flow to happen but also provide a place for that information to sit. And also, the National Center website has family educational materials, largely in English, and Spanish, and some traditional Chinese, that really helps families understand what role vision plays in their child's learning ability, in their child's development, what actions they could be taking to help support their child's vision.
And like I said, it doesn't take just one person. It takes an army to help facilitate healthy vision. So one thing I do encourage is that you establish community-provider relationships. Eye care providers in your area want to support your families and keep them healthy. So talk with them about the needs of the families that you serve. Who are you seeing? What languages are they speaking? What kinds of questions do they have? And make your eye care providers be a part of your circle to help support your families. And a great project for a parent or college student that might be in your area is to create a resource listing of all the local eye care providers -- when they're open, what insurance they might accept, where they might be located on a bus line, the ages of children seen, if possible -- to help sort of narrow down the "who do we call" question when a child is referred to an eye care provider. And invite those providers to come talk to your program.
If you have meetings for families and you're talking about health, make sure that you include an eye care provider so that they can answer questions about vision. Or even ask them to join your health advisory services committee. And some additional resources we have on the website, just to help facilitate that treatment adherence and communication among all the different stakeholders, can be seen here on the Prevent Blindness and National Center website. So we've got a great little sort of 1/3-sheet flier that talks about tips for wearing eyeglasses. And that's especially important for those kiddos that receive their first pair of eyeglasses, to help them understand how to take care of them, but also their parents. In the middle is eye health and safety curricula that is appropriate for preschool and on up. And so this curricula will
help the kids understand why vision is important, how some people take care of their eyes and why they might wear glasses, and has a lot of great supporting activities that are aligned with national health and safety curricula standards. And then the third item you see there on your screen, Eyes That Thrive In School, is a treatment adherence tool that can be used in your center that has both professional educational elements, family education elements, and then treatment tracking tools built into it.
They are free for download on the National Center website. And so I encourage you to check those out. It's a lot of great tools in multiple languages that help parents understand what their children's vision problem is, what the treatment was that was prescribed for them, and then classroom tools where the kid can put a sticker on the calendar every day that they wear their glasses or their patch, so that there's some treatment adherence that's happening in your classroom while they're under your care. So, like I said, these resources are on the National Center website. There's a lot more there as well. So we've got a lot of professional development, provider education tools, technical assistance, and communication tools. Some of those that I wanted to highlight beyond the one that Kay mentioned, the infant vision milestones checklist is on that website. And we also have -- let's see here -- some published materials. So we had an article on children's vision health in Exchange Magazine. We've got some information about vision screening training, which
I'll touch on here in a second, as well as information specific to optotype-based testing or instrument-based testing. We really kind of get down into the nitty-gritty on each of these topics and have resources for them on the website. As I mentioned, we do support a vision screening training certification course. It's really most appropriate for those in Head Start and older. We're in the process of developing support around younger children. But again, that's where the emerging evidence is. So we do not have that yet at this point in time. But for Head Start and on up, we do have a certification course that's available online or in person. And the link there to that information is on your screen. I encourage you to take a look at it. And we do have a link on the website called Year of Children's Vision, which was a variety of different resources, recorded webinars, PowerPoint presentations, specific resources for Head Start and Early Head Start programs that are all living under that title of Year of Children's Vision. So I encourage you to check that out, and the center's website. So I think we've made it to the Q&A portion. Okay. Here we go. So in no particular order, since our LEA images do not have the crowding bars or lines -- I'm sorry. I think -- is this one answered? Did we answer this one? Yeah. We did that. Yes. We did. I apologize.
Kay: I think we answered that.
Nancy: Yeah. I grabbed the wrong one.
Kay: Nancy?
Nancy: Mm-hmm? Yes, Kay.
Kay: I was scanning through some of the questions. And if you don't mind, I would like to go ahead and toss a couple out that have to do with -- That would be awesome. You're okay with that? Okay, great.
Nancy: Yes. Absolutely. Because I'm trying to scroll and I didn't see that the last one had been answered. But I tried to elevate some of them to the top that I thought would be good for you. But if you want to pick some, I think that's terrific. So go ahead.
Kay: Yeah. Not a problem. Lots of questions. Lots of great questions.
Nancy: Really.
Kay: Oh, perfect questions. So I'm seeing some questions coming in about, is it appropriate to do cover/uncover, or penlight, or some of these eye doctor tests? And anything such as that that would be considered an eye doctor test is not really recommended. Because if I went over here to the Eye Institute and asked all the residents to do a cover/uncover, it's not going to be -- they're going to have some difficulty. It's not an easy test to do. So those eye doctor-type tests are not recommended. Kira, do you want to respond to that, as well?
Kira: Yeah. Again, it's just a matter of, we try to ground all of our procedures that we recommend to this field in evidence. And there just is not evidence there that this test has been consistently implemented in a nonclinical setting with proper referrals. And so it's just not something that can be consistently trained on, promoted, and implemented across the field. I'm not saying there aren't people out there that can do it well in this setting. It's just what is consistently in evidence-based for this field. And this isn't a procedure that has that evidence for this early education setting.
Kay: Yeah. That was a nice way of answering that. Because some of the folks who are doing it may be doing it quite well. But, yeah. We want to make sure it's evidenced. Then I also saw a question on whether a 10-foot chart could be used at five feet. And the answer is no. Those lines are calibrated. And I'll not get into a lot of detail. But let's just say a five-foot chart is to be done at five feet and a 10 is to be done at 10. If you did use them at different distances, you'd have to apply a mathematical equation or a mathematical formula to get the correct visual acuity value. And I'm guessing you don't have a lot of time to do that with everything else you're responsible for doing. So, no. You would not use a 10-foot chart at five feet. And now, Kira, do you want to -- Kira, Nancy, if you see another question, those are just some I definitely wanted to -- oh. Someone asked about the lighthouse chart. Why is that one no longer recommended? Two reasons. One, the design of the charts that I have seen do not meet the national and international guidelines, where there should be five optotypes per line, spacing between the lines, spacing between the optotypes has to be done a certain way. The spacing between the lines have to be the height of the next line down. The spacing between the optotypes need to be the width of the optotype on that line. But again, the optotypes should be almost equal in legibility. And there was a recent study that looked at 9 or 11 different eye charts. And those optotypes were not equal in legibility. The umbrella was easier to identify than others. So you could be under-referring children. And the LEA Symbols and the HOTV are the preferred optotypes for young children --
Nancy: And I just -- Kay: -- based on research.
Nancy: -- pushed that slide back out to the audience, Kay.
Kay: Oh, thank you.
Nancy: And I was going to kill two birds with one stone. Somebody asked to post those slides again.
Kira: Right. Right. Thank you.
Nancy: But also to clarify the passing levels for each age. So I thought we could kill two birds with one stone with this one, Kay.
Kira: Do you want to talk about passing levels?
Kay: You go right ahead.
Kira: Okay. So, for children aged three years, with the optotype-based test, they should be able to see at 20/50 or better. If they're not seeing at 20/50, anything worse, higher than that, they should be referred. For children ages four and five, they should be seeing at 20/40 or better. So if you're getting any outcome of acuity higher than 20/40, then you need to be referring them on as well. So those are the referral criteria for age three, 20/50 is where they need to pass. Anything higher than an acuity reading of 20/40 for children aged four and five, they should be referred.
Nancy: Okay. So let me go back to some other ones. We're considering the GoCheck screening machine for Early Head Start. But it's not on the recommended list. So is there any information you could share about the selection process, because that one didn't make the list?
Kira: Yeah. I'll talk about this. So, the National Center for Children's Vision and Eye Health has a formal process in place right now that we ask manufacturers to submit published peer-reviewed study for the device, which really demonstrates a validated approach to using the tool with targeted age population -- so we're looking at, really, kids age five years and younger with this group -- in nonclinical settings, and really having studies that are well designed, and have a high enough "N" used, the number of subjects used in the studies to really show with much confidence that the tools are giving the expected outcomes. Right now, GoCheck eye screen -- there's a lot of new devices emerging out there that while they show some promise, they don't have the level of evidence behind them yet to really promote them with specific populations and specific settings. So we stay in communication with those manufacturers to say, you know, we'd like to see more evidence, here's what the field is asking, so that we have the confidence behind what we're recommending to make sure that the end users, the vision screeners, are picking the right tools for the right audience and the right setting. So I know you hear me say that a lot. But we really do follow carefully what evidence is out there to promote the best use in your targeted setting. So, at this point in time, we just don't have enough evidence formed.
Nancy: Thank you, Kira. Can you say a little bit more about the training and certification that someone would need to be able to do some of these screening tests, particularly the optotypes, the LEA, or HOTV?
Kira: Sure. I can talk about our vision screening training approach, with a caveat that there are some states out there that do have training specifically for preschool age and younger. And always, the state-mandated approach will override any national approach that we have. So just keep that caveat in mind. Our training that Prevent Blindness has set up is a certification that's good for three years, recognized nationally. And again, as I mentioned, it's available online and in person. The training covers the same thing in either format, where we discuss the common vision problems in children, what we're looking for, appearances, behaviors, complaints, that may indicate a possible vision problem, approaches to visual acuity assessment, whether that's optotype-based or instrument-based. We talk about what the referral criteria are, supporting families, and then having a strong follow-up approach. If that's done in an in-person class, we cover those topics. All of those different areas have a test that's been given. And we do have to have a certain number correct to pass that test. And then in person, we have a skills competency assessment where we see you with the vision screening tools, using them, making sure you have the right approach with those tools. The online version goes through each of those different topics in a modular format. Folks can log in and use that at their own pace and complete the modules as they go. Each module does have a test that goes with it, with a required passing amount, with number correct. And you get a couple of chances to take those tests if there's any issues with it. Once you take those online modules,
complete the test assessments, and watch the supporting videos, then we set up a video chat or have a local trainer in that area observe that individual and their screening skills, making sure that they understand the environment is correct for screening, they understand what the referral criteria are and how they're going be collecting data and follow-up. So all of those things are still checked sort of live and in person, with the same knowledge gain being done either in person or online.
Nancy: So based on your answer, your very thorough answer, I think it addresses a follow-up question from someone who wanted to know if you had to be a health care professional in order to do a screening with an instrument.
Kira: No. You just need to complete proper training and understand what you're looking for with that device, and then demonstrate that you can use it competently.
Nancy: Well, great. Thank you. Do you have anything you want to add about the Broken Wheel on three- to five-year-olds?
Kay: The Broken Wheel does not meet the national and international guidelines for standardized eye chart design. And you're also asking children for orientation and direction. And it just doesn't have the evidence to support its use with this age group.
Nancy: Thank you. And anything more you would like to add about the Blackbird system of vision screening?
Kay: Same answer. As all these different groups look at the research to support the optotypes that they recommend, there's just not the research there. And again, it doesn't meet the national and international guidelines. And I keep saying that because if the chart is not standardized, you're not getting the truest visual acuity value possible. And you could be over-referring or under-referring. Now that's not to say that if you use LEA symbols and HOTV you're going to be 100 percent. No test is ever 100 percent. But LEA symbols, for example, and HOTV, were included in the Vision in Preschoolers Study that Kira mentioned earlier. That is the benchmark study for types of screening to use in children in this age group. And that study was done in Head Start. And that test was not even included in the more common tests used. Now at one time it was used very often. But it just doesn't have the research for these national organizations to support the use.
Nancy: Great. Thank you very much. So here is a question about referral criteria and what referral criteria settings we should use for instrument-based screening tools. For example, the Plusoptix screener has five different settings to choose from for specificity and sensitivity.
Kay: Sometimes we say, talk to eye care professionals in your area and ask them what setting they want you to use to refer children. I know on the Spot, it's already set for different age groups. So depending on where you live, depending on how many eye care professionals are in your area, if it's possible, reach out to a few and say, at what point do you want me to start making referrals? Kira, would you add to that anything?
Kira: Yeah. It really is a balance of what you want to over- or under-refer in your program. When you're using instrument-based vision screening devices in more clinical settings, they tend to not try and over-refer so much. So you'll have much higher identification of disease and not so many missed or over-referred. When you're in more of a public health setting, your referral rates do tend more towards an
over-referral. So each of those different -- like in the Plusoptix the five different settings represents how much do I want to over-refer or under-refer. And so there's going to be that comfort level, as Dr. Nottingham Chaplin mentioned, that for the number of providers in our area, how much do we want to be feeding kids into the system. And so it is a balance that you should work out with your eye care providers in your area. Just say, okay. Here's the setting we're using. And with the feedback you're getting from them from eye exam results, you'll be able to compare that to your screening results to say, Okay, you know, that kid really didn't have a problem. This one did. And you can refine your referral criteria for that. So as you start off, many people use what the manufacturer has set. That's sort of the medium-of-the-road approach. If you're getting a lot of feedback from eye care providers in your community saying, yeah, I didn't find anything, or you aren't referring that many kids, maybe take another look at your referral criteria. But with instruments where you have abilities to pick your referral criteria, it takes a little bit of monitoring, assessment, and evaluation to get it right for the first year or so.
Kay: And I would totally echo what Kira just said that's incredibly important. And that is, if you can receive copies of your eye exam reports, it's always good to evaluate, and as part of evaluating your program, is to compare your vision screening results with those eye exam results. Do we have another question?
Nancy: We do. Thank you very much. But actually, this is more of a comment, I think, than a question. So this particular program is noting that they've found that the instrument-based screening is needed for preschoolers three to five who have developmental concerns. And they've had good luck with the instrument-based screening for that subset of the population who may have developmental concerns or delays. So I just thought I would share that. I don't know if that's a common experience or unique to that program. But I wanted to share that. So, let's see.
Kira: And can I just add to that statement, Nancy?
Nancy: Yes, please. Absolutely.
Kira: I just wanted to go back to Kay's slide around the children who were at increased risk. Again, she echoed this. If you want to use your traditional screening approach that you might use with the other kids, and in this case it's the instrument-based, they may pass and be successful. But there's still a good educational opportunity for those parents that their child does have a medical condition that may increase the risk. So it's still a good idea throughout the child's career to have a relationship with an eye care provider. So just continually passing visual screenings may not always catch everything. And since they are at an increased risk, it's a good idea for them to have an eye exam at some point.
Nancy: So, as a related question, is there anything you want to add? Perhaps not. But is there anything else you would want to add about a specific population that programs should be paying particular attention to because of a risk of higher incidence of eye and vision problems?
Kay: Kira, you could get into the ethnicities there. I'll add one quickly. For example, kids from Indian country are at a higher risk of having astigmatism, for example.
Kira: Yeah. As are Hispanic and African-American populations. But I would say those ones that -- if programs really want to consider their approach for those with a developmental delay, medical condition, or family history as you had in your slide, Kay, I think those are the ones that if you want to have some special education towards -- those are the families to target. I would say other ethnicities, most of them
have one eye condition or another they're at increased risk for. So the consistent screening is the right approach for the others.
Kay: And particularly in families where first-degree family members have had or still have amblyopia or strabismus -- misaligned eyes -- or they wore prescription spectacles early, those are some red flags. And you'd really want to pay attention to the children who have those family members with vision problems, disorders.
Nancy: So on a related basis, are there any age-appropriate visual acuity cutoffs for referrals to keep in mind when you're looking at the results of visual acuity screening? Kira, do you want to go over those numbers again?
Kira: Yeah.
Kay: 20/50 --
Kira: That would just be the passing thresholds. So, for those three-year-olds, it was 20/50. For four- and five-year-olds, it's 20/40. Or if you're using an instrument-based screen, you should have age-appropriate referral criteria that you're using for the device, depending on the device. And if it does indicate a refer, then you want to follow the instructions on the device.
Nancy: [Inaudible] the suggested length of the near-sight test for acuity?
Kay: If you're doing near-screening?
Nancy: Uh-huh.
Kay: 16 inches. And if you're doing near-screening, you would want a card that has a cord attached to it. Because the screening distance at near is more critical than it is at distance. And kids will lean close to the chart. So if it has a cord, that cord goes right at the temple close [Inaudible] very careful not to obviously hit the eye. And you want to keep that string on that cord tight so you know that you're maintaining the screening distance.
Nancy: Great. Thank you.
Kay: And it's hard to describe. Because I can see the chart in my head. And it's hard to ex zlain exactly what I'm talking about. But you just want to be able to maintain that 16 inches.
Nancy: Okay. Super. Thank you. So, lots of questions about the slides. And they will be available eventually on the Early Childhood Learning and Knowledge Center, although we're migrating to the new site. So things may be available a little more slowly than at other times. Because big things are coming when we get our new site. There are certainly more. And we'll have a chance to really go through the ones that we haven't answered with apologies to folks who were very thoughtful about putting all of your questions in. But we're almost to the top of the hour. So I don't know if you guys have any other closing remarks that you want to make. Just thanks for having us on today and a chance to share the information. Again, we try to do a good job with having evidence backing up all the stuff that we recommend. But one of the best sources of information is feedback from the field. So if anybody has any knowledge, experience, opinions about the items that we have and wants to give us some guidance, we always welcome that. So you'll have a link to the center to get back to us. Okay? Great. So thank you. I'll turn it over to April. Thank you both.
April: Thank you all. Thank you, Kira. Thank you Dr. Nottingham Chaplin, both from Prevent Blindness. And thank you so much, Nancy, for helping to vet all of these questions. This was a very engaging presentation. And we see that there's a lot of interest. So we'll be in touch to get some of these questions answered. If you would like more information or if you would like to email your question directly, the info line is right there, health@ecetta.info.
And so now, we will go ahead and pull up the post-webinar evaluation. There will be a link on your page. And if you go ahead and click that evaluation, answer the questions. And then you will get your certificate. And also, remember, if your colleague was not able to watch this, we can now give certificates for watching the archive. So feel free to send along the link for them to watch the archive. So the link is right there. Go ahead and take it.
And that concludes our webinar. So thank you very much to our presenters. And thank you all for attending the presentation.