A Guide for Vision Screening in California Public Schools

California Department of Education
1430 N Street
Sacramento, CA 95814-5901
April 2019

Table of Contents
A GUIDE FOR VISION SCREENING IN CALIFORNIA PUBLIC SCHOOLS .................... I
Acknowledgements....................................................................................................... 3
Section 1: Introduction ................................................................................................. 5
Objectives of the Vision Screening Program ............................................................... 5
Legal Basis for Vision Screening ................................................................................. 6
Minimum Requirements for a Vision Screening Program ............................................ 6
Table 1: Legal Requirements for Periodicity of the School Screening Program .......... 6
Early Vision Screening Interventions ........................................................................... 7
Personnel Authorized to Conduct Screening ............................................................... 7
Preparation of the Student for Vision Screening .......................................................... 8
Observation of the Student .......................................................................................... 8
Screening Procedure Considerations for Non-literate, Non-verbal, Non-EnglishSpeaking, and/or Very Young Students and/or Students with Special Needs ....... 8
Principles of Vision Screening ..................................................................................... 9
Visual Acuity ................................................................................................................ 9
Visual Acuity Screening ............................................................................................. 10
Basic Principles ......................................................................................................... 10
Table 2: Evidence-Based Pediatric Optotypes .......................................................... 10
Instrument-Based Screening ..................................................................................... 11
Section 2: Vision Screening Procedures .................................................................. 13External Observations ............................................................................................... 13
Distance Visual Acuity Optotype-Based Screening ................................................... 13
Critical Line and Threshold Screening ....................................................................... 19
Near Visual Acuity Optotype-Based Screening ......................................................... 22
Color Vision Deficiency Screening ............................................................................. 24
Instrument-Based Screening ..................................................................................... 26
Functional Vision Screening for Students with Special Needs................................... 27
Optional Tests ........................................................................................................... 27
Near Point of Convergence ....................................................................................... 27
Stereopsis .................................................................................................................. 30
Section 3: Planning and Follow-Up Procedures for Vision Screening ................... 33
Checklists for Implementation of a Vision Screening Program .................................. 33
Follow-Up Procedures ............................................................................................... 37
Follow-Up for Students with Glasses or a Known Vision Disorder ............................. 38
Appendix A .................................................................................................................. 41
Legal and Administrative Provisions for School-Based Vision Assessments............. 41i

California Code of Regulations .................................................................................. 41
California Education Code ......................................................................................... 41
Supervision of Health................................................................................................. 41
Employment ............................................................................................................... 42
General Powers—School Boards .............................................................................. 42
Employment of Medical Personnel ............................................................................ 43
Physical Examinations ............................................................................................... 43
Solicitations ............................................................................................................... 43
Appendix B .................................................................................................................. 44
Notifications and Form Templates ............................................................................. 44
Vision Screening Report ............................................................................................ 45
Report of Eye Examination Results to the School ..................................................... 46
Color Vision Screening Results .................................................................................. 47
Memorandum of Understanding (Sample) ................................................................. 48
Appendix C .................................................................................................................. 50
Frequently Asked Questions ...................................................................................... 50
Appendix D .................................................................................................................. 54
Glossary .................................................................................................................... 54ii

Acknowledgements
This edition of A Guide for Vision Screening in California Public Schools (2018 edition)is the result of collaborative efforts focused on children’s health. A sincere appreciation
to the following individuals and organizations for their concerted efforts:
Kira Baldonado, BA, Director of the National Center of Children’s Vision and Eye Health
Lydia C. Bourne, MA, BSN, RN, PHN, Legislative Advocate, Bourne, and Associates
Susie Brown, MSN, RN, Credentialed School Nurse, San Lorenzo Unfired School
District
Cheryl Burden, MSN, RN, PHN, NP, Program Manager Nursing Services, Oakland
Unified School District
Sheri E. Coburn, EdD, MS, RN, Director of Comprehensive Health Programs, San
Joaquin County Office of Education
Joyce Cox, BSN, MPH, RN, Program Specialist, Long Beach Unified School District
Vincent J. Cianci, OD, Pediatric Optometrist, Department of Pediatric Eye Services,
Neuro-ophthalmology, Binocular Vision and Strabismus, Kaiser Permanente
Angela M. Chen, OD, MS, Pediatric Optometrist, Southern California College ofOptometry at Marshall B. Ketchum University
Sue Cotter, OD, MS, FAAO, Professor, Southern California College of Optometry
Marshall B. Ketchum University
Anne DeJarnatt, BA, BSN, MSN, Credentialed School Nurse, Jefferson Elementary
School District
Joan D. Donofrio, MSN, Credentialed School Nurse, Folsom Cordova Unified School
District
Bob Garr, PDG 4C1, Sight Preservation and Awareness Volunteer, Lions Club
Helen Garr, MD4, Sight Preservation and Awareness Chair, MD4 Lions Club
Elise Harb, OD, MS, FAAO, Clinician Scientist, University of California, Berkeley,
School of Optometry
Kristine Huang, OD, MPH, Southern California College of Optometry at Marshall B
Ketchum University
Pamela Kahn, MPH, RN, Coordinator, Health and Wellness, Orange Department of
Education

3

Melinda B. Landau, RN, MS, Manager, Health and Family Support Programs, San Jose
Unified School District
John Lagomarsino, School Health Education Consultant, California Department of
Education
Yolanda Lasmarias, MA, MBA, RN, Administrator, Nursing Services, Los Angeles
Unified School District
Rachel McClanahan, DNP, RN, NCSN, Assistant Professor of Nursing, California State
University Fullerton.
Luisa Monson, MEd, BSN, RN, PHN, Vision Program Coordinator, Credentialed School
Nurse, San Diego Unified School District
April Nakayoshi, MPH, CHES, Vice President of Programs and Evaluation, Prevent
Blindness Northern California
P. Kay Nottingham Chaplin, EdD, Advisory Committee to the National Center forChildren’s Vision and Eye Health at Prevent Blindness, Good-Lite, School HealthCorporation, and Consultant to the Vision Screening Committee of the American
Association for Pediatric Ophthalmology and Strabismus
Mary O’Hara, MD, Professor of Ophthalmology and Pediatrics, University of California,
Davis.
Deborah Orel-Bixler, PhD, OD, Professor of Clinical Optometry, University of California,
Berkeley School of Optometry
Reena Patel, OD, Pediatric Optometrist, Southern California College of Optometry,
Marshall B Ketchum University
Susan E. Proctor, PhD, RN, FNASN, Professor Emerita, Community Health & School
Nursing, California State University, Sacramento
Kathy Ryan, MS, RN, FNP, President, California School Nurses Organization
James B. Ruben, MD, FAAP, Pediatric Ophthalmologist, The Permanente MedicalGroup
Anne Deem Saitofi, MSN, RN, NCSN, Credentialed School Nurse, Fontana Unified
School District
Sharyn W. Turner, RN, MA, PHN, President, California School Nurses of California
Foundation

4

Section 1: Introduction
The California Department of Education (CDE) is pleased to provide these visionscreening guidelines for students in California’s public schools. The CDE, working incollaboration with representatives from the ophthalmology and optometry professions,credentialed school nurses, educational leaders, and community-based organizations
specializing in vision screening, has established these standardized vision screening
guidelines to update the current school screening practice. The guidelines described inthis manual represent evidence-based methodology and current best practice in thefield of vision screening. They are intended to facilitate the identification of students with
common vision problems as early as possible, when treatment is most effective, tosupport academic success.
California public schools are committed to providing equal educational opportunities toall students. The school vision screening program has a vital role in the early
identification of serious vision problems that may contribute to academic disparities. To
fulfill this commitment, schools need to identify students with vision deficits that could
adversely affect learning so that the students can receive timely and appropriate care.
This publication is divided into three sections: (1) Introduction; (2) Vision Screening
Procedures that includes procedures for vision screening of students who are nonliterate, nonverbal, non-English-speaking, and/or very young students and/or students
with special needs; and (3) Planning and Follow-up. Forms related to vision screening
and applicable provisions from the California Code of Regulations (5 CCR) and theCalifornia Education Code (EC) are included in the appendices. In addition, a glossaryof technical terms and a list of selected references are provided.
Objectives of the Vision Screening Program
A vision screening program meets state requirements when it is provided under the
direction of qualified personnel. The major objectives of the vision screening program
are to:1. Identify students with potential vision deficits through:a. Administration of selected vision screening tools
b. Planned procedures of observation
2. Notify parents of each student identified as having a possible vision deficit andto encourage further examination through a professional comprehensive eyeand vision evaluation.
3. Establish follow-up procedures that will ensure that each identified student

receives appropriate follow-up care.
4. Inform teachers of students who have vision deficits about vision eye care5

professional’s recommendations and assist them in planning for neededadjustments in the educational program.
Legal Basis for Vision Screening
The 5 CCR and EC provide the legal basis for vision screening in California publicschools. Hyperlinks to pertinent sections of the EC and 5 CCR may be found in
Appendix A.
Minimum Requirements for a Vision Screening Program
Table 1 shows the legal requirements for periodicity of the school vision screening
program. Specific guidelines for screening procedures can be found in Section 2 of thisdocument.
Table 1: Legal Requirements for Periodicity of the School Screening Program
Grade Level

Distance Vision

Near Vision

Color Vision Deficiency

Transitional
Kindergarten/
Kindergarten

Required

Required

Not Required

Grade 1

Not Required

Not
Required

Required

Grade 2Required

Required

Grade 5
Grade 8Special Education

Required
Required
Required

Required
Required
Required

Required in subsequent
years only if not screenedin grade 1
See Above
See Above
Required

Early screening for Color Vision Deficiency is recommended. Since Transitional
Kindergarten and Kindergarten (TK/K) are not compensatory grades in California, and inaccordance with EC Section 49455, color vision deficiency screening appraisal need not
begin until the male pupil has reached the first grade. Color vision deficiency screening
is conducted once.
Vision screening initial assessment for special education students should occur with theestablishment of the Individualized Education Plan (IEP) and at each triennial review.
In addition, the vision screening program requirements should include the following:
1. Using evidence-based and/or best-practice screening procedures as outlined in
Section 2 of this document.

6

2. Recording vision screening results on the student’s permanent health record.
3. Having teachers continuously observe students for signs and symptoms that may
indicate possible eye or vision problems.
4. Conducting vision screening with students whose school performance indicates asuspected vision problem.
5. Rescreening all students who fail the initial screening. If a student fails a visionscreening that is conducted by a credentialed school nurse, physician orsurgeon, osteopath, or optometrist, a rescreen is not required.
6. Notifying parents/guardians of students who fail the second vision screening.
7. When necessary, assisting parents/guardians of students who fail the second
vision screening with obtaining follow-up care.
Early Vision Screening Interventions
While the EC does not require vision screening of preschool students, the National
Expert Panel to the National Center for Children’s Vision recommends vision screening
children ages three, four, and five years for eye and visual system disorders (Cotter,
Cyert, Miller, and Quinn, 2014). Best practice for this age group is screening at least
once (accepted minimum standard) or optimally, annually. Preschoolers at risk for vision
disorders and those with noticeable eye abnormalities, i.e., strabismus, ptosis, should
be referred directly to an eye care professional. Since children with neurodevelopmental
disorders, i.e., cerebral palsy, hearing impairment, Down syndrome, cognitive
impairment, autism spectrum disorders, or speech delay, have a higher rate of vision
problems than those without neurodevelopmental abnormalities, they should also bereferred directly to an ophthalmologist or optometrist for a comprehensive eye
examination. Additionally, when a parent or guardian believes his or her child may havea vision-related problem, an eye care professional should examine that child.
Personnel Authorized to Conduct Screening
Personnel in a school district or county offices of education (COE) who may be requiredor permitted to screen vision shall be qualified to conduct such tests (EC Section 49452
and the 5 CCR, Section 591).
Only the following persons shall conduct vision screening:
1. Duly qualified supervisors of health employed by the school district or COE.
2. A registered nurse who holds both (1) a license from the appropriate California
board or agency; and (2) a health and development credential, a standard
designated service credential with a specialization in health, a health services

7

credential as a school nurse, or a school nurse services credential.
3. Certificated school district or county employees who hold a teaching credential
and are qualified by training, including satisfactory completion of (1) six (6) hoursof vision screening (5 CCR, EC Section 592); or (2) an accredited college oruniversity course in vision screening of at least one semester unit.
4. Contracting agents who have met the requirements noted above and who havebeen authorized by the County Superintendent of Schools in which the district islocated to perform tests.
Preparation of the Student for Vision Screening
All students should be educated in an age and developmentally specific manner so thatthey understand the purpose of vision screening and their role. For example, when
preparing to screen preschool, kindergarten or younger primary students, the school
nurse should plan time to demonstrate screening procedures to the students and/or
practice optotype matching.
Observation of the Student
The teacher plays a key role in detecting suspected vision problems by observing a
student in classroom activities. A teacher’s observations of a student’s behavior andappraisal of a student’s achievement throughout the year are exceedingly importantbecause unusual behavior and/or poor school performance may indicate healthproblems, including eye or vision problems. Any student suspected of having a vision
problem, regardless of whether they are due for a screening, should be referred to theschool nurse for screening. Signs and symptoms of eye or vision problems may befound in Section 2.
Screening Procedure Considerations for Non-literate, Non-verbal, NonEnglish-Speaking, and/or Very Young Students and/or Students with Special
Needs
Personnel conducting vision screenings need to be aware of the following
considerations when screening students in preschool, TK/K, and special education
programs, as well as non-English speaking students. Students may have:
1. Short attention spans
2. Limited receptive and/or expressive language
3. English as a second language
4. Partially developed eye–hand coordination
5. Fear of new experiences and unfamiliar people
6. Disabilities that hinder their responses

8Young students and students with special needs require particular attention. The
cooperation of parents/guardians, teachers, teacher aides, and other school personnel
in ancillary services is critical for a successful outcome. Adults need to be sensitive tothe student’s actions and reactions to new experiences by:
1. Understanding the student’s fear of examiners and examinations.
2. Avoiding the use of terms such as nurse, examination, and testing.
3. Establishing rapport with the student.
4. Having personnel familiar to the student accompany the student to the visionscreening.
5. Conducting screening in familiar surroundings.
6. Presenting screening as a game.
7. Orienting students to screening by storytelling or other innovative
methods.
Planning, organizing, and implementing a vision screening program for students in needof special care parallel the steps in the regular screening program and processes
described earlier. The exact type of vision screening equipment and supplies usedshould remain open as new ones may be developed in the future. The addition of
instrument-based equipment for vision screening may be particularly applicable in thismore difficult to screen population.
Principles of Vision Screening
The rationale for school-based vision screening is for early identification of visualproblems that can impact a student’s ability to learn. These visual conditions include
amblyopia, strabismus, significant refractive errors, and/or eye pathology. Risk factors
include significant refractive errors, eye misalignment and/or media opacity in younger
students and myopia in older students. Standardized and efficient evidence-based
and/or best practice vision screening procedures, proper equipment, tools, and suitablephysical environment must be considered when vision screening students. Section 2
outlines equipment needs, room requirements, arrangement of equipment, screening
procedures, recording of results, referral procedures for optotype-based screening andcolor deficiency screening, and additional procedures.
Visual Acuity
Good visual acuity is a strong indicator that the visual system is functioning normally.
Normal eye and brain anatomy and communication, appropriate correction of significant
refractive error or absence of significant refractive error, and normal brain interpretation9

of visual information are prerequisites for good visual acuity. While screening for visualacuity is critical because it evaluates major aspects of the visual system, it is importantto realize that it does not appraise all aspects of cognitive processing, which could affecta student’s ability to learn (e.g., learning disabilities such as dyslexia).
Visual Acuity Screening
Per mandated screening requirements, distance and near visual acuity screening mustbe performed. Careful attention must be paid to the screening distance for both distanceand near vision screening; therefore, all acuity screening procedures should follow
manufacturer’s guidelines. Please refer to the California School Nurses Organization(CSNO) website at https://www.csno.org/ for tips regarding visual acuity screening.
Basic Principles
1. Regardless of vision screening results, if the school nurse or screener has
professional concerns that the student may have a vision problem, refer the
student to an eye care professional.
2. Distance vision should be screened for each eye independently (monocularly)
using appropriate occlusion methods that control for peeking (i.e., monocularlyoccluded screening glasses). Appropriate occlusion methods are discussed in
Section 2.
3. Evidence-based pediatric optotypes should be employed for screening, withmatching, if necessary, for younger students (Table 2). According to theAmerican Academy of Pediatrics, American Association for Pediatric
Ophthalmology and Strabismus, and the American Academy of Ophthalmology,“Sloan letter charts present letters in a standardized fashion and should be used
for acuity testing if they are available.”
Table 2: Evidence-Based Pediatric Optotypes
Currently Acceptable Optotypes
LEA SYMBOLS®

Not Acceptable Optotypes
Allen pictures

HOTV
Sloan Letters*
LEA NUMBERS®*
Patti Pics
Snellen*
N/A

Tumbling E
Blackbird
Landolt C“Sailboat” or Kindergarten Chart
Wright figures©
“House, Apple, Umbrella” or Lighthousesymbols*Indicated in children seven years and older

104. Optotype screening should utilize crowding to screen for amblyopia. For
example:a. Isolated optotypes with contour interaction/surround bars for younger
students.
b. Line of optotypes on a multiple lined chart for older students.
5. Vision screening protocols should minimize opportunities for the students tomemorize answers. For example:
a. Computer-based optotype software with optotype randomization.
b. Printed optotypes with multiple optotype choices at a given screening
acuity level.
c. Identifying optotypes from left to right with first eye and right to left withsecond eye.
6. Following any necessary practice/orientation with younger students, present agespecific critical acuity level optotypes for screening.
a. To pass a line, a student must correctly identify at least 51 percent (e.g.,3/5) of the optotypes correct at that particular acuity level.
b. If performing critical screening (as recommended in Table 6), there is noneed to record threshold visual acuity. Instead, record pass or fail at agespecific critical visual acuity level.
7. Perform near visual acuity binocularly.
a. The critical line visual acuity level to pass for all ages is 20/32.
Instrument-Based Screening
Instrument-based technologies, such as photoscreeners or handheld auto-refractors, do
not assess visual acuity, but rather identify amblyopia risk factors, primarily refractive
error. The use of instrument-based screening under an agreement with, or thesupervision of, an optometrist or ophthalmologist has been approved by the California
Legislature (EC Section 49455). A sample Memorandum of Understanding may befound in Appendix B. Instrument-based (photoscreening) uses optical images of theeye’s red reflex to estimate refractive error, eye gaze, and identify media opacity as wellas other visual conditions, such as ocular adnexal deformities (e.g., ptosis), all of which
put students at risk for developing amblyopia (American Academy of Pediatrics, 2016).
Best practices for instrument-based screening should be evidence-based, also referred
to as scientifically validated, and will evolve as technology changes. Screening devices

11require instrument- and age-specific pass/fail refractive error criteria. For a listing ofrecommended instrument-based screening protocols by the National Center forChildren’s Vision and Eye Health, visit the CSNO website at https://www.csno.org/. In
addition, up-to-date scientific evidence on instrument-based screening may also befound at https://www.csno.org/. Evidenced-based, instrument-based screening isparticularly useful as an alternative to optotype-based screening for:
1. Students with developmental disabilities.
2. Students who are younger (e.g., preschool or kindergarten) or pre-literate.
3. Students who are unable to be screened with traditional optotype-based
screening.
For students who are unable to complete visual acuity screening, instrument-based(photoscreening) may detect the risk factors for amblyopia; including refractive error,
strabismus and media opacities.
1. Show the instrument (photoscreener) to the student and tell them that you will betaking their picture. If, during screening, they do not look directly at the device,re-screening is suggested.
2. Adjust room lighting to avoid glare into the instrument.
3. High refractive error may exceed the measurement range of the instrument(photoscreener). If results cannot be obtained after three attempts, the student
should be referred for a comprehensive eye examination by a professional.
4. Be aware that the cut-off for clinically significant refractive error varies with age(from infants, preschoolers, and elementary school-age students). Most
instruments (photoscreeners) have different cut-off criteria for children versus
adults. Use the age-appropriate referral criteria.

12Section 2: Vision Screening Procedures
External Observations
School nurses, teachers, and other personnel should observe students for signs andsymptoms that may indicate a possible eye or vision problem. Various eye or vision
problem signs and symptoms are included below (Table 3). Observations should bemade throughout the year as students use varied types of materials, i.e., books,
whiteboards, and computer screens. If the student begins to frequently and or
consistently exhibit signs or symptoms, a referral should be made to the school nurse
for screening or to an eye care professional.
Table 3: Signs and Symptoms of a Possible Eye or Vision Problem
Student Signs• Eye turns in or out at any time
• Pupils/eyes appear to be different sizes• Red eyes and/or swollen eyelids• Excessive tearing• Droopy eyelids• Discharge from the eyes
• Sensitivity to light• Excessive Blinking• Squints, closes, or covers one eye• Squints to see board or far away
• Frequent headaches• Abnormal head posture or head tilt

Student Symptoms• Double vision• Blurry vision• Hazy vision• Difficulty seeing small print• Eye pain

Distance Visual Acuity Optotype-Based Screening
Distance visual acuity screening is considered the recommended practice for detecting
a vision problem for school-aged students in a vision screening setting.
The American Association for Pediatric Ophthalmology and Strabismus, American
Academy of Pediatrics, National Center for Children’s Vision and Eye Health, American
Academy of Ophthalmology and American Association of Certified Orthoptists
recommend attempting distance visual acuity screening of preschool students startingat age three.
Screening should be done with the use of furniture appropriate to the student’s size andequipment suggested by the manufacturer for a particular screening method. For moredetails on room environment and arrangement of equipment, refer to Section 2
Recommendations for Screening for Visual Acuity, Recommendations for
Photoscreening, and Recommendations for Testing Color Vision Deficiency
Screening.

13

Grades:
1. TK/K or upon first enrollment or entry into a California school.
2. Grades two, five, and eight.
3. Students being assessed for, or currently enrolled in, special education services
for the purposes of reporting on the IEP.
Room Requirements:
1. Adequate distance for screening chart (e.g., if screening with a 10-foot chart,
available space should be at least 12 feet).
2. Relatively quiet.
3. Normal classroom lighting.
4. Avoid glare on the chart surface or into the student’s eyes.
Equipment:
Visual Acuity Charts
Tests of visual acuity have an inverted pyramid or triangle format when visualizing adrawn line around the outside of the opotypes and should meet national andinternational eye chart design guidelines (Nottingham Chaplin & Bradford, 2011).
Examples of evidence-based, developmentally appropriate optotypes are pictured
below.
1. Optotypes should be of approximate equal legibility.
2. Each line should have five optotypes per line, unless the test of visual acuityis 9 x 14 inches, where chart size will not accommodate five optotypes on
the top two lines.
3. Horizontal spacing between optotypes should be equal to the width of the
optotypes on that line.
4. Vertical spacing between lines should be the height of the optotypes in thenext line down.
5. Opotype size should progress geometrically up or down the chart byapproximately 0.1 log units, which lists 20/32 instead of 20/30.
6. Optotypes should be high-contrast black on a white background and goodlighting conditions should be present.

14

Examples of evidence-based developmentally appropriate optotypes:
a. For Use with Students in Preschool
EyE Check Screener with LEA SYMBOLS®

b. For Use with Students in Transitional Kindergarten, Kindergarten, orGrade 1LEA SYMBOLS®

HOTV

c. For Use with Students in Grades 2–12
Sloan Letters

LEA NUMBERS®

1. Digital/Computer-Based Optotypes
Digital or computer-based optotypes, like acuity charts, are designed to identify
student’s visual abilities. Digital or computer-based systems feature an array of
screening tools that can be used among multi-age student populations. Some
digital/computer-based systems allow for randomization, thereby minimizing
memorization of the screening tool. Electronic optotypes can be presented
following a predetermined screening algorithm. Instead of a long instruction
manual telling thousands of screening personnel how to present different size

15

optotypes on a wall chart, the electronic system can be programmed to present
age appropriate optotypes according to pre-established screening
algorithms. There is less dependence on the examiner subjectively determining
what optotype to pick next as the software will independently choose the next
optotype size based upon response (correct vs incorrect) from the prior
optotype. Additionally, digital/computer-based systems minimize screener bias
by providing results based upon the student’s response.
Make sure the chart selected is developmentally appropriate and meets
national chart design guidelines. For example, many TK, K or non-English
speaking students may not know their alphabet, thus the LEA SYMBOLS® chartwith matching card would be an appropriate chart to use with those students.
Please visit the CSNO website at https://www.csno.org/ for updated informationon technological evidence-based practices for visual acuity screening.
2. Occluders
Occuding one eye is necessary to obtain accurate monocular measures ofvisual acuity; the eye not being tested needs to be covered completely. Holding
a hand, tissue or paper/plastic cup over the eye is not acceptable and not bestpractice because students can easily peek. Additionally, students may have an
increased risk of exposure to bacteria or viral pathogens by covering their eyewith their bare hand. Patching one with 2-inch surgical tape or adhesive patch
is a recommended best practice as it assures complete eye coverage.
Examples of acceptable forms of occluder (patch) options are identified below.
Examples of developmentally appropriate forms of occluders:a. For Use with Students in Preschool –Grade 1
Adhesive Eye Patch•

2-in Hypoallergenic Surgical Tape

Use the same patch/tape to occlude each eye of an individual student,
unless the student has visible crusty eye drainage.

16

•Use a new patch/tape for each student.
Occluder Glasses••

Clean occluder glasses between students with 70 percent isopropyl
alcohol.
Tip: Have more than one pair of occlude glasses for each screener toallow alcohol to dry fully between students.

b. For Use with Students in Grades 2–12
Paddle Occluder••

Mask Occluder

Clean occluder between students with 70 percent isopropyl alcohol.
Tip: Have more than one occluder for each screener to allow alcohol
to dry fully between students.

Positioning of Chart and Student
1. Students who are waiting to be screened should not be able to see the chartor hear the responses of other students being screened.
2. Place the chart at the approximate eye level of the students to be screened.
3. If using a 10-foot chart, place a piece of tape on the floor to mark a 10-foot(3 meter) distance between the chart and the student’s eyes. (10-footdistance better captures the student’s attention compared with 20 feet).
4. If screening a preschool student, place a piece of tape on the floor to mark a
5-foot (1.5 meter) distance between the chart and the student’s eyes or use
the cord accompanying many 5-foot tools.
5. Have the student stand with the measurement line midfoot (arch of foot)(Figure 1).

17

Figure 1: Recommended tape placement with midfoot measurement

Procedure
1. Screen with glasses on if student normally wears glasses for distanceviewing. If the student shares they have left their glasses at home, flag thestudent’s file/name so that you may try again when rescreening is done.
Keep the student’s contact information so you may contact thestudent/parent the evening before to remind them to bring their glasses toschool.
2. Screen right eye first (occlude left eye) then screen left eye (occlude righteye).
3. Carefully observe student during procedure to ensure there is no peeking,squinting, leaning forward, turning of the head or other signs and symptoms
related to visual problems (Table 3).
4. Encourage the student to guess if the student is unsure, but do not provide
sample answers (e.g., does that look like a circle?) and do not coach thestudent (e.g., are you sure?).
5. Do not rush the student.

18

Critical Line and Threshold Screening
Visual acuity referral criteria can be based on critical line or threshold screening
criteria. Critical line screening requires the student to correctly identify 3 of 5 optotypes
on a particular line based upon their age. Threshold screening requires the student tostart at the top of the eye chart and read down until they miss 3 of the 5 optotypes.
Table 6 identifies developmentally recommended approaches to vision screening.
Table 7 identifies the recommended pass/fail criteria for respective age groups.
Table 6: Developmentally Recommended Approaches to Vision Screening
Preschool, Transitional
Kindergarten(Critical Line Screening)
Use a matching card forstudents who are shy,
nonverbal, or do not know
their letters or shapes.

Familiarize the student withoptotypes by having thestudent identify optotypes on
the top line, if needed.

Have the three year-old
students identify optotypes
across the 20/50 critical line
and the four year-old
students identify optotypes
across the 20/40 critical line.
No further screening isnecessary if the student isunable to pass the criticalline. Refer this student for aneye examination.

Kindergarten and First
Entry(Threshold Screening)
Start with the top line
and ask the student to
identify the first
letter/symbol of eachline until the student
misses a letter/symbol.
If the student misses aletter/symbol on a line,
go to the line above
and ask the student to
identify optotypes
across the line.
The last line on which
the student correctly
identifies 3 of 5
optotypes is the visualacuity value for thateye.
Attempt to screen to the
20/20 line.

19

Grades 1 and Up(Critical Line Screening)
Familiarize the studentwith optotypes by having
the student identify
optotypes on the top line,
if needed.
Have the student identify
optotypes across the
20/32 critical line.

The student mustcorrectly identify at least 3
out of 5 optotypes to pass
the critical line.

No further screening isnecessary if the student isunable to pass the criticalline. Refer this student foran eye examination.

Referral Criteria:
During student screening, results will indicate a pass or fail response. Below, in
Table 7, are the developmentally appropriate visual acuity criteria that indicate areferral to an eye care professional.
Table 7: Developmentally Appropriate Referral CriteriaGroup

Threshold Screening Referral
Criteria

Preschool (Age Three)
20/60 or worse in either eye
Preschool/Transitional
20/50 or worse in either eye
Kindergarten (Age Four)Transitional
Kindergarten/Kindergarten
20/40 or worse in either eye(Age Five)
Grades One and up
Acuity 20/40 or worse in eithereye
All age groups
Greater than or equal to twoline difference between eyes
(e.g., 20/20, 20/32).

Critical Line Screening
Referral Criteria(Refer if miss 3 ormore optotypes online)
Distance 20/50 line
Distance 20/40 line
Recommend thresholdor photoscreen
Distance 20/32 line
Near 20/32 line

Students who cannot
be screened areStudents who cannot be
considered an
screened are considered an
automatic fail andautomatic fail and should beshould be referred forreferred for comprehensive
comprehensive eye
eye examination.
examination.
*Referral criteria are based upon evidenced-base practices as recommended by the
Vision Screening Taskforce. School districts and county offices of education may domore, but not less than the statue requires.
Students who cannot be screened should be referred for a comprehensive eye
examination (e.g., student will not tolerate patch or tape, will not wear occluder
glasses, refuses to identify optotypes, has variability in responses, etc.). Thesestudents are at a higher risk of having vision problems. If students are unable to bescreened (untestable) they should be considered an automatic fail and referred to aneye care professional for further evaluation.
Rescreening:
If a student fails a vision screening that is conducted by a credentialed school nurse,
physician or surgeon, osteopath, or optometrist, a rescreen is not required (ECsections 49591, 49455, 49594). A rescreen is required if initial screening is done by20someone other than those listed here and should be done prior to the vision screening
results report being given to the student’s family.
Recording:Districts should record results based on specific documentation systems. The results
may be recorded as pass (P) or fail (F). An example for recording results is:Distance:

Right
Left
Two-Line Difference

Pass/Fail
Pass/Fail
Pass/Fail/Not Tested

A two-line difference will not be tested if:
1. The failure criterion was already met for either eye, and2. Critical line screening was done.
Visual Acuity Screening Considerations for Students with Special Needs
Vision screening of preschool students or students with special needs should be
conducted by using methods and equipment suitable to the student’s developmental
level. The use of isolated optotype tests are to be avoided as they may fail to detect
amblyopia. For students who are unable to perform screening with letter visual acuity
screening charts (Sloan Letters), more appropriate tools include the LEA SYMBOLS®
(apple/heart, house, circle, and square shapes) or HOTV optotypes. Instrument-based
screening procedures can also be used. The following accommodations are presently
considered best practice for visual acuity screening of students aged three, four, andfive years:
1. Decreasing the screening distance from 10 feet (3 m) to 5 feet (1.5 m) improves
testability and sensitivity in detecting vision problems in preschoolers. Do not,however, use a tool at 5 feet that is calibrated for a 10-foot distance.
2. A training card within arms’ reach is used to teach the student to point to thematching symbol on a lap card.
3. The student should wear occluder glasses (fun frames with an opaqueocclude/frosted lens for each eye) rather than hands, tissues, or cups.
4. The student is first screened on either the 20/200 or 20/80 line (depending on
the chart version) to get them familiar with the task and then at the critical line
for their age (20/50 for age three and 20/40 for ages four and five years).
5. Prescreening activities may be carried out in regular classrooms to familiarize
the student with the English names of the symbols or the act of pointing to thematching card.

21

Near Visual Acuity Optotype-Based Screening
Near vision screening is an assessment that determines the student’s ability to see up
close.
Grades:
1. TK/K or upon first enrollment or entry into a California school district
2. Grades 2, 5, and 8
3. Students being assessed for or currently enrolled in special education services
for the purposes of reporting on the IEP.
Room Requirements:
1. Relatively quiet
2. Normal classroom lighting
3. Avoid glare on the chart surface or into the student’s eyes
Equipment:
1. Visual Acuity Cards
Age-appropriate near vision cards that meet national and international eye chart
design guidelines as detailed under “Distance Visual Acuity Optotype-Based
Screening” are recommended (see below). Cards with an attached string are
preferred to help maintain the screening distance of 16 inches (40 cm).
Examples of Grade Level Appropriate Charts for Near Visual Acuity OptotypeBased Screening
For Use with Students in TK/K—Grade 1
LEA SYMBOLS®

LEA NUMBERS

HOTV

22

For Use with Students in Grades 2–12
Sloan Letters

Procedure:
1. Screen with glasses on if student normally wears glasses for distance viewing. If
the student shares they have left their glasses at home, ask the runner or havethe student go to the office and ask a parent/caregiver or emergency contact tobring the student’s glasses to school so they may be screened. If unable toscreen the student with glasses on, flag the student’s file/name so that you may
try again when rescreening is done. Keep the student’s contact information so
you may contact the student/parent the evening before to remind them to bring
their glasses to school.
2. Screen with both eyes open.
3. Hold card at 16" (40 cm) screening distance.
4. If using a chart with a string, place the string at the temple near the eye andensure string is taut.
5. Do not allow the student to lean forward.
6. Familiarize the student with optotypes by asking the student to identify large
optotypes, if needed.
7. Ask the student to identify optotypes on the 20/32 critical line.
8. The student must correctly identify at least 3 out of 5 optotypes to pass that line.
9. No further screening is necessary if the student is unable to pass the critical line.
Referral Criteria:
Refer if the student is unable to pass the 20/32 line with both eyes open.

23

Recording:Districts should record results based on specific documentation systems. The
results may be recorded as Pass or Fail:
Near

Both eyes

Pass/Fail

Color Vision Deficiency Screening
Color vision deficiency is the inability to discern certain shades of color. The term color
blindness is incorrectly used to describe this visual condition. Most people with color
vision deficiency are able to see colors, but they have difficulty differentiating between
certain colors:
1. Shades of reds and greens (most common)
2. Shades of blues and yellows (less common).
People who are totally color blind, a condition called achromatopsia, can only see
things as black and white or in shades of gray. Depending on the cause, color vision
deficiency can range from mild to severe. It affects both eyes if it is inherited andusually just one eye if it is caused by injury or disease. Color vision is possible due tophotoreceptors in the retina of the eye known as cones. These cones have lightsensitive pigments that enable us to recognize color. Found in the macula (the central
part of the retina), each cone is sensitive to red, green, or blue light. The cones
recognize these lights based on their wavelengths.
Normally, the pigments inside the cones register different colors and send that
information through the optic nerve to the brain. This enables a person to distinguishcountless shades of color. However, if the cones don't have one or more light-sensitive
pigments, then a person will be unable to see one or more of the three primary colors.
Grades:1. Early screening for color vision deficiency is recommended, since TK/K are notcompensatory grades in California and in accordance with EC Section 49455,
color vision deficiency screening appraisal need not begin until the male pupil
has reached the first grade. Color vision deficiency screening is conducted
once.
Room Requirements:
1. Relatively quiet
2. Normal classroom lighting
3. Avoid glare on the chart surface or into the student’s eyes

24Equipment:
There are a few currently acceptable color vision deficiency screening books that may
be used in the educational setting (Table 9).
Table 9: Examples of Color Vision Deficiency Screening Tools.
Color Check
Complete Vision
Screener

Ishihara Color
Deficiency
PlatesColor Dx Pediatric

HRR
Pseudoisochromatic
PlatesProcedure:
1. Follow the manufacturer’s instructions regarding procedures for screening andscoring.
2. Screening should be done with both eyes open.
3. For students who are shy, nonverbal, or do not know their shapes or numbers,
show the student how to use a clean, soft paint brush or cotton swab topoint/trace targets on the color plates (do not allow use of fingers to trace
because oil on the skin can cause color changes to the plates).
Referral Criteria:
No referral needed. If the student does not pass the color vision deficiency screening,
inform the parents and advise them to consult with their eye care professional for
additional information on color vision deficiency. Inform the teachers and counselors sothey may adjust educational materials that require color discrimination.
Recording:Districts should record results based on specific documentation systems. The results
should be recorded as Pass (P) or Fail (F). An example for recording results is:Color Vision

PASS/FAIL

25

Color Vision Deficiency Screening for Students with Special Needs
The prevalence of color vision deficiencies in boys is 8 percent whereas, it is only 0.5
percent in girls; therefore, only boys are screened and need to be tested for color
vision deficiencies. Color vision deficiencies are inherited on the X-chromosome.
Both X-chromosomes need to be affected for a girl to have a color vision deficiency,
whereas boys inherit the affected X-chromosome from their mother (not their father).
Good lighting (illuminant-C or natural sunlight) is important. Follow the color vision
deficiency screening tool manufacturers’ instructions.
Instrument-Based Screening
Automated devices estimate refractive error and sometimes eye misalignment; they do
not measure visual acuity. Distance visual acuity screening is considered the preferredpractice for detecting a vision problem in school-age students in a vision screening
setting (American Academy of Pediatrics Section on Ophthalmology and Committee on
Practice and Ambulatory Medicine; American Academy of Ophthalmology; American
Association for Pediatric Ophthalmology and Strabismus; and American Association of
Certified Orthoptists, 2012). However, instrument-based screening is quick and it
requires minimal cooperation of the student; therefore it is useful in students who arepreverbal, preliterate, or developmentally delayed.
Grades:1. Students who are younger (e.g., preschool) or pre-literate
2. Students with special needs
3. Students who are unable to be screened with traditional optotype-based visualacuity screening
Equipment:
Since technology is constantly evolving, check CSNO’s website athttps://www.csno.org/ for updated recommendations and referral criteria for instrumentbased screening tools. Follow manufacturer’s guidelines for all instrument-based visionscreeners.
For students who are unable to complete visual acuity screening, instrument-based
photoscreening may be done to detect the risk factors for amblyopia and reduced
vision; including refractive error, eye alignment, and anisocoria (unequal pupil gaze.)
Procedure:
1. Show the photoscreener instrument to the student and tell them that you will be
26

taking their picture. If they do not look directly at the device during screening,
screen again, directing the student’s attention to the front of the device.
2. Adjust room lighting to avoid glare into the instrument.
3. High refractive errors may exceed the measurement range of the instrument. If
results cannot be obtained after three attempts, the student should be referred
for significant refractive error.
4. Be aware that the cutoff for clinically significant refractive error varies with age(from infants, preschoolers, and elementary school-age students). Most
instruments have different cut-off criteria for students versus adults. Use theage-appropriate referral criteria.
Functional Vision Screening for Students with Special Needs
For students who are untestable during in the vision screening (visual acuity, color
vision deficiency screening, photoscreening), Functional Vision Screening may beconsidered. As a minimum, this includes:
1. A review of the medical record
2. Consultation with the parent and teacher
3. Classroom observation
If based on the above functional vision screening results, no impact on classroom
participation is noted or anticipated, then a referral may not be needed. Remember thatreferral for a comprehensive eye examination is appropriate due to the high prevalenceof vision disorders in the population of students with special needs. Preschoolers, thatare unable to complete screening, are twice more likely to have vision problems thantheir peers who completed screening. Re-screening within six months or referral for acomprehensive eye examination are recommendation actions when initial screening
efforts are not incomplete.
Optional Tests
Near Point of ConvergenceThis screening evaluates the student’s ability to converge their eyes to a near target.
Poor convergence ability may cause symptoms such as double vision, headaches,
eyestrain, or loss of place when reading.
Grades:1. Grades One through Twelve

27

Room Requirements:
1. Relatively quiet
2. Normal classroom lighting
Equipment:
1. A small hand-held fixation target with details (e.g., tongue depressor with apicture sticker) (Figure 2)
2. Ruler
Figure 2: Examples of Small Hand-Held Fixation Target

28

Procedure:
1. Screen with glasses on if student normally wears glasses for reading or nearwork.
2. Screen with both eyes open.
3. Hold fixation target approximately 16 inches (40 cm) away from the student’seyes and instruct the student by saying, “Focus on this target and keep on it aslong as you can, but tell me if it becomes two.”
4. Slowly move the target toward the student’s eyes until the student sees two(double) or the examiner observes a loss of fusion (e.g., one eye moves
outward). Figure 3.
5. If double is reported, ask the student if the target stays two or if it goes back into
one; if it becomes one within 1–2 seconds, continue moving the target toward
the student’s eyes until the target becomes double and stays double.
6. Measure the distance from the temple near the eye to the point where the target
was double (break point).
Figure 3: Tool Used to Move Toward the Student’s Eyes.

29Referral Criteria:
Refer if break point is ≥ 2.5 inches (6 cm).
Recording:
Point of Convergence

PASS/FAIL

Stereopsis
Stereopsis screening evaluates how well the eyes work together to achieve depth
perception. Poor depth perception can be found in those with amblyopia, strabismus,
or other ocular pathologies.
Grades:1. Preschool–Grade Twelve
Room Requirements:
1. Relatively quiet
2. Normal classroom lighting
3. Avoid glare on the card surface or into the student’s eyes
Equipment:
1. Stereopsis Screening
A screening for stereopsis that uses random dot stereograms is recommended.
The Preschool Assessment of Stereopsis with a Smile (PASS 2) uses random
dot stereograms and can easily be used with preschool-age students (Table 10.)
Table 10: Preschool Assessment of Stereopsis with a Smile (PASS 2)
Picture of Kit and Contents Description of Kit Contents• Card A: Demonstration Card
• Card B: 480 seconds of arc for students inpreschool and TK• Card C: 240 seconds of arc for students in
Kindergarten through Grade Twelve• Blank Card
Procedures:
1. Screen with glasses on if student normally wears glasses.

30

2. Have the student wear the polarized glasses (over glasses, if worn).
3. Hold cards at 16 inches (40 cm) with the top of cards slightly tilted back towards
the screener at about 10 degrees.
4. For Preschool/TK:•Show card A (demo card) and the blank card and ask the student to point
to the card with the smiley face to ensure that the student can identify the
figure.

•If the student is unable to identify the demo card when presented with theblank card, stop screening and refer.

•

Show card B and the blank card and ask the student to point to thesmiley face.

•

Shuffle the cards behind your back to change the position of the smileyface and present the cards again; Repeat 5 times.

•

Student must correctly identify at least 4 out of 5 presentations to pass.

5. For Kindergarten–Grade Twelve:•Show card A (demo card) and the blank card and ask the student to point
to the card with the smiley face to ensure that the student can identify the
figure.

•If the student is unable to identify the demo card when presented with theblank card, stop screening and refer. Show card C and the blank card
and ask the student to point to the smiley face.

•

Shuffle the cards behind your back to change the position of the smileyface and present the cards again.

•

Repeat 5 times.

•

Student must correctly identify at least 4 out of 5 presentations to pass.

31

Referral Criteria:
When making a referral for stereopsis, similar to other screening, age considerations
should be made (Table 11.)
Table 11: Referral Criteria for Stereopsis
Group
Preschool/Transitional Kindergarten(Age Three and Four Years Old)
Kindergarten–Grade Twelve(Age ≥ Five years)

Referral Criteria
Unable to identify card B at least 4
out of 5 presentations
Unable to identify card C at least 4
out of 5 presentations

If the student is unable to identify the demo card when presented with a blank card,
stop screening and refer.
Recording:Districts should record results as based on specific documentation systems; an
example for recording results is:
Stereopsis

PASS/FAIL

32

Section 3: Planning and Follow-Up Procedures for Vision Screening
Checklists for Implementation of a Vision Screening Program
These checklists may be used to help school administrators and vision screeners
plan for and perform the screening:
Implementation Checklist for the Administrator
This checklist indicates some of the essential requirements for a vision screening
program in the school. It may be used in planning and evaluating a program.
Essential Requirements
 Is the school doing the vision screening on each student during kindergarten
or upon first enrollment or entry in a California school district of a pupil at anelementary school, and in grades two, five, and eight (as mandated in EC
Section 49455)?
 Does the vision screener meet the state requirements for personnel conducting
vision screening?
 Has the school calendar been cleared and dates established for staff training,
student orientation, screening, and screening of absentees?
 Has the qualified vision screener been provided with the necessary forms,
equipment, and appropriate space, and the latter confirmed with impacted
school personnel?
 Does the school nurse have a plan for follow-up on all referrals and vision
problems found?
 Has the school identified community resources available?
 Does the school have a plan to coordinate with community agencies that offer
help free of charge?
 Have parents/caregivers been informed, in writing, about the vision screening
program in the annual notification of parents’ rights?
 Have parents/caregivers been informed about waiving the vision screening, if
desired, by presenting a certificate from a physician and surgeon, a physician
assistant, or an optometrist that include the results of the student’s visionscreening, including visual acuity and color vision deficiency within the past
12 months?
 Have parents/caregivers been informed about waiving the vision screening, if
33

desired, by filing a written statement with the school principal stating that they
depend upon prayer for healing in the practice of their religion?
Implementation Checklist For the Vision Screener
The vision screener may be the school nurse or other authorized employee pursuant
to EC Section 49452, 5 CCR, and EC sections 590–592.
Essential Elements
 As mandated in EC Section 49455, is the school performing the vision screening
on each student in kindergarten or upon first enrollment in elementary school,
and in grades two, five, and eight? A pupil whose first enrollment occurs ingrade four or seven shall not be required to undergo vision screening in grades
five or eight.
 Are vision screeners trained and qualified in accordance with 5 CCR, and EC
sections 590 –592?
 Have arrangements been made for appropriate facilities to conduct thescreening and confirmation of screening dates?
 Have appropriate screening materials, and supplies been obtained; including
equipment/tools for distance visual acuity, near vision, and color deficiency
vision screening (for males only), and if appropriate, photoscreeners?
 If instrument-based screening is performed, is there an agreement with, or thesupervision, of an optometrist or ophthalmologist?
 Is there a plan in place for continual and regular observation (by the school
nurse and the classroom teacher) of the student’s eyes, appearance, behavior,visual performance, and perception that may indicate vision difficulties?
 Is there confirmation of community resources to assist in the implementation of
the program? Appropriate community personnel may include licensed
ophthalmologists, optometrists, and personnel from the Child Health andDisability Prevention Program, California Children Services, Parent Teachers
Association, local public health departments, service clubs, and other voluntaryorganizations
 Is there a supply of forms for the program, including “Report of School Vision
Screening,” “Report of Vision Exam to the School,” “Rechecks of Vision
Screening?”

34

Implementation Timeline Checklists for Vision Screener and Administrator
At the Beginning of the Year Has the school calendar been cleared and program dates established for a
student orientation to vision screening? Ensure vision screening date does notconflict with other school-related activities (i.e., Mandated fire or evacuation drill;
picture day).
 Has the school calendar been cleared and program dates established for staff
education?
 Has the school calendar been cleared and dates established for the screening?
 Has the school calendar been cleared and dates established for screening ofabsentees?
 Have necessary ancillary services been secured (e.g., persons to provide
screening assistance and custodial services)?
 Has a suitable physical environment been selected for screening and has theschedule of room use been communicated to impacted personnel?
 Has the equipment been inspected for proper functioning (e.g., extra bulbs andextension cords)?
Two to Three Weeks Before the Vision Screening Date
 Have appropriate personnel confirmed the dates and locations of screening andrescreening?
 Are the screening/recording work sheets, list of students, classrooms, and healthrecords available?
 Has a vision education program for students been scheduled as close to thescreening date as possible?
 Is there a plan for follow-up procedures?

35One Week Before the Screening Date
 Has the list of students to be screened been updated?
 Have staff and volunteers been reminded of screening dates and locations?
 Was a notice included in the school bulletin, paper, email, or website? Have
phone calls been made, using the district’s automated system, reminding
parents of vision screening and encouraging students to bring their glasses toschool for screening?
 Has the screening equipment been checked and is it ready for use?
 Are all screening materials ready for the implementation of the program?
 Confirm that the location for screening is available on the date of screening for
exclusive use for vision screening.
 Request bell schedules, campus maps, and duplicative student lists from school
office staff.
Day of Screening Arrive early to set up instrument and equipment. Ensure availability of extension
cords, tape, measuring tapes.
 Sign in at the office.
 Obtain bell schedule, campus map, and multiple class lists from office staff.
Thank office staff for their assistance.
 Greet and thank runner/volunteer. Provide just-in-time training to volunteer thatwill ensure student confidentiality and optimal student screening.
 Identify screening pattern, which grade levels should be screened first based
upon setting (i.e., some eighth grade students only have home room first period
and then change classes. To save time the school nurse will want to screenthese students first to minimize “chasing” students in other subject matterclasses).
 Record student results on screening sheets or in electronic student system assoon as possible.
 For students that have vision screening, visit student’s class(es) and connect
with student’s teacher to share that screening results indicate vision difficulty.
Discuss classroom accommodations/considerations to make to support thestudent until a formal report from eye care professional is returned (i.e., move36

student from back of classroom, closer to the board; recommend teacher
observes student for additional signs or symptoms of eye or vision problems).
Follow-Up Procedures
The focus of a follow-up program includes interpretation of findings; and transmittal of
information among school personnel, parents/guardians, and eye care professionals.
These important tasks are carried out mainly by the school nurse, assisted by otherschool personnel. The success of the program, however, depends on theimplementation of systematic follow-up procedures, such as the following:
1. Mail a written notification home (in their native language) to the parents or
guardians of a student with suspected vision problems (Appendix B, “Vision
Screening Report”) in a timely manner (two weeks). Written notification should
be culturally sensitive, easy to read, and should include next steps, including theimportance of a follow-up eye examination with an eye care professional withstudents who fail vision screening. In addition, it is recommended to include a
copy of the report in the student’s backpack.
2. Consider additional follow-up notification by telephone, text, email, or through aparent-nurse conference to ensure parental follow-through with the referral
recommendation.
3. Advise and strongly encourage the parents/guardians to take the referral form
with them to the student’s appointment with an eye care professional.
4. Refer parents/guardians in need of financial assistance to one of the following
sources:a. County health and human services agency for Temporary Assistance to
Needy Families
b. Lions Clubs and other fraternal organizations for glasses
c. Parent Teacher Association and other service organizations
d. California Children Services
e. Vision care plans-Vision Service Plan Sight for Students
f. Child Health and Disabilities Prevention Program (CHDP)
g. Medi-Cal for Families Programh. Covered California (Affordable Care Act)

37

i.

Other resources (First Five California, Vision to Learn, Prevent Blindness
Northern California, Faith-Based Organizations, Boys and Girls Club ofAmerica)

1. Advise the parents/guardians to return the referral form to the school after
obtaining an examination with an eye-care professional. The information on theform will help determine if adjustments are needed to the student’s educational
program.
2. Do not recommend a particular person or class of practitioner (ophthalmologist
or optometrist) for examining, treating, or correcting any eye or vision defect of
the student (EC Section 49456).
3. Maintain contact with the parents/guardians until the student has received thecomprehensive eye examination and necessary follow-up care. Communication
may be by telephone, email, text, or through a parent–nurse conference. A
conference should be supplemented by a written notice to the parents/guardiansregarding their student’s apparent eye or vision disorder.
4. Develop and supervise a system for recording screening results, pertinent
information and communication on a student’s health record or cumulativeelectronic record.
5. Inform parents/guardians at the time of registration, if it is the policy of the
district, that screening for visual acuity does not replace a professional
comprehensive eye examination and does not identify all vision problems.
After confirmation of any eye or vision disorders from the eye care professional, theschool nurse or designated school personnel, is to take the following actions:
1. Consult with teachers and counselors and recommend educational
adjustments, if necessary, to meet a student’s individual needs.
2. Follow through with appropriate procedures for non-correctable vision loss
(severe vision disabilities).
Follow-Up for Students with Glasses or a Known Vision Disorder
If the student wears glasses or has a known vision disorder, the school nurse ordesignated school personnel should first check to determine whether the school has
a record of the student’s eye examination. It is imperative to obtain the results of aprofessional examination and any recommendations that might affect school
performance. If a student has a vision disorder, the school nurse or designatedschool personnel should:

38

1. Ensure the student wears glasses if he or she has been prescribed corrective
lenses and/or monitor compliance with other therapeutic intervention, such as
wearing an eyepatch.
2. Facilitate student counseling regarding eye health and safety.
3. Emphasize the importance of continued follow-up with the student’s eye care
professional.
Follow-Up Procedures for Non-Correctable Vision Loss (Severe Vision
Disabilities Including Visual Impairment and/or Legal Blindness)
Eye care professionals may identify students who have vision disorders that cannot be
fully corrected through treatment. In those cases the school nurse or designated school
personnel should take the following actions:
1. Advise parents/guardians to consult with the student’s physicians or eye care
professionals regarding monitoring, treating or rehabilitating severe vision loss.
2. Refer parents/guardians to a special education program in the school district orto the county office of education (COE) for necessary information regarding
social services, teachers for the visually impaired, orientation and mobility
instructors, low-vision specialists, and guidance in school placement.
3. Refer parents/guardians to California Children Services as the student may be
eligible for services related to his or her vision disability (visual impairment orlegal blindness).
4. Review the eye care professional’s reports to determine if any adjustments inthe classroom arrangement or educational program are needed based on thestudent’s vision loss.
5. Maintain identification procedures for students with severe vision impairment aswell as monitor referral and follow-up services.
Follow-Up Procedures for Students Who Fail Color Vision Deficiency Screening
1. Failure in this screening is not cause for referral to an eye care professional.
Color vision deficiencies are inherited from the mother’s side of the family (Xlinked). A positive maternal family history of color vision deficiencies augments
the student’s screening results.
2. Use the “Color Vision Deficiency Screening” form letter in Appendix B toinform the parents/guardians of the student’s suspected color vision deficiency.
3. For additional information on notifying parents/guardians and teachers about
the student’s color vision deficiency, see Table 7 of this guide.
39

4. Consult with teachers to modify the use of color-coded educational materials.
Follow-up Procedures for Students in Special Education
1. Referral for a comprehensive eye examination is indicated due to the highprevalence of vision disorders (refractive error, strabismus, amblyopia, oculardisease, and visual impairment and/or legal blindness) in the population of
students with special needs.
2. For students who are untestable in the vision screening (distance and near,color vision deficiency screening, or instrument-based (photoscreening), theschool nurse may conduct a Functional Vision Screening. At a minimum, thisincludes:a. A review of the medical recordb. Consultation with the parent and teacher
c. Classroom observation
d. If, based on the above functional vision screening results, no impact onclassroom participation is noted, then a referral may not be required.

40

Appendix A
Page 1 of 3
Legal and Administrative Provisions for School-Based Vision Assessments
These guidelines were developed following legal and administrative provisions
found in the California Code of Regulations and California Education Code sections
referenced below.
California Code of Regulations
The California Code of Regulations (CCR), is the official compilation and publication of
the regulations adopted, amended or repealed by state agencies pursuant to the
Administrative Procedure Act. Properly adopted regulations that have been filed with theSecretary of State have the force of law.
The CCR is compiled into Titles and organized into Divisions containing the regulationsof state agencies.
CCR provisions related to Vision Testing are listed under Title 5 CCR, Division 1,
Chapter 2, Subchapter 3, Article 4 and may be accessed via the web athttps://govt.westlaw.com/calregs/Browse/Home/California/CaliforniaCodeofRegulations?guid=IB7F35940D47E11DEBC02831C6D6C108E&originationContext=documenttoc&t
ransitionType=Default&contextData=(sc.Default)
California Education CodeProvisions of California Education Code (EC) that address, or are related to, vison
assessment are listed below with a short descriptor of the section and a web link toaccess the full text.
Supervision of Health
EC Section 1750: Employment of Supervisors of Health
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1750.&lawCode=EDC
EC Section 1751: Authority to Contract for Provision of Health Services
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1751.&lawCode=EDC

41

Appendix A
Page 2 of 3
EC Section 1752: Provision of Health Service under District Agreement
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1752.&
lawCode=EDC
EC Section 1753: Credential Requirement
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1753.&
lawCode=EDC
EC Section 1754: Duties of Supervisors of Health
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=1754.&lawCode=EDC
Employment
EC Section 44871: Qualifications of Supervisors of Health
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=44871.&
lawCode=EDC
EC Section 44872: Standard Designated Services Credential with a Specialization in
Health; Services Credential with a Specialization in Health
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=44872.&
lawCode=EDC
EC Section 44873: Qualifications for a Physician
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=44873.&
lawCode=EDC
EC Section 44877: Qualifications for Nurse
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=44877.&
lawCode=EDC
EC Section 44878: Qualifications for Optometrist
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=44878.&
lawCode=EDC
General Powers—School Boards
EC Section 49400: Health and Physical Development of Pupils
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49400.&
lawCode=EDC

42

Appendix A
Page 3 of 3
Employment of Medical Personnel
EC Section 49422: Supervision of Health and Physical Development of Pupils
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49422.&
lawCode=EDC
EC Section 49426: School Nurse; Permissible Services; Legislative Intent
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49426.&
lawCode=EDC
Physical Examinations
EC Section 49450: Rules to Insure Proper Care and Secrecy
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49450.&
lawCode=EDC
EC Section 49451: Parent’s Refusal to Consent
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49451.&
lawCode=EDC
EC Section 49452: Sight and Hearing Test
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49452.&lawC
ode=EDCEC Section 49455: Vision Appraisal
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49455.&
lawCode=EDC
EC Section 49456: Report to Parent
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49456.&
lawCode=EDC
EC Section 49457: Report to Governing Board
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=49457.&
lawCode=EDC
Solicitations
EC Section 51520: Licensed Optometrist Solicitation
http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=51520.&
lawCode=EDC

43

Appendix B
Page 1 of 6
Notifications and Form Templates
Notifications and form templates provided within Appendix B are to assist local
educational agencies in meeting California Education Code requirements.
Sample Parent Notification
It is recommended that the local educational agencies place the following
notification in student handbooks and annual notifications to parents and guardiansof students.
HealthIn accordance with the California Education Code (EC) Section 49455, student visionscreening will be provided at school entry Transitional Kindergarten/Kindergarten, two,
five, and eighth grades and to all students enrolled in special education as required fortheir Individualized Education Plan. Additionally, vision screening may be provided toany student who exhibits signs and symptoms of eye or vision problems. Parents may
opt their child out of any non-emergency, invasive physical examination or screening
required as a condition of attendance, administered by the school or its agent, and notnecessary to protect the immediate health and safety of a student, including hearing or
vision screenings, or any physical examination or screening permitted or required understate law. Parents have the right to have their child’s vision tested outside of school (atthe parent’s expense) to meet the state law requirement.

44

Appendix B
Page 2 of 6
Vision Screening Report
Student Name: [enter student name] Date of Screening: [enter screening date]
School: [enter school name] Grade: [enter grade level] Teacher: [enter teacher name]
Dear Parent/Guardian:Your child recently received vision screening at school. Below are the screening results.
Visual Acuity Assessment
LensesLeft Eye

Right Eye

Near Both Eyes

With
LensesLeft 20/[Add Vision
Strength here] (or circle
PASS/FAIL)

Right 20/[Add Vision
Strength here] (or circle
PASS/FAIL)(Circle one
PASS/FAIL)

WithoutLensesLeft 20/[Add Vision
Strength here] (or circle
PASS/FAIL)

Right 20/[Add Vision
Strength here] (or circle
PASS/FAIL)(Circle one
PASS/FAIL)

Optional Screening (circle one or more)

Pass or Fail

NPC

(Circle one PASS/FAIL)

Stereo(Circle one PASS/FAIL)

Other(Circle one PASS/FAIL)

Comments:
Based on the above vision screening findings, your child needs to see an eye doctor fora full eye examination. Please take this form with you to the examination. Have thereverse side completed by the eye doctor, and return the completed form to your school
health office.
Signature of School Nurse

School Nurses’ Name

(School Nurse signs here)(Type in School Nurses’ Name)

School Nurses’ Telephone Number

School Nurses’ Email(Type in School Nurses’ Telephone
Number)(Type in School Nurses’ Email)45

Appendix B
Page 3 of 6
Report of Eye Examination Results to the School(To be filled out by Eye Care Professional)
Patient Name: [enter patient name]Date of Birth: [enter date of birth]

Name of Examiner: [enter examiner name]Date of Exam: [enter date of exam]

Street Address of Examiner: [enter street address]
City: [enter city name]

State: [enter state name] Zip Code: [enter zip code]

Phone Number: [enter phone number]
Visual Acuity
LensesLeft Eye

Right Eye

Near Both Eyes

With Lenses

Left 20/[Add Vision
Strength here] (orcircle PASS/FAIL)

Right 20/[Add Vision
Strength here] (orcircle PASS/FAIL)(Circle one
PASS/FAIL)

WithoutLensesLeft 20/[Add Vision
Strength here] (orcircle PASS/FAIL)

Right 20/[Add Vision
Strength here] (orcircle PASS/FAIL)(Circle one
PASS/FAIL)

Diagnosis: [enter diagnosis here]
Lens Requirements
Correction (circle
one)Type of Correction

Correction Needed

Correction Not
Required[If correction is not required,leave blank][If correction is not required,leave blank]

Correction
Required[If correction is required, circle
one GLASSES or CONTACT
LENS][If correction is required, circle
one WEAR AT ALL TIMES or
WEAR FOR DISTANCE ONLY
or WEAR FOR CLOSE WORK]

Additional Recommendations (Special seating, large print, special education placement,etc.): [enter additional recommendations here]
This form is approved by the State Superintendent of Public Instruction, as required by
California Education Code Section 49456, for reporting results of vision testing to parents
and guardians and for obtaining recommendations from the professional examiner.

46

Appendix B
Page 4 of 6
Color Vision Screening Results
Student Name: [enter student name]Date: [enter date]

School: [enter school name] Grade: [enter grade level] Teacher: [enter teacher name]
Dear Parent/Guardian:
By law (California Education Code [EC} Section 49455), your child received visionscreening and was found to have a color vision deficiency.
When children have a color vision deficiency they have a hard time telling the difference
between certain shades of color. These difficulties are usually related to telling thedifference between red and green or the colors with red and green in them. For
example, a person with a color deficiency may see red, orange and green colors as ayellow color. Also, violet and purple colors may look like blue colors.
Color vision deficiency is not a disease. It is something that is passed from parents totheir children (usually in male children.) It is thought that 1 in 12 males are born with it.
There is no treatment for color vision deficiency. Most people with color vision
deficiency adjust by learning to tell the difference between colors based on how brightthey are.
Awareness of a color vision deficiency is important as it may affect a person’s
performance in certain kinds of school activities involving color. We suggest you share
this information with your child’s teacher at the beginning of each school year. In
addition, note that a color vision deficiency may exclude some people from certain
occupations for which normal color vision is required. If you would like more
information regarding your child’s color vision deficiency, please contact your family
eye doctor or your school nurse.
Sincerely,
Signature of School Nurse(School Nurse signs here)

School Nurses’ Name
(Type in School Nurses’ Name here)

This form is approved by the State Superintendent of Public Instruction, as required by
EC Section 49456, for reporting results of vision testing to parents and guardians and for
obtaining recommendations from the professional examiner.

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Appendix B
Page 5 of 6
Memorandum of Understanding (Sample)( [enter school year here ] School Year)
This Memorandum of Understanding (MOU) stands as evidence that [enter name ofDistrict/County Office of Education (COE) here] and Dr. [enter name of
Optometrist/Ophthalmologist/Medical Doctor here] intend to work together for themutual goal of providing safe, effective, evidence-based, or best practice visionscreening approaches to pre-kindergarten through Twelfth grade students attending the[enter name of District/COE here] . The entities agree that the implementation of avision screening program using instrument-based (photoscreening) approaches willassist in furthering this goal. In accordance with California Education Code (EC) Section
49455, an agreement with or supervision by an eye care professional is required when
instrument-based (photoscreeners) tools are used by school nurses or trained
individuals in providing vision screening services to students. Additionally, in
accordance with EC Section 51520(c) it is mutually understood that solicitation of apupil, or the pupil's parent or guardian, or encourage, or advise treatment or
consultation for the pupil by the licensed optometrist, or any entity in which the licensed
optometrist has a financial interest, for any condition discovered in the course of thevision testing is prohibited.
The School District/COE shall: (examples only; may modify as needed)o Provide the vision screening personnel.
o Provide vision screening equipment.
o Orchestrate student vision screening among district/COE students.
o Ensure appropriate calibration and servicing as recommended by the
manufacturer.
o Make referral for students who fail screening and follow up on those student
referrals.
The Optometrist/Ophthalmologist shall: (Examples only; may modify as needed)o Provide just-in-time training on instrument-based screening equipment.
o Check for competency of the school nurse to use instrument-based
equipment.
o Provide technical assistance on instrument-based equipment.
o Assist with troubleshooting questions or other questions the school nurse may
have surrounding the use of instrument-based screening.

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Appendix B
Page 6 of 6
As part of this MOU the district shall compensate Dr. [enter name of
Optometrist/Ophthalmologist/Medical Doctor here] in the amount of $[enter dollar
amount here] for the agreement/supervision of instrument-based support. Thisagreement will terminate at the end of the school year. OR This agreement will continue
until one party elects to terminate the MOU by providing 30 days written notice.
Superintendent Signature, District/COE(Superintendent signs here)

Date of Signature(Type in Date of Signature here)

Optometrist/Ophthalmologist Business
Name(Optometrist/Ophthalmologist Businesssigns here)

Date of Signature(Type in Date of Signature here)

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Appendix C
Page 1 of 4
Frequently Asked Questions
Q. In what grades does vision screening need to take place?
A: Per California Education Code (EC) Section 49455, vision screening shalltake place during the kindergarten year or upon first enrollment or entry in a
California school district of a pupil at an elementary school, and in grades
two, five, and eight. A pupil whose first enrollment or entry occurs in grade
four or seven shall not be required to be appraised in the year immediately
following the pupil's first enrollment or entry.
Q. Do we need to screen students who are entering the school in grade three or six?
A: A student would need to be screened at grade three or six only if this is theirfirst enrollment or entry in a California school district or if they are enrolled in
special education.
Q. Is vision screening no longer required for students in grade ten?
A: EC Section 49455 specifies that vision screening shall take place through theeighth grade. Hearing screening is required through tenth grade (California
Code of Regulations, Title 17), so it is likely that many school nurses madethe assumption that vision screening was also required through tenth grade.
While a district may certainly choose to continue vision screening through thetenth grade, the EC mandates that it take place through the eighth grade.
R. When students are new to a California high school, do they still need to be screenedat that level (since we are not screening other high school students)?
A: No, EC Section 49455 requires that vision screening take place only throughgrade eight.
Q. If a student is screened using a photoscreener or autorefractor, do you still need toscreen near/far visual acuity utilizing an eye chart according to the EC?
A: EC Section 49455 does not indicate that both a photoscreening device andan eye chart need to be used when screening vision, but does require that50

Appendix C
Page 2 of 4
visual acuity be measured. If you use an instrument, and you cannot capture
an acuity measurement with the instrument, you will want to do a separate
screening in order to satisfy the requirements of EC Section 49455.
Q. Who is authorized to perform a screening if it is done outside of the school?
A: If the parent chooses to have their child’s vision tested outside of school, EC
Section 49455 states that a physician and surgeon, physician’s assistant, oran optometrist may do the screening in order to fulfill the screening mandate.
Q. Can a parent request to waive the screening requirement for their child?
A: Yes. There are two options that a parent may use to waive the visionscreening mandate if they so desire:
1. The parent/guardian presents a certificate from a physician andsurgeon, a physician assistant practicing in compliance with Chapter
76.7 (commencing with Section 3500) of Division 2 of the Businessand Professions Code, or an optometrist providing evidence of a visionscreening, including visual acuity and color vision. (In accordance withEC Section 49455).
2. A parent/guardian files a written statement stating that they will notconsent to a physical examination of their child. (In accordance withEC Section 49451).
Note: If a parent does not turn in any type of outside examination results or awritten request refusing to have their child undergo physical examinations, thechild will be screened during the mandated screening process per EC Section
49455.
Q. If a parent wants to waive the vision screening for their student, does the school alsoneed a note from a health care provider?
A: EC Section 49451 allows a parent/guardian to exempt their child fromscreenings in school by signing a statement indicating that they do notconsent to a physical examination of the child. There is no need for a healthcare provider to sign such an exemption.

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Appendix C
Page 3 of 4
Q. Why do we not point to optotypes on eye charts? It is tough to get small children to
know what we want them to see.
A: The World Health Organization (2003) states that it is permissible to pointline-by-line, but not optotype by optotype. Pointing at an optotype makes the
optotype easier to identify and may lead to false visual acuity value. If you
need to help young children know which optotype to identify, you can briefly
point to the optotype and quickly remove the pointer. If the optotype is in arectangle box, avoid breaking the box with the pointer.
Q. Are there any certificate programs to train Licensed Vocational Nurses (LVNs) tohelp provide the vision screenings?
A: LVNs are not authorized to perform vision screenings in public schools.
California Code of Regulations, Title 5, Division 1, Chapter 2, Subchapter 3,
Article 4 indicates who may perform vision screenings in public schools, and
LVNs are not included in the list of those who may do so.
Q. Do the regulations also include charter schools in California?
A: EC Section 49455 does not specifically address charter schools, so absent a
specific mandate in a charter school’s authorizing documents(Petition/Memorandum of Understanding [MOU]), it would not be required tocomply with this provision. A charter school would need to defer to its petition
and MOU to confirm whether the charter has incorporated the vision appraisal(pupil health screenings) or is collecting categorical funding for this program.
If a charter school representative is not sure of its obligation, it should checkwith its school administrator or legal counsel. Although charter schools were
not included in the law specifically, they always have the option to elect toperform vision screening.
Q. May we accept the vision screening results on the Child Health and Disability
Prevention (CHDP) Health Assessment in place of a school-based vision screening?
A: Yes, if the CHDP examination was done within the past year, was performedby one of the authorized practitioners listed in EC Section 49455 (a physician
and surgeon, a physician assistant practicing in compliance with Chapter 76.7
[commencing with Section 3500] of Division 2 of the Business andProfessions Code, or an optometrist) and includes the results of adetermination of the pupil’s vision, including visual acuity and if applicable,color vision.

52

Appendix C
Page 4 of 4
Q. Does the mandated vision screening need to include other tests such as
cover/uncover, muscle balance, or binocularity?
A: EC Section 49455 only requires screening of distance and near visual acuity,and color vision. A district may choose to screen for additional vision
problems, but not in place of screening for visual acuity and color vision.
Q. Does color vision have to be tested in first grade, or can it take place any time after
first grade?
A: EC Section 49455 states that color vision appraisal need not begin until the
male pupil has reached the first grade. There is no specific requirement as towhat grade it needs to take place in, however, earlier diagnosis of color vision
deficiency can lead to earlier intervention in the classroom, if need be.
Q. Will these new regulations apply to pre-school programs such as Head Start?
A: EC Section 49455 was written to apply to grades kindergarten through eightonly.
Q. Is the code the same for special education students? Do we need to screen thesestudents every year?
A: EC Section 49455 applies to all students, including special education
students. Special education students may have other assessments done as apart of their educational planning and it may be necessary to screen thesestudents more often than the law requires due to certain special education
requirements.

53Appendix D
Glossary
Term
Accommodation

Definition
Power (or ability) of the eye to alter the shape of its lens toadjust the focus for near and far.

Amblyopia

Often called lazy eye, amblyopia is loss of vision occurring at
the brain level when nerve cells in the visual part of the brain
do not receive sufficient use while the sense of sight isdeveloping.

Anisometropia

Condition in which the two eyes have significantly different
refractive error.

Astigmatism

Type of refractive error in which light rays do not focus
evenly on the retina due to an irregularly shaped cornea orlens curvature; objects at distance and near appear blurry
and distorted.

Binocular Vision

Fusion of the separate images seen by each eye, allowing
adequate depth perception.

Convergence

Coordinated inward movement of both eyes when looking at
a near object.

Convergence
insufficiency

Eye coordination deficiency in which the eyes have difficulty
converging when reading or doing close work.

Color Deficiency

Reduced ability to discriminate between colors, usually redgreen, less frequently blue-yellow.

Cover Test

The unilateral cover test (cover-uncover test) checks forstrabismus. The alternate cover test measures themagnitude of the eye alignment.

Conjugate Eye
Movements

Simultaneous movement of both eyes in the same direction.

Credentialed School
Nurse

A registered nurse that has completed a baccalaureate
program, up to 28 post baccalaureate units, and received a
specialized credential from the State of California on Teacher
Credentialing (California Education Code Section 49426).

Diopter

Unit of measurement of the refractive power of a lens.

Diplopia

Double vision or the perception of seeing two images of asingle object; images may be horizontal, vertical or diagonal.

Esophoria

Tendency for the eyes to turn inward.

54

Term
Esotropia

Definition
Type of strabismus in which one eye is looking straight andthe other eye is turned inward.

Exophoria

Tendency for the eyes to turn outward.

Exotropia

Type of strabismus in which one eye is looking straight andthe other eye is turned outward.

Fixation

Ability to hold focus on an object.

FusionOverlapping of the separate images seen by each eye into
one composite image.

Hyperopia(farsightedness)

Type of refractive error in which light rays come to focus
behind the retina: Distance objects can be seen more clearly
than near objects.

Hypertropia

Type of strabismus in which one ye is looking straight andthe other eye is turned upward.

Hypotropia

Type of strabismus in which one eye is looking straight andthe other eye is turned downward.

Myopia(nearsightedness)

Type of refractive error in which light rays come to focus in
front of the retina, resulting in blurred distance vision.

Nystagmus

A rapid involuntary oscillation of the eyes; the oscillation canbe side to side, up and down or rotary.

OD

Oculus dexter (right eye).

OS

Oculus sinister (left eye).

Occlusion

Obscuring the vision of one eye in order to test the vision of
the other.
Physician who specializes in the diagnosis and treatment ofrefractive and medical conditions related to eye. An
ophthalmologist may prescribe glasses, contact lenses, andother corrective measures and perform surgery. The initials
M.D. are used after the person’s name.
Professional who fills optical prescriptions for glasses bygrinding lenses, fitting them into frames, and performing
frame adjustments.
Doctor who specializes in the diagnosis and treatment ofrefractive and medical conditions related to the eye. An
optometrist may prescribe glasses, contact lenses, and othercorrective measures. The initials O.D. are used after the
person’s name.
Standardize target (often letters or symbols) on a visualacuity chart used to test vision.
Technique used to determine the refractive error of the eye.

Ophthalmologist

Optician

Optometrist

Optotype
Refraction

55

Term
Refractive error
Strabismus
Stereopsis
Threshold Screening

Visual acuity

Definition
Occurs when light rays are not focused on the retina; myopia,
hyperopia and astigmatism are refractive errors.
Misalignment of the eyes; esotropia, exotropia, hypertropia
and hypotropia are types of strabismus.
Perception of depth which results from the fusion of theseparate images seen by each eye; also known as 3D vision.
Method of visual acuity screening that where the student
begins at the top of the eye chart and reads down the chart
until the student misses 3 of 5 optotypes on a particular line.
Sharpness of vision; ability to distinguish target details at astandardized distance.

56