Kansas Vision Screening Form V02.22.16

Kansas Vision Screening Form v02.22.16

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Family
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Child’s Name
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DOB / Address:
City, State, Zip:
E-mail:
Phone:

Kansas Vision Screening Items

1. FIXATION (birth and up)

Tester is positioned facing the child at child's eye level. Present the object approximately 12" in front of child's nose at eye level and observe child's eyes. Both eyes should be directed toward the object for at least two (2) seconds. Use of initial noise to get attention is acceptable but do not provide continuous sound stimulation.
☐Pass =Child fixes on object with both eyes for at least 2 seconds.
☐Does not Pass=Child does not fixate on object, or fixates with one eye only. Any eye drifting is abnormal.

1. Tracking(4 months and up)

When completing the tracking test on children 12 months or older, position the object or light about 12” from the child’s eyes. Move object to get the child’s attention and let him look at it for 2-3 seconds. Slowly move object in an arc to the far left then to the far right for horizontal tracking. Then slowly move the object in an arc up to several inches above the child’s head and then down to several inches below his chin.
Record Results
Horizontal: ☐Smooth ☐Jerky ☐Not Present
Vertical: ☐Smooth ☐Jerky ☐Not Present
☐Pass = smooth tracking
☐Does Not Pass = tracking is jerky or not present

1. COVER-UNCOVER TEST(6 months and older)

Tester is positioned facing the child at child's eye level. Hold the object 12 inches away from the child’s bridge of nose and at eye level with your left hand.
Observe the child for fixation on the object. While the child is fixated on the object, cover the left eye with occluder for at least 3 seconds.
Watch the eye that is not covered for any movement. If fixation is lost, attempt to reestablish fixation by removing occluder. Attempt to cover the left eye again.
Fixation must be kept on the object for 3 seconds. Remove occluder and watch for any movement of the eye that was just uncovered. The left eye should remain in alignment with the eye that was not covered. Switch the object to your other hand. Repeat steps for this eye..
Record Results
☐Pass =Child maintains fixation on the object while an eye is covered. No movement of the eyes was detected.
☐Does Not Pass=Child does not maintain fixation with both eyes when either eye is covered or uncovered. Movement of only one eye is detected. One or both eyes “float” in or out.

1. Near Point of Convergence (6 months and older)

Screen with glasses on if individual wears them.
Seat individual in front of the screener. Hold a small object approximately 12" in front of the individual's face at eye level. Direct the individual's attention so eyes fixate on the small object. Move target object slowly at individual's eye level on midline toward the bridge of the individual's nose. Observe how both eyes follow the target object.
Record Results
☐Pass=Eyes converge and pupils constrict to focus on moving object and eyes have a symmetrical response until object is within 3" from the bridge of the nose.
☐Does Not Pass=Poor fixation or asymmetrical response of eyes to the moving object beyond 3" from the bridge of the nose, or eyes do not converge to 3" from bridge of nose.

1. Hirschberg Corneal Light Reflex (6 months and older)

Hold a penlight 8”-10” away from the child’s face directly in front of the eyes. Direct the light from the penlight in between the eyebrows. The child needs to fixate either on the penlight or on an object held near the light. Observe the reflection of the penlight in the pupils of both eyes. The reflection should be equally centered and slightly toward the nose. Sensitivity to light, rapid eye movement and poor fixation observed during this test are also reasons for referral.
Record Results
☐Centered in BOTH eyes
☐Equally centered SLIGHTLY nasal in BOTH eyes
☐Not centered in one or both eyes
☐Pass = centered in both eyes or slightly nasal
☐Does Not Pass = not centered in one or both eyes

1. Pupillary Appearance/Response(birth and up)

Pupils should be round, black and equal in size. They should change size, by getting smaller with light and larger ina darkened room. Seizure medications, neurological problems, & other medications can inhibit this response. Botheyes should react equally to changes in light.
Record Results
Right Eye: Response to light: ☐Absent ☐Sluggish ☐Quick
Round, black and equal in size to left eye? ☐YES ☐NO
Left Eye: Response to light: ☐Absent ☐Sluggish ☐Quick
Round, black and equal in size to right eye? ☐YES ☐NO
☐Pass = Both pupils respond quickly and are round, black and equal in size
☐Does Not Pass= Absent or sluggish response in either eye OR either pupil is not round, black or equal in size.

1. PediaVisonSPOT or PlusOptixScreener (6 months and older according to manufacturer’s instructions)

Auto refractive vison screener that indicates the need for corrective lenses. Please refer to the operator manual for pass/fail criteria.
*Attach the print out to this form.
Record Results
☐Pass
☐Refer=Refer to an ophthalmologist for further evaluation.
Comments:______
Summary
Referral Action = A child who does not pass one or more of the screening items, should be rescreened in two weeks. If a child does not receive a pass on the second screening, the child should be referred to ophthalmologist for further evaluation. A child who meets the refer criteria on page 1 should be referred at once for further evaluation.
☐Child to be rescreened in approximately two weeks.
☐Child referred to ophthalmologist
☐No further action needed at this time.
Referral made to______Date:______

Note: Parents are to receive a copy of this form