Preliminary report of the Colorado school vision screening interdisciplinary task force.
The proceedings of this meeting and the school vision screening guidelines that evolved are presented. Subsequent papers will report the efficacy of the screening battery once implemented.
School vision screening is riddled with a lack of agreement among professionals involved and no rules and regulations to enforce state laws that mandate vision screening. Prior to the task force group meeting in August 1990, facilitators interviewed participants individually to better understand the diverse opinions. Participants were invited to contribute pertinent articles to a background information packet that was distributed prior to the meeting. An agenda listing specific objectives also was drafted. The facilitators' tasks were were to keep the group task-oriented, on schedule, and able to reach agreement on each objective. William Coors addressed the group, reiterating the charge and expressing his personal concerns about school vision screening and the role of vision in learning.
OF THE PROBLEM
The first objective was to review current school vision screening guidelines. Although some task force members maintained initially that no problem existed, after considerable discussion, consensus was obtained that a problem and a core problem analysis was performed to identify the core problem.
The current Colorado state statute (HB 1408) reads:
"School children--sight and hearing tests. The sight and hearing of all children in the kindergarten, first, second, third, fifth, seventh and ninth grades, or children in comparable age groups referred for testing, shall be tested during the school year by the teacher, principal, or other qualified person authorized by the school district. Each school in the district shall make a record of all sight and hearing tests given during the school year and record the individual results of each test on each child's records. The parents or guardian shall be informed when a deficiency is found. The provision of this section shall not apply to any child whose parent or guardian objects on religious or personal grounds."
The Colorado School Health Guidelines  suggest screenings consist of observations and distance Snellen visual acuity for all children screening, and cover test for those in preschool, kindergarten, and first grade. School districts may do additional screenings, especially for students being assessed for special education or students referred by a teacher. School nurses usually perform the screenings or train personnel.
The task identified three specific problems with present vision screening programs:
1) Inadequate Vision Screening, including inconsistency among school districts which, in Colorado, have local autonomy, lack of personnel, equipment, and funds for screenings, inadequate training of personnel, and under referrals or over referrals.
2) Poor Implementation of Current Law, including no existing detailed rules and regulations, inconsistent compliance with present guidelines, incomplete data collection, lack of parental follow-through after screening, and lack of support from school administrators and community professionals.
3) Controversy, including disagreement on the role of vision in learning, the importance of each type of vision problem, and the importance of screening vs. complete examinations. In addition controversy existed among professionals involved, mainly ophthalmology and optometry but also among education and eye care professionals and among different factions within all professions.
Following careful consideration of the problems identified, the task force agreed inadequate identification and referral of children and youth with vision problems was the main core problem.
PURPOSE, OBJECTIVES, AND CRITERIA
The next task was to compose a purpose statement and identify specific objectives on how the group could affect the problem. The following purpose, objectives, and criteria were compiled.
Purpose. Development of a school vision screening program that: a) builds on the success of the current vision screening program, b) effectively identifies children and youth with vision problems, c) is acceptable to all concerned--youth, parents, educators, and health professionals, and d) is appropriate for implementation in schools with the potential to develop rules and regulations to operationalize existing state law.
Objectives. Achievement of the goals listed in the purpose statement by: a) identifying which vision problems should be screened, b) developing a vision screening battery, c) developing an implementation action plan that includes possible rules and regulations to operationalize state law, d) agreeing on a uniform reporting system, data analysis, and dissemination, and e) devising marketing strategies.
Criteria. School vision screening should consider: a) cost effectiveness in terms of time and personnel, b) reliability, c) minimizing false positives, d) sensitivity to identify vision problems, e) enforceability, and f) acceptability to optometrists, ophthalmologists, and school personnel.
VISION SCREENING BATTERY
The task force approached developing a school vision screening battery in three phases: identifying which vision problems should be screened, selecting specific tests, and determining pass/fail criteria for tests selected.
Vision Problems Screened. Much discussion and compromise was necessary to agree on which problems to be screened, the most difficult task. The task force began with a long list of potential vision problems that could be screened but only those vision problems that were consistent with the stated purpose and criteria made the final listing. Examples of vision problems considered but later eliminated were oculomotor motor development and accommodative dysfunction, which were dropped primarily due to controversy concerning their importance and lack of agreement on incidence. Fear of over-referrals generated by screening for these vision problems also was a strong factor. Although some task force members felt strongly that these vision problems were quite important and prevalent, the consensus was that if a large segment of the eye care providers do not accept these entities as significant vision problems and thus do not test for them, a situation of over referral and confusion would result by including them in the screening. The consensus was a screening should not surpass a routine examination. The group agreed these vision problems should be screened:
a) external eye abnormalities,
b) refractive errors such as myopia, hyperopia, and astigmatism,
c) amblyopia and organic diseases masquerading as amblyopia,
d) binocular dysfunction such as strabismus and convergence insufficiency, and
e) color vision defects
Battery of Tests. Once the group decided on which problems to be screened, putting together the test battery and determining pass/fail criteria were, in comparison, easier tasks. The task force reviewed several references including a textbook chapter,  several published articles, [3-6] and vision screening guidelines from the American Optometric Association  and the National Association of School Nurses.  Many tests were considered but only those that met the group's stated purpose and criteria were maintained. There were two tests that were considered but eliminated. Near visual acuity was eliminated because a lack of evidence exists that it would significantly helps the overall screening. Contrast sensitivity was eliminated because it is too new, not well understood by many practitioners, and its efficacy as a screening tool is not well established.
Pass/Fail Criteria. After the select battery of tests was determined, pass/fail criteria was established for each test. Criteria were, for the most part, extracted as conventional wisdom from published reports of previous screening guidelines. [3-8] Screening battery and pass/fail criteria includes:
a) Observation/history: as described in the Illinois program as the ABCs. 
b) Monocular distance visual acuity: failure is inability to see 20/30 in each eye or if one eye sees 20/20 and the other 20/30.
c) Plus lens hyperopia test: failure if able to clear 20/30 (or equivalent) at 20 feet through a +2.50 diopter lens.
d) Near point of convergence: failure if unable to converge to 6 inches (15 cm).
e) Cover Test: alternating cover test with distance fixation, any consistent movement of the eyes is a failure.
f) Stereo Test: failure if unable to achieve 100 seconds of arc.
g) Color vision: failure as dictated by specific test.
The battery of tests is intended to be administered to the same grades as present guidelines dictate (K,1,2,3,5,7,9) with the exception of color testing which should be done only for grade two. Tests will be modified for preschool, kindergarten, and first grade students. Detailed guidelines for the testing battery were written by a committee and are intended to become the rules and regulations to support the state statute for vision screening. A copy of the guidelines is available from the Community Nursing Section, Colorado Dept. of Health.
To ensure continued activity and follow through with the projects initiated, the task force outlined a committee structure and elected committee personnel cod co-chairpersons. Future meeting dates were set and a plan was outlined to achieve implementation of the new screening battery. The plan included a detailed flow chart. Data collection and analysis of the efficacy of this screening battery is planned and will be reported in future articles.
The significance of the vision screening battery derived from this task force is its development from an interdisciplinary group, addressing the concerns of the Dept. of Education, Dept. of Health, school nurses, ophthalmologists, and optometrists. This screening battery might be criticized by some as too brief and by others as too extensive. However, considering the diverse opinions contributing to the screening battery, compromise was necessary and practical. The screening is a workable compromise, practical for immediate implementation. It is intended to be a major step toward improving present vision screening guidelines with the ultimate goal of helping detect children with vision problems.
 Colorado School Health Guidelines. 2nd ed. Denver, Colo: Colorado Department of Education and Colorado Department of Health; 1986.  Leske MC, Hawkins BS. Screening: Relationship to diagnosis and therapy. In: Duane TD. Clinical Ophthalmology. Vol. 5. Philadelphia, Pa: JB Lipppincott; 1989.  Cohen AH, Lieberman S, Stolzberg M, Ritty JM. The NYSOA vision screening battery--a total approach. J Am Optom Assn. 1983;54(11):979.  Larson MR. Comprehensive vision screening program: Illinois' approach. J Am Optom Assn. 1988;59(1):26.  Ehrlich MI, Reinecke RD, Simons K. Preschool vision screening for amblyopia and strabismus: Programs, methods, guidelines, 1983. Surv Ophthalmol. 1983;28(3):145.  Peters HB, et al. The Orinda vision study. Am J Optom Arch Am Acad Optom. 1959;36(9):455-469.  Petrie E, Tumblin JC, Miller SC. The American Optometric Association Guidelines on Vision Screening. St. Louis, Mo: American Optometric Association; 1979.  Vision Screening Guidelines for School Nurses. Scarborough, Maine: National Association of School Nurses; 1985.
James C. Bosse, OD, 700 B Main St., Canon City, CO 81212; Jean Mallett, RN, MA, Greeley School District, 2305 59th Avenue Court, Greeley, CO 80634; and John Santoro, MD, 10001 N. Washington, Thornton, CO 80229. Colorado School Vision Screening Interdisciplinary Task Force participants were: Dept. of Health, Victoria Hertel, RN, MSN, Dept. of Education, Chuck Wright, MA, School Nurses, Betty Fitzpatrick, RN, MSN, SNP, Judy Kain, RN, BSN, and Jean Mallett, RN, MA, Opthalmologists, Randall S. Condit, MD, William Hines, MD, and John Santoro, MD, Optometrists, James C. Bosse, OD, Lynn Fishman Hellerstein, OD, and Dale G. Lervick, OD, Adolph Coors Foundation, William K. Coors and Linda Tafoya, and Atlanta Consulting Group, Diana Heard and Michael Burkart, PhD. This article was submitted April 22, 1991, and accepted for publication June 10, 1991.
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|Title Annotation:||Health Service Applications|
|Author:||Bosse, James C.; Mallett, Jean; Santoro, John|
|Publication:||Journal of School Health|
|Date:||Nov 1, 1991|
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