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Children's Vision and Eye Health
Considerations for Children's Vision Screening Programs During the Covid-19 Pandemic

Introduction

As schools, Head Start/Early Head Start, and early care and education programs reopen during the COVID-19 pandemic, practices that occurred routinely for decades must be reconsidered and redesigned to prevent the spread of the virus among children and staff, and ultimately, the community. Children’s vision screening is one of many services that meet critical needs of children and is an essential service to eliminate poor vision and eye health problems as a barrier to academic and classroom success. Fortunately, vision screeners can employ strategies to manage the risk of COVID-19 exposure and potential transmission during vision screening.

This document suggests considerations for modifying vision and eye health screening procedures during the COVID-19 pandemic. This document provides a summary of currently available resources that vision screeners and school nurses can consult as they formulate independent judgment.  This document is not intended to provide clinical standards or guidelines. Vision screeners and school nurses are responsible for complying with applicable federal, state, and local laws, regulations, ordinances, executive orders, policies, and any other applicable sources of authority, including any applicable standards of practice.

The science of COVID-19 is evolving rapidly. This document is dynamic and will be updated with the emergence of new knowledge and practices in risk management and reduction. It is important to be familiar with and closely follow all school district and local guidelines as well as federal and state infection-control recommendations. Conducting vision screening in school and community settings while adhering to physical distancing requirements will be challenging. We stress the importance of adhering to evidence-based vision screening procedures. Using modified vision screening practices without evidence may result in inappropriate referrals to eye care providers, causing children and parents/guardians unnecessary exposure to medical settings during a pandemic. Conversely, not adhering to evidence-based practices may miss a vision or eye health disorder and a proper referral to eye care.  Refer to the FAQ document for more detailed information on vision screening.

Downloads:

Vision Screening Considerations During the Coronavirus Disease 2019 (COVID-19) Pandemic for Schools, Head Start and Early Care and Education Programs

FAQ for Vision Screening Considerations


  • Some school districts, Head Start, and early education and care programs are barring individuals/volunteers who are not school employees into buildings during the pandemic (CDC). Investigate the program’s or school’s policy on visitors, contractors, and itinerant employees.
  • Verify the screening site has assigned a well-lit room where the ventilation is working properly per guidelines from the CDC.
  • Determine if the assigned room enables separate entrance and exit doors.
  • Verify the assigned room will be deep-cleaned and sanitized prior to use per CDC guidelines.
  • Identify the records that need to be maintained in the event contact tracing is required and request or create a template for managing that documentation.
  • Conduct a simulated dry run of the traffic flow, timing, spacing needs, supplies, and screening procedures with adults who are informed of, and participating in, safety procedures.
  • Verify availability of assigned monitors for children traveling to and from the screening room.
  • Every effort should be made to locate the vision screening room near sinks and running water for handwashing. Handwashing with soap and water is preferred by the CDC over using hand sanitizer. Verify handwashing facilities are fully stocked with hand towels, soap, and no-touch trash receptacles.
  • Identify who is responsible for notifying parents, teachers, and administrators of vision screening.
  • Schools, Head Start, and early care and education programs may have alternating days of in-person attendance, in which different cohort groups of students attend on set schedules. Screeners need to plan the schedule around cohorts.
  • Verify that face coverings will remain on students and adults during the entire screening session.
  • Children must wash hands per CDC guidelines for 20 seconds before and after screening.
  • Screeners must wash hands per CDC guidelines before screening, after any child contact, and at regular intervals throughout the day.
  • If soap and water are unavailable, hand sanitizer that contains at least 60% alcohol can be used.
  • Gloves are not necessary (CDC, 2020).
  • CDC handwashing guidelines recommend drying hands with paper towels or air drying, and do not include drying hands with motorized hand dryers.
  • Screeners and children should wear cloth face coverings per CDC guidelines during screening. The CDC provides instructions on how to properly wear a mask. Screeners should not conduct vision screening if they cannot wear a mask for a medical reason.
  • If children do not have a mask or the mask is not secure or does not cover the nose and mouth, disposable masks should be provided and should be put on by the child prior to entering the screening area.
  • Consider not performing a vision screening on any child who cannot wear a mask. Children who cannot wear a mask should be referred to their primary health care provider for vision screening. Masks are not required for:
    • children younger than age 2 years
    • children who have trouble breathing
    • children who are unable to comply with wearing a mask due to physical or mental health limitations or developmental delay
  • If a well-fitted mask is unavailable for a child, offer the screening later when a mask is available or masks for children are optional or unnecessary.
  • Screeners should wear cloth masks that fit snugly and cover the mouth and nose. Screeners may wear goggles that cover the sides of the eyes and/or a face shield with a mask. CDC does not recommend use of face shields as a substitute for cloth face coverings. Johns Hopkins offers additional guidance on face masks.
  • Children and screeners should wash their hands before putting on a cloth face covering.
  • Face coverings consistent with CDC guidelines.
  • Goggles (if screener chooses—in addition to face covering).
  • Face shield (if screener chooses in addition to face covering).
  • Sanitizer with at least 60% alcohol (for screener and older children only) and paper towels
  • Disinfectant wipes.
  • No-touch trash cans – with enough capacity for wipes, occluders, and paper towels.
  • Disposable occluders (do not use homemade paper occluders, nor tissues or hands – disposable occluders are available for purchase from vision supply vendors).
  • Disposable matching lap cards (for preschool children – make paper copies of the matching lap Card: one per child to be screened, and then discard).
  • Tape and or floor markings.
  • Entry and exit door signs.
  • Measuring tape or 6-foot measure.
  • Disposable single-use gloves for cleaning.
  • Cleaning supplies that meet EPA Guidelines for COVID-19.
  • Supplies for vision screening.
  • Verify the room assigned for screening was deep-cleaned and sanitized per CDC guidelines prior to entry.
  • Clean and disinfect frequently touched surfaces often (CDC Guidelines).
  • Develop and adhere to a schedule for increased routine cleaning and disinfection.
  • Cleaning products used by screener must be secured out of reach from children.
  • Do not use cleaning products near children.
  • Verify that there is adequate ventilation when using cleaning products in the screening space to prevent children or adults from inhaling toxic fumes.
  • Standard use of visual acuity charts used at a testing distance of 10 feet should be wiped clean with disinfecting wipes before and after each screening day.
  • Vision screening instruments (photoscreeners, autorefractors, etc.) should be cleaned and disinfected at the beginning and end of each screening day per manufacturer’s guidelines.
  • Do not allow food and beverages in the screening room.
  • Do not allow items (e.g., stuffed animals, books) that are difficult to clean or disinfect.
  • Ensure adequate supplies of disposable materials to eliminate sharing of high touch items such as occluders and matching lap cards.
  • Mass screening for color vision deficiency is not recommended. Consider postponing color vision deficiency screening if it is mandated in your program or state. If a teacher or parent is concerned about color vision, refer the child to an eye care provider.
  • Mark floors to provide a visual guide for maintaining 6-foot distancing between the screener, the child, and between adults.
  • The CDC recommends one-way traffic with separate entrance and exit doors.
  • Sanitize chairs used during vision screening between children’s use. Screener should wash hands after sanitizing objects.
  • Children should stand 6 feet apart while waiting outside the screening room. Mark floors where children should stand.
  • Do not call the entire class to the screening area and limit the number of children waiting – based on the amount of space available for waiting. If possible, screen children one at a time to ensure physical distancing space between children.
  • If pods or cohorts are used (AAP, 2020; CDC, 2020), clean and disinfect the screening area before children from another cohort or pod arrive.

Vision Screeners

  • Consider limiting screening personnel to three adults:
    • Screener,
    • Facility employee to clean chairs and monitor distancing, and
    • Staff to accompany children traveling to and from classroom and monitor handwashing before and after screening.
  • The CDC recommends cohorting of children and staff (CDC, 2020). Consider eliminating conducting screening at multiple schools, Head Start centers, or early care and education programs (CDC, 2020). If screeners are assigned to screen children at multiple schools or programs, allow 14 days to elapse between screenings in different locations. In communities where the virus is spreading, COVID-19 testing for screeners may be considered.
  • More details about screening can be found in the FAQs.
  • Screeners must be trained on all district, school, Head Start, or early care and education facilities’ COVID-19- related health and safety protocols ahead of screening.
  • The American Academy of Pediatrics (2020) recommends that all training be conducted virtually.
  • Screeners should make contact with screening site administrators 2 days in advance of screening to identify any changes in the facility’s health and safety protocol.

(Note, this section addresses adaptations to evidence-based vision screening recommendations during the Covid-19 pandemic. For more information on vision screening generally, please visit https://nationalcenter.preventblindness.org/vision-screening-guidelines-by-age/

  • Standard use of visual acuity charts, used at a testing distance of 10 feet and that children do not touch, should be wiped clean before and after each screening day (to protect the screeners) but need not be cleaned between each child’s screening.
  • Distance visual acuity screening can be performed according to safety standards. To minimize screening duration time, near acuity, color vision deficiency, and stereoacuity screening is not recommended at this time.
  • Please see the FAQ document for more detailed information on vision screening methods and tools.

Vision screening is an important component of pediatric preventative health care and should continue during the COVID-19 pandemic. Prevent Blindness developed the NCCVEH’s 12 Components of a Strong Vision Health System of Care. These components address parent and caregiver education as well as vision screening, referral to eye care, and more. Whether children attend Head Start, an early care and education program, or school, we encourage parents and guardians to observe and listen to a child for signs of a possible vision disorder. An appointment with an eye care provider should be made if there is ANY concern about a possible vision problem.  Close-up work required by online and remote learning can exacerbate a previously unknown vision problem. Therefore, parents and guardians need to be vigilant.

When a comprehensive vision screening program cannot be implemented (such as during virtual learning), a document describing signs of a possible childhood vision disorder can be given to parents and guardians. Programs and schools should stress the importance of having the child examined by an eye care provider if the child shows one or more of the signs or symptoms. An easy-to-use checklist for Head Start and early care and education programs is available through Prevent Blindness. From birth through the first birthday, chart screening is not developmentally possible and there is no evidence to support use of instruments in this age group. The NCCVEH recommends using the 18 Vision Development Milestones From Birth to Baby’s First Birthday in English or Spanish as a vision screening tool for Early Head Start and other early care and education programs.

School and community screenings are safety net programs. If screenings cannot be conducted, families should be instructed to take their children to their primary health care provider for a vision screening or eye care doctor for a comprehensive eye examination. Vision screening should be conducted as part of a regular well-child visit at the primary health care provider’s office. The American Academy of Pediatrics strongly encourages families to schedule and keep well-child checks throughout the COVID-19 pandemic. Parents and guardians should receive educational material about the importance of child vision health.

Teachers, administrators, nurses, vision screeners, support professionals, Head Start, Early Head Start, early care and education personnel, and para-professionals are anxious about the difficulties they are facing to meet new educational expectations. The considerations suggested in this document are designed to ensure that vision screening continues to help children have the best vision possible to succeed academically.

References

American Academy of Pediatrics. (2020, August 19).  COVID-19 Planning considerations: Guidance for school re-entry.  https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/

Centers for Disease Control and Prevention. (2020, May 19). Considerations for schools.  https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools.html

Centers for Disease Control and Prevention. (2020, July 23). Guidance for childcare programs that remain openhttps://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/guidance-for-childcare.html

Centers for Disease Control and Prevention. (2020, August 7). How to wear masks. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-to-wear-cloth-face-coverings.html

Centers for Disease Control and Prevention. (2020, July 15). Strategies for optimizing the supply of eye protection. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html

Centers for Disease Control and Prevention. (2020, August 1). Preparing K-12 administrators for a safe return to school in fall 2020.   https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/prepare-safe-return.html

Centers for Disease Control and Prevention. (2020, July 31). Public health guidance for community related exposures.  https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.html

Centers for Disease Control and Prevention. (2020, May 7). Reopening guidance for cleaning and disinfecting public spaces, workplaces, businesses, schools, and homes.
https://www.cdc.gov/coronavirus/2019-ncov/community/reopen-guidance.html

Centers for Disease Control and Prevention. (2020, March 3). Show me the science – When & how to use hand sanitizer in community settings.  https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html

Centers for Disease Control and Prevention. (2020, May 13). Symptoms of coronavirus.  https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

Centers for Disease Control and Prevention. (2020, August 11). Guidance for K-12 school administrators on the use of cloth face coverings in schools.  https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/cloth-face-cover.html

Centers for Disease Control and Prevention.  (2020, June 28). Use of cloth face coverings to slow the spread of COVID-19.  https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html

Centers for Disease Control and Prevention.  (2020, April 2). When and how to wash your hands.  https://www.cdc.gov/handwashing/when-how-handwashing.html

Centers for Disease Control and Prevention.  (2020, July 16). When to wear gloves.

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/gloves.html

Environmental Protection Agency. (2020, August 13). List N: Disinfectants for use against SARS-CoV-2 (COVID-19).  https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19

Head Start/ECLKC. (2020, August 5).  OHS COVID-19 updates.  https://eclkc.ohs.acf.hhs.gov/about-us/coronavirus/ohs-covid-19-updates

National Association of School Nurses.  (2016). Principles for practice:  Vision screening and follow-up.  Silver Spring, MD: NASN.

National Association of School Nurses. (2020, July 30). Return to school post COVID-19 closure considerations for students with disabilities and special healthcare needs. Silver Spring, MD: Author. https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/2020_07_23_Considerations_for_Post_COVID_Return_to_School_for_Students_with_Disabilities_and_Special_Healthcare_Needs.pdf

National Education Association. (2020, June 19).  All hands-on deck:  Initial guidance regarding reopening school buildingshttps://educatingthroughcrisis.org/wp-content/uploads/2020/06/27178-Initial-Guidance-for-Reopening-Schools_Final-1.pdf

Perencevich, E.N., Diekema, D.J. & Edmond, M.B. (2020) Moving personal protective equipment into the community.  Face shields and containment of COVID-19.  (EPub before print). JAMA, doi:10.1001/jama.2020.7477

Centers for Disease Control and Prevention.  (2020, June 3).  K-12 Schools and Child Care Programs:  FAQs for Administrators, Teachers, and Parents.  https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/schools-faq.html

Maragotis, L.L. (2020, August 14). Coronavirus face masks & protection FAQs. Johns Hopkins.  https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-face-masks-what-you-need-to-know

“Think of Vision” fact sheets for teachers of preschool and school-age children from Children’s Vision Massachusetts

Q. Can Head Start programs accept vision screening results from primary health care providers?

A. Yes. According to the Head Start Performance Standards, within 45 days of when a child first attends the program, the Head Start program can either obtain documentation of a primary health care provider screening or perform evidence-based vision screening.


Q. How do I conduct vision screening that requires me to be closer than 6 feet from the child, such as near acuity screening, stereoacuity screening, and color vision deficiency screening?

A. To minimize screening duration, color vision deficiency screening, near visual acuity screening, and stereoacuity screening are not recommended at this time.


Q. My state mandates color vision deficiency screening. How do I perform mass color vision deficiency screening during the COVID-19 pandemic?

A. Mass screening for color vision deficiency is not recommended. Consider postponing mandated mass color vision deficiency screening until a later date. Note that stereoacuity and near vision screening are also not recommended during the pandemic.


Q. Can a plexiglass partition be used to separate the child from the screener and the vision charts?

A. It is recommended that screeners conduct vision screening according to evidence-based guidelines. There is no published, peer-reviewed evidence that screening can be conducted accurately using a plexiglass partition. Plexiglass partitions are not recommended for vision screening.


Q. Can vision screening be conducted outdoors?

A. Vision screening can be conducted outdoors out of direct sunlight. Use of a tent or conducting screening under an outdoor covered picnic area is acceptable. Do a trial run to ensure the lighting is adequate and to verify if vision screening devices will function properly outdoors in young children with small pupils.

The screener should check the outdoor air quality and heat index. If children are recommended to stay inside, the outdoor screening should be moved indoors or rescheduled.


Q. How can I conduct photoscreening from 6 feet away?

A. Two instruments approved by the NCCVEH are used at a ~3-foot screening distance. When the instruments are outside the screening distance range, the screener is alerted via a message on the instrument monitor that the screener is too far away from the child and the instrument will neither capture a reading nor provide screening results. For children over age 2 years, both the child and screener should wear masks covering both the nose and mouth. The accuracy of screening results captured through face shields or plexiglass is unknown.

CDC guidelines define “close contact” with someone who has COVID-19 as being within 6 feet of the individual for 15 minutes or longer.

Instruments provide screening results in less than 1 minute.  Consider using vision screening instruments with children ages 1, 2, 3, 4, and 5 years. Consider using vision screening instruments for children 6 years and older ONLY if children cannot participate in optotype-based screening.

Consider the following precautions when using screening instruments within the 6-foot distance zone:

  • The screener should not enter the 6-foot physical distancing zone until the screener is ready to operate the device and is wearing appropriate personal protective gear.
  • Once the screening data are collected by the instrument, the screener should move outside the 6-foot physical distancing zone until the next child is ready for screening.
  • If a screening instrument cannot be operated according to best practices for use (room conditions, lighting requirements, positioning of the device in alignment with the child’s eyes, etc.) while COVID-19 risk management precautions are in place, then the device should not be used for screening.

Q. If a room with a separate entrance and exit is unavailable, what are my options?

A. People (both children and adults) cannot pass through doorways simultaneously. A child must wait until the previous child exits and is 6 feet away before entering the door to the room. Build additional time into the schedule.


Q. Our district is on a budget. Can I make my own occluders?

A. Do not make your own occluders. To ensure evidenced based screening, occluders should be purchased from a vision supply source.


Q. When I have special education students who cannot wear masks, what do I do?

A. Masks are effective for special education students who understand and comply with directions for use.  Students with sensitivity to touch, smell, or pressure may not tolerate masks. Adapted masks for teachers and staff, such as those with a clear panel to allow for visualization of lip reading and facial expressions, may be useful for some students.

Face shields combined with a mask are recommended for staff when a student cannot wear a mask and cannot control secretions, including sneezes, coughs, forced expiration of breath, or spitting. This combination is also recommended when staff are unable to maintain physical distancing, such as when providing personal hygiene. To fit properly, a face shield should extend below the chin anteriorly, to the ears laterally, and there should be no gap between the forehead and the device frame (Perencevich, Diekema, & Edmond, 2020).

The NCCVEH recommends a referral for a comprehensive eye examination for students who have certain conditions that place them at high-risk for a vision disorder.


Q. Do I need to screen a child who had an eye exam in the last 12 months?

A. A child who has had a comprehensive eye examination within the last 12 months does not need vision screening. However, it is important to have clear documentation of the eye exam in the child’s record. If there is no documentation, the child should be screened.


Q. Screeners in our program travel to different schools, sometimes more than one school daily. The 14-day break between schools is not feasible. What strategies do you suggest?

A. If the screeners’ schedules do not allow 14 days between schools, they can notify the facilities where they will be screening during the planning stage. Consider assigning screeners to specific geographic areas to prevent potential COVID-19 transmission across communities. In communities where the virus is spreading, COVID-19 testing for screeners may be considered.


Q. How do I clean and disinfect eye charts?

A:  For a detailed response to this question, visit the Good-Lite website, select the “More” link on the right side of the navigation bar, and open the PDF called “Cleaning and Disinfecting COVID-19 Considerations for Eye Charts and Near Vision Cards”.

 

This is a living document. Submit your questions and lessons learned for the next iteration of the  to Donna Fishman at [email protected].

This content was last updated on 8/20/2020.