Guidance

Child vision screening: screening competencies

Published 24 October 2017

Applies to England

1. Introduction

These competencies are designed for screeners responsible for the vision screening of children aged 4 to 5 years. They apply wherever vision screeners work. Note that the visual assessment of children aged 4 to 5 in special schools will normally be undertaken by an orthoptist.

The competencies represent the essential elements needed to run a safe, effective and standardised vision screening service. They are based on:

• an analysis of the core role of the vision screeners
• extended discussions with:
  • the British and Irish Orthoptic Society (BIOS) Special Interest Group Steering Committee
  • vision screeners
  • public health experts
  • screening leads
• feedback from an external consultation exercise

These competencies have been agreed by the members of the National Vision Screening Advisory Group to be effective yet pragmatic, achievable and cost effective. The competencies provide a clear outline for vision screeners of what they need to achieve together with a set of performance indicators for use by those responsible for assessing the performance of vision screeners.

The competencies and performance indicators will be used as the basis for the development of online e-learning resources to be undertaken on an annual basis.

The accompanying flow chart provides an outline of the initial learning and assessment pathway. Screening providers must allow appropriate annual continuing professional development in line with programme requirements.

2. Knowledge competencies

K1 - visual development

Competency

Understands the normal pattern of visual development in childhood and the impact of impaired visual acuity.

Performance statement or indicators

Explains that:

• visual acuity, eye alignment and binocular vision develop from birth to age 8
• each eye must be able to send clear and similar pictures to the brain in order to develop normally
• an adult level of acuity is reached between 5 to 8 years old
• children can appear to function well and seem visually normal because one eye is ‘doing all the work’
• a child who has undetected poor vision may show clumsiness, learning difficulties, behavioural problems and be disruptive in school
• impaired visual acuity can affect ability to learn and behaviour

K2 - common conditions

Competency

Identifies the common conditions that may interfere with normal visual development in childhood.

Performance statement or indicators

Can clearly:

• define the term visual acuity (a measure of our ability to detect fine detail)
• list and define types of refractive errors (hypermetropia, myopia, astigmatism)
• define amblyopia (reduced acuity but colloquially known as a lazy eye)

Is aware that:

• structural abnormalities of the eye can disrupt the normal development of visual acuity (cataract, corneal opacity, ptosis)
• children with disabilities are more likely to have visual problems

K3 - screening

Competency

Describes the basic principles of screening and the benefits of screening 4 to 5 year old children.

Performance statement or indicators

Understands that:

• screening is for whole populations
• screening has limitations
• evidence shows that the optimum age to screen is 4 to 5 years old
• aim of screening is the early detection and treatment of defects that may lead to a permanent visual impairment if left untreated

Identifies the steps in the screening pathway:

• identifying the eligible population
• informing parents
• obtaining consent, including the differences between opt-in and opt-out
• testing
• referral for diagnosis and treatment

K4 - local pathway

Competency

Understands own role in the local screening pathway.

Performance statement or indicators

Correctly identifies who is responsible for:

• identifying the eligible population
• informing parents
• obtaining parental consent - either opt-in or opt-out according to local policy
• booking the screening sessions
• liaising with schools
• following-up non-attenders

Correctly describes the reporting and referral pathway.

K5 - related policies and procedures

Competency

Shows awareness of related local policies and procedures.

Performance statement or indicators

Is familiar with local policies and procedures regarding:

• health and safety, including infection control and hand cleanliness
• risk assessment
• safeguarding
• consent
• audit requirements

K6 - the Keeler crowded logMAR test

Competency

Accurately describes the Keeler crowded logMAR test.

Performance statement or indicators

Explains that:

• the Keeler crowded logMAR test is appropriate for testing this age group
• each eye must be tested separately
• limiting factors can include age, ability, levels of co-operation
• the child should achieve 0.200 or better for each eye in order to pass the vision screening

Correctly identifies the specifics of the test:

• 3 metre test distance
• easy to use, durable, 2 ‘flip over’ books and matching card
• 6 letters are used - X V O H U Y
• 4 letters on each line, crowding bars surround each row
• each letter is given a score of 0.025

Describe how to complete the test if (a) undertaking it alone and (b) 2 screeners present.

3. Practical competencies

P1 - Planning

Competency

Liaises effectively with the school prior to the screening session (as determined by local practice).

Performance statement or indicators

Liaises to:

• confirm dates of screening session
• check that information and consent letters have been sent to parents

P2 - preparation for the screening session

Competency

Works with school staff to ensure smooth running of the screening session.

Performance statement or indicators

Routinely:

• obtains a list of children to be screened
• checks the consent status of each child
• discusses with the class teacher how the children will move between the classroom and test area (for example, escorted or independent), is a teaching assistant or other available

P3 - equipment

Competency

Collects together all the required equipment prior to beginning the screening session.

Performance statement or indicators

Checks that all required equipment is available and in working order:

• 2 Keeler crowded logMAR test books
• key card
• appropriate or recommended occlusive glasses or patches
• non-allergic tape
• anti-bacterial wipes
• tape measure
• pointer to point to letters
• relevant documentation
• light metre (optional)

P4 - environment

Competency

Ensures the test area is safe and appropriate for testing.

Performance statement or indicators

Checks the environment is:

• hazard free
• well-lit with no glare or shadows
• as free as possible from distractions and interruptions, such as noise and other children or staff ‘coming and going’
• of adequate size for 3 metre vision testing

Determines the position of the child and examiner during testing.

Accurately measures the 3 metre test distance and marks the positions of the child and the chart.

P5 - undertaking the test

Competency

Communicates effectively with the child throughout the vision screening test.

Performance statement or indicators

Demonstrates the communication skills necessary to:

• confirm the identity of the child and consent status
• gain the child’s trust and confidence
• explain in simple terms what the test involves
• give clear instructions to the child
• take account of the level of understanding, age, language and development of the child and any known disability
• overcome or minimise communication difficulties
• recognise non-compliance during screening tests and take appropriate action, recognising that this may be due to different factors (such as learning or other disability, autistic spectrum disorder)
• assess the child’s understanding and ability to complete the test prior to starting the test - check that the child is able to match or name the letters (using a practice run) - ensure that screening cards 2 and 3 are not used for this check
• give encouragement to the child throughout the test

P6 - the the Keeler crowded logMAR test

Competency

Undertakes the the Keeler crowded logMAR test correctly.

Performance statement or indicators

Carries out the the Keeler crowded logMAR test and:

• knows what action to take if the child normally wears glasses
• tests each eye separately
• ensures each eye is occluded properly and the child cannot peep with the covered eye
• uses a different Keeler logMAR booklet for each eye
• tests the right eye first using screening card S2
• always points to each letter from either below or above the crowding bars – no letters should be obscured during testing as this compromises the crowding effect
• if the child is unable to identify the first letter on the S2 screening card, moves to screening card S1 and asks the child to identify the letters on S1; move to S2 if all letters on S1 identified correctly
• correctly selects the start line
• tests all letters on start line
• proceeds to smaller or larger lines as necessary
• ensures 2 letters per line are correctly identified before testing smaller lines
• continues to test all letters on the line where errors occur
• tests all letters on 0.200 line if seen (testing can be stopped if this level of acuity is achieved)
• correctly identifies the corresponding Keeler logMAR score, and records immediately after testing each eye
• ensures the child holds their head straight during the test
• observes the child during testing for abnormal head posture such as turning or tilting the head, or attempting to ‘peep’ from behind occlusion; takes action to prevent this

P7 - record keeping

Competency

Accurately records the visual acuity score for each child.

Performance statement or indicators

Demonstrates the correct use of local documentation systems, including electronic systems as appropriate.

Accurately:

• records the result for each eye before removing the occlusion
• determines whether the acuity score meets the pass or fail criteria (whether reduced vision is suggested or not)
• records when it has not been possible to complete the screening test and the reasons why (including non-attenders)
• documents any concerns or observations from the vision test
• makes arrangements to discuss any problems experienced with the designated screening lead

P8 - reporting and referring

Competency

Correctly communicates the results of the screening test.

Performance statement or indicators

Prepares and sends correct results of the screening test to:

• parents (in accordance with local protocols)
• the designated screening lead

Initiates the referral process for children for who reduced vision is suggested (as determined by local policy).

Records and reports non-attendance.

P9.1 - other responsibilities

Competency

Complies with agreed local policies and procedures.

Performance statement or indicators

Adheres to local policy and procedures relating to:

• health and safety including infection control and hand cleanliness
• risk assessment
• consent
• safeguarding
• audit requirements

P9.2 - other responsibilities

Competency

Respects and maintains confidentiality.

Performance statement or indicators

Demonstrates understanding through only discussing the results with other health professionals unless the parent, carer or guardian has given consent for discussion with teachers.

P9.3 - other responsibilities

Competency

Recognises and reports safeguarding concerns appropriately.

Performance statement or indicators

As appropriate:

• observes the child for any signs of injury
• listens to what the child says
• documents and reports any concerns to the appropriate person