EYE HEALTH
PROGRAM
IN PUBLIC
SCHOOLS
By Lawrence J. Lawson, Jr., M.D., Robert A. McGuigan, M.D., and
Irma B. Fricke, R.N.
Department of Ophthalmology, Northwestern University ?iledical School and the Evanston Hospital, Evanston, Illinois
ADDRESS: (L.J.L., Office) 636 Church Street, Evanston, Illinois.
SPECIAL
ARTICLES
458
T THE present time there is no definite agreement among school health au-thonities on the best techniques for con-ducting an eye health program. Numerous instruments and procedures are available, the proponents of each claiming superiority over the others. In order to determine the efficiency of the eye health program in the Evanston (Illinois) Community Consoli-dated Schools, District No. 65, a study was performed from October, 1956, through September, 1958.
PROCEDURE AND METHODS
Each child was screened annually, includ-ing those already wearing glasses, by a regis-tened nurse using the self-illuminated Snellen
chart at 20 feet. The 20/30 standard was used from kindergarten to third grade, and the 20/20 standard through eighth grade. During the period of study, 15,891 children were
cx-amined by the nurses. Those with obvious ocu-lan defects (nvstagmus, strabismus, etc.) were
referred for professional examination even though they passed the visual acuity tests. Unequal vision was an indication for referral.
Teacher requests were also referred since the
teachers are able to observe a child’s behavior
throughout the school year.
All children who failed to pass the tests were rechecked before notifying the parents, who were allowed free choice of professional care. Those unable to afford private care were re-fenred to charity eye clinics.
A form was supplied to each child needing
professional care. This form was filled in by the practitioner consulted (78% were
oph-thalmologists) and returned to the school
au-thorities for tabulation. To avoid “dead
end” referrals, the school nurses investigated
those referred to determine that the parents were aware of the need for professional
examination.
RESULTS
In the study a total of 1,161 forms were returned after completion of the pnofes-sional examination. This indicates that 7.3% of the school population was found to be
in need of ocular care by the technique
em-ployed. This figure, however, represents
only those requiring care who had not
al-ready received professional advice, because
many children already wearing glasses were
able to pass the tests successfully. Of those referred in this series, 68% were given glasses. The “false” referral rate was
cx-ceedingly low, being only 4.2%. This rate
was based on the specialist’s opinion indi-cated on the completed form.
In this series, of those children examined
professionally and found to be in need of
care, 14.6% had passed previous tests. This does not imply that they were missed in prior testing, but illustrates that a group of children undergoing physical growth and development may develop myopia which becomes manifest during the year, whereas
it was not apparent previously. The follow-ing table of data from the series demon-strates the tendency for myopia and myopic
astigmatism to increase progressively with age through the grades.
The technique in this series, which did not specifically test muscle co-ordination, revealed that 1% of the total screened were reported to have some ocular muscle de-ficiency.
PERCENTAGE OF STUDENTS (BY GRADE) REFERRED,
\VHO \VEHE REPORTED TO HAVE MYOPIA OR Mvoic AsTIcrIATIsruI Grade Kindergarten 29.1 1st 35.0 2nd 46.5 3rd 65.9 4th 72.1 5th 75.2 6th 78.8 7th 82.9 8th 76.9
SPECIAL ARTICLES 459
DISCUSSION
This technique detected 7.3% of the total
grade-school population who needed
pro-fessional care and had not received it.
Gut-man1 reported that 10% of the student body
in his series had glasses and did not need
referral. This information added to the
sta-tistics of the present study implies that by
using this technique approximately 17.3%
of school children will be found in need of
ocular care. In a well controlled study it was determined that 26% of the students ideally require some form of ocular
treat-2
There is no simple yardstick to measure the status of visual function. The only method to find each child who requires vis-ual care is to arrange for a thorough and competent ocular examination for every child.3 The school program should aim only
to separate the normal from the abnormal,
and thus determine those who require a professional ocular examination. It should meet the following requirements: 1)
maxi-mum accuracy; 2) rapidity; 3) simplicity;
4) economy; 5) ease of recording; and 6) interest to the child. Excessive false refer-rals undermine the effectiveness of the pro-gram and create antagonism between the school and the parents. It also burdens the program with wasted effort by the nurses in unnecessary follow-up. The program must merit the respect of all concerned.2 The goal
must be that of a proper balance between a
high rate of correct referrals and a low per-centage of incorrect ones.
The low false referral rate in the present
study is commendable. The “high stand-ard” Snellen in the St. Louis survey’ had an over-referral rate of 7%. Foote and Cran& determined that their series with the Snel-len test for distance (20/20 standard) plus teacher judgment, produced results that are similar to those with the binocular stereo-scopic instruments, but had 7 to 14% less
incorrect referrals. The St. Louis study found 4% with some ocular muscle inco-or-dination when each child was given a com-plete ophthalmologic examination. This represents the theoretic goal.
Disturbances in ocular co-ordination are apparent prior to school age and are often associated with a decrease in the visual acuity in one eye. Thus, defective vision in one eye will expose defects related to stra-bismus in most cases, and can be detected
by simple distance-vision testing without
performing specific tests for ocular muscle co-ordination.
In a Florida survey5 70% of the ophthal-mologists did not believe the muscle bal-ance tests were important. In the same re-port, 85% referred by the telebinocular tests for muscle balance were normal! In a
sun-vey of New England ophthalmologistso 53.4% did not believe a test for heterotropia should be included.
Establishment of a plan in the school
system for determination of the ocular
health should be an essential part of the total health program. The term “visual screening” should be abandoned because it implies concern only with the visual por-tion of the ocular function, while “eye health program” expresses interest in the total performance of the eye. The early recognition of ocular defects and their prompt treatment will reduce the incidence of psychologic maladjustment and reduce the duration and expense of active ocular therapy. Those conditions which cannot be corrected and which influence the stu-dent’s scholastic performance can be ree-ognized and suitable modifications of the teaching program established.
school health authorities, an ophthalmic
consultant who is well informed on the
subject, the local medical society, and the
National Society for the Prevention of
Blindness. The effectiveness of an excellent health plan is lost unless a system of follow-up is made to insure that indicated treat-ment is obtained. Nurses and teachers
should be alert for the signs of ocular trouble in children. A reference list of
corn-plaints necessitating referral has been pub-lished.8
Terminology is important. Frequently parents interpret the results of the school screening programs as a thorough, compe-tent and complete testing procedure. It should be emphasized that only those with
the more apparent defects are detected and
referred. Thus a child’s ability to “pass”
does not completely rule out the existence of some ocular defect. Failure does not al-ways means positive abnormalities. The
term “failed eye test” should be abandoned and the expression “an ocular examination
is indicated” used in its place.
The frequency of determination of ocular health is important. At a minimum each child should be examined every 2 years,
preferably annually. Those children wear-ing glasses should also be checked.
Fre-quently they have not returned when ad-vised and are in need of further
profes-sional care. Good and Holmes’ reported
that an average of 26% of children wearing
glasses could not pass the screening tests.
Reports on the ocular status from the
phy-sician should be included in the child’s health record so that special problems may be recognized by the school health authori-ties and the teachers informed. The place-ment of a child in a school room should not be influenced by the presence or absence of glasses, but on the basis of a readily avail-able, accurate health record.
Hyperopia reaches its maximum at 6
years of age and subsequently diminishes.
If it is not excessive at that age, it should not be at any time in the future. We did
not include any specific tests for hyperopia
in our series. A study in Oregon’ reported
that of those referred for simple hyperopia, only 40% were judged to be in need of care (60% unnecessarily referred!). A brief test of near vision frequently does not select tIiose with marked hyperopia because children
have a large accommodative reserve.
The time required to examine each stu-dent is an important economic factor. Diskan’#{176} studied the various machines and determined that they required up to 6
mm-utes per student versus 1 minute for the
Snellen procedure.
Ryan” astutely warns against ophthalmic
practitioners conducting school
examina-tions because of the undue reliance on the results by the parent. In addition, the over-referrals would reflect on the practitioner.
The tests as we have used them can be
adequately performed without expensive
equipment or professionally trained person-nd. Since the aim of the program is to dis-cover those in need of ocular care, and is not diagnostic in scope,” the relationship
of the ophthalmic consultant should be strictly limited to that of an advisory ca-pacity. Under no circumstances should any individual be allowed to carry out the
ac-tual screening of school children, who could benefit financially by examining or treating those pupils who fail the tests. It is the
direct responsibility of the local school
health fficen to establish the technique
and standards for the eye health program
after appraisal of the various methods
available.
CONCLUSIONS
The efficiency of the Snellen tests as used
in the Evanston (Illinois) Public Schools was studied and compared with other
pub-lished reports. The results are satisfactory and we concur with the published reports
of the National Society for the Prevention of Blindness, which recommends the use
of the Snellen distance test plus teacher
ob-servation.1’ A program of eye health is discussed as part of the total medical health school program. An eye health program
SPECIAL ARTICLES 461
REFERENCES
1. Gutman, E. B. : School vision screening. Sight-Saving Rev., 24:212, 1956. 2. Thompson, M. A. : Vision and hearing
screening program in Prince George
County, Maryland. Am.
J.
Pub. Health,47:200, 1957.
3. Screening School Children for Visual Dc-fects. Children’s Bureau Publication No.
345. Washington, D.C., U.S. Dept. Health, Education and Welfare, 1954.
4. Foote, F. M., and Crane, M. M. : Evalua-tion of visual screening. Exceptional
Children, 20: 153, 1954.
5. Benton, C. D., Jr. : Evaluation of methods in school vision screening.
J.
FloridaM. A., 42:645, 1956.
6. Lancaster, W. B. : Standards for referral of school children for an eye examina-tion. Am.
J.
Ophth., 37:710, 1954.7. An Eye Health Program for Schools. Nat. Soc. for the Prevention of Blindness,
Publication No. 141, 1951.
8. A Guide for Eye Inspection and Testing Visual Acuity. Nat. Soc. for the
Preven-tion of Blindness, Publication No. 180, 1956.
9. Good, P., and Holmes, H. : A report on the visual screening program in public
dc-mentary school of Oak Park in 1950-1951. Illinois M.
J.,
104:128, 1953.10. Diskan, S. M. : A new screening test for school children. Am.
J.
Ophth., 39:369,1955.
11. Ryan, V. : A critical study of visual
screen-ing. Am.
J.
Optometry, 33:227, 1956.12. Washington State Medical Association: Visual screening of pre-school and school age children. Northwest Med., 57:802, 1958.
