Screening Process

Vision First aims to evaluate and treat each child enrolled in pre-kindergarten, kindergarten, or first grade at any public school in the city of Cleveland. Children with disabilities enrolled in the Division of Special Education are not included in the program because all of these children are required to have annual, full eye examinations. The Vision First program coordinator works with the nurse or principal at each school to establish a predetermined schedule prior to the start of the academic year. The program coordinator determines the number of times the van will visit each school based on school enrollments. The program requires parental consent forms for screenings and the administration of eye drops. School nurses and classroom teachers ensure the forms are provided to each student’s caregivers.

All evaluations take place inside the Vision First mobile van, which is a customized recreational vehicle with 2 screening lanes. Vision First personnel travel to each school and set up the van in the school parking lot or near the school entrance. Evaluations are conducted by an optometrist and an ophthalmic technician (who serves as the program coordinator and van driver).

Every child undergoes an initial screening that includes an assessment of monocular near and distance visual acuity using a Snellen chart or Allen figures, stereoacuity using the Titmus test, ocular alignment using cover and alternate cover tests, testing of extraocular movements, pupils, color vision (male subjects only), and pen light inspection for external abnormalities.

Children meeting the 2003 American Academy of Pediatrics vision screening referral criteria ( Table 1 ) immediately undergo a detailed examination by the on-site optometrist. These children receive cyclopentolate 1% and/or tropicamide 1% drops, depending on their iris color. Thirty minutes later, these children undergo cycloplegic retinoscopy and indirect ophthalmoscopy of the optic nerve and posterior pole by the on-site optometrist. Visual acuity is repeated using the cycloplegic refraction for all children with visual acuity ≤20/40 (kindergarten and first grade) or <20/40 (pre-kindergarten). Results are documented in a paper chart and basic biographical information and recommendations are summarized in a database (name, date, date of birth, visual acuity, screening pass vs failure, and failure reason, if applicable). A letter is mailed to each child’s home address with the results of the child’s evaluation (pass, failure, or unable to complete).

All children with a refractive error that meets prescription guidelines ( Table 2 ) are provided a free pair of spectacles. For the first 5 years, children were simply given a prescription and a voucher for a free pair of spectacles. Since academic year 2007–2008, children select a spectacle frame from up to 60 options prior to leaving the van. The program coordinator orders the glasses and a local optician visits each school to adjust the glasses to fit each child. The glasses are then given to the parents.

Children were diagnosed with amblyopia if either the visual acuity, with cycloplegic correction, was <20/40 in pre-kindergarten children or ≤20/40 in older children or there was a 2-line difference between each eye. Children were diagnosed with strabismus if there was any manifest vertical or horizontal deviation. Children were not classified as having strabismus if they had a phoria.

Referral Process

All children who meet the 2003 American Academy of Pediatrics vision screening referral criteria ( Table 1 ) are referred to a pediatric ophthalmologist for follow-up care. A list of all pediatric ophthalmologists, including private practice, academic, and county hospital–affiliated ophthalmologists, in the Cleveland metropolitan area is included in the referral letter. In addition, school nurses are provided with a list of all children at their school who are referred to pediatric ophthalmology. The program coordinator calls the parents of each child who is referred to pediatric ophthalmology to determine if the child had follow-up care and to answer any questions. The program coordinator works with the school nurse to ensure that all children who fail the initial screening are seen the following academic year if they are still enrolled in pre-kindergarten, kindergarten, or first grade.

Statistical Analysis

Statistical analyses were conducted using SAS Version 9.3 (SAS Institute Inc, Cary, North Carolina, USA). Trend analysis was conducted using the Cochran-Armitage Trend Test with a P value less than .05 considered statistically significant.

Rates of amblyopia and strabismus among first grade students were analyzed to determine if there was a decrease in prevalence rates over time. Pre-kindergarten and kindergarten students were eligible for repeat examinations, so comparing the overall prevalence rates of amblyopia or strabismus by year would result in the comparison of nonunique populations. Instead, we selected the cohort of first grade students in order to have unique groups for the statistical analysis. The first grade was chosen because first graders make up 44% of all students examined and because these students had the opportunity to undergo screenings during the 2 prior years.

The proportion of students screened was calculated by dividing the number of students screened by the total Cleveland Public Schools enrollment for grades pre-kindergarten, kindergarten, and first grade. This calculation is an estimate because enrollment data include the approximately 150 students in the Division of Special Education although these students are excluded from Vision First. Enrollment data were available for the last 6 academic years from 2008–2009 to 2013–2014.