Pediatric Vision Screening Guidance during the COVID-19 Pandemic

American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee

The sole purpose of this document is to provide guidance on conducting vision screening as part of regular preventative care activities in programs such as Early Head Start, Head Start, and in schools.  This document is based on the evidence available at the time of publishing but is not a substitute for sound judgment and public health guidelines in place and with which schools should comply.  

 The American Academy of Pediatrics (AAP), through its AAP guidance on school re-entry focusing on mitigating COVID-19 risks, and the federal Center for Disease Control (CDC) with its  back to school guidelines, serve as important references to help schools and other educational programs adjust to changing needs during the COVID-19 pandemic.

Vision screening remains an important component of regular pediatric preventative health care and should continue during the COVID-19 pandemic whenever possible. Vision screening can identify children who may otherwise have no outward symptoms of subtle ocular abnormalities or blurred vision that, if untreated, may lead to permanent vision loss or impaired academic performance in school. Fortunately, vision screening activities require only a brief exposure to a child. Such interactions in which social distancing of less than 6 feet cannot be maintained typically fall within the CDC finding that the use of facial coverings and limiting of such contacts to less than 15 minutes are effective in reducing the risk of infection transmission.   In addition to wearing masks, handwashingstaying home when sick and careful cleaning and disinfection  are other important principles to follow when vision screening. 

Masks. It is understood face coverings may be challenging for some children to wear. Several articles are accessible on-line that provide further insights into helping young children wear masks.

In addition to regular face masks, eye safety goggles/full face plastic masks may also be recommended by public health authorities.

Cleaning and Disinfection. During visual acuity-based screening sessions, wipe clean any surfaces touched by the child (e.g., plastic occluders, occluder glasses and matching response cards) between each use. Visual acuity charts should be wiped clean before and after each screening session to protect the screener.

Consider using disposable matching cards and eye occluders or individual adhesive eye patches to cover the non-tested eye during vision screening.  To complete an accurate screening assessment, care should always be taken to ensure the child cannot peak around the cover during any point of the screening.

During electronic Instrument-based screening sessions wipe clean any surfaces on the units touched by individual screeners before and after each screening session. Instrument-based screening is performed at a testing distance of about one meter but lasts only a few seconds.  This method of screening may be permitted by local health authorities as long as masks are worn by the screener and whenever possible, the child as well.

Modify Screening areas and sessions

Follow guidelines for social distancing as much as possible before, during and after screening sessions, being careful to wear masks whenever social distancing cannot be maintained.   

Vision screening performed either through or around a plexiglass partition may be feasible.  The partition can act as a clear barrier when social distancing for instrument-based screening cannot be maintained. (Some instrument models may function better than others when focused through such partitions.) 

Administering vision screening sessions outdoors in a shaded area may be feasible, especially for visual acuity screening.  However, a young child’s pupil size may be too small in daylight for electronic vision screening devices to function properly.

Any optional vision screening tests (eg color vision testing, near visual acuity testing and stereoacuity testing) should be avoided in order to minimize screening time. While the covers of color vision books can be wiped clean, the hard-cardboard pages may not be.  If color vision testing is indicated, children should not touch the pages directly.  Good alternatives to finger pointing may be the use of a pencil eraser or a fine paint brush.  Such pointers should be wiped clean between each use.

Outside Vision Screeners visiting schools. If a school or program designates outside individuals as essential workers to continue vision screening sessions, public health measures should be followed prior to entry into the school, such as: hand washing, wearing masks, symptom checking and perhaps separating visits by a single individual to separate schools by several days.   

Regular vision screening routines in schools or programs may need to be deferred whenever public health advisories recommend that children remain at home. However, vision screening should still be conducted in a pediatrician’s office as part of regular well child visits. The American Academy of Pediatrics strongly encourages families to schedule and keep regular well child checks as the best way to promote good overall health throughout the coronavirus pandemic.  

 While home vision screening tests with cell phone or laptop apps, or with visual acuity cards, are available for parents, none have been evaluated for their reliability in the home setting. If a parent suspects a vision or eye problem, a pediatrician or pediatric eye care provider should be contacted to examine the child.

Conclusion.  Vision screening serves to identify children who may otherwise have no outward symptoms of subtle ocular abnormalities or blurred vision that, if untreated, may lead to permanent vision loss or impaired academic performance in school. Personal prevention practices , including handwashingcloth face coverings, staying home when sick, and careful cleaning and disinfection are important principles to follow to mitigate transmission risk during vision screening. While school and community vision screening routines may need to be deferred in some areas, vision screening should still be conducted as part of the regular well child visits in a pediatrician’s office. When ocular concerns exist, with or without a vision screening, a thorough examination by a pediatric eye care provider is recommended.