Tagged with 'Vision Screening'

School Health Services Give Children a Bright Future

Shared with permission from the Healthy Schools Campaign.

Mary Ellen Barkman, the Medicaid Coordinator for Pinellas County Schools, the eighth largest school district in Florida, is passionate about their vision screening program. “We’re saving children’s lives,” she says.

Spot Vision ScreenerFor instance, last year, there was a new student in the district, a recent immigrant from Egypt who spoke only Arabic. Her teacher struggled to reach her and felt that beyond the language issue, the girl must have some cognitive problems. As part of her special education evaluation, she was tested with one of the district’s new Spot Vision Screeners. This quick screen showed that she had a serious muscle problem that caused triple vision. After she received the specialized prism glasses she needed and hearing aids for her hearing loss, she was at grade level within a year. “Without those screenings she may not have been able to reach her fullest potential,” Barkman says. “With help, children can have such a bright future.”

The district’s investment in spot screeners is the result of careful analysis of the district’s needs. Several years ago, school health services managers reported to Barkman that there was an issue with the district’s protocol for vision screenings. They were inefficient and time consuming, and they simply didn’t work for students who couldn’t talk or who had trouble sitting still or following instructions—often the very students who needed accurate screenings the most. The district researched many options and settled on Spot Vision Screeners, which work by taking a picture of the child’s eye and using it to screen for visual acuity, muscle imbalance and tumors. In fact, in the first year of using the screeners, the district identified a serious tumor in a student that had been missed by his primary care doctor. The machine creates a printout for parents that explains any follow-up services their child needs, and the district has formed partnerships with a vision van, local optometrists and the Lion’s Club to provide services for children who need follow-up services after screenings. And because the screeners are so easy to use, the district’s vision teams can make much more efficient use of their nurses to follow up with students who fail the screenings, rather than having to do the screenings themselves.

Barkman and the Pinellas County Schools team have woven together many different funding streams to build this unique program including Medicaid funding for the actual Spot Vision Screeners. Most of the funding comes from effective maximization of Medicaid billable services, such as Physical and Occupational Therapy, Speech Therapy, Nursing, Social Work, Psychology and Transportation and Administrative Claiming. Half of the reimbursement dollars are given to her program to spend on priorities they identify. The other half goes to operating to offset salary costs of billing providers. Because of this, Barkman works hard with her practitioners to make sure they are billing for all eligible services and maximizing Administrative Claiming reimbursement. They even developed their own electronic documentation system to make this easier. Over five years, the district has increased Medicaid revenue by $1.7 million to increase resources for students.

What’s next for Pinellas County? One priority is developing a micro-credentialing system for the one-on-one assistants who work with children with multiple challenges, to give them skills for physically transferring the children, feeding, seizure monitoring, CPR and social supports. Medicaid will support an increase in their salary after achieving the credential, which will allow them to be Medicaid-claimable health assistants. This invests Medicaid dollars directly into something that meets the needs of some of the district’s most vulnerable students.

“The key is out of the box thinking,” Barkman says, “and the box has gotten smaller.” She continues to look for ways to leverage whatever funding is available. “It’s such a blessing to be able to help a child reach their fullest potential. It’s important that people understand how important the Medicaid dollars are to that,” Barkman says.

Are Your Eye Charts Up to Date? The Evolution of Eye Charts Over the Past 150 Years

StandardizeEyeChartsEye charts are an important part of vision screening, but how did these vision screening tools look in 1915? What about 1862? The answer may surprise you.


When you think of the word “Snellen,” you probably think of Snellen’s legacy – the Snellen Eye Chart with the big "E" at the top. This chart continues to hold a place of prominence on many walls in school nurse's offices and in the hallways of medical practices today.

Snellen, a Dutch ophthalmologist, introduced the first version of his eye chart in 1862, as a way to determine visual acuity (Bennett, 1965). Recently featured on CBS Sunday Morning, Snellen's work set a new standard for vision screening. His Snellen Eye Chart and the  Snellen Ratio are still in wide use today.

Before 1862, oculists used varied and sometimes interesting methods to assess visual acuity.

When the first school setting vision screening program began in 1899, a Snellen chart was used. (Appleboom, 1985) Many versions of eye charts have come and gone over the years, and even today's version of Snellen's chart differs from the 1862 version.

But did you know that the time-honored Snellen chart is not the preferred letter chart for testing visual acuity in 2015?

Why is a Snellen chart not the preferred chart of 2015?


While Snellen charts revolutionized vision screening programs they do not adhere to national and international guidelines for standardized eye chart design (Nottingham Chaplin & Bradford, 2011). Six guidelines for standardized eye chart design are (Nottingham Chaplin & Bradford, 2011):

  1. Optotypes should be of approximate equal legibility.

  2. Each line on an eye chart should have the same number of optotypes (typically 5).

  3. Horizontal spacing between optotypes should be equal to the width of the optotypes on a line.

  4. Vertical spacing between lines should be the height of the optotypes in the next line down.

  5. The size of optotypes should progress geometrically up or down the chart by 0.1 log units (i.e., 20/32 vs. 20/30).

  6. Optotypes should be black on a white background under good lighting conditions (luminance between 80 cd/m2 and 160 cd/m2).

If you were to draw a line around the outside of the ototypes on an eye chart adhering to the national and international guidelines, you would see a chart with an inverted triangle. Conversely, if you outlined the optotypes on a chart that does not adhere to national and international guidelines, you would see a chart with a rectangle.


So, look at the eye chart yesyou use. Do you see the inverted pyramid or a rectangle?

What should we use instead of Snellen charts for Vision Screening?


Despite many state, public health, & district vision screening guidelines listing Snellen as the preferred chart for school aged children it has been recommended to use Sloan charts for vision screening.

Developed by Louise Littig Sloan, phD, and Dr. Palmer Good, of The Good-Lite Company, the preferred tests of visual acuity for school-aged children and adults use Sloan Letters as optotypes.

Sloan published information about those letters in 1959 (Sloan, 1959). which was later used by vision professionals to design a new, standardized chart in the inverted pyramid format.

It is recommended to switch from Snellen to Sloan charts to ensure an evidence-based test of visual acuity for school-aged children that meets national and international design guidelines for standardized eye charts.

School Health offers a variety of Sloan charts and cards that meet the national and international guidelines. Call us today for a consultation on the Sloan-related screening products that are available to you.

Shop Sloan & Snellen Charts & Cards>>

Request a FREE Vision Screening Consultation>>


Appelboom, T. M. (1985). A history of vision screening. The Journal of School Health, 55(4), 138-141.

Bennett, A. G. (1965). Ophthalmic test types. A review of previous work and discussions on some controversial questions. The British Journal of Physiological Optics, 22(4), 238-271.

Nottingham Chaplin, P. K., & Bradford, G. E. (2011). A historical review of distance vision screening eye charts: What to toss, what to keep, and what to replace. NASN School Nurse, 26(4), 221-227.