Remote visual screening education for teachers: a prospective longitudinal interventional study

ABSTRACT

Objective:  We aimed to assess the effectiveness of a remote training program designed to improve the ability of education professionals to conduct visual screening in children aged 2-5 years.

Methods:  This prospective longitudinal interventional study included 42 early childhood education professionals from a daycare center in São Paulo, Brazil. Participants completed a remote training program consisting of video-based lessons on eye health and visual screening techniques. Pre- and post-training assessments were conducted to evaluate changes in participants’ knowledge, confidence, and practical skills related to visual screening. Statistical analyses were performed using the McNemar-Bowker and Wilcoxon tests.

Results:  Post-training assessments demonstrated statistically significant improvements in participants’ knowledge, confidence, and ability to perform and explain visual screening procedures, including the use of the LEA Symbols chart and recognition of conditions such as amblyopia (p<0.001).

Conclusion:  The remote training program improved the preparedness of education professionals to conduct visual screening in young children and may enhance their ability to identify children requiring referral for further ophthalmologic evaluation. This approach may be adapted for broader implementation within eye health promotion initiatives. Study limitations include the absence of a control group, lack of long-term follow-up, use of a single-center convenience sample, and the absence of comparisons with alternative teaching methods.

Keywords:
Vision screening; Telemedicine; Amblyopia; Early diagnosis; Education, preschool; Visual acuity tests; Child, preschool; Surveys and questionnaires

Highlights

Remote training significantly improved teachers' knowledge of pediatric eye diseases.

Educators were successfully trained to perform visual screening using the LEA Symbols chart.

Distance education increased teachers' confidence in identifying visual disorders.

Remote training may facilitate the early detection of amblyopia in preschool settings.

In Brief

A remote training program for early childhood educators significantly improved their knowledge, practical skills, and confidence in conducting pediatric visual screening. The findings suggest that distance education can effectively equip nonophthalmologist educators to identify early visual disorders in children aged 2–5 years.

INTRODUCTION

From early childhood, adequate vision is essential for children's cognitive, social, and educational development, enabling participation in both formal and informal learning environments.(¹,²) According to the World Health Organization (WHO), at the launch of the VISION 2020 initiative, approximately 19 million children younger than 15 years were living with visual impairment, including 1.4 million with irreversible blindness. Nearly half of these cases were considered preventable, with refractive errors and amblyopia representing the leading causes.(²-⁶)

A global systematic review and meta-analysis on the prevalence of amblyopia estimated that approximately 99.2 million individuals were affected worldwide in 2019, with projections suggesting an increase to 221 million by 2040.(⁷) Studies have also shown that the prevalence of amblyopia in Latino children may be higher than that in children from other ethnic groups.(⁸,⁹) In a multiethnic study, amblyopia was detected in 2.6% of Hispanic/Latino children and 1.5% of African American children aged 30-72 months.(¹⁰) Several factors may contribute to the higher prevalence observed in these populations, including limited access to eye care services, underutilization of available services, insufficient public eye health policies, socioeconomic barriers, limited family support, reduced awareness of the importance of early detection, and shortages of trained professionals.(¹-⁴)

Visual screening in children is performed to identify reduced visual acuity and risk factors that may impair visual development.(¹⁰) In this context, community settings such as daycare centers, preschools, schools, and community health groups provide valuable opportunities for screening programs aimed at detecting visual impairment and other ocular abnormalities. These screenings may be conducted by healthcare professionals, education professionals, or trained laypersons. Previous studies have demonstrated that appropriately trained non-ophthalmologists can perform visual screening with acceptable accuracy.(¹¹-¹³)

In Brazil, despite public visual screening policies implemented through the Brazilian Public Health System (SUS - Sistema Único de Saúde) since the last century,(¹⁴-¹⁸) school-based eye health programs remain limited.(¹⁹) One major challenge is the lack of standardized training programs for education professionals responsible for implementing visual screening in schools. To date, no unified national training program has been developed to reach remote regions or to provide comprehensive eye health screening beyond visual acuity assessment alone.(¹⁰) Furthermore, most existing programs in Brazil have focused primarily on children older than 6 years.(²⁰)

In this context, the present research aimed to develop a distance education program to train education professionals to implement an eye health program for children aged 2-5 years, incorporating current evidence and extending beyond visual acuity assessment alone. Distance learning enables educational content to be delivered through digital platforms, which expanded significantly during the COVID-19 pandemic.(²¹,²²)

Additionally, a recent cluster-randomized controlled trial of school-based vision screening highlighted the importance of continued vision care and access to corrective eyewear, particularly for children from socioeconomically disadvantaged backgrounds. The study also emphasized the need for further intervention studies evaluating screening strategies.(²³)

The proposed virtual training program is intended to facilitate earlier referral of children with suspected visual disorders while improving screening quality and scalability. This approach may support broader implementation across diverse settings and contribute to the development of a standardized, evidence-based eye health program.(²⁴)

OBJECTIVE

We aimed to evaluate a virtual training protocol for education professionals designed to improve knowledge and skills related to pediatric eye care. The program was developed to train participants in performing visual acuity screening in children aged 2-5 years and assess the effectiveness of the intervention. The training content and assessment instruments were based on clinical guidelines and were intended to support the implementation of protocols for monitoring visual development disorders in preschool- and school-aged children.

METHODS

This prospective longitudinal interventional study included 42 early childhood education professionals from a daycare center affiliated with the São Paulo municipal government, the Aglaezinha Early Childhood Education Center, operated by the non-governmental organization Associação Ponto de Luz.

All study procedures were conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of the Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (CAAE: 78717324.0.0000.0068; #6.823.601). Written informed consent was obtained from all participants prior to study participation. Eligible participants were selected according to predefined inclusion and exclusion criteria.

The inclusion criteria were: employment as an early childhood education professional at the Ponto de Luz daycare center, which provides care for children aged 2-5 years; availability and willingness to participate in the training program and visual screening activities; recommendation by the institutional coordinator or voluntary enrollment; and provision of written informed consent.

The research team developed educational videos focused on pediatric eye health to train education professionals working with children aged 2-5 years.

The video content emphasized the importance of ophthalmologic screening in early childhood and was designed to support participants in conducting visual screening assessments, recognizing common eye disorders, identifying warning signs, and referring children requiring further evaluation.

The educational materials were developed in a concise and accessible format and covered the following topics: basic eye anatomy; the importance of visual screening in early childhood; recommended school-based eye health screening practices for this age group; recognition of warning signs suggestive of visual disorders; and visual acuity assessment.

The videos were made available free of charge through a secure virtual platform compliant with the Brazilian General Data Protection Law. Participants were able to access the material at any time and from any location over a 1-month period.

Education professionals completed online questionnaires before and after exposure to the educational videos to assess changes in knowledge related to pediatric eye health issues and visual screening procedures (Table 1). Additionally, participants completed a pre-training questionnaire regarding their perceptions of virtual learning, satisfaction, and expectations related to the educational content.

Table 1
Eye health knowledge assessment questionnaire

1. Do you know the main eye conditions that can cause vision loss in children?		() No	() A little	() Yes
2. Do you understand the importance of vision screening for children aged 2–5 years?		() No	() A little	() Yes
3. Do you know what myopia is?		() No	() A little	() Yes
4. Do you know what hyperopia is?		() No	() A little	() Yes
5. Do you know what astigmatism is?		() No	() A little	() Yes
6. Do you know what amblyopia is?		() No	() A little	() Yes
7. Do you know what strabismus is?		() No	() A little	() Yes
8. Do you know the risk factors for amblyopia that may be observed in children?		() No	() A little	() Yes
9. Do you know the correct procedure for performing visual acuity testing using the LEA Symbols chart?		() No	() A little	() Yes
10. Do you currently feel capable of performing visual acuity testing using the LEA Symbols chart?		() No	() A little	() Yes
11. Do you know which visual acuity test results obtained using the LEA Symbols chart require referral to a specialist?		() No	() A little	() Yes
12. Regarding visual acuity testing using the LEA Symbols chart, do you know how to:		() No	() A little	() Yes (For each item)
	a) Explain the test to the child?
	b) Position the chart on the wall at the appropriate distance using measuring tools?
	c) Proceed if the child already wears glasses?
	d) Ensure that one eye is properly occluded during testing?
	e) Correctly identify the symbols on the chart?
13. Do you feel able to recognize the following ocular abnormalities?		() No	() A little	() Yes (For each item)
	a) Red eye
	b) Eye deviation (strabismus)
	c) Abnormal or asymmetric red reflexes
	d) Involuntary eye movements
	e) Differences in eye appearance between the two eyes (e.g., asymmetry in size)
14. Do you currently feel confident explaining abnormal test findings to the child's guardians?		() No	() A little	() Yes (For each item)
15. Do you currently feel confident explaining abnormal test findings to the child?		() No	() A little	() Yes (For each item)

A synchronous virtual meeting between the research team and the education professionals was also conducted through an online platform to clarify questions, provide additional guidance, and collect participant feedback and suggestions.

Data analysis

Comparisons of the distribution of responses for each knowledge item before and after training were performed using the McNemar-Bowker test. To quantify knowledge acquisition, composite scores were generated as described in the Results section, and pre- and post-training scores were compared using the Wilcoxon signed-rank test for paired samples. Statistical significance was set at p<0.05. All statistical analyses were conducted using SPSS software, version 21.

RESULTS

The study included 42 education professionals, all of whom were women, with a mean age of 43 years. Most participants held a higher education degree (95.2%), and the majority were teachers (78.6%). All participants completed the training program and both the pre- and post-training questionnaires. None of the participants had previously participated in similar training programs (100%) (Table 2).

Table 2
Participant characteristics

Variable			n (%)
Role
		Assistant	3 (7.1)
		Teacher	33 (78.6)
		Coordinator	3 (7.1)
		Director	3 (7.1)
Sex
Female			42 (100.0)
Education level
		Incomplete higher education	2 (4.8)
		Complete higher education	40 (95.2)
Previous participation in similar training programs
		No	42 (100.0)
Age, years Median (range)			43 (27–60)

Table 3 demonstrates the impact of the training program on the knowledge and skills of education professionals regarding visual screening in children. Before training, many participants reported limited knowledge of common pediatric eye disorders, the importance of vision screening, and conditions such as myopia, hyperopia, and astigmatism. Following the intervention, the proportion of participants who reported knowing how to perform and explain visual acuity testing using the LEA Symbols chart increased from 4.8% to 47.6% (p<0.001). Similar improvements were observed in participants’ ability to recognize common visual disorders and manage situations involving children who already wore corrective glasses.

Table 3
Comparison of education professionals before and after training

Item		Pre-training		Post-training		p value*
		n	%	n	%
Do you know the main eye conditions that can cause vision loss in children?
	No	24	57.1	1	2.4	0.001
	A little	17	40.5	35	83.3
	Yes	1	2.4	6	14.3
Do you understand the importance of vision screening in children aged 2–5 years?
	No	14	33.3	2	4.8	0.002
	A little	23	54.8	26	61.9
	Yes	5	11.9	14	33.3
Do you know what myopia is?
	No	12	28.6	1	2.4	0.004
	A little	16	38.1	27	64.3
	Yes	14	33.3	14	33.3
Do you know what hyperopia is?
	No	28	66.7	11	26.2	0.002
	A little	7	16.7	22	52.4
	Yes	7	16.7	9	21.4
Do you know what astigmatism is?
	No	21	50.0	9	21.4	0.001
	A little	6	14.3	25	59.5
	Yes	15	35.7	8	19.0
Do you know what amblyopia is?
	No	34	81.0	10	23.8	<0.001
	A little	4	9.5	27	64.3
	Yes	4	9.5	5	11.9
Do you know what strabismus is?
	No	10	23.8	2	4.8	0.037
	A little	16	38.1	16	38.1
	Yes	16	38.1	24	57.1
Do you know which risk factors can be observed in children?
	No	35	83.3	11	26.2	<0.001
	A little	6	14.3	29	69.0
	Yes	1	2.4	2	4.8
Do you know the correct procedure for performing visual acuity testing using the LEA Symbols chart?
	No	36	85.7	5	11.9	<0.001
	A little	4	9.5	17	40.5
	Yes	2	4.8	20	47.6
Do you currently feel capable of performing visual acuity testing using the LEA Symbols chart?
	No	30	71.4	5	11.9	<0.001
	A little	7	16.7	31	73.8
	Yes	5	11.9	6	14.3
Do you know which results obtained during visual acuity testing using the LEA Symbols chart require referral to a specialist?
	No	36	85.7	8	19.0	<0.001
	A little	5	11.9	27	64.3
	Yes	1	2.4	7	16.7
Do you know how to explain the visual acuity test to the child?
	No	31	73.8	5	11.9	<0.001
	A little	7	16.7	26	61.9
	Yes	4	9.5	11	26.2
Do you know how to position the chart on the wall at the appropriate distance using measuring tools?
	No	30	71.4	5	11.9	<0.001
	A little	6	14.3	19	45.2
	Yes	6	14.3	18	42.9
Do you know what to do if the child already wears glasses?
	No	29	69.0	3	7.1	<0.001
	A little	7	16.7	18	42.9
	Yes	6	14.3	21	50.0
Do you know how to ensure that one of the child's eyes is properly covered during the test?
	No	29	69.0	2	4.8	<0.001
	A little	2	4.8	16	38.1
	Yes	11	26.2	24	57.1
Do you know how to point to the symbols on the chart?
	No	28	66.7	5	11.9	<0.001
	A little	3	7.1	10	23.8
	Yes	11	26.2	27	64.3
Red eye
	No	15	35.7	3	7.1	0.003
	A little	14	33.3	14	33.3
	Yes	13	31.0	25	59.5
Eye deviation (strabismus)
	No	22	52.4	5	11.9	0.001
	A little	12	28.6	18	42.9
	Yes	8	19.0	19	45.2
Different red reflexes (different brightness)
	No	27	64.3	4	9.5	<0.001
	A little	8	19.0	24	57.1
	Yes	7	16.7	14	33.3
Involuntary eye movements
	No	27	64.3	11	26.2	0.001
	A little	7	16.7	16	38.1
	Yes	8	19.0	15	35.7
Eyes with asymmetry in appearance or size
	No	17	40.5	3	7.1	0.005
	A little	16	38.1	21	50.0
	Yes	9	21.4	18	42.9
Do you currently feel confident explaining abnormal test findings to the child's guardians?
	No	22	52.4	10	23.8	0.009
	A little	12	28.6	23	54.8
	Yes	8	19.0	9	21.4
Do you currently feel confident explaining abnormal test findings to the child?
	No	24	57.1	7	16.7	0.002
	A little	12	28.6	25	59.5
	Yes	6	14.3	10	23.8

• ^*
  McNemar–Bowker test.

Table 4 presents the scoring system used to quantify participants’ knowledge and confidence before and after the ophthalmologic training program. Responses were scored as 0 for "No," 1 for "A little," and 2 for "Yes," with higher scores indicating greater knowledge or confidence. Four domain-specific scores were calculated: knowledge of eye disorders (0-22 points), knowledge of the use of the LEA Symbols chart (0-10 points), ability to identify ocular abnormalities (0-10 points), and confidence in explaining identified eye abnormalities (0-4 points). The total score ranged from 0 to 46 points and was calculated as the sum of all domain scores.

Table 4
Questions used to construct the knowledge and confidence scores

Knowledge Score on eye disorders		Knowledge Score on the use of the LEA symbols chart	Knowledge Score on recognition of ocular abnormalities	Confidence Score in managing detected ocular abnormalities
1. Do you know the main eye conditions that can cause visual impairment in children?	7. Do you know what strabismus is?	1. Do you know how to explain the visual acuity test to the child?	1. Do you know how to recognize red eye?	1. Do you currently feel confident explaining abnormal test findings sto the child's guardians?
2. Do you understand the importance of vision screening for children aged 2–5 years?	8. Do you know which risk factors for amblyopia can be observed in children?	2. Do you know how to position the chart on the wall at the correct distance using measurement tools?	2. Do you know how to recognize eye deviation (strabismus)?	2. Do you currently feel confident explaining abnormal test findings to the child?
3. Do you know what myopia is?
4. Do you know what hyperopia is?	9. Do you know the correct procedure for performing visual acuity testing using the LEA Symbols chart?	3. Do you know what to do if the child is already wearing glasses?	3. Do you know how to recognize abnormal red reflexes (differences in brightness)?
5. Do you know what astigmatism is?	10. Do you currently feel capable of performing visual acuity testing using the LEA Symbols chart?	4. Do you know how to ensure that one of the child's eyes is properly covered during the test?	4. Do you know how to recognize involuntary eye movements?
6. Do you know what amblyopia is?	11. Do you know which results obtained from visual acuity testing using the LEA Symbols chart require referral to a specialist?	5. Do you know how to point to the symbols on the chart?	5. Do you know how to recognize asymmetry between the eyes?

Table 5 presents the comparison of pre- and post-training scores among education professionals, reflecting changes in knowledge and skills following the intervention. Prior to training, participants demonstrated limited knowledge and practical ability in using the LEA Symbols chart and identifying common eye conditions. After the training, there was a substantial improvement across all assessed domains, with significantly higher scores in knowledge, practical skills, and confidence. In addition to improved knowledge and skills, participants reported increased confidence in performing visual screening and communicating findings to both children and their guardians.

Table 5
Pre- and post-training comparison of knowledge scores among education professionals

Variable	Pre-training			Post-training			p value*
	Median	Q1	Q3	Median	Q1	Q3
Knowledge Score on Ocular Problems	5.50	1.75	10.00	11.00	11.00	14.25	<0.001
Knowledge Score on LEA Symbols Chart Use	0.50	0.00	4.25	8.00	5.00	9.00	<0.001
Knowledge Score on Recognition of Ocular Abnormalities	3.00	1.00	5.25	6.00	5.00	8.25	<0.001
Confidence Score in Actions upon Detecting Ocular Abnormalities	0.00	0.00	2.00	2.00	1.00	2.25	0.006
Overall Score	11.00	3.00	20.25	26.50	23.00	31.50	<0.001

• ^*
  Wilcoxon signed-rank test for paired samples.

Table 6 summarizes participants’ feedback regarding the training program. Overall, 97.7% of participants reported an improvement in their visual screening knowledge, while 100% reported enhanced understanding of eye health in school settings and improved ability to recognize warning signs of visual disorders.

Table 6
Participants’ evaluation of the training program

Variable		n (%)
Eye screening in early childhood
	Knowledge improved
	Neutral	1 (2.3)
	Agree	24 (55.8)
	Strongly agree	18 (41.9)
The distance learning method was effective
	Neutral	6 (14.0)
	Agree	22 (51.2)
	Strongly agree	15 (34.9)
Rating of course content and presentation		4.3±0.8
Eye health in the pediatric school environment
Knowledge improved
	Neutral	0 (0)
	Agree	28 (65.1)
	Strongly agree	15 (34.9)
The distance learning method was effective
	Neutral	4 (9.3)
	Agree	26 (60.5)
	Strongly agree	13 (30.2)
Rating of course content and presentation of the class		4.3±0.8
Visual acuity
Knowledge improved
	Neutral	2 (4.7)
	Agree	25 (58.1)
	Strongly agree	16 (37.2)
The distance learning method was effective
	Neutral	4 (9.3)
	Agree	23 (53.5)
	Strongly agree	16 (37.2)
Rating of course content and presentation		4.3±0.8
Eye
Knowledge improved
	Neutral	0 (0.0)
	Agree	28 (65.1)
	Strongly agree	15 (34.9)
The distance learning method was effective
	Neutral	0 (0.0)
	Agree	29 (67.4)
	Strongly agree	14 (32.6)
Rating of course content and presentation		4.6±0.5
Recognition of warning signs
Knowledge improved
	Neutral	0 (0.0)
	Agree	27 (62.8)
	Strongly agree	16 (37.2)
The distance learning method was effective
	Neutral	0 (0.0)
	Agree	26 (60.5)
	Strongly agree	17 (39.5)
Rating of course content and presentation		4.5±0.5

Regarding the effectiveness of the distance learning approach, 86.0% of participants considered it suitable for delivering early childhood vision screening training, while 100% agreed that it was effective for improving understanding of eye conditions and recognition of warning signs. Overall, the training program received high satisfaction ratings, with mean scores ranging from 4.3 to 4.6 out of 5.

DISCUSSION

All teachers should be educated about the role of vision in learning.(²⁵) This information can be delivered through structured teacher training and continuing education programs. To the best of our knowledge, this is the first study to evaluate the effectiveness of video-based training materials developed by our research group for educating school professionals in pediatric visual screening. We observed a statistically significant improvement across all knowledge domains assessed in our questionnaire following the remote training intervention.

Health promotion aims to improve population health outcomes by empowering communities and creating supportive environments for health. In this context, strengthening the capacity of individuals who are in close contact with potential patients is a key component of effective health promotion strategies. In the present study, most participants were teachers (78.6%), reflecting their close and continuous contact with school-aged children. However, previous studies have shown that teachers often do not associate symptoms suggestive of visual impairment with underlying ocular pathology.(²⁶) In contrast, evidence also indicates that, with appropriate in-person training, teachers can effectively perform visual acuity assessments, achieving performance comparable to that of eye care professionals.(²⁷)

None of the participants had previously received training in eye health awareness, and they lacked the knowledge and tools required to recognize early signs of visual impairment. This gap in awareness may negatively affect children's learning and overall development. Despite efforts by the Brazilian public health system to implement vision screening programs in public schools, the integration of eye health education into teacher training curricula remains limited. This underscores the need for comprehensive initiatives to educate teachers and strengthen early detection and intervention for visual disorders in Brazilian classrooms.(²⁸,²⁹)

Distance learning has the potential to substantially improve access to training, particularly in low-income settings and regions with limited resources.(³⁰) By delivering educational content through remote platforms, knowledge can be disseminated without requiring professionals to travel physically to schools, which may be impractical at scale. Furthermore, with appropriate training, teachers may be able to identify visual problems more accurately, potentially reducing unnecessary referrals and avoiding additional burden on healthcare systems.(³¹)

In our study, more than 90% of participants considered distance learning effective across all assessed domains, with the exception of early childhood visual screening, which received an approval rate of 86%. The slightly lower approval in this domain may be related to the requirement for more hands-on application of screening procedures using tools that were initially unfamiliar to educators. However, overall acceptance of the distance learning approach was high. This finding is particularly relevant, as distance learning may help reduce educational disparities in underserved communities by improving access to training materials and standardizing knowledge delivery across settings.

This study has some methodological limitations that should be considered when interpreting the findings. The absence of a control group limits the ability to attribute observed improvements solely to the training intervention, as no comparison was made with untrained participants. Additionally, the use of convenience sampling from a single center may restrict the generalizability of the results to other educational settings or populations. The outcomes were based on self-reported measures of knowledge and confidence, which may be subject to social desirability bias. Furthermore, the study did not include long-term follow-up, limiting the assessment of knowledge retention over time. Clinical and practical outcomes, such as the impact of training on the identification or referral of children with visual impairments, were also not evaluated. Although the study was not designed to compare the video-based training with alternative instructional methods, these limitations should be considered when interpreting the results.

CONCLUSION

This study demonstrated that a remote training program significantly improved the knowledge, skills, and confidence of education professionals in conducting visual screening for children aged 2-5 years. The training enhanced participants’ understanding of common ocular conditions, including amblyopia, myopia, hyperopia, and astigmatism, and increased their confidence in performing and explaining visual acuity testing using the LEA Symbols chart. By strengthening educators’ competencies in visual screening, the broader implementation of such programs may improve the identification of children requiring referral for further ophthalmologic evaluation. However, the direct impact on clinical outcomes was not assessed in this study.

The results indicate that well-structured remote education can be an effective and feasible approach for training non-ophthalmic professionals in eye health screening, particularly in regions with limited access to specialized care. Its high acceptability supports the scalability of this distance learning approach and its potential to reduce disparities in training access across different settings.

Given the increasing burden of visual impairment, especially in underserved populations, wider implementation of such programs may contribute to more timely referrals and earlier detection of visual problems, thereby reducing the risk of avoidable developmental consequences. Future studies should evaluate the scalability of this training model and its integration into broader educational and public health systems, as well as its impact on real-world clinical outcomes.

DATA AVAILABILITY

The data supporting the findings of this study are included within the manuscript.

ACKNOWLEDGMENT

This work was supported by ZEREZES, which generously donated the glasses for the children.

REFERENCES

• ¹ World Health Organization (WJO). World report on vision. Noncommunicable Diseases, Rehabilitation and Disability (NCD), Sensory Functions, Disability and Rehabilitation (SDR). Geneva: WHO; 2019.
• ² Steinmetz JD, Bourne RR, Briant PS, Flaxman SR, Taylor HR, Jonas JB, et al.; GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021;9(2):e144-60.
• ³ Fricke TR, Tahhan N, Resnikoff S, Papas E, Burnett A, Ho SM, et al. Global Prevalence of Presbyopia and Vision Impairment from Uncorrected Presbyopia: Systematic Review, Meta-analysis, and Modelling. Ophthalmology. 2018;125(10):1492-9.
• ⁴ Yekta A, Hooshmand E, Saatchi M, Ostadimoghaddam H, Asharlous A, Taheri A, Khabazkhoob M. Global Prevalence and Causes of Visual Impairment and Blindness in Children: A Systematic Review and Meta-Analysis. J Curr Ophthalmol. 2022;34(1):1-15. Review.
• ⁵ Burton MJ, Ramke J, Marques AP, Bourne RR, Congdon N, Jones I, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489-551.
• ⁶ Backman H. Children at risk of developing amblyopia: when to refer for an eye examination. Paediatr Child Health. 2004;9(9):635-7.
• ⁷ Fu Z, Hong H, Su Z, Lou B, Pan CW, Liu H. Global prevalence of amblyopia and disease burden projections through 2040: a systematic review and meta-analysis. Br J Ophthalmol. 2020;104(8):1164-70.
• ⁸ Multi-ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the multi-ethnic pediatric eye disease study. Ophthalmology. 2008; 115(7):1229-36.e1.
• ⁹ Ying GS, Maguire MG, Cyert LA, Ciner E, Quinn GE, Kulp MT, et al.; Vision In Preschoolers (VIP) Study Group. Prevalence of vision disorders by racial and ethnic group among children participating in head start. Ophthalmology. 2014;121(3):630-6.
• ¹⁰ Hutchinson AK, Morse CL, Hercinovic A, Cruz OA, Sprunger DT, Repka MX, et al.; American Academy of Ophthalmology Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel. Pediatric Eye Evaluations Preferred Practice Pattern. Ophthalmology. 2023;130(3):222-70.
• ¹¹ Sabri K, Easterbrook B, Khosla N, Davis C, Farrokhyar F. Paediatric vision screening by non-healthcare volunteers: evidence based practices. BMC Med Educ. 2019;19(1):65.
• ¹² Rajalakshmi AR, Rajeshwari M. Efficacy of Bruckner's test for screening of refractive errors by non-ophthalmologist versus ophthalmologist: A comparative study. Middle East Afr J Ophthalmol. 2020;26(4):185-8.
• ¹³ Bruckner R. Exakte Strabismus diagnostik bei 1/2-3 jahrigen Kindern mit einem einfachen Verfahren, dem "Durchleuchtungstest.". Ophthalmologica. 1962;144(3):184-98.
• ¹⁴ BRASIL. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Passo a passo. PSE Programa Saúde na Escola: tecendo caminhos da intersetorialidade. Brasília: Ministério da Saúde; 2011. 46 pp.
• ¹⁵ Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Diretrizes de atenção à saúde ocular na infância: detecção e intervenção precoce para prevenção de deficiências visuais. Brasília (DF): Ministério da saúde, 2016. 44p.
• ¹⁶ Brasil. Ministério da Saúde. Programa Saúde na Escola. Brasília (DF): Ministério da Saúde; 2020.
• ¹⁷ Núcleo de Educação em Saúde Coletiva (NESCON). Programa Saúde na Escola: Promoção da saúde ocular e identificação de educandos com possíveis sinais de alteração. Belo Horizonte: NESCON; 2020. 46 p.
• ¹⁸ Fundo de Solidariedade e Desenvolvimento Social e Cultural de São Paulo (FUSSESP). Manual da comunidade escolar saúde ocular. Visao do futuro. São Paulo: FUSSESP; 2009.
• ¹⁹ Fernandes LA, Franzoi MA, Köptcke LS. A saúde ocular e o Programa Saúde na Escola: uma pesquisa documental. Saúde em Debate2024;46(Spec 3):213-26.
• ²⁰ Jonas DE, Amick HR, Wallace IF, Feltner C, Vander Schaaf EB, Brown CL, et al. Vision screening in children aged 6 months to 5 years: Evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;318(9):845-58.
• ²¹ Woolliscroft JO. Innovation in response to the COVID-19 pandemic crisis. Acad Med. 2020;95(8):1140-2.
• ²² Stults CD, Liang SY, Wilcox J, Nyong'o OL. Amblyopia Care Trends Following Widespread Photoscreener Adoption. JAMA Ophthalmol. 2024;142(3):188-97.
• ²³ Nishimura M, Wong A, Maurer D. Continued care and provision of glasses are necessary to improve visual and academic outcomes in children: experience from a cluster-randomized controlled trial of school-based vision screening. Can J Public Health. 2024;115(4):688-98.
• ²⁴ Donahue SP. How often are spectacles prescribed to "normal" preschool children? J AAPOS. 2004;8(3):224-9.
• ²⁵ Wilhelmsen GB, Felder M. Learning is visual: why teachers need to know about vision. IntechOpen; 2021. https://doi.org/10.5772/intechopen.93546
  » https://doi.org/10.5772/intechopen.93546
• ²⁶ Cavalcanti Junior J, Rebouças CB, Dantas RA, Pagliuca LM. Teachers’ knowledge about signs/symptoms which indicate low visual acuity in students. J Nurs UFPE on Line. 2015;9(4):7289-94.
• ²⁷ Manjunatha SN, Krishnaswamy R. Effectiveness of training teachers in vision screening of school children supported by foundation for the prevention of disability. Annals of Community Health. 2016;4(2):35-9.
• ²⁸ Salomão SR, Cinoto RW, Berezovsky A, Mendieta L, Nakanami CR, Lipener C, et al. Prevalence and causes of visual impairment in low-middle income school children in Sao Paulo, Brazil. Invest Ophthalmol Vis Sci. 2008; 49(10):4308-13.
• ²⁹ Tuong W, Larsen ER, Armstrong AW. Videos to influence: a systematic review of effectiveness of video-based education in modifying health behaviors. J Behav Med. 2014;37(2):218-33.
• ³⁰ Frehywot S, Vovides Y, Talib Z, Mikhail N, Ross H, Wohltjen H, et al. E-learning in medical education in resource constrained low- and middle-income countries. Hum Resour Health. 2013;11(1):4.
• ³¹ Shukla P, Vashist P, Singh SS, Gupta V, Gupta N, Wadhwani M, et al. Assessing the inclusion of primary school children in vision screening for refractive error program of India. Indian J Ophthalmol. 2018;66(7):935-9.

Edited by

• Associate Editor:
  Celso Moura Rebello Instituto Israelita de Ensino e Pesquisa Albert Einstein, São Paulo, SP, Brazil ORCID: https://orcid.org/0000-0002-4637-6295

Publication Dates

• Publication in this collection
  17 Aug 2026
• Date of issue
  2026

History

• Received
  08 June 2025
• Accepted
  08 Feb 2026