Pediatric vision screening has been extensively investigated in different community settings,1–5 and is a required element of pediatric well-care visits per the current joint guidelines of the American Academies of Pediatrics (AAP), Ophthalmology (AAO), and Certified Orthoptists (AACO), and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).6,7 In addition to detecting sight-threatening conditions and strabismus in young children, vision screening is also used in older children to detect potentially significant refractive errors that might adversely affect the ability of the child to succeed in school. The recommended acuity-based referral thresholds were intended to reflect age-appropriate acuity norms, based on the expert judgment of the AAP's Committee on Practice and Ambulatory Medicine, Section on Ophthalmology.7 However, given the perceived impact on classroom performance, it would be helpful to have corollary data regarding the actual visual demands encountered in classrooms. Referral thresholds for school-aged children could then be tailored to match actual visual requirements. Conversely, such data would also inform the development and implementation of rational age-appropriate opto-type standards in classrooms. Doing so could have the benefit of better accommodating children with visual deficits, including those who lack proper optical correction.
Current pediatric vision screening guidelines recommend screening examinations at least annually.6 For acuity-based screening, referral to a specialist is recommended if the acuity is 20/50 or worse in either eye in children younger than 4 years, 20/40 or worse in children 4 to 5 years of age, and 20/30 or worse in children older than 5 years.7–11 However, despite efforts at the primary care level to provide quality vision screening, only 30% to 60% of children ultimately receive a formal evaluation by a pediatric trained eye care provider,9 and compliance with glasses is highly variable.12 Multiple factors accounting for the low follow-up and compliance rates have been identified, including cost, lack of insurance, parental perceptions regarding necessity and urgency, and access to a pediatric eye care professional.12
These data suggest that limited resources, including the ability of parents to consistently provide glasses or contact lenses for their children, adversely affect the ultimate success of vision screening programs. These issues highlight the potential benefits of optimizing the specificity of acuity-based vision screening in school aged children in a way that reflects their actual visual needs, as well as developing appropriate guidelines and specifications for visual content in classrooms. Given the paucity of information in the literature,13-15 this study was designed to help close this gap in knowledge by investigating the actual logMAR and contrast sensitivity demands in a cross-sectional sample of kindergarten through grade 12 classrooms in New York City.
Patients and Methods
Classroom dimensions were measured to obtain actual viewing distances from various seating positions, including the sides and center of the front and back rows, to the smartboard or whiteboard. A typical classroom configuration is shown schematically in Figure 1. Permission was obtained from school officials at each of the schools visited.
Data collection sheet including ranges for Snellen and logarithm of the minimum angle of resolution (logMAR) equivalents at various seating locations. A and C = 20/102 to 20/229, B = 20/170 to 20/339, D and F = 20/54 to 20/109, and E = 20/57 to 20/123.
Text Dimensions and Contrast Quality
Horizontal and vertical dimensions of single letters from actual lecture content on smartboards and whiteboards in classrooms were measured in millimeters. Measurements of three separate, representatively sized, lower case and upper case letters were obtained for each classroom and mean values for each size were calculated. The teachers were not made directly aware of the study's purpose, and were simply asked by the school representative to leave the lesson plan text on display at the end of the school day.
The luminance contrast between text and background was estimated by taking digital photographs of the text on the smartboards or whiteboards and comparing the contrast to optotypes on a Pelli-Robson contrast sensitivity chart.16 Contrast sensitivity is defined as the log10 [background luminance/(background-optotype luminance)] of the lowest contrast optotype that an individual can accurately discern.17 The contrast between an optotype and a luminant background increases as the optotype's luminance approaches zero (ie, black optotype on white background). Conversely, the contrast between an optotype and the background decreases as the optotype's luminance increases and approaches background luminance. High contrast improves an optotype's visibility. An individual's contrast sensitivity refers to the minimum contrast required for the individual to correctly discern a standard optotype.
LogMAR and Snellen Equivalent Calculation
To calculate the angular size of the optotypes at different locations in the classroom, we assumed that (Letter Height)/(Viewing Distance) was approximately equal to the angular size of the optotype in radians, because tan = arctan for small angles. Radians could then be converted to minutes of angle by applying the following formula: (Minutes of Angle) = (Radians) × (360/2π) × (60).
To calculate a Snellen equivalent, we considered a 20/20 “E” optotype, by definition, to have an overall angular size of 5 minutes, with each light and dark bar of the “E” having an angular size of 1 minute. To calculate an approximate Snellen equivalent for a classroom optotype, we divided the total vertical angular size of the letter (in minutes of angle) by 5 and multiplied by 20. For example, a letter that had a total visual angle of 10 minutes was considered to be a 20/40 equivalent. The logMAR size of the optotype was calculated as the base 10 logarithm of the total angular size of the letter vertically (in minutes of angle) divided by 5, to reflect the angular size or minimum angle of resolution, of the component bars of the standard “E” (eg, logMAR = 0 for a 20/20 optotype, logMAR = 1 for a 20/200 optotype).
The following formulas were used to calculate the angular dimensions of optotypes:
Angular size of optotype (minutes of angle) = (total optotype height/viewing distance) × (360/2π) × 60
Snellen equivalent = (total optotype height/viewing distance) × (360/2π) × (60) × (20/5)
logMAR = Log10 (total angular size of optotype in minutes/5)
Upper case letters were considered to represent the maximum angular sizes of optotypes in each classroom, and lower case letters were considered to represent the minimum angular sizes.
Classroom dimensions, logMAR, Snellen equivalent, and contrast were grouped by grade levels (ie, elementary = kindergarten to 5th grades, middle school = 6th to 8th grades, and high school = 9th to 12th grades) and by seat location, (ie, front center, front side, back center, and back side). Measurements are presented as mean values with associated standard deviations. Differences in continuous variables between two groups were tested using an independent samples two-tailed t test. One-way analysis of variance was used to compare mean values among the different seat locations and grade levels. A P value of .05 or less was considered to be statistically significant.
A total of 14 classrooms, in five different schools, were assessed. The classes included a range of grades from kindergarten to high school. Three of the schools were private and two were public. Two schools were located in Manhattan, one in the Bronx, and two in Brooklyn. The mean classroom dimensions were 16 × 18 feet (depth by width), with a range of 8 × 10 feet to 23 × 23 feet (Table 1). The seating configurations of the classrooms varied, with some classrooms having individual seating and some having shared tables for 3 to 4 students per table. The position of the smartboard or whiteboard also varied, with some classes having the board positioned off to one side, and others having it centrally located at the front of the classroom.
Mean Classroom Dimensions
In most classrooms, text was projected onto smartboards. The use of whiteboards was infrequent. There were no chalkboards. The smallest, largest, range, and mean logMAR and Snellen equivalent of the letters are presented in Table 2, broken down by seat location in the classroom.
Average, Maximum, and Minimum Optotype Sizes in logMAR and Snellen Equivalent (N = 14)
Overall, the mean logMAR equivalent of lower case letters from seats in the center of the front row was 0.93 (Snellen equivalent = 20/170), whereas the mean value from the center of the back row was 0.46 (Snellen equivalent = 20/58) (P < .001). Similarly, for seating on the sides of the classrooms, the mean logMAR equivalent of lower case letters from the side of the front row was 0.71 (Snellen equivalent = 20/103), whereas the mean value from the side of the back row was 0.43 (Snellen equivalent = 20/54) (P = .001). These values indicate that the visual acuity demand from the seating in the back row was, on average, almost triple that of the front row.
Table 3 shows the logMAR and Snellen equivalent values by grade levels and seat positions. The mean logMAR value of optotypes viewed from the center of the front row in kindergarten to 3rd grade was 0.79 (Snellen equivalent = 20/123). In contrast, the mean value was 0.91 (Snellen equivalent = 20/162) in 5th to 7th grade classes and 1.02 (Snellen equivalent = 20/209) in 9th to 12th grades. No data were collected from 4th and 8th grades. Although logMAR values varied from classroom to classroom, even within the same school, the mean values did not vary significantly by school (P > .05) or grade level (P > .05).
Visual Demands Based on Seating
Optotype contrast was high for black markers on whiteboards (Pelli-Robson chart optotype contrast sensitivity = 0.00), but varied from 0.15 to 0.60 on smartboards. The position of smartboards relative to the overhead room lighting and the level of room lighting appeared to affect contrast and created glare, although the effect of these factors could not be quantitatively measured.
Narayanasamy et al14 determined that students spend approximately 80% of a typical school day in visual tasks, with 29% exclusively involving distance vision, suggesting that vision-related learning is an extremely important component of school-based education. Our data suggest that visual demands, as estimated from the logMAR values of optotypes shown to students, can vary greatly from classroom to classroom and within a given classroom based on seat position. Not surprisingly, the acuity demands of a back row seat were significantly higher than a front row seat, a disparity that predictably increased as room length increased. The logMAR difference between the front and back rows in our sample of classrooms was, on average, 0.47, corresponding to a roughly threefold difference in visual demand. In one 1st grade classroom, the difference was 0.81, representing a 6.4-fold difference.
Analysis of our data in the context of current vision screening guidelines6,7 suggests that children with visual acuity in the better eye of 20/30 or worse may have difficulty seeing letters from the back of some classrooms, whereas children in the front row may not have difficulty unless their visual acuity is worse than 20/80. Our findings are in general agreement with those of Langford and Hug,13 who also found that visual requirements increased significantly with back row seating. In contrast to their study, which found that visual demand increased with grade level from kindergarten to 5th grade, we did not find this trend. Their study did not assess demands in middle school or high school classrooms.
Contrast, which affects the visibility of text, was found to be highest with black markers on a whiteboard and lowest on smartboards in rooms with high levels of ambient illumination. This may be an important finding, because it has been reported that lecture content with low contrast can dramatically affect visual learning, especially in children with underlying visual abnormalities, including amblyopia.18–21
Although we did not attempt to measure the extent of letter crowding, we did notice that letters and words appeared at times to be closely spaced in some classrooms, particularly when whiteboards were used (data not shown). This is likely due to the fact that smartboards use computer-generated text, whereas the text on whiteboards is manually written by teachers, and therefore much more variable. Although crowding makes the visual resolution of individual optotypes more difficult in general, it has been identified as a particularly significant factor limiting reading speed in patients with amblyopia.22,23
According to New York State Department of Health guidelines, the square footage of classrooms should range between 17 and 22 square feet per student for rooms with less than 41 students and between 22 and 23 square feet per student for rooms with 41 to 60 students.24 The distance from the first row of seating to the screen is supposed to be no more than 1.5 to 2 times the width of the projected images (screen width). There are no stated differences in the mandated requirements with regard to grade level, nor are there requirements regarding classroom seating configuration or limits on distance to the back row. Perhaps more important, the guidelines contain no specific recommendations regarding optotype size or contrast,24 or appropriate alterations of these parameters in classes serving children with visual or cognitive impairment.
Our sample included schools from diverse neighborhoods and classrooms from public, private, and parochial schools. Although the sample size was relatively small, the wide range of logMAR and contrast values found among classrooms suggests that a larger sample size would have further defined the range and standard deviation of these values, but would not alter our fundamental conclusions. Because the actual classroom text was not uniformly formatted, and did not replicate the standardized form of optotypes used for visual acuity testing, our logMAR and Snellen equivalent calculations can only serve as approximations. Another limitation of the study is that the contrast between optotype and background was subjectively determined by comparing photographs of optotypes taken in the classroom to optotypes on a Pelli-Robson contrast sensitivity chart.17 However, because our methodology was internally consistent, our finding of marked inter-classroom variations is not likely due to methodological error. The impact of these variations on the visual performance of students, with and without visual impairment, requires further study.
Our data revealed that the mean logMAR demand to visualize lower case letters in the back row of a classroom was 0.46 (Snellen equivalent = 20/58), with a relatively wide range of values from classroom to classroom, even within the same school. By contrast, the mean logMAR demand in the front row was 0.93 (Snellen equivalent = 20/170). These data suggest that the currently recommended thresholds for referral in vision screening programs6,7 are sufficient to detect most children at risk for visual acuity related difficulty in the classroom.
The role of optotype contrast, and its variability among classrooms, is not addressed by current screening guidelines, but may also deserve consideration. To improve students' content visibility, higher contrast may be required, which can be achieved by selecting black letters against white backgrounds (contrast sensitivity = 0.00).
Finally, further studies correlating our data with uncorrected visual acuity data obtained from pediatric vision screening will help to clarify the proportion of children likely to encounter visual challenges in actual classrooms and to provide recommendations for policy development to better accommodate children with visual acuity impairments. This information can also help the Department of Education authorities establish lecture content guidelines among teachers and seating recommendations in the classrooms.
- Giordano L, Friedman DS, Repka MX, et al. Prevalence of refractive error among preschool children in an urban population: the Baltimore Pediatric Eye Disease Study. Ophthalmology. 2009;116(4):739–746, 746.e1–746.e4. doi:10.1016/j.ophtha.2008.12.030 [CrossRef]
- Traboulsi EI, Cimino H, Mash C, Wilson R, Crowe S, Lewis H. Vision First, a program to detect and treat eye diseases in young children: the first four years. Trans Am Ophthalmol Soc. 2008;106:179–185.
- Pizzarello L, Tilp M, Tiezzi L, Vaughn R, McCarthy J. A new school-based program to provide eyeglasses: childsight. J AAPOS. 1998;2(6):372–374. doi:10.1016/S1091-8531(98)90038-6 [CrossRef]
- Hark LA, Mayro EL, Tran J, et al. Improving access to vision screening in urban Philadelphia elementary schools. J AAPOS. 2016;20(5):439–443.e1. doi:10.1016/j.jaapos.2016.07.219 [CrossRef]
- Mehravaran S, Duarte PB, Brown SI, Mondino BJ, Hendler K, Coleman AL. The UCLA preschool vision program, 2012–2013. J AAPOS. 2016;20(1):63–67. doi:10.1016/j.jaapos.2015.10.018 [CrossRef]
- Donahue SP, Nixon CNSection on Opthamology, American Academy of PediatricsCommittee on Practice and Ambulatory Medicine, American Academy of PediatricsAmerican Academy of OphthalmologyAmerican Association for Pediatric Ophthalmology and StrabismusAmerican Association of Certified Orthoptists. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28–30.
- Donahue S, Baker C. Clinical Report. Procedures for the evaluation of the visual system by pediatricians. Pediatrics. 2016;137(1):1–9. doi:10.1542/peds.2015-3597 [CrossRef]
- Wallace D, Morse C, Melia M, et al. Pediatric eye evaluations preferred practice patterns. Ophthalmology. 2018;12(1):184–227. doi:10.1016/j.ophtha.2017.09.032 [CrossRef]
- U.S. Preventive Service Task Force. Recommendation statement. Vision screening for children 6 months to 5 years of age. JAMA. 2017;318:836–844. doi:10.1001/jama.2017.11260 [CrossRef]
- Shakarchi AF, Collins ME. Referral to community care from school-based eye care programs in the United States. Surv Ophthalmol. 2019;64(6):858–867. doi:10.1016/j.survophthal.2019.04.003 [CrossRef]
- Centers for Disease Control and Prevention. Vision health initiative. https://www.cdc.gov/visionhealth/risk/age.htm. Accessed July 6, 2019.
- Kimel LS. Lack of follow-up exams after failed school vision screenings: an investigation of contributing factors. J Sch Nurs. 2006;22(3):156–162. doi:10.1177/10598405060220030601 [CrossRef]
- Langford A, Hug T. Visual demands in elementary school. J Pediatr Ophthalmol Strabismus. 2010;47(3):152–156. doi:10.3928/01913913-20090818-06 [CrossRef]
- Narayanasamy S, Vincent SJ, Sampson GP, Wood JM. Visual demands in modern Australian primary school classrooms. Clin Exp Optom. 2016;99(3):233–240. doi:10.1111/cxo.12365 [CrossRef]
- Negiloni K, Ramani KK, Sudhir RR. Do school classrooms meet the visual requirements of children and recommended vision standards?PLoS One. 2017;12(4):e0174983. doi:10.1371/journal.pone.0174983 [CrossRef]
- Pelli DG, Robson JG, Wilkins AJ. The design of a new letter chart of measuring contrast sensitivity. Clin Vis Sci. 1988;2:187–199.
- Richman J, Spaeth GL, Wirostko B. Contrast sensitivity basics and a critique of currently available tests. J Cataract Refract Surg. 2013;39(7):1100–1106. doi:10.1016/j.jcrs.2013.05.001 [CrossRef]
- Bradley A, Freeman RD. Contrast sensitivity in anisometropic amblyopia. Invest Ophthalmol Vis Sci. 1981;21(3):467–476.
- Wang G, Zhao C, Ding Q, Wang P. An assessment of the contrast sensitivity in patients with ametropic and anisometropic amblyopia in achieving the corrected visual acuity of 1.0. Sci Rep. 2017;7(1):42043. doi:10.1038/srep42043 [CrossRef]
- Haegerstrom-Portnoy G, Schneck ME, Lott LA, Brabyn JA. The relation between visual acuity and other spatial vision measures. Optom Vis Sci. 2000;77(12):653–662. doi:10.1097/00006324-200012000-00012 [CrossRef]
- Preslan MW, Novak A. Baltimore vision screening project. Ophthalmology. 1996;103(1):105–109. doi:10.1016/S0161-6420(96)30753-7 [CrossRef]
- Norgett Y, Siderov J. Crowding in children's visual acuity tests—effect of test design and age. Optom Vis Sci. 2011;88(8):920–927. doi:10.1097/OPX.0b013e31821bd2d3 [CrossRef]
- Kanonidou E, Gottlob I, Proudlock FA. The effect of font size on reading performance in strabismic amblyopia: an eye movement investigation. Invest Ophthalmol Vis Sci. 2014;55(1):451–459. doi:10.1167/iovs.13-13257 [CrossRef]
- New York State Department of Health, Educational Services. Classroom Design Standards. April2010. https://www.health.ny.gov/professionals/ems/education/course_sponsors/docs/classroom_design_standards.pdf
Mean Classroom Dimensions
|Parameter||All (N = 14)||K to 3rd (n = 4)a||5th to 7th (n = 4)a||9 to 12th (n = 6)|
|Mean width (range, ft)||16.7 (8 to 25.5)||17.2 (8 to 25.5)||12.8 (11 to 16)||18.8 (13 to 23)|
|Mean depth (range, ft)||18.5 (10 to 23)||17.8 (10 to 24)||16.8 (14 to 20)||20.1 (14.5 to 23)|
Average, Maximum, and Minimum Optotype Sizes in logMAR and Snellen Equivalent (N = 14)
|Parameter||logMAR Maximum (Upper Case Letters)||logMAR Minimum (Lower Case Letters)|
|Front Center||Front Side||Back Center||Back Side||Front Center||Front Side||Back Center||Back Side|
| Mean ± SD||1.23 ± 0.22||1.06 ± 0.19||0.76 ± 0.13||0.74 ± 0.12||0.93 ± 0.29||0.71 ± 0.16||0.46 ± 0.21||0.43 ± 0.17|
| Range||0.69 to 1.66||0.94 to 1.48||0.52 to 1.01||0.55 to 0.94||0.83 to 1.32||0.49 to 0.99||0.10 to 0.79||0.13 to 0.67|
|Snellen equivalent (20/x)|
| Range||98 to 900||174 to 603||66 to 204||70 to 174||135 to 417||61 to 195||25 to 123||27 to 93|
Visual Demands Based on Seating
|Parameter||Front Center Seating||Back Center Seating|
|All||K to 3rda||5th to 7tha||9th to 12th||All||K to 3rda||5th to 7tha||9th to 12th|
| Mean ± SD||0.93 ± 0.29||0.79 ± 0.09||0.91 ± 0.25||1.02 ± 0.19||0.46 ± 0.22||0.25 ± 0.18||0.60 ± 0.22||0.50 ± 0.14|
| Range||0.59 to 1.32||0.71 to 0.91||0.59 to 1.18||0.80 to 1.32||0.10 to 0.80||0.10 to 0.52||0.38 to 0.80||0.29 to 0.69|
| Mean (20/x)||170||123||162||209||57||35||79||63|
| Range||77 to 417||102 to 162||77 to 302||126 to 417||25 to 126||25 to 66||48 to 126||39 to 98|
|Parameter||Front Side Seating||Back Side Seating|
|All||K to 3rda||5th to 7tha||9th to 12th||All||K to 3rda||5th to 7tha||9th to 12th|
| Mean ± SD||0.95 ± 0.20||0.59 ± 0.06||0.66 ± 0.21||0.81 ± 0.21||0.42 ± 0.17||0.26 ± 0.12||0.50 ± 0.21||0.48 ± 0.12|
| Range||0.48 to 0.99||0.50 to 0.63||0.48 to 0.88||0.70 to 0.99||0.13 to 0.69||0.13 to 0.43||0.26 to 0.69||0.38 to 0.62|
| Mean (20/x)||178||77||91||130||52||37||63||61|
| Range||60 to 195||63 to 85||60 to 151||100 to 195||26 to 97||26 to 53||36 to 97||47 to 83|