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Honolulu Moanalua Lions Club volunteer Steve Onoue still remembers the Kauluwela Elementary School third grader who clambered into his vision screening chair. Her red frames were too small and narrow, even for her young face. It was the same pair of glasses she had since kindergarten and the hidden culprit behind her headaches.

When she finally got a new pair weeks later, “her face lit up like a Christmas tree,” Onoue said.��

For nearly 25 years, volunteers like Onoue have taken on the responsibility of screening Hawaii children for vision and hearing problems, in hopes of catching issues early and preventing any conditions that would inhibit their learning.��

That’s because Hawaii hasn’t had a comprehensive vision screening program in schools since 1995, when it was stripped from the state Department of Health budget. Hawaii state requires that such a program be administered, but it has been ignored and multiple attempts in the Legislature to resurrect it have failed.

The hole it has left is “massive,” says Lt. Gov. Josh Green, who is working with the state to ease the process for nonprofit vision organizations working with Hawaii schools.

“It’s a little embarrassing that the state hasn’t been able to step into that space completely,” he said.����

Local organizations are trying to fill the gap, ramping up their screening programs in recent years, but they can only go so far. Last year, nonprofit organizations collectively screened about 50,000 Hawaii students, about a third of the total number of students enrolled across the state.��

Onoue says volunteers like him cannot offer medical advice, nor are they able to actively keep track of the students they refer on to doctors.������

“We don’t keep records, we just screen them, and hope parents take them to professional help,” Onoue said.��

A Dormant Program

Hawaii is one of 12 states that lack a comprehensive vision and hearing screening program in schools. Arizona, Idaho, Montana, New Hampshire, North Carolina, North Dakota, South Carolina, South Dakota, Utah, Wisconsin, and Wyoming — at all.��

A recession during the mid-1990s tightened Hawaii’s health budget and cuts were made across the board, according to Dale Matsumoto-Oi, former supervisor of the now-defunct Hearing and Vision Program at DOH’s School Health Services Branch. Officials at the time figured hearing and vision screenings could be done by the child’s personal doctor, since nearly everyone in Hawaii has health insurance.�� ��

The state Department of Education requires that students get physical examinations twice — once before the first grade and again in the seventh grade.

But just two vision checks throughout a child’s school career is not sufficient, said Matsumoto-Oi, and vision check-ups may not be happening at all. A recent health department survey of pediatricians found that some reported not having the proper equipment, staff, time or knowledge to test a child’s vision.����

Hearing and vision screenings are generally conducted in tandem. At its peak, the Department of Health Hearing and Vision program had a $500,000 budget and nearly two dozen employees, including audiologists and audiometric assistants who were all nationally certified to conduct both vision and hearing screenings. Vision checks were conducted almost annually at various grades.

As a result, thousands of students were identified every year and referred for follow-up exams or to see an eye doctor.��

“It was amazing, when you think about the numbers,” Matsumoto-Oi said.

Today, Matsumoto-Oi is the sole audiologist left at DOH. In the years since the program was cut, she has counseled nonprofit organizations, giving guidance on how to check eyes and ears as well as how to abide by federal privacy laws.

“They can only provide limited services,” she said. “There are children still not being reached.”

An estimated 15,000 children in Hawaii are in need of glasses, based on national statistics provided by Vision To Learn, a national organization that conducts screenings and provides eyeglasses to students for free.����

The need is overwhelming, says Elizabeth “Annie” Valentin, executive director of Project Vision Hawaii. Health insurance plans and prices for glasses and eye treatments vary and can be financially out of reach, even for those with private insurance.

Additionally, corrective lenses aren’t always the appropriate treatment, which is why eye exams and referrals to professionals are so important.

Understandably, young children have a harder time identifying when something is awry. But Valentin has also seen 18-year-olds who cannot identify the “Big E” on the Snellen eye chart.

“Whether you’re a kid or an adult, vision issues are so often overlooked,” Valentin said. “Things are not caught until it’s too late, so it’s already affected them. They think, ‘I’m not good at math,’ when it’s like, ‘No, you can be good at math, you just can’t see the board.’ We hear from teachers all the time about the improved behavioral outcomes of kids who just needed a pair of glasses.”����

Accessibility is also an issue, especially in communities far from optometrists and ophthalmologists. Untreated visual impairments are more common among low-income and minority students, who generally have a harder time getting to eye doctors and access to corrective lenses.

“If you’re in Kau, Molokai, or Waimea on Kauai, you’re going to be driving long distances,” Valentin said. A screening in West Kauai in 2016 yielded a 57% referral rate, the highest Vision To Learn had ever found across the nation. Officials are unsure why the Kauai referral rate was so high.��

Joining Forces

Project Vision Hawaii teamed up with national nonprofit Vision to Learn in 2015 to expand their reach across all islands, using mobile clinics.

This fall, the organizations will embark on a joint initiative to conduct a total of 60,000 vision screenings at Hawaii schools over the next three years, focusing on , where many students come from families with low incomes. Backed by a $300,000 state grant and private philanthropy, they expect to refer 3,000 students on to eye exams and ultimately distribute 2,400 glasses each school year over the next three years.��

Andrew Aguirre, the Hawaii program manager for Vision to Learn, says screenings usually yield 20% to 30% of children needing referrals to eye doctors. But making sure they actually get to that point can be a challenge. Nonprofits must receive consent forms from families before they conduct any screenings. As an opt-in program, Vision to Learn must receive a permission form.��

“Generally speaking, Hawaii has one of the lowest return rates of all forms for academics, so it’s already tough for schools to get the necessary documents they need,” said Aguirre, who used to work at a Hawaii public charter school.��

At Dole Middle School, for example, Vision to Learn found 120 children needed to see an optometrist, but none of the students identified used the available vouchers to go to a nearby optometrist in Kalihi, Aguirre said. But when Vision to Learn returned with glasses prescribed to them, the response was overwhelming.��

“They stepped back in shock,” he said. “One kid joked that he saw Instagram for the first time. Most of the teachers are already seeing a difference in participation and engagement, especially when it came to reading.”

Vision Volunteers

Roberta Jenkins, who chairs Hawaii’s District 50 Lions Club sight program, said volunteers across all islands managed to conduct 25,000 school vision screenings during the 2018-19 academic year. In the last couple of years, Lions Club volunteers have been able to upgrade to instrument-based screening.��

“We’ve done a lot more this year because it’s faster,” said Jenkins, a former principal at Laie and Mililani Waena elementary schools. “We know that if a student has problems with vision or hearing, their success is impacted. This is an area we felt is important, and if we can do it, let’s do it.”

Onoue has seen the results when he volunteers.��

“Before, vision screening used to be really intensive,” Onoue said. “Now, with one machine we can do an average of four to five kids per minute, per station. We’re looking at maybe no more than 15 seconds to screen a child.”��

The progress is encouraging, but there are shared concerns among those involved that there is no standard for screenings, and no data collected on results.����

Dr. Roger Ede, an optometrist based in Waipahu, has been involved with vision screening for preschool and elementary school children for decades. He volunteers with the Lions Club, serves on the Project Vision Hawaii board, and has long advocated for the development of a standard state vision screening protocol.��

“Unfortunately, until and unless the legislature is going to fund an agency or subagency within DOH or DOE that can help to oversee these kinds of standard protocols, there’s no impetus for organizations to follow such standards,” he said.�� ��

Matsumoto-Oi too is concerned about the consequences of having a state law carried out by various organizations. While grateful for the community groups, she said there’s no guarantee that all screenings are being provided appropriately.

The benefit of the former state program was the ability to maintain contact with families to ensure they were getting the vision care that they needed.��

“As a state program, we had the access to families,” she said. “We’d do three months of follow up just to ensure that they went to see a doctor and got the diagnosis and treatment. It was very comprehensive.”��

Screening benefits

When vision screening is implemented, improvements to classrooms are tremendous.��

A that analyzed the Vision To Learn method found that both reading and math grade point averages improved after glasses were distributed, likely because an estimated 80% of classroom learning is visual. The study also found that more than one-fifth of students have vision problems that can be found via vision screening, and the majority of impairments are easily corrected with glasses.��

Green says he is working with the state attorney general and DOE to switch the volunteer vision screenings from opt-in to opt-out, streamlining the process for volunteer groups.����

“We should expect all kids to have access to basic screenings, unless parents feel for a strong reason that they don’t want this basic good service for their kids,” he said. “It’s a noninvasive test, low impact, efficient and extremely low in cost. We’ll probably get 85% or more kids if we have an active opt-out provision.”��

In an emailed statement, the Hawaii Department of Education’s Office of Student Support Services said it plans to continue its collaboration with Vision to Learn and Project Vision Hawaii and is currently developing a formal agreement with the organizations.

The University of Hawaii’s School of Nursing and Dental Hygiene has also been involved with improving health screenings at DOE schools by providing visits from registered nurses and nursing practitioners to student health rooms.��

Aguirre and Valentin are hopeful the results they are demonstrating will highlight the need for a comprehensive state-backed program again.����

“That way we can ensure every generation of kids is getting the glasses and services they need, not just vision,” Aguirre said. “We’re going to be needing just shy of 7,500 glasses over the next three years, and hopefully by then the conversation will be real.”