Visual Function of Moderately Hyperopic 4- and 5-Year-Old Children in the Vision in Preschoolers - Hyperopia in Preschoolers Study

Peripapillary Retinal Nerve Fiber Layer and Macular Ganglion Cell-Inner Plexiform Layer Parameters and Their Associated Factors in Cynomolgus Macaques

Purpose

The purpose of this study was to define the normal range of peripapillary retinal nerve fiber layer (pRNFL), macular ganglion cell layer (mGCL), and macular inner plexiform layer (mIPL) thickness in cynomolgus macaques, and explore their inter-relationship and correlation with age, refractive errors, and axial length (AL).

Methods

In this cross-sectional study, we measured biometric and refractive parameters, and pRNFL/mGCL/mIPL thickness in 357 healthy cynomolgus macaques. Monkeys were divided into groups by age and spherical equivalent (SE). Correlation and regression analyses were used to explore the relationship between pRNFL and mGCL/mIPL thickness, and their correlation with the above parameters.

Results

The mean age, SE, and AL were 14.46 ± 6.70 years, -0.96 ± 3.23 diopters (D), and 18.39 ± 1.02 mm, respectively. The mean global pRNFL thickness was 95.06 ± 9.42 µm (range = 54-116 µm), with highest values in the inferior quadrant, followed by the superior, temporal, and nasal quadrants (P < 0.001). Temporal pRNFL thickness correlated positively with age (r = 0.218, P < 0.001) and AL (r = 0.364, P < 0.001), and negatively with SE (r = -0.270, P < 0.001). In other quadrants, pRNFL thickness correlated negatively with age and AL, but positively with SE. In the multivariable linear regression model, adjusted for sex and AL, age (β = -0.350, P < 0.001), and SE (β = 0.206, P < 0.001) showed significant associations with global pRNFL thickness. After adjusting for age, sex, SE, and AL, pRNFL thickness positively correlated with mGCL (β = 0.433, P < 0.001) and mIPL thickness (β = 0.465, P < 0.001).

Conclusions

The pRNFL/mGCL/mIPL thickness distribution and relationship with age, AL, and SE in cynomolgus macaques were highly comparable to those in humans, suggesting that cynomolgus monkeys are valuable animal models in ophthalmic research.

Quantitative assessment of colour fundus photography in hyperopia children based on artificial intelligence

OBJECTIVES

This study aimed to quantitatively evaluate optic nerve head and retinal vascular parameters in children with hyperopia in relation to age and spherical equivalent refraction (SER) using artificial intelligence (AI)-based analysis of colour fundus photographs (CFP).

METHODS AND ANALYSIS

This cross-sectional study included 324 children with hyperopia aged 3-12 years. Participants were divided into low hyperopia (SER+0.5 D to+2.0 D) and moderate-to-high hyperopia (SER≥+2.0 D) groups. Fundus parameters, such as optic disc area and mean vessel diameter, were automatically and quantitatively detected using AI. Significant variables (p<0.05) in the univariate analysis were included in a stepwise multiple linear regression.

RESULTS

Overall, 324 children were included, 172 with low and 152 with moderate-to-high hyperopia. The median optic disc area and vessel diameter were 1.42 mm2 and 65.09 µm, respectively. Children with high hyperopia had larger superior neuroretinal rim (NRR) width and larger vessel diameter than those with low and moderate hyperopia. In the univariate analysis, axial length was significantly associated with smaller superior NRR width (β=-3.030, p<0.001), smaller temporal NRR width (β=-1.469, p=0.020) and smaller vessel diameter (β=-0.076, p<0.001). A mild inverse correlation was observed between the optic disc area and vertical disc diameter with age.

CONCLUSION

AI-based CFP analysis showed that children with high hyperopia had larger mean vessel diameter but smaller vertical cup-to-disc ratio than those with low hyperopia. This suggests that AI can provide quantitative data on fundus parameters in children with hyperopia.

Longitudinal Changes in Refractive Development in Highly Hyperopic Children: A 2.6-11.2 Year Follow-up of Preschoolers Diagnosed with High Hyperopia

PURPOSE

This study aims to elucidate the longitudinal refractive and ocular biometric alterations in preschool children with high hyperopia who underwent early interventions.

METHODS

We conducted a retrospective analysis of preschool children diagnosed with high hyperopia at Tianjin Medical University Eye Hospital between 2011 and 2023. Inclusion criteria required an initial examination with cycloplegic refraction, bilateral spherical equivalent power (SE) ≥ +5.00D with a difference <1.00D, a minimum two-year follow-up, and at least three ocular biometric measurements. The annual axial growth rate evaluated emmetropization in highly hyperopic children. We applied Restricted Cubic Spline (RCS) models to explore potential nonlinear relationships between age and spherical equivalent, axial length, corneal curvature, and axial length-to-corneal curvature ratio. Additionally, Mixed-effects models were employed to investigate factors associated with changes in refractive error and axial length.

RESULTS

The study enrolled 60 eligible subjects, with a median initial diagnosis age of 3.5 years (IQR, 2.8-4.9 years) and a median last visit age of 9.3 years (IQR, 8.1-10.8 years). The average follow-up duration was 5.7 years. RCS analysis revealed notable nonlinear changes in spherical equivalent power, axial length, and axial length-to-corneal curvature ratio, although corneal curvature displayed no statistically significant nonlinear trend. Factors affecting SE changes included the presence of strabismus, the use of cycloplegia, baseline SE, and age. Conversely, changes in axial length solely correlated with baseline axial length and age.

CONCLUSION

Highly hyperopic preschool children undergoing early intervention display a marked emmetropization tendency, though most still remain moderately to highly hyperopic, with the progression of refractive changes showing non-uniform patterns with respect to age.

Detection of significant vision conditions in children using QuickSee wavefront autorefractor

PURPOSE

This study evaluated the ability of QuickSee to detect children at risk for significant vision conditions (significant refractive error [RE], amblyopia and strabismus).

METHODS

Non-cycloplegic refraction (using QuickSee without and with +2 dioptre (D) fogging lenses) and unaided binocular near visual acuity (VA) were measured in 4- to 12-year-old children. Eye examination findings (VA, cover testing and cycloplegic retinoscopy) were used to determine the presence of vision conditions. QuickSee performance was summarised by area under the receiver operating characteristic curve (AUC), sensitivity and specificity for various levels of RE. QuickSee referral criteria for each vision condition were chosen to maximise sensitivity at a specificity of approximately 85%-90%. Sensitivity and specificity to detect vision conditions were calculated using multiple criteria. Logistic regression was used to evaluate the benefit of adding near VA (6/12 or worse) for detecting hyperopia. A paired t-test compared QuickSee without and with fogging lenses.

RESULTS

The mean age was 8.2 (±2.5) years (n = 174). RE ranged up to 9.25 D myopia, 8 D hyperopia, 5.25 D astigmatism and 3.5 D anisometropia. The testability of the QuickSee was 94.3%. AUC was ≥0.92 (excellent) for each level of RE. For the detection of any RE, sensitivity and specificity were 84.2% and 87.3%, respectively, using modified Orinda criteria and 94.5% and 78.2%, respectively, using the American Academy for Pediatric Ophthalmology and Strabismus (AAPOS) guidelines. For the detection of any significant vision condition, the sensitivity and specificity of QuickSee were 81.1% and 87.9%, respectively, using modified Orinda criteria and 93% and 78.6%, respectively, using AAPOS criteria. There was no significant benefit of adding near VA to QuickSee for the detection of hyperopia ≥+2.00 (p = 0.34). There was no significant difference between QuickSee measurements of hyperopic refractive error with and without fogging lenses (difference = -0.09 D; p = 0.51).

CONCLUSIONS

QuickSee had high discriminatory power for detecting children with hyperopia, myopia, astigmatism, anisometropia, any significant refractive error or any significant vision condition.

How Do Most Young Moderate Hyperopes Avoid Strabismus?

Purpose

Uncorrected hyperopic children must overcome an apparent conflict between accommodation and vergence demands to focus and align their retinal images. This study tested hypotheses about simultaneous accommodation and vergence performance of young hyperopes to gain insight into ocular motor strategies used to maintain eye alignment.

Methods

Simultaneous eccentric photorefraction and Purkinje image tracking were used to assess accommodative and vergence responses of 26 adult emmetropes (AE) and 94 children (0-13 years) viewing cartoons. Children were habitually uncorrected (CU) (spherical equivalent refractive error [SE] -0.5 to +4 D), corrected and aligned (CCA), or corrected with a history of refractive esotropia (CCS). Accommodative and vergence accuracy, dissociated heterophoria, and vergence/accommodation ratios in the absence of retinal disparity cues were measured for 33- and 80-cm viewing distances.

Results

In binocular viewing, median accommodative lags for 33 cm were 1.0 D (AE), 1.33 D (CU), 1.25 D (CCA), and 1.0 D (CCS). Median exophorias at 80 and 33 cm were 1.2 and 4.5 pd (AE), 0.8 and 2.5 pd (CU), and 0 and 1.2 pd (CCA), respectively. Without disparity cues, most response vergence/accommodation ratios were between 1 and 2 meter angle/D (∼5-10 pd/D) (69% of AE, 44% of CU, 60% of CCA, and 50% of CCS).

Conclusions

Despite apparent conflict in motor coupling, uncorrected hyperopes were typically exophoric and achieved adultlike accuracy of both vergence and accommodation simultaneously, indicating ability to compensate for conflicting demands rather than bias to accurate vergence while tolerating inaccurate accommodation. Large lags and esophoria are therefore atypical. This analysis provides normative guidelines for clinicians and a deeper mechanistic understanding of how hyperopes avoid strabismus.

Accuracy and stability of accommodation and vergence responses during sustained near tasks in uncorrected hyperopes

This study investigated the accuracy and stability of accommodative and vergence functions in children with and without hyperopia while engaged in two sustained near tasks. The sustained accommodative and vergence characteristics of participants without refractive correction (n = 92, aged 5-10 years) with and without hyperopia (defined as cycloplegic retinoscopy ≥  + 1.00D and less than + 5.00D) were measured using eccentric infrared photorefraction (PowerRef 3; PlusOptix, Germany). Binocular measures of accommodation and eye position were recorded while participants engaged in 2 tasks at 25 cm for 15 min each: (1) reading small print on an Amazon Kindle and (2) watching an animated movie on liquid crystal display screen. Comprehensive visual assessment, including measurement of presenting visual acuity, amplitude of accommodation, and stereoacuity was conducted. The magnitude of accommodative and vergence responses was not related to refractive error (P > 0.05). However, there were inter-task differences in the accuracy and stability of the accommodative responses across refractive groups (P < 0.05). The relationship between accommodation and vergence was not significant in both tasks (P > 0.05). However, increased accommodative and vergence instabilities were associated with total accommodative response (P < 0.05). Despite having greater accommodative demand, uncorrected hyperopes accommodate comparably to emmetropic controls. However, uncorrected hyperopes have increased instabilities in their accommodative and vergence responses, which may adversely impact their visual experience.

Correlation between spherical equivalent and biometry parameters in adult Cynomolgus macaque

PURPOSE

To characterize the distribution of refractive and ocular biometry parameters and analyze the effect factors of the refractive status in cynomolgus monkey colonies.

METHODS

A Population-based cross-sectional study was conducted in adult cynomolgus macaque colonies. Animals were anesthetized with Zoletil 50. Intraocular pressure was measured using the Icare tonometer. Cycloplegic refraction (three drops of 1% tropicamide) and corneal radius of curvature (CRC) were measured using an autorefractor. The spherical equivalent (SE) was calculated. Biometric measurements, including the anterior chamber depth (ACD), lens thickness (LT), and axial length (AL), were obtained by A-scan ultrasonography. The AL-to-CR ratio (AL/CRC) was calculated. Central corneal thickness (CCT) and choroidal thickness (ChT) were measured using the Heidelberg Spectralis HRA OCT. Multiple regression analysis was performed to explore the association between refraction and ocular biometry.

RESULTS

Among 263 cynomolgus monkeys (aged 5-26 years), which consisted of 520 eyes, 29.42% had hyperopia, 27.12% had emmetropia, 33.27% had mild-to-moderate myopia and 10.19% had high myopia. The mean SE was -1.27 ± 3.44 Diopters (D). The mean CRC, CCT, AL, and ChT was 5.70 ± 0.22 mm, 454.30 ± 32.40 μm, 18.76 ± 0.89 mm and 188.96 ± 38.19 μm, respectively. The LT was the thickest in the hyperopic eyes. CRC was the lowest, and CCT was the thickest in high myopic eyes. AL increased, while ChT decreased as SE decreased. For the SE variance, AL alone explained 40.5%; age, AL, and CRC together explained 57.5%.

CONCLUSIONS

The refractive characteristics and biometry parameters of cynomolgus monkeys are highly comparable to those of humans. AL, CRC, and ChT showed the similar variation tendency in cynomolguses when compared to humans. Cynomolgus monkeys with naturally-occurring refractive errors may be a good animal model for refractive studies.

The Evolution and the Impact of Refractive Errors on Academic Performance: A Pilot Study of Portuguese School-Aged Children

The relationship between vision and academic performance has been discussed for a long time, with special emphasis on visual factors associated with learning problems. The objective of this pilot study is to obtain an initial idea about the evolution and the impact of refractive errors on school-aged children. A visual examination was performed on 252 children between the ages of 6 and 11 years, which consisted of objective refraction, subjective refraction, and accommodative and binocular tests. No significant differences were observed regarding the refractive state when taking academic performance into account (p > 0.05). However, it was determined that academic performance was better among children with a negative spherical equivalent. Studies with a larger sample size must be conducted to verify the results that were attained in this present pilot study, and these must likewise look at possible ways in which strategies can be implemented in schools to reduce myopia progression.

Detection of Significant Hyperopia in Preschool Children Using Two Automated Vision Screeners

SIGNIFICANCE

Moderate to high uncorrected hyperopia in preschool children is associated with amblyopia, strabismus, reduced visual function, and reduced literacy. Detecting significant hyperopia during screening is important to allow children to be followed for development of amblyopia or strabismus and implementation of any needed ophthalmic or educational interventions.

PURPOSE

This study aimed to compare the sensitivity and specificity of two automated screening devices to identify preschool children with moderate to high hyperopia.

METHODS

Children in the Vision in Preschoolers (VIP) study were screened with the Retinomax Autorefractor (Nikon, Inc., Melville, NY) and Plusoptix Power Refractor II (Plusoptix, Nuremberg, Germany) and examined by masked eye care professionals to detect the targeted conditions of amblyopia, strabismus, or significant refractive error, and reduced visual acuity. Significant hyperopia (American Association for Pediatric Ophthalmology and Strabismus definition of hyperopia as an amblyopia risk factor), based on cycloplegic retinoscopy, was >4.00 D for age 36 to 48 months and >3.50 D for age older than 48 months. Referral criteria from VIP for each device and from a distributor (PediaVision) for the Power Refractor II were applied to screening results.

RESULTS

Among 1430 children, 132 children had significant hyperopia in at least one eye. Using the VIP referral criteria, sensitivities for significant hyperopia were 80.3% for the Retinomax and 69.7% for the Power Refractor II (difference, 10.6%; 95% confidence interval, 7.0 to 20.5%; P = .04); specificities relative to any targeted condition were 89.9 and 89.1%, respectively. Using the PediaVision referral criteria for the Power Refractor, sensitivity for significant hyperopia was 84.9%; however, specificity relative to any targeted condition was 78.3%, 11.6% lower than the specificity for the Retinomax. Analyses using the VIP definition of significant hyperopia yielded results similar to when the American Association for Pediatric Ophthalmology and Strabismus definition was used.

DISCUSSION

When implementing vision screening programs for preschool children, the potential for automated devices that use eccentric photorefraction to either miss detecting significant hyperopia or increase false-positive referrals must be taken into consideration.

The Impact of Hyperopia on Academic Performance Among Children: A Systematic Review

PURPOSE

To assess the impact of uncorrected hyperopia and hyperopic spectacle correction on children's academic performance.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched 9 electronic databases from inception to July 26, 2021, for studies assessing associations between hyperopia and academic performance. There were no restrictions on language, publication date, or geographic location. A quality checklist was applied. Random-effects models estimated pooled effect size as a standardized mean difference (SMD) in 4 outcome domains: cognitive skills, educational performance, reading skills, and reading speed. (PROSPERO registration: CRD-42021268972).

RESULTS

Twenty-five studies (21 observational and 4 interventional) out of 3415 met the inclusion criteria. No full-scale randomized trials were identified. Meta-analyses of the 5 studies revealed a small but significant adverse effect on educational performance in uncorrected hyperopic compared to emmetropic children {SMD -0.18 [95% confidence interval (CI), -0.27 to -0.09]; P < 0.001, 4 studies} and a moderate negative effect on reading skills in uncorrected hyperopic compared to emmetropic children [SMD -0.46 (95% CI, -0.90 to -0.03); P = 0.036, 3 studies]. Reading skills were significantly worse in hyperopic than myopic children [SMD -0.29 (95% CI, -0.43 to -0.15); P < 0.001, 1 study]. Qualitative analysis on 10 (52.6%) of 19 studies excluded from meta-analysis found a significant (P < 0.05) association between uncorrected hyperopia and impaired academic performance. Two interventional studies found hyperopic spectacle correction significantly improved reading speed (P < 0.05).

CONCLUSIONS

Evidence indicates that uncorrected hyperopia is associated with poor academic performance. Given the limitations of current methodologies, further research is needed to evaluate the impact on academic performance of providing hyperopic correction.

Vision Screening, Vision Disorders, and Impacts of Hyperopia in Young Children: Outcomes of the Vision in Preschoolers (VIP) and Vision in Preschoolers - Hyperopia in Preschoolers (VIP-HIP) Studies

ABSTRACT

This review summarizes clinically relevant outcomes from the Vision in Preschoolers (VIP) and VIP-Hyperopia in Preschoolers (VIP-HIP) studies. In VIP, refraction tests (retinoscopy, Retinomax, SureSight) and Lea Symbols Visual Acuity performed best in identifying children with vision disorders. For lay screeners, Lea Symbols single, crowded visual acuity (VA) testing (VIP, 5-foot) was significantly better than linear, crowded testing (10-foot). Children unable to perform the tests (<2%) were more likely to have vision disorders than children who passed and should be referred for vision evaluation. Among racial/ethnic groups, the prevalence of amblyopia and strabismus was similar while that of hyperopia, astigmatism, and anisometropia varied. The presence of strabismus and significant refractive errors were risk factors for unilateral amblyopia, while bilateral astigmatism and bilateral hyperopia were risk factors for bilateral amblyopia. A greater risk of astigmatism was associated with Hispanic, African American, and Asian race, and myopic and hyperopic refractive error. The presence and severity of hyperopia were associated with higher rates of amblyopia, strabismus, and other associated refractive error. In the VIP-HIP study, compared to emmetropes, meaningful deficits in early literacy were observed in uncorrected hyperopic 4- and 5-year-olds [≥+4.0 diopter (D) or ≥+3.0 D to ≤+6.0 D associated with reduced near visual function (near VA 20/40 or worse; stereoacuity worse than 240")]. Hyperopia with reduced near visual function also was associated with attention deficits. Compared to emmetropic children, VA (distance, near), accommodative accuracy, and stereoacuity were significantly reduced in moderate hyperopes, with the greatest risk in those with higher hyperopia. Increasing hyperopia was associated with decreasing visual function.

Baltimore Reading and Eye Disease Study: vision outcomes of school-based eye care

OBJECTIVE

There are unmet needs for refractive correction in the pediatric population, especially in high-poverty communities. We reported the impact of refractive correction on vision outcomes over a 2-year follow-up in the Baltimore Reading and Eye Disease Study.

DESIGN

Prospective, school-based cohort study.

PARTICIPANTS

Students of second and third grades who were prescribed glasses during baseline assessment.

METHODS

We conducted baseline eye exams in 12 Baltimore public schools during the fall of school year 2014-15 with follow-up visits in the spring of school year 2014-15 (first follow-up) and school year 2015-16 (second follow-up). Visual acuity (VA) was measured at distance and near with correction. Refractive status was determined based on the eye with the larger refractive error and categorized as myopia, hyperopia, and astigmatism.

MAIN OUTCOME MEASURES

VA in better-seeing and worse-seeing eye at first and second follow-up, and acuity improvement from baseline.

RESULTS

In the 206 students (84% African American) who completed the first follow-up, both distance (from 0.14 ± 0.20 to 0.05 ± 0.10 logMAR) and near presenting VA (from 0.08 ± 0.16 to 0.03 ± 0.06 logMAR) improved from the baseline assessment; children with more severe hyperopia showed improvement in near VA by 0.05 ± 0.16 logMAR. Children who were prescribed glasses through a school-based research study had improved vision, which was sustained into the following school year.

CONCLUSIONS

Many second and third graders in Baltimore Schools needed refractive correction and benefited from provision of glasses with sustained vision improvement over the 2-year observation.

Effects of topical pilocarpine on ocular growth and refractive development in rabbits

PURPOSE

This study aimed to investigate whether topical pilocarpine affects ocular growth and refractive development as well as the underlying biochemical processes in early eye development in rabbits.

METHODS

Twenty three-week-old New Zealand white rabbits were treated with 0.5% pilocarpine in the right eye for 6 weeks. The left eyes served as contralateral controls. The effects of pilocarpine on refractive error, corneal curvature and ocular biometrics were assessed using streak retinoscopy, keratometry, and A-scan ultrasonography, respectively. Eyeballs were enucleated for histological analysis. The ciliary body and sclera were homogenized to determine the mRNA and protein expression levels of five subtypes of muscarinic receptors.

RESULTS

Compared to control eyes, pilocarpine-treated eyes exhibited approximately -1.63 ± 0.54 D myopia accompanied by a 0.11 ± 0.04 mm increase in axial length (AL) (p < 0.001, respectively). The anterior chamber depth (ACD) was reduced, whereas the lens thickness (LT) and vitreous chamber depth (VCD) increased (p < 0.001, respectively). Corneal curvature decreased over time but was not significantly different between treated and control eyes. The mRNA and protein expression levels of five subtypes of muscarinic receptors were upregulated in the ciliary body and downregulated in the sclera.

CONCLUSIONS

Based on these results, pilocarpine can induce myopic shift, increase LT, elongate VCD and AL, and reduce muscarinic receptor expression in the sclera early in development. These changes raise the possibility that pilocarpine may promote axial elongation in ocular development and facilitate the emmetropization of hyperopic eyes.

Long-term refractive outcomes in children with early diagnosis of moderate to high hyperopia

PURPOSE

The purpose of this study was to investigate the long-term outcome of moderate-to-high hyperopic refractive errors in childhood.

METHODS

We reviewed medical records from children diagnosed with hyperopia (≥3D) in the amblyogenic risk factors screening that is performed in a public hospital in Portugal. We included hyperopic children diagnosed between 2001 and 2011 with at least three available ophthalmologic evaluations (including one before the age of 3 years and one after a minimum period of 6 years after the first evaluation). Spherical equivalent (SE) was considered.

RESULTS

In total, 78 eyes from 39 children met the inclusion criteria (49% male). Mean age at first and last evaluation was 1.8 ± 0.9 years and 10.6 ± 2.7 years, respectively. Median follow-up was 130 months (range 72-193). At baseline evaluation, the mean SE was 4.5 ± 1.4 diopters, 36% of children had a SE ≥5.0 diopters, 23% had partially accommodative esotropia, 26% had accommodative esotropia and 51% had no eye deviation. At the last evaluation, the mean SE was 4.6 ± 1.7diopters. During follow-up, four children developed unilateral amblyopia (one because of anisometropia, three because of anisometropia and strabismus). From these, three recovered with treatment. Until the age of 10 years, the number of children that presented with strabismus did not decrease.

CONCLUSION

In our study, children with moderate to high hyperopia did not experience a significant reduction in the power of the refractive error. Although almost 50% of children had an initial deviation, only one had amblyopia at the end of follow-up. Implementing screening strategies for the early detection of this refractive error may prevent long-term vision morbidity in hyperopic children.

A Randomized Clinical Trial of Immediate Versus Delayed Glasses for Moderate Hyperopia in Children 3 to 5 Years of Age

PURPOSE

To compare visual acuity (VA) and binocularity outcomes in moderately hyperopic children with normal VA and binocularity assigned to glasses versus observation.

DESIGN

Prospective randomized clinical trial (RCT).

METHODS

One hundred nineteen 3- to 5-year-old children with hyperopia between +3.00D and +6.00D spherical equivalent were randomly assigned to glasses versus observation (with glasses prescribed if deteriorated for subnormal distance VA or near stereoacuity, or manifest strabismus). Follow-up occurred every 6 months. At 3 years, the treatment strategy was classified as "failed" if any of the following were met, both with and without correction: subnormal distance VA or stereoacuity; manifest strabismus; or strabismus surgery during follow-up.

RESULTS

Of 84 (71%) children who completed the primary outcome examination, failure occurred in five (12%; 95% confidence interval [CI]: 4%-26%) of 41 assigned to glasses and four (9%; 95% CI: 3%-22%) of 43 assigned to observation (difference = 3%; 95% CI: -12%-18%; P = .72). Deterioration prior to 3 years (requiring glasses per protocol) occurred in 29% (95% CI: 19%-43%) assigned to glasses and 27% (95% CI: 17%-42%) assigned to observation.

CONCLUSIONS

In an RCT comparing glasses to observation for moderately hyperopic 3- to 5-year-old children with normal VA and binocularity, failure for VA or binocularity was not common. With insufficient enrollment and retention, our study was unable to determine whether immediate glasses prescription reduces failure rate, but low failure rates suggest that immediate glasses prescription for these children may not be needed to prevent failure for VA and/or binocularity.

Validity of the Spot Vision Screener in detecting vision disorders in children 6 months to 36 months of age

PURPOSE

To evaluate the Spot Vision Screener in detecting targeted vision disorders compared to cycloplegic retinoscopy in children <3 years of age.

METHODS

Children, ages 6 months to 36 months underwent vision screening using the Spot Vision Screener. Results were compared to results of comprehensive eye examinations. Validity of the Spot was evaluated by calculating the area under the curve (AUC); the receiver operating characteristics (ROC) were used to determine optimal sensitivity and specificity for detection of targeted vision disorders.

RESULTS

A total of 249 children were included. The AUC for detecting targeted vision disorders as defined by the study specific criteria using the Spot was 0.790. Compared to cycloplegic retinoscopy, the Spot underestimated hyperopia by 1.02 D (95% CI, 0.86-1.17 D). For hyperopia ≥4.5 D spherical equivalent (n = 10), the mean difference between the Spot and cycloplegic retinoscopy was 3.46 D (95% CI, 1.95-4.98 D). In contrast, the Spot overestimated astigmatism compared to cycloplegic retinoscopy (-1.00 D vs -0.48 D; P < 0.001) by -0.52 D (95% CI, 0.43-0.62 D).

CONCLUSIONS

The Spot Vision Screener showed good overall validity in detecting targeted vision disorders. It was within 0.5 D and 1 D of cycloplegic retinoscopy with regard to low hyperopia and astigmatism. Higher hyperopic spherical equivalent refractive errors showed larger differences in mean values between the Spot and cycloplegic retinoscopy.

Longitudinal Changes in Spherical Equivalent of Moderate to High Hyperopia: 2- to 8-Year Follow-Up of Children at an Initial Age of 5.5 to 8.4 Years

Purpose

Moderate to high hyperopia is associated with visual deficits. Currently, to our knowledge no study has reported its longitudinal refraction change in a large sample of schoolchildren. We investigated the longitudinal changes in spherical equivalent (SE) refractive error among schoolchildren with moderate to high hyperopia.

Methods

Medical records of patients seeking refractions at Zhongshan Ophthalmic Center between 2009 and 2017 were reviewed retrospectively. Eligible criteria included hyperopia ≥+2.00 diopters (D) at an initial age of 6 to 8 years, at least three visits, and at least a 2-year follow-up. Individual pattern of refraction development was evaluated based on the mean rate of change in SE. Mixed-effect regression analysis was used to explore factors associated with the rate of change.

Results

A total of 1769 cases were identified. Median initial age was 6.4 (interquartile range [IQR], 5.9 to 7.1) years and median age at the final visit was 10.1 (IQR, 8.9 to 11.5) years. Median initial SE was +3.13 (IQR, +2.38 to +5.25) D. On average, participants experienced a myopic shift of -0.35 ± 0.27 D/year. A considerable number of eyes (721, 40.8%) demonstrated a longitudinal change of less than ±0.25 D/year and approximately 1 of 3 (611/1769) eyes demonstrated a change of >-0.50 and ≤-0.25 D/year. Children with greater initial hyperopia (β = -0.02, P < 0.001) experienced significantly faster reduction in hyperopic refraction. Age and sex had statistically significant but clinically insignificant impacts on the rate of hyperopia reduction.

Conclusions

Variation exists in the refraction development of schoolchildren with moderate to high hyperopia. A considerable percentage of eyes demonstrates longitudinally stable refraction.

Validity of the +1.50 plus lens screening test as a predictor of uncorrected moderate hyperopia

PURPOSE

Screening for uncorrected hyperopia in school children is important given its association with poorer visual function and academic performance. However, standard distance visual acuity screening may not detect low to moderate hyperopia. The plus lens test is used to screen for hyperopia in many school screening protocols, but has not been well validated. The current study investigated the effectiveness of the plus lens test to identify hyperopia in school children.

METHODS

Participants included Grade 2 school children. Monocular distance visual acuity (logMAR letter chart) was measured unaided, and then through a +1.50D lens, known as the plus lens test. Cycloplegic refraction was undertaken to classify moderate hyperopia (≥+2.00D). Sensitivity, specificity, positive predictive values (PPV) and negative predictive values (NPV) were calculated for commonly used cut-offs for the plus lens test: 6/6, 6/9 and less than two lines difference between unaided acuity and acuity through the plus lens test.

RESULTS

The sample included 59 children (mean age 7.2 ± 0.4 years). Fourteen (24%) children were classified as having uncorrected hyperopia. The sensitivity and specificity of the +1.50 plus lens test for identifying hyperopia were 0% and 98% respectively for a 6/6 cut-off, 29% and 91% for 6/9 cut-off, and 50% and 76% for a <2 line reduction between unaided acuity and acuity through the plus lens test. Receiver Operating Curve (ROC) analysis revealed area under curves of 0.69 based on acuity through the plus lens test, and 0.65 for a reduction in acuity through the plus lens test.

CONCLUSIONS

The plus lens test has low sensitivity for detecting uncorrected hyperopia using traditional cut-offs of 6/9 or better. This raises questions about the role of the plus lens test in school screening batteries.

Visual Profile of Children who Passed or Failed the UK School Vision Screening Protocol

Background:

We applied the National Screening Committee vision screening protocol [pass criterion monocular acuity ≤ 0.2 LogMAR in both eyes(BE)] to children four to five years old to investigate the visual profile of children who passed/failed. Previous studies have only evaluated those failing. The aim was to derive false positive and negative values, specificity/sensitivity of the vision screening protocol for detecting significant visual defects (strabismus and/or significant refractive error) and the utility of a ‘plus blur test’ in identifying hyperopia.

Methods:

Participants included 294 children (5.2 ± 0.4 yrs). In addition to the vision screening protocol (monocular acuity–3 m crowded Keeler LogMAR letters), acuities were recorded through +2.50D and +4.00D lenses and ocular alignment and cycloplegic refractive error were assessed. Using acuity measures, participants were classed as passing/failing the screening protocol. Each participant was also classed as having a strabismus and/or significant refractive error (hyperopia ≥ +4.00DS; myopia ≤ –0.50DS; astigmatism ≤ –1.50DC; anisometropia ≥ +1.50DS) or no significant visual defects.

Results:

Of the 284 children who completed all tests, 27.8% failed to achieve 0.2 LogMAR in BE. The acuity pass/fail criterion had a sensitivity of 70.4% and specificity of 82.2% for detecting strabismus and/or significant refractive error. Of those who failed, 51.9% (n = 41/79) had no strabismus and/or significant refractive error (false positives). Of those who passed, 7.8% (n = 16/205) had visual defects (false negatives). The ‘plus blur tests’ improved sensitivity in detecting significant refractive error (+2.50D & +4.00D 90.7%) but significantly reduced specificity (+2.50D = 65.2%; +4.00D = 60.9%).

Conclusions:

School-entry vision screening is reasonably sensitive and specific for detecting strabismus and/or significant refractive error. Most children with visions poorer than 0.2 LogMAR need refractive intervention, and the majority of the remainder are likely false positives for significant visual defects. One in 13 children who pass have either strabismus and/or significant refractive error (7.8%). The inclusion of a ‘plus blur test’ was not a useful addition to the vision screening protocol.

Prevalence, Characteristics, and Risk Factors of Moderate or High Hyperopia among Multiethnic Children 6 to 72 Months of Age: A Pooled Analysis of Individual Participant Data

PURPOSE

To describe the prevalence, ocular characteristics, and associated risk factors of moderate to high hyperopia in early childhood.

DESIGN

Pooled analysis of individual participant data from population-based studies.

PARTICIPANTS

Six- to 72-month-old multiethnic children who participated in 4 population-based studies of pediatric eye diseases.

METHODS

The pooled studies conducted comparable parental interviews and ocular examinations including cycloplegic autorefraction. Presence of hyperopia was defined based on cycloplegic refractive error in the worse eye. Multivariate analyses were performed to evaluate the association of potential risk factors with hyperopia risk.

MAIN OUTCOME MEASURES

Prevalence and odds ratios of moderate to high hyperopia (≥4.0 diopters [D]).

RESULTS

Cycloplegic refraction was completed in 15 051 children 6 to 72 months of age. Among these children, the overall prevalence of moderate to high hyperopia (≥4.0 D) in the worse eye was 3.2% (95% confidence interval, 2.9%-3.5%), accounting for 15.6% of all hyperopia (≥2.0 D). Among children with moderate to high hyperopia, both eyes were affected in 64.4%, 28.9% showed spherical anisometropia of 1.0 D or more, and 19.5% showed astigmatism of 1.5 D or more. Among 36- to 72-month-old children with moderate to high hyperopia, 17.6% wore glasses. Prevalence of moderate to high hyperopia was slightly less in 12- to 23-month-old children and was relatively stable in children 24 months of age and older. Non-Hispanic and Hispanic white race and ethnicity, family history of strabismus, maternal smoking during pregnancy, and being a participant in the United States studies were associated with a higher risk of moderate to high hyperopia (P < 0.05).

CONCLUSIONS

By assembling similarly designed studies, our consortium provided robust estimates of the prevalence of moderate to high hyperopia in the general population and showed that in 6- to 72-month-old children, moderate to high hyperopia is not uncommon and its prevalence does not decrease with age. Risk factors for moderate to high hyperopia differ from those for low to moderate hyperopia (2.0-<4.0 D) in preschool children, with family history of strabismus and maternal smoking during pregnancy more strongly associated with moderate to high hyperopia than low to moderate hyperopia.

HGF-rs12536657 and Ocular Biometric Parameters in Hyperopic Children, Emmetropic Adolescents, and Young Adults: A Multicenter Quantitative Trait Study

Introduction

Even though ocular refractive state is highly heritable and under strong genetic control, the identification of susceptibility genes remains a challenge. Several HGF (hepatocyte growth factor) gene variants have been associated with ocular refractive errors and corneal pathology.

Purpose

Here, we assess the association of an HGF gene variant, previously reported as associated with hyperopia, and ocular biometric parameters in a multicenter Spanish cohort.

Methods

An observational prospective multicenter cross-sectional study was designed, including a total of 403 unrelated subjects comprising 188 hyperopic children (5 to 17 years) and 2 control groups: 52 emmetropic adolescents (13 to 17 years) and 163 emmetropic young adults (18 to 28 years). Each individual underwent a comprehensive eye examination including cycloplegic refraction, and topographic and ocular biometric analysis. Genomic DNA was extracted from oral swabs. HGF single nucleotide polymorphism (SNP) rs12536657 was genotyped. Genotypic, allelic, and logistic regression analyses were performed comparing the different groups. A quantitative trait association test analyzing several biometric parameters was also performed using generalized estimating equations (GEEs) adjusting for age and gender.

Results

No association between rs12536657 and hyperopia was found through gender-adjusted logistic regression comparing the hyperopic children with either of the two control groups. Significant associations between mean topographic corneal curvature and rs12536657 for G/A (slope = +0.32; CI 95%: 0.04-0.60; p=0.023) and A/A (slope = +0.76; CI 95%: 0.12-1.40; p=0.020) genotypes were observed with the age- and gender-adjusted univariate GEE model. Both flat and steep corneal topographic meridians were also significantly associated with rs12536657 for the G/A and A/A genotypes. No association was found between rs12536657 and any other topographic or biometric measurements.

Conclusions

Our results support a possible role for HGF gene variant rs12536657 in corneal curvature in our population. To our knowledge, this is the first multicenter quantitative trait association study of HGF genotypes and ocular biometric parameters comprising a pediatric cohort.

Comparison of cycloplegic refraction between Grand Seiko autorefractor and Retinomax autorefractor in the Vision in Preschoolers-Hyperopia in Preschoolers (VIP-HIP) Study

PURPOSE

To evaluate the agreement of cycloplegic refractive error measures between the Grand Seiko and Retinomax autorefractors in 4- and 5-year-old children.

METHODS

Cycloplegic refractive error of children was measured using the Grand Seiko and Retinomax during a comprehensive eye examination. Accommodative error was measured using the Grand Seiko. The differences in sphere, cylinder, spherical equivalent (SE) and intereye vector dioptric distance (VDD) between autorefractors were assessed using the Bland-Altman plot and 95% limits of agreement (95% LoA).

RESULTS

A total of 702 examinations were included. Compared to the Retinomax, the Grand Seiko provided statistically significantly larger values of sphere (mean difference, 0.34 D; 95% LoA, -0.46 to 1.14 D), SE (mean, 0.25 D; 95% LoA, -0.55 to 1.05 D), VDD (mean, 0.19 D; 95% LoA, -0.67 to 1.05 D), and more cylinder (mean, -0.18 D; 95% LoA, -0.91 to 0.55 D). The Grand Seiko measured ≥0.5 D than Retinomax in 43.1% of eyes for sphere and 29.8% of eyes for SE. In multivariate analysis, eyes with SE of >4 D (based on the average of two autorefractors) had larger differences in sphere (mean, 0.66 D vs 0.35 D; P < 0.0001) and SE (0.57 D vs 0.26 D; P < 0.0001) than eyes with SE of ≤4 D.

CONCLUSIONS

Under cycloplegia, the Grand Seiko provided higher measures of sphere, more cylinder, and higher SE than the Retinomax. Higher refractive error was associated with larger differences in sphere and SE between the Grand Seiko and Retinomax.