Guidelines for automated preschool vision screening: a 10-year, evidence-based update

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

OBJECTIVE

To assess the effectiveness of a kindergarten vision screening program by randomly assigning schools to receive or not receive vision screening, then following up 1.5 years later.

METHODS

Fifty high-needs elementary schools were randomly assigned to participate or not in a vision screening program for children in senior kindergarten (SK; age 5‒6 years). When the children were in Grade 2 (age 6‒7 years), vision screening was conducted at all 50 schools.

RESULTS

Contrary to expectations, screened and non-screened schools did not differ in the prevalence of suspected amblyopia in Grade 2 (8.6% vs. 7.5%, p = 0.10), nor prevalence of other visual problems such as astigmatism (45.1% vs. 47.1%, p = 0.51). There was also no difference between screened and non-screened schools in academic outcomes such as the proportion of children below grade level in reading (33% vs. 29%) or math (44% vs. 38%) (p = 0.86). However, more children were wearing glasses in screened than in non-screened schools (10.2% vs. 7.8%, p = 0.05), and more children reported their glasses as missing or broken (8.3% vs. 4.7%, p = 0.01), suggesting that SK screening had identified successfully those in need of glasses. Examination of individual results revealed that 72% of children diagnosed and treated for amblyopia in SK no longer had amblyopia in Grade 2.

CONCLUSION

The prevalence of amblyopia and other visual problems was not reduced in Grade 2 by our SK vision screening program, perhaps because of poor treatment compliance and high attrition. The results suggest that a single screening intervention is insufficient to reduce visual problems among young children. However, the data from individuals with amblyopia suggest that continuing vision care and access to glasses benefits children, especially children from lower socioeconomic class.

[Bibliometric study and analysis of citation networks of visual screening in primary care]

AIM

Screenings make it possible to detect anomalies that can be treated and identify patients who require referral to a specialist. The objective is to identify the different areas of research and determine the most cited publications on screening in primary care.

METHODS

An analysis of publications and visualization of citation networks has been carried out using the Citation Network Explorer software. The bibliographic search was carried out with the Web of Science (WOS) database using the search term: "screening AND (vision OR eye OR ocular OR visual)".

RESULTS

We analyzed 16707 publications in all fields, 23919 citation networks have been found. The number of publications has increased, with 2021 being the year with the highest number. The majority are scientific articles and the predominant language is English. The most cited article is a global meta-analysis on the prevalence of glaucoma, showing the importance of screening for its early detection since it is essential to avoid blindness. Using the clustering function we found 8 groups with a significant number of publications where we have bibliography on certain eye diseases: glaucoma, diabetic retinopathy, pediatric amblyopia, keratoconus and dry eye.

CONCLUSIONS

The main areas of study in relation to screening are the detection of diseases such as glaucoma, retinopathy of prematurity, keratoconus and dry eye. As well as the detection through visual analysis of childhood amblyopia and vision loss in elderly patients. It also gives importance to performing ocular motility tests in problems of acquired brain damage.

Agreement in non-cycloplegic and cycloplegic refraction between a photoscreener and a calibrated autorefractor

INTRODUCTION

Photoscreeners have been shown to provide excellent measurements of the refractive error. However, whether they could be used for assessing cycloplegic refraction has not been examied. This study aimed to evaluate the agreement between cycloplegic and non-cycloplegic measurements obtained using a photoscreener and stationary autorefractor, respectively.

METHODS

This study included all patients undergoing routine ophthalmic examination at the Hygeia Clinic (Poland) from June to July 2022. Each patient underwent non-cycloplegic and cycloplegic refraction assessments using the 2WIN photoscreener (Adaptica SRL, Padova, Italy) and an ARK-1 stationary autorefractor ARK-1 (Nidek Co Ltd., Tokyo, Japan), respectively. Each pair of assessments was conducted in random order, and all values were determined at a vertical distance of 12 mm. The agreement between cycloplegic and non-cycloplegic measurements was assessed using paired t-tests, Bland-Altman and ABCD ellipsoids.

RESULTS

This analysis included 82 patients, of which 52 were female. Their mean age was 34.39 ± 13.13 years. The non-cycloplegic spherical equivalent (SE) did not differ significantly between the 2WIN (- 1.22 ± 2.45) and ARK-1 (- 1.19 ± 2.96) devices (p = 0.580). However, the cycloplegic SE values demonstrated more negative values with the 2WIN device (- 1.13 ± 2.19) than with the ARK-1 device (- 0.75 ± 3.03; p = 0.007). The non-cycloplegic and cycloplegic measurements were strongly correlated between the devices (r = 0.9473 and 0.9411, respectively). However, the correlation between their cycloplegic shifts in SE was low (r = 0.2645). Ellipsoid refraction aligned better non-cycloplegic (ARK-1 = 1.00; 2WIN = 1.74) than with cycloplegic refraction (ARK-1 = 1.43; 2WIN = 1.90).

CONCLUSION

While the cycloplegic measurements obtained with the 2WIN photoscreener were strongly correlated with those obtained with the ARK-1 stationary autorefractor for most of the analyzed parameters, they should not be considered interchangeable.

Pre-Cycloplegic Exam Benefit of Photoscreening and Accommodation-Relaxing Skiascopy

Background

Seeking a quick way to estimate refractions for challenging pediatric patients, we studied two non-contact methods with particular attention to accuracy and level of stress in uncovering cycloplegic hyperopia.

Methods

Newly referred and follow-up pediatric eye patients had timed school bus accommodation-relaxing skiascopy (SBARS) and Plusoptix A12 (Px) photoscreener testing before cyclopentolate 1% confirmatory examinations. The ABCD ellipsoid univariate method based on relative blur and vector components was used to compare dry sphero-cylinder refraction estimates with cycloplegic. Receiver operating characteristic (ROC) curves were used to determine screening value.

Results

Three compared refractions were attempted in 191 racially diverse children of whom 100 were age 0.2-3.9 years and 91 were 4 to 14 years. Plusoptix failed to yield a result in 21 and an additional 21 were interpreted as an excess sphere. Median spherical equivalent did not differ between Px and SBARS for 149 with Px readings but in hyperopic patients, Plusoptix uncovered 27% less hyperopia. The ellipsoid for SBARS of 0.8 was better than 2.4 for Plusoptix (Mann-Whitney p<0.001). Plusoptix was fastest (3-15 seconds) followed by SBARS (15-30 seconds) compared to 30-45 minutes for cycloplegic exam.

Conclusion

Non-contact quick refractive methods enhanced confirmatory cycloplegic pediatric exam in high-risk pediatric patients.

Characteristics of Visual Function in Children With Cerebral Palsy and Intellectual Disabilities in Urban Beijing

Objective

To investigate ocular development and the characteristics of visual function among children with cerebral palsy (CP) and intellectual disabilities in Beijing's Chaoyang District schools.

Methods

A total of 160 children (320 eyes) with CP and intellectual disabilities, including 86 males and 74 females aged between 6 and 18 years old (median, 13.5 years), were included in this study. A total of 214 healthy children aged 6 to 18 years (median, 10 years) were recruited as a control group for visual function, including 116 males and 98 females. Subjective far vision, objective vision (electrophysiological sweep visual evoked potential), corrected vision, near stereopsis, ametropia, the anterior segment, and the fundus were examined.

Results

A total of 232 eyes (76.32%) were ametropic among 304 eyes that could cooperate; 200 eyes (65.79%) were astigmatic, 16 eyes (5.26%) were hyperopic, and 120 eyes (39.47%) were myopic. A total of 64 children had strabismus (40%), and 24 had nystagmus (15%). The near stereopsis test showed that 72 children (64.29%) demonstrated 100″ and less. A total of 214 healthy children aged 6 to 18 years were recruited as a control group for visual function. There was a significant difference in visual functions between children with intellectual disabilities and those without (Z = -10.370; P < 0.001).

Conclusions

The prevalence of abnormal visual function in children with CP and intellectual disability was significantly higher than that in healthy children. Among them, myopia is the main refractive error, and the correction rate was low.

Translational Relevance

The electrical signals generated by stimulating the retina with black and white stripes are transmitted to the brain. Scanning electrophysiological devices can capture the activity of the cerebral cortex and convert it into an electroencephalogram. Scanning electrophysiological electrooculography is used to examine the objective vision of children with cerebral palsy.

Measurement Accuracy When Using Spot Vision Screener With or Without Cycloplegia in Young Adults

Purpose

There are many unclear points about the accuracy of measurement of cycloplegic refraction using the Spot Vision Screener (SVS). This study aimed to investigate the accuracy of SVS measurements with cycloplegia for myopia.

Materials and Methods

Forty-nine healthy subjects were included, and refraction was measured. Objective refractions were measured by SVS, table-mounted autorefractometer (RT7000), and handheld autorefractometer (Retinomax Screeen) at noncycloplegic and cycloplegic conditions by 1% cyclopentolate. Subjective noncycloplegic refraction was obtained by a visual acuity and refraction test performed by certified orthoptists using a cross-cylinder. One-way repeated-measures analysis of variance was used to examine whether the measured refractions fluctuate due to different reflection tests.

Results

In the noncycloplegic condition, the mean (±standard deviation) spherical equivalent (SE) measured by subjective method, SVS, RT7000, and Retinomax Screeen were -2.56 ± 3.00, -2.62 ± 2.38, -3.05 ± 2.84, and -3.26 ± 2.97, respectively. The subjective SE and objective SE measured by SVS had significantly less myopic value than the objective SE measured by two autorefractometers (p < 0.001). In the cycloplegic condition, the mean (± standard deviation) SE measured by SVS, RT7000, and Retinomax Screeen were -2.07 ± 2.66, -2.62 ± 2.98, and -2.66 ± 3.02, respectively. The objective SE measured by SVS had significantly less myopic value than SEs measured using other methods (p < 0.001). In the cycloplegic condition, SVS showed a fixed error wherein the SE was more hyperopic than that with the subjective method and SVS had a proportional error.

Conclusion

In the measurement under cycloplegic conditions, use of an autorefractometer rather than a photorefractometer such as SVS was preferable.

Kaleidos-based binocular vision analyzer for the estimation of refractive errors and horizontal ocular deviation in children

CLINICAL RELEVANCE

Knowing the agreement and interobserver variability of the 2WIN-S photorefractometer with cycloplegic retinoscopy and prism cover test is important for judging the clinical usefulness of the device.

BACKGROUND

This study aims to determine an agreement and interobserver reliability between 2WIN-S photorefractometer and cycloplegic retinoscopy for estimating refractive errors and between 2WIN-S and prism cover test for measuring horizontal ocular deviation in children.

METHODS

Two groups of 129 and 64 participants (range, 5 to 16 years) were recruited for the agreement and interobserver reliability studies, respectively. Non-cycloplegic 2WIN-S refraction was compared with cycloplegic retinoscopy for low and moderate myopia and hyperopia. Similarly, corneal reflex-function (CR-function) of 2WIN-S was compared with prism cover test for horizontal ocular deviation. Bland-Altman plots were used to depict agreement, and the intraclass correlation coefficient (ICC) was used for determining interobserver reliability of repeated measures.

RESULTS

The mean differences in spherical equivalent, J0 (Cartesian astigmatism) and J45 (oblique Jackson cross-cylinder) between cycloplegic retinoscopy and 2WIN-S were 1.10 (95% CI = 0.97 to 1.21, p < 0.001), -0.06 (95% CI = -0.09 to -0.03, p < 0.001) and 0.009 (95% CI = -0.01 to 0.03, p = 0.35), respectively. The overall median difference in the horizontal ocular deviation between prism cover test and 2WIN-S was -4.5 (Interquartile range = -12.0 to 4.0). For constant strabismus, this difference was insignificant (median= -2.0, interquartile range = -11.0 to 6.7, p = 0.19) between prism cover test and 2WIN-S. The ICC was high for the spherical equivalent (0.997; p < 0.001), J0 (0.932; p < 0.001) and J45 (0.901; p < 0.001), whereas it was low-to-moderate for horizontal ocular deviation (0.50; p < 0.001).

CONCLUSION

2WIN-S refraction was in agreement with cycloplegic retinoscopy for low and moderate myopia and hyperopia, and requires an adjustment for the consistent differences between cycloplegic retinoscopy and 2WIN-S refraction. The measurement of constant strabismus with 2WIN-S is comparable to that of prism cover test.

Global research of artificial intelligence in strabismus: a bibliometric analysis

Purpose

To analyze the global publications on artificial intelligence (AI) in strabismus using a bibliometric approach.

Methods

The Web of Science Core Collection (WoSCC) database was used to retrieve all of the publications on AI in strabismus from 2002 to 2023. We analyzed the publication and citation trend and identified highly-cited articles, prolific countries, institutions, authors and journals, relevant research domains and keywords. VOSviewer (software) and Bibliometrix (package) were used for data analysis and visualization.

Results

By analyzing a total of 146 relevant publications, this study found an overall increasing trend in the number of annual publications and citations in the last decade. USA was the most productive country with the closest international cooperation. The top 3 research domains were Ophthalmology, Engineering Biomedical and Optics. Journal of AAPOS was the most productive journal in this field. The keywords analysis showed that "deep learning" and "machine learning" may be the hotspots in the future.

Conclusion

In recent years, research on the application of AI in strabismus has made remarkable progress. The future trends will be toward optimized technology and algorithms. Our findings help researchers better understand the development of this field and provide valuable clues for future research directions.

A population-level post-screening treatment cost framework to help inform vision screening choices for children under the age of seven

PURPOSE/BACKGROUND

Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services.

METHODS

The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care.

RESULTS

Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5.

CONCLUSIONS

All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.

Pediatric Eye Care Treatment Rates and Community Compliance to a Spectacle Provision Program in an Underserved School District in San Diego, CA

Significance

The need for early identification and treatment of young children's refractive error needs has become a public health concern. The UCSD Eyemobile for Children (EyeMobile) provides vision screenings and comprehensive eye exams on the Eyemobile among a population of underserved, predominantly Hispanic preschool and elementary school children. The program also provides spectacles for children who fail eye exams due to refractive error.

Methods

We performed a retrospective cross-sectional analysis of all children screened from 2011 to 2017 by the Eyemobile across 10 San Diego elementary schools. We examined demographics, distance and near visual acuity, autorefraction, stereopsis, and color vision. To measure compliance to our spectacle program, we checked if children who were prescribed spectacles were wearing them, as instructed, at the following year's screening. Differences between compliance measures with respect to school, age, ethnicity, and gender were determined using chi-square analysis, while all other measures were fit to a binary logistic regression to determine statistically significant factors.

Results

A total of 12,176 elementary school children were screened between 2011 and 2017. Of these children, 5269 (43.3%) were referred for a comprehensive eye examination. Across six years, 3163 (60.0%) of the children referred completed their eye examinations. There was a significant increase (p < 0.001) in exam completion in the successive years. Exam completion was significantly higher in ten-year-olds (p = 0.0278) and in 3 of the 10 schools (p < 0.0001, p = 0.0027, and p = 0.0309). A total of 1089 (8.9% of screened) children were prescribed spectacles. Of the 409 children that were recorded with the compliance method, 342 (83.6%) were found to be fully compliant and wearing their spectacles as prescribed.

Conclusion

The Eyemobile program demonstrated high levels of compliance for both eye examination completion and prescribed spectacle wear in underserved populations in the San Diego region, compared to similar national programs.

Congenital Cataracts in Preterm Infants: A Review

A congenital cataract is one of the most treatable causes of visual impairment during infancy. Preterm infants who are born alive before 37 weeks of pregnancy need special care, including proper age documentation, preoperative assessment, and monitoring postoperatively for at least 24 hours. Management of cataracts in preterm infants is critical as regards the timing of cataract surgery and the challenges associated with cataract surgery and posterior segment management for retinopathy of prematurity (ROP). This narrative review aims to provide comprehensive insight and up-to-date clinical research findings regarding the pathophysiology and management of congenital cataracts in preterm infants.

IMI-Management and Investigation of High Myopia in Infants and Young Children

Purpose

The purpose of this study was to evaluate the epidemiology, etiology, clinical assessment, investigation, management, and visual consequences of high myopia (≤-6 diopters [D]) in infants and young children.

Findings

High myopia is rare in pre-school children with a prevalence less than 1%. The etiology of myopia in such children is different than in older children, with a high rate of secondary myopia associated with prematurity or genetic causes. The priority following the diagnosis of high myopia in childhood is to determine whether there is an associated medical diagnosis that may be of greater overall importance to the health of the child through a clinical evaluation that targets the commonest features associated with syndromic forms of myopia. Biometric evaluation (including axial length and corneal curvature) is important to distinguishing axial myopia from refractive myopia associated with abnormal development of the anterior segment. Additional investigation includes ocular imaging, electrophysiological tests, genetic testing, and involvement of pediatricians and clinical geneticists is often warranted. Following investigation, optical correction is essential, but this may be more challenging and complex than in older children. Application of myopia control interventions in this group of children requires a case-by-case approach due to the lack of evidence of efficacy and clinical heterogeneity of high myopia in young children.

Conclusions

High myopia in infants and young children is a rare condition with a different pattern of etiology to that seen in older children. The clinical management of such children, in terms of investigation, optical correction, and use of myopia control treatments, is a complex and often multidisciplinary process.

Analysis of risk factors associated with the high incidence of amblyopia in preterm infants at the corrected gestational age of 12 months

OBJECTIVE

To investigate the perinatal and in-hospital risk factors associated with the high incidence of amblyopia in preterm infants and to analyze the correlation between the amblyopia and neurodevelopment.

METHODS

Children discharged from the neonatal intensive care unit (NICU) at 12 months of corrected gestational age were retrospectively included in this study. Ocular screening was performed in children. At the risk of amblyopia was determined according to the American Academy of Ophthalmology Guidelines for automated preschool vision screening factors. Differences in perinatal characteristics, complications during hospitalization, and treatment modalities between the two groups of children were analyzed, and multifactorial logistic regression analysis was used to identify the independent risk factors for amblyopia. The results of developmental assessment were collected retrospectively to analyze the correlation between amblyopia and various aspects of neurological development.

RESULTS

A total of 128 preterm infants, 30 in the amblyopia risk group and 98 in the non-amblyopia risk group, were included in this study. Univariate analysis showed that the amblyopia risk group had lower birth weights, higher rates of asphyxia, preterm brain white matter injury, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), sepsis during hospitalization, and higher rates of treatment with pulmonary surfactant (PS), blood transfusion, invasive ventilator, and levothyroxine. Logistic regression analysis showed that BPD in the neonatal period (odds ratio [OR] 8.355, 95% confidence interval [CI] 1.492, 46.786), brain white matter injury (OR 16.742, 95% CI 0.684, 409.804), treatment with levothyroxine (OR 2.859, 95% CI 0.946, 8.639), and use of an invasive ventilator (OR 2.983, 95% CI 0.942, 9.445) were independent risk factors for amblyopia at 12 months of corrected gestational age, while the administration of glucocorticoids (OR 0.055, 95% CI 0.004, 0.737) was a protective factor. Regarding neurodevelopmental assessment, the number of infants with lagging fine motor development was greater in the amblyopia risk group.

CONCLUSION

The presence of BPD in the neonatal period, brain white matter damage in preterm infants, and use of levothyroxine and invasive ventilator were high risk factors for amblyopia. The use of glucocorticoids therapy was a protective factor. Children with risk of amblyopia had a higher rate of poor fine motor development.

Diagnostic performance of the Spot vision photoscreener for the detection of exodeviation in preschool-aged children

PURPOSE

To evaluate the diagnostic performance of the Welch Allyn Spot Vision photoscreener in preschool children for detecting exotropia, the most prevalent type of strabismus among Asian children.

METHODS

Children aged 3-6 years were screened using the Spot Vision photoscreener and then underwent a complete ophthalmologic examination on the same day. A child with exodeviation ≥8 Δ in the primary position using the cover-uncover test and the alternate prism cover test was confirmed to have exotropia. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the photoscreener in detecting exotropia were calculated. Subgroup analyses were performed according to the angle of deviation (≥25 Δ vs. <25 Δ) and fusional control (good/fair vs. poor).

RESULTS

Two hundred and ten children were included in this study. Among 80 exotropia-confirmed children, 23 needed referrals for exodeviation (screening-positive) and 57 were proven to be screening-negatives with the photoscreener. The overall sensitivity, specificity, PPV and NPV of the photoscreener for detecting exotropia were 28.8%, 95.4%, 79.3% and 68.5%, respectively. The positive and negative likelihood ratios were 6.26 and 0.75, respectively. Compared with the 57 children with false-negatives (71.3%), those with true-positive results with the photoscreener had significantly larger angles of exodeviation (p = 0.02) and a higher proportion of poor fusional control (p = 0.004). The photoscreener had low sensitivity even in detecting exotropia ≥25 Δ or those with poor fusional control (35.2% and 43.6%, respectively). Approximately 65% (42 out of 64) of the children with a significant exodeviation which needed strabismus surgery were not identified by the Spot Vision Photoscreener.

CONCLUSIONS

The Spot Vision photoscreener has low sensitivity for detecting exodeviation. It should not be used alone for assessing exotropia in preschool-aged children.

Early Detection of Refractive Errors by Photorefraction at School Age

Early detection and treatment of refractive defects during school age are essential to avoid irreversible future vision loss and potential school problems. Previously, vision screening of preschool children used methods based on subjective visual acuity; however, technologies such as photorefraction have promoted the detection of refractive errors quickly and easily. In this study, 1347 children from 10 schools in Madrid aged 4 to 12 years participated in a program of early detection of visual problems, which consisted of visual screening composed of anamnesis and photorefraction with a PlusOptix A12R. The prevalence of refractive errors was analyzed in terms of spherical equivalent, cylinder and its orientation, and potential cases of development of high myopia or amblyopia. Hyperopia predominates in the early years, but the number of myopic subjects is higher than that of hyperopic subjects from the age of ten onwards. At all ages, the predominant orientation of astigmatism was with-the-rule. On average, 80% of the myopic subjects were uncorrected. Potential high myopia increased with age, from 4 to 21% of the measured population. Potential amblyopia cases decreased across age groups, from 19 to 13.7%. There is a need to raise awareness of the importance of vision screening at school age to address vision problems.

Rise of the Machines? Comparison of Cycloplegic Refraction Using Retinoscopy and the Retinomax K-Plus 5 in Children

PURPOSE

To compare the ability to detect refractive anomalies in children using automated refraction versus retinoscopic cycloplegic refraction.

METHODS

A pediatric population from a pediatric eye institute underwent complete ophthalmic examinations. Children were randomly assigned to one of two pediatric optometrists who performed manual cycloplegic refraction using retinoscopy and automated cycloplegic refraction using a handheld autorefractometer (Retinomax K-plus 5; Right Mfg. Co., Ltd.). Recorded patient data included refraction values for each eye (sphere, astigmatism, and axis), use of glasses, and degree of cooperation.

RESULTS

Two hundred thirteen children were included. The mean age was 6.2 years. For all ages, strong associations were found in sphere and spherical equivalent (SE) measurements between the two methods (b = 0.78, P < .001; b = 0.71, P < .001; respectively). Among children older than 5 years, associations between the two methods were significant in all parameters (sphere: b = 0.99, P < .001; astigmatism: b = 0.69, P < .001; axis: b = 0.19, P < .05; SE: b = 0.97, P < .001), whereas among children 5 years and younger, a significant association was found only in the axis measurements (b = 0.31, P < .01). Retinomax K-plus 5 measurements showed significantly more hyperopic results in sphere measurements and higher astigmatism in all children examined, but this difference was markedly higher in children 5 years and younger. Good cooperation was observed in 94.1% of children older than 5 years and 77% of children 5 years and younger (P < .001).

CONCLUSIONS

The Retinomax K-plus 5 may be used for screening in children older than 5 years. However, in all age groups, it may not be accurate enough for treatment and decision making, even with good cooperation. [J Pediatr Ophthalmol Strabismus. 2022;59(6):380-387.].

Non-Cycloplegic and Cycloplegic Autorefraction with Retinomax: An Agreement Study in Preschoolers in Los Angeles, California

PURPOSE

To evaluate the agreement between non-cycloplegic autorefraction (NCAR) and cycloplegic autorefraction (CAR) in an ethnically diverse population of preschool-aged children and the validity of the screening criteria used to refer for further evaluation.

METHODS

This study included data from 7,073 preschoolers who underwent NCAR and CAR, which enabled refractive error classification based on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 2013 criteria. Right eye data of sphere and cylinder were used to compare NCAR to CAR via paired t-testing and vector analyses, and left eye data for an analysis on anisometropia. The sensitivity and specificity of screening referral criteria for refractive error were calculated.

RESULTS

Mean values of sphere differed between NCAR and CAR by 1.95 ± 1.45 D (p < .05) with 95% limits of agreement (LoA) of -0.94 to 4.85 D, with less discrepancy found in myopic eyes. The mean values of cylinder differed by -0.08 ± 0.43 D (p < .05) with 95% LoA of -0.93 to 0.77 D. Power vector results reflected a similar lack of agreement. The sensitivity and specificity of our screening referral criteria were, respectively, 66% and 84% for myopia, 66% and 98% for hyperopia, and 98% and 58% for astigmatism.

CONCLUSION

NCAR is insufficient in preschoolers for spherical refractive error referrals. Level of agreements was lower for spherical (15.5% within 0.5D) and higher for cylindrical refractive errors (89.6%) compared to CAR. In the absence of cycloplegic examination, screening programs using NCAR should utilize low referral thresholds for spherical refractive error.

[Detections of refractive risk factors for amblyopia with Plusoptix Autorefractor A09]

BACKGROUND

Amblyopia is the most frequent cause for decreased vision in childhood. Important risk factors for amblyopia (ARF) are refractive errors. The aim of this study was to examine the reliability of the Plusoptix Autorefractor A09 (POA09) to detect refractive ARF.

METHOD

This prospective non-blinded, one-armed study was conducted between February 2012 and September 2015. Children aged 6 months to 12 years were screened in kindergarten and schools for refractive errors. Thresholds for screening failure were hyperopia ≥ 3.5 diopters (D), myopia ≥ 3.0 D, anisometropia ≥ 1.5 D and astigmatism ≥ 1.5 D (axis 90° or 180° ± 10°) or ≥ 1.0 D (≥ 10° axis deviation of 90° or 180°). Children who failed screening were advised to see an ophthalmologist for a comprehensive eye examination. After the visit, parents were asked for the results of the examination. A reference group of children who did not fail screening also received a comprehensive eye examination. Based on the number of children who failed screening, we calculated the proportion of correctly detected refractive errors. Based on the children of the reference group we calculated the proportion of correctly excluded refractive errors and the false negative rate.

RESULTS

In this study 3170 children were screened, 715 children (22.3%) failed screening. For 460 of these (64.3%) follow-up was available and for 132 children information on refractive errors in cycloplegia was available. Most frequent refractive errors at screening were astigmatism (90.9%) and anisometropia (11.4%). Most frequent refractive errors in cycloplegia were astigmatism (56.8%) and hyperopia (18.9%). The proportion of correctly detected refractive errors in the screening was highest for astigmatism (60%) and anisometropia (53.3%), followed by hyperopia (33.3%) and myopia (25%).

CONCLUSION

The reliability of POA09 to detect refractive ARF in children without cycloplegia was limited, highlighting the importance of a systematic amblyopia screening. A screening in cycloplegia can increase the proportion of correctly detected refractive ARF and should be studied.

Evaluation of the Blinq Vision Screener in the Detection of Amblyopia and Strabismus in Children

Purpose

Amblyopia is a major health problem with an estimated 2% to 4% of the population affected. Screening combined with corrective measures, such as correction of refractive error and occlusion of the dominant eye, could reduce this prevalence. A new pediatric vision scanner, the blinq (Rebion, Boston, MA), studies the foveolar quality of fixation of each eye during binocular viewing. Based on the initial premise that poor quality foveolar or non-foveolar fixation is indicative of strabismus and, potentially of amblyopia, this study evaluates the effectiveness of the blinq screening device in detecting these two conditions compared to a standard ophthalmic examination (Gold Standard) based on the recommendations of the American Association for Pediatric Ophthalmology and Strabismus.

Material and Methods

A prospective study was performed on a total of 101 children between 2 and 8 years of age. These children were offered a test by the blinq screening device before a standard ophthalmological examination in the ophthalmology department of the Erasmus Hospital in Brussels, Belgium. The two tests were then compared.

Results

In a pediatric population heightened with amblyopia and strabismus (prevalence of 33.4%) and based on the Gold Standard Examination, the blinq device showed a specificity of 73.1% (95% confidence interval [CI] = 60.9%–83.2%) with a sensitivity of 91.2% (95% CI = 76.3%–98.1) to detect these conditions. The positive and negative predictive values were 63.3% (95% CI = 53.4%–72.2%) and 94.2% (95% CI = 84.6%–98%) respectively. The positive likelihood ratio (LR+) was 3.39 (95% CI = 2.26–5.11) for a negative likelihood ratio of 0.12 (95% CI = 0.04–0.36).

Conclusions

The blinq device has good sensitivity, but insufficient specificity to be used alone in the first line of screening. Whereas other devices on the market detect risk factors that may lead to amblyopia, the blinq pediatric vision scanner detects poor foveolar fixation and strabismus, giving it a potential advantage in sensitivity to directly detect strabismus, including microstrabismus. The blinq does not detect refractive abnormalities, however, and will therefore need to be improved in the future to be used alone in pediatric vision screening.

Translational Relevance

The blinq device detects visual axis alignment abnormalities with potential impact in the early detection of strabismus and subsequent associated amblyopia.

Refractive errors in a large dataset of French children: the ANJO study

Undetected refractive errors (REs) in children can lead to irreversible vision loss. This study aimed to show the proportions of REs in French children using cycloplegic refraction. Multicentre cross-sectional retrospective study including children with cycloplegic refraction and without associated ocular conditions from 2015 to 2018 in French eye clinics. The following data were collected: age, symptoms of eye strain, best-corrected visual acuity (BCVA), cycloplegic refraction. The analysis included 48,163 children (mean age: 7.75 years, range: 2 to 12 years). The proportion of each RE was as follows: emmetropia (− 0.50 < Spherical Equivalent (SE) ≤  + 2.0; 58.3%), hyperopia (+ 2.0 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$<$$\end{document}< SE \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le$$\end{document}≤+5; 17.2%), myopia (− 6 \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le$$\end{document}≤ SE \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\le$$\end{document}≤− 0.50; 15.5%), high myopia (SE < − 6; 0.5%), high hyperopia (SE >  + 5; 3.6%), mixed astigmatism (4.9%). Anisometropia (SE difference ≥ 1.5) was found in 5.0%. Functional amblyopia in children attending primary school (aged over 6 years) was encountered in 2.7%. Symptoms of eye strain were frequent (70%) but not specific to any RE. REs are frequently found in French children and may remain undetected in the absence of symptoms of eye strain. Few studies have investigated REs in children using cycloplegic refraction, which has been shown to be the gold standard for RE assessment.

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.

Multifaceted Amblyopia Screening with blinq, 2WIN, and PDI Check

Background

Novel devices target different facets of amblyopia risk factors (ARFs). Through birefringence, the Rebion blinq assesses binocular foveation. The Adaptica 2WIN is a multiradial infrared photorefractor that also estimates ocular alignment. PDI Check is a forced-choice, dynamic near-vision game for the autostereoscopic Nintendo 3DS.

Methods

New and returning patients to a pediatric ophthalmology clinic had concomitant confirmatory exams after all three vision screens had been validated with ROC curves, Bland–Altman plots, and Alaska Blind Child Discovery ellipsoid grades. Exam outcomes were classified by ARF visual acuity, strabismus, binocularity, and refractive errors following the 2021 AAPOS guidelines and Bosque–Hunter rubric for the blinq.

Results

A total of 202 ethnically diverse students aged 10±4 (4–19) years, 33% treatment-naïve, had a high (58%) prevalence of ARFs. Linear logMAR visual acuity, intereye differences, stereo and three-cone color correlated well between PDI Check and exams. Mean score on the 2WIN matched sphero-cylinder exam with ellipsoid scoring was 2.1±1.5. For AAPOS 2021 refractive plus strabismus, sensitivity/specificity for PDI Check was 68%/59%, 2WIN 72%/95%, and blinq 87%/32%. For the amblyopia or strabismus rubric, PDI Check was 79%/68%, 2WIN 56%/65%, and blinq 94%/37%.

Conclusion

Each device had advantages and disadvantages in screening this cohort of older, high-prevalence students, many of whom had already been treated. Validation methods should cover more than just refraction, as the new 2021 AAPOS guidelines do.

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Instrument Referral Criteria for PlusoptiX, SPOT and 2WIN Targeting 2021 AAPOS Guidelines

Background

Methods

Results

Conclusion

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Vision screening using a smartphone platform

Objective:

The main aim of this study was to evaluate the performance of a platform designed for pediatricians to screen amblyopia using a smartphone.

Methods:

The medical records of consecutive children who received visual screening using a smartphone platform were retrospectively reviewed. The smartphone was used with a flash concentrator case and a software for capturing images of both eyes simultaneously by a photorefraction mechanism. The platform performance was compared to the comprehensive ophthalmological examination, which is considered the gold standard for detecting amblyopia. Sensitivity, specificity, positive predictive value, and negative predictive value of the software in detecting amblyopia risk factors were calculated.

Results:

A total of 157 children were included, with a mean age of 6.0±.5 years (range 5–7). In 94% of the cases, the software was able to analyze the images and release a result, determining whether or not the child presented with amblyopia risk factors. Compared to the ophthalmological examination, the smartphone platform sensitivity in detecting amblyopia risk factors was 84%, the specificity was 74%, the positive predictive value was 86%, and the negative predictive value was 70%.

Conclusions:

The sensitivity and specificity of the smartphone photoscreening platform to detect amblyopia risk factors were within the range of traditional instrument-based vision screening technology. A smartphone photorefraction platform appears to be a promising cost-effective alternative to assist pediatricians and minimize obstacles to vision screening and amblyopia detection. Future studies are needed to gather additional comparative data.

Can photoscreening effectively detect amblyogenic risk factors in children with neurodevelopmental disability?

Purpose:

To analyze whether photoscreening can effectively detect amblyogenic risk factors in children with neurodevelopmental disability.

Methods:

A prospective study of 52 children attending a special school for children with neurodevelopmental disability from December 2017 to May 2018. All were initially tested with a photoscreening device: Welch Allyn® Spot® Vision Screener: model VS100 (Spot®) and further evaluated at a later date by a pediatric ophthalmologist, with a complete ocular evaluation including squint assessment, cycloplegic retinoscopy, and dilated fundus examination. The key parameters studied were demographic features, type of neurodevelopmental disability, refraction, ocular alignment, media clarity, any other ocular morbidity, and time taken for examination. The presence of amblyogenic risk factors (ARF) was analyzed as per the 2013 guidelines of the American Association for Pediatric Ophthalmology and Strabismus.

Results:

The mean age was 10.5 years (range: 1–17.5 years). Males (73.1%) outnumbered females (26.9%). The most common neurodevelopmental disability was cerebral palsy. Simple myopic astigmatism was the most common type of refractive error. Presence of ARF in our study was 73.1%. The sensitivity and specificity of photoscreening in detecting ARF were 96.5% and 63.61%, respectively, with a positive predictive value of 80% and negative predictive value of 92.31%. The predictive ability of photoscreening was 79.9% as per the area under curve. The average time taken for photoscreening was less than 60 s.

Conclusion:

Photoscreening can detect ARF with high sensitivity and reasonable specificity and is a handy, useful, and time-saving tool in screening children with neurodevelopmental disability.

Comparison of Two Photoscreeners in a Population of Syrian Refugee Children

PURPOSE

To evaluate children in the Za'atari refugee camp in Jordan to better understand the prevalence of ocular pathology and to compare two photoscreening devices to evaluate their utility.

METHODS

Families at the Syrian American Medical Society Clinic were offered vision screening for children aged 1 to 18 years. Participants were offered visual acuity measurement and photoscreening with two devices approved for use in the United States. If visual acuity in either eye was worse than 20/40 or either photoscreening device indicated possible pathology, a complete eye examination was performed with cycloplegic refraction and dilated examination.

RESULTS

Ninety-one participants completed the screening protocol. The average age of participants who completed the study was 7.8 years (range: 1 to 16 years). Twenty-eight participants (30.8%) failed at least one screening component. In this population, the following pathology was identified: astigmatism (12.1%), esotropia (9.9%), amblyopia (9.9%), hyperopia (7.7%), exotropia (3.3%), and myopia (1.1%). The Plusoptix vision screener (Plusoptix) had a sensitivity of 100% for the identification of amblyopia and 85% specificity. The GoCheck Kids application (Gobiquity) had a sensitivity of 66.67% for the identification of amblyopia and 94% specificity. The positive predictive value for the Plusoptix vision screener and the GoCheck Kids application for the detection of amblyopia risk factors was 77% for both.

CONCLUSIONS

The high rate of ophthalmic pathology identified in this study reinforces the urgent need for proper vision screening and intervention in this population. [J Pediatr Ophthalmol Strabismus. 2021;58(6):396-400.].

Physician Prescribing and Referral Patterns in Children with Cerebral Visual Impairment

SIGNIFICANCE

Cerebral visual impairment (CVI) is the leading cause of visual impairment in the developed world. Providing children with CVI with the appropriate treatment ensures the best possible visual outcome and potentially improves quality of life.

PURPOSE

The purpose of this study was to determine physician prescribing and visual rehabilitation referral patterns in children with CVI.

METHODS

A retrospective chart review was completed on children with CVI examined at Cincinnati Children's Hospital Medical Center from January 1, 2008, to March 1, 2018. Significant refractive error warranting correction was determined using the American Academy of Ophthalmology Preferred Guidelines and the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee Guidelines. The CVI Range was used as a surrogate to categorize CVI severity.

RESULTS

A total of 194 children were included. Sixty-eight (35%) had refractive error warranting correction and were prescribed glasses (group RC), 99 (51%) did not have refractive error warranting correction and were not prescribed glasses (group NRNC), 20 (10%) had refractive error warranting correction but were not prescribed glasses (group RNC), and 7 (4%) did not have refractive error warranting correction but were prescribed glasses (group NRC). There was greater than one-line Snellen equivalent difference between group RC (20/156) and group RNC (20/221). There was greater than six-line Snellen equivalent difference between group NRNC (20/149) and group NRC (20/35). Mean CVI Range score 2 values for each group were 5.9, 4.6, 4.8, and 7.1.

CONCLUSIONS

Children with less severe CVI were less likely to have significant refractive error but given glasses. Despite significant refractive error, children with more severe CVI were not prescribed glasses. Children with very low visual function were not prescribed glasses as frequently, possibly limiting their visual rehabilitation. Providers should ensure that all children with CVI are correctly prescribed glasses to provide the best possible visual outcome.

Ellipsoid Spectacle Comparison of Plusoptix, Retinomax and 2WIN Autorefractors

BACKGROUND

Handheld devices can automatically give an estimate of refraction. The established method for refraction comparison using spherical equivalent (M) and J0, J45 vector transformations by Bland-Altman analysis is too complex for non-eye doctors involved with vision screening and remote vision clinics. Therefore, a simpler comparison technique was developed.

METHODS

Based on the spectacle limit to resolve grade A 1 logMAR, B 3 logMAR and C 6 logMAR blur, J0, J45, and M are combined into the Alaska Blind Child Discovery (ABCD) composite ellipsoid GRADE system. Pediatric eye patients had confirmatory examination after dry refraction with three portable autorefractors: Plusoptix, 2WIN and Retinomax. The refractions were then compared using both Bland-Altman and ABCD composite. Performance to detect AAPOS amblyopia risk factors was also assessed.

RESULTS

A total of 202 children, mean age seven years, 28% high spectacle need and 43% AAPOS 2013 amblyopia risk factors showed high correlation with cycloplegic refraction (intraclass correlation 0.49 to 0.90) for sphere, J0 and J45 spectacle components. Plusoptix had more (10%) inconclusives due to patients out-of-range. The Retinomax was unable to screen some younger children and was less reliable for sphere but gave more precise astigmatism estimates. The proportion of autorefractions expected to give GRADE A/B high-need patients acuity improvement to 20/40 would be 41% for Plusoptix, 39% for 2WIN and 65% for Retinomax. Sensitivity/specificity for amblyopia risk factor detection was 80%/83% for Plusoptix, 72%/88% for 2WIN and 84%/73% for Retinomax.

CONCLUSION

The simplified spectacle comparison resembled Bland-Altman and could assist lay vision screeners and non-eye doctors attempting remote spectacle donation worldwide.

A Systematic Review of Clinical Practice Guidelines for Infectious and Non-infectious Conjunctivitis

PURPOSE

To systematically review and critically appraise clinical practice guidelines (CPGs) and summarise the recommendations for non-infectious and infectious conjunctivitis.

METHODS

CPGs published on non-infectious and infectious conjunctivitis between 2010 and March 2020 were reviewed, evaluated, and selected using nine items from the Appraisal of Guidelines for Research and Evaluation II tool (4, 7, 8, 10, 12, 13, 15, 22 and 23). CPGs with an average score for items 4, 7, 8, 12, or 22 below 3 and/or a sum of the two researchers' average score for all nine items less than 45 were excluded. Two authors independently extracted and validated the data using standardised forms.

RESULTS

Fifteen CPGs from five sources remained for data extraction. CPGs consistently recommended non-pharmacological interventions (artificial tears, cold compress, avoidance or removal of allergens) for non-infectious conjunctivitis and pharmacological interventions (topical anti-histamine, mast-cell stabiliser and dual-acting agent) for allergy types. Observation without treatment was strongly recommended for non-herpetic viral and bacterial infections. Systemic and topical anti-viral was consistently recommended for herpetic viral conjunctivitis, while systemic and topical antibiotics were recommended for chlamydial and gonorrhoeal conjunctivitis. The methods used to assess the level of evidence and the strength of recommendation varied among CPGs.

CONCLUSIONS

There are a number of high-quality CPGs for non-infectious and infectious conjunctivitis. While there were a number of consistencies in the recommendations provided within these CPGs, several inconsistencies were also identified. Many of which related to the scope of practise of the targeted end-user of the particular guideline.

Community based vision screening in preschool children; performance of the Spot Vision Screener and optotype testing

BACKGROUND

Children's vision screening children commonly uses optotype-based visual acuity or instrument-based methods measuring amblyogenic risk factors (ARFs).

OBJECTIVE

To compare the performance of the Spot Vision Screener (SVS) (PediaVision, Welch Allyn, NY) and a nurse-administered visual acuity screen (NVAS) in identifying ARFs and decreased visual acuity.

METHODS

A prospective, cross-sectional population-based study of preschool children in South-East Queensland, Australia. Eligible participants had both forms of screening by trained community nurses. All children with an abnormal result by either method as well as a cohort of randomly selected children who passed both assessments were assessed at a tertiary paediatric ophthalmology clinic.

RESULTS

Over a 10 month period, 2237 children (mean age; 64.4 ± 4.0 months) were screened from 38 schools. 6.4% of children failed SVS and 8.3% failed NVAS (with 3.8% overlap, failing both). The positive predictive value (PPV) in identifying either ARFs and/or reduced VA for the SVS and NVAS was 70.4% (95% Confidence Interval (CI): 61.6%-78.2%) and 60.5% (95% CI: 52.6%-67.9%) respectively. Highest PPV to detect either ARFs and/or reduced VA was achieved by a 'hybrid' method by combining failed NVAS and failed SVS: 91.0% (95% CI: 82.4 to 96.3) but this would risk children with sight impairment being missed in the community.

CONCLUSION

To our knowledge, this is the first population-based study providing detailed comparative measures of diagnostic accuracy for NVAS and SVS in preschool children. One in ten preschool children failed one or both screens. A number of children who required ophthalmic intervention were missed if only one screening method was utilized.

Outcomes after Cataract Surgery in High Myopes with Axial Length Differences of ≥2 mm

Purpose: To evaluate the visual outcome after cataract operations in high myopia patients, whose axial length differences are longer than 2 mm.Methods: A retrospective study was conducted on patients who had received phacoemulsification cataract surgery from January 2014 to June 2020. The patients whose axial lengths and inter-eye axial lengths exceeded 26 and 2 mm, respectively, were selected. Demographic data, axial lengths, central subfield macular thickness, retinal nerve fiber layer, and best-corrected visual acuities (BCVAs) before and at 6 months postoperatively were collected. The factors related to visual outcome were analyzed using univariate, multivariate linear regression.Results: Twelve patients had an inter-eye axial length difference longer than 2 mm. The average axial lengths of longer and shorter eyes were 29.17 ± 1.94 and 26.66 ± 2.51 mm, respectively (p = 0.02, Mann-Whitney U-test). The BCVAs (logarithm of minimal angle of resolution, logMAR) of the longer and shorter eyes before the surgery were 1.09 ± 0.62 and 0.19 ± 0.16, respectively (p = 0.03, Mann-Whitney U-test). The BCVAs (logMAR) of the longer and shorter eyes 6 months after surgery were 0.19 ± 0.16 and 0.08 ± 0.10, respectively (p = 0.11, Mann-Whitney U-test). In univariate linear regression analysis, the BCVAs 6 months after the surgery showed better preoperative BCVAs (p < 0.001) and a thinner central subfield macular thickness (p = 0.001). In multivariate linear regression analysis, the BCVA at 6 months after the surgery showed significant improvement compared with preoperative BCVA values (p < 0.001).Conclusions: High myopia patients whose axial length differences exceeded 2 mm showed improved VA after cataract surgery.

Effectiveness of Kanna photoscreener in detecting amblyopia risk factors

Purpose:

Amblyopia is a significant public health problem. Photoscreeners have been shown to have significant potential for screening; however, most are limited by cost and display low accuracy. The purpose of this study was validate a novel artificial intelligence (AI) and machine learning–based facial photoscreener “Kanna,” and to determine its effectiveness in detecting amblyopia risk factors.

Methods:

A prospective study that included 654 patients aged below 18 years was conducted in our outpatient clinic. Using an android smartphone, three images of each the participants’ face were captured by trained optometrists in dark and ambient light conditions and uploaded onto Kanna. Deep learning was used to create an amblyopia risk score based on our previous study. The algorithm generates a risk dashboard consisting of six values: five normalized risk scores for ptosis, strabismus, hyperopia, myopia and media opacities; and one binary value denoting if a child is “at-risk” or “not at-risk.” The presence of amblyopia risk factors (ARF) as determined on the ophthalmic examination was compared with the Kanna photoscreener.

Results:

Correlated patient data for 654 participants were analyzed. The mean age of the study population was 7.87 years. The algorithm had an F-score, 85.9%; accuracy, 90.8%; sensitivity, 83.6%; specificity, 94.5%; positive predictive value, 88.4%; and negative predictive value, 91.9% in identifying amblyopia risk factors. The P value for the amblyopia risk calculation was 8.5 × 10⁻¹⁴² implying strong statistical significance.

Conclusion:

The Kanna photo-based screener that uses deep learning to analyze photographs is an effective alternative for screening children for amblyopia risk factors.

Prediction and cost-effectiveness comparison of amblyopia screening methods at ages 3-4 years

PURPOSE

Compare the performance of different amblyopia screening tests.

METHODS

Based on exploratory factor analyses (EFA) of different screening tests performed in 3295 children, we created models of screening strategies in a matrix with: uncorrected visual acuity (UCVA), Plusoptix measurements (PO), Randot Stereo-test (SR), and Cover-Test (CT). Receiver Operating Characteristic (ROC) curves and confusion matrix were used to compare performance of different model's algorithm to predict new diagnosis of amblyopia. Estimated screening costs per screened and treated child were compared.

RESULTS

Regression analyses revealed that, although all models predicted amblyopia (all p < 0.001), only models including PO or UCVA had higher prediction capacity (R² > 0.4) and better discriminating ROC curves (AUC > 0.95; p < 0.001). For 96% sensitivity, UCVA + PO was the most cost-effective model, since the estimated average screening costs per treated child, almost doubled and tripled if using PO or UCVA alone, respectively, versus using both exams. When UCVA + PO is not possible to implement, adding SR to either UCVA or PO resulted in cost-savings of 28% and 18%, respectively.

CONCLUSIONS

In a previous unscreened population, aged 3-4 years, screening programs using either UCVA or PO alone, should reconsider doing both tests simultaneously, since, for a high level of sensitivity, using simultaneously UCVA + PO is more cost-effective, per screened, and treated amblyopia. Concerns relating higher time-consuming exams for the combination of UCVA + PO should be surpassed, since costs per treated child drop considerably. When children benefit from good primary-care routine examinations since birth, no benefit was found for using CT in a screening setting. SR showed little benefit.

Amblyopia risk factors among pediatric patients in a hospital-based setting using photoscreening

PURPOSE

The aim of our study was to determine the prevalence of amblyopia risk factors in children visiting the American University of Beirut Medical Center (AUBMC) using automated vision screening.

METHODS

This was a hospital-based screening of 1102 children aged between 2 and 6 years. Vision screening was performed using PlusoptiX S12 over 2 years (2018-2020). The need for referral to a pediatric ophthalmologist was based on the amblyopia risk factors set forth by the American Association for Pediatric Ophthalmology and Strabismus. Referred patients underwent a comprehensive eye examination.

RESULTS

A total of 1102 children were screened, 63 were referred for amblyopia risk factors (5.7%); 37/63 (59%) underwent comprehensive eye examination and 73% were prescribed glasses. Of the non-referred group of children, 6.35% had astigmatism, 6.25% were hyperopic and 3.27% were myopic. The refractive errors observed among the examined patients were distributed as follows: 41% astigmatism, 51% hyperopia, and 8% myopia; amblyopia was not detected. Refractive amblyopia risk factors were associated with the presence of systemic disorders. Bland-Altman plots showed most of the differences to be within limits of agreement.

CONCLUSION

Using an automated vision screener in a hospital-based cohort of children aged 2 to 6 years, the rate of refractive amblyopia risk factors was 5.7%. Hyperopia was the most commonly encountered refractive error and children with systemic disorders were at higher risk.

Costs and effectiveness of two models of school-entry visual acuity screening in the UK

Cost effectiveness of different visual screening modalities cannot be calculated without long-term outcome data. This paper reports detailed outcomes from a gold-standard UK recommended orthoptist-delivered screening (ODS) at 4-5 years in school, compared to a neighboring school-nurse delivered screening (SNDS), both feeding into the same treatment pathway. The target condition was reduced visual acuity (VA) of worse than logMAR 0.2 in either eye.Available records from screening databases and hospital records were analyzed, comparing the two services wherever possible.More screening data was available from the ODS. ODS: 5706 screened, 3.5% referred. False positives 6.5%, PPV 91.4%, sensitivity 97.9%, and specificity 99.8% for reduced VA. Cost per child with reduced vision detected £195.22, and per amblyope detected £683.28. The mean treatment cost per child with reduced VA was £331.68 and for amblyopia treatment was £458.65.SNDS: 5630 screened and 3.8% referred (plus some referrals to local optometrists lost to follow up). False positives 34%, PPV 53.2%, sensitivity and specificity estimated as 89.3% and 98.67%. Costs to secondary services of false positives were seven times greater. The cost per child with confirmed reduced vision seen at the hospital was 46% more; and per amblyope detected was 39% more.Outcomes for treatment post referral in both groups were similar and excellent. 86% of genuine referrals improved to within normal limits with glasses alone. Of 221 genuine referrals with final outcome data, all now have better than 0.2logMAR acuity in the better eye and only two (0.9%) have residual amblyopia in one eye worse than 0.4logMAR.About 14-18% of children with reduced VA would have passed AAPOS photoscreening referral criteria.An orthoptist-delivered single VA screen at 4-5 years is highly cost effective with good outcomes. The main contributing factors to success appear to be training and experience in accurate VA testing, the opportunity to rescreen equivocal results, and monitoring, audit, and feedback of outcomes.

Comparing School-Aged Refraction Measurements Using the 2WIN-S Portable Refractor in Relation to Cycloplegic Retinoscopy: A Cross-Sectional Study

Purpose

To assess the repeatability and agreement of refractive measurements using 2WIN-S photoscreening with the gold-standard cycloplegic retinoscope refraction.

Design

Single centre, cross-sectional study.

Methods

Spherical, cylindrical, axis, and spherical equivalent of 194 bilateral eyes of 97 children were assessed using a retinoscope and 2WIN-S. One week later, another operator repeated the 2WIN-S measurements. The primary outcome measures were to assess the repeatability and agreement between spherical equivalent, J0, and J45 readings of 2WIN-S. The repeatability of measurements was assessed by the within-subject standard deviation (2.77 Sw) and intraclass correlation coefficient (ICC). The agreement between devices was assessed using 95% limits of agreement. The extent of the agreement between cycloplegic retinoscopy and noncycloplegic 2WIN-S measurements was assessed using Bland–Altman analysis.

Results

The mean age ± SD was 10.3 ± 2.46 year (range, 4–14 years). The sphere, cylinder, and spherical equivalent measurements were found to be consistent with both apparatus (r value >0.86). ICC for SE, J0, and J45 was 0.900, 0.666, and 0.639, respectively; Sw for SE, J0, and J45 was 0.61D, 0.30D, and 0.31D, respectively; Bland–Altman analysis of retinoscopy with cycloplegia and 2WIN-S for SE was 184/194 (95%) in 95% confidence interval, and the mean value was 0.46. J0 was 184/194 (95%), and the mean value is −0.04. J45 was 181/194 (93%), and the mean value is −0.15.

Conclusion

The objective refractive measurement of 2WIN-S had good reliability and high agreement with the gold-standard retinoscopy refraction in children and adolescents. While consistency was observed, it is essential to take into consideration that it is a screening tool.

Spot Refractive Screening With or Without Maximum Atropine Cycloplegia in Preschool Chinese Children

PURPOSE

To evaluate averaged, repeat Spot Vision Screener (Welch Allyn) refractive screening with and without maximal atropine cycloplegia in preschool Chinese children.

METHODS

Refractive errors of 450 preschool children aged 3 to 6 years were measured by cycloplegic retinoscopy as the gold standard. The Spot Vision Screener was used to examine the refractive errors of these children before and after cycloplegia. The differences between the two methods were assessed using the Wilcoxon test and Bland-Altman plot. The accuracy of the Spot Vision Screener in detecting refractive errors was evaluated by receiver operating characteristic curve analysis.

RESULTS

Before cycloplegia, the Spot Vision Screener provided statistically significantly lower values of sphere (median difference: 1.50 diopters [D], 95% CI: 1.38 to 1.63 D) and spherical equivalent (median difference: 1.56 D, 95% CI: 1.50 to 1.69 D). For hyperopia of greater than 3.00 D spherical value (n = 118), the median difference between the Spot Vision Screener and cycloplegic retinoscopy was 2.63 D (95% CI: 2.50 to 2.88 D). The Bland-Altman plot showed that the difference between the results of the two examination methods was large. The sensitivity of the Spot Vision Screener for detecting refractive errors increased after the screening criteria were optimized.

CONCLUSIONS

The Spot Vision Screener was efficient in detecting anisometropia in Chinese preschool children. The Spot Vision Screener without cycloplegia underestimated the spherical value of hyperopia and the difference was larger when the cycloplegic hyperopia increased. The performance of the Spot Vision Screener without cycloplegia in detecting cycloplegic hyperopia was not complete. The instrument referral criteria of the Spot Vision Screener should be adjusted according to clinical practice, but it is not simple and users should do it with expert assistance. [J Pediatr Ophthalmol Strabismus. 2021;58(3):146-153.].

Instrument-based screening for amblyopia risk factors in a primary care setting in children aged 18 to 30 months

Amblyopia is the leading cause of vision impairment in children, and its early detection can avoid irreversible consequences for a child's visual ability. In this prospective study, to detect amblyopia risk factors, we examined patients aged 18 to 30 months in primary care settings. Patients were referred to an ophthalmologist for confirmation. The main aims were to detect amblyogenic risk factors and to assess the usefulness of a photoscreener in such settings. Out of 453 patients, 42 (9.3%) presented visual alterations according to the photoscreener, with astigmatism being the most common. The instrument had good sensitivity (89%) and specificity (91%), with a positive predictive value of 76% and a negative predictive value of 96%. Overall, 38% of the patients required follow-up, and 47% needed glasses. The automated screening device allowed these children to be diagnosed at an early stage.Conclusions: The use of a photoscreener to screen 2-year-old children in primary care settings was helpful and accurate. What is Known: • Early detection of amblyopic risk factors is important to avoid vision defects. However, it is very difficult to measure visual acuity using visual charts in children younger than 4 years old. What is New: • Instrument-based screening in children aged 18 to 30 months allows excellent detection of early amblyopia risk factors in primary care settings.

Mandated Kindergarten Eye Examinations in a US Suburban Clinic: Is It Worth the Cost?

Purpose

The state of Illinois has required an examination by an optometrist or ophthalmologist prior to mandatory kindergarten since 2008. This requirement has allowed us to gather information regarding disease prevalence in a local suburban population.

Methods

A retrospective chart review was undertaken of kindergarten eye examinations performed at the Wheaton Eye Clinic between September 2008 and February 2017. Inclusion criteria included school eye examination as a reason for the visit, and a cycloplegic refraction was completed.

Results

Of 3612 patient charts identified, 1085 satisfied the inclusion criteria, of which 48% were female. The average age of the patients was 5.3 years (range, 3.8 to 6.7). Historical characteristics showed 143 (13%) were premature, 28 (3%) patients were autistic and 109 (10%) were developmentally delayed. On examination, 56 (5%) had <20/40 (WHO mild visual impairment) vision in better seeing eye, 34 (3%) had spherical equivalent refractive error in either eye > +3.50 diopters and one < −3.00 diopters. Fifty-eight patients (5%) were diagnosed with amblyopia and 101 patients (9.3%) were given glasses. Abnormal external exam finding was found in 218 (20%) while 16 (1.5%) had an abnormal fundus finding. Thirteen percent (146/1085) had a clinically relevant diagnosis in our examinations, with a cost of $1635/diagnosis. In total, our follow-up rate was 83% (78/94).

Conclusion

Our rate of treatable ocular conditions discovered via state-mandated kindergarten eye examinations is similar to large-scale screening programs. The cost per condition found with full examinations was substantially higher; however, follow-up was more consistent.

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Measurement of visual acuity with a digital eye chart: optotypes, presentation modalities and repeatability

PURPOSE

Digital or computerised eye charts are becoming standard in the examination of visual acuity. Each instrument allows the selection of different optotypes, presentation modalities, and crowding. The aim of this study was to examine the differences in visual acuity (VA) measurement using a digital eye chart, comparing different optotypes and procedures, together with an evaluation of the repeatability of the measurement.

METHODS

Two groups of 52 participants aged between 18 and 31 years participated in the study. In the first experiment, VA thresholds were measured using LEA Symbols, Tumbling E, and Landolt Rings in monocular and binocular conditions using single line presentation and QUEST presentation. In the second experiment, we have compared all modalities of presentation together with a paper eye-chart and test the repeatability.

RESULTS

The results showed that thresholds for LEA Symbols are low. The modality of presentation affects these thresholds. For Landolt Rings and Tumbling E, the QUEST procedure gave significantly better thresholds than line presentation, while this difference was absent for LEA Symbols. In comparing all modalities of presentation, single letter and line presentation showed similar values, slightly better than block presentation. Paper eye-charts showed better values of VA. Repeatability and agreement were good for all presentations, but best for QUEST.

CONCLUSIONS

The QUEST modality of presentation provides a better threshold than line presentation except for LEA Symbols. Examiners using digital eye charts must take into account that not all modalities of presentation and optotypes are equivalent and give different VA thresholds. Specific thresholds need to be used for each optotype and presentation modality.

A smartphone ocular alignment measurement app in school screening for strabismus

Background

Strabismus is the leading risk factor for amblyopia, which should be early detected for minimized visual impairment. However, traditional school screening for strabismus can be challenged due to several factors, most notably training, mobility and cost. The purpose of our study is to evaluate the feasibility of using a smartphone application in school vision screening for detection of strabismus.

Methods

The beta smartphone application, EyeTurn, can measure ocular misalignment by computerized Hirschberg test. The application was used by a school nurse in a routine vision screening for 133 elementary school children. All app measurements were reviewed by an ophthalmologist to assess the rate of successful measurement and were flagged for in-person verification with prism alternating cover test (PACT) using a 2.4Δ threshold (root mean squared error of the app). A receiver operating characteristic (ROC) curve was used to determine the best sensitivity and specificity for an 8Δ threshold (recommended by AAPOS) with the PACT measurement as ground truth.

Results

The nurse obtained at least one successful app measurement for 93% of children (125/133). 40 were flagged for PACT, of which 6 were confirmed to have strabismus, including 4 exotropia (10△, 10△, 14△ and 18△), 1 constant esotropia (25△) and 1 accommodative esotropia (14△). Based on the ROC curve, the optimum threshold for the app to detect strabismus was determined to be 3.0△, with the best sensitivity (83.0%), specificity (76.5%). With this threshold the app would have missed one child with accommodative esotriopia, whereas conventional screening missed 3 cases of intermittent extropia.

Conclusions

Results support feasibility of use of the app by personnel without professional training in routine school screenings to improve detection of strabismus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01902-w.

Drive-by Photoscreening: Plusoptix, 2WIN and Blinq Amblyopia Detection During the COVID-19 Pandemic

Background

Community photoscreening for amblyopia had successfully been adopted by many communities, however many clinics curtailed screening as a result of the COVID-19 pandemic. We modified three conventional devices and tested them for outdoor, drive-by socially distanced photoscreening and refraction.

Methods

External frames that provide luminance control and focus distance were fashioned for plusoptiX S12 (Nuremberg, Germany), Adaptica 2WIN in Kaleidos case (Padova, Italy) and the Rebion blinq (Boston, USA). Children were screened by each device and then Retinomax (Righton, Japan) before AAPOS guideline validation.

Results

Eighty-eight children average age 8±7 years had precise refraction and alignment from which 69% AAPOS 2003 risk factors were determined. The sensitivity/specificity/inconclusive rate for plusoptiX was 85%/96%/16%, for 2WIN 79%/89%/5% and for blinq 43%/74%/8%. Blinq improved to 54%/70% when screening for amblyopia ± strabismus. Bland Altman analysis of spherical equivalent showed plusoptiX and 2WIN with less over-minus than Retinomax and J0 and J45 vectors highly reliable for astigmatism determination.

Conclusion

The infrared photorefractors in modified cases reliably screened amblyopia risk factors and refraction. The birefringent scanner provided drive-by results but less reliably with wire-frame opaque case than without the case in a dimly lit room. Modified drive-by photoscreeners could help reduce amblyopia and provide socially distanced refraction during an extended pandemic.

Effectiveness of the Spot Vision Screener in screening 3-year-old children with potential amblyopia in Japan

PURPOSE

The purpose of this study was to compare the efficiency of conventional screening and of the Spot™ Vision Screener (SVS)-based screening in detecting potential cases of amblyopia during the Visual examination in Three-Year-Old Health Screening Program (VTYOS), that need to be referred for comprehensive examination.

STUDY DESIGN

Population-based cross-sectional study METHODS: This study introduced the SVS-based test to the VTYOS (which includes primary, secondary, and comprehensive examinations) of Sagae, Yamagata Prefecture, Japan. Children aged 3 years 6 months scheduled to undergo the secondary examination were subjected to both the SVS-based (evaluation of refractive error and eye alignment) and conventional screening test (questionnaire and visual acuity evaluation). Success rates, proportion of children who needed a comprehensive examination, rates of actual comprehensive examinations, and positive predictive value were determined and compared between conventional screening and SVS-based screening.

RESULTS

There were 294 participants; the rate of success of SVS-based screening (99.7%) was higher than conventional screening (89.5%, p < 0.01). The proportion of participants found to need a comprehensive examination according to SVS-based findings (7.5%) was lower than that according to conventional screening-based findings (23.5%, p < 0.01). The positive predictive value of the SVS-based screening test (75.0%) was higher than that of the conventional screening test (31.6%, p < 0.01). SVS-based screening detected 2 cases of amblyopia in 225 cases that passed conventional screening.

CONCLUSION

The VTYOS should ideally add SVS-based screening to conventional screening.

Analysis of suspected visual impairment risks based on objective refraction in 3-year-old children

PURPOSE

To evaluate the relationship between uncorrected visual acuity and non-cycloplegic refractive value among 3-year-old children in a vision screening program in Japan.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

The participants were 1746 Japanese children screened from April 2009 to July 2018, and ranged in age from 36 to 47 months. Visual acuity and handheld refractive values were collected from the clinical records of 3-year-old children in a vision screening program. Multiple logistic regression analysis was used to evaluate the association between 0.3 logarithm of the minimum angle of resolution (logMAR) and > 0.3 logMAR. Correlation analysis was also performed for the presence of myopic shift.

RESULTS

Among the 1746 children (aged [mean ± standard deviation], 37.6 ± 1.6 months; percentage of boys, 50.4%), representing 3492 eyes, 116 eyes (3.3%) had > 0.3 logMAR. Multiple logistic regression analysis revealed that the risk factors for 1.75-2.00 diopter (D) spherical power (odds ratio [OR], 2.51; 95% confidence interval [CI] 1.12-5.64; P = 0.026) and 1.25-1.50 D cylindrical power (OR, 5.66; 95% CI 1.58-20.40; P < 0.01) were increased in eyes with > 0.3 logMAR. There was no myopic shift for 10 years (Spearman's rank correlation coefficient; P = 0.65).

CONCLUSION

It is important to set a threshold that comprises the characteristics of the autorefractor used in screening, and to ensure that, to help prevent amblyopia a thorough eye examination in ophthalmic institutions will be conducted taking into account population-based refractive values.

Validation of the 2WIN Corneal Reflexes App in children

PURPOSE

To test the reliability and accuracy of the 2Win Refractometer Corneal Reflexes App (CR App) in detecting manifest strabismus in pediatric patients.

METHODS

Prospective study involving 167 children with suspected strabismus (mean age 7.6 years; SD = 3.0, range 2-14 years) undergoing the CR App ocular alignment assessment (Pediatric Ophthalmologist) versus the alternate cover test with prism ocular alignment assessment for distance (Orthoptist) as the gold standard. The AAPOS 2013 guidelines for the detection of manifest strabismus in primary position (> 8 PD) were used.

RESULTS

Total sensitivity, specificity, PPV, and NPV for the CR App were 79.2%, 86.2%, 86.4%, and 78.9%, respectively. The overall inconclusive rate was 17.9%, but was 36.3% in children younger than 5. Sensitivity and PPV for vertical deviations were poor (33.3% and 12.5%, respectively). The accuracy of the CR App regarding the degree (in prism diopters) of manifest deviations was tested with the Wilcoxon signed rank sum test: correlation with the gold standard was good for esodeviations (p value = 0.765, not statistically significant) and poorer for exodeviations (p value = 0.056, still not statistically significant), whereas a significant difference (p value = 0.0001) was observed for vertical deviations.

CONCLUSION

The CR App showed good sensitivity, specificity, PPV, and NPV for manifest strabismus > 8PD in accordance with the AAPOS 2013 guidelines; sensitivity and PPV were poor for vertical deviations. The accuracy of the CR App was good for horizontal deviations, but poor for vertical deviations. The inconclusive result rate was high in younger children.