Screening for myopia and refractive errors using LogMAR visual acuity by optometrists and a simplified visual acuity chart by nurses

Cutoff values of axial length/corneal radius ratio for determining myopia vary with age among 3-18 years old children and adolescents

PURPOSE

To investigate the effectiveness and cutoffs of axial length/corneal radius (AL/CR) ratio for myopia detection in children by age.

METHODS

Totally, 21 kindergartens and schools were enrolled. Non-cycloplegic autorefraction (NCAR), axial length (AL), horizontal and vertical meridian of corneal radius (CR1, CR2), and cycloplegic autorefraction were measured. Receiver operating characteristic (ROC) curve was used to obtain the effectiveness and cutoff for myopia detection.

RESULTS

Finally, 7803 participants aged 3-18 years with mean AL/CR ratio of 2.99 ± 0.16 were included. Area under the ROC curve (AUC) of AL/CR ratio for myopia detection (0.958 for AL/CR1, 0.956 for AL/CR2, 0.961 for AL/CR) was significantly larger than that of AL (0.919, all P < 0.001), while AUCs of the three were similar with different cutoffs (> 2.98, > 3.05, and > 3.02). When divided by age, the ROC curves of AL/CR ratio in 3- to 5-year-olds showed no significance or low accuracy (AUCs ≤ 0.823) in both genders. In ≥ 6-year-olds, the accuracies were promising (AUCs ≥ 0.883, all P < 0.001), the cutoffs basically increased with age (from > 2.93 in 6-year-olds to > 3.07 in 18-year-olds among girls, and from > 2.96 in 6-year-olds to > 3.07 in 18-year-olds among boys). In addition, boys presented slightly larger cutoffs than girls in all ages except for 16 and 18 years old. For children aged 3-5 years, AL/CR ratio or AL combined with NCAR increased AUC to > 0.900.

CONCLUSION

AL/CR ratio provided the best prediction of myopia with age-dependent cutoff values for all but preschool children, and the cutoffs of boys were slightly larger than those of girls. For preschool children, AL/CR ratio or AL combined with NCAR is recommended to achieve satisfactory accuracy. AL/CR ratio calculated by two meridians showed similar predictive power but with different cutoffs.

Validation of the DYOP visual acuity test

PURPOSE

The dynamic optotype (DYOP) visual acuity (VA) test is based on motion detection rather than element resolution and has been proposed for routine clinical assessment. This investigation examined the validity, inter- and intra-session repeatability and subjective preference for the DYOP versus a static letter chart and examined its utility in detecting astigmatic defocus.

METHODS

VA of 103 participants was measured three times with the letter and DYOP charts and repeated within two weeks in 75 participants who also rated their subjective experience. The VA of 29 participants was measured using DYOP, letter, Landolt C, and Tumbling E charts, with habitual correction and astigmatism induced with +1.00, +2.00 or +3.00 cylinders at 45, 60, 90 and 180°.

RESULTS

The charts differed by a mean of 0.02 logMAR, with 81% of the measurements within one line of acuity. Inter-session, intraclass correlation coefficients, within-subject SD and repeatability were 0.03 logMAR, 0.95, 0.11 and 0.30 versus 0.01 logMAR, 0.92, 0.15 and 0.42 for the DYOP and letter charts, respectively. The DYOP was significantly more frustrating (1.79 vs.1.36), with 59% preferring the letter chart. The DYOP was least affected by induced astigmatism.

CONCLUSIONS

The DYOP and letter charts differed significantly in their mean values with wide limits of agreement. DYOP had better within-subject SD and narrower limits of agreement between sessions, though clinically insignificant, and performed significantly worse for the detection of uncorrected astigmatism. Thus, it is difficult to recommend this test for the clinical determination of refractive error.

Worsening vision at age 4-5 in England post-COVID: Evidence from a large database of vision screening data

PURPOSE

Myopia prevalence has increased in the UK at age 10-16y, but little is known about younger children. We hypothesise that if the 'myopia epidemic' is affecting young children, then there will be increasing rates of bilateral reduced unaided vision (V) at vision screenings of children 4-5 years of age.

METHODS

Retrospective anonymised data from computerised vision screening at age 4-5 years were analysed from serial cross-sectional data. Refractive error is not assessed in UK vision screening, so vision was investigated. Data were only included from schools that screened every year from 2015/16 to 2021/22. The criterion used was unaided monocular logMAR (automated letter-by-letter scoring) vision >0.20 in both the right and left eyes, so as to maximise the chances of detecting bilateral, moderate myopia rather than amblyopia.

RESULTS

Anonymised raw data were obtained for 359,634 screening episodes from 2075 schools. Once schools were excluded where data were not available for every year and data were cleaned, the final database comprised 110,076 episodes. The proportion (percentage and 95% CI) failing the criterion from 2015/16 to 2021/22 were 7.6 (7.2-8.0), 8.5 (8.1-8.9), 7.5 (7.1-7.9), 7.8 (7.4-8.2), 8.7 (8.1-9.2), 8.5 (7.9-9.0) and 9.3 (8.8-9.7), respectively. The slope of the regression line showed a trend for increasing rates of reduced bilateral unaided vision, consistent with increasing frequency of myopia (p = 0.06). A decreasing linear trendline was noted for children 'Under Professional Care'.

CONCLUSIONS

For children 4-5 years of age, there were signs of reduced vision over the last 7 years in England. Consideration of the most likely causes support the hypothesis of increasing myopia. The increase in screening failures highlights the importance of eye care in this young population.

Embedded AI system for interactive vision screen based on human action recognition

In recent years, vision screening has emerged globally for employment (on a yearly basis) within primary and high schools since myopia heavily affects school-aged children. However, this is a laborious and time-consuming task. This article proposes an intelligent system for "self-service" vision screening. Individuals can accomplish this task independently-without any assistance by technical staff. The technical solution involved within this platform is human action recognition realized by pose estimation (real-time human joint localization in images, including detection, association, and tracking). The developed system is based on a compact and embedded artificial intelligence platform, aided by a red-green-blue-D sensor for ranging and pose extraction. A set of intuitive upper-limb actions was designed for unambiguous recognition and interaction. The deployment of this intelligent system brings great convenience for large-scale and rapid vision screening. Implementation details were extensively described, and the experimental results demonstrated efficiency for the proposed technique.

Myopia

Myopia, also known as short-sightedness or near-sightedness, is a very common condition that typically starts in childhood. Severe forms of myopia (pathologic myopia) are associated with a risk of other associated ophthalmic problems. This disorder affects all populations and is reaching epidemic proportions in East Asia, although there are differences in prevalence between countries. Myopia is caused by both environmental and genetic risk factors. A range of myopia management and control strategies are available that can treat this condition, but it is clear that understanding the factors involved in delaying myopia onset and slowing its progression will be key to reducing the rapid rise in its global prevalence. To achieve this goal, improved data collection using wearable technology, in combination with collection and assessment of data on demographic, genetic and environmental risk factors and with artificial intelligence are needed. Improved public health strategies focusing on early detection or prevention combined with additional effective therapeutic interventions to limit myopia progression are also needed.

School-based epidemiology study of myopia in Tianjin, China

PURPOSE

To study the epidemiology of myopia in school-aged children in Tianjin and the relationship between visual acuity-based screening and refraction-based screening.

METHOD

This school-based prospective cohort study was performed on children from 42 elementary schools and 17 middle schools in Tianjin, China. Totally 14,551 children, ages ranging from 5 to 16 years, were included in this study. Uncorrected visual acuity (UCVA) was determined by logarithmic tumbling E chart. Non-cycloplegic photorefraction was examined by the Spot (v2.1.4) photoscreener. The relationship between the UCVA and refractive error was investigated for different age groups.

RESULTS

The overall prevalence of myopia at this school based screen is 78.2%, ranged from 10% at age of 5 to 95% at age of 16. The most dramatic increase in prevalence is from age of 6 (14.8%) to age of 7 (38.5%). The overall prevalence of high myopia is 2.5%. UCVA is found corresponding to spherical equivalent refraction (SER) in a manner of normal distribution and is significantly affected by age. When using UCVA to estimate the prevalence of myopia, the overall sensitivity and specificity are 0.824 and 0.820, respectively. Age-dependent optimal cutoff points and 95% confident intervals of such estimation are reported.

CONCLUSIONS

Myopia is heavily affecting school-aged children in Tianjin, China. The refraction screening is preferable for myopia screening, whereas the UCVA screening results need to be interpreted in an age-dependent manner for myopia estimation.

The Increasing Burden of Myopia in Israel among Young Adults over a Generation: Analysis of Predisposing Factors

PURPOSE

To determine the trends in prevalence of myopia in Israeli young adults over approximately a generation, as well as associated factors and variation in the impact of these factors on myopia prevalence in this region over time.

DESIGN

Retrospective, cross-sectional study.

PARTICIPANTS

One hundred four thousand six hundred eighty-nine consecutive persons 16 to 19 years of age born between 1971 and 1994 who had not yet enlisted in the Israeli Army but had completed the medical profiling process.

METHODS

Using data collected at a north Israel recruitment center, the prevalence of myopia over time was estimated, and a polynomial regression analysis was performed to assess significance of nonlinear trends. Associations of demographic and socioeconomic factors with myopia were assessed, and trends over time were analyzed using a factorial logistic regression.

MAIN OUTCOME MEASURES

The primary outcome measure was factors associated with the prevalence of myopia over time. The secondary outcome measure was a description of the change in prevalence of myopia over time.

RESULTS

The prevalence of myopia increased 1.284-fold over 24 years from 20.4% among participants born between 1971 and 1982 to 26.2% among participants born between 1983 and 1994. A quite similar increase was observed among males (from 17.9% to 22.7%, respectively) and females (from 23.9% to 30.8%, respectively). The factors found to be associated with myopia were as follows: more recent date of birth, female gender, more years of education, being the eldest child, non-Israeli ethnic origin, and urban residence. However, there were significant trends over time in the effects of some of these factors, most notably an attenuation of the difference between participants of different religions in the recent birth-years period. Most of these associations and trends were observed in both males and females separately, with some gender-specific variations. Immigrants from Ethiopia who were raised in Israel were highly more likely to demonstrate myopia than those who arrived at an older age.

CONCLUSIONS

This study demonstrated an increase in the prevalence of myopia and the possible associations of urbanization- and higher education-related factors among several subpopulations and the risk for myopia developing.

Using Decision Curve Analysis to Evaluate Common Strategies for Myopia Screening in School-Aged Children

Purpose: To evaluate common strategies for screening myopia. Methods: A total of 2,248 children aged 6 to 12 years from five randomly selected primary schools were included for the screening. Enrolled study participants underwent distant uncorrected visual acuity (UCVA, Standard Logarithmic Visual Acuity E Chart) and non-cycloplegic auto-refraction (NCAR, Topcon KR-8800). Among them, 1,639 children (72.9%) accepted cycloplegic auto-refraction. Taking rejection of cycloplegia into account, receiver operating characteristic curves were drawn to compare the accuracies of the four strategies (I, Cycloplegic auto-refraction; II, NCAR; III, UCVA; IV, Combination of UCVA and NCAR). Decision curve analysis (DCA) was used to compare net benefits. Tenfold cross-validation was used for statistical analyses. Results: For myopia (spherical equivalent refraction, SE ≤ -0.5D) screening, the mean sensitivities were 73.79% (SD: 5.40%), 85.57% (6.84%), 59.71% (13.49%), and 85.06% (6.68%) for Strategy I to IV; with mean specificities of 100% (0%), 87.43% (4.27%), 89.74% (10.25%), and 88.65% (5.07%), respectively. For screening early myopia (SE ≤ -0.5D and ≥-1.0D), the mean sensitivities were 73.44% (7.69%), 82.39% (5.32%), 54.27% (14.58%), and 81.76% (9.60%) for Strategy I to IV; with mean specificities of 100% (0%), 79.13% (4.86%), 85.48% (9.86%), and 81.17% (4.16%). Based on DCA, the net benefits of Strategy IV were the highest, with the probability thresholds ranging from 12% to 50%, after adjusting the TestHarms. For early myopia, the net benefits of Strategy IV were the highest with the probability threshold ranging from 5% to 34%. Conclusion: Combination of UCVA and NCAR produced the highest net benefits for myopia screening.

Incidence and progression of myopia and associated factors in urban school children in Delhi: The North India Myopia Study (NIM Study)

Aim

To evaluate the incidence and progression of myopia and factors associated with progression of myopia in school going children in Delhi.

Methods

Prospective longitudinal study of 10,000 school children aged 5 to 15 years screened after an interval of 1 year to identify new myopes (Spherical Equivalent≤ -0.5D) and progression of myopia in previously diagnosed myopic children. Association between risk factors and progression was analyzed using adjusted odds ratio.

Results

Of the 9,616 children re-screened (97.3% coverage), annual incidence of myopia was 3.4%with mean dioptric change of -1.09 ± 0.55. There was a significant higher incidence of myopia in younger children compared to older children (P = 0.012) and among girls compared to boys (P = 0.002). Progression was observed in 49.2%children with mean dioptric change of -0.27 ± 0.42 diopters. The demographic and behavioral risk factors were analyzed for children with progression (n = 629) and adjusted odds ratio values were estimated. Hours of reading-writing/week (p<0.001), use of computers/ video games (P<0.001) and watching television (P = 0.048) were significant risk factors for progression of myopia. Outdoor activities / time spent outdoors> 2 hours in a day were protective with an inverse association with progression of myopia (P< 0.001).

Conclusion

Myopia is an important health issue in India and is associated with long hours of reading and screen time with use of computers and video games. An annual eye vision screening should be conducted, and outdoor activities be promoted to prevent the increase of myopia among school children.

The epidemics of myopia: Aetiology and prevention

There is an epidemic of myopia in East and Southeast Asia, with the prevalence of myopia in young adults around 80-90%, and an accompanying high prevalence of high myopia in young adults (10-20%). This may foreshadow an increase in low vision and blindness due to pathological myopia. These two epidemics are linked, since the increasingly early onset of myopia, combined with high progression rates, naturally generates an epidemic of high myopia, with high prevalences of "acquired" high myopia appearing around the age of 11-13. The major risk factors identified are intensive education, and limited time outdoors. The localization of the epidemic appears to be due to the high educational pressures and limited time outdoors in the region, rather than to genetically elevated sensitivity to these factors. Causality has been demonstrated in the case of time outdoors through randomized clinical trials in which increased time outdoors in schools has prevented the onset of myopia. In the case of educational pressures, evidence of causality comes from the high prevalence of myopia and high myopia in Jewish boys attending Orthodox schools in Israel compared to their sisters attending religious schools, and boys and girls attending secular schools. Combining increased time outdoors in schools, to slow the onset of myopia, with clinical methods for slowing myopic progression, should lead to the control of this epidemic, which would otherwise pose a major health challenge. Reforms to the organization of school systems to reduce intense early competition for accelerated learning pathways may also be important.

Myopia screening: combining visual acuity and noncycloplegic autorefraction

PURPOSE

To explore the effectiveness of combining uncorrected visual acuity (UCVA) and noncycloplegic autorefraction (NCAR) for large-scale myopia screening in schoolchildren with a high prevalence of myopia.

METHODS

A total of 1687 children aged between 6 and 12 years, from five primary schools in the Baoshan district of Shanghai participated in the study. We measured UCVA and autorefraction before and after cycloplegia by a Topcon KR-8800. We drew receiver operating characteristic curves to achieve the best cutoff points and their corresponding sensitivities and specificities for the UCVA and NCAR, respectively. We then combined the UCVA and NCAR in serial order to explore the optimal criterion and its effectiveness. A specificity of 90% was set to compare the sensitivities among the three tests. The children were divided into three age groups (aged 6 to 7, 8 to 10, 11 to 12 years) to further examine this new method.

RESULTS

A total of 1639 children with an average age of 9.35 (SD, 1.6) years were finally included, among which 428 (26.11%) children were diagnosed as being myopic (spherical equivalent refraction (SER) less than or equal to -0.5 diopters [D]). For the UCVA, the cutoff point is 0.2 logarithm of the minimum angle of resolution (20/32), with a sensitivity and specificity of 63.6% and 94.0%, respectively. For NCAR, the cutoff point is SER less than or equal to -0.75 D, with a sensitivity and specificity of 88.6% and 86.1%, respectively. When UCVA is combined with NCAR, the best cutoff point is UCVA less than or equal to 0 logarithm of the minimum angle of resolution (20/20) and SER less than or equal to -0.75 D, with a sensitivity and specificity of 84.4% and 90.5%, respectively. At a specificity of 90%, the sensitivities are 63.55%, 78.50%, and 84.35%, respectively, for UCVA, NCAR, and the combination test. In all age groups, the combination test had the highest sensitivities among the three tests.

CONCLUSIONS

In a population with a high prevalence of myopia, combining the UCVA and NCAR in serial order achieved higher sensitivity than either of the two tests alone, when specificity was set at 90%.

The cost-effectiveness of Welcome to Medicare visual acuity screening and a possible alternative welcome to medicare eye evaluation among persons without diagnosed diabetes mellitus

OBJECTIVE

To estimate the cost-effectiveness of visual acuity screening performed in primary care settings and of dilated eye evaluations performed by an eye care professional among new Medicare enrollees with no diagnosed eye disorders. Medicare currently reimburses visual acuity screening for new enrollees during their initial preventive primary care health check, but dilated eye evaluations may be a more cost-effective policy.

DESIGN

Monte Carlo cost-effectiveness simulation model with a total of 50 000 simulated patients with demographic characteristics matched to persons 65 years of age in the US population.

RESULTS

Compared with no screening policy, dilated eye evaluations increased quality-adjusted life-years(QALYs) by 0.008 (95% credible interval [CrI], 0.005-0.011) and increased costs by $94 (95% CrI, −$35 to$222). A visual acuity screening increased QALYs in less than 95% of the simulations (0.001 [95% CrI, −0.002 to 0.004) and increased total costs by $32 (95% CrI, −$97 to $159) per person. The incremental cost-effectiveness ratio of a visual acuity screening and an eye examination compared with no screening were $29 000 and$12 000 per QALY gained, respectively. At a willingness-to-pay value of $15 000 or more per QALY gained, a dilated eye evaluation was the policy option most likely to be cost-effective.

CONCLUSIONS

The currently recommended visual acuity screening showed limited efficacy and cost-effectiveness compared with no screening. In contrast, anew policy of reimbursement for Welcome to Medicare dilated eye evaluations was highly cost-effective.

The cost-effectiveness of three screening alternatives for people with diabetes with no or early diabetic retinopathy

OBJECTIVE

To determine whether biennial eye evaluation or telemedicine screening are cost-effective alternatives to current recommendations for the estimated 10 million people aged 30-84 with diabetes but no or minimal diabetic retinopathy.

DATA SOURCES

United Kingdom Prospective Diabetes Study, National Health and Nutrition Examination Survey, American Academy of Ophthalmology Preferred Practice Patterns, Medicare Payment Schedule.

STUDY DESIGN

Cost-effectiveness Monte Carlo simulation.

DATA COLLECTION/EXTRACTION METHODS

Literature review, analysis of existing surveys.

PRINCIPAL FINDINGS

Biennial eye evaluation was the most cost-effective treatment option when the ability to detect other eye conditions was included in the model. Telemedicine was most cost-effective when other eye conditions were not considered or when telemedicine was assumed to detect refractive error. The current annual eye evaluation recommendation was costly compared with either treatment alternative. Self-referral was most cost-effective up to a willingness to pay (WTP) of U.S.$37,600, with either biennial or annual evaluation most cost-effective at higher WTP levels.

CONCLUSIONS

Annual eye evaluations are costly and add little benefit compared with either plausible alternative. More research on the ability of telemedicine to detect other eye conditions is needed to determine whether it is more cost-effective than biennial eye evaluation.

Prevalence of uncorrected refractive error and other eye problems among urban and rural school children

Background:

Uncorrected refractive error is an avoidable cause of visual impairment.

Aim:

To compare the magnitude and determinants of uncorrected refractive error, such as age, sex, family history of refractive error and use of spectacles among school children 6-15 years old in urban and rural Maharashtra, India.

Study Design:

This was a review of school-based vision screening conducted in 2004-2005.

Materials and Methods:

Optometrists assessed visual acuity, amblyopia and strabismus in rural children. Teachers assessed visual acuity and then optometrists confirmed their findings in urban schools. Ophthalmologists screened for ocular pathology. Data of uncorrected refractive error, amblyopia, strabismus and blinding eye diseases was analyzed to compare the prevalence and risk factors among children of rural and urban areas.

Results:

We examined 5,021 children of 8 urban clusters and 7,401 children of 28 rural clusters. The cluster-weighted prevalence of uncorrected refractive error in urban and rural children was 5.46% (95% CI, 5.44-5.48) and 2.63% (95% CI, 2.62-2.64), respectively. The prevalence of myopia, hypermetropia and astigmatism in urban children was 3.16%, 1.06% and 0.16%, respectively. In rural children, the prevalence of myopia, hypermetropia and astigmatism was 1.45%, 0.39% and 0.21%, respectively. The prevalence of amblyopia was 0.8% in urban and 0.2% in rural children. Thirteen to 15 years old children attending urban schools were most likely to have uncorrected myopia.

Conclusion:

The prevalence of uncorrected refractive error, especially myopia, was higher in urban children. Causes of higher prevalence and barriers to refractive error correction services should be identified and addressed. Eye screening of school children is recommended. However, the approach used may be different for urban and rural school children.

Contribution of refractive errors to visual impairment in patients at korle-bu teaching hospital

SUMMARY OBJECTIVE

To determine the contribution of refractive error to visual impairment in visually impaired patients attending Korle-Bu Teaching Hospital, Ghana.

METHOD

This study was conducted over a period of 1 year beginning October 2002 at Korle-Bu Teaching Hospital. Every 4th consecutive new case attending the eye clinic, aged 6 years and above was selected and interviewed using a structured questionnaire. A Snellen's chart was used to determine the unaided visual acuity, visual acuity with spectacles where the patient was wearing one, and visual acuity with pin hole with or without spectacles. Improvement in visual acuity by 2 or more lines on the Snellen's chart when looking through the pin hole was regarded as an indication of refractive error.

RESULTS

A total of 1,069 respondents, 594 female and 475 male were recruited into the study. One hundred and fifteen (115) patients (10.76%) were found to have impaired vision (Visual acuity worse than 6/18 to PL in the better eye). The vision of 51 of those with impaired vision improved when looking through the pin hole. Refractive error with Visual Acuity worse than 6/18 was present in 4.8% of all patients who attended the eye clinic. Refractive error was present in 44.3% of patients with visual impairment.

CONCLUSION

Visual impairment was a common presentation and uncorrected refractive error was a major cause of visual impairment.

A comparison of autorefraction and subjective refraction with and without cycloplegia in primary school children

PURPOSE

To evaluate the accuracy of autorefraction using three autorefractors comparing to subjective refraction in diagnosing refractive error in children.

DESIGN

A cross-sectional study.

METHODS

setting: Community based study. study population: 117 children sampled from primary schools. procedures: All subjects underwent autorefraction using three auto refractors and subjective refraction with and without cycloplegia. main outcome measures: Spherical power, cylindrical power, and spherical equivalence (SE).

RESULTS

Without cycloplegia, the mean SE were significantly different for Retinomax K plus 2 (-1.55 diopters, SD 2.37 diopters; 95% CI -1.98 to -1.12; P < .0001) and Canon RF10 (-1.11 diopters; SD 2.61 diopters; 95% CI -1.59 to -0.64; P = .0023) compared with monocular subjective refraction (-0.80 diopters; SD 2.25 diopters; 95% CI -1.21 to -0.35). Mean SE was significantly different for Grand Seiko WR5100K (-0.79 diopters; SD 2.40 diopters; 95% CI -1.23 to -0.35; P = .0002) compared with binocular subjective refraction (-0.62 diopters; SD 2.51 diopters; 95% CI -1.07 to -0.16). With cycloplegia, there was no significant difference in mean SE between refraction methods. Sensitivity and specificity results for the diagnosis of myopia: Without cycloplegia: Retinomax K plus 2 (sensitivity 1.0, specificity 0.51); Canon RF10 (sensitivity 0.92, specificity 0.81); and Grand Seiko WR5100K (sensitivity 0.91, specificity 0.98). With cycloplegia: Retinomax K plus 2 (sensitivity 0.97, specificity 0.99); Canon RF10 (sensitivity 0.97, specificity 0.96); and Grand Seiko WR5100K (sensitivity 1.0, specificity 0.97).

CONCLUSIONS

Under noncycloplegic conditions, all three autorefractors have a tendency towards minus over correction in children resulting in over diagnosis of myopia. However autorefractors were accurate under cycloplegic conditions.