Associations between hyperopia and other vision and refractive error characteristics

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effects of refractive status on the outcomes of strabismus surgery in patients with esotropia

BACKGROUND

The success of the strabismus surgery can hinge on several factors. One of these factors is refractive condition like hyperopia or myopia. Our study seeks to evaluate the surgical outcomes in patients with esotropia and myopia.

METHODS

This case-control study encompassed all surgical cases of esotropia at Torfe and Negah Hospital between 2016 and 2021, which satisfied our specified inclusion criteria. The initial variables from electronic medical records were collected, including demographic, clinical, and surgery-related factors. At the final follow-up appointment, the level of eye deviation, both at distance and near, was recorded. We considered the operation a "success" for patients with a post-surgery distance eye deviation of 10(Pd) or less. Patients with greater deviation were classified as surgery failure. Statistical analyses were executed using SPSS software (version 16.0), and a P-value less than 0.05 was considered significant.

RESULTS

Of the 194 patients evaluated, 112 were incorporated into the study. Surgical failure was observed in 14.29% of myopic patients, 29.79% of hyperopic patients, and 31.82% of emmetropic patients. The myopia group displayed a 0.19 odd ratio for surgical failure compared to the combined hyperopia and emmetropia groups, not statistically significant (OR: 0.19, CI 95%: 0.03-1.02). Additionally, patients diagnosed with Lateral Rectus Under-action were found to be 6.85 times more likely to experience surgery failure(OR: 6.85, CI 95%: 1.52-30.94). An elevated risk of surgical failure was also identified in patients who underwent Inferior Oblique Weakening procedure, indicated by a 3.77-fold increase in the odds ratio for failure(OR: 3.77, CI 95%: 1.08-13.17).

CONCLUSION

In our study, despite numerical disparities, there was no statistical difference among the success rates of all esotropia patients with different refractive errors. The patients with LRUA or IOOA showed lower success rates. Myopic patients had higher post-op overcorrection with lower reoperation rates compared to hyperopic or emmetropic patients.

Ocular Biometric Components in Hyperopic Children and a Machine Learning-Based Model to Predict Axial Length

Purpose

The purpose of this study was to investigate the development of optical biometric components in children with hyperopia, and apply a machine-learning model to predict axial length.

Methods

Children with hyperopia (+1 diopters [D] to +10 D) in 3 age groups: 3 to 5 years (n = 74), 6 to 8 years (n = 102), and 9 to 11 years (n = 36) were included. Axial length, anterior chamber depth, lens thickness, central corneal thickness, and corneal power were measured; all participants had cycloplegic refraction within 6 months. Spherical equivalent (SEQ) was calculated. A mixed-effects model was used to compare sex and age groups and adjust for interocular correlation. A classification and regression tree (CART) analysis was used to predict axial length and compared with the linear regression.

Results

Mean SEQ for all 3 age groups were similar but the 9 to 11 year old group had 0.49 D less hyperopia than the 3 to 5 year old group (P < 0.001). With the exception of corneal thickness, all other ocular components had a significant sex difference (P < 0.05). The 3 to 5 year group had significantly shorter axial length and anterior chamber depth and higher corneal power than older groups (P < 0.001). Using SEQ, age, and sex, axial length can be predicted with a CART model, resulting in lower mean absolute error of 0.60 than the linear regression model (0.76).

Conclusions

Despite similar values of refractive errors, ocular biometric parameters changed with age in hyperopic children, whereby axial length growth is offset by reductions in corneal power.

Translational Relevance

We provide references for optical components in children with hyperopia, and a machine-learning model for convenient axial length estimation based on SEQ, age, and sex.

Hyperopia in schoolchildren: Investigating the impact on vision and determining appropriate methods for screening

INTRODUCTION

Hyperopia is associated with reduced vision and educational outcomes in schoolchildren. This study explored the impact of clinically significant hyperopia (≥+2.00 D) on visual function in schoolchildren and compared the ability of different screening tests (alone and in combination) to detect this level of hyperopia.

METHODS

Vision testing including monocular logMAR visual acuity (VA) measured to threshold (distance [DVA], near [NVA] and DVA through a plus lens [+2.50 D]), stereoacuity and cycloplegic autorefraction (tropicamide 1%) were undertaken on 263 schoolchildren (mean age: 11.76 years ± 3.38) in Queensland, Australia. Vision measures were compared between children with clinically significant hyperopia in at least one meridian (≥+2.00 D) and emmetropia/low hyperopia (>0.00 and <+2.00 D). Receiver operating curve (ROC) analysis was performed to identify optimal pass/fail criteria for each test and the diagnostic accuracy of individual and combinations of tests.

RESULTS

Thirty-two children had clinically significant hyperopia and 225 had emmetropia/low hyperopia. DVA and NVA were worse (p < 0.01), while the difference in DVA through a plus lens was less in children with clinically significant hyperopia (p < 0.01). ROC analysis for individual tests resulted in areas under the curve (AUCs) ranging from 0.65 to 0.85. Combining screening tests revealed that failing one or more of the following tests was most effective for detecting hyperopia: DVA, NVA and difference in DVA through a plus lens, resulting in a sensitivity and specificity of 72% and 81%, respectively.

CONCLUSION

Significant differences in visual function existed between schoolchildren with clinically significant hyperopia and emmetropia/low hyperopia. Combining measures of DVA and NVA and the difference in DVA through a plus lens demonstrated good discriminative ability for detecting clinically significant hyperopia in this population.

Prescribing patterns for paediatric hyperopia among paediatric eye care providers

PURPOSE

To survey paediatric eye care providers to identify current patterns of prescribing for hyperopia.

METHODS

Paediatric eye care providers were invited, via email, to participate in a survey to evaluate current age-based refractive error prescribing practices. Questions were designed to determine which factors may influence the survey participant's prescribing pattern (e.g., patient's age, magnitude of hyperopia, patient's symptoms, heterophoria and stereopsis) and if the providers were to prescribe, how much hyperopic correction would they prescribe (e.g., full or partial prescription). The response distributions by profession (optometry and ophthalmology) were compared using the Kolmogorov-Smirnov cumulative distribution function test.

RESULTS

Responses were submitted by 738 participants regarding how they prescribe for their hyperopic patients. Most providers within each profession considered similar clinical factors when prescribing. The percentages of optometrists and ophthalmologists who reported considering the factor often differed significantly. Factors considered similarly by both optometrists and ophthalmologists were the presence of symptoms (98.0%, p = 0.14), presence of astigmatism and/or anisometropia (97.5%, p = 0.06) and the possibility of teasing (8.3%, p = 0.49). A wide range of prescribing was observed within each profession, with some providers reporting that they would prescribe for low levels of hyperopia while others reported that they would never prescribe. When prescribing for bilateral hyperopia in children with age-normal visual acuity and no manifest deviation or symptoms, the threshold for prescribing decreased with age for both professions, with ophthalmologists typically prescribing 1.5-2 D less than optometrists. The threshold for prescribing also decreased for both optometrists and ophthalmologists when children had associated clinical factors (e.g., esophoria or reduced near visual function). Optometrists and ophthalmologists most commonly prescribed based on cycloplegic refraction, although optometrists most commonly prescribed based on both the manifest and cycloplegic refraction for children ≥7 years.

CONCLUSION

Prescribing patterns for paediatric hyperopia vary significantly among eye care providers.

Genetic causal inference between amblyopia and perinatal factors

Amblyopia is a common visual disorder that causes significant vision problems globally. Most non-ocular risk factors for amblyopia are closely related to the intrauterine environment, and are strongly influenced by parent-origin effects. Parent-origin perinatal factors may have a direct causal inference on amblyopia development; therefore, we investigated the causal association between perinatal factors and amblyopia risk using a one-sample Mendelian Randomization (MR) with data from the UK Biobank Cohort Data (UKBB). Four distinct MR methods were employed to analyze the association between three perinatal factors (birth weight [BW], maternal smoking, and breastfeeding) and amblyopia risk, based on the summary statistics of genome-wide association studies in the European population. The inverse variance weighting method showed an inverse causal association between BW and amblyopia risk (odds ratio, 0.48 [95% CI, 0.29-0.80]; p = 0.004). Maternal smoking and breastfeeding were not causally associated with amblyopia risk. Our findings provided a possible evidence of a significant genetic causal association between low BW and increased amblyopia risk. This evidence may highlight the potential of BW as a predictive factor for visual maldevelopment and the need for careful management of amblyopia risk in patients with low BW.

A School Eye Health Rapid Assessment (SEHRA) planning tool: Module to survey the magnitude and nature of local needs

Background

Eye conditions in children can have negative consequences on visual functioning and quality of life. There is a lack of data on the magnitude of children with eye conditions who need services for effective planning of school eye health programmes. To address this, the School Eye Health Rapid Assessment (SEHRA) tool is being developed to collect data to support school eye health programme planning.

Methods

The module, ‘the magnitude and nature of local needs in school children’ is the first of six modules in the SEHRA tool. The module outlines a school-based cluster survey designed to determine the magnitude of eye health needs in children. This paper outlines the survey sampling strategy, and sample size calculations.

Results

The requirements for the SEHRA survey indicate that in regions where a larger sample size is required, or where fewer schools are recruited to the survey, confidence in the accuracy of the data will be lower.

Conclusions

The SEHRA survey module ‘the magnitude and nature of local needs in school children’ can be applied in any context. In certain circumstances, the confidence in the survey data will be reduced.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13927-x.

The effect of peripheral defocus on axial growth and modulation of refractive error in hyperopes

Purpose

To establish whether axial growth and refractive error can be modulated in hyperopic children by imposing relative peripheral hyperopic defocus using multifocal soft contact lenses.

Methods

A prospective controlled study with hyperopic participants allocated to a control or test group. Control group participants were corrected with single vision spectacles and changes to axial length and refractive error were followed for 3 years. For the test group, axial growth and post‐cycloplegic refractive error were observed with participants wearing single vision spectacles for the first 6 months of the trial and then corrected with centre‐near multifocal soft contact lenses with a 2.00 D add for 2 years. The central ‘near’ portion of the contact lens corrected distance refractive error while the ‘distance’ portion imposed hyperopic defocus. Participants reverted to single vision spectacles for the final 6 months of the study.

Results

Twenty‐two participants, mean age 11.13 years (SD 1.72) (range 8.33–13.92), completed the trial. Axial length did not change during the first 6 months in either group (p = 1.00). Axial growth across the 2‐year intervention period was 0.17 mm (SEM 0.04) (p < 0.0005) in the test group versus 0.06 mm (SEM 0.07) (p = 0.68) in the control group. Axial length was invariant during the final 6 months in either group (p = 1.00). Refractive error was stable during the first 6 months in both groups (p = 1.00). Refractive error change across the 2‐year intervention period was −0.26 D (SEM 0.14) (p = 0.38) in the test group versus −0.01 D (SEM 0.09) (p = 1.00) in the control group. Neither the test (p = 1.00) nor control (p = 0.63) group demonstrated a change in refractive error during the final 6 months.

Conclusions

The rate of axial growth can be accelerated in children with hyperopia using centre‐near multifocal soft contact lenses.

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

SIGNIFICANCE

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

PURPOSE

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

DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

ABSTRACT

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

Pediatric spectacle prescription: Understanding practice patterns among ophthalmologists and optometrists in Saudi Arabia

PURPOSE

This study aims to understand the approach to prescribing spectacles for children and the interpretation of refractive errors among ophthalmologists/optometrists in Saudi Arabia.

METHODS

A cross-sectional survey was conducted between September and November 2018 using a database of online registrants for ophthalmologists and optometrists practicing in Saudi Arabia. The survey included 10 multiple-choice questions designed to elicit information about how ophthalmologists and optometrists deal with commonly encountered case scenarios covering different practical aspects of pediatric refraction. The responses were compared using the proportion of pediatric clientele received in the respondents' practices (Group A: <25%, Group B: 25%) and drawing upon concepts from the published literature.

RESULTS

One hundred and three participants, including ophthalmologists, specialists/registrars, and optometrists from across Saudi Arabia, participated in this survey. Approximately 25% were classified as Group A. Large discrepancies were observed between the participants' responses and actual practices based on guideline recommendations. Responses varied significantly between Groups A and B on certain issues pertaining to pseudomyopia (P < 0.001), anisometropia (P = 0.033), and high astigmatism (P = 0.023).

CONCLUSION

Practice patterns regarding pediatric spectacle prescription varied among ophthalmologists and optometrists in Saudi Arabia. The approach to managing refractive errors in children was better among ophthalmologists/optometrists servicing a larger pediatric clientele, suggesting the need to increase awareness among all groups of ophthalmologists/optometrists.

Stereoacuity Among Patients with Refractive Error at University of Gondar, Northwest Ethiopia

PURPOSE

This study aimed to assess the level of stereopsis, proportion of poor stereopsis, and factors influencing stereopsis in adults with refractive error.

METHODS

This was a cross-sectional, descriptive study conducted on 153 adults with refractive error at Gondar University Hospital Tertiary Eye Care Center from April 08 to June 07, 2019. Structured questionnaires and ophthalmic instruments (Retinoscope, Worth Four Dot test and TNO Stereo plates) were used to collect the data. Data were entered and analyzed with Statistical Package for Social Sciences (SPSS) version 20. The result was summarized using summary statistics such as mean. Chi-squared test of association was applied between stereopsis and independent variables.

RESULTS

The level of stereopsis after correction of refractive error ranged from 1.89 to 2.65 log arc second. Before correction of refractive error, poor stereopsis was observed in 46.4% of the participants, while after correction, it dropped to 39.8% (CI: 95%: 31.1%-47.8%). Stereopsis after correction had a significant association with age, best visual acuity, type of refractive error, and fusional status at distance with a p value < 0.05.

CONCLUSION

Given refractive error corrected, the mean stereopsis in patients with refractive error was 2.42 log arc second. Proportion of poor stereopsis was noted in 39.8% of the participants corrected for refractive error. Age, best corrected visual acuity, type of refractive error, and fusional status had a significant association with stereopsis. Further studies on stereoacuity on a large scale are recommended.

Correction of Low-Moderate Hyperopia Improves Accommodative Function for Some Hyperopic Children During Sustained Near Work

Purpose

This study investigated whether refractive correction improved accommodative function of hyperopic children while engaged in two sustained near activities.

Methods

Sustained accommodative function of 63 participants (aged 5–10 years) with varying levels of uncorrected hyperopia (>/= +1.00 D and < + 5.00 D spherical equivalent in the least hyperopic eye) was measured using eccentric infrared photorefraction (PowerRef 3; PlusOptix, Germany). Binocular accommodation measures were recorded while participants engaged in 2 tasks at 25 cm for 15 minutes each: an “active” task (reading small print on an Amazon Kindle), and a “passive” task (watching an animated movie on liquid crystal display [LCD] screen). Participants also underwent a comprehensive visual assessment, including measurement of presenting visual acuity, prism cover test, and stereoacuity. Reading speed was assessed with and without hyperopic correction. Refractive error was determined by cycloplegic retinoscopy.

Results

Hyperopic refractive correction significantly improved accuracy of accommodative responses in both task (pairwise comparisons: t = −3.70, P = 0.001, and t = −4.93, P < 0.001 for reading and movie tasks, respectively). Accommodative microfluctuations increased with refractive correction in the reading task (F_(1,61) = 25.77, P < 0.001) but decreased in the movie task (F_(1,59) = 4.44, P = 0.04). Reading speed also significantly increased with refractive correction (F_(1,48) = 66.32, P < 0.001).

Conclusions

Correcting low-moderate levels of hyperopia has a positive impact on accommodative performance during sustained near activity in some schoolchildren. For these children, prescribing hyperopic correction may benefit performance in near vision tasks.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

DESIGN

Prospective randomized clinical trial (RCT).

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Evaluation of the Spot Vision Screener for children with limited access to ocular health care

PURPOSE

To compare the sensitivity, specificity, and referral rate of the Spot Vision Screener (Welch Allyn Inc, Skaneateles Falls, NY) with the gold standard cycloplegic measurements acquired using the Retinomax in a population of underprivileged children and teenagers with limited access to medical care.

METHODS

Children were recruited for the study by social workers in the vicinity of Robert Debre Hospital, Paris, France. Refractive errors (hyperopia of ≥ +2.00 D spherical equivalent [SE]; myopia of ≤ -0.50 D SE; astigmatism of ≥1.00 D between the two main meridians; anisometropia of ≥1.00 D SE difference between eyes) were assessed using the Spot Vision Screener and the Retinomax. Sensitivity (true positive rate), specificity (true negative rate), and referral rate of this Spot Vision screening program were evaluated.

RESULTS

A total of 82 eyes of 41 subjects (19 males) were included; mean age was 126 months of age (range, 48-246). The sensitivity of the Spot Vision Screener for the detection of refractive errors was 82.35%; specificity was 91.67%. The sensitivity of the Spot Vision Screener to detect hyperopia, myopia, astigmatism, and anisometropia was 27.27%, 84.61%, 78.57%, and 66.67%, respectively. Its specificity to detect hyperopia, myopia, astigmatism, and anisometropia was 100%, 98.55%, 89.71% and 94.29%, respectively.

CONCLUSIONS

The specificity of the Spot Vision Screener to detect refractive errors was found to be relatively high (>90%). However, its low sensitivity for hyperopia seems to remain a major limitation of the device, because hyperopia is particularly important to detect in children given its high prevalence and possible adverse consequences. Global programs using cycloplegic measurements should be considered an alternative.

Threshold Values of Myopic Anisometropia Causing Loss of Stereopsis

Purpose

The aim of the study was to determine the threshold values of myopic anisometropia that lead to the loss of stereoacuity in most of patients.

Materials and Methods

Forty healthy subjects were included in the study. The inclusion criteria were as follows: lack of any functional or morphological ophthalmological disorders, or detectable damage to the visual system, anisometropia equal or less than 0.25 D in a spherical equivalent, and full stereoscopic vision for near and for distance. Myopic anisometropia was evoked by placing different focusing lenses in front of the right eye of the subject in the trial frame. Stereoscopic vision was assessed with the use of the Titmus test (dots) (Stereo Fly Test Stereo Optical Co. Inc.) for near and the Randot test for distance (Distance Randot Stereotest Stereo Optical Co. Inc.).

Results

The threshold values for different types of myopic anisometropia for the loss of stereopsis in more than 50% of patients were determined. For near, this value was 3 D for sphere and “against the rule astigmatism” and 4 D for “with the rule astigmatism”. For distance, the values were 2 D for sphere and “against the rule astigmatism” and 3 D for “with the rule astigmatism.” Conclusions. Myopic anisometropia of more than 2 D can cause a significant impairment of binocular vision. Stereoacuity at distance is more sensitive to myopic anisometropia than stereoacuity at near. Myopic anisometropia involving “against the rule” astigmatism potentially affects binocularity more than anisometropia with regular astigmatism. A prompt correction of anisometropia of more than 2 D is needed in children to prevent the development of amblyopia.

Surgical and sensory outcomes in patients with intermittent exotropia according to preoperative refractive error

BACKGROUND/OBJECTIVES

To analyze the surgical and sensory outcomes of intermittent exotropia according to refractive errors and the factors associated with surgical success.

SUBJECTS/METHODS

A total of 326 children were divided into three groups according to preoperative refractive error; hyperopic eyes with SE ≥+2D (hyperopic group), eyes with SE between -1D and +2D (emmetropic group), and myopic eyes with SE ≤-1D (myopic group). The surgical outcomes and the sensory outcomes measured by near and distant stereoacuity were compared among the three groups.

RESULTS

The surgical success rate in hyperopic group was significantly lower compared to myopic group at last follow-up (P = 0.012). Preoperative near stereopsis was not different among three groups, however, the distance stereopsis was significantly deteriorated in the hyperopic group compared to the other two groups (Titmus; P = 0.168, FD2; P < 0.001, DR; P = 0.048). There was postoperative improvement in both near and distant stereopsis in all three groups (Titmus; P = 0.009, FD2; P = 0.021, DR; P = 0.036) and no significant difference was found in the postoperative distant stereopsis among the three groups.

CONCLUSIONS

Preoperative refractive error is a prognostic factor of surgical success in patients with intermittent exotropia. Patients with hyperopia achieved less favorable surgical outcome compared to myopic patients. The preoperative distant stereoacuity was decreased in hyperopic patients compared to myopic patients, which eventually improved after surgery and showed no significant difference at postoperative measurements.

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

PURPOSE

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

DESIGN

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

PARTICIPANTS

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Binocular temporal visual processing in myopia

Our ability to utilize binocular visual information depends on the visibility of the retinal images in each eye, which varies with both their spatial and temporal frequency content. Although the effects of spatial information on binocular function have been established, the effects of temporal frequency on binocularity are less well understood. These factors may also vary with refractive error if spatiotemporal sensitivity is affected by structural changes during the emmetropization process that may differentially affect distinct ganglion cells. In a cross-sectional study, we evaluated the potential effects of temporal and spatial frequency on binocularity in young individuals with emmetropia or myopia. Stereopsis and binocular balance were measured as a function of temporal (0-12 Hz) and spatial (1-8 c/deg) frequency. Stereopsis thresholds were measured by determining the minimum disparity at which subjects accurately identified the depth of bandpass-filtered rings. Binocular balance was measured by determining the relative contrast at which subjects reported dichoptic bandpass-filtered letters with equal frequency. Stereopsis thresholds were temporal but not spatial frequency dependent whereas binocular balance was spatial and temporal frequency dependent. There were no differences in monocular spatiotemporal contrast sensitivity between refractive groups in our sample. However, individuals with myopia showed reduced stereopsis with flickering stimuli and greater binocular imbalance at higher spatial and lower temporal frequencies compared to emmetropes. Differences in binocular vision between emmetropia and corrected myopia depend on temporal as well as spatial frequency and may be the cause or consequence of abnormal emmetropization during visual development.

Effect of Peripheral Defocus on Axial Eye Growth and Modulation of Refractive Error in Hyperopes: Protocol for a Nonrandomized Clinical Trial

Background

Hyperopia occurs due to insufficient ocular growth and a failure to emmetropize in childhood. In anisohyperopia, it is unclear why one eye may remain hyperopic while the fellow eye grows toward an emmetropic state. Animal studies have shown that manipulating peripheral defocus through optical means while simultaneously providing correct axial focus can either discourage or encourage axial eye growth to effectively treat myopia or hyperopia, respectively. Myopia progression and axial eye growth can be significantly reduced in children and adolescents through the use of multifocal contact lenses. These contact lenses correct distance central myopia while simultaneously imposing relative peripheral myopic defocus. The effect of correcting distance central hyperopia while simultaneously imposing relative peripheral hyperopic defocus is yet to be elucidated in humans.

Objective

The objective of our study is to understand the natural progression of axial eye growth and refractive error in hyperopes and anisohyperopes and to establish whether axial eye growth and refractive error can be modified using multifocal contact lenses in hyperopes and anisohyperopes.

Methods

There are 3 elements to the program of research. First, the natural progression of axial eye growth and refractive error will be measured in spectacle-wearing hyperopic and anisohyperopic subjects aged between 5 and <20 years. In other words, the natural growth of the eye will be followed without any intervention. Second, as a paired-eye control study, anisohyperopes aged between 8 and <16 years will be fitted with a center-near multifocal design contact lens in their more hyperopic eye and a single-vision contact lens in the fellow eye if required. The progression of axial eye growth and refractive error will be measured and compared. Third, subjects aged between 8 and <16 years with similar levels of hyperopia in each eye will be fitted with center-near multifocal design contact lenses in each eye; the progression of axial eye growth and refractive error in these subjects will be measured and compared with those of subjects in the natural progression study.

Results

Recruitment commenced on 6 June 2016 and was completed on 8 April 2017. We estimate the data collection to be completed by April 2020.

Conclusions

This trial will establish whether axial eye growth can be accelerated in children with hyperopia by imposing relative peripheral hyperopic defocus using center-near multifocal contact lenses.

Trial Registration

ClinicalTrials.gov NCT02686879; https://clinicaltrials.gov/ct2/show/NCT02686879 (Archived by Webcite at http://www.webcitation.org/71o5p3fD2)

Registered Report Identifier

RR1-10.2196/9320

Spectacle prescription in children: Understanding practical approach of Indian ophthalmologists

Purpose:

The aim of this study is to survey the management approach, regarding spectacle prescription in children, among Indian ophthalmologists.

Methods:

A web-based, anonymous questionnaire (multiple choice questions dealing with practical aspects of pediatric refraction), was sent to available database of Indian ophthalmologists. The survey responses (depicted in %) were compared using the amount of pediatric clientele in one's practice (Group A: <25%, Group B: 25% or more). The responses were also analyzed in relation to the published concepts from literature.

Results:

Two hundred and ten ophthalmologists (2.74% response rate; 48% in Group A), from all over India, responded to the survey. There were wide discrepancies in the responses (both, in and among, Groups A and B; P > 0.05, Chi-square test), as to when and how much refractive error to prescribe in children, for a given situation.

Conclusion:

A wide gap exists between pediatric spectacle prescription patterns of Indian ophthalmologists, as compared to the recommended pediatric ophthalmology protocols. The management approach, for certain situations concerning the pediatric refraction, was better among those with higher pediatric clientele.

Stereoacuity and refractive, accommodative and vergence anomalies of South African school children, aged 13–18 years

Aim: The aim of this study was to explore possible associations between stereoacuity and refractive, accommodative and vergence anomalies.Methods: The study design was cross-sectional and comprised data from 1056 high school children aged between 13 and 18 years; mean age and standard deviation were 15.89 ± 1.58 years. Using a multi-stage random cluster sampling, participants were selected from 13 high schools out of a sample frame of 60 schools in the municipality concerned. In the final sample, 403 (38%) were males and 653 (62%) females. Refractive errors, heterophoria, near point of convergence, fusional vergences and accommodative functions (amplitude, facility, response and relative) were evaluated. Stereoacuity was evaluated using the Randot stereotest and recorded in seconds of arc where reduced stereoacuity was defined as worse than 40 s arc.Results: Overall, the mean stereoacuities (in seconds of arc) of the children with anomalies were the following: those with refractive errors (52.6 ± 36.9), with accommodative anomalies (53.1 ± 34.1) and with vergence anomalies (48.29 ± 31.1). The mean stereoacuity of those with vergence anomalies was significantly better than that of those with either refractive errors or accommodative anomalies (p = 0.02). In the refractive error category, only anisometropia had significantly reduced mean stereoacuity compared to emmetropia (Mann–Whitney U: p = 0.01). The mean stereoacuity of cases of accommodative anomalies was significantly reduced compared to those without such anomalies (Mann–Whitney U: p = 0.01). Similarly, the mean stereoacuity of cases with vergence anomalies was significantly reduced compared to those without vergence anomalies (p = 0.02).Conclusion: Refractive errors, accommodative or vergence anomalies are more likely to have reduced mean stereoacuity than cases without such anomalies. Refractive errors or accommodative anomalies had significantly more reduced stereoacuity than vergence anomalies. These findings suggest that the Randot stereotest could be used to identify those with such anomalies, and this study extends knowledge regarding the possible use of stereoacuity as a useful tool to screen for binocular anomalies.

Main visual symptoms associated to refractive errors and spectacle need in a Brazilian population

AIM

To determine the main visual symptoms in a Brazilian population sample, associated to refractive errors (REs) and spectacle need to suggest priorities in preventive programs.

METHODS

A cross-sectional study was conducted in nine counties of the southeast region of Brazil, using a systematic sampling of households, between March 2004 and July 2005. The population was defined as individuals aged between 1 and 96y, inhabitants of 3600 residences to be evaluated and 3012 households were included, corresponding to 8010 subjects considered for participation in the survey, of whom 7654 underwent ophthalmic examinations. The individuals were evaluated according their demographic data, eye complaints and eye examination including the RE and the need to prescribe spectacles according to age. Statistical analysis was performed using SPSS software package and descriptive analysis using 95% confidence intervals (P<0.05).

RESULTS

The main symptom detected was asthenopia, most frequent in the 2^nd and 3^rd decades of life, with a significant decline after the 4^th decade. Astigmatism was the RE most associated with asthenopia. Reduced near vision sight was more frequent in those ≥40y with a progressive decline thereafter. Spectacles were most frequently required in subjects of ≥40 years of age.

CONCLUSION

The main symptom related to the vision was asthenopia and was associated to astigmatism. The greatest need for spectacles prescription occurred after 40's, mainly to correct near vision. Subjects of ≥40 years old were determined to be at high risk of uncorrected REs. These observations can guide intervention programs for the Brazilian population.

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

PURPOSE

To compare visual performance between emmetropic and uncorrected moderately hyperopic preschool-age children without strabismus or amblyopia.

DESIGN

Cross-sectional study.

METHODS

setting: Multicenter, institutional. patient or study population: Children aged 4 or 5 years. intervention or observation procedures: Visual functions were classified as normal or reduced for each child based on the 95% confidence interval for emmetropic individuals. Hyperopic (≥3.0 diopters [D] to ≤6.0 D in the most hyperopic meridian; astigmatism ≤1.50 D; anisometropia ≤1.0 D) and emmetropic status were determined by cycloplegic autorefraction.

MAIN OUTCOME MEASURES

Uncorrected monocular distance and binocular near visual acuity (VA); accommodative response; and near random dot stereoacuity.

RESULTS

Mean (± standard deviation) logMAR distance visual acuity (VA) among 248 emmetropic children was better than among 244 hyperopic children for the better (0.05 ± 0.10 vs 0.14 ± 0.11, P < .001) and worse eyes (0.10 ± 0.11 vs 0.19 ± 0.10, P < .001). Mean binocular logMAR near VA was better in emmetropic than in hyperopic children (0.13 ± 0.11 vs 0.21 ± 0.11, P < .001). Mean accommodative response for emmetropic children was lower than for hyperopic subjects for both Monocular Estimation Method (1.03 ± 0.51 D vs 2.03 ± 1.03 D, P < .001) and Grand Seiko (0.46 ± 0.45 D vs 0.99 ± 1.0 D, P < .001). Median near stereoacuity was better in emmetropic than in than hyperopic children (40 sec arc vs 120 sec arc, P < .001). The average number of reduced visual functions was lower in emmetropic than in hyperopic children (0.19 vs 1.0, P < .001).

CONCLUSIONS

VA, accommodative response, and stereoacuity were significantly reduced in moderate uncorrected hyperopic preschool children compared to emmetropic subjects. Those with higher hyperopia (≥4 D to ≤6 D) were at greatest risk, although more than half of children with lower magnitudes (≥3 D to <4 D) demonstrated 1 or more reductions in function.

Vision Screening of Younger School Children by School Teachers: A Pilot Study in Udaipur City, Western India

PURPOSE

To assess the reliability of school teachers for vision screening of younger school children and to study the pattern of vision problems.

METHODS

In this cross-sectional study, trained school teachers screened 5,938 school children aged 3 to 8 years for vision and ocular disorders. Children were cross screened by professionals to assess the reliability of the teachers in vision screening and detecting ocular disorders in these children. The pattern of visual acuity, ametropia and ocular disorders was studied.

RESULTS

Sensitivity and specificity of the vision screening by school teachers was 69.2% (95% CI: 66.8-71.5%) and 95.3% (95% CI: 94.5-95.8%), respectively. The positive predictive value was 83.5% (95% CI: 81.4-85.6%) and negative predictive value was 89.8% (95% CI: 88.8-90.6%). The kappa statistic was 0.68 (95% CI: 0.66-0.7).

CONCLUSION

School teachers could effectively screen younger school children for vision assessment and ocular disorders.

Current Understanding of What Infants See

The current understanding of what infants see varies greatly among healthcare and education specialists. Even among ophthalmologists and pediatric neurologists in charge of clinical examinations of infants, opinions vary on what infants perceive, recognize, and use for communication and learning. It is, therefore, of interest to review publications from several specialties to learn whether new information is available on the development of visual functions and use of vision. Ten percent of total publications on this subject are reviewed here based on the usefulness of their content for improving early diagnosis and intervention of vision disorders in infants.