Sensitivity and specificity of a visual acuity screening protocol performed with the Lea Symbols 15-line folding distance chart in preschool children

Prevalence and associated factors of visual impairment among adults aged 40 and above in Southern Ethiopia, 2022

Visual impairment is a functional limitation of the eye caused by a disorder or disease that can reduce one's ability to perform daily activities. Many studies in Ethiopia have focused on childhood visual impairments. We assessed the prevalence and factors associated with visual impairment among adults aged 40 and above. Community-based cross-sectional study was done and a systematic sampling technique was used to select 655 participants. Data were collected by interviewer administered questionnaire, E-Snell chart, pinhole, torch light, and magnifying loupe. SPSS version 25 was used for analysis. Bivariate and multivariate analyses were performed to identify factors associated with outcome variable. The overall prevalence of visual impairment was found to be 36.95% (95% CI 33.2-40.8%). Factors associated with a higher odds of visual impairment included aged 51-60 years (AOR 2.37, 95% CI 1.29-4.44), aged 61 and above (AOR 8.9, 95% CI 4.86-16.3), low wealth index (AOR 1.91, 95% CI 1.14-3.2), divorced and widowed (AOR 4.67, 95% CI 2.77-7.86), no formal education (AOR 14.28, 95% CI 2.82-71.46), not utilizing eyeglass (AOR 3.94, 95% CI 1.65-9.40). The prevalence of visual impairment was relatively high compared to other studies. Age, marital status, occupation, educational status, wealth index, and not using eyeglasses were significantly associated with visual impairment. Refractory error is the leading cause of visual impairment. Early eye care service interventions are needed in this area.

Prevalence of Visual Impairment and Associated Factors Among Older Adults in Southern Ethiopia, 2022

Background

Visual impairment is a functional limitation of the eye brought on by a disorder or disease that can make it more difficult to carry out daily tasks. Visual impairment causes a wide range of public health, social, and economic issues, particularly in developing nations, where more than 90% of the world's visually impaired people reside. Although many studies conducted in Ethiopia related with the topic, there were focused on childhood visual impairments.

Objectives

To assess the prevalence and factors associated with visual impairment among older adults.

Methodology

A community-based cross-sectional study design was conducted in Arba Minch Zuria District. Systematic sampling technique was employed to select 655 adults aged 40 and above. Data were gathered through face-to-face interviews and visual acuity measurements, and SPSS version 25 was used for analysis. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with visual impairment.

Results

The overall prevalence of visual impairment was found to be 36.95% (95% CI=33.2-40.8%). Factors associated with a higher odds of visual impairment included aged 51-60 years (AOR=2.37,95%CI=1.29-4.44), aged 61 and above (AOR=8.9, 95%CI=4.86-16.3), low wealth index ((AOR=1.81, 95%CI: 1.14-3.2), divorced and widowed (AOR=4.67, 95%CI:2.77-7.86), no formal education (AOR=14.28, 95%CI: 2.82-71.46), not utilizing eyeglass (AOR=3.94, 95%CI (1.65-9.40). The most possible causes of visual impairment were found to be refractive error and cataract.

Conclusions and Recommendations

The prevalence of visual impairment among study population was relatively high, and more than three-fifths of participants had unilateral visual impairment. Age, marital status, occupation, educational status, wealth index, and not wearing of prescribed eyeglasses were significantly associated with visual impairment. Refractive error is the leading cause of visual impairment. Awareness of spectacle use and expanding cataract surgery coverage are urgently needed in this area.

Validation of the Waterloo Differential Visual Acuity Test (WatDAT) and Comparison With Existing Pediatric Tests of Visual Acuity

Purpose

The new Waterloo Differential Acuity Test (WatDAT) is designed to allow recognition visual acuity (VA) measurement in children before they can typically undertake matching tests. The study purpose was to validate WatDAT in adults with normal and reduced VA.

Methods

Eighty adults (18 to <40 years of age) participated (32 normal VA, 12 reduced VA, and 36 simulated reduced VA). Monocular VA was measured on two occasions in random order for WatDAT (versions with 3 and 5 distractors for Faces and Patti Pics house among circles), Lea Symbols, Kay Pictures and Patti Pics matching tests, Teller Acuity Cards, Cardiff Acuity Test, and Early Treatment Diabetic Retinopathy Study (ETDRS) letter chart. Pediatric tests were validated against ETDRS using limits of agreement (LoA), sensitivity, and specificity. The LoA for repeatability were also determined.

Results

WatDAT showed minimal bias compared with ETDRS, and LoAs, which were similar to pediatric matching tests (0.241-0.250). Both preferential looking tests showed higher bias and LoAs than ETDRS. Matching tests showed good agreement with ETDRS, except for Kay Pictures and Lea Uncrowded test, which overestimated VA. WatDAT showed high sensitivity (>0.96) and specificity (>0.79), which improved with criterion adjustment and were significantly higher than for the preferential looking tests. LoA for repeatability for WatDAT 3 Faces and WatDAT 5 Faces were comparable with the ETDRS.

Conclusions

WatDAT demonstrates good agreement and repeatability compared with the gold-standard ETDRS letter chart, and performed better than preferential looking tests, the alternative until a child can undertake a matching VA test.

Translational Relevance

Good validity of the Waterloo Differential Acuity Test was demonstrated in adults as a first step to showing its potential for detecting childhood visual disorders.

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.

Pattern of comorbidities in school-aged children with cerebral palsy in Cross River State, Nigeria

BACKGROUND

To describe the pattern of comorbidities in school-aged children with cerebral palsy (CP) and to identify which, if any, were associated with poor school attendance. A cross-sectional study, using the key informant methodology, between December 2017 and July 2018 was conducted in Cross River State, Nigeria. Assessments, confirmation of CP and identification of systemic comorbidities using standard tools and questionnaires were performed. Children confirmed to have CP between the ages 4 to 15 years were included.

RESULTS

Three hundred and eighty-eight children were confirmed to have CP, 59% males. The mean age was 9.2 years ± SD 4.0; 28% were non-ambulatory (gross motor function classification system (GMFCS) level IV-V) and spastic CP was seen in 70%. Comorbidities included Speech impairment 85%, feeding difficulties 86%, and swallowing difficulties 77%, learning difficulties 88%, abnormal behaviour 62%, visual acuity impairment 54%, objective perceptual visual disorders 46%, communication difficulties 45%, epilepsy 35%, hearing impairment 12% and malnutrition 51%. Learning difficulties (OR 10.1, p < 0.001; CI: 3.6-28.1), visual acuity impairment (OR 2.8, p = 0.002; CI: 1.5-5.3), epilepsy (OR 2.3, p = 0.009; CI:1.2-4.3) manual ability classification scale 4-5 (OR 4.7,p = 0.049; CI:1.0-22.2) and CP severity (GMFCS V-VI) OR 6.9 p = 0.002, CI: 2.0-24.0.) were seen as increasing the likelihood of poor school attendance.

CONCLUSION

Comorbidities were common, and some were associated with limited school attendance. A multidisciplinary tailored approach to care, with application of available therapeutic interventions for comorbidities is suggested. This may be useful in reducing barriers to school attendance.

Reduced visual acuity in children from 5 to 6 years old, with LEA chart

PURPOSE

To assess visual acuity in 5-year-old children with LEA chart and to estimate the frequency of reduced visual acuity in this age.

METHOD

Study aimed at children attending the last year of preschool education in Public Kindergartens and Private Social Solidarity Institutions (IPSS) under the influence Regional Health Administration of the Médio Tejo, in Portugal. The 15-line LEA charts at 3 m were used and the presentation visual acuity was measured monocularly starting with the right eye. The ETDRS-fast methodology was used.

RESULTS

A total of 3072 children participated, being 51% male and 54% from rural area. A rate of 13.7% children with a reduced level of visual acuity was found, that is, visual acuity worse or equal to 0.2 logMAR in at least one eye, or an interocular difference greater than two lines.

CONCLUSION

This research shows that reduced VA frequency rate in children between 5 and 6 years old is high. The literature presents amblyopia (refractive and/or strabismic) and uncorrected refractive errors without amblyopia as the main cause of reduced VA in childhood, and these anomalies negatively affect child development, especially at the educational level. Reduced VA interferes with performance on a number of key tasks in the learning process. Thus, it is important to preserve the running program to identify these deficits and lead to their correction before the beginning of the school stage.

Comparison of the pediatric vision screening program in 18 countries across five continents

PURPOSE

Incorporating mass pediatric vision screening programs as part of a national agenda can be challenging. This review assessed the implementation strategy of the existing pediatric vision screening program.

METHODS

A search was performed on PubMed, EBSCO host MEDLINE Complete, and Scopus databases encompassing the past ten years for mass pediatric screening practice patterns that met the selection criteria regarding their objectives and implementation. Results were analyzed from 18 countries across five continents.

RESULTS

Eight countries (44%) offered screening for distance visual acuity only, where the majority of the countries (88%) used either Snellen or Tumbling E chart. High-income countries initiated screening earlier and applied a more comprehensive approach, targeting conditions other than reduced vision only, compared with middle-income countries. Chart-based testing was most commonly performed, with only three countries incorporating an instrument-based approach. Lack of eyecare and healthcare practitioners frequently necessitated the involvement of non-eyecare personnel (94%) as a vision screener including parent, trained staff, and nurse.

CONCLUSIONS

Implementation of a vision screening program was diverse within countries preceded by limited resources issues. Lack of professional eyecare practitioners implied the need to engage a lay screener. The limitation of existing tests to detect a broader range of visual problems at affordable cost advocated the urgent need for the development of an inexpensive and comprehensive screening tool.

Diagnostic accuracy and agreement between visual acuity charts for detecting significant refractive errors in preschoolers

BACKGROUND

Preschool vision screenings are considered to be cost-effective methods to identify children with vision disorders. The children of this age group are poor at communicating their symptoms and hence screening is mandated. This study is aimed at estimating the diagnostic accuracy and agreement of Lea, HOTV and E visual acuity charts for detecting significant refractive errors.

METHODS

A cross-sectional study was conducted, in which monocular unaided vision assessment of each study participant was performed with Lea, HOTV and E charts. Stereo acuity was measured with the Randot Preschool Test and a comprehensive eye examination including dilatation was performed. Significant refractive error was defined as hyperopia > 3.25 D, myopia > 2.00 D, astigmatism > 1.50 D, anisometropia if interocular difference > 1.00 D for hyperopia, > 3.00 D for myopia or > 1.50 D for astigmatism. Sensitivity, specificity, positive and negative predictive values were estimated. Bland-Altmann plots were generated to help identify the level of agreement between the vision charts.

RESULTS

A total of 256 eyes were analysed. Lea, HOTV and E had sensitivities of 87.8 per cent, 90.2 per cent and 90.2 per cent, respectively. Specificity and positive predictive values were better for HOTV (77.3 per cent, 65.5 per cent) and Lea (75 per cent, 62.6 per cent), compared to E chart (69.8 per cent, 58.7 per cent). Negative predictive values for Lea, HOTV and E charts were 92.8 per cent, 93.8 per cent and 93.8 per cent, respectively. Bland-Altmann analysis showed good agreement between Lea and HOTV, Lea and E, and HOTV and E visual acuity charts. The acuity difference was least between Lea and HOTV charts (0.1 logMAR). Eighty-five (33.2 per cent) eyes had significant refractive errors. Eighty (94.1 per cent) eyes were astigmatic.

CONCLUSION

The diagnostic accuracy of the visual acuity charts was high for the identification of significant refractive errors in preschool children. There was very good agreement between the visual acuity charts.

Zagreb Amblyopia Preschool Screening Study: near and distance visual acuity testing increase the diagnostic accuracy of screening for amblyopia

AIM

To present and evaluate a new screening protocol for amblyopia in preschool children.

METHODS

Zagreb Amblyopia Preschool Screening (ZAPS) study protocol performed screening for amblyopia by near and distance visual acuity (VA) testing of 15 648 children aged 48-54 months attending kindergartens in the City of Zagreb County between September 2011 and June 2014 using Lea Symbols in lines test. If VA in either eye was >0.1 logMAR, the child was re-tested, if failed at re-test, the child was referred to comprehensive eye examination at the Eye Clinic.

RESULTS

78.04% of children passed the screening test. Estimated prevalence of amblyopia was 8.08%. Testability, sensitivity, and specificity of the ZAPS study protocol were 99.19%, 100.00%, and 96.68% respectively.

CONCLUSION

The ZAPS study used the most discriminative VA test with optotypes in line as they do not underestimate amblyopia. The estimated prevalence of amblyopia was considerably higher than reported elsewhere. To the best of our knowledge, the ZAPS study protocol reached the highest sensitivity and specificity when evaluating diagnostic accuracy of VA tests for screening. The pass level defined at ≤0.1 logMAR for 4-year-old children, using Lea Symbols in lines missed no amblyopia cases, advocating that both near and distance VA testing should be performed when screening for amblyopia.

Test Re-Test Reliability and Validity of Different Visual Acuity and Stereoacuity Charts Used in Preschool Children

BACKGROUND

Preschool vision screenings are cost effective ways to detect children with vision impairments. The use of any vision tests in children must be age appropriate, testable, repeatable and valid.

AIM

To compare the test re-test reliability, sensitivity and specificity of different visual acuity and stereo acuity charts used in preschool children.

MATERIALS AND METHODS

Monocular visual acuity of 90 subjects (180 eyes) of age 36 to 71 months was assessed with HOTV, Lea and E-chart in a preschool located in a semi urban area, Manipal, Karnataka. After the vision assessment, stereo acuity was recorded using Frisby and Titmus stereo charts followed by comprehensive eye examination. Repeated measurements of visual acuity and stereo acuity were done one week after the initial assessment.

RESULTS

Mean age of children was 53± 10 months with equal gender distribution. Intra class correlation (ICC) of Lea, HOTV, E-chart, Frisby and Titmus charts were 0.96, 0.99, 0.92, 1.0 and 1.0 respectively. The area under receiver operating curve (ROC) for Lea and E-chart was 0.892 and 0.776. HOTV was considered as the gold standard as it showed the least difference on repeated measurements. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of E-chart was 99, 15, 45, 94 and 21.8 percent, and Lea was 93, 56, 59 and 92 percent. The sensitivity, specificity, PPV and NPV of Frisby was 75, 27, 9, 92 percent were as of Titmus was 75, 13, 8 and 85 percent respectively.

CONCLUSION

HOTV chart can be used as the gold standard for measuring visual acuity of pre-schoolers in a semi urban area. Lea chart can be used in the absence of HOTV chart. Frisby and Titmus charts are good screening tools, but with poor diagnostic criteria.

Child neuroanatomical, neurocognitive, and visual acuity outcomes with maternal opioid and polysubstance detoxification

BACKGROUND

Maternal opioid and polysubstance use during pregnancy is associated with an increased risk of child neurocognitive and visual problems and neuroanatomical differences. We hypothesized that, in contrast to findings from a previous study of children born to mothers not detoxified, children born to detoxified mothers would not show gross neuroanatomical and neurocognitive differences.

METHODS

Mothers with opioid and polysusbstance abuse problems and their infants (n = 11 + 12) were recruited from residential treatment institutions. Comparison mothers and infants (n = 12 + 12) were recruited from child health centers. The studies were approved by the Regional Committee of Medical Research Ethics. Children had magnetic resonance imaging scanning, neurocognitive, and visual acuity testing at 4.5 years. Neuroanatomical, cognitive, and visual acuity characteristics were compared across groups by analysis of variance and general linear models.

RESULTS

There were no significant differences across groups in neuroanatomical volumes, or cortical thickness, area, or volume. There were no differences in general neurocognitive functioning, but significantly lower left eye visual acuity, and a trend toward lower binocular visual acuity, in the drug-exposed relative to the comparison group.

CONCLUSIONS

The present study does not demonstrate gross differences relative to a comparison group in neuroanatomical and general neurocognitive characteristics of children born to mothers with opioid and polysubstance abuse who were detoxified during pregnancy. However, visual acuity was significantly lower in the drug-exposed group, requiring attention. There is a pressing need for additional and larger studies of long-term and specific child outcomes in this at-risk group.

Reliability and validity of an automated computerized visual acuity and stereoacuity test in children using an interactive video game

PURPOSE

To evaluate the test-retest reliability and validity of the new automated computerized distance visual acuity and stereoacuity test for children, which uses an interactive video game.

DESIGN

Retrospective, observational case series.

METHODS

A total of 102 children aged between 3 and 7 years underwent the Snellen visual acuity test, the Distance Randot Stereotest, and the new automated computerized distance visual acuity and stereoacuity test. The test-retest reliability and validity of the automated computerized tests were assessed and compared with the Snellen visual acuity test and the Distance Randot Stereotest with frequency distributions of the differences, Bland-Altman plots, and Deming regression.

RESULTS

The automated computerized distance visual acuity test had high test-retest reliability (95% limits of agreement ±0.18 logMAR, 90.0% of the differences within 0.2 logMAR) and acceptable validity as compared with the Snellen visual acuity chart (95% limits of agreement ±0.27 logMAR, 81.3% of the differences within 0.2 logMAR). The automated computerized distance stereoacuity test had high test-retest reliability (95% limits of agreement ±0.29 log arc second, 95.1% of the differences within 0.3 log arc second) and acceptable validity as compared with the Distance Randot Stereotest (95% limits of agreement ±0.35 log arc second, 93.9% of the differences within 0.3 log arc second).

CONCLUSIONS

The new automated computerized distance visual acuity and stereoacuity test, which uses an interactive video game, has good reliability and acceptable validity compared with the Snellen visual acuity chart and the Distance Randot Stereotest.

Validity of vision screening tests by teachers among school children in Mashhad, Iran

PURPOSE

To determine the sensitivity and specificity of vision screening in Iranian schools where teachers have provided screening services for over 10 years.

METHODS

In a cross-sectional study, using random cluster sampling, 1163 school children were selected from 14 clusters. Data of vision tests performed by teachers were derived from 847 student records and compared with data obtained by optometrists. Measurement of the uncorrected visual acuity was done using the E chart by both the teachers and the optometrists. Examinations performed by optometrists were regarded as gold standard in this study and the sensitivity and specificity of the examinations performed by teachers were evaluated against them. Uncorrected visual acuity worse than 20/25 in the better eye was considered as the cut-off point for students' visual impairment.

RESULTS

The sensitivity and specificity of the screening tests performed by the teachers were 37.5% and 92.0%, respectively. The positive and negative predictive values were 25.0% and 95.4%, respectively. There was no significant difference in the validity of the vision test between males and females (P = 0.093 for sensitivity and P = 0.052 for specificity).

CONCLUSION

Our findings showed that teachers missed a significant number of children with vision impairment and the examinations performed by teachers lacked the required sensitivity for case detection. The number of false negative results should be minimized through continued investment in accurate screening processes.

The potential cost-effectiveness of amblyopia screening programs

PURPOSE

To estimate the incremental cost-effective-ness of amblyopia screening at preschool and kindergarten, the costs and benefits of three amblyopia screening scenarios were compared to no screening and to each other: (1) acuity/stereopsis (A/S) screening at kindergarten, (2) A/S screening at preschool and kindergarten, and (3) photoscreening at preschool and A/S screening at kindergarten.

METHODS

A probabilistic microsimulation model of amblyopia natural history and response to treatment with screening costs and outcomes estimated from two state programs was programmed. The probability was calculated that no screening and each of the three interventions were most cost-effective per incremental quality-adjusted life year (QALY) gained and case avoided.

RESULTS

Assuming a minimal 0.01 utility loss from monocular vision loss, no screening was most cost-effective with a willingness to pay (WTP) of less than $16,000 per QALY gained. A/S screening at kindergarten alone was most cost-effective at a WTP between $17,000 and $21,000. A/S screening at preschool and kindergarten was most cost-effective at a WTP between $22,000 and $75,000, and photoscreening at preschool and A/S screening at kindergarten was most cost-effective at a WTP greater than $75,000. Cost-effectiveness substantially improved when assuming a greater utility loss. All scenarios were cost-effective when assuming a WTP of $10,500 per case of amblyopia cured.

CONCLUSION

All three screening interventions evaluated are likely to be considered cost-effective relative to many other potential public health programs. The choice of screening option depends on budgetary resources and the value placed on monocular vision loss prevention by funding agencies.

Screening for visual impairment in children ages 1-5 years: update for the USPSTF

CONTEXT

Screening could identify preschool-aged children with vision problems at a critical period of visual development and lead to treatments that could improve vision.

OBJECTIVE

To determine the effectiveness of screening preschool-aged children for impaired visual acuity on health outcomes.

METHODS

We searched Medline from 1950 to July 2009 and the Cochrane Library through the third quarter of 2009, reviewed reference lists, and consulted experts. We selected randomized trials and controlled observational studies on preschool vision screening and treatments, and studies of diagnostic accuracy of screening tests. One investigator abstracted relevant data, and a second investigator checked data abstraction and quality assessments.

RESULTS

Direct evidence on the effectiveness of preschool vision screening for improving visual acuity or other clinical outcomes remains limited and does not adequately address whether screening is more effective than no screening. Regarding indirect evidence, a number of screening tests have utility for identification of preschool-aged children with vision problems. Diagnostic accuracy did not clearly differ for children stratified according to age, although testability rates were generally lower in children 1 to 3 years of age. Treatments for amblyopia or unilateral refractive error were associated with mild improvements in visual acuity compared with no treatment. No study has evaluated school performance or other functional outcomes.

CONCLUSIONS

Although treatments for amblyopia or unilateral refractive error can improve vision in preschool-aged children and screening tests have utility for identifying vision problems, additional studies are needed to better understand the effects of screening compared with no screening.

The accuracy of photoscreening at detecting treatable ocular conditions in children with Down syndrome

BACKGROUND

Children with Down syndrome (DS) have an increased prevalence of ocular disorders, including amblyopia, strabismus, and refractive error. Health maintenance guidelines from the Down Syndrome Medical Interest Group recommend ophthalmologic examinations every 1 to 2 years for these children. Photoscreening may be a cost-effective option for subsequent screening evaluations after an initial complete examination, but no study has evaluated the accuracy of photoscreening in children with DS. The purpose of this study is to determine the sensitivity, specificity, and positive and negative predictive values of photoscreening in detecting treatable ocular conditions in children with DS.

METHODS

Photoscreening and complete ophthalmologic evaluations were performed in 50 consecutive 3- to 10-year-old children with DS. Sensitivity, specificity, and positive and negative predictive values were calculated with the use of ophthalmologic examination findings as the reference standard.

RESULTS

Most children were able to complete photoscreening (94% with Medical Technology and Innovations [MTI] and 90% with Visiscreen OSS-C [VR]). Many children had an identified diagnosis on ophthalmologic examination (n = 46, 92%). Of these, approximately one-half (n = 27, 54%) had one or more condition(s) requiring treatment. Both the MTI and VR photoscreening devices had a sensitivity of 93% (95% confidence interval 0.76-0.99) for detecting treatable ocular conditions. The specificities for the MTI and VR photoscreening were 0.35 (0.18-0.57) and 0.55 (0.34-0.74), respectively.

CONCLUSIONS

Photoscreening is sensitive but less specific at detecting treatable ocular conditions in children with DS. In specific instances, the use of photoscreening in the DS population has the potential to save time and expense related to routine eye examinations, particularly in children with a normal baseline comprehensive examination.