Performance of Photoscreener in Detection of Refractive Error in All Age Groups and Amblyopia Risk Factors in Children in a Tribal District of Odisha: The Tribal Odisha Eye Disease Study (TOES) # 3

Retinoscopes: Past and present

BACKGROUND

Retinoscopy is arguably the most important method in the eye clinic for diagnosing and managing refractive errors. Advantages of retinoscopy include its non-invasive nature, ability to assess patients of all ages, and usefulness in patients with limited cooperation or communication skills.

AIM

To discuss the history of retinoscopes and examine current literature on the subject.

METHODS

A search was conducted on the PubMed and with the reference citation analysis (https://www.referencecitationanalysis.com) database using the term "Retinoscopy," with a range restricted to the last 10 years (2013-2023). The search string algorithm was: "Retinoscopy" (MeSH Terms) OR "Retinoscopy" (All Fields) OR "Retinoscopes" (All Fields) AND [(All Fields) AND 2013: 2023 (pdat)].

RESULTS

This systematic review included a total of 286 records. Publications reviewed iterations of the retinoscope into autorefractors, infrared photo retinoscope, television retinoscopy, and the Wifi enabled digital retinoscope.

CONCLUSION

The retinoscope has evolved significantly since its discovery, with a significant improvement in its diagnostic capabilities. While it has advantages such as non-invasiveness and broad applicability, limitations exist, and the need for skilled interpretation remains. With ongoing research, including the integration of artificial intelligence, retinoscopy is expected to continue advancing and playing a vital role in eye care.

Prevalence of Amblyogenic Risk Factors Among School Children in India Using the Spot Vision Screener

INTRODUCTION

Amblyopia is a common cause of preventable visual impairment in children, affecting 1% to 6% globally. This study assesses amblyopia prevalence and risk factors among school children in rural Telangana, India, using the Spot Vision Screener (Welch Allyn, Inc., Skaneateles Falls, New York, USA), a portable, noninvasive device recommended for automated vision screening.

METHODS

A cross-sectional study was conducted on 714 schoolchildren aged 5-10 years. Screening was performed using the Spot Vision Screener, evaluating refractive errors, ocular alignment, and other amblyopia risk factors. Children identified with potential amblyogenic factors were referred for comprehensive ophthalmological evaluation to confirm diagnosis.

RESULTS

Out of 714 children screened, 84 were referred by the Spot Vision Screener for further evaluation. Subsequent examination by ophthalmologists confirmed amblyopia in 65 children, resulting in a prevalence of 9.10%. Myopic refractive error was the most prevalent (69.23%), followed by astigmatism (21.53%) and hypermetropia (9.23%) among amblyopia cases.

CONCLUSION

The Spot Vision Screener proved to be a reliable tool for identifying amblyopia risk factors in school children, facilitating early detection and referral for appropriate management. This study underscores the importance of implementing effective vision screening programs in rural settings to mitigate preventable childhood blindness.

The Performance of Spot Photoscreener in 6 to 10 Weeks Infants in China: A Cross-Sectional Study

Purpose

To compare the refractive errors measured by the Spot photoscreener (with or without cycloplegia) to cycloplegic retinoscopy in 6- to 10-week-old infants.

Materials and Methods

101 right eyes from 101 healthy infants aged 6 to 10 weeks were recruited for this cross-sectional observational study. Refractive errors were measured using Spot photoscreener before and after cycloplegia, as well as cycloplegic retinoscopy. Comparisons between the refractive measurements were performed using one-way ANOVA with the post hoc Tukey HSD test or Kruskal-Wallis test with the Steel-Dwass test according to the data normality. Pearson's correlation test and 95% confidence intervals were calculated. The agreement was evaluated using a Bland-Altman plot with 95% limits of agreement of the differences.

Results

Spot photoscreener was found to underestimate the spherical equivalent by 2.33 Diopters (D) in these infants. Following the induction of cycloplegia, the spherical equivalent measured by Spot photoscreener was in excellent agreement with cycloplegic retinoscopy with the mean difference of 0.01 D. Spot photoscreener overestimated cylindrical parameter by 0.2 D with poor agreement with cycloplegic retinoscopy no matter whether cycloplegia was induced. It had good agreement with cycloplegic retinoscopy in the J0 vector than the J45 vector measurement.

Conclusions

With the induction of cycloplegia, Spot photoscreener can accurately evaluate spherical equivalent in hyperopic infants with mild-to-moderate astigmatism. While it may provide valuable measurements of astigmatism, discrepancies in cylinder and axis should be taken into account.

Evaluation of cycloplegic and noncycloplegic performance of spot vision screener in detection of amblyopia risk factors using 2021 AAPOS guidelines

PURPOSE

This research evaluates the effectiveness of the Spot Vision Screener (SVS) before and after cycloplegia to detect amblyogenic refractive errors in children.

METHODS

Children ages 3 to 10 years old were screened by the SVS before and after cycloplegia. Sensitivity, specificity, positive and negative predictive value, paired t-test, Bland-Altman plot and receiver operating characteristic area under the curve were evaluated by comparing the results of the SVS (v3.0.05) measurements with the results of the cycloplegic Topcon autorefractometer according to the 2021 guidelines of the American Association for Pediatric Ophthalmology and Strabismus.

RESULTS

Both eyes of 211 patients aged 3 to 10 years old were included. Regarding the amblyopia risk factors, the noncycloplegic SVS had 65.7 % sensitivity, 94.9 % specificity, 81.2 % positive predictive value and 89.3 % negative predictive value. The SVS's sensitivity increased from 65.7 % to 81.9 % with cycloplegia compared to noncycloplegic SVS results. The sensitivity detection of hyperopia was improved from 4.2 % to 100 % after cycloplegia. Areas under the receiver operator characteristic curve for noncycloplegic SVS and cycloplegic SVS were 0.506 (95 % CI, 0.395 to 0.646, p = 0737) and 0.905 (95 % CI, 0.915 to 0.971, p < 0.001) for hyperopia, respectively. Using the +1.64 D revised cutoff criteria for hyperopia increased sensitivity from 4.2 % to 78 %.

CONCLUSION

Noncycloplegic SVS measurements showed relatively high specificity in detecting amblyopia risk factors. The fact that noncycloplegic measurements have a very low sensitivity for hyperopia is an important weakness of the SVS, especially because hyperopia is the most frequently encountered refractive error in very young children. It should be noted that amblyogenic hyperopia may be overlooked by an SVS without cycloplegia.

Performance of the Spot Vision Screener in children with Down syndrome and other special needs

BACKGROUND

Amblyopia is a common cause of monocular vision impairment and disproportionally affects developmentally delayed children. Photoscreeners have been suggested as a method to detect amblyopia risk factors (ARFs) in children with developmental disabilities who may not be amenable to traditional vision screening methods. The Spot Vision Screener is a commonly used photoscreener for detecting ARF and has shown excellent sensitivity and accuracy in the general pediatric population. The purpose of this study was to evaluate its accuracy in children with Down syndrome and other special needs.

METHODS

Children with various disabilities or delays were recruited from outpatient clinics at the Children's Hospital of Colorado. Participants had their photograph taken with Spot before and after pupil dilation and cycloplegia. Images were compared to results of a comprehensive clinical eye examination.

RESULTS

A total of 100 children participated in the study. Images could not be obtained in 12 children; 5 children did not attend their clinical examination. The overall sensitivity of Spot was 90%, with a positive predictive value of 80% in undilated subjects. The area under the receiver operator curve (AUROC) was 0.68 (95% CI, 0.57-0.79), which did not differ significantly from the AUROC after dilation/cycloplegia (0.68; 95% CI, 0.54-0.81).

CONCLUSIONS

The Spot Vision Screener could be used by primary care clinics and vision screening programs with a high sensitivity to determine which patients with Down syndrome and special needs should be referred for clinical examination.

Evaluation and Follow-up of Myopia Prevalence Among School-Aged Children Subsequent to the COVID-19 Home Confinement in Feicheng, China

Importance

Progression of myopia in a school-aged population due to home confinement (January to May 2021) during the COVID-19 pandemic has been previously reported. A key remaining question was whether the myopia spike in children aged 6 to 8 years persisted.

Objective

To investigate the changes in refractive status and prevalence of myopia in school-aged children 1 year after home confinement ended in China.

Design, Setting, and Participants

This cross-sectional study with a cohort substudy prospectively evaluated data from school-based photoscreening in Feicheng, China. Children aged 6 to 13 years participated in 8 screenings from 2015 to 2021.

Exposures

Noncycloplegic photorefraction was conducted using the Spot Vision photoscreener.

Main Outcomes and Measures

The main outcomes were the differences in spherical equivalent refraction (SER) and prevalence of myopia between 2020 (during home confinement) and 2021 (after home confinement). The SER was recorded for each child, and the prevalence of myopia was calculated annually for each age group.

Results

A total of 325 443 children participated in the study (51.4% boys, 48.6% girls; age range, 6 to 13 years). Compared with 2020, the mean SER of children in 2021 increased significantly for those aged 6 (0.42 diopters [D]), 7 (0.41 D), and 8 (0.33 D) years. The prevalence of myopia in 2021 was similar to in 2019 for each age group (aged 6 years: 7.9% vs 5.7%; aged 7 years: 13.9% vs 13.6%; aged 8 years: 29.5% vs 26.2%). Both the prevalence of myopia and mean SER for these children returned to their prepandemic levels.

Conclusions and Relevance

Compared with 2020, the prevalence of myopia among children aged 6 to 8 years in the 2021 screenings decreased, and the mean SER returned to prepandemic level. The refractive development in children aged 6 to 8 years may be most susceptible to environmental changes. These findings support the premise that age 6 to 8 years is a critical period for myopia development and suggest a need to focus preventive interventions for myopia control on children in this age range.

Positive predictive value of dual-modality vision screening in school children 4-7 years of age-a retrospective review in Queensland, Australia

PURPOSE

To report the outcomes and positive predictive value (PPV) of vision screening in schoolchildren 4-7 years of age through the Primary School Nurse Health Readiness Program (PSNHRP) in Queensland, Australia.

METHODS

A retrospective review of schoolchildren who underwent vision screening between January 2017 and December 2020 was conducted. Vision screening was performed through a dual-examination method, using the Parr 4m letter-matching vision test with crowding bars and the Spot photoscreener. Children were referred to an optometrist or ophthalmologist for review as required and if they failed either screening modality. PPVs were calculated based on whether a visual abnormality was confirmed by an ophthalmologist or optometrist.

RESULTS

Of 185,685 eligible children, 176,164 (94.9%) consented to vision screening, 164,890 (93.6%) consented children underwent vision screening, and of those 12,148 (7.4%) were referred for an eye assessment. Of the 8,659 children with a known outcome (71.3% of referred), 6,011 (69.4% of known outcomes) had a confirmed visual abnormality and 2,648 (30.6%) children did not. The PPV was 0.73 when a referral was indicated by the photoscreener result, 0.76 when indicated by visual acuity testing, and 0.91 when indicated by both the photoscreener and visual acuity testing.

CONCLUSIONS

The PSNHRP vision screening program showed a high uptake, and the dual screening method was effective in identifying visual abnormalities, with higher PPV when both visual acuity and photoscreener results indicated a need for referral.

Associations between anthropometric indicators and refraction in school-age children during the post-COVID-19 era

Purpose

To explore the associations between anthropometric indicators and refraction in school-aged children in the post-COVID-19 era.

Methods

Data were collected from 25,644 children aged 7 to 12 years in 48 elementary schools in Tianjin. The comprehensive examination included height, weight, systolic blood pressure (SBP), diastolic blood pressure (DBP), refraction, and calculation of BMI, with a follow-up visit after 6 months. Myopia was defined as spherical equivalent refraction (SER) ≤-0.50 diopter (D). Bivariate correlation coefficients and multiple linear regression models were used to explore the cross-sectional and longitudinal associations between anthropometric indicators (height, weight, BMI, SBP, and DBP) and refraction.

Results

The mean changes in height, weight, BMI, SBP, DBP, and SER of the participants were 4.03 ± 2.18 cm, 3.10 ± 2.39 kg, 0.45 ± 1.16 kg/m², 2.26 ± 14.74 mmHg, 2.18 ± 11.79 mmHg and -0.17 ± 0.51 D, respectively. Overall, height, weight, BMI, SBP, and DBP were all correlated with SER (r = -0.324, r = -0.234, r = -0.121, r = -0.112, r = -0.066, both p < 0.001), and changes in height and weight were correlated with changes in SER (r = -0.034, -0.031, both p < 0.001). Furthermore, multiple linear regression analysis revealed that the association of BMI, SBP, and DBP with SER was significant in myopic children but not in non-myopic children. The association between changes in weight and changes in SER was only present in non-myopic children but not in myopic children.

Conclusion

Height and weight were negatively correlated with SER in both cross-sectional analysis and longitudinal changes, indicating that children's height, weight and growth rate may be used as a reference indicator for myopia risk prediction and myopia progression monitoring.

Performance of a photoscreener in detecting accommodation spasm

CLINICAL RELEVANCE

For a correct spectacle prescription, accommodation spasm should not be overlooked in the measurements made using an autorefractometer. Although this can be easily understood with cycloplegia, it is not practical. Therefore, investigating practical methods that can predict excess accommodation will be useful in clinical practice.

BACKGROUND

To evaluate the performance of a photoscreener in detecting pseudo-myopia due to accommodation spasm and whether it eliminates the need for cycloplegia.

METHODS

Study was conducted in Van Training and Research Hospital. The manifest refraction of the patients was measured using an by an autorefractometer followed by a photoscreener before cycloplegia. Cycloplegic refraction errors were detected using an autorefractometer. Patients with pseudo-myopia due to accommodation spasm were diagnosed by observing a significant hyperopic shift in cycloplegic autorefractometer values compared to the non-cycloplegic values and were included in study. Cycloplegic autorefractometer and non-cycloplegic photoscreener measurements were compared.

RESULTS

The mean non-cycloplegic autorefractometer values were as follows: --6.34 ± 1.29D, -0.42 ± 0.58D, and -6.55 ± 1.36D for spherical, cylindrical, and spherical equivalents, respectively. These values were 0.23 ± 0.63D, -0.21 ± 0.41D, and 0.11 ± 0.73D for cycloplegic autorefractometer measurements, respectively. Cycloplegic autorefractometer values showed a significant hyperopic shift of 6.57 ± 1.26D and 6.67 ± 1.34D for spherical and spherical equivalents, respectively, compared to non-cycloplegic values (p < 0.001 for both). There was no significant difference between non-cycloplegic photoscreener and cycloplegic autorefractometer measurements for spherical, cylindrical, and spherical equivalents (p = 0.126, p = 0.078, and p = 0.053, respectively). . There was agreement between the measurements in the Bland-Altman graph.

CONCLUSION

There was consistency between non-cycloplegic photoscreener and cycloplegic autorefractometer measurements in patients with pseudomyopia due to accommodation spasm. Therefore, photoscreener measurements can be a fast, practical, cost-effective examination method for screening these patients without the need for cycloplegia.

Agreement and diagnostic accuracy of vision screening in preschool children between vision technicians and spot vision screener

Purpose

Screening preschool children for vision-related disorders poses a challenge. This study is designed to determine the agreement and diagnostic accuracy of the spot vision screener (SVS) in screening preschool children compared to screening procedure by vision technicians (VT).

Methods

This study was conducted as a part of the ongoing study titled "Initiative for Screening Children for Refractive Errors and other Eye Health Needs (I-SCREEN)." Children from 33 Anganwadis (preschools) in two districts, Adilabad district of Telangana and Krishna district of Andhra Pradesh, in South India, underwent eye health screening by a VT and by a trained community eye health workers (CEHW) using the SVS. Findings were compared for agreement and diagnostic accuracy of assessment.

Results

A total of 976 preschool children were screened by the VT and separately by the CEHW using the SVS in Adilabad (15 schools) and Krishna (18 schools) districts. The overall mean age of these children was 2.5 years (SD ± 1.3 years). There were 48 (4.9%) referrals by VT compared to 105 (10.8%) referrals by CEHW using SVS. The overall sensitivity of SVS was 91.7% (95% CI: 80%-97.7%) and the specificity was 93.4% (95% CI: 91.6%-94.9%). Positive predictive value was 41.9% (95% CI: 32.3%-51.9%) and negative predictive value was 99.5% (95% CI: 98.8%-99.9%) with a moderate agreement (0.54; 95% CI 0.49-0.64) between VT screening and screening with SVS.

Conclusion

The SVS showed good diagnostic accuracy and agreement in screening for possible vision-related disorders in preschool children.

Progression of Myopia in School-Aged Children After COVID-19 Home Confinement

Question

Is home confinement due to coronavirus disease 2019 associated with the burden of myopia?

Findings

In this cross-sectional study that included 194 904 photoscreening tests conducted in 123 535 children, a substantial myopic shift (−0.3 diopters) was noted after home confinement due to coronavirus disease 2019 for children aged 6 to 8 years. The prevalence of myopia increased 1.4 to 3 times in 2020 compared with the previous 5 years.

Meaning

Home confinement due to coronavirus disease 2019 appeared to be associated with a substantial myopic shift in children; younger (aged 6-8 years) children’s refractive status may be more sensitive to environmental changes than older children, given that they are in an important period for the development of myopia.

Importance

Time spent in outdoor activities has decreased owing to home confinement for the coronavirus disease 2019 (COVID-19) pandemic. Concerns have been raised about whether home confinement may have worsened the burden of myopia owing to substantially decreased time spent outdoors and increased screen time at home.

Objective

To investigate the refractive changes and prevalence of myopia in school-aged children during the COVID-19 home confinement.

Design, Setting, and Participants

A prospective cross-sectional study using school-based photoscreenings in 123 535 children aged 6 to 13 years from 10 elementary schools in Feicheng, China, was conducted. The study was performed during 6 consecutive years (2015-2020). Data were analyzed in July 2020.

Exposures

Noncycloplegic photorefraction was examined using a photoscreener device.

Main Outcomes and Measures

The spherical equivalent refraction was recorded for each child and the prevalence of myopia for each age group during each year was calculated. The mean spherical equivalent refraction and prevalence of myopia were compared between 2020 (after home confinement) and the previous 5 years for each age group.

Results

Of the 123 535 children included in the study, 64 335 (52.1%) were boys. A total of 194 904 test results (389 808 eyes) were included in the analysis. A substantial myopic shift (approximately −0.3 diopters [D]) was found in the 2020 school-based photoscreenings compared with previous years (2015-2019) for younger children aged 6 (−0.32 D), 7 (−0.28 D), and 8 (−0.29 D) years. The prevalence of myopia in the 2020 photoscreenings was higher than the highest prevalence of myopia within 2015-2019 for children aged 6 (21.5% vs 5.7%), 7 (26.2% vs 16.2%), and 8 (37.2% vs 27.7%) years. The differences in spherical equivalent refraction and the prevalence of myopia between 2020 and previous years were minimal in children aged 9 to 13 years.

Conclusions and Relevance

Home confinement during the COVID-19 pandemic appeared to be associated with a significant myopic shift for children aged 6 to 8 years according to 2020 school-based photoscreenings. However, numerous limitations warrant caution in the interpretation of these associations, including use of noncycloplegic refractions and lack of orthokeratology history or ocular biometry data. Younger children’s refractive status may be more sensitive to environmental changes than older ages, given the younger children are in a critical period for the development of myopia.

Does the Accuracy and Repeatability of Refractive Error Estimates Depend on the Measurement Principle of Autorefractors?

Purpose

The purpose of this study was to determine the accuracy and repeatability of refractive errors obtained using three autorefractors based on different measurement principles, vis-à-vis, gold-standard retinoscopy.

Methodology

Accuracy of noncycloplegic, sphero-cylindrical refractive error of 234 eyes was obtained using the rotary prism-based RM-8900 closed-field autorefractor, photorefraction based Spot vision screener, wavefront aberrometry based E-see, and streak retinoscopy by four different examiners, masked to the results of each other. Intersession repeatability of autorefractors was determined by repeat measurements in a subset of 40 subjects.

Results

Retinoscopy values of M, J₀, and J₄₅ power vectors for the cohort ranged from -10.2 to 8 D, -1.4 to 1.8 D, and -0.9 to 1.2 D, respectively. Across autorefractors, the interequipment bias of M and J₀ power vectors were statistically insignificant (< ±0.5 D; P > 0.05) but the corresponding limits of agreement were ±2.5 and ±1 D, respectively, without any trend across instruments or the patient's age (P > 0.5). Repeatability of M and J₀ power vectors were ±0.75 D and ±0.40 D, respectively, across autorefractors. The range of J₄₅ power vector was too narrow for any meaningful analysis.

Conclusions

Refractive errors measured using autorefractors operating on different principles show minimal bias and good short-term repeatability but relatively large agreement limits, vis-à-vis, retinoscopy. Among them, the wavefront aberrometry based E-see autorefractor performs relatively better in all measurement parameters evaluated here.

Translational Relevance

Although autorefractor estimates of noncycloplegic refractive error appears independent of their measurement principle, their relatively poor agreement with gold-standard retinoscopy warrants caution while used for screening and quantification of refractive errors.

Prevalence of Amblyopia After Photoscreening

PURPOSE

To assess the prevalence of amblyopia in a population of adolescents screened for amblyogenic risk factors at preschool age.

METHODS

Data were retrospectively collected from the preschool screening for amblyogenic risk factors routinely performed in the authors' hospital. A stratified random sampling was used. A school from the region was randomly selected and then two grades were randomly selected. All classes from these grades were evaluated and only children who were previously screened for amblyogenic risk factors were included. Ophthalmological examination included best visual acuity (distance and near, Early Treatment of Diabetic Retinopathy Study scale and Jaeger eye chart) and stereopsis (Randot Stereo Test; Stereo Optical Company, Inc). Sample size was estimated as more than 283 participants. Pertinent data were extracted for analysis.

RESULTS

A total of 520 children were recruited, and 299 met the inclusion criteria. Fifteen percent of children (n = 46) had results at the screening that prompted a further ophthalmological evaluation and 9% of children (n = 26) had meaningful refractive errors or strabismus. Overall amblyopia prevalence was 1.00%. One of the 3 children who developed amblyopia had microstrabismus, and the remaining 2 children had a previous positive screening result but missed the follow-up evaluations. At the follow-up evaluation, 79.3% (n = 237) of children were not wearing glasses.

CONCLUSIONS

A structured screening may allow the early detection of amblyogenic factors and prevent further vision deterioration in children, thus improving their long-term quality of life. The prevalence of amblyopia in this study was lower than that recently stated for Europe. [J Pediatr Ophthalmol Strabismus. 2020;57(6):372-377.].

Tribal Odisha Eye Disease Study (TOES) # 7. Prevalence of refractive error in children in tribal Odisha (India) school screening

Purpose

To describe the prevalence of refractive error in school children in a tribal district, Rayagada, Odisha state, India.

Methods

In a cross-sectional school eye health study, the students with diminished vision and other ocular abnormalities were referred for a further eye examination to the vision technicians after initial screening by the trained school teachers. The examination by vision technicians consisted of an external eye examination, photorefraction using a Spot screener and subjective correction. Those not improving with subjective correction were referred to the ophthalmologist for further examination.

Results

The school teachers measured vision in 153,107 children; 5,990 students reached a vision technician. There was a near equal number of boys (50.06%) and girls (49.94%). The average age was 10.5 ± 2.63 (range: 5-15) years. The prevalence of refractive error was 9.7% (95% [CI]; 9.0-10.5%) in the vision technician-examined children. Myopia (4.9%) and astigmatism (5.4%) were more common than hyperopia (0.2%). The presenting visual acuity (PVA) was worse in children with hypermetropia (PVA 20/100-20/200 in 40% of children). Spherical equivalent of refractive error did not have a good correlation with age (R² = 1.3); but increasing age was associated with increased risk of myopia (odds ratio 1.14; 95% CI 1.09-1.20; P < 0.001).

Conclusion

The quantum of refractive error was close to other similar studies in India but the prevalence of myopia was relatively less.

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.

Evaluation of the Spot Vision Screener in comparison with the orthoptic examination in visual screening in 3-5 year-old schoolchildren

PURPOSE

To evaluate the Spot Vision Screener (SVS) compared with the orthoptic examination for detection of amblyopia risk factors in preschools.

METHODS

This prospective study included children with a visual screening organized by the department of "le" (PMI) in Côte d'Or (Burgundy, France), between June 2017 and April 2018. All children were evaluated with the SVS followed by a clinical orthoptic examination. Results with the SVS were compared with those obtained by clinical orthoptic examination.

RESULTS

A total of 1236 subjects were included in the study from 100 preschools. The mean age of the children was 3.6±0.7 years, and 627 were female (50.7%). The orthoptic examination detected 308 (24.9%) children with subnormal visual acuity for age in one eye or both. In children with a history of prematurity, the orthoptic examination was more frequently abnormal (P=0.002), which was not seen with the SVS (P=0.050). The SVS screened 20 (1.6%) children with strabismus, while 40 (3.2%) were detected by orthoptic examination. At the end of the screening, the SVS detected 182 (14.7%) suspect patients while 311 (25.1%) suspect patients were detected after the orthoptic examination. Comparing SVS with orthoptic examination, agreement was fair (κ=0.4).

CONCLUSION

The SVS can be a useful device for visual screening, but agreement with the orthoptic examination was only fair. The Spot vision screener should be used in conjunction with a clinical orthoptic examination.

Accuracy of noncycloplegic photorefraction using Spot photoscreener in detecting amblyopia risk factors in preschool children in an Indian eye clinic

Purpose:

To evaluate the accuracy of Spot photoscreener (PS) as a noncycloplegic photorefractor in detecting amblyopia risk factors (ARFs) in preschool children in an Indian eye clinic setting. Also, to derive appropriate cutoff values for screening to obtain maximum sensitivity and specificity of the device in detecting ARF.

Methods:

This was a cross-sectional study conducted in the outpatient pediatric eye clinic at a tertiary eye care institute. A Spot PS was used to screen all the children between the ages of 6 months and 5 years that presented to the eye clinic from August 2018 to October 2018. This screening was followed by a complete eye examination, including cycloplegic refraction by a masked examiner. The 2013 American Association for Pediatric Ophthalmology and Strabismus (AAPOS) guidelines were considered the standard cutoff values for clinically significant refractive error in children younger than 5 years of age.

Results:

The study comprised of 219 children. The Spot PS diagnosed 135 (61.64%) children with ARF as compared with 124 (56.62%) children detected by clinic examination. For ARF detection, the Spot photoscreeneer had 85.48% sensitivity, 69.47% specificity, 78.52% positive predictive value and 78.57% negative predictive value. The sensitivity for detection of strabismus and hypermetropia was very low (42% and 36%, respectively). The 95% limits of agreement ranged from −5.48 to +5.59 diopters (D) with a bias of 0.06 D for spherical equivalent between noncycloplegic photorefraction and cycloplegic refraction.

Conclusion:

The Spot PS may be used as a screening tool to detect ARF in children younger than 5 years of age keeping its limitations in consideration. However, the performance can be improved by modifying the cutoff values for the referral.

Diagnostic test accuracy of Spot and Plusoptix photoscreeners in detecting amblyogenic risk factors in children: a systemic review and meta-analysis

PURPOSE

Amblyopia is a permanent visual impairment developed in early childhood. Recently, instrument-based photoscreeners have been widely used for vision screening to detect amblyopia risk factors, which is key for the prevention and treatment of amblyopia. This meta-analysis aims to evaluate the diagnostic test accuracy of Spot and Plusoptix photoscreeners in detecting risk factors for amblyopia in children.

METHODS

An electronic literature search was performed in October 2018 using the MEDLINE, Embase, and Web of Science databases. Twenty-one publications with a total of 5022 subjects were included. Subjects given a comprehensive examination were considered to have amblyopia or amblyogenic risk factors based on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria guidelines.

RESULTS

The overall sensitivity for Spot and Plusoptix was 87.7% and 89.4%, respectively (p = 0.38); the specificity was 78.0% and 89.9%, respectively (p = 0.90). For subjects under 7 years old (preschool children), the overall sensitivity for Spot and Plusoptix was 91.7% and 90.2%, respectively (p = 0.81); the specificity was 82.6% and 93.0%, respectively (p = 0.46).

CONCLUSION

Both Spot and Plusoptix photoscreeners demonstrated good sensitivity and specificity in detecting amblyopia risk factors in children, especially at preschool ages. There was no significant difference in diagnostic test accuracy between them.

Clinical Performance of the Spot Vision Photo Screener before and after Induction of Cycloplegia in Children

Aim

To compare the clinical performance of the Spot Vision Screener used to detect amblyopia risk factors (ARFs) in children before and after induction of cycloplegia; the children were referred because they met the screening criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

Methods

The Spot Vision Screener and a standard autorefractometer were used to examine 200 eyes of 100 children aged 3–10 years, before and after cycloplegia induction, in terms of ARFs. Sensitivity, specificity, and positive and negative predictive values for the detection of significant refractive errors were measured using the AAPOS referral criteria. It was explored that Spot Screener data were affected by cycloplegia. The extent of agreement between cycloplegic/noncycloplegic photoscreening data and cycloplegic autorefraction measurements was assessed using Wilcoxon and Spearman correlation analyses.

Results

The Spot's sensitivity was improved from 60.9% to 85.3% and specificity from 94.9% to 87.4% with cycloplegia compared to cycloplegic standard autorefractometer results. The positive predictive value of Spot was 75.7%, and the negative predictive value was 90.4% without cycloplegia. With cycloplegia, the positive predictive value of Spot was 63.6% and the negative predictive value was 95.8%.

Conclusions

The Spot Screener afforded moderate sensitivity and high specificity prior to cycloplegia. The sensitivity and negative predictive value improved after induction of cycloplegia. Examiners should be aware of the effects of cycloplegia on their findings.

Tribal Odisha Eye Disease Study # 4: Accuracy and utility of photorefraction for refractive error correction in tribal Odisha (India) school screening

Purpose

To compare the photorefraction system (Welch Allyn Spot™) performance with subjective refraction in school sight program in one Odisha (India) tribal district.

Methods

In a cross-sectional study school students, aged 5-15 years, referred after the preliminary screening by trained school teachers received photoscreening and subjective correction. The photoscreener was compared to subjective refraction in the range of +2D to -7.5D. Statistical analysis included Friedman nonparametric test, Wilcoxon signed-rank test, linear regression, and Bland-Altman plotting.

Results

The photoscreener was used in 5990 children. This analysis included 443 children (187 males, 256 females, and the mean age was 12.43 ± 2.5 years) who received both photorefraction and subjective correction, and vision improved to 6/6 in either eye. The median spherical equivalent (SE) with spot photorefraction was 0.00 D (minimum -5.0D; maximum +1.6 D), and with subjective correction was 0.00D (minimum -6.00 D; maximum +1.5 D). The difference in the SE between the two methods was statistically significant (P < 0.001) using Friedman nonparametric test; it was not significant for J 45 and J 180 (P = 0.39 and P = 0.17, respectively). There was a good correlation in linear regression analysis (R2 = 0.84) and Bland-Altman showed a good agreement between photorefraction and subjective correction in the tested range.

Conclusion

Photorefraction may be recommended for autorefraction in school screening with reasonable accuracy if verified with a satisfactory subjective correction. The added advantages include its speed, need of less expensive eye care personnel, ability to refract both eyes together, and examination possibility in the native surrounding.