U.S. Preventive Services Task Force. Screening for visual impairment in children younger than age 5 years: recommendation statement

Prevalence of Comprehensive Eye Examination in Preschool Children With Eye Conditions

Introduction

The purpose of this study is to assess the prevalence of comprehensive eye examinations in multiethnic preschool children, including children with visually significant eye conditions, and identify factors associated with comprehensive eye examinations.

Methods

A sample of 9,197 African American, Hispanic, Asian American, and non-Hispanic White children aged 6-72 months was recruited for the Multi-Ethnic Pediatric Eye Disease Study from 2003 to 2011. Logistic regression performed in 2022 identified independent factors associated with parent-reported history of comprehensive eye examinations. The proportion of children with previous comprehensive eye examinations and the proportion with undetected amblyopia or strabismus were measured.

Results

The prevalence of comprehensive eye examinations was 6.3% overall and 38.3%, 24.8%, 19.1%, 15.1%, and 9.8% among children with strabismus, amblyopia, significant anisometropia, hyperopia, and astigmatism, respectively. Children without prior comprehensive eye examinations were more likely to have undetected amblyopia or strabismus than those with comprehensive eye examination history (ps<0.001). The prevalence of comprehensive eye examinations was higher among older children. Prevalence varied by race/ethnicity, with 8.1%, 7.9%, 6.3%, and 4.9% of non-Hispanic White, Asian American, African American, and Hispanic children having had prior comprehensive eye examinations, respectively; however, the differences did not remain after adjusting for other associated factors. Older age, a primary caregiver with a college/university degree or higher, having vision insurance, gestational age <33 weeks, neurodevelopmental disorder diagnosis, strabismus, and ocular disease history were all statistically significantly associated with a relatively higher prevalence of comprehensive eye examinations in multivariable analyses.

Conclusions

Comprehensive eye examinations were uncommon among preschool children, including those with treatable vision disorders. Interventions, such as parent education and vision insurance, are needed to imaprove comprehensive eye examination access and utilization for at-risk preschool children.

Comprehensive review of amblyopia: Types and management

The optimal method of treatment for a child depends on the patient's age at the time of diagnosis, the onset and type of amblyopia, and the degree of compliance attainable. In deprivation amblyopia, the cause of visual impairment (e.g., cataract, ptosis) needs to be treated first, and then the disorder can be treated such as other types of amblyopia. Anisometropic amblyopia needs glasses first. In strabismic amblyopia, conventionally amblyopia should be treated first, and then strabismus corrected. Correction of strabismus will have little if any effect on the amblyopia, although the timing of surgery is controversial. Best outcomes are achieved if amblyopia is treated before the age of 7 years. The earlier the treatment, the more efficacious it is. In selected cases of bilateral amblyopia, the more defective eye must be given a competitive advantage over the comparatively good eye. Glasses alone can work when a refractive component is present, but occlusion might make the glasses work faster. The gold standard therapy for amblyopia remains occlusion of the better eye although penalization is also evidenced to achieve equal results. Pharmacotherapy has been shown to achieve suboptimal outcomes. Newer monocular and binocular therapies based on neural tasks and games are adjuncts to patching and can also be used in adults.

Ocular Disorders among Preschool Children in Southwest Nigeria

PURPOSE

The aim of the study was to determine the prevalence and causes of ocular disorders among preschool children.

METHODS

A multi-stage random sampling technique was used to select 560 children from a total of 9944 children aged 3-5 years attending nursery schools in the study area. Demographic and other relevant data were collected from the children. They underwent full ophthalmic evaluation including anterior and posterior segment examination as well as cycloplegic autorefraction.

RESULTS

Out of the 560 children screened, 170 (30.3%) were 3 years old, 183 (32.7%) were 4 years old, while the remaining 207 (37.0%) were 5 years old. Male-to-female ratio was 1:1.1. Visual acuity was testable using Lea symbol chart in 90% of the children. Ocular disorders were found in 61 eyes of 35 children giving a prevalence of 6.3%. The most common ocular disorder among participants was refractive error (3.9%), followed by allergic conjunctivitis (1.3%). Other identified ocular disorders were strabismus (0.9%), congenital cataract (0.4%), congenital ptosis (0.4%), optic atrophy (0.4%), ectopia lentis (0.2%), and phthisis bulbi (0.2%). There was no statistically significant difference in the distribution of ocular disorders by age or gender.

CONCLUSION

Screening is useful in early detection and treatment of ocular disorders in preschool children. Uncorrected refractive error which was identified as the major ocular disorder in these children is treatable. Periodic preschool vision screening would reduce the burden of uncorrected refractive error and other ocular disorders which can interfere with the learning skills of young children entering school.

Identifying barriers to referrals in preschool-age ocular screening in Southern India

Purpose:

The aim of this study was to identify barriers to follow-up among children aged 0–5 years who failed ocular screening.

Methods:

A cross-sectional, descriptive study was conducted for screening children aged 0–5 years, covering three districts of South India from January 2012 to December 2012. Screening was performed under Lavelle Paediatric Eye Care Project, included under Integrated Child Development Services (ICDS) program. A survey was conducted within 60 days of the screening, with the parents of children who failed to follow up at base hospital. Family demographics, parental awareness of childhood eye diseases and eye care for children, and barriers to follow up eye care were assessed.

Results:

A total of 19,408 children were screened. Among them, 913 (4.7%) failed screening and were referred. 319 (35%) of those referred attended the base hospital, of which 133 (41.6%) had no abnormality on detailed examination. 111 (34.7%) had refractive errors, 10 (3%)) had strabismus, and three (1%) had amblyopia. 62 (19.4%) had other ocular conditions. Parents of 324/594 (65%) children who did not attend the base hospital were traced and completed the questionnaire. Low level of education, low income, types of occupation, and distance factors were the main barriers to follow-up of referral in preschool children. Factors such as cost of time taking off from work and monthly family income were statistically significant (P < 0.001).

Conclusion:

Education, financial status, and distance factors were the main barriers to follow up of referral in preschool children. Identification of these barriers to follow up and improving the referral services could help in detecting visual problem effectively.

Comparison of Plusoptix S12R photoscreener with cycloplegic retinoscopy and autorefraction in pediatric age group

Purpose:

To compare refractive measurements of noncycloplegic photoscreener Plusoptix S12R with cycloplegic retinoscopy, noncycloplegic autorefractor, and cycloplegic autorefractor in children.

Methods:

The study population (200 eyes of 100 children) was divided into two groups: Group 1 (age 3–7 years) and Group 2 (age 8–15 years). In Group 1, Plusoptix was compared with cycloplegic retinoscopy. In Group 2, Plusoptix was compared with cycloplegic retinoscopy and autorefraction. The second group was made because the younger group was found to be uncooperative for autorefraction. Paired t-test and Pearson's correlation were used for statistical analysis.

Results:

The mean difference in sphere (DS), spherical equivalent (DSE), and cylinder (DC) between cycloplegic retinoscopy and Plusoptix in Group 1 was 0.68 ± 0.55 (P < 0.001), 0.77 ± 0.61 (P < 0.001), and 0.18 ± 0.28 (P < 0.001), respectively. In Group 2, DS, DSE, and DC between cycloplegic retinoscopy and Plusoptix were 0.86 ± 0.49 (P < 0.001), 0.97 ± 0.51 (P < 0.001), and 0.23 ± 0.28 (P < 0.001); between cycloplegic autorefractor and Plusoptix were 0.69 ± 0.47 (P < 0.001), 0.74 ± 0.49 (P < 0.001), and 0.10 ± 0.31 (P = 0.002); and between noncycloplegic autorefractor and Plusoptix were − 0.25 ± 0.39 (P < 0.001), −0.19 ± 0.41 (P < 0.001), and 0.11 ± 0.31 (P < 0.001), respectively. Pearson's correlation coefficients of S, SE, and C between Plusoptix and cycloplegic retinoscopy were 0.948, 0.938, and 0.924 in Group 1 and 0.972, 0.972, and 0.946 in Group 2, and these values were statistically significant. Bland–Altman plots showed good agreement between cycloplegic retinoscopy and Plusoptix in both groups. Plusoptix gave axis values within 10° of cycloplegic retinoscopy in 81.56% of eyes in Group 1 and in 71.44% of eyes in Group 2.

Conclusion:

Plusoptix photoscreener can be used for prescription of axis of cylinder in children; however, other refractive measurements must be refined by cycloplegic retinoscopy.

Deep Learning-Based Prediction of Refractive Error Using Photorefraction Images Captured by a Smartphone: Model Development and Validation Study

Background

Accurately predicting refractive error in children is crucial for detecting amblyopia, which can lead to permanent visual impairment, but is potentially curable if detected early. Various tools have been adopted to more easily screen a large number of patients for amblyopia risk.

Objective

For efficient screening, easy access to screening tools and an accurate prediction algorithm are the most important factors. In this study, we developed an automated deep learning–based system to predict the range of refractive error in children (mean age 4.32 years, SD 1.87 years) using 305 eccentric photorefraction images captured with a smartphone.

Methods

Photorefraction images were divided into seven classes according to their spherical values as measured by cycloplegic refraction.

Results

The trained deep learning model had an overall accuracy of 81.6%, with the following accuracies for each refractive error class: 80.0% for ≤−5.0 diopters (D), 77.8% for >−5.0 D and ≤−3.0 D, 82.0% for >−3.0 D and ≤−0.5 D, 83.3% for >−0.5 D and <+0.5 D, 82.8% for ≥+0.5 D and <+3.0 D, 79.3% for ≥+3.0 D and <+5.0 D, and 75.0% for ≥+5.0 D. These results indicate that our deep learning–based system performed sufficiently accurately.

Conclusions

This study demonstrated the potential of precise smartphone-based prediction systems for refractive error using deep learning and further yielded a robust collection of pediatric photorefraction images.

Critical Assessment of an Ocular Photoscreener

PURPOSE

To determine the accuracy of the PlusoptiX A12 photoscreener (PlusoptiX, Inc., Atlanta, GA) in detecting amblyopia or ambylogenic risk factors in pediatric patients in Nebraska.

METHODS

Using the PlusoptiX A12 photoscreener, data were collected from pediatric patients seen at a single pediatric ophthalmology practice. Each patient was screened using the device and also received a comprehensive ophthalmic examination. The results of the PlusoptiX A12 photoscreener were compared to the gold standard, comprehensive ophthalmic examination findings. The assessment of amblyopia or amblyogenic risk factors in the patients was based on the updated American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria guidelines.

RESULTS

Data were collected from 219 consecutive pediatric patients (438 eyes) during the 3-month study period. Among the patients, 87 (40%) children were determined to have amblyopia or ambylogenic risk factors after the comprehensive pediatric ophthalmology examination based on the AAPOS guidelines. The PlusoptiX A12 photoscreener was found to have a sensitivity of 93.02%, specificity of 84.96%, false-positive rate of 9.13%, false-negative rate of 2.74%, positive predictive value of 80.00%, and negative predictive value of 94.96%.

CONCLUSIONS

The PlusoptiX A12 photoscreener is viable and comparable to various commercially available devices in the detection of refractive amblyogenic risk factors based on the Nebraska pediatric patient population. Future studies may show increased sensitivity by combining the use of the PlusoptiX A12 photoscreener with an alternate cover test. [J Pediatr Ophthalmol Strabismus. 2018;55(3):194-199.].

Unilateral Posterior Polymorphous Corneal Dystrophy Presented as Anisometropic Astigmatism: 3 Case Reports

Background

Posterior polymorphous corneal dystrophy (PPCD) is typically considered bilateral and asymptomatic. However, few case reports on patients with unilateral PPCD with asymmetric refractive error have mentioned anisometropic amblyopia development. In support of this, we report 3 cases of unilateral PPCD that presented as anisometropic astigmatism. Visual prognosis related to amblyopia development is discussed.

Case Presentation

All 3 patients had a band lesion in the affected eye and a difference of at least 1.5 diopters in cylindrical refractive error between their eyes. The affected eye had a greater amount of astigmatism in all cases. Two patients (Cases 1 and 2) also had amblyopia in the affected eye. Case 1 was a 25-year-old male with a unilateral PPCD diagnosis and a band lesion involving the visual axis. Case 2 was an 11-year-old boy diagnosed with unilateral PPCD. The boy was treated with occlusion and atropine therapy over a 2-year period. Case 3 was a 4-year-old girl diagnosed with unilateral PPCD. The girl had a 30-month history of corrective spectacle use and had no amblyopia. In all cases, the corneal endothelial cell count was lower in the affected eye than in the unaffected contralateral eye.

Conclusions

Practitioners should closely monitor patients with unilateral PPCD for astigmatic anisometropia and amblyopia development. Visual prognosis for patients with unilateral PPCD may be related to lesion position, age at diagnosis, astigmatism severity, and early-childhood corrective spectacle use.

A Comparison of Patched HOTV Visual Acuity and Photoscreening

Early detection of significant vision problems in children is a high priority for pediatricians and school nurses. Routine vision screening is a necessary part of that detection and has traditionally involved acuity charts. However, photoscreening in which “red eye” is elicited to show whether each eye is focusing may outperform routine acuity testing in pediatric offices and schools. This study compares portable acuity testing with photoscreening of preschoolers, kindergarteners, and 1st-graders in 21 elementary schools. School nurses performed enhanced patched acuity testing and two types of photoscreening in a portable tent. Nearly 1,700 children were screened during spring semester 2004, and 14% had confirmatory exams by community eye care professionals. The results indicate that one form of photoscreening using a Gateway DV-S20 digital camera is significantly more sensitive to children with significant vision problems, as well as being the most cost effective (85% specificity and only $0.11 per child). This suggests that the adaptation of photoscreening into a routine vision screening protocol would be beneficial for efficiently detecting vision problems that could lead to 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.

Performance of the Plusoptix A09 photoscreener in detecting amblyopia risk factors in Chinese children attending an eye clinic

Purpose

To assess the accuracy of the Plusoptix A09 photoscreener in detecting amblyopia risk factors in children and determine referral criteria when using Plusoptix A09 for a large-scale vision screening.

Methods

Pediatric patients attending our eye clinic underwent a comprehensive ophthalmic examination that included photorefraction, orthoptic examination, anterior segment assessment, fundus examination and cycloplegic retinoscopy. The measurements were collected for statistical analyses.

Results

One hundred and seventy-eight children (mean age ± SD: 6.2±2.4 years, range: 2.2 to 14.1 years) were included in the study. The mean spherical equivalent (SE) obtained using Plusoptix A09 (P_SE) was 0.57 D lower than that obtained from cycloplegic retinoscopy (CR_SE) (P = 0.00). However, there was no statistically significant difference of Jackson cross cylinder J₀ and J₄₅ between Plusoptix A09 (P_J) and cycloplegic retinoscopy (CR_J) (P = 0.14, P = 0.26). The relationship of SE obtained from Plusoptix A09 and SE obtained from cycloplegic retinoscopy was presented as the equation: CR_SE = 0.358 + 0.776 P_SE + 0.064 P_SE² + 0.011 P_SE³. Based on the Receiver Operating Characteristic (ROC) curve, the Plusoptix A09 had an overall sensitivity of 94.9% and specificity of 67.5% for detecting refractive amblyopia risk factors. The sensitivity and specificity of the Plusoptix A09 for detection of strabismus were 40.7% and 98.3%, respectively; detection of amblyopia and/or strabismus was 84.7% and 63.2%, respectively.

Conclusions

The Plusoptix A09 photoscreener underestimated hyperopia and overestimated myopia according to SE when compared with cycloplegic retinoscopy. The accuracy of the Plusoptix A09 in detecting amblyopia risk factors in children could be improved by the regression equation and optimized criteria for refractive amblyopia risk factors developed in the present study. Moreover, the Plusoptix A09 photoscreener is not suitable for a large-scale strabismus screening when it is applied solely.

Prevalence of amblyopia in primary school children in Qassim province, Kingdom of Saudi Arabia

PURPOSE

To determine the prevalence and causes of amblyopia in primary school children in Qassim province, Kingdom of Saudi Arabia (KSA).

MATERIALS AND METHODS

In this cross sectional study, 5176 children, aged 6 to 13 years (mean - 9.53 ± 1.88 years) were evaluated. There were 2573 (49.71%) males and 2603 (50.29%) females. Distance visual acuity (V/A) was tested monocularly using a logMAR chart with and without correction. Cycloplegic refraction was performed in children with reduced vision. To determine the etiology of amblyopia, children were enrolled if there was a difference in V/A of two or more lines between eyes or an absolute reduction in acuity <20/30 in either eye, that could not be corrected by refraction. P ≤ 0.05 was considered statistically significant.

RESULTS

There 202 out of 5176 (3.90%) with ambylopia. There are 98 (1.88%) amblyopic females. There was no statistical difference in gender for amblyopes (P > 0.05). The prevalence of amblyopia was statistically significant higher in the older age group (10-13 year) compared to younger age group (6 to 9 years) (P < 0.05). Unilateral amblyopia (3.24%) was more frequent than bilateral amblyopia (0.66%). The most frequent causes of amblyopia were refractive error (94.56%), of which anisometropic amblyopia was present in 77.72%, isoametropic amblyopia in 16.84% and strabismus in 5.44%.

CONCLUSION

The prevalence of amblyopia in Qassim province, KSA, is 3.9% which is similar or higher than other published studies on amblyopia. Anisometropic refractive errors are the most common underlying cause for this population. We recommend implementation of visual screening programs for children with appropriate clinical and social settings for early detection and proper management of amblyopia.

Ten-Year Results of Home Vision-Screening Test in Children Aged 3-6 Years in Seoul, Korea

PURPOSE

To characterize the prevalence of refractive error and amblyopia among three- to six-year-old children during the period from 2002 to 2011.

METHODS

About 31,400 children annually (from 16,592 to 40,816) during the period from 2002 to 2011 were enrolled. The preschool vision screening was performed by the Korean Foundation for the Prevention of Blindness (KFPB) annually during a period that extended from March to September. We reviewed the KFPB annual report about the home vision-screening test as performed during the period from 2002 to 2011. Changes in the prevalence and types of refractive error, strabismus, and amblyopia that manifested throughout this period were analyzed.

RESULTS

The prevalence of refractive errors ranged from 1.10% in 2002 to 0.42% in 2011. The prevalence of hyperopia and myopia changed little throughout the 10-year study period. Myopia and hyperopia were equally common among the population examined (χ(2)-test, p = 0.137). The prevalence of anisometropia decreased over time. The annual prevalence of amblyopia ranged from 0.39% to 0.06%, while the overall prevalence of amblyopia dropped from 0.25% in 2002 to 0.06% in 2011. The prevalence of strabismus was highest in 2006 (0.30%) and had decreased by 0.06% in 2011. The type of strabismus showed no significant difference over time (χ(2)-test, p = 0.579).

CONCLUSIONS

The prevalence of amblyopia, refractive error, anisometropia, and strabismus was lower in 2011 than in early 2000. The prevalence of hyperopia and myopia as well as strabismus remained similar throughout the study period.

Comparison of photorefraction, autorefractometry and retinoscopy in children

Photorefractive devices have been evaluated for their effectiveness in detecting anisometropia, hyperopia, myopia, and astigmatism. We investigated the reliability of Plusoptix S08, the newest photoscreener, and Topcon autorefractometer by comparing them with cycloplegic retinoscopy. Plusoptix S08, cycloplegic retinoscopy, and cycloplegic autorefractometer measurements for 235 eyes of 118 children (59 female, 59 male) with a mean age of 4.9 ± 2.6 and median age of 5 years (range 1-12) were conducted. The Plusoptix S08 produced the following mean (± SD) results--spherical 0.27 ± 1.64, cylindrical power -0.81 ± 0.71, axis 89.73 ± 61.18, and spherical equivalent -0.05 ± 1.61. The cycloplegic retinoscopy produced the following mean (± SD) results--spherical 0.12 ± 1.35, cylindrical power -0.89 ± 0.71, axis 92.18 ± 68.39, and spherical equivalent -0.15 ± 1.31. The cycloplegic autorefractometer produced the following mean (± SD) results--spherical 0.16 ± 1.44, cylindrical power -0.88 ± 0.72, axis 90.86 ± 68.21, and spherical equivalent -0.12 ± 1.41. This study has shown that cycloplegic autorefractometer and retinoscopy results are similar and Plusoptix S08 is a very safe, easy-to-use and reliable screening method of refraction, especially for ophthalmologists unskilled in retinoscopy. Plusoptix S08 is a useful tool for estimating refraction in patients for whom conventional autorefraction is not an option.

Identifying barriers to follow-up eye care for children after failed vision screening in a primary care setting

PURPOSE

To identify barriers to follow-up eye care in children who failed a visual acuity screening conducted by their primary care provider.

METHODS

Children aged 3-14 years who failed a visual acuity screening were identified. A phone survey with the parent of every child was conducted 4 months after the screening. Family demographics, parental awareness of childhood eye diseases and eye care for children, and barriers to follow-up eye care were assessed.

RESULTS

Of 971 children sampled, 199 (20.5%) failed a visual acuity screening. The survey was completed by the parents of 58 children (29.1%), of whom 27 (46.6%) presented for follow-up examination. The most common reason for failure to follow-up was parental unawareness of screening results (29.3%). Follow-up rates were higher in children with previous eye examinations than in those without (81% versus 17%; P = 0.005) and in children who waited <2 months for a follow-up appointment than in those who had to wait longer (100% versus 63%; P = 0.024). Child's sex, ethnicity, and health insurance status, parent's marital, education and employment status, household income, and transportation access were not associated with statistically significant different follow-up rates.

CONCLUSIONS

Parental unawareness of a failed visual acuity screening is an important barrier to obtaining follow-up. Strategies to improve follow-up rates after a failed visual acuity screening may include communicating the results clearly and consistently, providing education about the importance of timely follow-up, and offering logistic support for accessing eye appointments to families.

The accuracy of the plusoptiX A08 photoscreener in detecting risk factors for amblyopia in central Iowa

PURPOSE

To evaluate the accuracy of the plusoptiX A08 photoscreener in detecting risk factors for amblyopia in children aged 0-5 years in central Iowa.

METHODS

The medical records of consecutive patients seen at 1 practice during a 2-month period were retrospectively reviewed. All patients were screened with the plusoptiX A08 photoscreener and received a comprehensive pediatric ophthalmology examination. Photoscreening results, according to our age-based criteria, were compared with the comprehensive examination findings. Patients were considered to have amblyopia or amblyogenic risk factors in the comprehensive examination based on the American Association for Pediatric Ophthalmology and Strabismus referral criteria guidelines.

RESULTS

A total of 290 children were examined during the study period. Of these, 190 (66%) patients were found to have amblyopia or amblyogenic risk factors during the pediatric ophthalmology examination on the basis of American Association for Pediatric Ophthalmology and Strabismus guidelines. The plusoptiX A08 offered an overall testability rate of 98%, sensitivity of 87%, specificity of 88%, positive predictive value of 93%, and negative predictive value of 78%. The sensitivity for detection of strabismus ≤20(Δ) was 52%.

CONCLUSIONS

The plusoptiX showed a high sensitivity for the detection of refractive amblyogenic risk factors and had a high successful testability rate in infants; however, it had low sensitivity for detecting strabismus ≤20(Δ). We postulate that sensitivity for detecting amblyogenic risk factors can be improved by combining the use of this instrument with a cover or stereo test.

Associations of anisometropia with unilateral amblyopia, interocular acuity difference, and stereoacuity in preschoolers

PURPOSE

To evaluate the relationship of anisometropia with unilateral amblyopia, interocular acuity difference (IAD), and stereoacuity among Head Start preschoolers using both clinical notation and vector notation analyses.

DESIGN

Multicenter, cross-sectional study.

PARTICIPANTS

Three- to 5-year-old participants in the Vision in Preschoolers (VIP) study (n = 4040).

METHODS

Secondary analysis of VIP data from participants who underwent comprehensive eye examinations, including monocular visual acuity testing, stereoacuity testing, and cycloplegic refraction. Visual acuity was retested with full cycloplegic correction when retest criteria were met. Unilateral amblyopia was defined as IAD of 2 lines or more in logarithm of the minimum angle of resolution (logMAR) units. Anisometropia was defined as a 0.25-diopter (D) or more difference in spherical equivalent (SE) or in cylinder power and 2 approaches using power vector notation. The percentage with unilateral amblyopia, mean IAD, and mean stereoacuity were compared between anisometropic and isometropic children.

MAIN OUTCOMES MEASURES

The percentage with unilateral amblyopia, mean IAD, and mean stereoacuity.

RESULTS

Compared with isometropic children, anisometropic children had a higher percentage of unilateral amblyopia (8% vs. 2%), larger mean IAD (0.07 vs. 0.05 logMAR), and worse mean stereoacuity (145 vs. 117 arc sec; all P<0.0001). Larger amounts of anisometropia were associated with higher percentages of unilateral amblyopia, larger IAD, and worse stereoacuity (P<0.001 for trend). The percentage of unilateral amblyopia increased significantly with SE anisometropia of more than 0.5 D, cylindrical anisometropia of more than 0.25 D, vertical and horizontal meridian (J0) or oblique meridian (J45) of more than 0.125 D, or vector dioptric distance of more than 0.35 D (all P<0.001). Vector dioptric distance had greater ability to detect unilateral amblyopia than cylinder, SE, J0, or J45 (P<0.001).

CONCLUSIONS

The presence and amount of anisometropia were associated with the presence of unilateral amblyopia, larger IAD, and worse stereoacuity. The threshold level of anisometropia at which unilateral amblyopia became significant was lower than current guidelines. Vector dioptric distance is more accurate than spherical equivalent anisometropia or cylindrical anisometropia in identifying preschoolers with unilateral amblyopia.

Improving the rate of preschool vision screening: an interrupted time-series analysis

OBJECTIVE

To implement a 6-month quality improvement project in 13 clinics in North Carolina to improve vision screening rates for children 3 through 5 years of age.

METHODS

We trained each clinic in approaches to vision screening and selected champions to provide feedback based on a 3-month baseline chart audit of up to 90 charts in each clinic and then 60 monthly chart audits in each clinic.

RESULTS

Overall, the baseline rate of distance vision testing (92%) and stereopsis testing (80%) was high. By the end of the project, there were increases in both the rate of distance vision testing (97%; P < .001) and stereopsis testing (89%; P < .001). Initially, there were many different tests used to assess distance visual acuity and some variation in the thresholds used for referral for eye care. Tests were standardized across clinics by the end of the project. The proportion of all children who were untestable was high throughout the project, including 45% among 3-year-olds by the end of the project. Follow-up rescreening was rarely documented. By the end of the project, only 48% of children with an abnormal screen result were documented to be referred. Within each clinic, concerns about the accuracy of testing persisted throughout the project.

CONCLUSIONS

We were successful in standardizing vision testing. Even with training, the proportion of untestable children was high. Rates of documented referral were low, which reflects provider concerns about testing accuracy. New strategies are needed to improve testability and ensure timely referral and follow-up after an abnormal vision screen result.

Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement

OBJECTIVE

The goal was to provide an update of the 2004 US Preventive Services Task Force (USPSTF) statement about screening for visual impairment in children <5 years of age.

METHODS

The USPSTF examined evidence on the association of screening for visual impairment in children 1 to 5 years of age with improved health outcomes, the accuracy of risk factor assessment and screening tests, the effectiveness of early detection and treatment, and the harms of screening and treatment.

RECOMMENDATION

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors (grade B recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of vision screening for children <3 years of age (I statement).

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.

Findings from the Vision in Preschoolers (VIP) Study

The Vision in Preschoolers (VIP) Study Group conducted a multicenter, multidisciplinary, two-phase study to evaluate the performance of vision screening tests for identifying pre-school children with amblyopia, strabismus, significant refractive error, or unexplained reduced visual acuity (VA). The results of the VIP Study provide evidence-based guidelines for preschool vision screening. The best screening tests administered by eye care professionals were non-cycloplegic retinoscopy, Retinomax Autorefractor, SureSight Vision Screener, and linear, crowded Lea Symbols VA at 10 feet. The best screening tests administered by trained nurses and/or lay screeners were Retinomax, SureSight, and VIP single, crowded Lea Symbols VA screening test system at 5 feet. Eye care professionals can improve detection of strabismus by combining unilateral cover test with a refraction test and trained lay screeners can improve detection of strabismus by combining Stereo Smile II with SureSight. The best performing tests had high testability whether performed by trained eye care professionals, nurses, or lay screeners (>or=98%). Although very few children were unable to complete these tests, a child who was "unable" was much more likely to have a vision problem than a child who passed; therefore, children who are unable to complete one of these tests should be referred for further evaluation. When screening using the Retinomax, repeated testing to achieve the manufacturer's suggested confidence number is valuable and improves specificity. Federal initiatives to increase the number of pre-school children receiving vision screening or examination will increase the number of pre-school children identified with amblyopia, strabismus, and/or significant refractive error. Although there is general agreement regarding the importance of early detection of amblyopia, controversy exists regarding the importance of early detection of refractive error. Because of the high prevalence of significant refractive errors and lack of evidenced-based guidelines for correction of refractive error in pre-school children, future research is needed to evaluate the value of correcting refractive errors in preschoolers who do not have amblyopia and/or strabismus.

Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study

OBJECTIVE

To determine the age-specific prevalence of strabismus in white and African American children aged 6 through 71 months and of amblyopia in white and African American children aged 30 through 71 months.

DESIGN

Cross-sectional, population-based study.

PARTICIPANTS

White and African American children aged 6 through 71 months in Baltimore, MD, United States. Among 4132 children identified, 3990 eligible children (97%) were enrolled and 2546 children (62%) were examined.

METHODS

Parents or guardians of eligible participants underwent an in-home interview and were scheduled for a detailed eye examination, including optotype visual acuity and measurement of ocular deviations. Strabismus was defined as a heterotropia at near or distance fixation. Amblyopia was assessed in those children aged 30 through 71 months who were able to perform optotype testing at 3 meters.

MAIN OUTCOME MEASURES

The proportions of children aged 6 through 71 months with strabismus and of children aged 30 through 71 months with amblyopia.

RESULTS

Manifest strabismus was found in 3.3% of white and 2.1% of African American children (relative prevalence [RP], 1.61; 95% confidence interval [CI], 0.97-2.66). Esotropia and exotropia each accounted for close to half of all strabismus in both groups. Only 1 case of strabismus was found among 84 white children 6 through 11 months of age. Rates were higher in children 60 through 71 months of age (5.8% for whites and 2.9% for African Americans [RP, 2.05; 95% CI, 0.79-5.27]). Amblyopia was present in 12 (1.8%) white and 7 (0.8%) African American children (RP, 2.23; 95% CI, 0.88-5.62). Only 1 child had bilateral amblyopia.

CONCLUSIONS

Manifest strabismus affected 1 in 30 white and 1 in 47 African American preschool-aged children. The prevalence of amblyopia was <2% in both whites and African Americans. National population projections suggest that there are approximately 677,000 cases of manifest strabismus among children 6 through 71 months of age and 271 000 cases of amblyopia among children 30 through 71 months of age in the United States.

Effectiveness of screening preschool children for amblyopia: a systematic review

BACKGROUND

Amblyopia and amblyogenic factors like strabismus and refractive errors are the most common vision disorders in children. Although different studies suggest that preschool vision screening is associated with a reduced prevalence rate of amblyopia, the value of these programmes is the subject of a continuing scientific and health policy discussion. Therefore, this systematic review focuses on the question of whether screening for amblyopia in children up to the age of six years leads to better vision outcomes.

METHODS

Ten bibliographic databases were searched for randomised controlled trials, non-randomised controlled trials and cohort studies with no limitations to a specific year of publication and language. The searches were supplemented by handsearching the bibliographies of included studies and reviews to identify articles not captured through our main search strategy.

RESULTS

Five studies met the inclusion criteria. Of these, three studies suggested that screening is associated with an absolute reduction in the prevalence of amblyopia between 0.9% and 1.6% (relative reduction: between 45% and 62%). However, the studies showed weaknesses, limiting the validity and reliability of their findings. The main limitation was that studies with significant results considered only a proportion of the originally recruited children in their analysis. On the other hand, retrospective sample size calculation indicated that the power based on the cohort size was not sufficient to detect small changes between the groups. Outcome parameters such as quality of life or adverse effects of screening have not been adequately investigated in the literature currently available.

CONCLUSION

Population based preschool vision screening programmes cannot be sufficiently assessed by the literature currently available. However, it is most likely that the present systematic review contains the most detailed description of the main limitations in current available literature evaluating these programmes. Therefore, future research work should be guided by the findings of this publication.

Use of a Noncycloplegic Autorefractor to Perform Vision Screening in Preschools

Early detection and treatment of vision disorders in children are important to avoid lifelong visual impairment; however, preschool vision-screening rates are low. Traditional methods of screening lack the precision of objective tests and are difficult to administer in preschoolers. This study adopted a method using school nurses to conduct vision screening in preschoolers with a portable autorefractor. In addition, the effectiveness of the school nurse in conducting follow-up was evaluated. In a sample of 600 children, more than 98% completed the screening, and 7% were referred for follow-up evaluation. Seventeen percent of parents had plans to follow-up after receiving a brochure indicating that their child would benefit from a comprehensive eye exam. However, after a conversation with the school nurse, 86% had plans to schedule an evaluation with an eye care professional. Of the 15 students with known follow-up, 10 received glasses. The described method is effective in identifying young children with potential vision problems and facilitating their correction after contact made by the school nurse.

Diagnosis and treatment of refractive errors in the pediatric population

PURPOSE OF REVIEW

The diagnosis and successful treatment of visually significant refractive errors in children are a subject of continued study and debate.

RECENT FINDINGS

Treatment of significant refractive errors is widely accepted to reduce lifelong vision loss from amblyopia. Children aged 3-5 years may be screened for unexplained vision loss, refractive errors and amblyogenic factors using traditional eye charts as well as newer modalities such as autorefractors and photoscreeners. The accuracy of various screening methods is variable throughout the literature. Debate remains as to who is best suited to administer vision screening tests. Compliance with follow-up with an eye-care professional once a child is identified with an amblyogenic factor remains suboptimal. Treatment of significant refractive errors in certain populations of pediatric patients with refractive surgery shows promise but requires further study.

SUMMARY

The timely diagnosis of significant refractive errors in children remains a significant challenge, especially for ages 3-5 years, but treatment may provide significant improvement of visual acuity and quality of life.

Does assessing eye alignment along with refractive error or visual acuity increase sensitivity for detection of strabismus in preschool vision screening?

PURPOSE

Preschool vision screenings often include refractive error or visual acuity (VA) testing to detect amblyopia, as well as alignment testing to detect strabismus. The purpose of this study was to determine the effect of combining screening for eye alignment with screening for refractive error or reduced VA on sensitivity for detection of strabismus, with specificity set at 90% and 94%.

METHODS

Over 3 years, 4040 preschool children were screened in the Vision in Preschoolers (VIP) Study, with different screening tests administered each year. Examinations were performed to identify children with strabismus. The best screening tests for detecting children with any targeted condition were noncycloplegic retinoscopy (NCR), Retinomax autorefractor (Right Manufacturing, Virginia Beach, VA), SureSight Vision Screener (Welch-Allyn, Inc., Skaneateles, NY), and Lea Symbols (Precision Vision, LaSalle, IL and Good-Lite Co., Elgin, IL) and HOTV optotypes VA tests. Analyses were conducted with these tests of refractive error or VA paired with the best tests for detecting strabismus (unilateral cover testing, Random Dot "E" [RDE] and Stereo Smile Test II [Stereo Optical, Inc., Chicago, IL]; and MTI PhotoScreener [PhotoScreener, Inc., Palm Beach, FL]). The change in sensitivity that resulted from combining a test of eye alignment with a test of refractive error or VA was determined with specificity set at 90% and 94%.

RESULTS

Among the 4040 children, 157 were identified as having strabismus. For screening tests conducted by eye care professionals, the addition of a unilateral cover test to a test of refraction generally resulted in a statistically significant increase (range, 15%-25%) in detection of strabismus. For screening tests administered by trained lay screeners, the addition of Stereo Smile II to SureSight resulted in a statistically significant increase (21%) in sensitivity for detection of strabismus.

CONCLUSIONS

The most efficient and low-cost ways to achieve a statistically significant increase in sensitivity for detection of strabismus were by combining the unilateral cover test with the autorefractor (Retinomax) administered by eye care professionals and by combining Stereo Smile II with SureSight administered by trained lay screeners. The decision of whether to include a test of alignment should be based on the screening program's goals (e.g., targeted visual conditions) and resources.

Preschool vision screening by family physicians

PURPOSE

To determine the rate of preschool vision screening in family practice. To evaluate attitudes and beliefs about the importance of, and barriers to, preschool vision screening.

METHOD

Mail survey of a national sample of family physicians.

RESULTS

The response rate was 35% (237 of 671 eligible respondents). Most (90%) considered preschool vision screening important. The majority (91%) included some component of the eye examination as part of their routine well-child care for preschool-aged children. The likelihood of formal screening increased with age (3 years, 36%; 4 years, 58%; 5 years, 73%; P < .01). Most (88%) used a wall chart to test for visual acuity. Stereoacuity was rarely (7%) tested. Barriers included the perception that children are uncooperative (39%) and that screening is too time-consuming (21%). Fifty-nine percent would only consider using a vision screening test if its false-positive rate was 10% or less. Some (26%) reported that all children should be examined by an optometrist or ophthalmologist prior to school entry, regardless of any screening.

CONCLUSIONS

The rate of screening by family physicians is similar to that by pediatricians. Providing education regarding optimal vision screening strategies and expected outcomes of screening may be important for improving both the rate and the quality of preschool vision screening. Ophthalmologists may play an important role in this process through the feedback they provide to referring physicians.

Vision and oral health needs of individuals with intellectual disability

Over the past 20 years, there has been an increased emphasis on health promotion, including prevention activities related to vision and oral health, for the general population, but not for individuals with intellectual disability (ID). This review explores what is known about the prevalence of vision problems and oral health conditions among individuals with ID, presents a rationale for the increased prevalence of these conditions in the context of service utilization, and examines the limitations of the available research. Available data reveal a wide range of prevalence estimates for vision problems and oral health conditions, but all suggest that these conditions are more prevalent among individuals with ID compared with the general population, and disparities exist in the receipt of preventive and early treatment for these conditions for individuals with ID. Recommendations for health improvement in these areas include better health planning and monitoring through standardized population-based data collection and reporting and increased emphasis on health promotion activities and early treatment in the healthcare system.

Amblyopia

Results from recent randomised clinical trials in amblyopia should change our approach to screening for and treatment of amblyopia. Based on the current evidence, if one screening session is used, screening at school entry could be the most reasonable time. Clinicians should preferably use age-appropriate LogMAR acuity tests, and treatment should only be considered for children who are clearly not in the typical range for their age. Any substantial refractive error should be corrected before further treatment is considered and the child should be followed in spectacles until no further improvement is recorded, which can take up to 6 months. Parents and carers should then be offered an informed choice between patching and atropine drops. Successful patching regimens can last as little as 1 h or 2 h a day, and successful atropine regimens as little as one drop twice a week. Intense and extended regimens might not be needed in initial therapy.

Preschool vision screening in pediatric practices

A national sample of pediatricians was surveyed to evaluate preschool vision screening practices (response rate 55%, 377 of 690 eligible respondents). The rate of acuity screening for 3-year-old children was low (35%), but increased for 4- (73%) and 5-year-old children (66%). Few used photoscreening or autorefraction (8%). Common barriers were that screening is too time-consuming and children are uncooperative. Half reported that there should be separate reimbursement for vision screening. Financial incentives may be important for ensuring the delivery of preschool vision screening, as well as adoption of emerging screening technologies if such devices are shown to be effective.

Visual Plasticity and Its Clinical Applications

Normal visual development requires: 1) environmental factors (i.e. sensory experience) and 2) molecular programs that are genetically determined. Experience determines the development and preservation of visual cortical circuitry in accordance with Hebb's principle. The molecular and genetic mechanisms that regulate visual plasticity are less known. Visual experience induces postnatal neural activity that triggers a cascade of molecular processes including release of neurotrophic factors from target neurons and genetic expression of protein synthesis, transcription factors and neurotransmitters. The continuous sensory experience induces activity-dependent tuning of synaptic connections. The present knowledge permits some manipulation of plasticity and the induction of functional changes beneficial for vision. Three areas of intervention will be discussed: 1) enhancement of visual experience for children with ocular disorders, 2) re-organization of visual cortical maps, 3) retinal and cortical implants (prostheses) and transplants.