US Preventive Services Task Force vision screening recommendations

Comparison of the new self-contained darkroom refractive screener versus table-top autorefractor and cycloplegia retinoscopy in detecting refractive error

PURPOSE

By comparing the results of the new self-contained darkroom refractive screener (YD-SX-A) versus table-top autorefractor and cycloplegic retinoscopy, to evaluate the performance of the YD-SX-A in detecting refractive error in children and adolescents and then judge whether it can be used in refractive screening.

METHODS

Cross-sectional study. 1000 participants between the ages of 6 and 18 who visited the Optometry Center of the People's Hospital of Guangxi Zhuang Autonomous Region from June to December 2022 were selected. First, participants were instructed to measure their diopter with a table-top autorefractor (Topcon KR8800) and YD-SX-A in a noncycloplegic setting. After cycloplegia, they were retinoscopy by a professional optometrist. The results measured by three methods were collected respectively. To avoid deviation, only the right eye (1000 eyes) data were used in the statistical analysis. The Bland-Altman plots were used to evaluate the agreement of diopters measured by the three methods. The receiver operating characteristic (ROC) curves was used to analysis effectiveness of detecting refractive error of YD-SX-A.

RESULTS

The average age of participants was 10.77 ± 3.00 years, including 504 boys (50.4%) and 496 girls (49.6%). When YD-SX-A and cycloplegia retinoscopy (CR) were compared in the myopia group, there was no statistical difference in spherical equivalent (SE) (P > 0.05), but there was a statistical difference in diopter spherical (DS) and diopter cylinder (DC) (P < 0.05). Comparing the diopter results of Topcon KR8800 and CR, the difference between each test value in the myopia group was statistically significant (P < 0.05). In the hyperopia group, the comparison between YD-SX-A and CR showed no statistically significant differences in the DC (P > 0.05), but there were significant differences in the SE and DS (P < 0.05). In the astigmatism group, the SE, DS, and DC were statistically different, and the DC of YD-SX-A was lower than that of CR and Topcon KR8800. Bland-Altman plots indicated that YD-SX-A has a moderate agreement with CR and Topcon KR8800. The sensitivity and specificity of YD-SX-A for detecting myopia, hyperopia and astigmatism were 90.17% and 90.32%, 97.78% and 87.88%, 84.08% and 74.26%, respectively.

CONCLUSION

This study has identified that YD-SX-A has shown good performance in both agreement and effectiveness in detecting refractive error when compared with Topcon KR8800 and CR. YD-SX-A could be a useful tool for large-scale population refractive screening.

Analysis of risk factors associated with the high incidence of amblyopia in preterm infants at the corrected gestational age of 12 months

OBJECTIVE

To investigate the perinatal and in-hospital risk factors associated with the high incidence of amblyopia in preterm infants and to analyze the correlation between the amblyopia and neurodevelopment.

METHODS

Children discharged from the neonatal intensive care unit (NICU) at 12 months of corrected gestational age were retrospectively included in this study. Ocular screening was performed in children. At the risk of amblyopia was determined according to the American Academy of Ophthalmology Guidelines for automated preschool vision screening factors. Differences in perinatal characteristics, complications during hospitalization, and treatment modalities between the two groups of children were analyzed, and multifactorial logistic regression analysis was used to identify the independent risk factors for amblyopia. The results of developmental assessment were collected retrospectively to analyze the correlation between amblyopia and various aspects of neurological development.

RESULTS

A total of 128 preterm infants, 30 in the amblyopia risk group and 98 in the non-amblyopia risk group, were included in this study. Univariate analysis showed that the amblyopia risk group had lower birth weights, higher rates of asphyxia, preterm brain white matter injury, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), sepsis during hospitalization, and higher rates of treatment with pulmonary surfactant (PS), blood transfusion, invasive ventilator, and levothyroxine. Logistic regression analysis showed that BPD in the neonatal period (odds ratio [OR] 8.355, 95% confidence interval [CI] 1.492, 46.786), brain white matter injury (OR 16.742, 95% CI 0.684, 409.804), treatment with levothyroxine (OR 2.859, 95% CI 0.946, 8.639), and use of an invasive ventilator (OR 2.983, 95% CI 0.942, 9.445) were independent risk factors for amblyopia at 12 months of corrected gestational age, while the administration of glucocorticoids (OR 0.055, 95% CI 0.004, 0.737) was a protective factor. Regarding neurodevelopmental assessment, the number of infants with lagging fine motor development was greater in the amblyopia risk group.

CONCLUSION

The presence of BPD in the neonatal period, brain white matter damage in preterm infants, and use of levothyroxine and invasive ventilator were high risk factors for amblyopia. The use of glucocorticoids therapy was a protective factor. Children with risk of amblyopia had a higher rate of poor fine motor development.

Identification and critical appraisal of evidence for interventions for refractive error to support the development of the WHO package of eye care interventions: a systematic review of clinical practice guidelines

PURPOSE

The World Health Organization is developing a Package of Eye Care Interventions (PECI) to support the integration of eye health care into national health programmes. Interventions included in the PECI should be based on robust evidence where available. Refractive error is a leading cause of blindness and vision impairment and is a PECI priority condition. The aim of this study was to provide high-quality evidence to support the development of the PECI by identifying and critically appraising clinical practice guidelines (CPGs), and extracting recommendations for refractive error interventions.

METHODS

We searched for CPGs on refractive error published in the last 10 years. We conducted the searches initially in February and March 2019 and repeated them in March 2020. We evaluated the quality of potentially relevant guidelines using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

We identified 12 high-quality CPGs relevant to refractive error, written by six organisations from three high-income countries. Organisations used a variety of frameworks to assess the strength of recommendations based on available evidence, with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) being most common. Vision screening for children aged 3 to 5 years was recommended consistently. Evidence for screening and eye evaluations at other ages was weaker, although ophthalmic professional organisations consistently recommended regular evaluations. Recommendations on optical and laser correction of refractive error were limited and did not consider implications for low resource settings. Interventions for slowing myopia progression in children were recommended, but these will need regular updating as new evidence emerges.

CONCLUSIONS

Current high-quality guidelines on refractive error have been formulated in high-income countries. Recommendations focused on prevention and treatment of refractive error in low-and middle-income countries are lacking. Regular updating of systematic reviews and CPGs is essential to ensure that robust evidence is promptly appraised and incorporated into recommendations for eye health care practitioners.

A systematic review of clinical practice guidelines for myopic macular degeneration

Background

Myopic macular degeneration (MMD) is a primary cause of blindness and visual impairment in many parts of the world. A review of clinical practice guidelines (CPGs) for intervention selection are required with the increasing demand for MMD management in clinical practice as well as in national health services. Therefore, we aim to systematically review CPGs for MMD and assist the recommendations development of the Package of Eye Care Interventions (PECI) program of the World Health Organization.

Methods

A systematic review of CPGs published on MMD between 2010 and April 2020 was conducted. Guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Cochrane systematic reviews were also included when the evidence from included CPGs were inadequate or contradict.

Results

After applying exclusion criteria and conducting the quality appraisal, two CPGs were finally included. The average of the AGREE II ratings for the identified Guidelines were 56 and 63 respectively (7 for each item). To provide further information on interventions for MMD, one Cochrane review on MMD was additionally identified and included in the study. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) drugs were recommended for patients with myopic choroidal neovascularization (mCNV) as first-line therapy to improve vision and reduce central macular thickness, and ranibizumab showed significant effectiveness compared to photodynamic therapy (PDT). PDT was recommended to be performed in those resistant to the treatment by one CPG but lacked of adequate description and support. Data extracted from the Cochrane systematic reviews indicated that anti-VEGF therapy for mCNV had significant effectiveness in improving visual acuity and reducing CMT compared to PDT with moderate to low certainty of evidence. Ranibizumab and bevacizumab were considered as equally effective with moderate certainty.

Conclusions

The outcomes of this review suggest that high quality clinical practice guidelines for MMD management are limited. Intravitreal injection of anti-VEGF agents was recommended as an effective intervention to treat myopic CNV as the first-line treatment, while there was inadequate guidance for the application of PDT in myopic CNV management. The use of other interventions for MMD were not recommended at this time and additional evidence is called for.

Recent Advances in Screening and Treatment for Amblyopia

Amblyopia is the most common cause of monocular visual impairment in children, with a prevalence of 2-3%. Not only is visual acuity reduced in one eye but binocular vision is affected, fellow eye deficits may be present, eye-hand coordination and reading can be affected, and self-perception may be diminished. New technologies for preschool vision screening hold promise for accessible, early, and accurate detection of amblyopia. Together with recent advances in our theoretical understanding of amblyopia and technological advances in amblyopia treatment, we anticipate improved visual outcomes for children affected by this very common eye condition. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

A Systematic Review of Clinical Practice Guidelines for Infectious and Non-infectious Conjunctivitis

PURPOSE

To systematically review and critically appraise clinical practice guidelines (CPGs) and summarise the recommendations for non-infectious and infectious conjunctivitis.

METHODS

CPGs published on non-infectious and infectious conjunctivitis between 2010 and March 2020 were reviewed, evaluated, and selected using nine items from the Appraisal of Guidelines for Research and Evaluation II tool (4, 7, 8, 10, 12, 13, 15, 22 and 23). CPGs with an average score for items 4, 7, 8, 12, or 22 below 3 and/or a sum of the two researchers' average score for all nine items less than 45 were excluded. Two authors independently extracted and validated the data using standardised forms.

RESULTS

Fifteen CPGs from five sources remained for data extraction. CPGs consistently recommended non-pharmacological interventions (artificial tears, cold compress, avoidance or removal of allergens) for non-infectious conjunctivitis and pharmacological interventions (topical anti-histamine, mast-cell stabiliser and dual-acting agent) for allergy types. Observation without treatment was strongly recommended for non-herpetic viral and bacterial infections. Systemic and topical anti-viral was consistently recommended for herpetic viral conjunctivitis, while systemic and topical antibiotics were recommended for chlamydial and gonorrhoeal conjunctivitis. The methods used to assess the level of evidence and the strength of recommendation varied among CPGs.

CONCLUSIONS

There are a number of high-quality CPGs for non-infectious and infectious conjunctivitis. While there were a number of consistencies in the recommendations provided within these CPGs, several inconsistencies were also identified. Many of which related to the scope of practise of the targeted end-user of the particular guideline.

Effectiveness of Kanna photoscreener in detecting amblyopia risk factors

Purpose:

Amblyopia is a significant public health problem. Photoscreeners have been shown to have significant potential for screening; however, most are limited by cost and display low accuracy. The purpose of this study was validate a novel artificial intelligence (AI) and machine learning–based facial photoscreener “Kanna,” and to determine its effectiveness in detecting amblyopia risk factors.

Methods:

A prospective study that included 654 patients aged below 18 years was conducted in our outpatient clinic. Using an android smartphone, three images of each the participants’ face were captured by trained optometrists in dark and ambient light conditions and uploaded onto Kanna. Deep learning was used to create an amblyopia risk score based on our previous study. The algorithm generates a risk dashboard consisting of six values: five normalized risk scores for ptosis, strabismus, hyperopia, myopia and media opacities; and one binary value denoting if a child is “at-risk” or “not at-risk.” The presence of amblyopia risk factors (ARF) as determined on the ophthalmic examination was compared with the Kanna photoscreener.

Results:

Correlated patient data for 654 participants were analyzed. The mean age of the study population was 7.87 years. The algorithm had an F-score, 85.9%; accuracy, 90.8%; sensitivity, 83.6%; specificity, 94.5%; positive predictive value, 88.4%; and negative predictive value, 91.9% in identifying amblyopia risk factors. The P value for the amblyopia risk calculation was 8.5 × 10⁻¹⁴² implying strong statistical significance.

Conclusion:

The Kanna photo-based screener that uses deep learning to analyze photographs is an effective alternative for screening children for amblyopia risk factors.

Scope and costs of autorefraction and photoscreening for childhood amblyopia-a systematic narrative review in relation to the EUSCREEN project data

Background

Amblyopia screening can target reduced visual acuity (VA), its refractive risk factors, or both. VA testing is imprecise under 4 years of age, so automated risk-factor photoscreening appears an attractive option. This review considers photoscreening used in community services, focusing on costs, cost-effectiveness and scope of use, compared with EUSCREEN project Country Reports describing how photo- and automated screening is used internationally.

Methods

A systematic narrative review was carried out of all English language photoscreening literature to September 10th 2018, using publicly available search terms. Where costs were considered, a CASP economic evaluation checklist was used to assess data quality.

Results

Of 370 abstracts reviewed, 55 reported large-scale community photoscreening projects. Five addressed cost-effectiveness specifically, without original data. Photoscreening was a stand-alone, single, test event in 71% of projects. In contrast, 25 of 45 EUSCREEN Country Reports showed that if adopted, photoscreening often supplements other tests in established programmes and is rarely used as a stand-alone test. Reported costs varied widely and evidence of cost-effectiveness was sparse in the literature, or in international practice. Only eight (13%) papers compared the diagnostic accuracy or cost-effectiveness of photoscreening and VA testing, and when they did, cost-effectiveness of photoscreening compared unfavourably.

Discussion

Evidence that photoscreening reduces amblyopia or strabismus prevalence or improves overall outcomes is weak, as is evidence of cost-effectiveness, compared to later VA screening. Currently, the most cost-effective option seems to be a later, expert VA screening with the opportunity for a re-test before referral.

Comparison between two autorefractor performances in large scale vision screening in Chinese school age children

AIM

To evaluate the effectiveness of Grand Seiko Ref/Keratometer WAM-5500 compared to Topcon KR800 autorefractor in detecting refractive error in large scale vision screening for Chinese school age children with the WHO criteria.

METHODS

A total of 886 participants were enrolled with mean age of 9.49±1.88y from Tianjin, China. Spherical equivalent (SE) was obtained from un-cycloplegic autorefraction and cycloplegic autorefraction. Topcon KR 800 (Topcon) and Grand Seiko WAM-5500 (WAM) autorefractors were used. Bland-Altman Plot and regression were generated to compare their performance. The overall effectiveness of detecting early stage refractive error was analyzed with receiver operating characteristic (ROC) curves.

RESULTS

The mean SE was -0.98±1.81 diopter (D) and the prevalence of myopia was 48.9% defined by WHO criteria according to the result of cycloplegic autorefraction. The mean SE of un-cycloplegic autorefraction with Topcon and WAM were -1.21±1.65 and -1.20±1.68 D respectively. There was a strong linear agreement between result obtained from WAM and cycloplegic autorefraction with an R² of 0.8318. Bland-Altman plot indicated a moderate agreement of cylinder values between the two methods. The sensitivity and specificity for detecting hyperopia were 90.52% and 83.51%; for detecting myopia were 95.60% and 90.24%; for detecting astigmatism were 79.40% and 90.21%; for detecting high myopia were 98.16% and 98.91% respectively.

CONCLUSION

These findings suggest that both Grand Seiko and Topcon autorefractor can be used in large-scale vision screening for detecting refractive error in Chinese population. Grand Seiko gives relatively better performance in detecting myopia, hyperopia, and high myopia for school age children.

Successes and shortfalls of community Plusoptix photoscreening: results from the iSee study in Southwestern Ontario

OBJECTIVE

The purpose of this work is to provide the final results from a community-wide photoscreening program in Southwestern Ontario for children aged 18 to 72 months, and to estimate the prevalence of amblyogenic risk factors in this population.

STUDY DESIGN

Prospective, multisite photoscreening program.

PARTICIPANTS

5959 children aged 18-72 months were recruited and screened in Southwestern Ontario at 210 locations over a period of 3 years and 4 months.

METHODS

Ophthalmic screening examinations were performed with the Plusoptix S12 photoscreener. The threshold for the referral criteria used was the manufacturer's criteria on receiver operating characteristics 4.

RESULTS

The screening was negative in 5386 children (90.4%), positive in 403 (6.8%), and unreadable in 170 (2.9%); 42% of all screened children were ≤36 months old. The estimated amblyogenic risk factor prevalence of anisometropia was 4.0%, astigmatism was 3.1%, hyperopia was 1.1%, myopia was 0.4%, and strabismus was 0.4%. Of the 403 referred children, 99 (24.5%) completed a formal eye examination based on the responses returned to the study site.

CONCLUSIONS

This is the first Canadian study that provides data on amblyogenic risk factors based on a volunteer-led photoscreening program. Photoscreening is an effective screening tool, particularly for pre-school-aged children; however, the lack of mandatory follow-up to ensure that children receive proper treatment based on cycloplegic refraction reduces the efficacy of screening.

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.

Refractive Status and Amblyopia Risk Factors in Chinese Children with Autism Spectrum Disorder

Amblyopia risk factors in children with autism spectrum disorders (ASD) are usually hard to detect in early childhood due to poor cooperation and has not been reported in the Chinese population. We screened 168 Chinese children with ASD, aged between 3 and 8 years, and 264 age-matched neurotypical children with Spot photoscreener and basic ophthalmologic examinations. Children with ASD were found to have normal refractive status but significantly higher incidence of strabismus (16.1%), compared with control children (1.5%) (p < 0.01). Most of the cases of strabismus found in children with ASD were classified as esodeviation. Strabismus in children with ASD should be considered more seriously as an amblyopia risk factor by ophthalmologists and other healthcare professionals.

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.

Evaluation of a smartphone photoscreening app to detect refractive amblyopia risk factors in children aged 1-6 years

Purpose

To determine the specificity and sensitivity of a smartphone app (GoCheckKids [GCK] used as a photoscreening tool on the iPhone 7 to detect refractive amblyopia risk factors in children aged 1–6 years.

Participants and methods

A prospective, multicenter, 10-month evaluation of children aged 1–6 years old who underwent photoscreening with the GCK app to detect amblyopia risk factors. The first acceptable quality photograph of each study subject was evaluated by trained technicians using GCK’s proprietary automated image processing algorithm to analyze for amblyopia risk factors. Trained graders, masked to the cycloplegic clinical data, remotely reviewed photographs taken with the app and compared results to the gold standard pediatric ophthalmology examinations using the 2013 American Association for Pediatric Ophthalmology & Strabismus amblyopia risk factor guidelines. Primary outcome was the ability of the GCK app to identify amblyopia risk factors compared to the cycloplegic refraction.

Results

There were 287 patient images analyzed. The overall sensitivity and specificity in detecting amblyopia risk factors were 76% and 85%, respectively using manual grading. The overall automated grading results had a sensitivity and sensitivity in detecting amblyopia risk factors of 65% and 83%, respectively.

Conclusion

The GCK smartphone app is a viable photoscreening device for the detection of amblyopia risk factors in children aged 1–6 years.

Compared performance of Spot and SW800 photoscreeners on Chinese children

Purpose

To evaluate the effectiveness of Spot photoscreener and SW800 vision screener in detecting amblyopia risk factors in Chinese children between 4 and 6 years of age.

Methods

One hundred and thirteen children (226 eyes) underwent complete ophthalmologic examination, cycloplegic retinoscopy refraction, prism cover tests and photoscreen using both Spot (v2.1.4) and SW800 (v1.0.1.0) photoscreeners. The agreement of results obtained from photoscreener and retinoscopy was evaluated by paired t-test as well as Pearson correlation test. The sensitivity and specificity of detecting amblyopia risk factors were calculated based on the American Association of Pediatric Ophthalmology and Strabismus 2013 guidelines. The overall effectiveness of detecting amblyopia risk factors by using either photoscreener was analysed by receiver operating characteristic (ROC) curves.

Results

A strong linear agreement was observed between Spot and retinoscopy (p<0.01) in aspects of spherical equivalent (SE, Pearson’s r=0.95), dioptre sphere (DS, r=0.97), dioptre cylinder (DC, r=0.84) and horizontal deviation (Hdev, r=0.91), with overall −0.17 D myopic shift of SE. Significant correlation was also shown between SW800 and retinoscopy (p<0.01) in aspects of SE (r=0.90), DS (r=0.93), DC (r=0.82) and Hdev (r=0.80), with overall −0.12 D myopic shift of SE. The overall sensitivity and specificity in detecting amblyopia risk factors were 94.0% and 80.0% for Spot and 88.8% and 81.1% for SW800.

Conclusion

The measurements of Spot and SW800 photoscreener showed a strong agreement with cycloplegic retinoscopy refraction and prism cover tests. The performance of both screeners in detecting individual amblyopia risk factors is satisfactory. ROC analysis indicates that the Spot and SW800 performed very similarly in detecting amblyopia risk factors.

Paediatric Eye Services: How Much of the Workload Is Amblyopia-Related?

AIMS

The proportion of patients seen by the paediatric eye service that attend for reasons related to amblyopia has not been quantified. The purpose of this study was to quantify the proportion of patients seen in the paediatric eye service attending for reasons related to amblyopia.

METHODS

Records of all eye appointments of children attending the Hillingdon Hospitals NHS Foundation Trust and St Mary's Hospital Imperial College Healthcare NHS Trust over one month in 2009 were examined to determine the diagnosis and reason for attendance.

RESULTS

Seven hundred and four patients had appointments booked at St Mary's and Hillingdon in March 2009. The fail-to-attend rates were not significantly different at the 2 sites (19% at St Mary's and 9% at Hillingdon; P=0.75). Of the 704 patients, 533 (St Mary's, 252 [75%]; Hillingdon, 281 [76%]) were attending for amblyopia-related reasons. Of the overall 982 booked appointments, 770 (79%) were amblyopia-related.

CONCLUSIONS

Amblyopia diagnosis and management is clearly the most common cause of attendance to the paediatric eye service, accounting for over three-quarters of outpatient visits.

Performance of Spot Photoscreener in Detecting Amblyopia Risk Factors in Chinese Pre-school and School Age Children Attending an Eye Clinic

Purpose

To evaluate the effectiveness of Spot photoscreener in detecting amblyopia risk factors meeting 2013 the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) criteria in Chinese preschool and school-age children.

Methods

One hundred and fifty-five children (310 eyes), aged between 4 to 7 years (5.74 ± 1.2 years) underwent complete ophthalmologic examination, photoscreening, and cycloplegic retinoscopy refraction. The agreement of the results obtained with the photoscreening and retinoscopy was evaluated by linear regression and Bland-Altman plots. The sensitivity and specificity of detecting amblyopia risk factors were calculated based on the AAPOS 2013 guidelines. The overall effectiveness of detecting amblyopia risk factors was analyzed with Receiver Operating Characteristic (ROC) curves.

Result

The mean refractive errors measured with the Spot were: spherical equivalent (SE) = 0.70 ± 1.99 D, J0 = 0.87 ± 1.01 D, J45 = 0.09 ± 0.60 D. The mean results from retinoscopy were: SE = 1.19 ± 2.22 D, J0 = 0.77 ± 1.00 D, J45 = -0.02 ± 0.45 D. There was a strong linear agreement between results obtained from those two methods (R² = 0.88, P<0.01). Bland–Altman plot indicated a moderate agreement of cylinder values between the two methods. Based on the criteria specified by the AAPOS 2013 guidelines, the sensitivity and specificity (in respective order) for detecting hyperopia were 98.31% and 97.14%; for detecting myopia were 78.50% and 88.64%; for detecting astigmatism were 90.91% and 80.37%; for detecting anisometropia were 93.10% and 85.25%; and for detection of strabismus was 77.55% and 88.18%.

Conclusion

The refractive values measured from Spot photoscreener showed a moderate agreement with the results from cycloplegic retinoscopy refraction, however there was an overall myopic shift of -0.49D. The performance in detecting individual amblyopia risk factors was satisfactory, but could be further improved by optimizing criteria based on ROC curves.

Preschool vision screening: update on guidelines and techniques

PURPOSE OF REVIEW

To discuss the current preschool vision screening (PVS) guidelines and review some of the newest vision screening techniques. The different vision screening practices and barriers to screening are discussed.

RECENT FINDINGS

Vision screening guidelines, which have been developed in response to the advances in technology and increased understanding of the developing visual system, have been recently updated by some of the major medical organizations that endorse vision screening. With advances in vision screening technology, there is a growing trend for screening at younger ages.

SUMMARY

PVS has been widely endorsed by various medical organizations as an effective way to detect preventable and treatable vision problems of childhood. Although PVS is widely recommended, actual screening rates remain low. There are several real and perceived barriers to screening which often prevents successful screening programs. Current vision screening guidelines take into account the recent advances in technology. With the development of new devices, vision screening can effectively be performed at younger ages.

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.

Guidelines for automated preschool vision screening: a 10-year, evidence-based update

In 2003 the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee proposed criteria for automated preschool vision screening. Recent literature from epidemiologic and natural history studies, randomized controlled trials of amblyopia treatment, and field studies of screening technologies have been reviewed for the purpose of updating these criteria. The prevalence of amblyopia risk factors (ARF) is greater than previously suspected; many young children with low-magnitude ARFs do not develop amblyopia, and those who do often respond to spectacles alone. High-magnitude ARFs increase the likelihood of amblyopia. Although depth increases with age, amblyopia remains treatable until 60 months, with decline in treatment effectiveness after age 5. US Preventive Services Task Force Preventative Services Task Force guidelines allow photoscreening for children older than 36 months of age. Some technologies directly detect amblyopia rather than ARFs. Age-based criteria for ARF detection using photoscreening is prudent: referral criteria for such instruments should produce high specificity for ARF detection in young children and high sensitivity to detect amblyopia in older children. Refractive screening for ARFs for children aged 12-30 months should detect astigmatism >2.0 D, hyperopia >4.5 D, and anisometropia >2.5 D; for children aged 31-48 months, astigmatism >2.0 D, hyperopia > 4.0 D, and anisometropia >2.0 D. For children >49 months of age original criteria should be used: astigmatism >1.5 D, anisometropia>1.5 D, and hyperopia >3.5 D. Visually significant media opacities and manifest (not intermittent) strabismus should be detected at all ages. Instruments that detect amblyopia should report results using amblyopia presence as the gold standard. These new American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines will improve reporting of results and comparison of technologies.

The accommodative lag of the young hyperopic patient

PURPOSE

To determine the accommodative accuracy of infants and young children before they had had any form of clinical intervention or treatment, in an attempt to determine the difference between 'normal' and 'abnormal' visual experience for these individuals.

METHODS

Nott retinoscopy was performed on 111 subjects in binocular viewing conditions at a viewing distance of 50 cm. The target was a naturalistic cartoon image with a broadband spatial frequency amplitude spectrum.

RESULTS

Accommodative accuracy was not related to age (4-90 months). In the group found to have no apparent clinical abnormality (n = 71), the mean lag in the more hyperopic meridian of the least ametropic eye was 0.34 diopters (D). When considering the group as a whole, those with less than approximately 4 D of hyperopia demonstrated similar lags, while those with higher hyperopia, amblyopia, or strabismus had more variable lags. An ROC analysis designed to detect hyperopia >5 D in any meridian, amblyopia and/or strabismus had an area under the curve of 0.90 (95% confidence interval [CI], 0.82 to 0.95), and for a lag criterion of 1.3 D had a sensitivity of 83.3% and a specificity of 96.5%.

CONCLUSIONS

These data from a relatively small but broad sampling of age and clinical status suggest that clinically normal young infants and children with low amounts of hyperopia have similar lags of accommodation from the first few months after birth. Subjects with greater than 4 D of hyperopia, or amblyopia or strabismus, have more variable lags and therefore evidence of abnormal visual experience.

Retinoblastoma in a child after normal autorefraction and traditional vision screening

Retinoblastoma is an ocular malignancy that can put a patient's sight and, in some instances, life at risk. Here we report the case of a 2-year-old child who presented to her pediatrician with a 2-week history of left-sided leukocoria caused by retinoblastoma. Results of traditional office-based vision screening and automated vision screening, which often identify but are not specifically designed to detect rare diseases such as retinoblastoma, had been normal in the antecedent 7 months. She underwent enucleation of the left eye and has done well postoperatively. This case highlights the importance of assessing ocular media clarity by using red-reflex testing at multiple intervals during the preschool years, particularly in light of the recently published US Preventive Services Task Force guidelines for preschool vision screening, which gave an "insufficient evidence" level for vision screening in children younger than 3 years and failed to address red-reflex examination.