Testing stereopsis in the preschool child: is it clinically useful?

Grenzen und Möglichkeiten des Lang-Stereotests

Hintergrund

Der Lang-Test ist ein beliebter Stereotest und wird immer wieder auch als Screeningtool angewandt. Er ist einfach zu handhaben und bereits im Säuglingsalter einsetzbar. Dennoch ist im Alltag nicht immer klar, wie Testergebnisse am geeignetsten dokumentiert bzw. interpretiert werden soll(t)en. Besonders für den Ausschluss eines (Mikro‑)Strabismus und/oder einer Amblyopie scheint es relevant, die Erkenntnislage bezüglich der Grenzen und Möglichkeiten des Lang-Stereotests etwas exakter zu beleuchten.

Material und Methode

Es wurden im Rahmen einer Literaturrecherche die Ergebnisse von Studien zur Messgenauigkeit und Durchführbarkeit des Lang-Stereotests bei Augengesunden, manifesten Schielern und Amblyopen gesammelt und dargestellt.

Resultate

Obwohl das Evidenzniveau gering ist, bestätigen die Ergebnisse einiger Studien, dass weder der Lang I noch der Lang II dafür geeignet ist, einen (Mikro‑)Strabismus und/oder eine Amblyopie auszuschließen. Bis zu 36 % der Kinder mit (Mikro‑)Strabismus erreichen ein positives Ergebnis beim Lang I. Bei Amblyopie ex Anisometropie sind es sogar 20–75 %, wobei die Tiefe der Amblyopie verantwortlich für diese große Streuung zu sein scheint.

Schlussfolgerung

Der Lang-Stereotest hat besonders im Säuglings- und Kleinkindalter unbestreitbare Vorteile. Gerade bei diesem „einfachen“ Test ist der ordnungsgemäßen Durchführung und sauberen, kritischen Interpretation der Antworten große Bedeutung zuzuschreiben. So darf reines auf die Figuren Zeigen nicht als positive Testantwort interpretiert werden. Einmal mehr bestätigen die Studien: Der Lang-Stereotest eignet sich als ergänzendes Tool, erlaubt aber niemals als alleiniges Screeningtool eine Aussage über Schielen oder Nichtschielen der kleinen PatientInnen.

The prevalence and diagnosis of 'stereoblindness' in adults less than 60 years of age: a best evidence synthesis

PURPOSE

Stereoscopic vision (or stereopsis) is the ability to perceive depth from binocular disparity - the difference of viewpoints between the two eyes. Interestingly, there are large individual differences as to how well one can appreciate depth from such a cue. The total absence of stereoscopic vision, called 'stereoblindness', has been associated with negative behavioural outcomes such as poor distance estimation. Surprisingly, the prevalence of stereoblindness remains unclear, as it appears highly dependent on the way in which stereopsis is measured.

RECENT FINDINGS

This review highlights the fact that stereopsis is not a unitary construct, but rather implies different systems. The optimal conditions for measuring these varieties of stereoscopic information processing are discussed given the goal of detecting stereoblindness, using either psychophysical or clinical stereotests. In that light, we then discuss the estimates of stereoblindness prevalence of past studies.

SUMMARY

We identify four different approaches that all converge toward a prevalence of stereoblindness of 7% (median approach: 7%; unambiguous-stereoblindness-criteria approach: 7%; visual-defect-included approach: 7%; multiple-criteria approach: 7%). We note that these estimates were derived considering adults of age <60 years old. Older adults may have a higher prevalence. Finally, we make recommendations for a new ecological definition of stereoblindness and for efficient clinical methods for determining stereoblindness by adapting existing tools.

The usefulness of the Retinomax autorefractor for childhood screening validated against a Danish preterm cohort examined at the age of 4 years

BACKGROUND AND PURPOSE

Refractometers have gained a foothold in childhood screening for ophthalmic disorders. Given the results of an ophthalmic follow-up of an extremely preterm Danish cohort, the results of the Retinomax autorefractor were further evaluated.

MATERIALS AND METHODS

A nationwide cohort of infants born before gestational age 28 weeks (n=178) and 56 term controls were examined at the age of 4 years. Refraction was given as the cycloplegic Retinomax value. For this study, we analysed the equipment's confidence value on the printout and equipment-induced myopization (as the difference between refraction measured before and after topical cyclopentholate 1%), both items hypothetical with a view to having identified factual ophthalmic deviations.

RESULTS

Thirty-two of 42 eyes with visual acuity ≤0.4 had high Retinomax confidence values (8-9); the Retinomax values were also high in 10 of 12 children with strabismus and lack of stereopsis. Low values (1-6) were recorded in 11 single eyes, 5 of which were normal (false positives). Three children already known to have low vision were unable to cooperate. The overall mean value for equipment-induced myopization was 1.9 D (range, 0-6.87 D). Myopization showed no correlation with visual acuity and corneal curvature, and a weak positive correlation with refractive value disappeared when the myopic outliers were excluded.

CONCLUSIONS

The hand-held Retinomax seemed to be reliable for assessing refraction in 4-year-old children, provided a cycloplegic agent is applied; if used alone, the Retinomax would have missed several cases of ophthalmic deviation during screening. Equipment-induced myopization was not indicative.

Stereoacuity norms for school-age children using the Frisby stereotest

BACKGROUND

The Frisby stereotest and the TNO test for stereoscopic vision are popular clinical tests for assessing stereoacuity: however, reference data for school-age children for the Frisby stereotest are limited. This study compared stereoacuity results of both tests in a large sample of typically developing school-age children.

METHODS

Primary (elementary school grades 1-6) and post-primary (high school grades 7-11) students aged 6-16 years were recruited and assessed in schools. Stereoacuity thresholds were measured using the Frisby and TNO stereotests. Children with ocular pathology, anisometropia of ≥1.00 D, interocular difference of visual acuity ≥0.2 logMAR, or strabismus were excluded.

RESULTS

A total of 212 children were recruited; data for 186 subjects were analyzed. Median Frisby stereoacuity scores were, for crossed disparity, 20 arcsec for primary and 10 arcsec for post-primary children and, for uncrossed disparity, 25 arcsec (primary) and 10 arcsec (post-primary). TNO stereoacuity was 60 arcsec for both age groups. For Frisby stereoacuity, scores of 85 arcsec (crossed) and 170 arcsec (uncrossed) or better were achieved by 95% of primary school children; scores of 85 arcsec (crossed and uncrossed) or better were achieved by 95% of post-primary subjects. A statistically significant difference in median stereoacuity scores was noted across age groups for the Frisby stereotest (crossed: z = 4.67, P < 0.0001; uncrossed: z = 4.67, P < 0.0001). No statistically significant difference in stereoacuity scores was noted with the TNO stereotest (z = 1.35, P = 0.18). A significant weak correlation was found between the Frisby and TNO stereotests (Frisby [crossed], r = 0.21 P < 0.005).

CONCLUSIONS

These data describe normative values for the Frisby stereotest for children aged 6-16 years. Participants recorded significantly better stereoacuity scores with the Frisby stereotest than the TNO stereotest. The Frisby stereotest values are weakly correlated with the TNO stereoacuity test.

Accuracy of the Lang II stereotest in screening for binocular disorders in 6-year-old children

PURPOSE

To assess the accuracy of the Lang II stereotest in screening for strabismus, amblyopia, and anisometropia in 6-year-old children.

DESIGN

Cross-sectional population-based study.

METHODS

The Sydney Myopia Study examined 1765 6-year-old children (78.9% of eligible) who were identified by random cluster sampling of 34 schools in Sydney, Australia. Sensitivity and specificity of the Lang II stereotest was determined by best stereoacuity. Cycloplegic autorefraction, assessment of visual acuity, and ocular motility were conducted.

RESULTS

Test sensitivity ranged from 21.4% for anisometropia (> or =1.0 diopter) to 31.3% for amblyopia. The detection rate for new cases of amblyopia ranged from 20% to 40%; the detection rate for new cases of strabismus was 30%. Specificity was >98% in all three conditions. Children with false-negative results included newly diagnosed cases of strabismus (14 of 25 children) or amblyopia (5 of 12 children).

CONCLUSION

The Lang II stereotest, when used alone, has very limited value as a screening test of binocular dysfunction.

A study on the clinical usefulness of digitalized random-dot stereoacuity test

Existing methods of stereoacuity testing need specific glasses or optical device for use. We have designed a new stereoacuity test for the digitalized, random-dot stereogram and researched its clinical usefulness. A digitalized, random-dot, stereoacuity test card was created with a computer program that used a preferred symbol and the designed system was tested along with the Randot preschool stereoacuity, Titmus-fly and Lang tests to compare their sensitivity and specificity. The mean success rate of the digitalized, random-dot test was 98.2%, while the rates of the Randot preschool stereoacuity, Titmus-fly and Lang tests were 89.3%, 74.2% and 86.1%, respectively. Sensitivity and specificity of the new test were 100% and 95.3%, respectively, which were not that different from those of the Randot preschool stereoacuity, Titmus-fly and Lang tests. We found that the digitalized, random-dot, stereoacuity test has a high success rate and can be appropriately used in medical examinations and follow-up tests for strabismus patients.

Stereoacuity at distance and near

PURPOSE

Because previous studies have reported conflicting evidence, we examined a possible difference in stereoacuity between distance and near, in particular using a random-dot display. We compared distance and near stereoacuities using identical presentation formats at the two distances.

METHODS

Twelve young adults with low, stable refractive errors and apparently normal binocular vision participated. Stereoacuity was determined with a Mentor B-VAT II using Random Dot E (BVRDE) and Contour Circles (BVC) stereograms presented on a standard monitor (25 x 19.3 cm) at 518 cm (distance-habitual) and a small monitor (2.0 x 1.4 cm) at 40 cm (near-habitual). To examine whether accommodation-convergence influenced stereoacuity, testing at 40 cm was repeated with the addition of +2.50 DS lenses and base-in prisms (near-compensated) that created the same accommodation and convergence demands as for distance-habitual viewing.

RESULTS

The two stereotests produced similar findings. Stereoacuity was not significantly different for distance-habitual and near-habitual viewing of the BVRDE (p = 0.43) and BVC (p = 0.79) stereotests. Near-compensated stereoacuity was worse than near-habitual (BVRDE, p = 0.005; BVC, p = 0.004) and distance-habitual (BVRDE, p = 0.05; BVC, p = 0.003) for both stereotests. Because near stereoacuity with yoked prisms (control condition) was the same as without prism (near-habitual), prism-induced optical distortions cannot account for the difference.

CONCLUSIONS

Stereoacuity was not different at distance and near under normal viewing conditions. The conflict between subject knowledge of target proximity and the optically-induced relaxation of accommodation and convergence, or an inaccurate accommodative-convergence response, might have caused poor near-compensated stereoacuity.

Screening for amblyopia and strabismus with the Lang II stereo card

PURPOSE

To evaluate the effectiveness of the Lang II stereo card as a screening test for amblyopia and/or strabismus.

METHODS

A total of 1046 children aged 12-13 years were examined in a field study in the Göteborg area, Sweden. In addition to the Lang II stereo card, the examination included visual acuity, cover testing, cycloplegic refraction, and inspection of the optical media and posterior pole.

RESULTS

If every incorrect subject response was considered a reason for referral, the Lang II test would have correctly identified 82% (23 subjects) of the 28 children with manifest strabismus and 38% (11 subjects) of the 29 children with amblyopia. The test failed to refer 45% (21 subjects). Of all subjects referred, 44 (63%) were found to be ophthalmologically normal.

CONCLUSIONS

The Lang II stereo card is neither a reliable nor an efficient method of screening for amblyopia and/or strabismus.

Randot stereoacuity norms in a population of Saudi Arabian children

BACKGROUND: The onset and development of stereoacuity in children have been investigated by several authors. In addition to the study of those aspects of stereopsis, it is also important to collect normative data, which can be applied in the clinical setting. The purpose of this study was to establish Randot stereoacuity norms using a Saudi Arabian children population. METHOD: The Randot stereo test was used to measure stereoacuity for 791 male primary school children (aged six to 12 years) with normal vision. A battery of tests was used to establish that each child had normal eyes and vision prior to the stereoacuity measurement. RESULTS: The range of stereoacuities for all the age groups at 40 cm was 70 to 20 seconds of arc, except for the nine-year-old children in whom the range was 50 to 20 seconds of arc. More than one half (57.5 per cent) of the children achieved 29 seconds of arc. The mean stereoacuity for all of the children was 25.32 seconds of arc with a standard deviation of 9.93 seconds of arc. The mean stereoacuity for the children decreased from 29.11 seconds of arc at six years to 23.61 seconds of arc at 11 years. An inter-subject variation in stereoacuity development was observed. CONCLUSION: This paper provides normative data for Randot stereoacuity for children. The range and mean values presented here will be useful as reference data for clinical diagnosis of normalcy or otherwise of stereoacuity in children of similar ages when the Randot stereo test is used.

The modified frisby stereotest

BACKGROUND

The Frisby stereotest commonly is used in clinical practice to estimate stereoacuity. Assessment of the presence or absence of stereopsis is valuable particularly in toddlers because of the difficulties encountered in this age group with assessment of other aspects of visual function, such as monocular visual acuities.

METHODS

The present study describes two modifications to the Frisby stereotest: 1) the introduction of a nonstereo practice plate; and 2) the use of an auditory "reward" for correct identification of the target. These modifications aim to increase the success rate of the test and provide a means to discriminate between testable and untestable children. Subjects were 165 children aged between 0.5 and 47 months.

RESULTS

The modifications improved the age range over which results could be obtained with the Frisby test, allowing infants as young as 7 months to complete testing. By 12 months of age, more than 60% of children were able to complete testing. The modifications also allowed the examiner to distinguish untestable children from those without stereopsis.

CONCLUSIONS

By simple modification of the Frisby stereotest, the authors have increased the ease with which the Frisby stereotest can be used to assess stereoacuity in infants and children and provided a means by which children unable to cooperate with testing can be distinguished from those without stereopsis.

Preschool vision screening: rationale, methodology and outcome

Although population outcome studies support the utility of preschool screening for reducing the prevalence of amblyopia, fundamental questions remain about how best to do such screening. Infant photoscreening to detect refractive risk factors prior to onset of esotropia and amblyopia seems promising, but our current understanding of the natural history of these conditions is limited, thus limiting the prophylactic potential of early screening. Screening for strabismic, refractive and ocular disease conditions directly associated with amblyopia is more clearly proven, but the diversity of equipment, methods and subject populations studied make it difficult to draw precise summary conclusions at this point about the efficacy of photoscreening. Sensory-based testing of preschool-age children exhibits a similar combination of promise and limitations. The visual acuity tests most widely used for this purpose are prone to problems of testability and false negatives. Moreover, the utility of random-dot stereograms has been confused by misapplication, and new small-target binocularity tests, while attractive, are as yet inadequately field-proven. The evaluation standard for any screening modality is treatment outcome. However, variables in amblyopia classification and quantitative definition differences, timing of presentation, nonequivalent treatment comparisons, and compliance variability have been uncontrolled in virtually all extant studies of amblyopia treatment outcome, making it difficult or impossible to evaluate either the relative efficacy of different treatment regimens for amblyopia or the effects of age on treatment outcome within the preschool age range. The latter issue is a central one, since existence of such an age effect is the primary rationale for screening at younger rather than older preschool ages. The relatively low prevalence of amblyopia makes it difficult to achieve a high screening yield in terms of predictive value, but functionally increasing prevalence by selective screening of high risk populations causes further problems. Unless a "supertest" can be devised, with very high sensitivity and specificity, health policy decisions will be required to determine which of these two characteristics should be emphasized in screening programs. Performance of screening tests can be optimized, however, with adequate training, perhaps via instructional videotapes.

Small-target random dot stereogram and binocular suppression testing for preschool vision screening

BACKGROUND

New, small-target (< 1 degree) random dot stereogram (STRDS) and binocular suppression (STBS) tests appropriate for preschool vision screening were developed to correct the shortcomings of previous such tests, particularly missed cases of anisometropic amblyopia such as found with some RDS-based testing.

METHODS

In Experiment 1, the tests were administered to 14 patients with current or a recent history of moderate (< or = 20/60) anisometropic amblyopia, or with accommodative esotropia or monofixation syndrome. All subjects had good binocularity (< or = 100" contour stereoacuity). In Experiment 2, the new tests were administered in a screening setting to a group of 112 three- to five-year-olds to determine testability. Visual acuity, cover testing, and photoscreening were administered as control measures.

RESULTS

In Experiment 1, eleven of the 14 patients failed both tests. Two anisometropic amblyopes passing one or both tests had an acuity < or = 20/30 in the worse eye and < or = 25" stereoacuity. Three anisometropic amblyopia patients failing the STRDS passed another RDS test with similar disparity but a larger target size, confirming a report34 that anisometropic amblyopes may pass RDS testing with parafoveal stereopsis despite the presence of central suppression. The STRDS and STBS tests indicated 80% and 96% specificity, respectively, with the original methodologies; STRDS specificity increased to 95% with retesting with a different methodology. Administration time was 30 sec to 60 sec per test.

CONCLUSION

Small-target RDS or suppression testing may be more effective for strabismus and amblyopia screening of preschoolers than previous RDS test formats.

Does stereopsis matter in humans?

Stereopsis has been one of the most popular fields of vision research for well over a century and is routinely measured in clinical practice, yet its functional significance has been largely neglected. Stereopsis is disrupted by blur, amblyopia and strabismus and is of potential value as a means of indirect screening for visual disorders in childhood. However, evidence for the functional effects of stereoscopic deficits is sparse. Recent investigations indicate that binocularity is an advantage in certain tasks, especially in the comprehension of complex visual presentations and those requiring good hand-eye coordination. The assumption derived from the evolutionary theory that stereopsis represents an adaptation by primates to arboreal life needs to be questioned. While the functional aspects of stereopsis are still not fully understood the direction that future research should take to unravel this important issue is apparent.

TNO stereopsis test as an aid to the prevention of amblyopia

In this investigation, carried out under a Youth Health Care postgraduate course in Nijmegen, the stereopsis of a school population of 730 children, aged 4-18 years, was recorded and clinically evaluated. Stereopsis was measured using the TNO test, a random-dot stereo test especially designed for the early detection of amblyopia. The main aims of this study were to establish the validity of the TNO test as a screening test for amblyopia, obtain information about the variability and age dependence of stereopsis, and to evaluate the efficacy of amblyopia prevention. The most important findings can be summarized as follows: 1. All amblyopes are detected by the TNO test's recommended referral criterion of 240 sec arc (binocular threshold parallax in sec arc). 2. The red-green anaglyphs used in the test do not pose problems for individuals with a colour vision deficiency. 3. The ability to discriminate depth improves by a factor of two over the age interval 4-12 years. 4. A stereoacuity of < or = 120 sec arc is a good predictor of normal or correctable normal vision, and may therefore help in evaluating the often incomplete results of eye tests of young children. 5. Where there is an increased perinatal risk, there is a greater chance of disturbed binocular vision. 6. It is estimated that 75% of amblyopes remain amblyopic, possibly because of delayed detection; 60% of the amblyopes in the population examined were not identified before the age of 5 years.