Performance of four new photoscreeners on pediatric patients with high risk amblyopia

Validation of the eye screening tool GoCheck Kids for the detection of amblyopia risk factors in toddlers in Flanders

PURPOSE

To assess the validity of the GoCheck Kids photoscreening application (Gobiquity Mobile Health, Scottdale, AZ) on iPhone, which was used (2018-2022) as standard of care by Child and Family (Kind en Gezin) to detect amblyopia risk factors in children 12-30 months of age.

METHODS

Between August 2021 and May 2022, 453 children 11-16 months of age underwent a confirmatory ophthalmic examination within 2 months of GoCheck Kids photoscreening at Child and Family, Flanders, Belgium. Additionally, manual review was performed by specialists of GoCheck Kids. Diagnostic metrics were assessed using the 2013 criteria of the American Association for Pediatric Ophthalmology and Strabismus as reference.

RESULTS

Specificity was similar for automatic screening with or without manual review: 90.0% (95% CI, 87.6%-92.3%) and 90.3% (95% CI, 88.0%-92.7%), respectively. Sensitivity was estimated at 52.0% (95% CI, 35.6%-68.4%) for automatic grading and 56.0% (95% CI, 39.7%-72.3%) after manual review. Positive predictive values for automatic screening and manual review were, respectively, 23.2% (95% CI, 13.9-32.5) and 25.5% (95% CI, 15.8-35.1). Negative predictive values for automatic screening and manual review were, respectively, 97.0% (95% CI, 95.6-98.4) and 97.2 (95% CI, 95.8-98.6).

CONCLUSIONS

In our study cohort of children around 12 months of age, the GoCheck Kids application had a specificity of 90% for the targeted amblyopia risk factors, with sensitivity just over 50%.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Home-based screening tools for amblyopia: a systematic review

Amblyopia is an important public health concern. While home-based screening may present an effective solution, this has not been rigorously assessed in a systematic review. A systematic review was performed using Ovid MEDLINE, PubMed, The Cochrane Library, Embase, Web of Science Core Collection, and Clinicaltrials.gov. All studies reporting the diagnostic accuracy of home-based screening tools for amblyopia among children were included. Studies involving orthoptist or ophthalmologist-led screening and adult subjects were excluded. The main outcome measure was the diagnostic accuracy expressed as sensitivity and specificity. Among 3670 studies identified, 28 were eligible for inclusion in our systematic review. The age range of patients were less than 1 month to 16 years old. 7 studies used internet-based tools, 16 used smartphone/tablet applications, 3 used digital cameras, and 3 used home-based questionnaires and visual acuity tools. All studies included a reference standard except one, which was a longitudinal study. 21 studies had full ophthalmological examination whilst 6 studies had validated visual acuity measurement tools as gold standards. Of the 27 studies which compared against a reference test, only 25 studies reported sensitivity and specificity values. Using the QUADAS-2 tool, 50% of studies were deemed to have applicability concern due to patient selection from tertiary centres and unclear methods for recruitment. There is a need to improve the quality of diagnostic accuracy studies, standardise thresholds for detecting amblyopia, and ensure consistent reporting of results. Further research is needed to evaluate the suitability of these tools for amblyopia screening.

Automated screening devices for vision screening in preschool children: A comparison of the PlusoptiX S12C photoscreener and retinomax K+3 autorefractor

Introduction

Automated vision screening devices such as photoscreeners and autorefractors have been used to accurately identify amblyopia, refractive amblyopia risk factors (ARFs), and refractive error in young children; however, there is conflicting data about the effectiveness of different screening devices. We compared the performance of two commercially available screening devices in preschool children.

Methods

Children aged 3 to 5 years attending 5 preschools in Anaheim Elementary School District were screened with the PlusoptiX S12C photoscreener using ROC 3 referral criteria and Retinomax K+3 autorefractor in March 2022. Screened children were offered free cycloplegic eye examinations performed by optometrists on the UCI EyeMobile for Children mobile clinic. Children were evaluated for the presence of refractive ARFs using 2021 American Association for Pediatric Ophthalmology and Strabismus age-based referral criteria guidelines for instrument-based screening.

Results

A total of 158 children were screened and 79 children received cycloplegic examinations. At least one refractive ARF was found in 20% of examined children, corresponding to a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 94%/89%/68%/98% for the PlusoptiX and 100%/65%/42%/100% for the Retinomax.

Discussion

In detecting refractive ARFs, the PlusoptiX was found to have a higher specificity and PPV while the Retinomax had a higher sensitivity and NPV. While both devices demonstrated a high sensitivity and NPV, we found that the PlusoptiX performed better overall as a screening device for our program as the Retinomax referred too many children.

Canon CP-TX1 camera - As a screening tool for amblyogenic risk factors

Purpose:

To evaluate the Canon CP-TX1 camera as a screening tool for ARFs in a pediatric population and estimate the prevalence of ARFs.

Methods:

In a pediatric outpatient space, largely in the immunization clinic, after obtaining parental consent, we encouraged children to be photographed from a distance of 5 feet in a dim room by using a CP-TX1 camera with the red-eye reduction feature off. Based on the captured red reflex, children were labeled as normal (symmetrical red reflexes in the two eyes, with no visible crescents); all others were considered as abnormal or positive for ARFs. All photographed children were assessed by an optometrist/refractionist for VA by age-appropriate methods. Data were entered into a 2 × 2 contingency table on statpages.org, and diagnostic indices were calculated with 95%CI.

Results:

With a sample of 262 children, we obtained a sensitivity of 0.82, a specificity of 0.98, a positive predictive value of 0.92, a negative predictive value of 0.94, a positive likelihood ratio of 41.06, a negative likelihood ratio of 0.17, and a prevalence of 0.24 for ARFs

Conclusion:

CP-TX1 performed well as a screening tool to identify ARFs in children. Placing such a camera in an immunization clinic offers a chance to identify children with ARFs at a time when amblyopia is eminently reversible.

Instrument Referral Criteria for PlusoptiX, SPOT and 2WIN Targeting 2021 AAPOS Guidelines

Background

Methods

Results

Conclusion

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Effectiveness of a photoscreener in identifying undiagnosed unilateral amblyopia at vision screening of 3-year-old children in Japan

PURPOSE

In Japan a basic preparatory ophthalmic examination is routinely performed for 3-year-old children. This study aimed to determine the value of incorporating a photoscreener into the examination and evaluate parents' satisfaction with the photoscreener examination.

STUDY DESIGN

Prospective study.

METHODS

Children aged 42-47 months in Nagasaki City, Japan, underwent a visual acuity test by a parent at home and by automated vision screening using a photoscreener at their local municipal health center between October 2018 and March 2019. Subjects were children referred to Nagasaki University Hospital for examination after failing either test. Children previously diagnosed with strabismus and/or amblyopia were excluded. A questionnaire survey evaluated the level of satisfaction with the photoscreener-based screening by parents who attended these examinations at the local municipal health center.

RESULTS

Of children who completed the two tests, 52 (failed visual acuity test, 3; failed photoscreener examination, 49) were referred for examination. Of the 49 photoscreener failures, 12 were diagnosed with amblyopia: unilateral amblyopia with anisometropic hyperopia in 10 (83.3%), and bilateral amblyopia with astigmatism and hyperopia in 2 (16.7%). The photoscreener detected all 12 cases of amblyopia, whereas the home-based visual acuity test detected only two cases. More than 80% of 1035 parents were satisfied with the photoscreener examination.

CONCLUSION

Unilateral amblyopia with anisometropic hyperopia was easily overlooked with the home-based test but was detectable by photoscreener examination. The photoscreener proved to be an effective screening tool for amblyopia in children and was considered a satisfactory examination by a high proportion of parents.

Can photoscreening effectively detect amblyogenic risk factors in children with neurodevelopmental disability?

Purpose:

To analyze whether photoscreening can effectively detect amblyogenic risk factors in children with neurodevelopmental disability.

Methods:

A prospective study of 52 children attending a special school for children with neurodevelopmental disability from December 2017 to May 2018. All were initially tested with a photoscreening device: Welch Allyn® Spot® Vision Screener: model VS100 (Spot®) and further evaluated at a later date by a pediatric ophthalmologist, with a complete ocular evaluation including squint assessment, cycloplegic retinoscopy, and dilated fundus examination. The key parameters studied were demographic features, type of neurodevelopmental disability, refraction, ocular alignment, media clarity, any other ocular morbidity, and time taken for examination. The presence of amblyogenic risk factors (ARF) was analyzed as per the 2013 guidelines of the American Association for Pediatric Ophthalmology and Strabismus.

Results:

The mean age was 10.5 years (range: 1–17.5 years). Males (73.1%) outnumbered females (26.9%). The most common neurodevelopmental disability was cerebral palsy. Simple myopic astigmatism was the most common type of refractive error. Presence of ARF in our study was 73.1%. The sensitivity and specificity of photoscreening in detecting ARF were 96.5% and 63.61%, respectively, with a positive predictive value of 80% and negative predictive value of 92.31%. The predictive ability of photoscreening was 79.9% as per the area under curve. The average time taken for photoscreening was less than 60 s.

Conclusion:

Photoscreening can detect ARF with high sensitivity and reasonable specificity and is a handy, useful, and time-saving tool in screening children with neurodevelopmental disability.

Photoscreener results with and without cycloplegia and their reliability according to biometric parameters

PURPOSE

Our goal in this study is to compare the results of a photoscreener (Plusoptix A12C) with and without cycloplegia and to investigate its reliability as a function of biometric parameters.

METHODS

In total, 250 eyes of 125 children with a mean age of 6.77±1.59years were included in the study. The results of cycloplegic and noncycloplegic Plusoptix A12C measurements and autorefractometer with cycloplegia (CA) were compared. The spherical equivalent (SE) differences between CA and noncycloplegic Plusoptix A12C measurements (NPO) with CA and cycloplegic Plusoptix A12C measurements (CPO) were compared with axial length (AL), anterior chamber depth (ACD), corneal radius of curvature (CR), mean keratometry (meanK) and axial length/corneal radius of curvature ratio (AL/CR) values. The relationships between these were examined.

RESULTS

According to amblyopia risk factors (ARFs) based on the criteria in the 2013 AAPOS guidelines, 33 eyes (13%) in the NPO results and 34 eyes (13.6%) in the CPO results were found to be at risk for amblyopia. According to the CA results, the NPO had 67.3% sensitivity and 94.5% specificity, and the CPO 69.4% sensitivity and 89.1% specificity in detecting the values of refractive amblyopia factors determined by the AAPOS. In regard to refraction values determined by the AAPOS for amblyopia, according to CA results, the NPO had 71.4% sensitivity and 88.4% specificity in detecting myopia; 33.3% sensitivity and 93.6% specificity in detecting hyperopia; and 79.4% specificity and 71.2% sensitivity in detecting astigmatism. With regard to refraction values determined by the AAPOS for amblyopia, according to CA results, the CPO had 80.9% sensitivity and 90% specificity in detecting myopia; 13.3% sensitivity and 89.2% specificity in detecting hyperopia; and 44.9% sensitivity and 30.8% specificity in detecting astigmatism. When the SE differences between the CA and NPO values were compared with biometric parameters, a negative correlation was observed with ACD, AL, and especially AL/CR ratio.

CONCLUSION

Both the NPO and CPO showed moderate sensitivity and high specificity in detecting ARFs based on the criteria in the 2013 AAPOS guidelines. Sensitivity for detecting hyperopic risk factors was lower than for myopia and astigmatism. The CPO has no additional clinical advantage. A negative correlation was found between biometric parameters and NPO results. Thus, the NPO is more reliable in myopic children with higher axial lengths, deeper anterior chambers, and increased AL/CR ratios.

The positive predictive value of photoscreening devices for amblyogenic conditions

PURPOSE

To determine the positive predictive value (PPV) of four photoscreening devices in detecting amblyogenic risk factors (ARFs).

METHODS

This is a retrospective cohort study of 1,200 failed vision screenings (FVS) referred to a pediatric eye care practice from general pediatric practices over a 5-year period. Comprehensive eye examinations and cycloplegic refractions were performed. Examination findings and FVS parameters were collected through chart review after completion of visits. Inclusion criteria were age 1-8 years, eye examination within 3 months of initial FVS, and availability of FVS and visit documentation.

RESULTS

A total of 689 patients met inclusion criteria and were included in final analysis. The PPVs were 64.3% (95% CI, 62.73-65.81) for iScreen (n = 455), 26.8% (95% CI, 26.32-27.25) for Spot (n = 113), 18.9% (95% CI, 17.95-19.92) for Plusoptix (n = 38), and 18.5% (95% CI, 17.86-19.19) for GoCheck Kids (n = 55). For comparison, patients referred for failed Titmus tests were also analyzed. The PPV for Titmus testing was 39.3% (95% CI, 36.65-41.99; n = 28).

CONCLUSIONS

The only screening device with a PPV >50% was the iScreen. PPV is a useful metric, because it enables referring providers to guide patients on a post-screening plan and to choose devices that minimize over-referral. Device PPV in the general pediatric population can be markedly different from device PPV in already existing pediatric eye care populations due to inherently different prevalence of ARFs. The iScreen also detected conditions such as cataracts, anisocoria, eyelid abnormalities, esotropia, exotropia, hypertropia, and amblyogenic astigmatism.

Community based vision screening in preschool children; performance of the Spot Vision Screener and optotype testing

BACKGROUND

Children's vision screening children commonly uses optotype-based visual acuity or instrument-based methods measuring amblyogenic risk factors (ARFs).

OBJECTIVE

To compare the performance of the Spot Vision Screener (SVS) (PediaVision, Welch Allyn, NY) and a nurse-administered visual acuity screen (NVAS) in identifying ARFs and decreased visual acuity.

METHODS

A prospective, cross-sectional population-based study of preschool children in South-East Queensland, Australia. Eligible participants had both forms of screening by trained community nurses. All children with an abnormal result by either method as well as a cohort of randomly selected children who passed both assessments were assessed at a tertiary paediatric ophthalmology clinic.

RESULTS

Over a 10 month period, 2237 children (mean age; 64.4 ± 4.0 months) were screened from 38 schools. 6.4% of children failed SVS and 8.3% failed NVAS (with 3.8% overlap, failing both). The positive predictive value (PPV) in identifying either ARFs and/or reduced VA for the SVS and NVAS was 70.4% (95% Confidence Interval (CI): 61.6%-78.2%) and 60.5% (95% CI: 52.6%-67.9%) respectively. Highest PPV to detect either ARFs and/or reduced VA was achieved by a 'hybrid' method by combining failed NVAS and failed SVS: 91.0% (95% CI: 82.4 to 96.3) but this would risk children with sight impairment being missed in the community.

CONCLUSION

To our knowledge, this is the first population-based study providing detailed comparative measures of diagnostic accuracy for NVAS and SVS in preschool children. One in ten preschool children failed one or both screens. A number of children who required ophthalmic intervention were missed if only one screening method was utilized.

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.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Utilizing minicomputer technology for low-cost photorefraction: a feasibility study

Eccentric photorefraction is an objective technique to determine the refractive errors of the eye. To address the rise in prevalence of visual impairment, especially in rural areas, a minicomputer-based low-cost infrared photorefractor was developed using off-the-shelf hardware components. Clinical validation revealed that the developed infrared photorefractor demonstrated a linear working range between +4.0 D and -6.0 D at 50 cm. Further, measurement of astigmatism from human eye showed absolute error for cylinder of 0.3 D and high correlation for axis assessment. To conclude, feasibility was shown for a low-cost, portable and low-power driven stand-alone device to objectively determine refractive errors, showing potential for screening applications. The developed photorefractor creates a new avenue for telemedicine for ophthalmic measurements.

Prevalence of Amblyopia After Photoscreening

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Plusoptix photoscreener use for paediatric vision screening in Flanders and Iran

PURPOSE

Photoscreening assesses risk factors for amblyopia, as an alternative to measurement of visual acuity (VA) to detect amblyopia, on the premise that its early correction could prevent development of amblyopia. We studied implementations of Plusoptix photoscreening in existing population-based screening in Flanders and Iran.

METHODS

In Flanders, VA is measured at age 3, 4 and 6, photoscreening was added to existing screening at age 1 and 2.5 years in 2013. In Iran, VA is measured at ages 3-6 years, photoscreening was added at ages 3-6 years between 2011 and 2016. Plusoptix use was analysed in the literature for detection of risk factors for amblyopia and amblyopia itself, for ages 0-3 and for 4-6. A questionnaire, containing seven domains: existing vision screening, addition of photoscreening, implementation in screening program, training, attendance, diagnosis and treatment, and costs was distributed. In Iran, screening procedures were observed on site.

RESULTS

Implementation of Plusoptix photoscreening was mainly analysed from questionnaires and interviews, its effectiveness from literature data. In Flanders, of 56 759 children photoscreened at age one (81% of children born in 2013), 9.2% had been referred, 13% of these were treated, mostly with glasses, resulting in an increase of 4-year-old children wearing glasses from 4.7% to 6.4%. In Iran, 90% of children aged 3-6 years participated in vision screening in 2016, but only those who failed the vision test were subjected to photoscreening.

CONCLUSIONS

In Flanders, the use of Plusoptix photoscreening at ages 1 and 2.5 resulted in an increase of children wearing glasses, but it remains unknown how many cases of amblyopia have been prevented. Studies are needed to determine the relation between size and sort of refractive error and strabismus, and the increased chance to develop amblyopia.

Effectiveness of the iPhone GoCheck Kids smartphone vision screener in detecting amblyopia risk factors

BACKGROUND

The recently released GoCheck Kids iPhone photoscreening app is designed to detect amblyopia risk factors (ARFs) in young children and includes remote review of images captured by smartphone. We aimed to evaluate the system's accuracy in detecting AAPOS guidelines ARFs.

METHODS

Patients 6 months through 6 years of age at Medical University of South Carolina were recruited for this prospective study. Presence of age-specific ARF was determined based on a complete ophthalmic examination and compared with the GoCheck Kids recommendations.

RESULTS

A total of 244 children were included (average age, 42 months; 51% male). Sensitivity of the GoCheck Kids iPhone with remote review to detect ARFs was 90.5%; specificity, 68.1%; positive predictive value, 56.8%; negative predictive value, 94.0%. Two of the 7 false negative results had hyperopia of >4 D, 4 had astigmatism, and 1 had anisometropia. Remote review of all images improved sensitivity.

CONCLUSIONS

The GoCheck Kids app had good sensitivity and adequate specificity in detecting AAPOS ARFs in our enriched cohort of young children.

Comparison of photoscreening and autorefractive screening for the detection of amblyopia risk factors in children under 3 years of age

PURPOSE

To evaluate the effectiveness of photoscreening and autorefractive screening for the detection of amblyopia risk factors (ARFs) in a cohort of preterm and term-born children <3 years of age.

METHODS

In this cross-sectional study, the Spot Vision photoscreener and the SureSight autorefractor were used to screen participants. The diagnostic and predictive values of the devices in detecting ARF based on American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 2013 referral criteria was calculated using manufacturer criteria, the VIP 90 (90% specificity) and VIP 94 (94% specificity) criteria from the Vision in Preschool (VIP) study, and criteria recommended by Rowatt and colleagues. Results were evaluated using receiver operating characteristic (ROC) curves.

RESULTS

A total of 368 patients (mean age, 14.4 ± 10.4 months) were included. The ARF rate was 25% according to the 2013 AAPOS criteria. The highest specificity and positive predictive values (PPV) were obtained with Spot Vision manufacturer criteria (specificity, 0.91; PPV, 0.69). SureSight manufacturer criteria showed very low specificity and PPV values (specificity, 0.43; PPV, 0.35) and a high false positive rate (57%). The highest specificity and PPV values for SureSight were obtained with the Rowatt criteria (specificity, 0.86; PPV, 0.62).

CONCLUSIONS

In our study cohort, photoscreening with the Spot Vision manufacturer criteria seemed sufficient for vision screening in the 0-3 years age group, with high specificity values. The Rowatt criteria may increase performance of the SureSight in this age group.

Positive predictive value and screening performance of GoCheck Kids in a primary care university clinic

PURPOSE

To determine the positive predictive value (PPV) of GoCheck Kids, a smartphone-based photoscreener, to detect refractive amblyopia risk factors (ARFs) in children 3-48 months of age.

METHODS

The medical records of all children ≤48 months of age who failed GoCheck Kids photoscreening at a University of California, San Francisco, pediatric clinic between February 2017 and August 2018 and subsequently examined at the pediatric ophthalmology clinic were reviewed retrospectively. The PPV of GoCheck Kids was determined, where a true positive represents an abnormal cycloplegic refractive error according to the 2013 American Association of Pediatric Ophthalmology and Strabismus Vision Screening Committee criteria. For patients ≤12 months of age, refractive error thresholds were based on the 2017 American Academy of Ophthalmology Preferred Practice Patterns Pediatric Eye Evaluation guidelines.

RESULTS

A total of 2,963 children were screened with GoCheck Kids. Of these, 172 (5.8%) failed the screening, of whom 115 (67%) were evaluated in the pediatric ophthalmology clinic. The mean age was 24.9 ± 11.1months (range, 3-48). Fifty-seven patients met ARF criteria yielding a PPV of 50% (95% CI, 41%-60%). The PPV was higher in patients of Latino/hispanic ethnicity (75%; 95% CI, 57%-100%; P < 0.01) and changed significantly with increasing age (P = 0.03). Patients who were screened between age 3-12 months had the lowest PPV at 26% (95% CI, 14%-47%).

CONCLUSIONS

Modifying refractive error thresholds based on patient age and prevalence of ARFs in a population may improve the PPV of GoCheck Kids in a community-based screening program.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Refraction and pupil diameter in 3-year- and 1-month-old children as measured by Spot Vision Screener

Spot Vision Screener (SVS) can conduct refraction tests for both eyes within a short period. This study aims to evaluate the refraction and pupil diameters of 3-year- and 1-month-old Japanese children using SVS in regular medical checkup. We examined 2438 eyes of 1219 children (age: 3-year- and 1-month) in Fujieda (Shizuoka, Japan) to assess their refraction and pupil diameters and eye-position screening conducted by SVS. SVS successfully measured 1217 children (99.8%). Regarding the right eye refraction, the spherical power was +0.70 ± 0.55 D (median, +0.75 D), and the cylindrical power was −0.67 ± 0.49 D (median, −0.50 D). The pupil diameter of the right eyes was 5.57 ± 0.79 (median, 5.60) mm. we could obtain a large number of basic data for 3-year- and 1-month-old Japanese children. However, refraction and pupil diameter of children were not normally distributed, so careful handling of children’s basic data on the eye is necessary.

Autonomous early detection of eye disease in childhood photographs

The "red reflex test" is used to screen children for leukocoria ("white eye") in a standard pediatric examination, but is ineffective at detecting many eye disorders. Leukocoria also presents in casual photographs. The clinical utility of screening photographs for leukocoria is unreported. Here, a free smartphone application (CRADLE: ComputeR-Assisted Detector of LEukocoria) was engineered to detect photographic leukocoria and is available for download under the name "White Eye Detector." This study determined the sensitivity, specificity, and accuracy of CRADLE by retrospectively analyzing 52,982 longitudinal photographs of children, collected by parents before enrollment in this study. The cohort included 20 children with retinoblastoma, Coats' disease, cataract, amblyopia, or hyperopia and 20 control children. For 80% of children with eye disorders, the application detected leukocoria in photographs taken before diagnosis by 1.3 years (95% confidence interval, 0.4 to 2.3 years). The CRADLE application allows parents to augment clinical leukocoria screening with photography.

How Many Plusoptix S04 Measures Yield the Most Sensitive Amblyopia Screening?

PURPOSE

To analyze how the Plusoptix S04 (Plusoptix, Atlanta, GA), a widely used technology for amblyopia screening, predicts amblyopia.

METHODS

A total of 1,547 children aged 3 to 4 years underwent a non-invasive eye examination in a whole population screening. The Plusoptix was measured binocularly three consecutive times. Seven models were developed: the first (P1), second (P2), and third (P3) measure of Plusoptix, the mean of P1, P2, and P3 (Pmean123), the maximal value of P1, P2, and P3 (Pmax123), the mean of P1 and P2 (Pmean12), and the maximal value of P1 and P2 (Pmax12).

RESULTS

Internal consistency was excellent for sphere, cylinder (alpha = 0.92 vs 0.97), aniso-sphere, and aniso-cylinder (alpha = 0.87 vs 0.86). All models predicted amblyopia (P < .001); there was 2.3% new diagnosis and 5.1 events per variable. A bootstrap analysis with 1,000 samples confirmed the stability of the model. Astigmatism (P < .001; odds ratio [OR] = 2.1 to 3.6) and aniso-sphere (P < .001; OR = 3.6 to 9.0) predicted amblyopia. Although sphere, when measurable, did not predict amblyopia (P > .19; OR = 1.2 to 1.3), the likelihood of amblyopia presence was 100 times higher when the Plusoptix displayed "hyper." All receiver operating characteristic (ROC) curves were significant (P < .001), with no differences between them (all P > .16). Adjusting the cut-off from ROC curves for the highest sensitivity, Pmax12 referred 31.9% and 16.1% fewer patients than P1 and Pmean12, respectively. A third measure revealed accommodation-related false-negative results; therefore, adding measurements showed no benefit.

CONCLUSIONS

This was the first study to assess the Plusoptix's prediction of amblyopia. When aiming for maximal sensitivity, the Plusoptix refers many children (> 20% children in all models). The first measure refers more children than two measures. Non-measurable results must be considered abnormal because the chance of amblyopia presence was high. [J Pediatr Ophthalmol Strabismus. 2019;56(5):305-312.].

Refractive error of Saudi children enrolled in primary school and kindergarten measured with a spot screener

AIMS

To evaluate the refractive status of young Saudi schoolchildren with a "Spot Screener."

SUBJECTS AND METHODS

This cross-sectional study was conducted from January to July 2016 in Riyadh, Saudi Arabia. Children of kindergarten (3-5 years) and grades 1 and 2 (6-7 years) were screened for refractive error (RE) using the handheld Spot Screener (Welch Allyn, Skaneateles Falls, NY, USA). Data were collected on age, gender, and spectacle use. The pass/fail notation from the Spot Screener and the RE were documented. Children with a "fail" were re-tested with an autorefractor (AR). The rate of agreement was evaluated for the spherical equivalent (SE) from the Spot Screener and AR.

RESULTS

We examined 300 schoolchildren and 114 preschool children. The prevalence of RE was 22% in schoolchildren and 25% in preschoolers. There were 183 (61%) hyperopes, 110 (36.7%) myopes, 6 (2%) emmetropes, and 29 (9.7%) astigmats (>2 D cylinder) in grade 1 and 2. There were 85 (74.6%) hyperopes, 22 (19.3%) myopes, 7 (6.1%) emmetropes, and 10 (8.8%) astigmats among preschoolers. The SE differed between the AR and the Spot Screener in 17 (28%) children of 61 failed Spot Screener tests. Accommodation (9, 53%) and high astigmatism (8, 47%) were the main underlying causes of the difference. The Spot Screener could identify RE for the first time in 51 (17%) schoolchildren and 26 (22%) preschoolers. End-users suggested that Spot Screener was child-friendly and quick to test RE.

CONCLUSIONS

The Spot Screener could be a good initial screening tool for RE in young schoolchildren.

The Repeatability of Values Measured Using the Spot Vision Screener in Healthy Children and Children with Refractive Errors

Purpose: To determine the repeatability of refractive values measured using the Spot vision screener in healthy children and children with refractive errors. Methods: This cross-sectional study included 170 eyes of 85 healthy children (normal group), and 50 eyes of 25 children wearing spectacles for refractive errors (spectacles group). The spherical equivalent value, cylindrical value, and inter-ocular differences in the spherical equivalent values were analyzed. The repeatability of the refractive values measured using the Spot vision screener was determined using intra-class correlation coefficients (ICCs) and 95% limits of agreement. Results: In the normal group, ICC values for the spherical equivalent value, cylindrical value, and amount of anisometropia were 0.77, 0.80, and 0.64, respectively. In the spectacles group with spectacles they were 0.89, 0.67, and 0.78, respectively. In the spectacles group without spectacles they were 0.96, 0.78, and 0.97, respectively. The 95% limits of agreement between consecutive measurements for the spherical equivalent value, cylindrical value, and amount of anisometropia were within ±1.00 D in the normal group and the spectacles group with spectacles, and over ±1.00 D in the spectacles group without spectacles. Conclusions: The Spot vision screener can ensure better than moderate repeatability with and without spectacles.

The Positive Predictive Value of Smartphone Photoscreening in Pediatric Practices

PURPOSE

To compare smartphone photoscreening with other commercial objective screeners for amblyopia screening for young children.

METHODS

Ten pediatricians in four practices employed Nokia 1020 smartphones (Espoo, Finland) with single-axis Gobiquity software (Scottsdale, AZ) during well-child visits. Outcomes of confirmatory pediatric ophthalmology examinations were prospectively compared using American Association for Pediatric Ophthalmology and Strabismus uniform standards.

RESULTS

Five percent of 6,310 in-office screenings were referred: 25% for high anisometropia, 31% for hyperopia, and 15% for myopia. The positive predictive value (PPV) in 217 follow-up examinations was 68% (95% confidence interval: 62% to 74%) by 2013 age-stratified standards and 77% (confidence interval: 71% to 83%) by 2003 American Association for Pediatric Ophthalmology and Strabismus standards. The follow-up rate was 65%.

CONCLUSIONS

Smartphone photoscreening had PPV comparable with other commercial objective screeners. Simple, valid photoscreeners should help pediatricians achieve widespread compliance with screening guidelines to reduce the burden of pediatric amblyopia vision impairment. [J Pediatr Ophthalmol Strabismus. 2018;55(6):393-396.].

Preschool Vision Screening: Where We Have Been and Where We Are Going

PURPOSE

To discuss the evolution of instrument-based screening to detect amblyopia and its risk factors, and to summarize the importance of preschool vision screening.

DESIGN

Expert commentary.

METHODS

Author experiences were supplemented by a review and interpretation of pertinent medical literature.

RESULTS

Amblyopia remains a public health problem, as it is a common cause of monocular visual impairment. As a disease, amblyopia detection is best obtained by appropriate vision screening rather than by yearly mandated comprehensive eye examinations for all children; the US Preventative Services Task Force (USPSTF) recently reaffirmed their recommendations for vision screening in preschool children. Vision screening devices have evolved over the past 4 decades ranging from photoscreeners that use instantaneously developing film, to autorefractors that detect amblyopia risk factors, to nerve fiber layer scanners that detect the microtropia that nearly always accompanies amblyopia. When it is detected early, effective treatment for amblyopia can be initiated.

CONCLUSIONS

Amblyopia is a reversible cause of vision loss in children. Vision screening devices and screening programs have been extensively studied-experts and literature agree: vision screening devices and programs are cost-effective, are efficient, and are effective methods for amblyopia detection. The authors support the regular use of instrument-based vision screening in the medical home for all children until they reach a developmental stage where they can participate reliably in optotype-based vision screening.

Effectiveness of the GoCheck Kids Vision Screener in Detecting Amblyopia Risk Factors

PURPOSE

The GoCheck Kids smartphone photoscreening app (Gobiquity Mobile Health, Scottsdale, Arizona, USA), introduced in 2014, is marketed to pediatricians with little published validation. We wished to evaluate the GoCheck Kids Screener for accuracy in detecting amblyopia risk factors (ARF) using 2013 American Association for Pediatric Ophthalmology and Strabismus guidelines.

DESIGN

Validity assessment.

METHODS

Children 6 months to 6 years of age presenting from October 2016 to August 2017 were included. Children were screened with the GoCheck preloaded Nokia Lumia 1020, software version 4.6 with image processing version R4d, prior to undergoing a comprehensive eye examination by a pediatric ophthalmologist masked to the screener results. Determination of the presence of age-specific ARF was made based upon the examination and compared with the GoCheck recommendation.

RESULTS

A total of 206 children were included (average age 43 months). When compared to examination, GoCheck had a sensitivity of 76.0% and specificity of 67.2% in detecting ARF. Positive predictive value was 57.0% and negative predictive value 83.0%. The screener results of 13 children were changed from "no risk factors" to "risk factors identified" based on the GoCheck remote review process. Four images remained "not gradable" and screening was unsuccessful in 3 children.

CONCLUSION

In our high-risk population, this version of the Gocheck Kids smartphone app was useful in identifying ARF in children who are often not able to cooperate with visual acuity testing. This study informs pediatricians about the efficacy of this new screener as they make decisions about how to best detect vision problems in young children.

The PlusoptiX Photoscreener and the Retinomax Autorefractor as Community-based Screening Devices for Preschool Children

PURPOSE

To compare the performance of the PlusoptiX S12 mobile photoscreener and the Retinomax K+3 Autorefractor as screening devices in preschool children.

METHODS

Children ranging from 3 to 5 years of age from 11 San Diego County preschools underwent vision screening in their schools where ambient light could not always be controlled using both the Retinomax and the PlusoptiX. Cycloplegic refraction on the consented children was subsequently performed on the UCSD EyeMobile for children on-site at the school locations.

RESULTS

A total of 321 children were screened with the PlusoptiX and Retinomax. The PlusoptiX referred 22% of children, of whom 70% of the referrals were read as "unable". The Retinomax referred 13% and there were no "unables". Similar results occurred in the cycloplegic-refracted 182 consented children-64% of the PlusoptiX referrals were read as "unable" . Only one third of these "unables" required glasses. Both devices referred the four children with amblyopia and one case of strabismus. However, PlusoptiX's 3 false negatives had amblyopia risk factors (ARFs) while the one Retinomax's false negative did not have ARFs. The Retinomax screening had 95% sensitivity and 94% specificity. The PlusoptiX screening had 86% sensitivity and 84% specificity.

CONCLUSION

In this preschool population and environment, the PlusoptiX referred 63% more than the Retinomax in addition to a lower specificity and sensitivity. Adjusting PlusoptiX referral criteria might not substantially improve the specificity of the PlusoptiX due to the high numbers of "unables".

Paediatric vision screening in the primary care setting in Ontario

Objectives

Early intervention is critical to prevent treatable causes of vision loss in children. The objectives of the current study are: (1) to assess how well primary care physicians in Ontario follow the vision screening guidelines for children as recommended by the Canadian Paediatric Society and the Rourke Baby Record and (2) to identify barriers to vision screening in the primary care setting.

Design

Cross-sectional survey.

Methods

A 19-question survey was mailed out to 1000 randomly selected family physicians (family MDs), 1000 general practitioners (GPs) and 1000 paediatricians in Ontario as listed in the 2013 Canadian Medical Directory.

Results

A total of 719 completed surveys were included in the analysis (449 from family MDs/GPs and 270 from paediatricians). Vision screening was reported to be performed by 65% of family MDs/GPs and 52% of general paediatricians at every well child visit. While red reflex was reported to be checked by 94% of all physicians in children under 3, it was only performed by 25% of respondents for children over 3. Thirty seven percent of all physicians reported never performing a visual acuity test in any age group. When asked about the obstacles preventing them from performing vision screening, lack of training (family MDs/GPs: 50%, paediatricians: 42%), time constraints (family MDs/GPs: 42%; paediatricians: 40%) and inadequate reimbursement (family MDs/GPs: 17%; paediatricians: 15%) were the most commonly cited reasons.

Conclusions

Strategies to improve vision screening are necessary given that early intervention is crucial to prevent treatable causes of vision loss in children.

Use of the Spot Vision Screener for patients with developmental disability

PURPOSE

To determine whether the Spot Vision Screener effectively detects amblyopia risk factors (ARFs) in patients with developmental disability using the 2013 guidelines of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

METHODS

Children with developmental disability presenting for complete pediatric ophthalmologic examination were prospectively enrolled between June 2012 and March 2016. The following data were analyzed: presence of ARFs according to the AAPOS guidelines, refraction, eye alignment, and other ocular pathology.

RESULTS

A total of 100 children (average age, 5.7 years; range, 2.2- 9.2 years) were included. The prevalence of ARFs in this cohort was 38%. The sensitivity of the Spot Vision Screener in detecting amblyopia risk factors was 84%; the specificity, 62%. The positive predictive value was 58%; the negative predictive value, 86%.

CONCLUSIONS

In our study cohort the Spot Vision Screener provided good sensitivity and adequate specificity for a screening examination. Automated screeners may be useful in screening children with developmental disability.

Performance of the Spot Vision Screener in Children Younger Than 3 Years of Age

PURPOSE

To evaluate the use of the Spot Vision Screener (Spot; Welch Allyn, Skaneateles Falls, New York, USA) for detection of amblyopia risk factors in children aged 6 months to 3 years, as defined by the 2013 guidelines of the American Association for Pediatric Ophthalmology and Strabismus.

DESIGN

Reliability analysis.

METHODS

In this study, children seen from June 1, 2012, to April 30, 2016 were tested with the Spot during a routine visit. Enrolled children underwent a comprehensive eye examination including cycloplegic refraction and sensorimotor testing within 6 months of the testing date by a pediatric ophthalmologist masked to the Spot results.

RESULTS

A total of 184 children were included. The Spot successfully obtained readings in 89.7% of patients. Compared with the ophthalmologist's examination, the Spot had an overall sensitivity of 89.8% and a specificity of 70.4%.

CONCLUSION

The Spot achieved good sensitivity and specificity for detection of amblyopia risk factors in this young cohort, particularly in the older subgroup. Our data offer support for automated vision screening in young children.

Instrument-based pediatric vision screening

PURPOSE OF REVIEW

The purpose is to review currently available instruments for vision screening in young children.

RECENT FINDINGS

Instrumentation continues to evolve. Although the current generation of photoscreeners and autorefractors strive to identify amblyopia risk factors, newer technology aims to directly identify amblyopia in young children. Acceptance of instrument-based vision screening for this population has led to increased reimbursement for the procedure in primary care practices.

SUMMARY

Instrument-based vision screening in the young child is an accepted method of screening for amblyopia. Innovations in instrumentation will continue to improve its implementation.

Comparison between refraction measured by Spot Vision Screening™ and subjective clinical refractometry

OBJECTIVE

The purpose of this study was to evaluate the accuracy of Spot Vision Screening™ as an autorefractor by comparing refraction measurements to subjective clinical refractometry results in children and adult patients.

METHODS

One-hundred and thirty-four eyes of 134 patients were submitted to refractometry by Spot and clinical refractometry under cycloplegia. Patients, students, physicians, staff and children of staff from the Hospital das Clínicas (School of Medicine, University of São Paulo) aged 7-50 years without signs of ocular disease were examined. Only right-eye refraction data were analyzed. The findings were converted in magnitude vectors for analysis.

RESULTS

The difference between Spot Vision Screening™ and subjective clinical refractometry expressed in spherical equivalents was +0.66±0.56 diopters (D), +0.16±0.27 D for the vector projected on the 90 axis and +0.02±0.15 D for the oblique vector.

CONCLUSIONS

Despite the statistical significance of the difference between the two methods, we consider the difference non-relevant in a clinical setting, supporting the use of Spot Vision Screening™ as an ancillary method for estimating refraction.

Field Evaluation of Automated Vision Screening Instruments: Impact of Referral Criteria Choice on Screening Outcome

PURPOSE

Automated vision screeners can identify children with amblyopia risk factors. Two screening instruments having different referral criteria were evaluated in a community setting: SPOT (Pediavision, Lake Mary, FL) (sensitive manufacturer's referral criteria) and plusoptiX S08 (Plusoptix GmbH, Nuremberg, Germany) (specific modified Arthur referral criteria).

METHODS

All children were screened by SPOT, and referred children were then screened using plusoptiX. Referred children received a gold standard examination to determine whether amblyopia risk factors were present.

RESULTS

A total of 2,801 treatment-naïve children were screened using SPOT. Of these, 307 (11.0%) were referred by SPOT and subsequently screened by plusoptiX; 100 received a gold standard examination. Amblyopia risk factors were present in 43% (43 of 100) referred by SPOT compared to 72.7% (32 of 44) for plusoptiX. Eleven of 56 referred by SPOT had amblyopia risk factors that would have been missed by plusoptiX, including three with mild amblyopia.

CONCLUSIONS

PlusoptiX with modified Arthur referral criteria can be a highly specific screening device detecting amblyopia risk factors without missing children with moderate/severe amblyopia.

Accuracy of the Spot and Plusoptix photoscreeners for detection of astigmatism

PURPOSE

To evaluate the accuracy of the Spot (V2.0.16) and Plusoptix S12 (ROC4, V6.1.4.0) photoscreeners in detecting astigmatism meeting AAPOS referral criteria in students from a population with high prevalence of astigmatism.

METHODS

Students attending grades 3-8 on the Tohono O'odham reservation were examined. Screening was attempted with both the Spot and Plusoptix photoscreeners. Results were compared to cycloplegic refraction. Screening attempts providing no estimate of refractive error were considered fail/refer. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for detection of refractive errors were determined using AAPOS referral criteria and receiver operating characteristic area under the curve (ROC AUC) analysis was conducted for measures of astigmatism. Agreement between screening and cycloplegic refraction measurements of astigmatism, spherical equivalent, and anisometropia were assessed using t tests and correlation analyses.

RESULTS

A total of 209 students were included. Of the total, 116 (55%) met examination-positive criteria based on cycloplegic refraction, with 105 of those (90%) meeting the criterion for astigmatism. Measurements success rates were 97% for Spot and 54% for Plusoptix. Comparing the Spot and the Plusoptix, sensitivity was 96% versus 100%, specificity was 87% versus 61%, PPV was 90% versus 76%, and NPV was 94% versus 100% for detection of refractive error. Both screeners overestimated astigmatism by 1/3 D to 2/3 D. AUC for astigmatism was 0.97 for Spot and 0.83 for Plusoptix.

CONCLUSIONS

In this highly astigmatic population, the Spot and the Plusoptix had similar sensitivity, but the Spot had better specificity and measurement success rates. Compared with results from study samples with lower rates of astigmatism, our results highlight the need to assess the ability of screening instruments to detect individual types of refractive errors.

A 1-Year Review of Amblyopia and Strabismus Research

PURPOSE

This current review highlights some of the literature published in the past year from April 2013 to May 2014.

DESIGN

Literature Review.

METHODS

The present review is based on an extended search for pertinent articles on amblyopia and strabismus published during the specified period.

RESULTS

Many articles are often not very comparable to one another because of a lack of randomized clinical trials with most of the studies being retrospective in nature. There is often disagreement on some terminology. Typically, the definition of binocular vision is rarely related to the tests used for evaluating it.

CONCLUSIONS

The authors conclude that adult strabismus patients seem to gain benefits from corrective surgery not only for their ocular misalignment, but also for social anxiety levels that may be associated with improvements in their quality of life and disability levels.

Validation of Spot screening device for amblyopia risk factors

PURPOSE

To validate the Spot Vision Screener, a handheld digital screening device that evaluates children for amblyopia risk factors as defined by 2013 criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS), in the setting of a controlled pediatric ophthalmology clinic.

METHODS

During a 3-month period, children 2-9 years of age were screened using Spot in a pediatric ophthalmology clinic before receiving a gold standard eye examination. Gold standard examinations were evaluated using the 2013 AAPOS Vision Screening Committee guidelines and compared with results from Spot, which were evaluated using two different manufacturer referral criteria: v1.0.3 and v1.1.51. The specificity and sensitivity for each set of referral criteria to detect both amblyopia risk factors and amblyopia were calculated.

RESULTS

A total of 233 children were included. Of these, 155 were successfully screened and analyzed according to two different referral criteria. Spot screeing revealed ambyopia risk factors in 109 patients; examination confirmed amblyopia in 64. Using the original manufacturer's criteria (v1.0.3), Spot was 89% sensitive and 71% specific in detecting amblyopia risk factors. The updated referral criteria (v1.1.51) were applied to the same 155 patients, and specificity improved to 88% (P < 0.02); sensitivity remained minimally affected, at 85% (P < 0.05). Spot-v1.0.3 was 92% sensitive and 41% specific in detecting amblyopia, whereas Spot-v1.1.51 was 89% sensitive and 53% specific for detecting amblyopia.

CONCLUSIONS

The Spot-v1.0.3 had high sensitivity but overreferred for suspected myopia and strabismus; Spot-v1.1.51 maintained high sensitivity and improved specificity. The original referral criteria has a high sensitivity to detect amblyopia risk factors but low specificty; v1.1.51 criteria increases specificity with minimal impact on sensitivity.

Calibration and validation of the 2WIN photoscreener compared to the PlusoptiX S12 and the SPOT

PURPOSE

Pediatricians are interested in the amblyopia detection ability of photoscreeners, whereas ophthalmologists ponder their value as autorefractors. The 2WIN (Adaptica, Padova, Italy) is a new device capable of estimating refractive error and ocular alignment by infrared photoscreening.

METHODS

Sequential pediatric eye patients with a high (56% to 60%) prescreening prevalence of amblyopia risk factors were screened with the PlusoptiX S12 (PlusoptiX, Inc., Atlanta, GA), SPOT (PediaVision, Lake Mary, FL), and 2WIN photoscreeners before confirmatory examination adhering to American Association for Pediatric Ophthalmology and Strabismus guidelines and Alaska Blind Child Discovery institutional review board protocol. Instrument referral guidelines determined through phase 1 comparison was then applied on additional patients for validation in phase 2.

RESULTS

Sixty-two children (age: 1 to 10 years, mean: 5.2 years) were screened with all three devices before cycloplegic examination. Refractive results were inconclusive due to pupil size, cooperation, and out-of-range values. Values for sensitivity (91% and 78%), specificity (71% and 59%), and inconclusive rate (10% and 13%) were found for PlusoptiX and SPOT. The 2WIN was calibrated for this age range (phase 1), yielding 71% sensitivity, 67% specificity, and a 5% inconclusive rate. Regression compared to examination for the PlusoptiX, SPOT, and 2WIN, respectively, were sphere (r(2): 0.76, 0.87, and 0.58), cylinder power (r(2): 0.67, 0.56, and 0.50), and cylinder axis (r(2): 0.71, 0.41, and 0.40). A preferred 2WIN instrument criteria set was determined from the receiver operating characteristic curve. In phase 2, with 117 patients comparing 2WIN to PlusoptiX A-09, sensitivity was 73% and 85%, specificity was 76% and 73%, and inconclusive rate was 8% and 12%, respectively. The three instant-interpreting photorefractors performed well on amblyopic children, with the 2WIN having low inconclusive results. The PlusoptiX outperformed the SPOT and 2WIN as an autorefractor, particularly with respect to astigmatism power and axis.

CONCLUSIONS

The new 2WIN is a promising addition to portable photoscreeners for amblyopia detection and estimating refractive error.

The W.H.E.E.L.S. Preschool Vision Screening Program's Initial Outcomes for 12,402 Children Screened Using the Plusoptix Photoscreener

Objective. To report the results of the W.H.E.E.L.S. Prevent Blindness Mid-Atlantic vision screening program that targets preschoolers using the Plusoptix Photoscreener (Plusoptix Inc., Nuremburg, Germany). Methods. Trained program staff members conducted vision screenings at up to 113 preschool programs in the Richmond metropolitan area for four consecutive years; a cross-sectional analysis was performed. Results and Discussion. From September 2010 to March 2014, 15,075 preschoolers have been offered a free vision screening; 12,402 (82%) have been screened. A total of 3,018 (24%) have failed the screening and were recommended to follow up with an eye care specialist for a comprehensive examination; only 30% reported complying. Significant refractive errors were more frequently the cause for a failed screening. Conclusions. The W.H.E.E.L.S. program has identified a high number of preschoolers with significant amblyopic risk factors that were previously unknown to be present. Undesirably low follow-up reporting outcomes from children who fail a vision screening examination were consistent with other reports. Nevertheless, having a mobile vision screening program that uses photoscreening technology in targeting children prior to school entry is an efficient and cost-effective way to detect vision disorders in a timely manner.