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PubMed1994

Community photoscreening of six to nine month old infants for amblyopiogenic risk factors.

Photorefraction (PR) is gaining acceptance as potentially the most effective objective screening technique for amblyopia risk factors in the preverbal child. This study determined the validity and feasibility of using the Auckland eccentric photorefractor in the detection of amblyopiogenic factors in six to nine month old infants in an established community-based vision screening program. Photographs were analysed and compared to results of clinical examination including cycloplegic refraction. Amblyopia risk factors were present in 7.2% of the infants clinically examined. Analysis only of readable photographs in children who were also clinically examined, gave sensitivities ranging from 71% to 79%, and specificities ranging from 81% to 86%. Inclusion in the analysis of photo-failures lowered sensitivity figures to 56% to 61%, and specificity to 63% to 70%. Photofailures were predominantly due to poor operator technique. Calculation of kappa scores indicated fair observer reliability. In conclusion, PR could provide a feasible and sufficiently reliable screening technique in the infant, but requires adequate training and auditing of screening personnel performance for optimum effectiveness.

Amblyopia↗
PubMed2004

Educating the educators: increasing grade-school teachers' ability to detect vision problems.

BACKGROUND: The State University of New York College of Optometry/University Optometric Center conducts vision screenings in various public schools in New York City. A study was devised to determine whether teachers' abilities to detect vision problems in their students could be enhanced. METHODS: Students of two different grade schools were screened, in 1998-1999 and again two years later. In 1998-1999, the week before each group of students was to be screened, teachers were asked to indicate which children were felt to have vision problems. In 2000-2001, prior to the screenings, a lecture on vision and its relationship to learning was given to the same teachers who had responded two years earlier, and handouts and brochures delineating vision problems were also given to each teacher. A comparison was then made of the teachers' ability to detect vision problems before and after the teacher education. RESULTS: In the first year, 111 of 377 of children screened (29%) were referred. Teachers correctly identified 39% of the acuity failures and 29% of the functional failures. Two years later, a total of 31% of children were referred. The same teachers correctly identified 68% of the acuity failures and 67% of the functional failures. CONCLUSIONS: There was a statistically significant increase in the ability of teachers to correctly identify children with learning problems based on education. Both the accuracy of identifying children with acuity problems, as well as identifying children with functional visual problems, increased. Based on these results, it is recommended that an in-service lecture be given to school teachers to heighten their awareness of vision problems that may impact learning performance.

Child↗
PubMed2005

Prevalence of abnormal vision in one-year-old Thai children, based on a prospective cohort study of Thai children (PCTC).

OBJECTIVES: To collect preliminary data on the prevalence of abnormal vision in one-year-old Thai children. MATERIAL AND METHOD: A retrospective study was conducted using data collected from a prospective cohort study of Thai children (PCTC) carried out during 2000-2002, to examine the prevalence of abnormal vision in one-year-olds. Data from five districts in five provinces were examined. One-year-old children in the present study underwent vision screening and eye examination performed by non-medical research assistants. RESULTS: There were records from 3,898 children in five districts, 49.7% females and 50.2% males. Their eye examinations showed very good vision in 77.8% (9.8 cy/cm at 38 cm), good vision in 21.5% (6.5 cy/cm at 38 cm), and fair vision in 0.7% (< or = 1.6 cy/cm at 38 cm). Normal ocular motility was found in 99.7% and 99.9% had normal anterior segment and lens. No strabismus was found in 99.4%, 99.9% had normal pupil light reflex, 99.8% had normal red reflex, 93.6% could fix and follow at 3 months of age, 85.7% could detect a falling object at 6 months, and 78.5% of mothers and 46.5% of fathers regularly played with the children. Logistic regression analysis indicated that some factors had statistical significance, such as "fix and follow" by 1 month of age, and lack of father-child interaction, but these were not clinically significant. Using Kappa analysis, the authors combined groups 1 (very good vision) and 2 (good vision) to create a "normal vision" category. If children had 2 abnormal eye examinations (eye exam for strabismus, cornea, anterior chamber, lens, pupil and red reflex), the authors recommended sending them to a specialist. The sensitivity and specificity of the visual screening and eye examination instruments were 19.23% and 99.38%, respectively. The Kappa statistic was 0.17. These instruments are not appropriate for eye screening in one-year-old children. CONCLUSION: More than 99% of the children examined had normal results. The majority of children could fix and follow from 2-3 months of age. The early fix and follow development may be related to better visual acuity. The interaction between father and child may be associated with eye development. However, eye screening of one-year-old children by assistant researchers may be inappropriate due to lack of expertise and experience.

Age Factors↗
PubMed1993

[Visual acuity testing of three- and four-year old nursery school and kindergarten children].

Visual acuity testing was conducted on 1,531 children in nursery schools and kindergartens in Chita district, for the purpose of determining the rate of successfully performing the test, as well as the visual acuity of those shown to be normal by various ophthalmologic examinations. The rate of successful performance of the visual acuity test increased monthly with increasing age, with maximum changes seen at 4-5 months after the third birthday. The rate of successful performance of the test at the third birthday was 73%, progressively increasing up to 95% in the successive 6 months. The rate at the fourth birthday became almost 100%. Average of visual acuity of 3.0-year old children was 0.55, and for 3.5-year olds was 0.82. The average visual acuity reached 0.88 at 4.0 years of age, and at 4.5 years of age became 0.97. In view of the results obtained, it is concluded that children who could not successfully perform a visual acuity test at 3.0-years of age should be tested again at 3.5-years of age. Preferably the vision screening should be performed during the period between 3.5- and 4.0-years of age, for reliability and efficiency. Accordingly, the screening standards should also be changed with consideration given to visual development of children of this age.

Child↗
PubMedDate not supplied

Services provided for preschool-aged children with suspected amblyopia.

BACKGROUND: Little is known about the pattern and variation of care offered to preschool-aged children who have had an abnormal vision screening test. PURPOSE: To evaluate the variations in pediatric eye care services and availability of optometrists and ophthalmologists for preschool-aged patients, referral patterns, and barriers to providing care as perceived by eye care specialists. METHODS: A survey was mailed to 542 ophthalmologists and a random sample of 501 optometrists actively practicing in Michigan. RESULTS: The response rate was 65% (optometrists, 75%; ophthalmologists, 57%). More optometrists than ophthalmologists evaluated preschool-aged children (97% vs 79%; P < .001). Of these, most managed amblyopia (80% vs 77%; P = .372) and strabismus (89% vs 80%; P = .002) themselves. Fewer optometrists than ophthalmologists dilated eyes routinely during the first evaluation of a preschool-aged child (39% vs 93%; P < .001). The leading barrier to care for preschool-aged children reported by both optometrists and ophthalmologists was difficulty of the examination (25% vs 23%; P = .501). Optometrists reported that most of their patients were referred from community-based screening programs or by parent self-referral. Ophthalmologists reported that most of their preschool-aged patients were referred from primary care providers. CONCLUSIONS: There are different sources of referrals for optometrists and ophthalmologists. Although most eye care specialists treat amblyopia, the types of care offered by optometrists and ophthalmologists differ. Future studies should address the impact that these patterns have on outcomes and cost. The results of these studies should be shared with those responsible for screening.

Amblyopia↗
PubMed2005

The relationship between anisometropia, patient age, and the development of amblyopia.

PURPOSE: Anisometropia is a common cause of amblyopia. The relationship between anisometropia, patient age, and the development of amblyopia is unknown. Photoscreening identifies children with anisometropia in a manner that is not biased by visual acuity and allows a unique opportunity to evaluate how patient age influences the prevalence and depth of anisometropic amblyopia. METHODS: A statewide preschool photoscreening program screened 120,000 children and identified 792 with anisometropia greater than 1.0 diopter. Age was correlated with visual acuity and amblyopia depth. Data were compared with those from 562 strabismic children similarly identified. RESULTS: Only 14% (6/44) of anisometropic children aged 1 year or less had amblyopia. Prevalence was 40% (32/80) for 2-year-olds, 65% (119/182) for 3-year-olds, and peaked at 76% (age 5). Amblyopia depth also increased with age. Moderate amblyopia prevalence was 2% (ages 0 to 1), 17% (age 2), and rose steadily to 45% (ages 6 to 7). Severe amblyopia was rare prior to age 4, 9% at age 4, 14% at age 5, and 9% at ages 6 to 7. In contrast, children with strabismus had a stable prevalence of amblyopia (30% at ages 0 to 2, 42% at ages 3 to 4, 44% at ages 5 to 7). CONCLUSIONS: Younger children with anisometropic refractive error have a lower prevalence and depth of amblyopia than do older children. By age 4, when most children undergo traditional screening, amblyopia has usually already developed. New vision screening technologies that allow early detection of anisometropia provide ophthalmologists an opportunity to intervene early, perhaps retarding, or even preventing, the development of amblyopia.

Age Factors↗
PubMed2005

Visual impairment and use of eye-care services and protective eyewear among children--United States, 2002.

Visual impairment is an important cause of developmental disability among children. Ocular conditions, if undetected or untreated, can have substantial long-term implications for the quality of life of the child and the family and can place a burden on public health resources. For these reasons, the national health objectives for 2010 now include three vision objectives for children: 1) reducing visual impairment and blindness, 2) increasing the proportion of preschool children who receive vision screening, and 3) increasing the use of protective eyewear in recreational activities and hazardous situations around the home (objective nos. 28-2, 28-4, and 28-9a). When these objectives were published in November 2000, baseline data were available for only one objective, that of reducing visual impairment and blindness among children. To address all three childhood vision objectives, CDC analyzed data from the 2002 National Health Interview Survey (NHIS). This report summarizes the results of that analysis, which indicated that the prevalence of visual impairment and the use of eye-care services were significantly higher among children aged >6 years, compared with younger children, and varied by race/ethnicity and family income. As a result of that analysis, national baselines are now available for all three objectives. Collaborative efforts of all relevant agencies, health professionals, educators, and the public are needed to achieve the national childhood vision objectives for 2010.

Adolescent↗
PubMed2006

Legislative issues facing pediatric ophthalmology in 2006.

PURPOSE OF REVIEW: There has been a surge in legislative activity concerning children's vision in recent years. This review will summarize and compare newly enacted state statutes and review legislation that has been introduced at both the state and federal level. Detailed reference sites are provided and may be a useful resource for those involved in legislative advocacy. RECENT FINDINGS: The legislative arena has often mirrored the disparate views of ophthalmology and optometry regarding the most appropriate methods for identifying vision problems in young children. While state legislation mandating comprehensive eye examinations for all asymptomatic and risk free children was passed in Kentucky in 2000, no other state since has successfully enacted and implemented similar legislation. In contrast, numerous states, have enacted mandatory preschool vision screening legislation. Federal legislation, introduced separately by ophthalmology and optometry, would provide funds for uninsured children's eye exams, but the two bills have important differences in eligibility requirements. Issues such as eye safety and retinoblastoma detection have also been addressed through the legislative process. SUMMARY: There has been a myriad of state and federal legislative activity in the area of children's vision. The momentum is likely to continue as additional states file new legislation.

Child↗
PubMed1998

Normative values for the nearpoint of convergence of elementary schoolchildren.

BACKGROUND: Nearpoint of convergence (NPC) values of 8 to 10 cm are widely used to diagnose binocular dysfunctions such as convergence insufficiency. However, there are no published age-related normative values in the literature to substantiate these values. METHODS: Subjects were 297 schoolchildren in kindergarten, third grade, and sixth grade who had passed a school-based Modified Clinical Technique vision screening. Each child had the NPC break and recovery taken three times using a standardized protocol developed by the Convergence Insufficiency and Reading Study group. The examiners used an Astron International (ACR/21) Accommodative Rule with a movable column of 20/30 letters as the target. RESULTS: For each grade, the distribution of NPC break was right skewed, with a concentration of values between 1 and 6 cm. At least 85% of the subjects in each grade had an NPC break < or = 6 cm. NPC break values (mean +/- SD) were 3.3 +/- 2.6 cm for kindergartners, 4.1 +/- 2.4 cm for third graders, and 4.3 +/- 3.4 cm for sixth graders, and the means were found to be statistically different (analysis of variance, p = 0.031). NPC recoveries (mean +/- SD) for the three groups were 7.3 +/- 4.8 cm, 8.7 +/- 4.2 cm, and 7.2 +/- 3.9 cm, respectively, which were also significantly different (analysis of variance, p = 0.027). The recovery distributions were more symmetric and less skewed than those for break. For each grade level, there was a strong positive relationship between NPC recovery and NPC break, but the difference between NPC recovery and break had a low correlation with the NPC break. SUMMARY: Kindergartners had somewhat better NPC breaks than third or sixth graders, whereas no clear age trend was present for NPC recovery. A supporting study using a random sample of clinic patients (aged 10-12 years) suggests that patients with NPC breaks > 6 cm are more than twice as likely to be symptomatic than patients with NPC breaks < or = 6 cm. Based on these results and the NPC break distributions in this study, a clinical cutoff value of 6 cm is suggested for patients of elementary school age. A cutoff value in the 6- to 10-cm range is recommended for children of elementary school age in a screening context. The exact value within this range depends on the level of concern with identifying patients who have visual signs and symptoms associated with a receded NPC.

Accommodation, Ocular↗
PubMed1996

Prevalence of ocular disorders among 6- and 7-year-olds in Santa Monica, California.

BACKGROUND: Undetected ocular disorders can cause serious problems in a child's mental and social development. METHODS: To investigate relationships between ocular disease, gender and ethnicity in children, vision screening examination data was analyzed from the UCLA Mobile Eye Clinic (MEC), collected from 1985 to 1990 on first graders (69.9 percent 6- and 30.1 percent 7-year-olds) in Santa Monica, California. RESULTS: The sample consisted of 1,469 individuals, of whom 48.1 percent were female and 51.9 percent were male. Ethnicity data was available from 1988 to 1990 on 834 individuals, of whom 46.9 percent were Hispanic, 27.9 percent were White. 11.5 percent were Black, 4.4 percent were Asian, and 9.2 percent were of other races. Significantly more females than males had refractive errors, specifically hyperopia and astigmatism, and uncorrected visual acuity of 20/50 or worse in at least one eye. There were no significant associations of ethnicity or sex with any other disease category. The overall prevalences of other diseases were less than 4 percent. Of the 6- and 7-year-olds studied in Santa Monica, California, 18.5 percent had refractive errors. CONCLUSIONS: Screening for ocular disorders at an early age allows for detection of problems, especially refractive errors, that might affect school performance if uncorrected.

California↗
PubMed2005

Pediatric Amblyopia Risk Investigation Study (PARIS).

PURPOSE: To assess the learning curve, testability, and reliability of vision screening modalities administered by pediatric health extenders. DESIGN: Prospective masked clinical trial. METHODS: Two hundred subjects aged 3 to 6 underwent timed screening for amblyopia by physician extenders, including LEA visual acuity (LEA), stereopsis (RDE), and noncycloplegic autorefraction (NCAR). Patients returned for a comprehensive diagnostic eye examination performed by an ophthalmologist or optometrist. RESULTS: Average screening time was 5.4 +/- 1.6 minutes (LEA), 1.9 +/- 0.9 minutes (RDE), and 1.7 +/- 1.0 minutes (NCAR). Test time for NCAR and RDE fell by 40% during the study period. Overall testability was 92% (LEA), 96% (RDE), and 94% (NCAR). Testability among 3-year-olds was 73% (LEA), 96% (RDE), and 89% (NCAR). Reliability of LEA was moderate (r = .59). Reliability of NCAR was high for astigmatism (Cyl) (r = .89), moderate for spherical equivalent (SE) (r = .66), and low for anisometropia (ANISO) (r = .38). Correlation of cycloplegic autorefraction (CAR) with gold standard cycloplegic retinoscopic refraction (CRR) was very high for SE (.85), CYL (.77), and moderate for ANISO (.48). CONCLUSIONS: With NCAR, physician extenders can quickly and reliably detect astigmatism and spherical refractive error in one-third the time it takes to obtain visual acuity. LEA has a lower initial cost, but is time consuming, moderately reliable, and more difficult for 3-year-olds. Shorter examination time and higher reliability may make NCAR a more efficient screening tool for refractive amblyopia in younger children. Future study is needed to determine the sensitivity and specificity of NCAR and other screening methods in detecting amblyopia and amblyopia risk factors.

Amblyopia↗
PubMed2003

The manifestation of noncycloplegic refractive state in pre-school children is dependent on autorefractor design.

PURPOSE: To investigate the factors that govern the manifestation of hyperopic refractive errors of pre-school children when tested with and without the application of cycloplegics. METHODS: Forty-three pre-school children (mean age, 3.68 +/- 0.59 years) were tested before and during cycloplegia in the following order: retinoscopy with optical fogging; Retinomax K plus; Welch Allyn SureSight (DAV SureSight), and PowerRefractor. In the case of the PowerRefractor, the children viewed a difference of Gaussian target (0.20 cpd) at 3.5 m in addition to viewing the instrument LED sources. RESULTS: Instruments with close working distances (Retinomax) showed the greatest underestimation of hyperopia and the largest variation, followed by the instruments having a greater working distance (PowerRefractor LED view and retinoscopy). The addition of a far target (PowerRefractor difference of Gaussian view) showed the least underestimation, whereas DAV SureSight showed a mean overestimation of the refractive state. CONCLUSION: When autorefractors are applied to vision screening of pre-school children without the use of cycloplegics, autorefractor designs must be developed that both stabilize and relax the child's accommodation. Our results suggest that designs should include large working distances and distant fixation targets.

Accommodation, Ocular↗
PubMed2004

How often are spectacles prescribed to "normal" preschool children?

INTRODUCTION: Legislation to require formal eye examination prior to school entry is being considered in several states and is supported by optical trade organizations. Pediatric ophthalmologists cite anecdotal cases that suggest children receive spectacles unnecessarily, but data to support this are lacking. METHODS: Eye examination results from children referred to local eye doctors following a statewide preschool photoscreening program were reviewed to determine how often glasses were prescribed for children who did not have amblyogenic factors (those with false-positive screenings). RESULTS: Of 102,508 preschool children screened, 890 children did not have amblyogenic factors (false-positive screenings). Nevertheless, spectacles were prescribed for 174 (19.5%) of these children. Only 5/272 children (1.8%) were prescribed glasses following examination by a pediatric ophthalmologist, while glasses were prescribed for 24/205 children (11.7%) examined by comprehensive ophthalmologists and 145/413 (35.1%) of children seen by optometrists (P < 0.001). Eighty children were prescribed glasses for refractive error ranging from -0.75 sph to +2.00 sph, 32 of whom had spherical equivalent of 1D or less. CONCLUSIONS: While some preschoolers without amblyogenic factors may require spectacle correction, a significant percentage of children are probably prescribed glasses unnecessarily. Extrapolation of these data to the United States population suggests that a single mandatory eye examination prior to school entry could cost over 200,000,000 US dollars yearly for unnecessary spectacles. Vision screening programs with high referral rates, and health policy proposals supporting comprehensive preschool eye exams, must consider these unnecessary costs.

Child, Preschool↗
PubMed2005

Comparison of monocular autorefraction to comprehensive eye examinations in preschool-aged and younger children.

BACKGROUND: Monocular autorefraction is a newly available technology for vision screening that has been advocated to test young children. Such devices automatically determine the refractive state of each eye, but cannot directly detect amblyopia or strabismus. OBJECTIVE: To compare the results of a commercially available monocular autorefractor (SureSight; Welch Allyn Medical Products, Skaneateles Falls, NY) with findings from a comprehensive eye examination for significant refractive error, strabismus, and amblyopia. METHODS: Children 5 years and younger who were new patients attending a pediatric ophthalmology clinic were tested with the monocular autorefractor without dilation and underwent a comprehensive eye examination that included dilation. MAIN OUTCOME MEASURES: The proportion of children who could be tested and the sensitivity and specificity of the screening. RESULTS: Of the 170 children enrolled (age, <3 years, n = 80; age range, 3-5 years, n = 90), 36% had abnormal eye examination findings. Most (84%) children 3 years or older could be tested compared with 49% of the children younger than 3 years (P<.001). Among those who were testable, for children younger than 3 years the sensitivity was 80% (95% confidence interval [CI], 44%-97%) and the specificity was 41% (95% CI, 24%-61%). For children aged 3 to 5 years, the sensitivity was 88% (95% CI, 68%-97%) and the specificity was 58% (95% CI, 43%-71%). CONCLUSIONS: Our findings suggest that screening children aged 3 to 5 years with monocular autorefraction would identify most cases of visual impairment but would be associated with many false-positive results. For children younger than 3 years, testability was low and results were nonspecific.

Age Factors↗
PubMed2005

Empiric determination of corrected visual acuity standards for train crews.

PURPOSE: Probably the most common visual standard for employment in the transportation industry is best-corrected, high-contrast visual acuity. Because such standards were often established absent empiric linkage to job performance, it is possible that a job applicant or employee who has visual acuity less than the standard may be able to satisfactorily perform the required job activities. For the transportation system that we examined, the train crew is required to inspect visually the length of the train before and during the time it leaves the station. The purpose of the inspection is to determine if an individual is in a hazardous position with respect to the train. In this article, we determine the extent to which high-contrast visual acuity can predict performance on a simulated task. METHODS: Performance at discriminating hazardous from safe conditions, as depicted in projected photographic slides, was determined as a function of visual acuity. For different levels of visual acuity, which was varied through the use of optical defocus, a subject was required to label scenes as hazardous or safe. RESULTS: Task performance was highly correlated with visual acuity as measured under conditions normally used for vision screenings (high-illumination and high-contrast): as the acuity decreases, performance at discriminating hazardous from safe scenes worsens. CONCLUSIONS: This empirically based methodology can be used to establish a corrected high-contrast visual acuity standard for safety-sensitive work in transportation that is linked to the performance of a job-critical task.

Adult↗
PubMed1992

Orthoptists reduce false-positive hospital referrals.

This paper describes changes in the pattern of new referrals of children from birth to 2 years-of-age to the Hospital Eye Service in Oxford, following the implementation of a community-based orthoptic secondary vision-screening programme. The findings show that the number of false positive referrals was reduced by a half following the introduction of the service; false-positive referrals were also discharged sooner. This paper reports the findings of this survey and the results demonstrate the cost-effectiveness of the programme compared to outpatient attendance.

Community Health Services↗
PubMed1993

Reliability of high- and low-contrast letter charts.

The aim of this study was to measure the reliability, in test score units, of several clinical tests which use high- and low-contrast letters, and to provide an estimate of what constitutes a significant change in performance over time. Patients with normal vision and with early or subtle eye disease were recruited so that the results would be representative of the population likely to present for primary vision screening. Patients were tested on the Bailey-Lovie logMAR chart, the Regan low-contrast letter charts and the Pelli-Robson low-contrast letter chart on two occasions; the two test sessions were separated by at least four weeks to give an estimate of reliability appropriate for the conditions under which the tests are likely to be used. A 'significant change', i.e. one which would be observed in only about 5% of patients with stable visual performance, was about +/- 2 'steps' of the measurement scale, i.e. +/- 2 lines for the Bailey-Lovie and Regan charts and +/- 2 letter groups for the Pelli-Robson chart.

Adult↗