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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↗

Relationship between anisometropia, patient age, and the development of amblyopia.

PURPOSE: Previous studies evaluating the effect of anisometropia on amblyopia development have been biased because subject selection occurred as a result of decreased acuity. Photoscreening identifies anisometropic children in a manner that is not biased by acuity, and allows an opportunity to evaluate how patient age influences the prevalence and depth of amblyopia. DESIGN: Retrospective observational study of preschool children with anisometropia. METHODS: A statewide preschool photoscreening program screened 119,311 children and identified 792 with anisometropia >1.0 diopters. We correlated age with visual acuity and amblyopia depth. Results were compared with 562 strabismic children similarly identified. RESULTS: Only 14% (six of 44) of anisometropic children aged 1 year or younger had amblyopia. Amblyopia was detected in 40% (32 of 80) of 2-year-olds, 65% (119 of 182) of 3-year-olds, and 76% of 5-year-olds. 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 for children aged 0 to 3, 9% at age 4, and 14% at age 5. Children with strabismus had a relatively stable prevalence (30% ages 0 to 2; 42% ages 3 to 4; and 44% ages 5 to 7) and depth of amblyopia. CONCLUSIONS: Younger children with anisometropia have a lower prevalence and depth of amblyopia than older children. By age 3, 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.

Aging↗

Scotopic measurement of normal pupil size with the Colvard pupillometer and the Nidek auto-refractor.

PURPOSE: To compare prospectively, pupil size with the Nidek AR700A auto-refractor and the Colvard pupillometer. METHODS: Pupil diameter was measured in 46 eyes at 2 min intervals in a low mesopic and under photopic light conditions. RESULTS: The mean pupil diameter was 4.8+/-1.0mm with the Colvard pupillometer and 4.8+/-0.9mm with the Nidek auto-refractor in low mesopic light conditions. The mean photopic pupil diameter was 3.3+/-0.8mm with the Colvard pupillometer and 3.9+/-0.8mm with the Nidek auto-refractor. CONCLUSION: The pupil sizes are very similar with both instruments.

Adult↗

Editorial.

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Humans↗

Editorial.

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Humans↗

A decade of contact lens prescribing trends in the United Kingdom (1996-2005).

PURPOSE: To document contact lens prescribing trends in the United Kingdom over the past decade (between 1996 and 2005). METHODS: An annual survey of contact lens prescribing trends was conducted each year by asking a random selection of optometrists and dispensing opticians to provide information relating to 10 consecutive contact lens fits between January and March. RESULTS: Over the 10-year survey period, 1251 practitioners returned survey forms representing a total of 12,050 contact lens fits. The mean (+/-standard deviation) age of lens wearers was 33+/-13 years of which 64% were female. Over the survey period, rigid lens new fits decreased from 22% to 4%. Low water content lenses reduced from 20% to 2% of new soft lens fits. Soft toric lenses gradually increased to the point where they accounted for the expected proportion of patients with astigmatism>or=1.00DC (i.e. >20% of soft lens fits). Monthly and daily disposable lenses accounted for >90% of all soft lens fits between 2003 and 2005. The proportion of new soft fits and refits prescribed as extended wear has gradually increased, stabilizing at about 5% of new fits and 12% of refits. Multi-purpose lens care solutions increased from 60% of all care systems in 1997 to 91% in 2005. Rigid lenses and monthly replacement soft lenses are predominantly worn on a full time basis, whereas daily disposable soft lenses are mainly worn part time. CONCLUSIONS: This survey indicates that technological advancements such as the development of new lens materials, manufacturing methods and lens designs have had a significant impact on the contact lens market over a relatively short period of time.

Adolescent↗

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↗

Nondiagnosed uveal melanomas.

PURPOSE: To determine the proportion of nondiagnosed uveal melanomas after evaluation by optometrists or ophthalmologists. DESIGN: Retrospective observational cohort study. PARTICIPANTS: Four hundred thirty-three ophthalmic oncology patients with uveal melanoma. METHODS: This was a retrospective study of uveal melanoma patients from a single ophthalmic oncology center. We sent questionnaires to living patients we had treated between 1980 and 2000 for uveal melanoma. Patients were divided into those who had an examination within 1 year before diagnosis of a melanoma in which the tumor was not detected, those patients who were being observed with a known pigmented uveal tumor, and those who had not had an eye examination for at least 10 years. MAIN OUTCOME MEASURE: The detection of unsuspected melanomas. RESULTS: We determined that 37% of patients referred to us with a newly discovered uveal melanoma had been examined within a year, without a uveal melanoma being detected. Of patients whose medical records were obtained, 71% had eyes that had been dilated and the tumor not found. The patients in whom the tumors were nondiagnosed within 1 year of referral to us had a mean tumor thickness of 6 mm and a mean tumor diameter of 12 mm. Ninety percent of the tumors were partially posterior to the equator. Patients who had been observed by their outside ophthalmologist with a choroidal pigmented tumor had significantly smaller tumors (P<0.005). CONCLUSIONS: There are a notable number of patients seen by general ophthalmologists with symptomatic uveal melanomas in whom the diagnosis is not established. It is likely that screening efforts for this relatively rare condition are often not efficacious.

Adolescent↗

Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision In Preschoolers Study.

PURPOSE: To compare 11 preschool vision screening tests administered by licensed eye care professionals (LEPs; optometrists and pediatric ophthalmologists). DESIGN: Multicenter, cross-sectional study. PARTICIPANTS: A sample (N = 2588) of 3- to 5-year-old children enrolled in Head Start was selected to over-represent children with vision problems. METHODS: Certified LEPs administered 11 commonly used or commercially available screening tests. Results from a standardized comprehensive eye examination were used to classify children with respect to 4 targeted conditions: amblyopia, strabismus, significant refractive error, and unexplained reduced visual acuity (VA). MAIN OUTCOME MEASURES: Sensitivity for detecting children with > or =1 targeted conditions at selected levels of specificity was the primary outcome measure. Sensitivity also was calculated for detecting conditions grouped into 3 levels of importance. RESULTS: At 90% specificity, sensitivities of noncycloplegic retinoscopy (NCR) (64%), the Retinomax Autorefractor (63%), SureSight Vision Screener (63%), and Lea Symbols test (61%) were similar. Sensitivities of the Power Refractor II (54%) and HOTV VA test (54%) were similar to each other. Sensitivities of the Random Dot E stereoacuity (42%) and Stereo Smile II (44%) tests were similar to each other and lower (P<0.0001) than the sensitivities of NCR, the 2 autorefractors, and the Lea Symbols test. The cover-uncover test had very low sensitivity (16%) but very high specificity (98%). Sensitivity for conditions considered the most important to detect was 80% to 90% for the 2 autorefractors and NCR. Central interpretations for the MTI and iScreen photoscreeners each yielded 94% specificity and 37% sensitivity. At 94% specificity, the sensitivities were significantly better for NCR, the 2 autorefractors, and the Lea Symbols VA test than for the 2 photoscreeners for detecting > or =1 targeted conditions and for detecting the most important conditions. CONCLUSIONS: Screening tests administered by LEPs vary widely in performance. With 90% specificity, the best tests detected only two thirds of children having > or =1 targeted conditions, but nearly 90% of children with the most important conditions. The 2 tests that use static photorefractive technology were less accurate than 3 tests that assess refractive error in other ways. These results have important implications for screening preschool-aged children.

Amblyopia↗

Detection of undiagnosed glaucoma by eye health professionals.

PURPOSE: To examine the clinical features of undiagnosed open-angle glaucoma (OAG) in people who have attended an eye care provider within the previous 12 months and to suggest strategies to assist in the early detection of glaucoma. DESIGN: Population based cross-sectional study. PARTICIPANTS: Permanent residents aged 40 years and older at recruitment during 1992 through 1996. METHODS: A cluster-stratified random sample of 4744 participants from the urban and rural cohorts was studied. Structured standardized interviews and dilated ocular examinations were conducted in all eligible participants. Data on demographic characteristics, prior knowledge of eye disease, use of eye care services, intraocular pressures, cup-to-disc ratios, visual fields, and photography of optic discs were obtained. All suspected glaucoma cases were submitted to a panel of 6 ophthalmologists to determine glaucoma diagnosis. MAIN OUTCOME MEASURES: Clinical features of participants seen by eye health professionals within the previous 12 months who have previously undiagnosed OAG, previously diagnosed OAG, and no glaucoma. RESULTS: Thirty-five previously undiagnosed and 43 previously diagnosed participants had visited an optometrist or ophthalmologist or both in the previous 12 months. Age and gender were not significantly different between the undiagnosed and diagnosed glaucoma cases. After logistic regression, the type of eye professional seen (odds ratio [OR], 45.17; 95% confidence interval [95% CI], 5.89-346.17; P = 0.0002) and the presence of visual field defects (OR, 0.06; 95% CI, 0.01-0.69, P = 0.020) were the only statistically significant variables between the diagnosed and undiagnosed glaucoma groups. CONCLUSIONS: Raised intraocular pressure should not be relied on as the only triggering factor in glaucoma investigations.

Adult↗

Glaucoma detection.

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Diagnostic Techniques, Ophthalmological↗

Vision screening.

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Amblyopia↗