Detection of Significant Hyperopia in Preschool Children Using Two Automated Vision Screeners

Abstract

Moderate to high uncorrected hyperopia in preschool children is associated with amblyopia, strabismus, reduced visual function, and reduced literacy. Detecting significant hyperopia during screening is important to allow children to be followed for development of amblyopia or strabismus and implementation of any needed ophthalmic or educational interventions.PURPOSE: This study aimed to compare the sensitivity and specificity of two automated screening devices to identify preschool children with moderate to high hyperopia.METHODS: Children in the Vision in Preschoolers (VIP) study were screened with the Retinomax Autorefractor (Nikon, Inc., Melville, NY) and Plusoptix Power Refractor II (Plusoptix, Nuremberg, Germany) and examined by masked eye care professionals to detect the targeted conditions of amblyopia, strabismus, or significant refractive error, and reduced visual acuity. Significant hyperopia (American Association for Pediatric Ophthalmology and Strabismus definition of hyperopia as an amblyopia risk factor), based on cycloplegic retinoscopy, was >4.00 D for age 36 to 48 months and >3.50 D for age older than 48 months. Referral criteria from VIP for each device and from a distributor (PediaVision) for the Power Refractor II were applied to screening results.RESULTS: Among 1430 children, 132 children had significant hyperopia in at least one eye. Using the VIP referral criteria, sensitivities for significant hyperopia were 80.3% for the Retinomax and 69.7% for the Power Refractor II (difference, 10.6%; 95% confidence interval, 7.0 to 20.5%; P = .04); specificities relative to any targeted condition were 89.9 and 89.1%, respectively. Using the PediaVision referral criteria for the Power Refractor, sensitivity for significant hyperopia was 84.9%; however, specificity relative to any targeted condition was 78.3%, 11.6% lower than the specificity for the Retinomax. Analyses using the VIP definition of significant hyperopia yielded results similar to when the American Association for Pediatric Ophthalmology and Strabismus definition was used.DISCUSSION: When implementing vision screening programs for preschool children, the potential for automated devices that use eccentric photorefraction to either miss detecting significant hyperopia or increase false-positive referrals must be taken into consideration.

Vision Screening, Vision Disorders, and Impacts of Hyperopia in Young Children: Outcomes of the Vision in Preschoolers (VIP) and Vision in Preschoolers – Hyperopia in Preschoolers (VIP-HIP) Studies

“…Additional analysis showed that as the magnitude of hyperopia (on cycloplegic refraction) increased over the range of 4 D to 10 D, the sphere power measurement of the Power Refractor did not increase correspondingly, suggesting the potential for photoscreeners to fail to identify significant hyperopia. 32,42 Lea Symbols visual acuity testing at 10-feet viewing distance had somewhat higher sensitivity than HOTV visual acuity testing for identification of 1 or more vision disorders, but the differences were not statistically significant. 19 Referral criteria have been published previously for noncycloplegic retinoscopy, Retinomax and SureSight autorefractors, Lea and HOTV visual acuity tests, Power Refractor II, and Random Dot E and Stereo Smile II stereoacuity (tests that did not use a central reading center for test interpretation).…”

Validation of the PowerRef 3 for Measuring Accommodation: Comparison With the Grand Seiko WAM-5500A Autorefractor

“…The PowerRefractor was previously found to be less precise in measuring refractive error for individuals with high hyperopia, 36 and the PowerRef II showed less accuracy in detecting significant hyperopia. 53 This difference could have resulted from individuals accommodating through their hyperopia during measurements because they were not cyclopleged, making the use of the PowerRef 3 and its predecessors potentially less accurate as a screening tool for detecting hyperopic refractive error. Participants in the current study were required to have a (corrected) visual acuity of 0.1 logMAR (20/25 Snellen equivalent), but refractive error was not obtained, and future investigations should examine the influence of refractive error on agreement.…”

The Value of Eccentric Infrared Photorefraction in Evaluating Keratoconus

“…In practice, commercial photorefractors obtain images of both eyes simultaneously to estimate their refractive state. [3][4][5] To do this, the field of view of the infrared camera is expanded, thus compromising the spatial resolution of each eye's image representation. Should the proposed technology translate into commercial use for identification of eyes with corneal distortions, it should be able to produce results like Figs.…”

“…Commercially available photorefractors (e.g., Spot Vision Screener, Welch Allyn and Plusoptix S16, Plusoptix GmbH) meet all these criteria for screening refractive anomalies of the eye. [3][4][5] They are noninvasive with a measuring distance of 1 m, handheld, and able to obtain synchronous data from both eyes rapidly (measurements require no more than a few seconds) and can be operated by nontechnical staff with minimal training. These devices are also quite tolerant to head movement and thus do not require precise control of head position.…”

“…Astigmatism is measured by estimating this luminance gradient across multiple axes by changing the position of the LED array, relative to the camera aperture. Commercial photorefractors implementing this technology estimate the spherocylindrical refractive error of both eyes simultaneously from a remote distance in a few seconds (e.g., Spot Vision Screener [Welch Allyn, Skaneateles Falls, NY] and plusoptiX S16 [Plusoptix GmbH, Nuremberg, Germany]) 3–5 . Additional information such as binocular gaze position and pupil diameter is also obtained in sync with refractive error in these devices.…”