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Background Comprehensive vision screening programmes for children are an important part of public health strategy, but do not exist in many countries, including Tonga. This project set out to assess: (1) the functional vision of children attending primary schools in Tonga and (2) how a new recognition acuity test (The Auckland Optotypes displayed on a tablet computer) compares to use of a standardised eye chart in this setting. Methods Children from three Tongan primary schools were invited to participate. Acuity testing was conducted using a standardised recognition acuity chart (Lea symbols) and the tablet test displaying two formats of The Auckland Optotypes. Measures of ocular alignment, stereo acuity and non-cycloplegic photorefraction were also taken. Results Parents of 249 children consented to participate. One child was untestable. Only 2.8 per cent of testable children achieved visual acuity worse than 0.3 logMAR in the weaker eye. Results from the Spot Photoscreener suggested that no children had myopia or hyperopia, but that some children had astigmatism. The tablet test was practical in a community setting, and showed ±0.2 logMAR limits of agreement with the Lea symbols chart. Conclusion The sample of children in Tongan primary schools had good functional vision. A modified version of the tablet acuity test is a promising option for vision screening in this context.

Recognition acuity-the minimum size of a high-contrast object that allows us to recognize it-is limited by optical and neural elements of the eye and by processing within the visual cortex. The perceived size of objects can be changed by motion-adaptation. Viewing receding or looming motion makes subsequently viewed stimuli appear to grow or shrink, respectively. It has been reported that resulting changes in perceived size impact recognition acuity. We set out to determine if such acuity changes are reliable and what drives this phenomenon. We measured the effect of adaptation to receding and looming motion on acuity for crowded tumbling-T stimuli (). We quantified the role of crowding, individuals' susceptibility to motion-adaptation, and potentially confounding effects of pupil size and eye movements. Adaptation to receding motion made targets appear larger and improved acuity (-0.037 logMAR). Although adaptation to looming motion made targets appear smaller, it induced not the expected decrease in acuity but a modest acuity improvement (-0.018 logMAR). Further, each observer's magnitude of acuity change was not correlated with their individual perceived-size change following adaptation. Finally, we found no evidence that adaptation-induced acuity gains were related to crowding, fixation stability, or pupil size. Adaptation to motion modestly enhances visual acuity, but unintuitively, this is dissociated from perceived size. Ruling out fixation and pupillary behavior, we suggest that motion adaptation may improve acuity via incidental effects on sensitivity-akin to those arising from blur adaptation-which shift sensitivity to higher spatial frequency-tuned channels.

In patients with anisometropic or strabismic amblyopia, interocular suppression can be minimized by presenting high contrast stimulus elements to the amblyopic eye and lower contrast elements to the fellow eye. This suggests a structurally intact binocular visual system that is functionally suppressed. We investigated whether suppression can also be overcome by contrast balancing in children with deprivation amblyopia due to childhood cataracts. To quantify interocular contrast balance, contrast interference thresholds were measured using an established dichoptic global motion technique for 21 children with deprivation amblyopia, 14 with anisometropic or mixed strabismic/anisometropic amblyopia and 10 visually normal children (mean age mean=9.9years, range 5-16years). We found that interocular suppression could be overcome by contrast balancing in most children with deprivation amblyopia, at least intermittently, and all children with anisometropic or mixed anisometropic/strabismic amblyopia. However, children with deprivation amblyopia due to early unilateral or bilateral cataracts could tolerate only very low contrast levels to the stronger eye indicating strong suppression. Our results suggest that treatment options reliant on contrast balanced dichoptic presentation could be attempted in a subset of children with deprivation amblyopia.

IntroductionFor many people, settling in a new country is associated with a new identity as an ‘ethnic minority’, one that can remain through future generations. People who are culturally distinct from the dominant population group may experience a variety of barriers to accessing healthcare, including linguistic and cultural barriers in communication, navigation of an unfamiliar health system and unconscious or overt discrimination. Here, we outline the protocol of a scoping review to identify, describe and summarise interventions aimed at improving access to eye care for non-Indigenous, non-dominant ethnic groups residing in high-income countries.Methods and analysisWe will search MEDLINE, Embase and Global Health from their inception to July 2019. We will include studies of any design that describe an intervention to promote access to eye care for non-Indigenous, non-dominant ethnic groups. Two authors will independently review titles, abstracts and full-text articles for inclusion. Reference lists from all included articles will also be searched. In cases of disagreement between initial reviewers, a third author will help resolve the conflict. For each included article, we will extract data about the target population, details of the intervention delivered and the effectiveness of or feedback from the intervention. Overall findings will be summarised with descriptive statistics and thematic analysis.Ethics and disseminationThis review will summarise existing literature and as such ethics approval is not required. We will publish the review in an open-access, peer-reviewed journal, and draft appropriate summaries for dissemination to the wider community. This wider community could include clinicians, policymakers, health service managers and organisations that work with non-dominant ethnic groups. Our findings will also feed into the ongoing Lancet Global Health Commission on Global Eye Health.

Purpose Sloan letters displayed by the Electronic Visual Acuity (EVA) system are the gold standard for recognition acuity measurement in research settings. However, letters are not always appropriate for children. The Auckland Optotypes (TAO) are a new, open-access set of 10 pictograms available in regular and vanishing formats. We sought to assess feasibility of using both formats of TAO for measuring visual acuity (VA) in children using a Bayesian adaptive staircase, in a community setting. Methods We tested 121 children (5-12 years old) with both formats of TAO, a handheld flipchart vision screener (Parr vision test), as well as the gold standard EVA. We measured feasibility of the three comparison tests in three ways. First, using limits of agreement (LoA) with EVA, second, calculating area under the receiver operating characteristic curve (AUC), and finally, investigating trial-by-trial responses. Results Agreement between tests was within test-retest reliability of EVA measures (LoATAO regular = ±0.14, LoATAO vanishing = ±0.15, LoAP arr = ±0.16 logMAR). TAO tests were highly effective at identifying children with vision impairment (AUCTAO regular = 0.96, AUCTAO vanishing = 0.95), whereas Parr was less effective (AUCP arr = 0.82). In 5-6 year old children there was an enhanced advantage of TAO (AUCTAO regular = 0.97, AUCTAO vanishing = 0.98) over Parr (AUCP arr = 0.75). Although each child completed 16 trials, approximately 10 trials were sufficient to achieve excellent LoA, and six trials sufficient for accurate screening. Conclusion Threshold VA assessment and vision screening are feasible using both vanishing and regular formats of TAO.

Clinicians rely heavily on stereoacuity to measure binocular visual function, but stereo-vision represents only one aspect of binocularity. Lab-based tests of sensory eye dominance (SED) are commonplace, but have not been translated to wider clinical practice. Here we compare several methods of quantifying SED in a format suitable for clinical use. We tested 30 participants with ostensibly normal vision on eight tests. Seven tests (#1-7) were designed to quantify SED in the form of an interocular balance-point (BP). In tests #1-6, we estimated a contrast-BP, the interocular difference in contrast required for observers to be equally likely to base their judgement on either eye, whereas in test #7 we measured binocular rivalry (interocular ratio of sensory dominance duration). We compare test-retest reliability (intra-observer consistency) and test-validity (inter-observer discriminatory power) and compare BP to stereoacuity (test #8). The test that best preserved inter-observer differences in contrast balance while maintaining good test-retest reliability was a polarity judgement using superimposed opposite-contrast polarity same-identity optotypes. A reliable and valid measure of SED can be obtained rapidly (20 trials) using a simple contrast-polarity judgement. Tests that use polarity-rivalrous stimuli elicit more reliable judgments than those that do not. SIGNIFICANCE STATEMENT: Although sensory eye dominance is central to understanding normal and disordered binocular vision, there is currently no consensus as to the best way to measure it. Here we compare several candidate measures of sensory eye dominance and conclude that a reliable measure of SED can be achieved rapidly using a judgement of stimulus contrast-polarity.

Background Children with deprivation amblyopia due to childhood cataract have been excluded from much of the emerging research into amblyopia treatment. An investigation was conducted to determine whether contrast-balanced binocular treatment - a strategy currently being explored for children with anisometropic and strabismic amblyopia - may be effective in children with deprivation amblyopia. Methods An unmasked, case-series design intended to assess proof of principle was employed. Eighteen children with deprivation amblyopia due to childhood cataracts (early bilateral n = 7, early unilateral n = 7, developmental n = 4), as well as 10 children with anisometropic (n = 8) or mixed anisometropic and strabismic amblyopia (n = 2) were prescribed one hour a day of treatment over a six-week period. Supervised treatment was available. Visual acuity, contrast sensitivity, global motion perception and interocular suppression were measured pre- and post-treatment. Results Visual acuity improvements occurred in the anisometropic/strabismic group (0.15 ± 0.05 logMAR, p = 0.014), but contrast sensitivity did not change. As a group, children with deprivation amblyopia had a smaller but statistically significant improvement in weaker eye visual acuity (0.09 ± 0.03 logMAR, p = 0.004), as well a significant improvement in weaker eye contrast sensitivity (p = 0.004). Subgroup analysis suggested that the children with early bilateral deprivation had the largest improvements, while children with early unilateral cataract did not improve. Interestingly, binocular contrast sensitivity also improved in children with early bilateral deprivation. Global motion perception improved for both subgroups with early visual deprivation, as well as children with anisometropic or mixed anisometropic/strabismic amblyopia. Interocular suppression improved for all subgroups except children with early unilateral deprivation. Conclusion These data suggest that supervised contrast-balanced binocular treatment should be further investigated as a treatment option for children with deprivation amblyopia. However, for children with more severe deprivation amblyopia due to early unilateral cataracts, supplementary or alternative options should also be explored.

IntroductionGlobally, there are an estimated 370 million Indigenous people across 90 countries. Indigenous people experience worse health compared with non-Indigenous people, including higher rates of avoidable visual impairment. Countries such as Australia and Canada have service delivery models aimed at improving access to eye care for Indigenous people. We will conduct a scoping review to identify and summarise these service delivery models to improve access to eye care for Indigenous people in high-income countries.Methods and analysisAn information specialist will conduct searches on MEDLINE, Embase and Global Health. All databases will be searched from their inception date with no language limits used. We will search the grey literature via websites of relevant government and service provider agencies. Field experts will be contacted to identify additional articles, and reference lists of relevant articles will be searched. All quantitative and qualitative study designs will be eligible if they describe a model of eye care service delivery aimed at Indigenous populations. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each service delivery model, we will extract data on the context, inputs, outputs, Indigenous engagement and enabling health system functions. Where models were evaluated, we will extract details. We will summarise findings using descriptive statistics and thematic analysis.Ethics and disseminationEthical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve access to eye care services for Māori in Aotearoa New Zealand. The findings will be useful to policymakers, health service managers and clinicians responsible for eye care services in New Zealand, and other high-income countries with Indigenous populations. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings.

Purpose Reliable estimation of visual acuity requires that observers maintain a constant distance from the target, but use of chin rests is not always feasible. Our aim was to quantify children's movement during community testing and its impact on near (40 cm) and intermediate (150 cm) acuity measures. Methods Thirty-three 7-year-old children performed several acuity tests run on a tablet computer, administered in the child's home by a trained lay screener. The tablet webcam was used to derive a continuous estimate of the child's position during testing. We estimated acuity using both the recommended viewing distance and using trial-by-trial estimates of the child's physical distance from the screen. Results Although initial positioning in the 40-cm viewing distance condition was accurate, on 18% of trials children moved sufficiently to support a 0.1 logMAR improvement in acuity, leading 16% of staircases to overestimate acuity by more than one line. Initial positioning for the 150-cm condition was less accurate, but the longer viewing distance minimized the impact of children's movement on the visual angle of the target. Overall, at 150 cm 8% of staircases were overestimated by more than 0.1 logMAR. Conclusions Children move substantially during intermediate and near acuity tests despite assessors encouraging maintenance of the correct viewing distance. Translational Relevance Real-time estimates of the child's physical distance from the target are possible when assessments are conducted on camera-enabled devices. Correction for movement will likely lead to more accurate measures of near and intermediate visual acuity.

PurposeTo understand how we might improve the provision of medical care for children with cataracts.DesignA phenomenological design was employed. Semi-structured interviews were conducted to capture rich descriptions of the phenomena. Our goal in the interview and the analysis was to understand the sources of distress associated with treatment for cataract and deprivation amblyopia which (1) could be addressed by the medical community and (2) related to treatment adherence.SettingInterviews were conducted by a non-clinician researcher in New Zealand (NZ) in a location chosen by informants. In NZ, the red reflex screening test is performed shortly after birth, and surgery to remove paediatric cataracts is publicly funded.ParticipantsFamilies of children who had a history of cataract in Auckland, NZ were posted an invitation to participate. Twenty families were interviewed.ResultsOur analysis illustrated that informants described a wide range of experiences, from declined cataract surgery to full adherence to medical advice including years of patching for more than 4 hours a day. Across these experiences, we identified three relevant themes; timing of diagnosis, communication between the parent and clinician, and parental social support networks.ConclusionThe medical community may be better placed to support families dealing with childhood cataract by improving detection of childhood cataract, building appropriate communication pathways and promoting social support, with an emphasis on empathetic, individualised care.

When measuring recognition acuity in a research setting, the most widely used symbols are the Early Treatment of Diabetic Retinopathy Study (ETDRS) set of 10 Sloan letters. However, the symbols are not appropriate for patients unfamiliar with letters, and acuity for individual letters is variable. Alternative pictogram sets are available, but are generally comprised of fewer items. We set out to develop an open-access set of 10 pictograms that would elicit more consistent estimates of acuity across items than the ETDRS letters from visually normal adults. We measured monocular acuity for individual uncrowded optotypes within a newly designed set (The Auckland Optotype [TAO]), the ETDRS set, and Landolt Cs. Eleven visually normal adults were assessed on regular and vanishing formats of each set. Inter-optotype reliability and ability to detect subtle differences between participants were assessed using intraclass correlations (ICC) and fractional rank precision (FRP). The TAO vanishing set showed the strongest performance (ICC = 0.97, FRP = 0.90), followed by the other vanishing sets (Sloan ICC = 0.88, FRP = 0.74; Landolt ICC = 0.86, FRP = 0.80). Within the regular format, TAO again outperformed the existing sets (TAO ICC = 0.77, FRP = 0.75; Sloan ICC = 0.65, FRP = 0.64; Landolt ICC = 0.48, FRP = 0.63). For adults with normal visual acuity, the new optotypes (in both regular and vanishing formats) are more equally legible and sensitive to subtle individual differences than their Sloan counterparts. As this set does not require observers to be able to name Roman letters, and is freely available to use and modify, it may have wide application for measurement of acuity.