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Objectives: Considering the escalating incidence of strabismus and its consequential jeopardy to binocular vision, there is an imperative demand for expeditious and precise screening methods. This study was to develop an artificial intelligence (AI) platform in the form of an applet that facilitates the screening and management of strabismus on any mobile device., Methods: The Visual Transformer (VIT_16_224) was developed using primary gaze photos from two datasets covering different ages. The AI model was evaluated by 5-fold cross-validation set and tested on an independent test set. The diagnostic performance of the AI model was assessed by calculating the Accuracy, Precision, Specificity, Sensitivity, F1-Score and Area Under the Curve (AUC)., Results: A total of 6194 photos with corneal light-reflection (with 2938 Exotropia, 1415 Esotropia, 739 Vertical Deviation and 1562 Orthotropy) were included. In the internal validation set, the AI model achieved an Accuracy of 0.980, Precision of 0.941, Specificity of 0.979, Sensitivity of 0.958, F1-Score of 0.951 and AUC of 0.994. In the independent test set, the AI model achieved an Accuracy of 0.967, Precision of 0.980, Specificity of 0.970, Sensitivity of 0.960, F1-Score of 0.975 and AUC of 0.993., Conclusions: Our study presents an advanced AI model for strabismus screening which integrates electronic archives for comprehensive patient histories. Additionally, it includes a patient-physician interaction module for streamlined communication. This innovative platform offers a complete solution for strabismus care, from screening to long-term follow-up, advancing ophthalmology through AI technology for improved patient outcomes and eye care quality., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

To improve access to vision care and to enable mass vision screening, a smartphone app has been developed to measure refractive errors. Without needing any external attachment, the app running on a standalone phone can be used by lay personnel to measure subjective refraction. Its validity has been pilot-tested in clinical settings and underserved communities. The app estimates the refractive error by measuring the distances of far points for discerning visual stimuli. Spherical equivalent refraction and astigmatism can be measured using Tumbling E letters and grating patterns, respectively. The purpose of this paper is to describe the measurement protocols for performing subjective refraction using the app. Experimental results with 34 subjects (30 eyes for spherical equivalent and 38 eyes for astigmatism assessment) are presented. Measurement with the app was compared with standard clinical methods. The average absolute error of spherical equivalent refraction was 0.63D, and the average absolute error of astigmatism measurement was 0.28D. In addition, 22 subjects were enrolled to evaluate inter-pupillary distance (IPD) measurement with the app. The average absolute error in IPD measurement with the app was 1.2 mm. The protocol for measuring IPD with the app is also described.

Clinical Relevance: Understanding devices used for vision screening, including their potential utilisation and validity, will facilitate proper utilisation of this technology., Background: The Acuidrive is a self-illuminated, hand-held, visual acuity screening device intended for use in policing, with visual acuity assessed roadside to identify drivers who may not meet vision standards for driving. The target is presented binocularly at 24 cm, and +4.00 D lenses eliminate the accommodation requirement. This study investigates its validity and applicability relative to the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart., Methods: There were 36 participants, half younger adults aged 18-30 years and half older adults aged 50-70 years. The subjects underwent binocular visual acuity testing using the Acuidrive device and an ETDRS chart displayed on a monitor. Eyes were corrected for distance using lenses in a trial frame, and additional trial lenses provided four blur levels: zero, +0.50 DS, +1.00 DS and +1.50 DS. Luminances for the devices were similar at approximately 100 cd/m 2 . ETDRS chart measurements were conducted both with room lighting on and off., Results: The Acuidrive device underestimated the ETDRS visual acuity across all blur levels, with mean differences of 0.24 ± 0.07 logMAR and 0.18 ± 0.10 logMAR for room lights on and off, respectively. To predict ETDRS visual acuity of poorer than 0.34 logMAR (6/12 = ), a screening level of 0.50 logMAR (6/19) with the Acuidrive device provided high sensitivity and specificity (86% and 79% with lights-on, and 85% and 78% with lights-off). Visual acuity was better for the older group than the younger group by approximately 0.10 logMAR., Conclusion: There was an offset of 0.2 logMAR (two lines) between visual acuity measures for the Acuidrive device and an ETDRS chart. The Acuidrive device has the potential to be a viable screening tool with refinement to its construction.

Purpose: To evaluate Spot in detecting American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Amblyopia risk factors (ARF) and for ARF myopia and hyperopia with variations in ocular pigments., Design: Diagnostic screening test evaluation., Methods: Study population: Children presented for a complete eye examination in pediatric clinic. The study population included 1040 participants, of whom 273 had darkly pigmented eyes, 303 were medium pigmented, and 464 were light pigmented., Intervention: Children were screened with the Spot vision screener before the complete eye examination. A pediatric ophthalmologist then completed an eye examination, including cycloplegic refraction. The pediatric ophthalmologist was blinded to the result of the Spot vision screener., Main Outcome: The association between Spot screening recommendation and meeting one or more ARF/ARF + Amblyopia criterion, Spot measured spherical equivalent, and ARF myopia and hyperopia detection., Results: The area under the receiver operative characteristic curve (AUC) for myopia was excellent for all. The AUC for hyperopia was good (darker-pigmented: 0.92, medium-pigmented: 0.81, and lighter-pigmented: 0.86 eyes). The Spot was most sensitive for ARF myopia (lighter-pigmented: 0.78, medium-pigmented: 0.52, darker-pigmented: 0.49). The reverse was found for hyperopia; however, sensitivity was relatively poor. The Spot was found most sensitive for hyperopia in the darker-pigment group (0.46), 0.27 for medium-pigment, and 0.23 for the lighter-pigment cohort., Conclusions: While the Spot was confirmed as a sensitive screening test with good specificity in our large cohort, the sensitivity of the Spot in detecting AAPOS guidelines for myopia and hyperopia differed with variations in skin pigment. Our results support the consideration of ethnic and racial diversity in future advances in photorefractor technology., (Copyright © 2024 Elsevier Inc. All rights reserved.)

To evaluate the usefulness of the Tokyo Metropolitan Government's Eye Health Screening Program for 3-year-old children, which combines the Single-Picture Optotype Visual Acuity Chart (SPVAC) and Spot™ Vision Screener (SVS) tests. This was a retrospective, observational, matched study. Patients who underwent the eye health screening program and had abnormalities were classified into 3 groups according to the outcomes of the SPVAC (SPVAC-passed, SPVAC-P; SPVAC-failed, SPVAC-F) and SVS (SVS-passed, SVS-P; SVS-failed, SVS-F) tests as follows: SPVAC-P/SVS-F, SPVAC-F/SVS-P, and SPVAC-F/SVS-F. We evaluated the age at examination, SPVAC and SVS test success rates, and SVS refractive power. Additionally, the rates of refractive error, amblyopia, and strabismus were compared among the 3 groups. The SPVAC-P/SVS-F, SPVAC-F/SVS-P, and SPVAC-F/SVS-F groups comprised 158, 28, and 74 eyes, respectively. The mean age was 37.4 months. The success rates of the SPVAC and SVS tests were 69.8% and 96.2%, respectively. The mean SVS hyperopia value in the SPVAC-F/SVS-F group (2.71 ± 1.50 D) was significantly higher than that of the SPVAC-P/SVS-F group. The mean SVS astigmatism and myopia values were -2.21 diopter (D) ± 1.09 D and -3.40 ± 1.82 D, respectively; they did not differ significantly from that of the SPVAC-P/SVS-F group. Significant differences were observed in the refractive error, amblyopia, and strabismus rates among the 3 groups. Regarding disease determination, no significant difference was observed among participants who passed and failed the SPVAC test, regardless of the outcome of the other test. However, a significant difference was observed between those passing and failing the SVS tests. The SPVAC method used to screen 3-year-old children should be modified to commence at 42 months of age or be replaced with a single Landolt C test. The SVS test is useful for screening younger patients. Furthermore, the SVS test showed that the degree of hyperopia was higher in patients who did not pass the SPVAC test., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Slit lamp biomicroscope is the right hand of an Ophthalmologist. Even though precise, its bulky design and complex working process are limiting constraints, making it difficult for screening at outreach camps, which are an integral part of this field for the purpose of eliminating needless blindness. The torchlight is the main tool used for screening. Recently, the integration of smartphones with instruments and the digitization of slit lamp has been explored, to provide simple and easy hacks. By bringing the slit of the slit lamp to traditional torchlight, we have created "The Slitscope". It combines the best of both worlds as a simple innovative do-it-yourself novel technique for precise cataract screening. It is especially useful in peripheral centers, vision centers, and outreach camps. We present two prototypes which can also be 3D printed., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Objectives: Determining the accuracy of cycloplegic refractive error measurements made with the Spot Vision Screener (SVS, Welch Allyn Inc, Skaneateles Falls, NY, USA) is important for refractive assessment of uncooperative patients during optometric examinations. This study compared cycloplegic refractive errors measured by SVS and tabletop autorefractometer to cycloplegic retinoscopy in children., Materials and Methods: Eighty-eight eyes of 44 subjects were examined in the study. Refractive error measurements were obtained under cycloplegia using retinoscopy, SVS, and Nidek ARK-530 tabletop autorefractometer (ARK-530, Nidek, Japan). Spherical and cylindrical values, spherical equivalents (SE), and Jackson cross-cylinder values at axes of 0° (J0) and 45° (J45) were recorded. Correlations between methods were analyzed using intraclass correlation coefficient (ICC) and Bland-Altman analysis., Results: The mean age was 7 years (range: 6 months-17 years). Sixteen (36%) of the subjects were female and 28 (64%) were male. For SE there was excellent agreement between retinoscopy and SVS (ICC: 0.924) and between retinoscopy and tabletop autorefractometer (ICC: 0.995). While there was a moderate correlation between retinoscopy and SVS for cylindrical values (ICC: 0.686), excellent correlation was detected between retinoscopy and autorefractometer (ICC: 0.966). J0 and J45 crosscylinder power values were not correlated between retinoscopy and SVS (ICC: 0.472) or retinoscopy and tabletop autorefractometer (ICC: 0.442). Retinoscopy was correlated with both SVS and tabletop autorefractometer for all parameters within ±1.96 standard deviations in Bland-Altman analysis., Conclusion: Cycloplegic retinoscopy is the gold standard for refractive error measurement in the pediatric population. However, it requires time and experienced professionals. This study revealed moderate to good agreement between SVS and retinoscopy, with better agreement in spherical errors than cylindrical errors. Although the SVS is intended for screening programs, it may also be useful in the pediatric eye office to estimate spherical refractive error in uncooperative patients., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2024 by the Turkish Ophthalmological Association / Turkish Journal of Ophthalmology published by Galenos Publishing House.)

Purpose: This research evaluates the effectiveness of the Spot Vision Screener (SVS) before and after cycloplegia to detect amblyogenic refractive errors in children., Methods: Children ages 3 to 10 years old were screened by the SVS before and after cycloplegia. Sensitivity, specificity, positive and negative predictive value, paired t-test, Bland-Altman plot and receiver operating characteristic area under the curve were evaluated by comparing the results of the SVS (v3.0.05) measurements with the results of the cycloplegic Topcon autorefractometer according to the 2021 guidelines of the American Association for Pediatric Ophthalmology and Strabismus., Results: Both eyes of 211 patients aged 3 to 10 years old were included. Regarding the amblyopia risk factors, the noncycloplegic SVS had 65.7 % sensitivity, 94.9 % specificity, 81.2 % positive predictive value and 89.3 % negative predictive value. The SVS's sensitivity increased from 65.7 % to 81.9 % with cycloplegia compared to noncycloplegic SVS results. The sensitivity detection of hyperopia was improved from 4.2 % to 100 % after cycloplegia. Areas under the receiver operator characteristic curve for noncycloplegic SVS and cycloplegic SVS were 0.506 (95 % CI, 0.395 to 0.646, p = 0737) and 0.905 (95 % CI, 0.915 to 0.971, p < 0.001) for hyperopia, respectively. Using the +1.64 D revised cutoff criteria for hyperopia increased sensitivity from 4.2 % to 78 %., Conclusion: Noncycloplegic SVS measurements showed relatively high specificity in detecting amblyopia risk factors. The fact that noncycloplegic measurements have a very low sensitivity for hyperopia is an important weakness of the SVS, especially because hyperopia is the most frequently encountered refractive error in very young children. It should be noted that amblyogenic hyperopia may be overlooked by an SVS without cycloplegia., Competing Interests: Declaration of competing interest None of the following authors have any proprietary interests or conflicts of interest related to this submission. Erkan Bulut, Ozlem Dayi, Yusuf Çelik, Hatice Bulut, Emel Başar., (Copyright © 2024. Published by Elsevier B.V.)

Electroretinography (ERG) provides crucial insights into retinal function and the integrity of the visual pathways. However, ERG assessments classically require a complicated technical background with costly equipment. In addition, the placement of corneal or conjunctival electrodes is not always tolerated by the patients, which restricts the measurement for pediatric evaluations. In this short review, we give an overview of the use of the RETeval portable ERG device (LKC Technologies, Inc., Gaithersburg, MD, USA), a modern portable ERG device that can facilitate screening for diseases involving the retina and the optic nerve. We also review its potential to provide ocular biomarkers in systemic pathologies, such as Alzheimer's disease and central nervous system alterations, within the framework of oculomics., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: The aim of this study was to describe a new type of medical device that allows for internet-enabled patient self-screening, without the aid of an ophthalmic professional, through biomicroscopy self-imaging and self-measurement of the best-corrected visual acuity (BCVA)., Methods: In this prospective nonrandomized comparative study, 56 patients were instructed to screen their own eyes using a custom-built e-Device containing miniaturized slitlamp optics and a visual acuity Snellen chart virtually projected at 20 ft. BCVA measurements were recorded, and biomicroscopic videos were scored for image quality of the anterior segment status on a scale from 1 to 5 (1 = poor and 5 = excellent) by a blinded observer., Results: After a short instruction, all patients were able to self-image their eyes and perform a self-BCVA measurement using the e-Device. Patient self-image quality with the e-Device scored on average 3.3 (±0.8) for videos (n = 76) and 3.6 (±0.6) for photographs (n = 49). Self-BCVA measurement was within 1 Snellen line from routine BCVA levels in 66 of 72 eyes (92%). When compared with conventional biomicroscopy, patient self-biomicroscopy allowed for recognition of the relevant pathology (or absence thereof) in 26 of 35 eyes (74%); 9 cases showed insufficient image quality attributed to device operating error (n = 6) and mild corneal edema and/or scarring (n = 3). Patient satisfaction with the device was 4.4 (±0.9)., Conclusions: An e-Device for combined BCVA self-measurement and biomicroscopy self-imaging may have potential as an aid in remote ophthalmic examination in the absence of an ophthalmic professional and may be considered for patients who are unable to visit an ophthalmic clinic for routine follow-up., Competing Interests: G. R. J. Melles is a consultant for DORC International/Dutch Ophthalmic USA and SurgiCube International. All other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this manuscript. The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The intent of this study was to determine the diagnostic accuracy of several diagnostic tests for age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataract, as well as the proportions of patients with eye disease from each of 3 enrolling clinics., Design: Diagnostic accuracy study., Methods: Patients ≥50 years old in a diabetes, thyroid, and general medicine clinic were screened using visual acuity, tonometry, and fundus photography. Photographs were graded at the point-of-screening by non-ophthalmic personnel. Participants with positive screening test results in either eye and a 10% random sample with negative results in both eyes were referred for an in-person, reference-standard ophthalmology examination., Results: Of 889 participants enrolled, 229 participants failed at least 1 test in either eye, of which 189 presented for an ophthalmic examination. An additional 76 participants with completely normal screening test results were referred for examination, of which 50 attended. Fundus photography screening had the highest yield for DR (sensitivity: 67%; 95% confidence interval [CI]: 39%-87%), visual acuity screening for cataract (sensitivity: 89%; 95% CI: 86%-92%), and intraocular pressure screening for glaucoma or suspected glaucoma (sensitivity: 25%; 95% CI: 14%-40%). The burden of disease was relatively high in all 3 clinics, with at least 1 of the diseases of interest (ie, AMD, DR, glaucoma or suspected glaucoma, or cataract) detected in 25% of participants (95% CI: 17-35%) from the diabeteses clinic, 34% (95% CI: 22%-49%) from the thyroid clinic, and 21% (95% CI: 13%-32%) from the general clinic., Conclusions: Non-expert eye disease screening in health clinics may be a useful model for detection of eye disease in resource-limited settings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Significance: A new device attached to a smartphone was created for objective vision screening of young children including infants and newborns. The device is compact, lightweight, portable, cost-effective, and easy to operate. Therefore, it is suitable for screening large numbers of children in clinical settings, schools, and communities., Purpose: This article introduces a new device attached to a smartphone for objective vision screening. It can detect and categorize significant refractive errors, anisometropia, strabismus, cloudy ocular media, and ptosis that may cause amblyopia., Methods: The new device applies the same principles as conventional streak retinoscopy but examines both eyes simultaneously and records the results electronically. The device comprises optical elements that produce a precise streak light beam and move it across a child's both eyes. The smartphone's video camera catches and records the motion of retinal reflex inside the child's pupils. By observing the direction of motion of the retinal reflex relative to the light beam motion, as well as its speed, width, and brightness, the examiner is able to assess the individual and comparative refractive status, ocular alignment, and other conditions., Results: Vision screening with this device does not require any subjective response from children. The examination can be performed and analyzed by nonprofessionals after a short learning period of time. Because the examination results are electronically recorded by the smartphone, they can be stored in the child's files and sent out for professional consultations., Conclusions: The new device will provide the same functions as conventional streak retinoscopy but examines a child's both eyes simultaneously, so that, in addition to categorizing refractive errors and assessing clarity of refractive media of the eyes, it can also detect anisometropia, strabismus, and anisocoria. In addition to showing the examination results on the smartphone's screen, the device can also store the results electronically., Competing Interests: Conflict of Interest Disclosure: None of the authors have reported a financial conflict of interest., (Copyright © 2020 American Academy of Optometry.)

We determined the repeatability-reproducibility of refraction values and pupil size measured using the Spot Vision Screener and compare the obtained values with those measured using the binocular open-field autorefractor Grand Seiko WAM 5500 in healthy adults. This cross-sectional study included 22 eyes of 22 healthy adults with emmetropia to myopia. For each participant, spherical equivalent value, cylindrical value, and pupil size were measured in the right eye using the Spot Vision Screener and Grand Seiko autorefractor devices by two different orthoptists under two conditions: monocular and binocular (three consecutive refraction measurements). Repeatability-reproducibility of values measured using both devices were evaluated using intra-class correlation coefficients (ICCs). The mean spherical equivalent value measured using the Spot Vision Screener was -2.79D in the monocular condition and -2.69D in binocular condition, which showed a small significant difference to those measured using the Grand Seiko autorefractor (-2.98D and -2.93D, respectively). The mean cylindrical value measured using the Spot Vision Screener was -0.59D in the monocular condition and -0.52D in the binocular condition, which showed a small significant difference compared with those measured using the Grand Seiko autorefractor in the binocular condition (-0.70D and -0.75D, respectively). Correlation coefficients of the spherical equivalent values, cylindrical values, and pupil sizes measured using both devices were R=0.959 (P<0.001), R=0.243 (P=0.260) and R=0.917 (P<0.001), respectively, in the monocular condition and R=0.962 (P<0.001), R=0.444 (P=0.040), and R=0.832 (P<0.001), respectively, in the binocular condition. ICC values of spherical equivalent value in intra-rater or inter-rater were more than 0.99 in both devices and conditions. ICC values of cylindrical values under the binocular condition in the Spot Vision Screener were 0.636 in intra-rater and 0.574 in inter-rater, which were lower than those of the Grand Seiko autorefractor (0.874 and 0.839, respectively). ICC values of pupil sizes under the binocular condition in the Spot Vision Screener were 0.871 in intra-rater and 0.760 in inter-rater, which were lower than those of the Grand Seiko autorefractor (0.967 and 0.943, respectively). The refractive value and pupil size obtained using the Spot Vision Screener showed high repeatability and reproducibility and were similar to the values obtained using the Grand Seiko autorefractor. Thus, the Spot Vision Screener, an automated vision screener, is a reliable portable refractor and pupillometry device for measuring refractive errors in clinical settings.

Background: Vision screening in children of preschool age (age 3-5 years) gives the opportunity for timely detection of amblyopia. The tools that would be used for screening must have high rates of testability in these young children, and must have high enough sensitivity and specificity to be reliable and cost effective., Aims: To assess the performance of the Lea symbols chart as a screening tool in children aged 3 to 5 years attending primary schools in Kwara State, Nigeria., Methods: Visual acuity (VA) of 464 children selected from 12 schools by a multistage sampling procedure was checked using the Lea symbols chart by trained Lea screeners. Children meeting the referral criteria and untestable children had a comprehensive eye examination. Testability rates, sensitivity, specificity, positive, and negative predictive values were analyzed based on age and gender, with corresponding significance values generated., Results: Testability rates among 5 year olds were as high as 99.1%, decreasing significantly to 95.5% in 4 year olds and 85.7% in 3 year olds (p value < 0.001). Visual acuity performance improved with age (p value 0.002) but was unrelated to gender. The Lea symbols chart had an overall specificity of 77.4% (63.2% among 3 year olds and 83.5% among 5 year olds). At VA thresholds of 6/12 for 5 year olds and 6/15 for 3-4 year olds, the screening tool became 87.7% specific among 3 year olds and 94.3% specific among 5 year olds (overall 92.5%)., Conclusion: The Lea symbols chart was found to be a useful screening tool in this environment, especially among 5 year olds. The reduced specificity among 3-4 year olds may prompt further research into the appropriate VA thresholds for 3-4 year olds to reduce the burden of unnecessary comprehensive eye evaluations resulting from too many false positive results., Competing Interests: None

Background: Young children's vision screening, as part of a preventative health care service, produces great value for developing regions. Besides yielding a high return on investment from forestalling surgeries using a low-cost intervention at a young age, it improves school performance and thus boosts future labor force quality. Leveraging low-skilled health care workers with smartphones and automated diagnosis to offer such programs can be a scalable model in resource-limited areas., Objective: This study aimed to develop and evaluate an effective, efficient, and comprehensive vision screening solution for school children in resource-limited areas. First, such an exam would need to cover the major risk factors of amblyopia and myopia, 2 major sources of vision impairment effectively preventable at a young age. Second, the solution must be integrated with digital patient record-keeping for long-term monitoring and popular statistical analysis. Last, it should utilize low-skilled technicians and only low-cost tools that are available in a typical school in developing regions, without compromising quality or efficiency., Methods: A workflow for the screening program was designed and a smartphone app was developed to implement it. In the standardized screening procedure, a young child went through the smartphone-based photoscreening in a dark room. The child held a smartphone in front of their forehead, displaying pre-entered personal information as a quick response code that duplexed as a reference of scale. In one 10-second procedure, the child's personal information and interpupillary distance, relative visual axis alignment, and refractive error ranges were measured and analyzed automatically using image processing and artificial intelligence algorithms. The child's risk for strabismus, myopia, and anisometropia was then derived and consultation given., Results: A preliminary evaluation of the solution was conducted alongside yearly physical exams in Luoyang, Henan, People's Republic of China. It covered 20 students with suspected strabismus and 80 randomly selected students, aged evenly between 8 and 10. Each examinee took about 1 minute, and a streamlined workflow allowed 3 exams to run in parallel. The 1-shot and 2-shot measurement success rates were 87% and 100%, respectively. The sensitivity and specificity of strabismus detection were 0.80 and 0.98, respectively. The sensitivity and specificity of myopia detection were 0.83 and 1.00, respectively. The sensitivity and specificity of anisometropia detection were 0.80 and 1.00, respectively., Conclusions: The proposed vision screening program is effective, efficient, and scalable. Compared with previously published studies on utilizing a smartphone for an automated Hirschberg test and photorefraction screening, this comprehensive solution is optimized for practicality and robustness, and is thus better ready-to-deploy. Our evaluation validated the achievement of the program's design specifications., (©Shuoxin Ma, Yongqing Guan, Yazhen Yuan, Yuan Tai, Tan Wang. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 13.07.2020.)

Purpose: Screening for visual problems in stroke survivors is not standardised. Visual problems that remain undetected or poorly identified can create unmet needs for stroke survivors. We report the validation of a new Vision Impairment Screening Assessment (VISA) tool intended for use by the stroke team to improve identification of visual impairment in stroke survivors., Methods: We conducted a prospective case cohort comparative study in four centres to validate the VISA tool against a specialist reference vision assessment. VISA is available in print or as an app (Medicines and Healthcare products Regulatory Agency regulatory approved); these were used equally for two groups. Both VISA and the comprehensive reference vision assessment measured case history, visual acuity, eye alignment, eye movements, visual field and visual inattention. The primary outcome measure was the presence or absence of visual impairment., Results: Two hundred and twenty-one stroke survivors were screened. Specialist reference vision assessment was by experienced orthoptists. Full completion of screening and reference vision assessment was achieved for 201 stroke survivors. VISA print was completed for 101 stroke survivors; VISA app was completed for 100. Sensitivity and specificity of VISA print was 97.67% and 66.67%, respectively. Overall agreement was substantial; K=0.648. Sensitivity and specificity of VISA app was 88.31% and 86.96%, respectively. Overall agreement was substantial; K=0.690. Lowest agreement was found for screening of eye movement and near visual acuity., Conclusions: This validation study indicates acceptability of VISA for screening of potential visual impairment in stroke survivors. Sensitivity and specificity were high indicating the accuracy of this screening tool. VISA is available in print or as an app allowing versatile uptake across multiple stroke settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Significance: Vision screenings are conducted to detect significant refractive errors, amblyopia, and ocular diseases. Vision screening devices are desired to have high testability, sensitivity, and specificity. Spot has demonstrated high testability, but previous reports suggest that the Spot has low sensitivity for detecting amblyogenic hyperopia and moderate sensitivity for amblyogenic astigmatism., Purpose: This study assessed the concurrent validity of detecting amblyogenic refractive errors by the Spot (v.1.1.50; Welch Allyn Inc., Skaneateles Falls, NY) compared with cycloplegic retinoscopy., Methods: A total of 475 subjects (24 to 96 months) were screened by Spot and then received a masked comprehensive examination. Sensitivity and specificity, Bland-Altman plot, receiver operating characteristic area under the curve, and paired t test were evaluated by comparing the results of the Spot (v1.1.50) using the manufacturer referral criteria with the results of the comprehensive examination using the 2013 American Association for Pediatric Ophthalmology and Strabismus criteria., Results: The Spot (v.1.1.50) referred 107 subjects (22.53%) for the following: 18.73% (89/475) astigmatism, 4.63% (22/475) myopia, 0.42% (2/475) hyperopia, and 2.11% (10/475) anisometropia. The sensitivity and specificity of the Spot vision screener for detecting amblyogenic risk factors were 86.08% (95% confidence interval [CI], 76.45 to 92.84%) and 90.15% (95% CI, 86.78 to 92.90%). Areas under the curve were 0.906 (95% CI, 0.836 to 0.976) for hyperopia, 0.887 (95% CI, 0.803 to 0.972) for spherical equivalent, and 0.914 (95% CI, 0.866 to 0.962) for astigmatism. A modified hyperopia criteria cutoff of greater than +1.06 D improved the sensitivity from 25 to 80% with 90% specificity. The current cutoff criterion, greater than -1.75 D, for astigmatism seemed optimal., Conclusions: This study shows that the Spot vision screener accurately detects low spherical refractive errors and astigmatism. Lowering the hyperopia cutoff criteria from the current Spot screener referral criteria improves the sensitivity with desired (high) specificity.

Purpose: To determine the accuracy of the Spot Vision Screener (Welch Allyn, Skaneateles Falls, NY) in children 6 years and older and recommend device thresholds to improve its accuracy for the detection of refractive error., Methods: The Spot Vision Screener results were compared with three gold standard conditions of increasingly narrow refractive error criterion. The sensitivity, specificity, positive predictive value, and negative predictive value of the Spot Vision Screener in detecting each gold standard criterion were calculated. The most accurate threshold setting for each parameter was identified by calculating the area under the curve receiver operating characteristic., Results: The Spot Vision Screener was able to successfully evaluate 313 of 330 children (95%). The sensitivity of the Spot Vision Screener to detect American Association for Pediatric Ophthalmology and Strabismus guidelines for amblyopia risk factors was 89.5% and the specificity was 76.7%. The sensitivity decreased to 80% and the specificity increased to 75.3% with narrower refractive criteria. The sensitivity in detecting refractive criteria improved with the proposed optimized device thresholds. Estimates for the general population indicate that the positive predictive value is reasonable at 52.3% to 61.8%, depending on the stringency of the criteria, with excellent negative predictive values., Conclusions: In school-aged children, the primary screening focus shifts from preventing amblyopia to detecting visual disturbances, including refractive error, that may interfere with academic performance. In this age group, the Spot Vision Screener was an acceptable method of detecting significant refractive error with improved sensitivity with threshold optimization. [J Pediatr Ophthalmol Strabismus. 2020;57(3):146-153.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To evaluate the accuracy of Spot photoscreener (PS) as a noncycloplegic photorefractor in detecting amblyopia risk factors (ARFs) in preschool children in an Indian eye clinic setting. Also, to derive appropriate cutoff values for screening to obtain maximum sensitivity and specificity of the device in detecting ARF., Methods: This was a cross-sectional study conducted in the outpatient pediatric eye clinic at a tertiary eye care institute. A Spot PS was used to screen all the children between the ages of 6 months and 5 years that presented to the eye clinic from August 2018 to October 2018. This screening was followed by a complete eye examination, including cycloplegic refraction by a masked examiner. The 2013 American Association for Pediatric Ophthalmology and Strabismus (AAPOS) guidelines were considered the standard cutoff values for clinically significant refractive error in children younger than 5 years of age., Results: The study comprised of 219 children. The Spot PS diagnosed 135 (61.64%) children with ARF as compared with 124 (56.62%) children detected by clinic examination. For ARF detection, the Spot photoscreeneer had 85.48% sensitivity, 69.47% specificity, 78.52% positive predictive value and 78.57% negative predictive value. The sensitivity for detection of strabismus and hypermetropia was very low (42% and 36%, respectively). The 95% limits of agreement ranged from -5.48 to +5.59 diopters (D) with a bias of 0.06 D for spherical equivalent between noncycloplegic photorefraction and cycloplegic refraction., Conclusion: The Spot PS may be used as a screening tool to detect ARF in children younger than 5 years of age keeping its limitations in consideration. However, the performance can be improved by modifying the cutoff values for the referral., Competing Interests: None

Purpose: To investigate outcomes of routine vision screening compared to as-indicated ophthalmological investigation of all children born preterm in a Danish region from 1997 to 2014., Methods: All children born preterm (gestation age < 32 weeks or birthweight < 1500 g) screened for retinopathy of prematurity (ROP) were divided into two groups. From 1997 to 2009, only children treated for ROP or referred for visual problems received ophthalmological investigation (as-indicated group). From 2010 to 2014, all ROP-screened infants were offered ophthalmological investigation at 6 months and 3 years of age (screening group)., Results: A total of 560 children were included in the as-indicated period, 41 and 87 were referred for ophthalmological investigation at 6 months and 3 years, respectively. In the screening period, 295 children were included, 251 and 150 of whom underwent vision evaluation at 6 months and 3 years, respectively. Mean visual acuity was 4.1 cycles per degree with Teller acuity cards at 6 months and 0.78 decimal at 3 years. At 3 years, 2.7%(n = 11) in the as-indicated versus 3.5%(n = 10) screening group had visual acuity < 6/18 (p = 0.24). Cerebral palsy (n = 28) and epilepsy (n = 5) were significantly related to vision impairment (p = 0.001/0.006), while treated ROP was not (n = 13). Refractive error was common at 3 years (61%), especially astigmatism (50%). Gestational age, birthweight and ROP were not associated with vision impairment or refractive error., Conclusion: Screening preterm children at 6 months and 3 years did not reveal more visually impaired children compared to examination when indicated., (© 2019 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

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., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the effect of anterior chamber depth and axial length on clinical performance of the Spot Vision Screener in detecting amblyopia risk factors in children aged 3-10 years., Methods: A total of 300 eyes from 150 patients aged 3-10 years were prospectively tested with Spot Vision Screener (firmware version 3.0.02.32, software version 3.0.04.06) and a standard autorefractometer (Nidek ARK-1). The anterior chamber depth and axial length were measured with an optical biometer (Nidek AL-Scan). The sensitivity and specificity values for detecting significant refractive errors using the referral criteria of the American Association for Pediatric Ophthalmology and Strabismus were determined. Pearson's correlation analysis was employed to evaluate the relationship between the Spot Vision results and the anterior chamber depth and axial length., Results: Compared with the standard autorefractometer results, the Spot Vision Screener's sensitivity and specificity was 59% and 94%, respectively. The differences between the cycloplegic autorefractometer and the Spot Vision Screener spherical equivalents were negatively correlated with anterior chamber depth (r=-0.48; p<0.001) and axial length (r=-0.45; p<0.001)., Conclusion: The Spot Vision Screener has moderate sensitivity and high specificity, using the criteria of the American Association for Pediatric Ophthalmology and Strabismus. The anterior chamber depth and axial length affect the Spot Vision results.

We report a case of accommodative spasm in an 8-year-old girl discovered by handheld photoscreener. The patient was found to have a Chiari I malformation, and managed with atropine drops and reading glasses, ultimately with improvement in her symptoms. We believe this to be the first case of accommodative spasm diagnosis aided by the use of a handheld photoscreener.

Purpose: To evaluate parents' performance in using the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Vision Screening App (application) as a vision screening tool among preschool children and to evaluate the reliability of this app., Methods: A total of 195 5- and 6-year-old preschoolers were recruited from children attending Hospital Selayang, Selangor, Malaysia, to test the app. Uncooperative children and those with visual acuity of >logMAR 0.6 were excluded. Results from parents and the screening doctor using the app (Lea symbols) to test visual acuity were compared to each other and to gold standard vision testing by an optometrist using the Lea symbols chart., Results: Children 5 years of age represented 46.7% of the study population. The mean age of parents was 37.27 ± 7.68 years. Bland-Altman scatterplot agreement between assessors mainly was within the 95% confidence interval for bilateral eyes screening. Parents obtained a sensitivity of 86.6% (right vision) and 79.5% (left vision) and specificity of 78.9% (right vision) and 71.8% (left vision). Parents took a mean of 191.2 ± 70.82 seconds for bilateral screening. The intraclass correlation coefficient between optometrist and parents in bilateral eyes screening was good (P < 0.001). Cronbach's α for all three assessors was >0.7, indicating high internal reliability of the app. Most parents (178/195 [91.3%]) strongly agreed on the app's acceptability and ease of use., Conclusions: The AAPOS Vision Screening App used by parents is a promising tool for visual acuity screening among Malaysian preschool children and a reliable app for vision screening., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate a smartphone-based application's (Peek Acuity) ability to assess visual acuity and screen for ocular conditions in children, we compared visual acuity assessment between Peek Acuity and the pediatric ophthalmology examination and evaluated Peek Acuity's ability to identify children with referable ocular conditions., Study Design: We prospectively recruited 111 children age 3-17 years, presenting to a pediatric ophthalmology clinic, who could follow instructions. Monocular visual acuity assessments by Peek Acuity and standard clinical methods were performed in randomized order. We compared visual acuity assessments between methods using intraclass correlation coefficient (ICC) and evaluated Peek Acuity's ability to identify children with referable ocular conditions., Results: ICC comparing visual acuity assessed between methods was 0.88 (95% CI 0.83-0.92) for first and 0.85 (95% CI 0.78-0.89) for second eyes examined. ICC among 3 to 5-year-olds (preschool-age children) was 0.88 (95% CI 0.77-0.94) for first and 0.45 (95% CI 0.13-0.68) for second eyes examined. Peek Acuity had a sensitivity of 83%-86% for decreased vision and 69%-83% for referable ocular disease. Sensitivity was highest among 3 to 5-year-olds with decreased vision, 93%-100%., Conclusions: Overall, Peek Acuity visual acuity assessment correlated well with visual acuity assessed by standard clinical methods, though preschool-age children appeared more susceptible to examination fatigue. Peek Acuity performed adequately as a screening tool and had the greatest sensitivity among those with decreased vision and preschool-age children., Trial Registration: ClinicalTrials.gov: NCT03212222., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To test the accuracy and validity of the 2Win and the plusoptiX A12R refractometers in detecting amblyopia risk factors., Methods: Children were screened using both devices, using two sets of referral criteria each, and underwent complete ophthalmic examination, including cycloplegic refraction. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Median values for the pairs of refractometers were compared using the Wilcoxon signed-rank sum test for sphere, cylinder, and power vectors J0 and J45 for axis (both eyes)., Results: A total of 284 eyes of 142 children (mean age, 37.9 ± 19.8 months) were included. Comparison of mean cycloplegic and manifest refractometer measurements provided statistically significant differences in both eyes. For sphere, the means were lower and for cylinder, higher for both devices, and both correlated well with the gold standard for astigmatic power vectors J0 and J45. Using referral criteria 1, the sensitivity, specificity, PPV and NPV, and inconclusive results were 67.4%, 83.7%, 87.9%, 59.4%, and 4.9%, respectively, for the 2Win, with sensitivity of 13% in the hyperopia group; 73.1%, 95.9%, 96.6%, 69.1%, and 10.6%, respectively, for the plusoptiX A12R, with a sensitivity of 33.3% in the hyperopia group. Using criteria 2, the values were 98.8%, 38.8%, 73.9%, and 95.0% (2Win) and 94.9%, 65.3%, 81.3%, and 88.9% (plusoptiX A12R)., Conclusions: In manifest conditions, the accuracy of the 2Win and plusoptiX A12R refractometers is low in hyperopia and astigmatism, but the devices are well correlated with each other, and both have high specificity; sensitivity is low in hyperopia, resulting in the underestimation of hyperopic refractive error. The optional Plusoptix sensitive referral criteria seems to be appropriate for the A12R. The 2Win provided fewer inconclusive results and was preferred for use with younger and developmentally delayed children., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To validate the smartphone photography as a screening tool for amblyogenic conditions in children., Methods: Children between 5 to 8 years attending eye out patient department (OPD) were photographed (by an optometrist) with a smartphone to capture their pupillary red reflexes followed by clinical examination by the principal investigator (PI). The PI on the basis of clinical examination identified children with significant amblyogenic conditions and, subsequently, two ophthalmologists independently categorized the photographs on the basis of color, symmetry, and shape of the pupillary reflex into normal or abnormal. The identification of amblyogenic conditions on clinical examination was compared to that on photography. Refractive errors <3D and anisometropia <2D were excluded. Sensitivity, specificity, positive predictive value, and negative predictive value of smartphone photography screening were determined., Results: In all, 250 children were screened. Clinically 23.6% were harboring amblyogenic conditions. The mean sensitivity and specificity of screening by smartphone were 94% and 91%, respectively., Conclusion: Smartphone photography is a reliable tool for detection of amblyogenic conditions in children., Competing Interests: There are no conflicts of interest.

Purpose: To evaluate the Spot Vision Screener in detecting targeted vision disorders compared to cycloplegic retinoscopy in children <3 years of age., Methods: Children, ages 6 months to 36 months underwent vision screening using the Spot Vision Screener. Results were compared to results of comprehensive eye examinations. Validity of the Spot was evaluated by calculating the area under the curve (AUC); the receiver operating characteristics (ROC) were used to determine optimal sensitivity and specificity for detection of targeted vision disorders., Results: A total of 249 children were included. The AUC for detecting targeted vision disorders as defined by the study specific criteria using the Spot was 0.790. Compared to cycloplegic retinoscopy, the Spot underestimated hyperopia by 1.02 D (95% CI, 0.86-1.17 D). For hyperopia ≥4.5 D spherical equivalent (n = 10), the mean difference between the Spot and cycloplegic retinoscopy was 3.46 D (95% CI, 1.95-4.98 D). In contrast, the Spot overestimated astigmatism compared to cycloplegic retinoscopy (-1.00 D vs -0.48 D; P < 0.001) by -0.52 D (95% CI, 0.43-0.62 D)., Conclusions: The Spot Vision Screener showed good overall validity in detecting targeted vision disorders. It was within 0.5 D and 1 D of cycloplegic retinoscopy with regard to low hyperopia and astigmatism. Higher hyperopic spherical equivalent refractive errors showed larger differences in mean values between the Spot and cycloplegic retinoscopy., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare refractive measurements of noncycloplegic photoscreener Plusoptix S12R with cycloplegic retinoscopy, noncycloplegic autorefractor, and cycloplegic autorefractor in children., Methods: The study population (200 eyes of 100 children) was divided into two groups: Group 1 (age 3-7 years) and Group 2 (age 8-15 years). In Group 1, Plusoptix was compared with cycloplegic retinoscopy. In Group 2, Plusoptix was compared with cycloplegic retinoscopy and autorefraction. The second group was made because the younger group was found to be uncooperative for autorefraction. Paired t-test and Pearson's correlation were used for statistical analysis., Results: The mean difference in sphere (DS), spherical equivalent (DSE), and cylinder (DC) between cycloplegic retinoscopy and Plusoptix in Group 1 was 0.68 ± 0.55 (P < 0.001), 0.77 ± 0.61 (P < 0.001), and 0.18 ± 0.28 (P < 0.001), respectively. In Group 2, DS, DSE, and DC between cycloplegic retinoscopy and Plusoptix were 0.86 ± 0.49 (P < 0.001), 0.97 ± 0.51 (P < 0.001), and 0.23 ± 0.28 (P < 0.001); between cycloplegic autorefractor and Plusoptix were 0.69 ± 0.47 (P < 0.001), 0.74 ± 0.49 (P < 0.001), and 0.10 ± 0.31 (P = 0.002); and between noncycloplegic autorefractor and Plusoptix were - 0.25 ± 0.39 (P < 0.001), -0.19 ± 0.41 (P < 0.001), and 0.11 ± 0.31 (P < 0.001), respectively. Pearson's correlation coefficients of S, SE, and C between Plusoptix and cycloplegic retinoscopy were 0.948, 0.938, and 0.924 in Group 1 and 0.972, 0.972, and 0.946 in Group 2, and these values were statistically significant. Bland-Altman plots showed good agreement between cycloplegic retinoscopy and Plusoptix in both groups. Plusoptix gave axis values within 10° of cycloplegic retinoscopy in 81.56% of eyes in Group 1 and in 71.44% of eyes in Group 2., Conclusion: Plusoptix photoscreener can be used for prescription of axis of cylinder in children; however, other refractive measurements must be refined by cycloplegic retinoscopy., Competing Interests: There are no conflicts of interest.

Purpose: The purpose of this study was to compare refraction measurements for children with the PlusOptix S09 and Spot Vision with cycloplegic retinoscopy., Methods: One hundred thirty-six eyes of 68 children (26 boys and 42 girls) were evaluated prospectively. The subjects were separated into two groups. Group 1 comprised the subjects age between 5 and 9 years. Group 2 comprised the subjects age between 10 and 18 years. Photorefraction with PlusOptix S09, photorefraction with Spot Vision and cycloplegic retinoscopy were performed in each patient. Spherical equivalents, spherical power, cylindrical power and axis values were compared between three methods., Results: The mean age of the patients was 7.12 ± 1.5 years in group 1 and 12.24 ± 1.8 years in group 2. Spherical equivalent and spherical power measured with PlusOptix S09 were statistically smaller than measured with cycloplegic retinoscopy for group 1 (p = 0.001, p = 0.001) and for group 2 (p = 0.000, p = 0.000). The mean cylindrical power measured with PlusOptix S09 was not statistically different compared to cycloplegic retinoscopy for both groups (p = 0.314, p = 0.05). Spherical equivalents measured with Spot Vision were statistically smaller than measured with cycloplegic retinoscopy for both groups (p = 0.000, p = 0.012). Spherical power measured with Spot Vision was statistically smaller than measured with cycloplegic retinoscopy for group 1 (p = 0.000), but the difference was not statistically significant for group 2 (p = 0.084). The mean cylindrical power measured with Spot Vision was statistically higher than cycloplegic retinoscopy for both groups (p = 0.000, p = 0.012)., Conclusions: PlusOptix S09 and Spot Vision devices give acceptable results for screening, but prescription of spectacles should not be made according to PlusOptix S09 or Spot Vision devices alone.

Purpose: The PowerRef 3 is frequently used in studying the near triad of accommodation, vergence and pupil responses in normal and clinical populations. Within a range, the defocus measurement of the PowerRef 3 is linearly related to the eye's defocus. While the default factory-calibrated slope of this relation (calibration factor) is 1, it has been shown that the slope can vary across individuals. Here, we addressed the impact of changes in viewing distance, age and defocus of the eye on the calibration factor., Methods: We manipulated viewing distance (40 cm, 1 m and 6 m) and recruited participants with a range of accommodative capabilities: participants in their 20s, 40s and over 60 years old. To test whether any effect was larger than the range of measurement reliability of the instrument, we collected data for each condition four times: two in the same session, another on the same day, and one on a different day., Results: The results demonstrated that viewing distance did not affect the calibration factor over the linear range, regardless of age or uncorrected refractive error. The largest proportion of the variance was explained by between-subject differences., Conclusions: Calibration data for the PowerRef 3 were not sensitive to changes in viewing distance. Nevertheless, our results re-emphasise the relevance of calibration for studies of individual participants., (© 2019 The Authors. Ophthalmic and Physiological Optics published by John Wiley & Sons Ltd on behalf of College of Optometrists.)

Successful vision screening efforts require the implementation of 12 key components of a strong vision health system of care. The National Center for Children's Vision and Eye Health (NCCVEH) at Prevent Blindness partnered with the National Association of School Nurses (NASN) to provide guidance around these 12 components via a Vision and Eye Health webpage on the NASN website ( https://www.nasn.org/nasn-resources/practice-topics/vision-health ). This online resource is organized according to the 12 Components of a Strong Vison Health System of Care to support school nurses accountable for screening the vision of preschool and K-12 students. This NCCVEH/NASN webpage addresses key activities that support a child's vision health-beginning with parent/caregiver education and ending with an annual evaluation of the school's vision health system. Each of these 12 components will be described in NASN School Nurse . The May 2019 installment provided information about the 12 components approach as a whole and details on Family Education and a Comprehensive Communication/Approval Process. This installment describes Components 3 and 4: Vision Screening Tools and Procedures and Vision Health for Children with Special Health Care Needs.

Background: A near vision game has been developed for the autostereoscopic screen of the Nintendo 3DS console. Ease of use and time for testing by non-English-speaking patients was not known., Methods: Adult and pediatric patients in a remote Burma clinic were compared with US military staff with each performing conventional near acuity, Stereo Fly, and Ishihara color in addition to PDI Check game, so results could be correlated and timed., Results: Seventeen Burma adults (aged 19-58), 20 Burma children (aged 7-15), and 14 US military staff (aged 21-36) completed the testing. Conventional testing correlated with PDI Check for stereo (P < 0.001), acuity oculo dexter (P < 0.01), acuity oculo sinister (P < 0.01). For visual acuity and stereopsis, the intraclass coefficient was 0.55 [95% confidence interval (CI) 0.28-0.72] and 0.62 (95% CI 0.41-0.77) respectively, but with few color deficient cases color was 0.30 (95% CI -0.05 to 0.60). The time in seconds to complete near vision testing with PDI Check (172 ± 27, overall; 198 ± 34, Burma; 99 ± 20, military) was significantly (25% ± 18%) briefer than conventional testing (226 ± 31, overall; 270 ± 34, Burma; 126 ± 20, military). The Burma patients took significantly longer than the military staff (234 ± 25 vs 112 ± 14, P < 0.01). Time for Burma children did not differ from Burma adults for PDI (109 ± 47 vs 217 ± 54, P = 0.42) and for conventional testing (266 ± 51 vs 275 ± 52, P = 0.80)., Conclusions: Non-English-speaking Burma children and adults were able to reliably perform 3 types of near vision testing with a Nintendo 3DS game 25% quicker than the 2 to 3 minutes for conventional methods. They were slower than experienced US military staff adults.

Purpose: To evaluate the ability of the PDI Check (PDI Check LLC, Anchorage, AK) near vision screening game to assess monocular acuity, stereopsis, suppression, and color., Methods: Children and adults consented to perform the PDI Check Quick Screening game following conventional near testing of patched Rosenbaum acuity, Titmus Fly stereo, Worth 4-dot, and Ishihara color. Time to complete each test and preferred method were recorded., Results: A total of 77 patients (5 to 63 years old) attempted all tests. There was a positive correlation between the PDI Check and conventional tests for all visual tasks. Using previously determined instrument referral criteria, sensitivity/specificity was determined for right acuity (67%/91%), left acuity (55%/94%), stereopsis (87%/95%), red-green color (80%/99%), and ocular suppression (58%/98%). Screening time was 202 ± 96 versus 99 ± 42 seconds for the PDI Check and the game was preferred by 87%., Conclusions: The PDI Check provided a valid assessment of near vision in less than half the time of conventional testing without patches or goggles. This Quick Screening version may help eye technicians and physicians with time efficiency in the frequent task of near visual assessment. [J Pediatr Ophthalmol Strabismus. 2019;56(4):234-237.]., (Copyright 2019, SLACK Incorporated.)

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., (© 2019 The Authors Ophthalmic & Physiological Optics © 2019 The College of Optometrists.)

Purpose: To compare the sensitivity, specificity, and referral rate of the Spot Vision Screener (Welch Allyn Inc, Skaneateles Falls, NY) with the gold standard cycloplegic measurements acquired using the Retinomax in a population of underprivileged children and teenagers with limited access to medical care., Methods: Children were recruited for the study by social workers in the vicinity of Robert Debre Hospital, Paris, France. Refractive errors (hyperopia of ≥ +2.00 D spherical equivalent [SE]; myopia of ≤ -0.50 D SE; astigmatism of ≥1.00 D between the two main meridians; anisometropia of ≥1.00 D SE difference between eyes) were assessed using the Spot Vision Screener and the Retinomax. Sensitivity (true positive rate), specificity (true negative rate), and referral rate of this Spot Vision screening program were evaluated., Results: A total of 82 eyes of 41 subjects (19 males) were included; mean age was 126 months of age (range, 48-246). The sensitivity of the Spot Vision Screener for the detection of refractive errors was 82.35%; specificity was 91.67%. The sensitivity of the Spot Vision Screener to detect hyperopia, myopia, astigmatism, and anisometropia was 27.27%, 84.61%, 78.57%, and 66.67%, respectively. Its specificity to detect hyperopia, myopia, astigmatism, and anisometropia was 100%, 98.55%, 89.71% and 94.29%, respectively., Conclusions: The specificity of the Spot Vision Screener to detect refractive errors was found to be relatively high (>90%). However, its low sensitivity for hyperopia seems to remain a major limitation of the device, because hyperopia is particularly important to detect in children given its high prevalence and possible adverse consequences. Global programs using cycloplegic measurements should be considered an alternative., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine whether facilitating access to instrument-based screening equipment will increase the total number of high-quality, age-appropriate vision screenings provided to the preschool aged population., Methods: The goal of the Naples Lions Amblyopia Elimination Project was to place a SPOT Vision Screener (Welch Allyn, Skaneateles Falls, NY) in every pediatric medical home using philanthropic dollars. Participating medical homes agreed to provide data on the number of children screened, number of referrals made, criteria for referral, and follow-up notes regarding examination outcomes., Results: In 2012, only 4 of the 23 pediatric medical homes in Collier County were using instrument-based vision screening equipment. By 2017, 19 of the 25 pediatric medical homes (76%) used SPOT Vision Screeners. In 2017, 6,052 preschool children were screened in these 19 pediatric medial homes., Conclusions: The concept for this community-based philanthropic effort is original in its design and implementation and is a significant step forward in the goal to eliminate preventable permanent vision loss in children. [J Pediatr Ophthalmol Strabismus. 2019;56(3):146-150.]., (Copyright 2019, SLACK Incorporated.)

Recently, several professional groups have recommended a change from chart-based to instrument-based screening for preschool-age children, but the effect of this change on health care utilization is unknown. We performed a secondary analysis of a site-randomized quality improvement project on transitioning from chart-based to instrument-based vision screening for 3- to 5-year-old children in primary care. We analyzed visit rates to ophthalmologists and optometrists and costs of such care before and after implementation of instrument-based vision screening with comparison to nonparticipating practices. The implementation of instrument-based vision screening resulted in a decrease in visits to eye care specialists from 83.1 visits per 1000 children per year to 55.0, a reduction of 33.8%; no comparable reduction was seen in nonparticipating practices. The cost of services by eye care specialists fell from $65 715 per 1000 children per year prior to $55 740, a decline of 15.2%; similar costs among control practices rose 13.4%.

Background: The evidence on diagnostic test accuracy (DTA) of diabetic retinopathy (DR) screening utilising photographic studies by non-ophthalmologist personnel in low and middle-income country (LMIC) settings is scarce. We aimed to assess DTA of DR screening using a nonmydriatic hand-held digital camera by trained general physicians in a non-ophthalmic setting., Methods: This study is a validation of a screening intervention. We selected 700 people with diabetes (PwDM) > 18 years of age, not previously screened or treated for DR, presenting at a tertiary medical clinic in Sri Lanka. Two-field retinal imaging was used to capture fundus images before and after pupil dilatation, using a hand-held non-mydriatic (Visuscout 100®-Germany) digital retinal camera. The images were captured and graded by two trained, masked independent physician graders. The DTA of different levels of DR was assessed comparing physician's grading with a retinologist's clinical examination by mydriatic bio-microscopy, according to a locally adopted guideline., Results: Seven hundred eligible PwDM were screened by physician graders. The mean age of participants was 60.8 years (SD ±10.08) and mean duration of DM was 9.9 years (SD ±8.09). Ungradable image proportion in non-mydriatic imaging was 43.4% (either eye-31.3%, both eyes 12.1%). This decreased to 12.8% (either eye-11.6%, both eyes-1.2%) following pupil dilatation. In comparison to detection of any level of DR, a referable level DR (moderate non-proliferative DR and levels above) showed a higher level of DTA. The sensitivity of the defined referable DR was 88.7% (95% CI 81.7-93.8%) for grader 1 (positive predictive value [PPV] 59.1%) and 92.5% (95% CI 86.4-96.5%) for grader 2 (PPV 68%), using mydriatic imaging, after including ungradable images as screen positives. The specificity was 94.9% (95% CI 93.6-96.0%) for grader 1 (negative predictive value [NPV] 99%) and 96.4% (95% CI 95.3-97.3%) for grader 2 (NPV 99.4%)., Conclusions: The Physicians grading of images from a digital hand-held non-mydriatic camera at a medical clinic, with dilatation of pupil of those who have ungradable images, provides a valid modality to identify referable level of DR. This could be a feasible alternative modality to the existing opportunistic screening to improve the access and coverage., Trial Registration: Current Controlled Trials ISRCTN47559703 . Date of Registration 18th March 2019, Retrospectively registered.

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.

Purpose: To investigate a new algorithm to perform an automated non-cycloplegic refraction in adults., Methods: Fifty healthy subjects were measured twice (test-retest) with the new automated subjective refraction method and with the conventional clinician subjective refraction procedure. Objective refraction was also measured with the Grand Seiko WAM-5500 autorefractor. The new automated method was inspired on the root finding bisection algorithm and on the Euclidean distances in the power vector domain. The algorithm was implemented in a computer that was synchronized with a customized motorized phoropter. Repeatability was mainly assessed with the within-subject standard deviation (Sw) and accuracy was mainly assessed with the limits of agreement., Results: The within-subject standard deviations of the power vector components (M, J0, J45) obtained for the right eye are (±0.13, ±0.04, ±0.05)D and (±0.17, ±0.03, ±0.07)D, respectively, for the clinical and the automated subjective refraction methods. The limits of agreement (with the clinical method) for the automated and the objective methods are, respectively (±0.56, ±0.18, ±0.31)D and (±0.77, ±0.15, ±0.18)D. Similar results are obtained for the left eye., Conclusions: The proposed automated method is repeatable and more accurate than objective techniques in healthy adults. However, it is not accurate enough to replace the clinical subjective refraction yet and it should be tested in a wider population in terms of age, refraction and different ocular conditions. Despite these important limitations, this method has been shown to be a potentially valuable method to improve the access to primary eye care services in developing countries., (Copyright © 2018 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: To evaluate the effectiveness of Spot photoscreener and SW800 vision screener in detecting amblyopia risk factors in Chinese children between 4 and 6 years of age., Methods: One hundred and thirteen children (226 eyes) underwent complete ophthalmologic examination, cycloplegic retinoscopy refraction, prism cover tests and photoscreen using both Spot (v2.1.4) and SW800 (v1.0.1.0) photoscreeners. The agreement of results obtained from photoscreener and retinoscopy was evaluated by paired t-test as well as Pearson correlation test. The sensitivity and specificity of detecting amblyopia risk factors were calculated based on the American Association of Pediatric Ophthalmology and Strabismus 2013 guidelines. The overall effectiveness of detecting amblyopia risk factors by using either photoscreener was analysed by receiver operating characteristic (ROC) curves., Results: A strong linear agreement was observed between Spot and retinoscopy (p<0.01) in aspects of spherical equivalent (SE, Pearson's r=0.95), dioptre sphere (DS, r=0.97), dioptre cylinder (DC, r=0.84) and horizontal deviation (Hdev, r=0.91), with overall -0.17 D myopic shift of SE. Significant correlation was also shown between SW800 and retinoscopy (p<0.01) in aspects of SE (r=0.90), DS (r=0.93), DC (r=0.82) and Hdev (r=0.80), with overall -0.12 D myopic shift of SE. The overall sensitivity and specificity in detecting amblyopia risk factors were 94.0% and 80.0% for Spot and 88.8% and 81.1% for SW800., Conclusion: The measurements of Spot and SW800 photoscreener showed a strong agreement with cycloplegic retinoscopy refraction and prism cover tests. The performance of both screeners in detecting individual amblyopia risk factors is satisfactory. ROC analysis indicates that the Spot and SW800 performed very similarly in detecting amblyopia risk factors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This population based cross sectional study was conducted to detect amblyopia risk factors and myopia in a rural district of Northwestern Turkey by using PlusoptiX S12R (Photoscreener PlusoptiX Inc., Nuremberg, Germany)., Methods: Children from 38 rural schools in Caycuma district of Zonguldak Turkey underwent vision screening in their school using PlusoptiX S12 photoscreener. Data were analyzed using the factory default level 5 referral criteria targeting 80% sensitivity and 95% specificity. Referral, unable readings, and positive predictive value (PPV) were reported., Results: Data from 2846 children were analyzed. Mean age was 7.9 years (±0.8) (range 36 months to 11 years). Three hundred ten (11%) were referred of whom 32% were read as 'unable'. 150 children (48% of the referred) received a gold standard examination. Positive predictive value of PlusoptiX was 69%. PPV was 83% when unable readings were excluded. 93 children with amblyopia risk factors were identified. Only 26% (n = 25) had received glasses priorly. 49 children had amblyopia of whom 33 were newly diagnosed., Conclusions: PlusoptiX showed a reasonable level of positive predictive value in community setting and the device could be a useful tool for vision screening in preschoolers and schoolers. We found most of the amblyogenic refractive errors were underdiagnosed in rural school children leading to a call for action on vision screening.

Aim: To compare visual acuity using the LEA symbol chart with Snellen E test chart in preschool children of age 3-5 years. Patients and methods : Inclusion criteria: 50 emmetropic children aged 3 to 5 years. Exclusion criteria: Strabismus, amblyopia, ametropia, and any organic eye disease. A pseudo randomized protocol was used to test visual acuity (VA) in each subject monocularly on both eyes using Snellen E chart and LEA symbol chart. Visual acuity for both charts was scored as smallest optotype size which the child correctly identified 3 of maximum 4 optotypes. The strength of agreement on VA between two charts was tested using Interclass correlation coefficient (ICC). A Mann-Whitney U test was applied to compare both the groups. Results: Boys: Girls = 26:24 with a mean age and standard deviation of 4.12 + 0.79 years. ICC between Snellen's and LEA symbol chart was 0.256 and 0.213 for right and left eye respectively. Analysis of the two samples using Mann-Whitney test showed a significant difference between the two charts (p value <0.000). Conclusion: LEA symbol test showed only a fair agreement with Snellen E charts for visual acuity measurements. Visual acuity measurement with LEA symbol chart showed significantly higher scores as compared to Snellen's chart.

Purpose: To compare the axial length measurements obtained by a new swept source optical coherence tomography based biometer-ARGOS with partial coherence interferometry based biometer -IOL master in school children between the ages of 11-17., Methods: A prospective, cross-sectional, device comparison study was conducted in a school vision screening program comparing the axial length (AL) and corneal curvature (K) measurements obtained by two biometers- ARGOS and IOL master. Children with 6/9 vision or better, without any ocular abnormalities were included in the study. Two trained optometrists performed the measurements and were masked for the outcome measures., Results: The sample size was 188 with a mean(SD) age of 13.88±1.69 years, of which 101 were boys. The mean (SD) AL was 23.94± 1.01 mm with Argos and 23.83 ± 1.03 mm with IOL Master (paired t-test, p>0.05). The mean K was 43.62D±1.59 with Argos and 43.64D±1.61 with IOL master (paired t-test, p>0.05). There was a strong positive correlation between the biometers for AL (r = 1.00, p<0.0001) and K (r = 0.99, p<0.0001). The mean difference in axial length between the two biometers was 0.11± 0.04 mm and the limits of agreement were between -0.02 to -0.19. The mean difference in corneal curvature was 0.02±0.15D and the limits of agreement were between -0.28 to 0.32D., Conclusion: Axial length measurements using SS-OCT and PCI based biometers were in agreement and comparable among children between the ages of 11 to 17., Competing Interests: The authors have declared that no competing interests exist.

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)