Advances in Pediatric Vision Screening

To examine the diversity in paediatric vision and hearing screening programmes in Europe. Themes for comparison of screening programmes derived from literature were used to compile three questionnaires on vision, hearing, and public health screening. Tests used, professions involved, age, and frequency of testing seem to influence sensitivity, specificity, and costs most. Questionnaires were sent to ophthalmologists, orthoptists, otolaryngologists, and audiologists involved in paediatric screening in all EU full-member, candidate, and associate states. Answers were cross-checked. Thirty-nine countries participated; 35 have a vision screening programme, 33 a nation-wide neonatal hearing screening programme. Visual acuity (VA) is measured in 35 countries, in 71% of these more than once. First measurement of VA varies from three to seven years of age, but is usually before age five. At age three and four, picture charts, including Lea Hyvarinen, are used most; in children over four, Tumbling-E and Snellen. As first hearing screening test, otoacoustic emission is used most in healthy neonates, and auditory brainstem response in premature newborns. The majority of hearing testing programmes are staged; children are referred after 1-4 abnormal tests. Vision screening is performed mostly by paediatricians, ophthalmologists, or nurses. Funding is mostly by health insurance or state. Coverage was reported as >95% in half of countries, but reporting was often not first-hand. Largest differences were found in VA charts used (12), professions involved in vision screening (10), number of hearing screening tests before referral (1-4), and funding sources (8).

Association of Sociodemographic Characteristics with Pediatric Vision Screening and Eye Care: An Analysis of the 2021 National Survey of Children's Health

Screening for macular disorders: the optometrist's perspective Ann E Elsner, Brett J King School of Optometry, Indiana University, Bloomington, IN, USA Abstract: Macular screening services can take many forms, offering a variety of roles for optometrists. The need for screening has been demonstrated in industrialized and developing nations alike. Populations of particular interest for macular screening services include individuals at high risk for diabetes, not just diagnosed diabetics, since a significant proportion of those with diabetes do not realize it. Individuals who know they have diabetes are frequently not examined at the recommended intervals. Related populations include patients with a high likelihood of retinal vascular disease and high blood pressure. A second population is older individuals, who are at risk for age-related macular degeneration and degenerative myopia, key causes of vision loss depending upon geographic location and ethnicity. Images showing the complexity of lesions from diabetic retinopathy, age-related macular degeneration, and degenerative myopia illustrate the challenges of screening and classification. A third population to be screened is the large pediatric one. While many children are at risk for developing myopia, which could lead to high myopia, the risk of myopia and retinal damage is far more common in individuals who had low birth weight or premature birth. A variety of types of screening instrumentation are discussed in terms of practicality of use and cost. The technical challenges in populations with dark eyes, small pupils, and poor anterior-segment media are discussed. We discuss the wealth of screening strategies, from permanent sites with trained staff and expert graders to planned campaigns that target specific populations. Successful screening systems include instrumentation that is used within its limits, feedback and supervision during screening and grading, and clear pathways for referral for a complete examination or treatment. Keywords: vision screening, diabetic retinopathy, diabetic macular edema, age-related macular degeneration, degenerative myopia, pediatric vision screening&nbsp

BACKGROUND:Vision impairment in children, the leading causes of which are untreated refractive errors and amblyopia, is a significant global health issue. This study focuses on the current practices of vision impairment screening of children and adolescents by family medicine physicians in the Eastern Region of Saudi Arabia. The aim of this study was to evaluate the methods used by family medicine physicians to screen vision and identify areas requiring improvement to enhance early detection and treatment.MATERIALS AND METHODS:A cross-sectional descriptive study was conducted among 172 family medicine physicians in the Eastern Region of Saudi Arabia from 2023 to 2024. Data were collected using via social media and visits using a self-administered questionnaire comprising questions on sociodemographics, current screening methods, and physicians’ confidence in performing various visual assessment tests. Descriptive statistics were used to summarize the data, and Chi-square test was used to determine associations between physician demographics and screening practices.RESULTS:The study found that visual inspection of the external eye was the most commonly used test for both over and under 3 years of age while visual acuity tests with letters or numbers and red reflex were used by 41.9% and 40.1% for over and under 3 years old, respectively. However, significant gaps were identified in training and resource availability; many physicians lacked access to advanced screening tools as well as sufficient training in pediatric ophthalmology.CONCLUSION:The study highlights the need for enhanced training programs and better resource allocation to improve vision screening practices by family medicine physicians. Implementing comprehensive training in pediatric vision screening and ensuring access to appropriate screening tools are critical steps toward the improvement of early detection and treatment of vision impairment in children and adolescents.

We report a new model of community-based secondary vision screening and demonstrate that a high proportion of children can be effectively managed in such a clinic without referral to the hospital eye service (HES). We performed a 64-month retrospective study of a secondary vision screening clinic providing the combined skills of an optometrist and orthoptist in a community setting. Particular attention was given to the diagnosis and management of children not referred to the HES. During this period, 1755 children were sent appointments and 74% (1300) attended the clinic. The community orthoptist and school nurses referred 53% of the patients and health visitors, general practitioners and community medical officers made 32% of the clinic referrals. Spectacles were prescribed for 41% of the children and 8% were prescribed patching. Sixteen per cent of the children were referred on to the HES. This model of care using the combined expertise of the orthoptist and optometrist is able to diagnose and manage the majority of children who have failed primary vision screening and avoids unnecessary referrals to the HES.

Background:Evidence on how social and school-level contexts shape pediatric vision screening outcomes is limited, particularly in sub-Saharan Africa. We examined the association between individual and contextual factors and vision screening outcomes in a pilot enhanced school-based vision screening program (ESVSP) in Kumasi, Ghana.Methods:We conducted a cross-sectional study using data from an ESVSP to detect eye disorders in schoolchildren aged 4 to 22 years. Outcomes were the presence of eye disorders and referral adherence. Exposure variables were individual [(age, sex, socioeconomic status (SES)], and contextual [school type (public vs private)] factors. Logistic regression was used to estimate unadjusted (OR) and adjusted (aOR) odds ratios with 95% confidence intervals (CI).Results:We analyzed data for 1,123 children screened and 299 referred. The average age was 10.2 (±2.6) years. Overall, 34% (n=382) had suspected eye disorders, and 32.8% (n=98) adhered to the referral. After adjusting for key variables, children attending public (32.2%) compared to private (67.8%) schools had 45% lower odds of identified eye disorders (aOR= 0.55; 95% CI 0.37, 0.83). Children with low (13.3%) compared to high (28.6%) SES had 70% lower odds of referral adherence (aOR= 0.30; 95% CI 0.12, 0.80).Conclusion:In this pilot school-based program, school context and socioeconomic status were associated with suspected pediatric vision and eye disorders, and referral adherence, respectively. These findings highlight equity-relevant gaps in referral adherence and underscore the need for context-specific strategies to strengthen referral pathways in low-resource settings.

Vision is crucial for childhood development, and ensuring good vision in children is one of the United Nation’s sustainability goals. Most countries have a childhood vision screening programme, and in Norway screening in children aged 4–5 years is performed in community health centres (CHC). Specialist health services such as ophthalmology and/or orthoptics are the referral bodies. However, access to these may be limited and they may be a long distance away from the child’s home, while optometrists are often more available and accessible. This study aims to investigate if vision screening reliably detects vision problems and to explore if using paediatric optometry as a referral body can relieve the specialist health services. The study also aims to report frequency of refractive errors and management of vision problems in this age group. Of 274 children who attended vision screening by school nurses at the CHC in Kongsberg, Norway, parents of 213 (77.7%) consented to a separate eye and vision examination by a paediatric optometrist. Agreements in screening results between school nurses and the paediatric optometrists were evaluated. Separately, an ophthalmologist and an orthoptist assessed records from the eye examinations through a digital communication tool (Eyecheck System AS). Agreements in diagnoses and management decisions between optometrists and the specialist health services were evaluated. Amblyopia or ocular pathology was found in 1.9% of the children, which were all identified by the vision screening. The vision screening had a sensitivity and specificity of 62.3% and 58.6%, respectively, for detecting other vision problems in need of treatment or follow-up. Hypermetropia was present in 82.7% of the children (58.0% low, 18.5% moderate, 6.5% high hypermetropia), 16.4% had emmetropia and 1.0% had myopia. Glasses were prescribed to 8.5% of the children and 16.4% were scheduled for follow-ups. There was a high level of agreement in management between optometrists and specialists (ophthalmologist 80.3%, orthoptist 81.7%). The vision screening reliably detected amblyopia and ocular pathology, and most refractive errors were detected. The high degree of agreement between the three eye care professions suggests that paediatric optometrists can be used as the referral body for this age group. Availability of a digital communication tool provides support for the paediatric optometrists in their decision making and can help relieve the specialist health services by providing children with an eye examination and vision correction earlier and more easily.

Clinical accuracy of the AAPOS pediatric vision screening referral criteria

BackgroundAlthough pediatric vision screening now passes evidence-based scrutiny, and has recent AAP guidelines, routine acuity testing in pediatric offices may still perform poorly.MethodsFrom 6/2002 through 8/2005, all children aged 0–6 directly referred by pediatric caregivers to one pediatric ophthalmologist were compared as to referral indication: failed acuity, strabismus, and positive Brückner test. AAPOS gold standard exam criteria was applied and compared to community photoscreening.ResultsBy referral indication, the following are numbers and predictive values: acuity (n = 80, PPV 51%), Brückner (n = 74, PPV = 89%), strabismus (n = 432, PPV = 81%). Community photoscreening referred n = 392 with PPV = 91%. The objective tests and strabismus queries were not age-dependent.ConclusionThe pediatric home best conforms to WHO guidelines due to case-continuous finding and assistance with treatment compliance particularly for strabismus. Objective tests outperform acuity testing in referral for refractive amblyopia including Brückner test in experienced hands. Observation and history best refers strabismus.

Research data are not shared. Supplementary Figure 1. Geographical representation of the hospital and health services (HHS) in Queensland. Source: https://www.health.qld.gov.au/maps. Supplementary Table 3. Outcomes of children referred for a formal eye examination. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

BackgroundThe visual demands of modern classrooms are poorly understood yet are relevant in determining the levels of visual function required to perform optimally within this environment.MethodsThirty‐three Year 5 and 6 classrooms from eight south‐east Queensland schools were included. Classroom activities undertaken during a full school day (9-am to 3-pm) were observed and a range of measurements recorded, including classroom environment (physical dimensions, illumination levels), text size and contrast of learning materials, habitual working distances (distance and estimated for near) and time spent performing various classroom tasks. These measures were used to calculate demand‐related minimum criteria for distance and near visual acuity, contrast and sustained use of accommodation and vergence.ResultsThe visual acuity demands for distance and near were 0.33 ± 0.13 and 0.72 ± 0.09 logMAR, respectively (using habitual viewing distances and smallest target sizes) or 0.33 ± 0.09 logMAR assuming a 2.5 times acuity reserve for sustained near tasks. The mean contrast levels of learning materials at distance and near were greater than 70 per cent. Near tasks (47 per cent) dominated the academic tasks performed in the classroom followed by distance (29 per cent), distance to near (15 per cent) and computer‐based (nine per cent). On average, children engaged in continuous near fixation for 23 ± 5 minutes at a time and during distance‐near tasks performed fixation changes 10 ± 1 times per minute. The mean estimated habitual near working distance was 23 ± 1 cm (4.38 ± 0.24 D accommodative demand) and the vergence demand was 0.86 ± 0.07Δ at distance and 21.94 ± 1.09Δ at near assuming an average pupillary distance of 56-mm.ConclusionsRelatively high levels of visual acuity, contrast demand and sustained accommodative‐convergence responses are required to meet the requirements of modern classroom environments. These findings provide an evidence base to inform prescribing guidelines and develop paediatric vision screening protocols and referral criteria.

A clinical look at the AAPOS pediatric vision screening referral criteria to predict amblyopia

To develop a method to identify preschools with the greatest need for vision screening, correlations between socioeconomic status, preschool capacity, and rates of pediatric vision screenings performed by a community vision screening program were investigated. Geoinformatics mapping software was used to visually display the areas of greatest need. Vision screening data from a community vision screening program, child care facility data from California Department of Social Services, and income data from the U.S. Census Bureau through ArcGIS software (Esri) were collected. When possible, data were consolidated at the ZIP code level. Kolmogorov-Smirnov analysis was used to determine correlations between data elements. Licensed child care facilities were scored on a scale (from 1 to 5) based on the socioeconomic status of the ZIP code and the facility capacity. The scoring system prioritized larger facilities in lower income communities to most efficiently use vision screening program resources. There was a positive correlation between the capacity of the child care facility and the median household income (P = .005). Second, we found a positive correlation between child care capacity and the median household income (P = .005). Licensed child care facilities were mapped and colored using GIS software according to their cumulative score. Challenges to vision screening in under-served communities include the lack of child care facilities and smaller facility size. The use of a scoring system and mapping software can direct vision screening programs to reach a greater number of children with the most efficient use of resources. [J Pediatr Ophthalmol Strabismus. 2022;59(6):375-379.].

The Spot Vision Screener (SVS) is designed to detect significant ametropia, anisometropia, and strabismus in non-dilated eyes. This study evaluates the efficacy of the SVS in paediatric visual screening. All children screened during the paediatric visual screening day in Lausanne in 2016 were evaluated with the SVS, conventional monocular autorefractors, and clinical orthoptic examination. Recommendations for a further eye examination of the SVS were compared with those issued from traditional clinical screenings (monocular refraction and orthoptic examination). One hundred and sixty-eight consecutive children were included. The median age was 3.9 years. The SVS median spherical equivalent (SE) was + 0.25 D OU and it detected seven cases of (4.2%) anisometropia (SE difference ≥ 1 D). The conventional monocular autorefractor median SE was - 0.13D OU and 20 cases of anisometropia (11.9%) were detected. Refraction could not be measured in 1.2% of patients with SVS versus 17.2% with monocular refractors. The SVS screened two manifest strabismus cases against five manifest and > 100 latent strabismus with orthoptic examination. As expected, the SVS was unable to assess reactions to monocular occlusion, visual acuity, and stereovision as well as to detect ocular motility disorders without strabismus in the primary position, and missed two cases of abnormal Brückner reflexes. Overall, the SVS identified 66 suspect patients (39.3%) against 102 (60.7%) after complete clinical examination. The SVS can be a useful objective screening tool for non-ophthalmologists. However, because it fails to detect ocular motility troubles, organic visual acuity loss, or to assess the visual potential, it should only be used in association with a clinical examination, even in routine screening procedures.

Introduction: Cataract is defined as the opacity of the lens, which leads to reduced vision and can eventually result in blindness. In pediatric patients, it has a poor visual prognosis if not diagnosed early. Objective: The aim of our study is to clinically and demographically characterize pediatric cataract patients in a referral hospital of a developing country, as well as to identify the challenges faced in providing care for these patients. Subjects and Methods: A cross-sectional descriptive observational study was conducted, including all pediatric patients diagnosed with cataract over a 10-year period. Results: A total of 95 patients were studied, comprising 113 eyes. The most common clinical presentation was leukocoria. The median age at diagnosis was 24 months (interquartile range [IQR]: 80 months), and the median time from diagnosis to surgery was 1 month (IQR: 2 months). The median follow-up time after surgery was 3 months (IQR: 1–12 months). The most common cause of loss to follow-up was financial or personal difficulties faced by the parents, accounting for 20% of cases. Conclusions: Red reflex examination is essential during pediatric visual screening to ensure early diagnosis of cataract. The age at diagnosis varies depending on the etiology and may be influenced by socioeconomic status and local factors such as access to healthcare services.