1. PEDIATRIC VISION SCREENING
GUIDELINES FOR PRIMARY CARE PROVIDERS AND SCHOOL NURSES

2. Learning Objectives
Appreciate the importance of vision screening during childhood.
Understand methods that enhance the accuracy of visual acuity screening.
Appreciate new technologies that can identify signs of potential vision problems.

3. PEDIATRIC VISUAL ACUITY SCREENING

4. Why Perform Vision Screening?
Primary Care Providers and School Nurses:
The first line of defense to detect preventable vision loss in children.
Recommended as part of the
American Academy of Pediatrics
Bright Futures Periodicity
schedule.
Why do children lose vision?
Amblyopia: commonly referred to as “lazy eye”

5. Amblyopia
Amblyopia is a decrease in vision development that happens when the brain does not get normal stimulation from the eye(s).
Abnormal development of vision results when one or both eyes send a blurred or distorted image to the brain.
The brain is unable to “learn” to see clearly with that eye, even when glasses are used.

6. Amblyopia
Only children can get amblyopia. If it is not treated in childhood, it results in permanent loss of vision.
The most common cause of vision loss in adults years of age is untreated childhood amblyopia.
Amblyopia is most commonly caused by untreated refractive errors, strabismus, or defects within the eye (e.g. cataract).

7. Screening Early is Best
School-aged vision screening may occur too late:
Amblyopia starts becoming refractory to treatment after 5 years of age.
Permanent vision loss occurs by 7 years of age.

8. Vision Screening in the United States
National Eye Institute (NEI)
Amblyopia affects 2 - 3% of children in the United States
An estimated 4.5 million children with preventable vision loss.

9. Visual Acuity Screening is the Current Gold Standard
In cooperative children, direct measurement of visual acuity using visual acuity charts remains the gold standard for vision screening.
Vision screening devices measure risk factors for amblyopia, not the actual visual acuity. This is why visual acuity charts are still the gold standard.

10. Barriers to Screening Poor cooperation of young children
Takes too long to perform
Staff not adequately trained
Poor reimbursement for providers

11. Visual Acuity Screening Guidelines
Age-Dependent Thresholds
Vision Screening Recommendations (PDF print format) provided by the Vision Screening Committee of AAPOS:

12. Newborn to 35 Months (0-3 years)
Take a health history, including eye problems in close relatives.
Check vision (tracking), eye movement, and ocular alignment.
Corneal light reflexes or cover testing
Examine the eyes, eyelids, and pupils and red reflexes.

13. 36 Months to 47 Months (3–4 years)
Measure Visual Acuity
Must be able to identify the majority of the 20/50 line optotypes with each eye.
Testing should be done at 10 feet.
Opposite eye must be effectively covered.

14. 36 Months to 47 Months (3-4 years) Recommended Chart Types
Lea Symbols
HOTV Letters

15. Less than Ideal Chart Choices Not Recommended for Children
Sailboat chart is not scientifically standardized. Children have trouble with the concept of the tumbling E, it is difficult for them to form the E with their hands and adds the motor/interpretation task of having them orient their hand in the appropriate direction.

16. 48 Months to 59 Months (4-5 years)
Must be able to identify the majority of the 20/40 line optotypes with each eye.
HOTV Match Card
Using a match card with either Lea symbols or HOTV optotypes greatly facilitates the responsiveness of younger children who may be shy and less cooperative.

17. 60 Months and Older (5+ years)
Must be able to identify the majority of the 20/32 (or 20/30)* line with each eye.
Sloan letters (shown)
Preferred over Snellen Letters
Snellen charts have a 20/30 line*
Repeat testing:
Every 1-2 years
Sloan letter chart

18. AAPOS Vision Screening Kit Conforms to AAPOS/AAO/AACO/AAP Visual Acuity Standards
Contents:
Occluder patches
Occluder glasses
Occluder paddle
10 ft. measuring cord
Match response card
Acuity charts:
-Sloan letters
- Available with choice of Lea symbols or HOTV letters
Two instructional DVDs
The kit can be purchased in one of two versions, Lea Symbols or HOTV letters, through Good Lite for $69
Lea Symbol/Sloan letter version:
HOTV/Sloan letter version:
A 10% discount is available for orders of 5 or more kits. For this special offer, please
AAPOS is offering a basic screening kit to assist anyone who screens vision, including school nurses, Lions Club members, Head Start, and medical personnel working in pediatrics and family medicine.
The AAPOS Vision Screening Kit is for screening the vision of individuals beginning at age 3 through adulthood.
Kit Contents:
Spiral-bound, multisided, distance visual acuity eye charts that can be hung on a wall or held in the hands.
Sloan Letters for when children know their letters.
Purchaser can choose from one of two versions with either LEA Symbols or HOTV letters for preschoolers and for children who do not yet know their letters.
Screening is conducted at 10 feet.
Full-Chart Threshold and Single Critical Line formats:
Threshold screening involves beginning at the top of an eye chart and moving down the chart until the child or adult misses 3 of 5 optotypes.
Critical line screening is using only the line which the child or adult should correctly identify 3 of 5 optotypes according to age.
Children ages 36 to 47 months should correctly identify 3 of 5 optotypes on the 20/50 line.
Children ages 48 to 59 months should correctly identify 3 of 5 optotypes on the 20/40 line.
Children aged 60 months and older, and adults, should correctly identify 3 of 5 optotypes on the 20/32 line.
Adhesive occlusion patches.
Black hand-held flip paddle occluder for children aged 10 and older and adults who will not tolerate patches.
Children's Fun Frames Occluder Glasses for children under age 10 years who will not tolerate patches.
10-foot cord for measuring screening distance between chart and child's or adult's eyes.
Translucent Response Panel for matching.
Instructions printed on one of the eye chart cards.
School Nurse Vision Screening Tutorial DVD created by Kathy Lee, MD, PhD, for the American Academy of Ophthalmology's Leadership Development Project, which rolled out at NASN in 2010 and now includes a Spanish version.
A second DVD with Vision Screening Results Reporting Form to copy and distribute to individuals undergoing screening.
Information included on Reporting Form describes the importance of a follow-up eye exam to copy and distribute to parents/guardians when their children do not pass vision screening or are untestable on multiple rescreens
AAPOS Vsion Screening Kit

19. Threshold and Critical Line Options
Both options are available in the AAPOS Vision Screening Kit and the AAPOS Vision Screening App.

20. Threshold Screening
Reading down the eye chart until a Threshold line is crossed…
e.g. 20/32 for age 5+ years
Or as far down as possible.
Allows for inter-ocular comparison between the two eyes.
Refer children with a two-line difference between eyes.
Sloan Letter Threshold Screening
10/xx on left side of chart is screening distance; 20/xx on right side of chart is Snellen equivalency and the number to report.
• Use with children and adolescents (including adults) who comfortably know their letters and are aged 5 years and older.
• Use 10-foot cord from Kit to measure screening distance between chart and child’s eyes.
• Child may stand during screening or sit on a chair.
• Hold, or hang, chart at child’s eye level.
• Cover left eye with patch. Use black occluder only for children aged 10 years and older and only if patches are unavailable or are not tolerated.
• Starting at the top line, ask child to identify the first letter on the left side of each line and move down the chart until a letter is missed.
• Avoid pointing to, and holding pointer, at the letters to be identified. Holding the pointer at the letter makes it easier for the child to identify the letter and the screener
could under-detect a vision disorder. Instead, briefly point to the letter and quickly remove pointer.
• When child misidentifies a letter, return to the line above the missed letter and ask child to identify each letter on that line.
• Continue asking child to identify each letter on each lower line until child misses 3 on one line (continue asking child to identify the full line even when 3 or more are missed).
• Repeat with right eye covered, using the first letter on the right side of each line.
• Visual acuity score = The last line on which the child correctly identified 3 of 5 letters.
• Pass = Correctly identifying 3 of 5 letters on the 20/32 line with each eye.
• Fail and rescreen within 6 months or refer = Missing 3 or more letters on the 20/32 line, or any line above the 20/32 line, with either eye.
• Fail and rescreen within 6 months or refer = Two-line difference between the eyes, even within the passing range – e.g., 10/10 (20/20) and 10/16 (20/32).
LEA Symbols or HOTV Letters– Threshold Screening
• Use with preschoolers beginning at age 3 years until children comfortably know their letters.
• With both eyes uncovered, ask child to identify symbols on the 20/100 line to ensure child understands the screening task.
• Children call LEA Symbols whatever name they choose (i.e., circle may be a hula-hoop, etc.).
• If child says “I don’t know”, screener can provide two choices and ask child to select one. For example, for the circle, the screener could say, “Some children think
this is a circle; others think it is a ball. What do you think?”
• Children may use response panel to match symbols by pointing at the symbol matching the symbol to identify on the chart.
• Screener can place individual cards on table, or on floor, in front of child. Child may point to or hold an individual card to match the symbol on the chart or children can
step on the individual card on the floor to match the symbol on the chart.
• Cover left eye with adhesive patch. Use occluder glasses only if patches are unavailable or are not tolerated. Use black occluder only for children aged 10 years and older.
• Starting at the top line, ask child to identify the first symbol on the left side of each line and move down the chart until a symbol is missed.
• Avoid pointing to, and holding pointer, at the symbols to be identified. Holding the pointer at the symbol makes it easier for the child to identify the symbol and the
screener could under-detect a vision disorder. Instead, briefly point to the symbol and quickly remove pointer.
• When child misidentifies a symbol, return to the line above the missed symbol and ask child to identify each symbol on that line.
• Continue asking child to identify each symbol on each lower line until child misses 3 on one line (continue asking child to identify the full line even when 3 or more are missed).
• Always say “good job” or other supportive words, even when child responds incorrectly.
• Repeat with right eye covered, using the first symbol on the right side of each line.
• Visual acuity score = The last line on which the child correctly identified 3 of 5 symbols.
• Pass = For children aged months = Correctly identifying 3 of 5 symbols on the 20/50 line with each eye.
• Pass = For children aged months = Correctly identifying 3 of 5 symbols on the 20/40 line with each eye.
• Pass = For children aged 60 months and older = Correctly identifying 3 of 5 symbols on the 20/32 line with each eye.
• Fail and rescreen within 6 months or refer = For children aged months = Missing 3 or more symbols on the 20/50 line, or any line above the 20/50 line, with either eye.
• Fail and rescreen within 6 months or refer = For children aged months = Missing 3 or more symbols on the 20/40 line, or any line above the 20/40 line, with either eye.
• Fail and rescreen within 6 months or refer = For children aged 60 months and older = Missing 3 or more symbols on the 20/32 line, or any line above the 20/32 line,
with either eye.

21. Critical Line Screening is Faster Only read a single “critical” line with each eye
Sloan Letters Critical Line Screening
10/xx on left side of chart is screening distance; 20/xx on right side of chart is Snellen equivalency and the number to report.
• Use with children and adolescents (including adults) who comfortably know their letters and are aged 5 years and older.
• Use 10-foot cord from Kit to measure screening distance between chart and child’s eyes.
• Child may stand during screening or sit on a chair.
• Hold, or hang, chart at child’s eye level.
• Cover left eye with patch and bottom boxed line on chart with your hand or paper. Use black occluder only for children aged 10 years and older and only if patches are
unavailable or are not tolerated.
• Ask child to identify letters in top boxed line on chart.
• Repeat with right eye covered and top boxed line covered.
• Pass = Correctly identifying 3 of 5 letters with each eye.
• Fail and rescreen within 6 months or refer = Missing 3 or more letters with either eye.
LEA Symbols or HOTV Letters Critical Line Screening
• Use with preschoolers beginning at age 3 years until children comfortably know their letters.
• Select chart to match child’s age; one chart is for ages months, one is for ages months, and one is for ages 5 years and older.
• With both eyes uncovered, ask child to identify symbols on the 20/100 line to ensure child understands the screening task.
• Children call LEA Symbols whatever name they choose (i.e., circle may be a hula-hoop, etc.).
• If child says “I don’t know”, screener can provide two choices and ask the child to select one. For example, for the circle, the screener could say, “Some children
think this is a circle; others think it is a ball. What do you think?”
• Children may use response panel to match symbols by pointing at the symbol matching the symbol to identify on the chart.
• Screener can place individual cards on table, or on floor, in front of child. Child may point to or hold an individual card to match the symbol on the chart or children can
step on the individual card on the floor to match the symbol on the chart Cover left eye with patch and bottom boxed line on chart with your hand or paper.
• Cover left eye with patch and bottom boxed line on chart with your hand or paper. Use occluder glasses only if patches are unavailable or are not tolerated. Use black
occluder only for children aged 10 years and older.
• Ask child to identify symbols on top boxed line on chart.
• Avoid pointing to, and holding pointer, at the symbols to be identified. Holding the pointer at the symbol makes it easier for the child to identify the symbol and the
screener could under-detect a vision disorder. Instead, briefly point to the symbol and quickly remove pointer.
• Repeat with right eye covered and top boxed line covered (no need to do 20/100 line again).
• Pass = = For children aged months = Correctly identifying 3 of 5 symbols on the 20/50 line with each eye.
• Pass = For children aged months = Correctly identifying 3 of 5 symbols on the 20/40 line with each eye.
• Pass = For children aged 60 months and older = Correctly identifying 3 of 5 symbols on the 20/32 line with each eye.
• Fail and rescreen within 6 months or refer = For children aged months = Missing 3 or more symbols on the 20/50 line with either eye.
• Fail and rescreen within 6 months or refer = For children aged months = Missing 3 or more symbols on the 20/40 line with either eye.
• Fail and rescreen within 6 months or refer = For children aged 60 months and older = Correctly identifying 3 of 5 symbols on the 20/32 line with each eye.
Each chart has two boxed critical lines: one for each eye.

22. Supplemental AAPOS Vision Screening Kit
Basic kit plus
Stereo testing
Color vision testing
Near acuity charts for testing at 16 inches.
The kit can be purchased through Good Lite for $250
The AAPOS Vision Screening Kit: Supplemental Screening Package is for screening the vision of individuals beginning at age 3 through adulthood.
Kit Contents:
Spiral-bound, multisided, near eye charts with attached 16-inch cord.
Sloan Letters for when children know their letters.
LEA Symbols for preschoolers and for children who do not yet know their letters.
Full-Line Threshold and Single-Line Critical Line formats:
Threshold screening involves beginning at the top of an eye chart and moving down the chart until the child or adult misses 3 of 5 optotypes.
Critical line screening is using only the line which the child or adult should correctly identify 3 of 5 optotypes according to age.
Children ages 3 and 4 years should correctly identify 3 of 5 optotypes on the 20/40 line.
Children aged 5 years and older, and adults, should correctly identify 3 of 5 optotypes on the 20/32 line.
Adhesive occlusion patches.
Black hand-held flip paddle occluder for children aged 10 and older and adults who will not tolerate patches.
Children’s Fun Frames Occluder Glasses for children under age 10 years who will not tolerate patches.
Random Dot Butterfly stereopsis test with intermediate-sized polarized glasses.
16-Plate pseudoisochromatic color vision test.
Instructions printed on eye chart card.
School Nurse Vision Screening Tutorial DVD created by Kathy Lee, MD, PhD, for the American Academy of Ophthalmology’s Leadership Development Project, which rolled out at NASN in 2010 and now includes a Spanish version.
DVD with:
Vision Screening Results Reporting Form to copy and distribute to individuals undergoing screening.
Information included on Reporting Form describes the importance of a follow-up eye exam to copy and distribute to parents/guardians when their children do not pass vision screening or are untestable on multiple rescreens.
AAPOS Supplemental Screening Package

23. Computerized Eye Charts
Apps for tablets / phones
Desk and Laptop programs
On-line programs

24. AAPOS Vision Screening App. for iPad
Available in the ITunes App Store for $29.99
Conforms to AAPOS/AAO/AACO/AAP Vision Screening Guidelines.
AAPOS Vision Screening App Description:

Quickly and easily screen the vision of children and adults beginning at age 3 years with evidence-based LEA Symbols and Sloan Letters. App is based on the basic distance Vision Screening Kit created by AAPOS. 

Charts include both full-chart threshold and critical line formats using either LEA Symbols or Sloan Letters optotypes. Critical line screening is a quick method for screening where individuals are screened using only the line that matches their age. 

Each test format can be used for distance screening at 10ft/3m or for near vision screening at 16in/40cm.

Each screening test starts with a practice screen to familiarize the screenee with the process. Then quickly move to the screening test for first the right eye and then the left eye. The Pass/Fail criteria is indicated for the age group in each screen. 

The AAPOS Vision Screening App is appropriate for anyone who screens vision, including medical personnel working in pediatrics and family medicine, Head Start personnel, school nurses, and Lions Club members.
Note: This app is designed for iPads with high resolution retina displays.
AAPOS Vision Screening App for iPad available in iTunes Store

25. On-line Visual Acuity Screening
The Jaeb Center for Health Research is a nonprofit center for clinical trials and epidemiologic research in ophthalmology and diabetes.
Pediatric Eye Disease Investigator Group (PEDIG)
JVAS (Jaeb Visual Acuity Screener) is free for Windows PCs. JVAS
Pediatric visual acuity screener meant for non-ophthalmic health care professionals.

26. JVAS (Jaeb Visual Acuity Screener)
Free Test distance 5 feet (1.5 m)
JVAS also has an HOTV matching card PDF available for download
JVAS link:
HOTV Matching Card.pdf
An HOTV Matching Card is included in the program download. You can download the matching card directly by clicking the link above.Resources:
An HOTV Matching Card is included in the program download. You can download the matching card directly by clicking the link above.
JVAS Tutorial - Coming Soon!
A short video showing how to use the application.
JVAS HOTV matching card

27. Reimbursement for Acuity Screening
CPT 99173
Use with screening tests of visual acuity
Wall charts
Computerized eye charts
AAPOS Vision Screening Kit
May be reimbursed separately or may be bundled into the well-child visit. Varies by state and insurance carrier.

28. PEDIATRIC PHOTOSCREENING

29. Instrument-Based Screening: Commonly Called “Photoscreening”
Photoscreeners, autorefractors, and other devices do not replace visual acuity screening with eye charts.
Particularly helpful in children ages 1-5 years.
PlusOptix S12c

30. Visual Acuity Screening is the Current Gold Standard
Direct measurement of visual acuity using vision charts is the current gold standard for vision screening, unless the child is not reliably able to perform such a test

31. What is the Difference Between Vision Screening with Eye Charts and Vision Screening Devices?
Vision screening with eye charts tests the actual visual acuity (20/20 etc.)
Vision screening devices typically do not test visual acuity directly.
Screening devices test for eye conditions or risk factors that may cause decreased vision or amblyopia

32. What is a Photoscreener or Autorefractor?
An instrument that takes a photographic image of the eye’s red reflex, or some other measurement, to estimate the refractive error.
“prescription” of the eye
Also may detect ocular misalignment and other conditions degrading or blocking line of sight (cataract).
PlusOptix S09 Screenshot 32

33. Common Photoscreeners and Autorefractors
iScreen
Righton
Retinomax
Welch Allyn SureSight
Welch Allyn
“Spot”
PlusOptix S12R

34. Photoscreeners
These photos reveal that this child has farsightedness (hyperopia) indicated by the characteristics of the crescent formed in the “red reflex” (seen as a white crescent in this B&W photo)
Photoscreeners originally did use photos!
For example, the MTI photoscreener, which was first introduced in The camera used instant film with an off axis flash which rotates 90 degrees between images. Two consecutive photos were taken on each patient resulting in a photograph showing the first image on the top and the 2nd image on the bottom printed on a special high-resolution Polaroid film. Based on the shape and size and location of the crescents a determination could be made as to whether the child has significant hyperopia, myopia, astigmatism or strabismus. Myopic crescents show on the same side of the flash while hyperopic crescents show opposite to the flash.
Source: EyeWiki
Authors: David Silbert MD, Noelle Matta CO
MTI Photoscreener 34

35. Typical Photoscreeners in Use
iScreen
PlusOptix S12
Typical testing distance is about 3.5 feet or 1 meter. This limits but does not fully prevent the effects of accommodation.

36. Other Vision Screening Devices

37. Diopsys “Enfant” Diopsys “Enfant” VEP vision test.
Tests the entire visual pathway: “front to back”
Eye
Optic nerve
Visual cortex

38. EyeSpy 20/20 Automated computer software Tests:
Visual acuity
Stereopsis
Color vision
Runs on a standard laptop or desktop computer

39. EyeSpy 20/20
After testing the visual acuity of each eye, the program generates a report
With cloud-based storage, EyeSpy 20/20 can integrate and store data collected from other devices such as photoscreeners and school databases

40. REBIScan Pediatric Vision Scanner
Retinal birefringence technology.
Tests for the amblyopia by detecting microstrabismus.

41. REBIScan Pediatric Vision Scanner
Assesses foveal fixation.
Amblyopic eyes are found to have abnormal fixation (microstrabismus).

42. When to Photoscreen? Generally not before 1 year of age.
Poor fixation behavior impedes measurement.
The false positive rate is high.
There is a low likelihood of ophthalmic intervention.
Except for constant strabismus, cataract, glaucoma, retinoblastoma.
Correction of refractive error typically delayed.

43. Photoscreening is Useful For:
Most children ages 1-3 years.
Usually unable to perform visual acuity chart tests.
Some children ages 3-5 years.
Acuity chart testing is preferred, but…
Photoscreening is the recommended alternative if the child is not reliably able to perform acuity chart testing.

44. Photoscreening is Not Experimental
The United States Preventative Services Task Force (USPSTF) has recognized photoscreening as appropriate methodology for vision screening of children aged 3-5 years.
US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics :127:340-6.
Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing. All members volunteer their time to serve on the USPSTF, and most are practicing clinicians.

45. Photoscreening is Endorsed by the American Academy of Pediatrics
The American Academy of Pediatrics has issued a policy statement supporting the use of these technologies for preschool vision screening
Miller JM, Lessin HR, American Academy of Pediatrics Section on Ophthalmology; Committee on Practice and Ambulatory Medicine; American Academy of Ophthalmology: American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Instrument-based pediatric vision screening policy statement. Pediatrics :983-6.

46. Photoscreening May be Better ( ? )
A randomized, controlled, multi-centered cross-over study demonstrated photoscreening to be superior to direct testing of visual acuity for screening of well children ages 3-6 years in the pediatric office.
Salcido AA, Bradley J, Donahue SP. Predictive value of photoscreening and traditional screening of preschool children. J AAPOS 2005 Apr;9(2):
Major Articles
Predictive Value of Photoscreening and Traditional Screening of Preschool Children
April A. Salcido,a Joel Bradley, MD,b and Sean P. Donahue, MD, PhDb,c,d
Purpose: To compare the usefulness of traditional vision screening and photoscreening of 3- and 4-year-old children in the pediatrician’s office. Methods: Following training of pediatricians and office staff, six pediatric clinics used both the MTI PhotoScreenerTM (Medical Technology Industries, LLC, Riviera Beach, FL) and traditional acuity and stereopsis screening materials (HOTV charts/Random Dot E tests as recommended by established AAP-MCHB-PUPVS guidelines) during well-child exams. Clinics used one testing method for a 6-month period and switched to the other for the following 6 months, in a randomized manner. Referred children received a complete eye examination with cycloplegic refraction by local ophthalmologists or optometrists who forwarded the results to Vanderbilt Ophthalmology Outreach Center. Amblyogenic factors were defined using standardized published criteria. Results: Six hundred five children were screened with the photoscreener and 447 were screened with traditional techniques. Mean time for screening was less with the photoscreener: 2.5 versus 5.9 minutes (P 􏰀 0.01). Untestable rates were similar (18% vs 10%, respectively P 􏰁 NS), but higher with the photoscreener due to one clinic’s 70% unreadable rate. Referral rates were also similar: 3.8% versus 4.5%. The positive predictive value (PPV) rate differed greatly. With follow-up results obtained from 56% of referred children, 73% of photoscreening referred children (8/11 examined) had amblyogenic factors confirmed on formal eye exams, whereas all children referred using traditional screening methods (10/10 examined) were normal. Conclusion: Photoscreening is more time efficient than traditional screening and has a significantly higher PPV in 3- and 4-year-old children. This study was unable to validate traditional screening techniques in this preschool age group. If these results can be replicated, support for traditional vision screening must undergo intense scrutiny, and attention should be turned toward making photoscreening feasible for widespread implementation. (J AAPOS 2005;9: )
Amblyopia is stated to be the most prevalent child- hood visual disorder, affecting 2 to 5% of the pop- 1
take place. Earlier vision screening can detect children with amblyopia and amblyogenic factors at an appropriate
1,6-12
mal preschool vision screening, including formal testing of visual acuity and ocular alignment, beginning at age 3.7 However, despite these recommendations, most children are not screened, perhaps because traditional vision screening methods typically are felt to have high overre- ferral rates, low sensitivity, and low specificity.13,14 These techniques also require a considerable amount of time and are dependent on the child’s understanding, cooperation, and patience, and therefore, are relatively difficult in the 3-year-old child.
Several nontraditional vision-screening methods have
recently been introduced commensurate with recent ad-
vances in technology. These include automated noncy-
cloplegic autorefraction, photorefraction, and photo-
screening. Off-axis photoscreeners, specifically the MTI
PhotoScreenerTM, capture two images of each eye as a
Polaroid photograph. The photograph can then be inter-
preted to detect high myopia and amblyogenic factors such as
high hyperopia, strabismus, media opacity, and anisometro-
pia. The American Academy of Pediatrics has recently
released a statement supporting the use of photoscreening 15
ulation. If the condition is left untreated, an indi- vidual will generally have poor vision, perhaps even legal blindness, in the amblyopic eye for the duration of his lifetime.2,3,4 The Prospective Amblyopia Treatment Study has demonstrated that amblyopia treatment is highly ef- fective when it occurs within a sensitive period.5 Unfortu- nately this window typically closes prior to the start of formal schooling, which is when screening can most easily
age where treatment is effective. The American Academy of Pediatrics recommends for-
From the Vanderbilt University College of Arts and Science,a Department of Pediatrics,b Department of Ophthalmology and Visual Sciences,c and Department of Neurology,d Vanderbilt University School of Medicine, Nashville, TN. Presented at AAPOS Meeting, March 24, 2003, Kona, HI.
This work was supported by Research to Prevent Blindness, New York, NY; Cumberland Pediatric Foundation; American Academy of Pediatrics; Project Universal Preschool Vision Screening. This study was conducted at Vanderbilt University.
None of the authors have any financial interest in any vision screening technology. Submitted April 1, Revision accepted October 24, Reprint requests: Sean P. Donahue, MD, PhD, Ophthalmology and Visual Sciences, Vanderbilt University School of Medicine, 8000 Medical Center East, Nashville, TN
Copyright © 2005 by the American Association for Pediatric Ophthalmology and Strabismus /2005/$35.00 􏰂 0 doi: /j.jaapos
for preschool vision screening. The advantages of pho-
114 April 2005
Journal of AAPOS
Journal of AAPOS Volume 9 Number 2 April 2005
toscreening include its portability, time efficiency, and potentially high positive predictive value when performed in a well-controlled setting with appropriate interpretation and referral criteria.16,17,18 However, a significant disad- vantage of the MTI system is that photographic interpre- tation is not immediately available and there is a high degree of variability in photographic interpretation.1,19-21 Training, of both the screeners and the image interpreters, is time consuming, yet vitally important for success.16 In addition, photoscreening is significantly more expensive than traditional methods because of the cost of the camera, the film, and the photograph interpretation. Finally, pho- toscreening detects amblyogenic factors rather than amblyopia, and the natural history of many of these am- blyogenic factors is unknown, that is, the likelihood of amblyopia developing for various magnitudes of amblyo- genic factors in children of various ages has not been determined.
In 1998, the task force on Preschool Vision Screening that was commissioned by the Maternal Child Health Bureau and the National Eye Institute called for the Amer- ican Academy of Pediatrics to investigate the efficiency of traditional techniques for preschool vision screening (Project Universal Preschool Vision Screening).22 As part of the resultant study, we sought to compare traditional vision screening with photoscreening using the MTI Pho- toScreenerTM in a prospective randomized trial.
METHODS Screening Sites
This study used six pediatric clinics representative of the diverse population in the middle Tennessee area. The prac- tices encompass several counties throughout the midstate and range from 2500 to 15,000 pediatric patients per practice, of whom approximately 70% are Caucasian (Table 4). Each of the pediatric practices is a member of the Cumberland Pe- diatric Foundation, a consortium of pediatric practices in the mid-Tennessee area dedicated to improving outcomes by performing clinical and outcomes research.
The Study Design
This was a prospective, randomized, crossover, observa- tional study. IRB approval was obtained from Vanderbilt University Medical Center and parental consent was ob- tained prior to testing. Each clinic used both methods of screening within two separate, but consecutive, 6-month periods. Beginning October 1, 2001, each site was ran- domized to either traditional screening or photoscreening. After 6 months, the technique was changed, so that each site used both methods within the 1-year period. No sites used photoscreening before and had varying use of eye charts, but no mandate for traditional screening.
Preceding actual training at the clinical sites, at least one pediatrician from each practice attended a 2-hour Continuing Medical Education course, sponsored by the
Salcido, Bradley, and Donahue 115
Department of Ophthalmology and Visual Services and the Cumberland Pediatric Foundation, at Vanderbilt Uni- versity Medical Center. He or she was given an overview and explanation of the purpose and protocol of the study, followed by actual training of each method of preschool vision screening.
Each of the six participating pediatric clinics had a site visit with a complete 2-hour training session attended by all persons who would intend to screen, including but not limited to the primary care physician, practice nurses, and office staff nursing personnel. They were given full and detailed instruction about the testing method to which they had been randomized and the importance and relevance of preschool vision screening using a slide presentation and visual demonstrations. During the training seminar, trainees practiced screening on one another. Additionally, if the clinic was training to use the photoscreener, examples of readable and unreadable pho- tographs were viewed and studied.
Six months into the study, a training course was again held at each of the clinics to learn the second method of screening. Retraining was attempted again at two sites when it became apparent that the screeners were having difficulty obtaining adequately focused photoscreening images. Training time was identical for each technique, and we believed adequate to allow detection of children with amblyopia.
All screenings took place in the primary care setting as part of scheduled preventative medicine visits and well- child visits for 3- and 4-year-old children. Theoretically, all eligible children were supposed to have been offered enrollment in the study; it is highly unlikely that this occurred, since these practices see many more well chil- dren than were enrolled. Children presenting with ocular symptomatology or with urgent care visits were not to have been offered enrollment. All enrolled children were supposed to have had no obvious handicaps and be without any previous or existing eye conditions.
All the clinics had eye charts in place for screening prior to the start of the study. However, none had formal screening programs in place.
Screening Tests Traditional Screening. The criteria for screening,
defined by the AAP-PUPVS study, were used. Briefly, formal acuity testing, alignment testing, and stereopsis were accessed. Monocular distance acuity was tested with HOTV (Wilson Ophthalmic Corp., Mustang, OK) charts at a distance of 10 feet. Critical lines were 20/40 for children 36 to 47 months of age and 20/30 for children 48 to 59 months of age. Testing of five-letter rows began at the 20/100 level. The pretest was done binocularly, and at this point it was determined if the child would answer verbally or by letter matching. The child was to identify or match four targets 20/100 or greater in size before actually beginning. The screening
116 Salcido, Bradley, and Donahue
was then conducted monocularly by patching each eye in separate, but successive trials. One or two targets were presented on each line up to the respective critical line. At the critical line, all five targets were presented and the pass criterion was to match four of the five optotypes with each eye. If the determined level was unattainable, the child was referred.
Stereopsis was measured through a Random Dot E test (Stereo Optical Co., Inc., Chicago, IL) at a distance of 40 cm. All testing (including all pretesting) was done binoc- ularly with the polarized glasses on. The pretest examined the child’s ability to perform the test by identifying the location of the three-dimensional E correctly in four of five trials. The actual test procedure tested the child’s ability to locate the stereo E in four of five nonsystematic presentations. If the child failed to do so, he or she was referred.
Alignment testing was performed using a cover–uncover test at near with an age-appropriate accommodative target.
Photoscreening. The photoscreening arm used the MTI PhotoScreenerTM. The MTI PhotoScreenerTM uses an eccentric, off-axis flash. The photographic image is taken from a 1-meter distance in a dimly lit room. Two photographs are taken (of the eyes) to detect refractive error at 90 and 180°. Immediate examination of the pho- tograph by the screener is necessary to determine if the picture is adequate for further reading. To be considered readable, the photograph needed to be of adequate focus, show two pupils in each image captured, and have a pupil size of 4 to 8 mm for each pupil. Up to three pictures were taken to obtain a readable photograph. Children having three consecutive unreadable photographs were classified as being untestable. The photographs were then for- warded to the Vanderbilt Ophthalmic Imaging Center (VOIC) for analysis as previously described.16 For each child, a determination was made as pass, refer, or unread- able. Unreadable included all children who could not be photographed after three attempts as well as those whose photographs were felt to be readable at the screening site, but determined to be unreadable by VOIC. Following interpretation, results were returned to the pediatric of- fices where they were distributed to the patients.
Visual History and External Inspection. For all chil- dren in each session, an observation of any structural deformities and proper symmetry through an external in- spection was performed using penlight evaluation. Any child with abnormalities was referred. Additionally, par- ents were questioned about the family history and any systemic review factors affecting the child to determine additional risk factors. If none of these factors was present and the parent had no reason for concern, the child was passed. Referral on the basis of family history of strabismus was left to the screener (and pediatrician’s) discretion and did not occur in any case.
TABLE 1. Eye examination failure criteria (amblyogenic factors)
1. Anisometropia (sph or cyl) 􏰃1.00 D 2. Any manifest strabismus 3. Hyperopia 􏰃 􏰂3.50 D in any meridian 4. Myopia 􏰀 􏰄3.00 D in any meridian 5. Any media opacity 6. Astigmatism 􏰃1.5 D at 90° or 180° 􏰃1.0 D at oblique axis
Data Collection, Referrals, and Follow-Up
At the end of each week within the period of the study, clinics sent their screening forms to the VOIC. Upon arrival, results of traditional methods were placed directly into a central database. Only initials and dates of birth were recorded for each passing child, but for referred or untestable children, all fields, which included contact in- formation and initial reason for referral, were filled.
Results of photoscreening were first sent to VOIC for formal interpretation and then were inputted into the database in the same format as the traditional screening results. An informational packet was sent to the parents of referred children that included general information about amblyopia and vision screening, a list of ophthalmologists and optometrists in their surrounding area (with the in- surance plans in which they participated), and an evalua- tion sheet to be given to their eye doctor at the time of appointment. This evaluation was to be filled out by the eye doctor and then returned to Vanderbilt Medical Cen- ter for entry into the database.
If follow-up information was not obtained after 4 weeks, Vanderbilt University Ophthalmology Department staff contacted parents. Up to three separate attempts were made to reach parents, both at their home and at their workplace, to convince them to schedule an eye examina- tion for their child. If there was no success, the family was no longer contacted, but their primary care physician was notified of their reluctance. Five of the 20 children with follow-up were reached because of this.
Follow-up data were analyzed from the evaluating eye doctor’s examination results; children having refraction without cycloplegia were excluded. Results were analyzed to determine the presence or absence of amblyogenic factors. These factors were the same as used for our other photoscreening studies16-18 and are listed in Table 1.
RESULTS
The study group consisted of children 36 to 59 months of age. A total of 1052 children was screened: 52% were 3-year-olds (36 to 47 months) and 48% were 4-year-olds (48 to 59 months) (Table 2). Forty-two percent of children enrolled were screened with traditional vision screening methods, while 58% were tested using photoscreening. Four-year-olds made up 49% of traditional screening and 48% of the photoscreening. Three-year-olds represented the remaining percentages of each method, 51 and 52%, respectively (Table 2).
TABLE 2. Characteristics of screened children Photoscreening
Salcido, Bradley, and Donahue 117
3-Year-Olds (36-47 months)
Number screened 316 Testable 244 Nontestable 72 Pass 231 Referrals 13
FIG 1. The above graph shows years) and 4- (4 years) year-old or traditional (Trad) screening passed or referred. Children who could not be tested were consid- ered untestable.
Photoscreening was attempted on 605 children. Twen- ty-three children had photographs that met the criteria for referral (3.8%); 494 children passed, and 111 were untest- able due to photographs being unreadable (18%) (Figure 1). It should be noted that approximately one-third of the unreadable photographs came from one clinic site specif- ically where the unreadable rate totaled 70%, despite sev- eral attempts to retrain clinic personnel (Table 4). This occurred because no single person took accountability for the screening in that clinic site, and the various screeners varied. In three of the other five sites, the unreadable rate ranged from 21 to 25%. The amount of time spent pho- toscreening each child averaged 2.5 minutes. Of the 23 children referred for photoscreening, 14 received eye ex- ams and 11 had cycloplegic refractions (Table 3). Of the 11 children who had appropriate examinations, 8 (73%) had amblyogenic factors confirmed on the formal exami- nation: 4 had anisometropia (􏰂2.00; 􏰂3.50; 􏰄3.25; 􏰂3.75 cyl), 2 had astigmatism (􏰂1.75 cyl; 􏰂4.00 cyl), 1 had strabismus (accommodative esotropia with 20/200 ambly- opia), and 1 had high hypermetropia (􏰂4.50 sphere). Five of these children had amblyopia (two or more line differ- ence in acuity) at the time of the formal examination, including three with acuity worse than 20/100. One child who was referred from photoscreening for possible stra- bismus had an unmistakable strabismus on the photo-
Traditional Screening
4-Year-Olds (48-59 months) Total
Grand Total
TABLE 3. Follow-up of referred children PhotoScreener Traditional Total
the distribution of results for 3- (3 children using photoscreening (PS) methods. Testable children were
Number referred after screening
Number with follow-up examination results
Number with adequate eye exam
Number with amblyopia or amblyogenic conditions
Number with nonamblyogenic refractive errors
Number who received treatment*
Positive predictive value Number having amblyopia
23 (3.8%) 14 (61%)
73% 5 (45%)
20 (4.0%) 10 (50%) 10
0 10 1
0% 0 (0%)
43 (4.0%) 24 (56%) 21 (88%)
8 13 6
38% 5 (24%)
*“Treatment” was defined by the examining eye doctor and could have included spectacles, patching, or other treatments, even in the absence of a documented amblyogenic factor.
graph; however, the examination results showed him to be orthotropic. It is unclear if this child had a tropia that re- solved, an intermittent deviation, or a constant tropia that was missed by the examining doctor. However, if this child were classified as abnormal, it would increase the positive predictive value of photoscreening in this study to 82%.
Traditional screening methods were attempted on 447 children. When the 6-month crossover occurred, two of the clinics that had used photoscreening chose not to continue in the traditional vision-screening arm of the study, although they had received the proper training to do so. The sites did not provide a reason for stopping the study; they simply did not enroll patients despite encour- agement. On average approximately 6 minutes was spent screening each child, compared with 2.5 minutes for pho- toscreening. Two clinics reported needing an average of 10 to 13 minutes per child for screening (Table 4). Forty- six (10%) children were not testable with traditional tech- niques, while 399 passed and 20 were referred (4.5%). The referral rate was comparable between the two methods. Untestable rates ranged from 4.9 to 28%, with two of the four sites exceeding 25% (Figure 1). Of the 21 referred children using traditional methods, 10 received eye exams and all had cycloplegic refraction performed. No child was found to have amblyogenic factors; all referrals have proved to be false positives (Table 3). This difference
118 Salcido, Bradley, and Donahue
TABLE 4. Characteristics of individual sites
Pediatric Clinic
Photo Screening
Number of patients Number of pediatricians Number of children Pictures taken Minutes per child Referred Unreadable
Number of children Minutes per child Referred Untestable
Centennial
4.0 1 (1.7%) 10 (17%) 52
(3.8%) 13 (25%)
Green Hills
15,
1.8 5 (2.0%) 9 (3.7%)
Rivergate
2.5 1 (1%)
23 (22%)
8 (3.3%) 12 (4.9%)
Springfield
Photoscreener
(11%) 33 (25%)
Traditional
5 (4.8%) 8 (7.6%)
Vanderbilt
4.8 1 (2.2%) 32 (70%)
Columbia
10,
3.0 0 (0%) 4 (21%)
46,
(3.8%) 111 (18%)
20 (4.5%) 46 (10%) 47
(11%) 13 (28%)
between the groups was highly significant (P 􏰀 0.001; Fisher exact test). Data for individual sites are detailed in Table 4.
DISCUSSION
Multiple sets of guidelines currently exist for preschool vision screening. The technique used, the age of the child tested, and the critical line for referral all differ. In addi- tion, many of the techniques, and most of the guidelines, have never been validated adequately using large sample field studies. As a result, state mandates and organizational guidelines differ substantially.23
In 1998, the Maternal Child Health Bureau and the National Institutes of Health commissioned a task force to investigate the status of preschool vision screening in the United States. This study is part of that effort and is the first randomized, prospective study to compare both types of vision screening in the pediatrician’s office. Our results demonstrate that both photoscreening and traditional vi- sion screening had similar testability rates and similar pass and refer rates. However, while 73% of children referred via photoscreening had amblyogenic factors confirmed on formal testing, traditional vision screening failed to iden- tify any children having amblyogenic factors. This is par- ticularly bothersome since the randomized crossover de- sign should have produced similar numbers of children with amblyogenic factors in each group. Thus, in this study, traditional vision screening not only had a high false-positive rate, but also presumably missed all children having amblyogenic factors (low sensitivity). It is unclear if using full-time screeners or altering the testing method- ology would have produced similar results.
Most validation studies of traditional vision screening techniques in the past have used highly trained orthoptists, or other eye care personnel, and vision screening methods other than the HOTV preschool charts.9-14 In fact, there are scant data validating the effectiveness of most current methods of traditional screening,22 and almost no data
from screening programs that use practice nurses in the pediatrician’s office. Wall and colleagues recently reported that vision screening of 3-year-olds is rarely done in the primary care physicians office,14 probably because the col- lective experience of pediatricians is similar to that found in this study. Even when such children do fail screening, only 26% are referred, probably due to similar concerns.24 We chose the HOTV charts as the screening methodol- ogy here since it was the panel consensus that the MCHB task force charged screening sites to validate. It may be that other techniques would be more efficient in such a setting, especially if the length of the pretest or test pro- tocol itself caused children to lose interest. However, this remains to be studied.
In contrast to traditional vision screening, photo- screening with the MTI Photoscreener actually has had significant validation during the past 5 years. Data from the Tennessee Outreach Program has been collected prospectively on nearly 100,000 children aged 12 to 71 months. (We did not originally perform photoscreening in the pediatrician’s office as it was our experience that photoscreening was not accepted as a valid technique, and we encountered resistance from the pediatricians.) Data from this program have been extensively reported; briefly the referral rate is approximately 4%, and with follow-up rates exceeding 80% of referred children, the positive predictive value is approximately 65%.16,17 While the setting was different in this study than the Tennessee Outreach model, the referral rate and pre- dictive value positive are strikingly similar. In addition, pilot demonstration screenings of over 5000 preschool children in Beijing and Hong Kong, China, and Sao Paulo and Sao Jose, Brazil, have resulted in similar referral and testability rates (data not shown). Finally, sensitivity data have also been reported from this pro- gram using identical criteria for referral and examina- tion failure as reported here.18 Other reports providing lower sensitivity and unacceptably high referral rates
with the MTI Photoscreener were performed prior to our demonstrating the importance of centralized inter- pretation using well-defined referral criteria.20,21
This study has several limitations, including the lack of a complete follow-up of all referred children and the lack of cycloplegia in some optometric examinations. In addi- tion, the inability of at least one clinic to properly use the photoscreener (even after additional training) greatly in- creased the untestability rate for this technique. However, it should be noted that similar problems will probably occur if photoscreening becomes an accepted standard in pediatricians’ offices. It also should be noted that the same clinic with the 70% unreadable photograph rate also re- ported the longest amount of time spent per child and chose not to continue participation using traditional tech- niques. Unarguably, the greatest limitations of photo- screening are the lack of immediate feedback and the lack a well-trained network of reading centers. The develop- ment of digital photographic systems will eventually pro- duce an automated image acquisition and analysis system, but in the absence of such a system, it would be premature to recommend large-scale implementation of such instru- mentation as the standard of care.
Since nearly 60% of the tested children were tested using photoscreening, a higher number of children with amblyopia (and amblyogenic factors) should have been detected by photoscreening compared with traditional screening. For example, if the prevalence of amblyogenic factors is 5% and of amblyopia is 1.5%, one would have expected photoscreening to refer 30 children with amblyo- genic factors and 9 with amblyopia, compared with 22 and 7, respectively, with traditional screening. Since only ap- proximately 50% of referred children received adequate examinations, the number of children who were detected with amblyopia (5 and 0) may not be statistically different than what we expected (4.5 and 3.5), given the small sample size. Nevertheless, the fact remains that traditional screening significantly underdetected children with am- blyogenic factors; it is unclear if traditional techniques should be designed to detect these children, however, rather than those with amblyopia.
Snowden recently questioned the validity of traditional preschool vision screening on the basis of an unknown natural history and lack of prospective data about the effectiveness of screening techniques.25,26 Others have suggested that some types of traditional screening have an unacceptably high false-positive rate.27 While the conclu- sions of Snowden have mostly been rejected by several studies since that time,5,9-11,28 our experience suggests that traditional vision screening has significant limitations when performed in the pediatrician’s office, but that photoscreen- ing shows promise. Clearly, our sample of referred children is extremely small and inadequate to produce any concrete conclusions. In addition, the poor follow-up after pediatri- cian referral is bothersome and must be addressed by any mandated screening program. Nonetheless, we believe
Salcido, Bradley, and Donahue 119
that the results of this study continue to validate the effectiveness of photoscreening when it is performed properly, and that photoscreening is probably more effec- tive than the traditional vision screening performed in this study for 3- and 4-year-old children. Other methodology for traditional screening may be more effective, but this was not evaluated.
The authors acknowledge the participation of Tammy M. Johnson, MPH, in the design of the study and in the training of study partici- pants.
References
1. Simons K. Preschool vision screening: rationale, methodology and outcome. Surv Ophthalmol 1996;41:3-30.
2. Hartmann EE. Overview of Amblyopia. In: Vision Screening in the Preschool Child. Proceedings of a conference held September 10-11, 1998; Bethesda, MD. Genetic Services Branch, Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services; 1999.
3. Stager D, Birch E, Weakley D. Amblyopia and the pediatrician. Pediatr Ann 1990;17:
4. Kelsey A. Amblyopia: the condition, the challenge and the cure. J Ophthalmic Nurs Technol 1998;17:227-9.
5. Pediatric Eye Disease Investigator Group. A randomized trial of atropine vs. patching for treatment of moderate amblyopia in chil- dren. Arch Ophthalmol 2002;120:
6. Pattison B, Plymat K. Vision screening of school children: should it be continued?. Contemp Nurse 2001;10:
7. American Academy of Pediatrics Committee on Practice and Ambu- latory Medicine and Section on Ophthalmology. Eye examination and vision screening in infants, children and young adults. Pediatrics 1996;98:153-7.
8. Dobson V. Target Population. In: Vision Screening in the Preschool Child. Proceedings of a conference held September 10-11, 1998; Bethesda, MD. Genetic Services Branch, Maternal and Child Health Bureau, Health Resources and Services Administration, US Depart- ment of Health and Human Services; 1999.
9. Williams C, Harrad RA, Harvey I, Sparrow JM, The ALSPAC Study Team. Screening for amblyopia in preschool children: results of a population-based, randomized controlled study. Avon Longitudinal Study of pregnancy and childhood. Ophthalm Epidemiol 2001;8:
10. Williams C, Harrad RA, Harvey I, Sparrow JM, The ALSPAC Study Team. Amblyopia treatment outcomes after screening before or at age three years: follow-up from randomized trail. BMJ 2002;324: 1549.
11. Eibschitz-Tsimhoni M, Friedman T, Naor J, Eibscitz N, Friedman Z. Early screening for amblyogenic risk factor lowers the prevalence and severity of amblyopia. J AAPOS 2000;4:194-9.
12. Kvarnstrom G, Jakobsson P, Lennerstrand G. Visual screening of Swedish children: an ophthalmological evaluation. Acta Ophthalmol Scand 2001;79:240-4.
13. Simons K. Vision Screening Techniques: A Survey. In: Vision Screening in the Preschool Child. Proceedings of a conference held September 10-11, 1998; Bethesda, MD. Genetic Services Branch, Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services; 1999.
14. Wall T, Marsh-Tootle W, Evans H, Fargason C, Ashworth C, Hardin M. Compliance with vision-screening guidelines among a national sample of pediatricians. Ambulatory Pediatr 2002;2:
15. Committee on Practice and Ambulatory Medicine and Section on Ophthalmology; American Academy of Pediatrics. Use of photo- screening for children’s vision screening. Pediatrics 2002;109:
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Donahue SP, Johnson TM, Leonard-Martin TC. Screening for amblyogenic factors using a volunteer lay network and the MTI photoscreener: initial results from 15,000 preschool children in state- wide effort. Ophthalmology 2000;107:
Donahue SP, Johnson TM. Age-based refinement of referral criteria for photoscreening. Ophthalmology 2001;108:
Donahue SP, Johnson TM, Ottar W, Scott WE. Sensitivity of photoscreening to detect high-magnitude amblyogenic factors. J AAPOS 2002;6:86-91.
Mohan KM, Miller JM, Dobson V, Harvey EM, Sherrill DL. Inter- rater and intra-rater reliability in the interpretation of MTI Photo- screener photographs of Native American preschool children. Oph- thalmol Vis Sci 2000;77:
Tong PY, EnkeMiyazaki E, Bassin RE, the National Children’s Eye Care Foundation Study Group. Screening for amblyopia in preverbal children with photoscreening photographs. Ophthalmology 1998; 105:
Simons BD, Siatkowski RM, Schiffman JC, Berry BE, Flynn JT. Pediatric photoscreening for strabismus and refractive errors in a high-risk population. Ophthalmology 2000;107:
22. Hartmann EE, Dobson V, Hainline L, Marsh-Tottle Quinn G, Ruttman M, Schmidt P, Simons K. Preschool vision screening: summary of a task force report. Pediatrics 2000;106:
23. Ciner EB, Dobson V, Schmidt PP, et al. A survey of vision screening policy of preschool children in the United States. Surv Ophthalmol 1999;43:
24. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screen- ing in pediatric practice: a study from the Pediatric Research in Office Setting (PROS) Network. Pediatrics 1992;89:834-8.
25. Snowdon SK, Stewart-Brown SL. Preschool vision screening. Health Technol Assess 1997;1:1-98.
26. Stewart-Brown SL, Snowdon SK. Evidence-based dilemmas in pre- school vision screening. Arch Dis Child 1998;78:406-7.
27. Marsh-Tootle W. Traditional Vision Screening Methods and Out- comes. In: Vision Screening in the Preschool Child. Proceedings of a conference held September 10-11, 1998; Bethesda, MD. Genetic Services Branch, Maternal and Child Health Bureau, Health Re- sources and Services Administration, US Department of Health and Human Services; 1999.
28. Simons K, Preslan M. Natural history of amblyopia untreated owing to lack of compliance. Br J Ophthalmol 1999;83:582-7.
An Eye on the Arts – The Arts on the Eye
On the planet of the blind, no one needs to be cured. Blindness is another form of music, like the solo clarinet in the mind of Bartók.
On the planet of the blind, the citizens live in the susurrus of cricket wings twinkling in inner space.
You can hear the stars on the windless nights of June.
On the planet of the blind, people talk about what they do not see, like Wallace Stevens, who freely chased tigers in red weather. Here, mistaken identities are not the stuff of farce. Instead, unvexed, the mistaken discover new and friendly adjacent arms to touch.
On this particular planet, the greyhounds get to snooze at last in the tall grass.
The sighted are beloved visitors, their fears of blindness assuaged with fragrant reeds. On the planet of the blind, everyone is free to touch faces, paintings, gardens—even the priests who have come here to retire.
—Stephen Kuusisto (from Planet of the Blind)

47. Referral Criteria for Photoscreening
Considerations:
Age of patient
Passing criteria are more generous (higher thresholds) for younger children and more stringent (lower thresholds) for older children.
Sensitivity
High rate of detection but also high rate of referrals for false positives.
Specificity
Fewer false positives but will miss some at-risk kids.

48. ***WARNING***
It should be noted that while these criteria are the recommended risk factors to identify patients at risk, this is not the same thing as recommended settings for the photoscreening device. Variables such as accommodation by the child being tested can significantly impact the data obtained by the device and you should consult with your device manufacturer for device-specific recommendations.

49. Warning!
There is a difference between the Refractive Risk Factor Target numbers on the preceding table and what the screening instrument settings should be.
Children can accommodate tremendous amounts (change the focusing power of their eyes).
this potentially affects some of the instrument readings
Device manufacturers will have guidelines specific to your needs.
Myopia and Hyperopia thresholds are most affected by the child’s ability to accommodate. The Astigmatism and Anisometropia thresholds are affected to a much lesser degree.

50. Reimbursement for Photoscreening
CPT 99174
Use with automated photoscreening and autorefraction:
Photoscreeners
Autorefractors
Fixation “Pediatric Vision Scanner”
Do not use which is only for tests of actual visual acuity (eye charts)

51. Thank You
For more information about the AAPOS vision screening kits, including how to order one please go to:
AAPOS Screening Kit
Also available from:
American Academy of Pediatrics (AAP) Bookstore: or
Good-Lite:
Authors: Daniel Neely, MD and Geoff Bradford, MS, MD on behalf of the AAPOS Vision Screening Committee. Updated 6/8/15