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PURPOSE: Interventions such as eye exams and glasses are used to correct visual problems that may lead to amblyopia, an irreversible decrease in visual acuity. Children with limited access to these interventions are more likely to have unaddressed visual problems that can lead to amblyopia or negatively impact school performance. This study compared vision screening results of children in schools with Title 1 or Non-Title 1 designation to investigate the link between poverty and vision. METHODS: Data from KidsFIRST vision screenings conducted with the SPOTTM photoscreener performed in Rapid City Area elementary schools were compared across multiple parameters. Students were referred for eye examinations based on identifying the following problems: anisometropia, anisocoria, astigmatism, myopia, hyperopia, gaze misalignment, or a combination. RESULTS: Overall, eye exam referral rates have increased since 2012 (11.9% in 2012, 19.7% in 2023), with a disproportionate increase in referrals from Title 1 schools (25.2% in 2023) vs. Non-Title 1 schools (11.9% in 2023) (p < 0.001). This is largely due to a significantly higher prevalence of astigmatism referrals in Title 1 students (20.9%) compared to Non-Title 1 students (7.5%). Although a higher percentage of Title 1 students are reported to have eye correction (24.4% vs 16.6%), only a slightly higher percentage of Title 1 students wore eye correction during screening (11.5% vs 10.5%). CONCLUSION: Students at Title 1 schools may have a higher rate of amblyopia risk factors. Additional eye care-based interventions should be taken to reduce the risk of amblyopia in this population.

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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.

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Background: Seeking a quick way to estimate refractions for challenging pediatric patients, we studied two non-contact methods with particular attention to accuracy and level of stress in uncovering cycloplegic hyperopia. Methods: Newly referred and follow-up pediatric eye patients had timed school bus accommodation-relaxing skiascopy (SBARS) and Plusoptix A12 (Px) photoscreener testing before cyclopentolate 1% confirmatory examinations. The ABCD ellipsoid univariate method based on relative blur and vector components was used to compare dry sphero-cylinder refraction estimates with cycloplegic. Receiver operating characteristic (ROC) curves were used to determine screening value. Results: Three compared refractions were attempted in 191 racially diverse children of whom 100 were age 0.2-3.9 years and 91 were 4 to 14 years. Plusoptix failed to yield a result in 21 and an additional 21 were interpreted as an excess sphere. Median spherical equivalent did not differ between Px and SBARS for 149 with Px readings but in hyperopic patients, Plusoptix uncovered 27% less hyperopia. The ellipsoid for SBARS of 0.8 was better than 2.4 for Plusoptix (Mann-Whitney p<0.001). Plusoptix was fastest (3-15 seconds) followed by SBARS (15-30 seconds) compared to 30-45 minutes for cycloplegic exam. Conclusion: Non-contact quick refractive methods enhanced confirmatory cycloplegic pediatric exam in high-risk pediatric patients.

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ABSTRACT Objective: To assess the performance of a portable autorefractor as refractor and screening tool for refractive errors in schoolchildren. Methods: Cross-sectional observational study. Refractometric measurements of children between 5 and 10 years old were obtained through four methods: 2WIN under non-cycloplegic conditions, and 2WIN, conventional autorefractor, and retinoscopy, under cycloplegic conditions. Correlations and agreement between the methods and accuracy of the portable autorefractor to define whether to prescribe glasses were assessed. Results: The mean age ± standard deviation was 6.87 ± 1.42 years. The portable autorefractor without cycloplegia showed a high correlation with retinoscopy (0.77) but tended to underestimate hyperopia and overestimate high astigmatism. Regarding screening for prescription of glasses in comparison with the reference method "retinoscopy," the sensitivity of the portable autorefractor without cycloplegia was calculated to be 100,00% and the specificity, 34.3%. Conclusion: The portable autorefractor should be used as a screening tool and, when prescribing glasses, the tendency of underestimating hyperopia and overestimating high astigmatism should be kept in mind.

RESUMO Objetivo: Avaliar o desempenho de um autorrefrator portátil como refrator e ferramenta de triagem para erros de refração em crianças em idade escolar. Métodos: Estudo observacional transversal. As medidas refratométricas de crianças de 5 a 10 anos foram obtidas por meio de quatro métodos: 2WIN em condições não cicloplégicas e 2WIN, autorrefrator convencional e retinoscopia, em condições cicloplégicas. Foram avaliadas as correlações e a concordância entre os métodos e a acurácia do autorrefrator portátil para definir a prescrição de óculos. Resultados: A média de idade ± desvio-padrão foi de 6,87 ± 1,42 anos. O autorrefrator portátil sem cicloplegia apresentou alta correlação com a retinoscopia (0,77), mas tendeu a subestimar a hipermetropia e a superestimar o alto astigmatismo. Em relação à triagem para prescrição de óculos em comparação com o método de referência retinoscópio, a sensibilidade do autorrefrator portátil sem cicloplegia foi calculada em 100,00% e a especificidade, em 34,3%. Conclusão: O autorrefrator portátil deve ser usado como ferramenta de triagem e, ao se prescreverem óculos, deve-se ter em mente a tendência de subestimar a hipermetropia e superestimar o alto astigmatismo.

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PURPOSE/BACKGROUND: Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services. METHODS: The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care. RESULTS: Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5. CONCLUSIONS: All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.

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PURPOSE: Amblyopia is a leading cause of preventable and treatable vision loss in the pediatric population. Instrument-based screening of amblyopia-risk factors is being widely adopted but the audit of its results is still lacking. We sought to review the existing evidence regarding the outcomes of photoscreening applied to children under the age of three years. METHODS: A three-database search (Pubmed, ISI Web of Science, and Scopus) was performed from inception to March 2021. A meta-analysis of proportions was conducted to summarize the referral rate, untestable rate and positive predictive value (PPV). RESULTS: Thirteen studies were selected among 705 original abstracts. The quantitative analysis included twelve studies enrolling 64,041 children. Of these, 13% (95%CI: 7-19%) were referred for further confirmation of the screening result. Astigmatism was the most common diagnosis both after screening and after ophthalmologic assessment of referred children. The pooled untestable rate and PPV were 8% (95%CI: 3-15%) and 56% (95%CI: 40-71%), respectively. CONCLUSION: There is no global consensus on the optimal age, frequency or what magnitude of refractive error must be considered an amblyopia-risk factor. Optimization of referral criteria is therefore warranted.

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Purpose: In 2022, an inexpensive multi-radial infrared photoscreener, the AI Optic was released in a similar format as the 2012 PlusoptiX a-12 but utilizing artificial intelligence (AI) for online, central image interpretation. We studied them because no prior comparative validation concerning amblyopia risk factors and particularly refractive error has been done. Patients and Methods: Children from a pediatric ophthalmology practice had AI Optic and PlusoptiX-a12 photoscreen concomitantly during comprehensive examination with precisely measured strabismus and refraction. Validation to AAPOS 2021 and 2013 guidelines was evaluated with receiver operating characteristic (ROC) curves while refractive estimates were compared by the ABCD ellipsoid univariable technique. Results: In 200 ethnically diverse children aged 1-18, 148 were 4 years or older, 35% had developmental delays, and 2/3 had amblyopia risk factors (ARF). Area under the ROC curve (AUC) targeting AAPOS 2021 refractive plus strabismus for age ≥4 years was 0.58 for AI Optic and 0.74 for PlusoptiX while for children <4 years, AUC was 0.53 for AI Optic and 0.72 for PlusoptiX. For 134 comparable sphero-cylinder refractions, the ABCD Ellipsoid median (interquartile ranges) for AI Optic right eye 2.53 (1.54, 4.01) and left eye 3.05 (1.83, 5.00) did not approximate actual refraction as well as by PlusoptiX right eye 1.88 (1.12, 2.86) and left eye 2.10 (1.26, 3.04) Mann Whitney z=3.7 right and 4.2 left, p<0.001 each. AI Optic via central "AI" reading gave sphero-cylinder and referral estimates in all but 16 of 200 high risk children whereas Plusoptix had 25 inconclusives. On the other hand, with inconclusives scored as a refer, Plusoptix outperformed AI Optic in terms of ARF validation and refractive estimate. Conclusion: Plusoptix provided more valid amblyopia and refractive screening than the cheaper AI Optic. Clinics must weigh cost versus performance, and central data sharing before selecting one of these vision-saving devices.

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Purpose: To describe and compare vision screening programmes and identify variance in number and type of tests used, timing of screening, personnel involved, monitoring and funding to be used as data for optimising, disinvesting or implementing future screening programmes. Methods: A questionnaire consisting of nine domains: demography & epidemiology, administration & general background, existing screening, coverage & attendance, tests, follow-up & diagnosis, treatment, cost & benefit and adverse effects was completed by Country Representatives (CRs) recruited from 47 countries. Results: The questionnaire was sufficiently completed for 46 Countries: 42 European countries, China, India, Malawi and Rwanda. Variation of provision was found in; age of screening (0-17 years), tests included (23), types of visual acuity (VA) test used (35 different optotypes), personnel (13), number of screens per child (median 5, range 1-32), and times VA tested (median 3, range 1-30). Infant screening is offered in all countries, whereas childhood vision screening is offered at least once in all countries, but not all regions of each country. All 46 countries provide vision screening between the ages of 3-7 years. Data on screening outcomes for quality assurance was not available from most countries; complete evaluation data was available in 2% of countries, partial data from 43%. Conclusion: Vision screening is highly variable. Some form of VA testing is being undertaken during childhood. Data collection and sharing should be improved to facilitate comparison and to be able to optimise vision screening programmes between regions and countries.

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BACKGROUND: Children's vision screening children commonly uses optotype-based visual acuity or instrument-based methods measuring amblyogenic risk factors (ARFs). OBJECTIVE: To compare the performance of the Spot Vision Screener (SVS) (PediaVision, Welch Allyn, NY) and a nurse-administered visual acuity screen (NVAS) in identifying ARFs and decreased visual acuity. METHODS: A prospective, cross-sectional population-based study of preschool children in South-East Queensland, Australia. Eligible participants had both forms of screening by trained community nurses. All children with an abnormal result by either method as well as a cohort of randomly selected children who passed both assessments were assessed at a tertiary paediatric ophthalmology clinic. RESULTS: Over a 10 month period, 2237 children (mean age; 64.4 ± 4.0 months) were screened from 38 schools. 6.4% of children failed SVS and 8.3% failed NVAS (with 3.8% overlap, failing both). The positive predictive value (PPV) in identifying either ARFs and/or reduced VA for the SVS and NVAS was 70.4% (95% Confidence Interval (CI): 61.6%-78.2%) and 60.5% (95% CI: 52.6%-67.9%) respectively. Highest PPV to detect either ARFs and/or reduced VA was achieved by a 'hybrid' method by combining failed NVAS and failed SVS: 91.0% (95% CI: 82.4 to 96.3) but this would risk children with sight impairment being missed in the community. CONCLUSION: To our knowledge, this is the first population-based study providing detailed comparative measures of diagnostic accuracy for NVAS and SVS in preschool children. One in ten preschool children failed one or both screens. A number of children who required ophthalmic intervention were missed if only one screening method was utilized.

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PURPOSE: To analyze whether photoscreening can effectively detect amblyogenic risk factors in children with neurodevelopmental disability. METHODS: A prospective study of 52 children attending a special school for children with neurodevelopmental disability from December 2017 to May 2018. All were initially tested with a photoscreening device: Welch Allyn® Spot® Vision Screener: model VS100 (Spot®) and further evaluated at a later date by a pediatric ophthalmologist, with a complete ocular evaluation including squint assessment, cycloplegic retinoscopy, and dilated fundus examination. The key parameters studied were demographic features, type of neurodevelopmental disability, refraction, ocular alignment, media clarity, any other ocular morbidity, and time taken for examination. The presence of amblyogenic risk factors (ARF) was analyzed as per the 2013 guidelines of the American Association for Pediatric Ophthalmology and Strabismus. RESULTS: The mean age was 10.5 years (range: 1-17.5 years). Males (73.1%) outnumbered females (26.9%). The most common neurodevelopmental disability was cerebral palsy. Simple myopic astigmatism was the most common type of refractive error. Presence of ARF in our study was 73.1%. The sensitivity and specificity of photoscreening in detecting ARF were 96.5% and 63.61%, respectively, with a positive predictive value of 80% and negative predictive value of 92.31%. The predictive ability of photoscreening was 79.9% as per the area under curve. The average time taken for photoscreening was less than 60 s. CONCLUSION: Photoscreening can detect ARF with high sensitivity and reasonable specificity and is a handy, useful, and time-saving tool in screening children with neurodevelopmental disability.

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BACKGROUND: ROP screening is vital in care of premature infants but is considered burdensome, difficult and time consuming for ophthalmologists. This study assessed the reduction in workload following the introduction of nurse-led WFDRI to a large neonatal nursery. METHODS: We report a retrospective audit of 628 infants screened for ROP in the years 2010, 2013 and 2019 at the Royal Women's Hospital, Victoria. The last complete year of screening for ROP using binocular indirect ophthalmoscopy (BIO) alone (2010) was compared with two subsequent years after the introduction of nurse-led WFDRI. The main outcome measures were the time taken to report and document WFDRI and the time taken to undertake BIO examination of a premature infant and document the results. RESULTS: The ophthalmologist's time taken to conduct BIO, review images and document the results per 100 patient examinations was reduced from 16.7 hours before introduction of WFDRI to 3.7 hours. Similarly, the weekly time spent on this component of ROP screening fell from 2.3 hours per week to 0.8 and 1.0 hours per week after introduction of WFDRI. CONCLUSIONS: The introduction of nurse-led WFDRI has resulted in a dramatic and sustained reduction in ophthalmologist workload involved in ROP screening in a large Australian neonatal nursery. This may result in improved retention of the ophthalmic workforce required to undertake ROP screening.

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Amblyopia is the leading cause of vision impairment in children, and its early detection can avoid irreversible consequences for a child's visual ability. In this prospective study, to detect amblyopia risk factors, we examined patients aged 18 to 30 months in primary care settings. Patients were referred to an ophthalmologist for confirmation. The main aims were to detect amblyogenic risk factors and to assess the usefulness of a photoscreener in such settings. Out of 453 patients, 42 (9.3%) presented visual alterations according to the photoscreener, with astigmatism being the most common. The instrument had good sensitivity (89%) and specificity (91%), with a positive predictive value of 76% and a negative predictive value of 96%. Overall, 38% of the patients required follow-up, and 47% needed glasses. The automated screening device allowed these children to be diagnosed at an early stage.Conclusions: The use of a photoscreener to screen 2-year-old children in primary care settings was helpful and accurate. What is Known: • Early detection of amblyopic risk factors is important to avoid vision defects. However, it is very difficult to measure visual acuity using visual charts in children younger than 4 years old. What is New: • Instrument-based screening in children aged 18 to 30 months allows excellent detection of early amblyopia risk factors in primary care settings.

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PURPOSE: To evaluate the Spot Vision Screener (SVS) compared with the orthoptic examination for detection of amblyopia risk factors in preschools. METHODS: This prospective study included children with a visual screening organized by the department of "le" (PMI) in Côte d'Or (Burgundy, France), between June 2017 and April 2018. All children were evaluated with the SVS followed by a clinical orthoptic examination. Results with the SVS were compared with those obtained by clinical orthoptic examination. RESULTS: A total of 1236 subjects were included in the study from 100 preschools. The mean age of the children was 3.6±0.7 years, and 627 were female (50.7%). The orthoptic examination detected 308 (24.9%) children with subnormal visual acuity for age in one eye or both. In children with a history of prematurity, the orthoptic examination was more frequently abnormal (P=0.002), which was not seen with the SVS (P=0.050). The SVS screened 20 (1.6%) children with strabismus, while 40 (3.2%) were detected by orthoptic examination. At the end of the screening, the SVS detected 182 (14.7%) suspect patients while 311 (25.1%) suspect patients were detected after the orthoptic examination. Comparing SVS with orthoptic examination, agreement was fair (κ=0.4). CONCLUSION: The SVS can be a useful device for visual screening, but agreement with the orthoptic examination was only fair. The Spot vision screener should be used in conjunction with a clinical orthoptic examination.

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BACKGROUND: The Rebion blinq binocular birefringent ocular alignment screener was recently commercially released, but it did not yet have validation by American Association for Pediatric Ophthalmology and Strabismus (AAPOS) uniform guidelines. METHODS: Children and adults from a high-risk eye practice had screening by blinq with validation by AAPOS 2003 guidelines. Then, the blinq was compared to the Adaptica 2WIN with CR corneal reflex strabismus estimation by AAPOS 2003 guidelines plus additional efforts to identify patients with diminished binocularity. RESULTS: Blinq in 100 patients compared to 2003 AAPOS amblyopia risk factors (ARF) had sensitivity 67%, specificity 75% and PPV of 82%. Both blinq and 2WIN were completed by 87 patients median age 6.5 years. Sensitivity, specificity and positive predictive value (PPV) for blinq were 75%, 68% and 81% whereas 2WIN had 91%, 68% and 84%. The blinq referred two young patients with isolated, small-angle strabismic amblyopia that 2WIN refractive function passed. CONCLUSION: Despite its non-refractive design to identify binocular foveation, blinq performed well with refractive and strabismic uniform risk factors and a PPV greater than 80%. CLINICAL TRIALS REGISTRY: NCT04195711.

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PURPOSE: This study aimed to determine whether the plusoptiX vision screener (PVS) can be used to detect amblyogenic risk factors (ARFs) as defined by the American Association for Paediatric Ophthalmology and Strabismus Vision Screening Committee guidelines (2013) for automated vision screening devices. METHODS: In this cross-sectional study, children attending a special needs school underwent screening with the PVS and complete ophthalmologic examinations. Ophthalmologic examinations were used as the gold standard to compute the prevalence, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and testability. RESULTS: Forty-four children with special needs (mean age, 8.5 years; range, 4-18 years) were included. The PVS recommended referral of 31 cases (referral rate 70%). Thirty-nine of the 44 children (89%) met the referral-positive threshold for strabismus, reduced vision and/or amblyogenic factors on examination. The plusoptiX had a sensitivity of 40% (confidence interval [CI] 7%-83%), specificity of 78% (CI 55%-85%), PPV of 15% (CI 3%-46%), and NPV of 90.3% (CI 73%-97%). The PVS underestimated refractive errors by 0.67 to 0.71 D in the right (P < 0.001) and left eyes (P = 0.002). Testability was relatively low, with the PVS at 75% compared to the gold standard examination at 100%. CONCLUSION: We found that although the plusoptiX photoscreener might be a useful tool in pediatric vision screening, it might not perform as well in children with intellectual disabilities. Utilization of the PVS as a single screening device may fail to identify a considerable proportion of young children with ARFs or amblyopia.

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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.

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Amblyopia can be improved or eliminated more easily when treated early in life. Because amblyopia in older children is generally less responsive to treatment (Holmes et al., 2011), there is a premium on the early identification of amblyopia and its risk factors and the subsequent treatment thereof. Clinical preference is to institute treatment in children before 7 years of age when an optimal visual outcome is typically easier to obtain.

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Amblyopia detection is important to ensure proper visual development and avoid permanent decrease of visual acuity. This condition does not produce symptoms, so it is difficult to diagnose if a vision problem actually exists. However, because amblyopia treatment is limited by age, early diagnosis is of paramount relevance. Traditional vision screening (conducted in <3 years) is related with difficulty in getting cooperation from a subject to conduct the eye exam, so accurate objective methods to improve amblyopia detection are necessary. Handheld devices used for photoscreening or autorefraction could offer advantages to improve amblyopia screening because they reduce exploration time to just few seconds, no subject collaboration is needed, and they provide objective information. The purpose of this review is to summarize the main functions and clinical applicability of commercially available devices for early detection of amblyopia and to describe their differences, advantages, and limitations. Although the studies reviewed are heterogeneous (due to wide differences in referral criteria, use of different risk factors, different types of samples studied, etc), these devices provide objective measures in a quick and objective way with a simple outcome report: retest, pass, or refer. However, due to major limitations, these devices are not recommended, and their use in clinical practice is limited.

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The goal of early childhood vision screening is to detect subnormal vision and amblyopic risk factors that threaten visual development so that treatment can be initiated early to yield the highest benefit. Hand-held, portable, instrument-based vision screening devices can be used in children as young as 6 months of age. We assessed the feasibility of hand-held photoscreeners to screen for vision disorders in pre-school children in Hawai'i. A total of 137 preschool children on O'ahu in the "Tutu and Me"/Partners in Development program were screened at 6 different locations using the Plusoptix S12 hand-held photoscreener. Once technical issues were resolved, screening was fast and well tolerated. Possible vision abnormalities were found in 11 of the 137 children (8%). Poor compliance for follow-up with formal vision examination limited our ability to confirm these abnormalities. We conclude that photoscreening has the potential to facilitate early childhood vision screening in Hawai'i. The optimal referral criteria for use in Hawai'i will need to be determined after considering the age of the screening population and the available medical resources in Hawai'i. Early detection of treatable eye disorders has far-reaching benefits for the visual development and long term health and well-being of children. A comprehensive early childhood vision screening program in Hawai'i utilizing automated hand-held photoscreeners may have public health value. Such a program should integrate referral to an eye care professional for confirmation and management of vision disorders of at-risk children found on screening.

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OBJECTIVE: The purpose of this study was to assess the feasibility and accuracy of vision photoscreening a large cohort of asymptomatic children age 6 months to 6 years. METHODS: Photoscreening was performed at the 6 and 18 months and annually at the 2- to 5-year scheduled pediatric health assessment visits. RESULTS: A total of 1976 children underwent photoscreening for amblyopic risk factors during an 18-month period; 167 of them (8.5%) screened positive. Of the 94 study children who were evaluated by a pediatric ophthalmologist, 25 required intervention at their initial visit (26.6%). Ten children were diagnosed with amblyopia, representing 0.5% of all children screened. CONCLUSION: Vision photoscreening of 1976 young children identified 10 with previously undiagnosed amblyopia and an additional 15 with treatable pre-amblyopic risk factors. It is unlikely that any of these children with serious refractive errors would have been detected without the use of in-office vision photoscreening.

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