Nicola S. Logan

Refractive error and visual impairment in school children in Northern Ireland

Aims To describe the prevalence of refractive error (myopia and hyperopia) and visual impairment in a representative sample of white school children. Methods The Northern Ireland Childhood Errors of Refraction study, a population-based cross-sectional study, examined 661 white 12–13-year-old and 392 white 6–7-year-old children between 2006 and 2008. Procedures included assessment of monocular logarithm of the minimum angle of resolution (logMAR), visual acuity (unaided and presenting) and binocular open-field cycloplegic (1% cyclopentolate) autorefraction. Myopia was defined as −0.50DS or more myopic spherical equivalent refraction (SER) in either eye, hyperopia as ≥+2.00DS SER in either eye if not previously classified as myopic. Visual impairment was defined as >0.30 logMAR units (equivalent to 6/12). Results Levels of myopia were 2.8% (95% CI 1.3% to 4.3%) in younger and 17.7% (95% CI 13.2% to 22.2%) in older children: corresponding levels of hyperopia were 26% (95% CI 20% to 33%) and 14.7% (95% CI 9.9% to 19.4%). The prevalence of presenting visual impairment in the better eye was 3.6% in 12–13-year-old children compared with 1.5% in 6–7-year-old children. Almost one in four children fails to bring their spectacles to school. Conclusions This study is the first to provide robust population-based data on the prevalence of refractive error and visual impairment in Northern Irish school children. Strategies to improve compliance with spectacle wear are required.

Global variations and time trends in the prevalence of childhood myopia, a systematic review and quantitative meta-analysis: implications for aetiology and early prevention

The aim of this review was to quantify the global variation in childhood myopia prevalence over time taking account of demographic and study design factors. A systematic review identified population-based surveys with estimates of childhood myopia prevalence published by February 2015. Multilevel binomial logistic regression of log odds of myopia was used to examine the association with age, gender, urban versus rural setting and survey year, among populations of different ethnic origins, adjusting for study design factors. 143 published articles (42 countries, 374 349 subjects aged 1–18 years, 74 847 myopia cases) were included. Increase in myopia prevalence with age varied by ethnicity. East Asians showed the highest prevalence, reaching 69% (95% credible intervals (CrI) 61% to 77%) at 15 years of age (86% among Singaporean-Chinese). Blacks in Africa had the lowest prevalence; 5.5% at 15 years (95% CrI 3% to 9%). Time trends in myopia prevalence over the last decade were small in whites, increased by 23% in East Asians, with a weaker increase among South Asians. Children from urban environments have 2.6 times the odds of myopia compared with those from rural environments. In whites and East Asians sex differences emerge at about 9 years of age; by late adolescence girls are twice as likely as boys to be myopic. Marked ethnic differences in age-specific prevalence of myopia exist. Rapid increases in myopia prevalence over time, particularly in East Asians, combined with a universally higher risk of myopia in urban settings, suggest that environmental factors play an important role in myopia development, which may offer scope for prevention.

Childhood ethnic differences in ametropia and ocular biometry: the Aston Eye Study.

Citation information: Logan NS, Shah P, Rudnicka AR, Gilmartin B & Owen CG. Childhood ethnic differences in ametropia and ocular biometry: the Aston Eye Study. Ophthalmic Physiol Opt 2011, 31, 550–558. doi: 10.1111/j.1475‐1313.2011.00862.x

Ocular blood flow measurements in healthy human myopic eyes

BackgroundTo evaluate the haemodynamic features of young healthy myopes and emmetropes, in order to ascertain the perfusion profile of human myopia and its relationship with axial length prior to reaching a degenerative state.MethodsThe retrobulbar, microretinal and pulsatile ocular blood flow (POBF) of one eye of each of twenty-two high myopes (N = 22, mean spherical equivalent (MSE) ≤−5.00D), low myopes (N = 22, MSE−1.00 to−4.50D) and emmetropes (N = 22, MSE ± 0.50D) was analyzed using color Doppler Imaging, Heidelberg retinal flowmetry and ocular blood flow analyser (OBF) respectively. Intraocular pressure, axial length (AL), systemic blood pressure, and body mass index were measured.ResultsWhen compared to the emmetropes and low myopes, the AL was greater in high myopia (p < 0.0001). High myopes showed higher central retinal artery resistance index (CRA RI) (p = 0.004), higher peak systolic to end diastolic velocities ratio (CRA ratio) and lower end diastolic velocity (CRA EDv) compared to low myopes (p = 0.014, p = 0.037). Compared to emmetropes, high myopes showed lower OBFamplitude (OBFa) (p = 0.016). The POBF correlated significantly with the systolic and diastolic blood velocities of the CRA (p = 0.016, p = 0.036). MSE and AL correlated negatively with OBFa (p = 0.03, p = 0.003), OBF volume (p = 0.02, p < 0.001), POBF (p = 0.01, p < 0.001) and positively with CRA RI (p = 0.007, p = 0.05).ConclusionHigh myopes exhibited significantly reduced pulse amplitude and CRA blood velocity, the first of which may be due to an OBF measurement artefact or real decreased ocular blood flow pulsatility. Axial length and refractive error correlated moderately with the ocular pulse and with the resistance index of the CRA, which in turn correlated amongst themselves. It is hypothesized that the compromised pulsatile and CRA haemodynamics observed in young healthy myopes is an early feature of the decrease in ocular blood flow reported in pathological myopia. Such vascular features would increase the susceptibility for vascular and age-related eye diseases.

School vision screening, ages 5–16 years: the evidence-base for content, provision and efficacy

The optometric profession in the UK has a major role in the detection, assessment and management of ocular anomalies in children between 5 and 16 years of age. The role complements a variety of associated screening services provided across several health care sectors. The review examines the evidence‐base for the content, provision and efficacy of these screening services in terms of the prevalence of anomalies such as refractive error, amblyopia, binocular vision and colour vision and considers the consequences of their curtailment. Vision screening must focus on pre‐school children if the aim of the screening is to detect and treat conditions that may lead to amblyopia, whereas if the aim is to detect and correct significant refractive errors (not likely to lead to amblyopia) then it would be expedient for the optometric profession to act as the major provider of refractive (and colour vision) screening at 5–6 years of age. Myopia is the refractive error most likely to develop during primary school presenting typically between 8 and 12 years of age, thus screening at entry to secondary school is warranted. Given the inevitable restriction on resources for health care, establishing screening at 5 and 11 years of age, with exclusion of any subsequent screening, is the preferred option.

Reproducibility-repeatability of choroidal thickness calculation using optical coherence tomography.

Purpose. To evaluate the repeatability and reproducibility of subfoveal choroidal thickness (CT) calculations performed manually using optical coherence tomography (OCT). Methods. The CT was imaged in vivo at each of two visits on 11 healthy volunteers (mean age, 35.72 ± 13.19 years) using the spectral domain OCT. CT was manually measured after applying ImageJ processing filters on 15 radial subfoveal scans. Each radial scan was spaced 12° from each other and contained 2500 A-scans. The coefficient of variability, coefficient of repeatability (CoR), coefficient of reproducibility, and intraclass correlation coefficient determined the reproducibility and repeatability of the calculation. Axial length (AL) and mean spherical equivalent refractive error were measured with the IOLMaster and an open view autorefractor to study their potential relationship with CT. Results. The within-visit and between-visit coefficient of variability, CoR, coefficient of reproducibility, and intraclass correlation coefficient were 0.80, 2.97% 2.44%, and 99%, respectively. The subfoveal CT correlated significantly with AL (R = −0.60, p = 0.05). Conclusions. The subfoveal CT could be measured manually in vivo using OCT and the readings obtained from the healthy subjects evaluated were repeatable and reproducible. It is proposed that OCT could be a useful instrument to perform in vivo assessment and monitoring of CT changes in retinal disease. The preliminary results suggest a negative correlation between subfoveal CT and AL in such a way that it decreases with increasing AL but not with refractive error.

Sampling and measurement methods for a study of childhood refractive error in a UK population

Background There is a paucity of data describing the prevalence of childhood refractive error in the United Kingdom. The Northern Ireland Childhood Errors of Refraction study, along with its sister study the Aston Eye Study, are the first population-based surveys of children using both random cluster sampling and cycloplegic autorefraction to quantify levels of refractive error in the United Kingdom. Methods Children aged 6–7 years and 12–13 years were recruited from a stratified random sample of primary and post-primary schools, representative of the population of Northern Ireland as a whole. Measurements included assessment of visual acuity, oculomotor balance, ocular biometry and cycloplegic binocular open-field autorefraction. Questionnaires were used to identify putative risk factors for refractive error. Results 399 (57%) of 6–7 years and 669 (60%) of 12–13 years participated. School participation rates did not vary statistically significantly with the size of the school, whether the school is urban or rural, or whether it is in a deprived/non-deprived area. The gender balance, ethnicity and type of schooling of participants are reflective of the Northern Ireland population. Conclusions The study design, sample size and methodology will ensure accurate measures of the prevalence of refractive errors in the target population and will facilitate comparisons with other population-based refractive data.

Shape of the posterior vitreous chamber in human emmetropia and myopia

PURPOSE To compare posterior vitreous chamber shape in myopia to that in emmetropia. METHODS Both eyes of 55 adult subjects were studied, 27 with emmetropia (mean spherical error [MSE] ≥ -0.55; <+0.75 D; mean +0.09 ± 0.36 D) and 28 with myopia (MSE -5.87 ± 2.31 D). Cycloplegic refraction was measured with a Shin Nippon autorefractor and anterior chamber depth and axial length with a Zeiss IOLMaster. Posterior vitreous chamber shapes were determined from T2-weighted magnetic resonance imaging (3.0-T) using procedures previously reported by our laboratory. Three-dimensional surface model coordinates were assigned to nasal, temporal, superior, and inferior quadrants and plotted in two dimensions to illustrate the composite shape of respective quadrants posterior to the second nodal point. Spherical analogues of chamber shape were constructed to compare relative sphericity between refractive groups and quadrants. RESULTS Differences in shape occurred in the region posterior to points of maximum globe width and were thus in general accord with an equatorial model of myopic expansion. Shape in emmetropia is categorized distinctly as that of an oblate ellipse and in myopia as an oblate ellipse of significantly less degree such that it approximates to a sphere. There was concordance between shape and retinotopic projection of respective quadrants into right, left, superior, and inferior visual fields. CONCLUSIONS Prolate ellipse posterior chamber shapes were rarely found in myopia, and we propose that spherical shape in myopia may constitute a biomechanical limitation on further axial elongation. Synchronization of quadrant shapes with retinotopic projection suggests that binocular growth is coordinated by processes that operate beyond the optic chiasm.

Computation of retinal contour in anisomyopia

It is well documented that myopia is associated with an increase in axial length of the posterior vitreous chamber. Whether equatorial or transverse dimensions are likewise affected in myopia is relevant to further understanding of the development of ametropia. We have utilised a computing method to determine retinal contour from real eye measurements of keratometry, A-scan ultrasonography and peripheral refraction as a means of assessing the transverse dimensions of the vitreous chamber. This technique has been applied to a 21-year-old female Caucasian anisomyope with a refractive error of R -1.50/-0.50 x 130 and L -4.00/-0.50 x 160. Anisomyopia offers a special opportunity for inter-eye comparison of different degrees of myopia. The repeatability of the technique was assessed by taking 10 separate sets of the aforementioned measurements and thus generating 10 retinal contours for each eye. We conclude that this method is repeatable and is capable of demonstrating differences between anisomyopic eyes although validation against in vivo measurements is required.

Visual acuity measures do not reliably detect childhood refractive error - an epidemiological study

Purpose To investigate the utility of uncorrected visual acuity measures in screening for refractive error in white school children aged 6-7-years and 12-13-years. Methods The Northern Ireland Childhood Errors of Refraction (NICER) study used a stratified random cluster design to recruit children from schools in Northern Ireland. Detailed eye examinations included assessment of logMAR visual acuity and cycloplegic autorefraction. Spherical equivalent refractive data from the right eye were used to classify significant refractive error as myopia of at least 1DS, hyperopia as greater than +3.50DS and astigmatism as greater than 1.50DC, whether it occurred in isolation or in association with myopia or hyperopia. Results Results are presented from 661 white 12-13-year-old and 392 white 6-7-year-old school-children. Using a cut-off of uncorrected visual acuity poorer than 0.20 logMAR to detect significant refractive error gave a sensitivity of 50% and specificity of 92% in 6-7-year-olds and 73% and 93% respectively in 12-13-year-olds. In 12-13-year-old children a cut-off of poorer than 0.20 logMAR had a sensitivity of 92% and a specificity of 91% in detecting myopia and a sensitivity of 41% and a specificity of 84% in detecting hyperopia. Conclusions Vision screening using logMAR acuity can reliably detect myopia, but not hyperopia or astigmatism in school-age children. Providers of vision screening programs should be cognisant that where detection of uncorrected hyperopic and/or astigmatic refractive error is an aspiration, current UK protocols will not effectively deliver.