Robert W. Arnold

Guidelines for automated preschool vision screening: a 10-year, evidence-based update.

In 2003 the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee proposed criteria for automated preschool vision screening. Recent literature from epidemiologic and natural history studies, randomized controlled trials of amblyopia treatment, and field studies of screening technologies have been reviewed for the purpose of updating these criteria. The prevalence of amblyopia risk factors (ARF) is greater than previously suspected; many young children with low-magnitude ARFs do not develop amblyopia, and those who do often respond to spectacles alone. High-magnitude ARFs increase the likelihood of amblyopia. Although depth increases with age, amblyopia remains treatable until 60 months, with decline in treatment effectiveness after age 5. US Preventive Services Task Force Preventative Services Task Force guidelines allow photoscreening for children older than 36 months of age. Some technologies directly detect amblyopia rather than ARFs. Age-based criteria for ARF detection using photoscreening is prudent: referral criteria for such instruments should produce high specificity for ARF detection in young children and high sensitivity to detect amblyopia in older children. Refractive screening for ARFs for children aged 12-30 months should detect astigmatism >2.0 D, hyperopia >4.5 D, and anisometropia >2.5 D; for children aged 31-48 months, astigmatism >2.0 D, hyperopia > 4.0 D, and anisometropia >2.0 D. For children >49 months of age original criteria should be used: astigmatism >1.5 D, anisometropia>1.5 D, and hyperopia >3.5 D. Visually significant media opacities and manifest (not intermittent) strabismus should be detected at all ages. Instruments that detect amblyopia should report results using amblyopia presence as the gold standard. These new American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines will improve reporting of results and comparison of technologies.

A randomized trial of atropine vs patching for treatment of moderate amblyopia: Follow-up at age 10 years

OBJECTIVE To determine the visual acuity outcome at age 10 years for children younger than 7 years when enrolled in a treatment trial for moderate amblyopia. METHODS In a multicenter clinical trial, 419 children with amblyopia (visual acuity, 20/40-20/100) were randomized to patching or atropine eyedrops for 6 months. Two years after enrollment, a subgroup of 188 children entered long-term follow-up. Treatment after 6 months was at the discretion of the investigator; 89% of children were treated. MAIN OUTCOME MEASURE Visual acuity at age 10 years with the electronic Early Treatment Diabetic Retinopathy Study test. APPLICATION TO CLINICAL PRACTICE Patching and atropine eyedrops produce comparable improvement in visual acuity that is maintained through age 10 years. RESULTS The mean amblyopic eye acuity, measured in 169 patients, at age 10 years was 0.17 logMAR (logarithm of the minimum angle of resolution) (approximately 20/32), and 46% of amblyopic eyes had an acuity of 20/25 or better. Age younger than 5 years at entry into the randomized trial was associated with a better visual acuity outcome (P < .001). Mean amblyopic and sound eye visual acuities at age 10 years were similar in the original treatment groups (P = .56 and P = .80, respectively). CONCLUSIONS At age 10 years, the improvement of the amblyopic eye is maintained, although residual amblyopia is common after treatment initiated at age 3 years to younger than 7 years. The outcome is similar regardless of initial treatment with atropine or patching.

Comparison Between the plusoptiX and MTI Photoscreeners

OBJECTIVE Both the Medical Technology and Innovations (MTI) and plusoptiX photoscreeners are used to objectively screen for amblyogenic risk factors in children. The MTI has been extensively studied, but the limited availability of film may render it obsolete. We compared the MTI with the plusoptiX, a newer digital photoscreener, for the ability to detect amblyogenic factors when compared with a comprehensive pediatric ophthalmic examination. We believe our results will help to guide community-based vision screening programs. METHODS One hundred fifty-one children were examined consecutively in our office. Each patient was screened with the MTI and plusoptiX devices on the same day as part of a comprehensive pediatric ophthalmic examination. Results via MTI were evaluated by an expert masked examiner (R.W.A.), and the plusoptiX results were interpreted by the incorporated software. RESULTS Sixty-five percent of patients were found to have amblyopia or amblyogenic risk factors during the pediatric ophthalmic examination conducted via the American Association of Pediatric Ophthalmology and Strabismus referral criteria. We found the MTI photoscreener to have a sensitivity of 83.6%, specificity of 90.5%, false- positive rate of 9.4%, false-negative rate of 16.3%, and positive predictive value of 94.2%. The plusoptiX demonstrated a sensitivity of 98.9%, specificity of 96.1%, false- positive rate of 3.7%, false-negative rate of 1.0%, and positive predictive value of 97.9%. CONCLUSION The MTI and plusoptiX photoscreeners proved to be effective when compared with a comprehensive cycloplegic pediatric ophthalmic examination. The plusoptiX, however, was found to have a higher sensitivity and specificity than the MTI.

Sensitivity to vasovagal maneuvers in normal children and adults

In 15 male and 15 female healthy subjects who were 10 to 48 years of age, we studied alterations in heart rate and finger blood flow in response to the cold pressor test and four strong vasovagal maneuvers: diving response (apneic facial exposure to an ice water bag), Valsalva maneuver (forced expiration against a column of mercury to 40 to 50 mm Hg), unilateral carotid sinus massage, and oculocardiac reflex (inflation of a Honan balloon against one eye). Peripheral vasoconstriction as a consequence of the diving response paralleled the vasoconstriction from the cold pressor test, but it preceded the bradycardia that resulted from the diving response maneuver. In contrast, the rate of finger blood flow was high during the bradycardia that followed stage 4 of the Valsalva maneuver. Changes in heart rate correlated with age for the diving response, the Valsalva maneuver, and the oculocardiac reflex. Changes in heart rate and finger blood flow were not dependent on sex. The change in heart rate noted with the diving response was significantly correlated with that noted with the Valsalva maneuver and the oculocardiac reflex. Changes in finger blood flow did not correlate with changes in heart rate for any maneuver. This study provides a response profile of relative sensitivities to strong vasovagal maneuvers in normal children and adults.

Amblyopia risk factor prevalence.

PURPOSE In 2003, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) published a set of risk factors for amblyopia. The intent was to promote uniformity of reporting and development in screening. Because this prevalence is not yet known, this meta-analysis is an attempt to estimate it. METHODS Major community preschool eye examination studies were reviewed and AAPOS cut-offs estimated. RESULTS The approximate prevalence of anisometropia is 1.2%, hyperopia is 6%, astigmatism is 15%, myopia is 0.6%, strabismus is 2.5%, and visual acuity less than 20/40 is 6%. The mean combined prevalence is 21% ± 2% compared to a prevalence of amblyopia 20/40 and worse of 2.5%. CONCLUSIONS Knowing risk factor prevalence simplifies validation efforts. Amblyopia screening with a risk factor sensitivity less than 100% is expected and desirable.

Performance of four new photoscreeners on pediatric patients with high risk amblyopia.

PURPOSE A new study by the American Academy of Pediatrics touts the benefits of photoscreening, especially in preverbal children who cannot yet perform monocular acuity screening. Emerging devices have not been compared in young and developmentally challenged children. METHODS Consecutive patients in a pediatric eye practice had a comprehensive eye examination and four photoscreens: PlusoptiX (PlusoptiX, Nuremburg, Germany), SPOT (PediaVision, Lake Mary, FL), iScreen (iScreen, Memphis, TN), and the GoCheckKids application (Gobiquity, Aliso Viejo, CA) for the iPhone 4s (Apple, Cupertino, CA) with Delta Center Crescent interpretation. They were validated according to the 2003 American Association for Pediatric Ophthalmology and Strabismus uniform guidelines. RESULTS One hundred eight children aged 1 to 12 years participated, with 56% having amblyopia risk factors and 10% having autism. For the four devices, sensitivity, specificity, and inconclusive results were as follows: PlusoptiX (83%, 86%, 23%), SPOT (80%, 85%, 4%), iScreen (75%, 88%, 13%) and iScreen (with Delta Center Crescent) (92%, 88%, 0%), and GoCheckKids (with Delta Center Crescent) (81%, 91%, 3%). CONCLUSIONS Even in high risk and young children, current instrument-based screeners can reliably screen for refractive and strabismic risk factors that lead to amblyopia. Some devices can reduce the proportion of inclusive results in challenging cases.

Acquired Divergent Strabismus: Presumed Metastatic Gastric Carcinoma to the Medial Rectus Muscle

A patient with rapidly progressive metastatic gastric carcinoma developed diplopia and diminished adduction of the right eye. The right medial rectus muscle belly was enlarged, as shown by computed tomography. This case is unusual, because gastric carcinoma comprises only 1% of orbital metastases and less than 5% of all orbital metastases localize to extraocular muscle.

Susceptibility to retinopathy of prematurity in Alaskan natives

Threshold retinopathy of prematurity occurred in 11 of 34 Alaskan natives compared with 10 of 93 non-natives. Natives constitute 16% of the state population. This significant Alaskan native preponderance was not explained by differences in prenatal or intensive care unit morbidity except that the intervals from birth to extubation and birth to cryotherapy were shorter for natives.

A Comparison of Patched HOTV Visual Acuity and Photoscreening

Early detection of significant vision problems in children is a high priority for pediatricians and school nurses. Routine vision screening is a necessary part of that detection and has traditionally involved acuity charts. However, photoscreening in which “red eye” is elicited to show whether each eye is focusing may outperform routine acuity testing in pediatric offices and schools. This study compares portable acuity testing with photoscreening of preschoolers, kindergarteners, and 1st-graders in 21 elementary schools. School nurses performed enhanced patched acuity testing and two types of photoscreening in a portable tent. Nearly 1,700 children were screened during spring semester 2004, and 14% had confirmatory exams by community eye care professionals. The results indicate that one form of photoscreening using a Gateway DV-S20 digital camera is significantly more sensitive to children with significant vision problems, as well as being the most cost effective (85% specificity and only

Lack of Global Vagal Propensity in Patients with Oculocardiac Reflex

0.11 per child). This suggests that the adaptation of photoscreening into a routine vision screening protocol would be beneficial for efficiently detecting vision problems that could lead to amblyopia.