Relative peripheral hyperopia leads to greater short-term axial length growth in White children with myopia.

PURPOSE: Controversy exists regarding the influence of peripheral visual experience on the onset and progression of childhood myopia. This longitudinal, observational study evaluated the relationship between relative peripheral refraction (RPR) and changes in refractive error and axial length (AL) over 12 months in White children aged 6-7 and 12-13 years with a range of baseline refractive errors. METHODS: Cycloplegic baseline autorefraction at horizontal retinal eccentricities of 0° and ±30° were recorded with the Shin-Nippon NVision-K 5001 while AL was measured using the Zeiss IOLMaster 700. Measurements were repeated after 12 months on a subgroup. Refractive data were transposed into power vectors as mean spherical equivalent (M), J0 and J45 . RPR was calculated by subtracting central from peripheral measurements. Participants were defined as myopic (M ≤ -0.50 D), premyopic (-0.50 D < M ≤ +0.75 D), emmetropic (+0.75 D < M < +2.00 D) or hyperopic (M ≥ +2.00 D). RESULTS: Data were collected from 222 and 245 participants aged 6-7 and 12-13 years, respectively. Myopic eyes demonstrated, on average, more hyperopic RPR. Emmetropes and premyopes displayed emmetropic RPR, and hyperopes showed a myopic RPR. Fifty-six 6- to 7-year-olds and seventy 12- to 13-year-olds contributed 12-month repeated measures. Longitudinal data demonstrated a significant relationship between a more hyperopic RPR in the nasal retina and greater short-term axial elongation in teens with myopia at baseline (ß = 0.69; p = 0.04). Each dioptre of relative peripheral hyperopia in the nasal retina was associated with an additional 0.10 mm (95% CI: 0.02-0.18 mm) annual increase in AL. CONCLUSIONS: Hyperopic RPR in the nasal retina of myopic children is indicative of increased risk for rapid axial elongation and may be a useful metric to support decision-making in myopia management.

An evaluation of the IOLMaster 700 and its agreement with the IOLMaster v3 in children.

PURPOSE: To evaluate the repeatability and reproducibility of the swept-source optical coherence tomographer Zeiss IOLMaster 700 and compare its outputs with those obtained using partial coherence interferometry (Zeiss IOLMaster v3) in a healthy, paediatric population. METHODS: This is a cross-sectional, observational study. Examiner 1 took two sets of biometric measurements (axial length [AL], mean corneal radius of curvature [Kmean ], anterior chamber depth [ACD] and lens thickness [LT]) using the IOLMaster 700, and one set of measurements (AL, Kmean and ACD) using the IOLMaster v3. Examiner 2 took one full set of measurements using the IOLMaster 700. Mean differences and 95% limits of agreement (LOA) were calculated, and Bland and Altman plots used to explore repeatability and reproducibility of the IOLMaster 700 alongside establishing its agreement with the IOLMaster v3. RESULTS: Mean participant age was 7.52 ± 0.58 years. Repeatability analyses demonstrated small mean differences and narrow 95% LOA for AL (0.001, -0.013 to 0.015 mm), Kmean (0.002, -0.020 to 0.024 mm), ACD (-0.003, -0.031 to 0.024 mm) and LT (0.001, -0.024 to 0.026 mm), respectively. Similarly, small mean differences and narrow 95% LOA established excellent reproducibility (AL 0.001, -0.016 to 0.018 mm; Kmean -0.001, -0.027 to 0.025 mm; ACD -0.010, -0.041 to 0.021 mm; LT 0.002, -0.016 to 0.020 mm). The IOLMaster 700 and IOLMaster v3 demonstrated good agreement with small mean differences and narrow 95% LOA (AL 0.009, -0.034 to 0.052 mm; Kmean 0.016, -0.013 to 0.044 mm; ACD 0.134, 0.055 to 0.212 mm). CONCLUSIONS: When used within a paediatric population, these data demonstrate the IOLMaster 700 to be highly repeatable and reproducible for measures of AL, Kmean , ACD and LT. There is excellent inter-instrument agreement between the IOLMaster 700 and IOLMaster v3 for measures of AL and Kmean . ACD measurements show weaker agreement. These data will be useful when considering reports from population-based studies of refractive error and clinical myopia research.

Axial growth and refractive change in white European children and young adults: predictive factors for myopia.

This report describes development of spherical equivalent refraction (SER) and axial length (AL) in two population-based cohorts of white, European children. Predictive factors for myopic growth were explored. Participants were aged 6-7- (n = 390) and 12-13-years (n = 657) at baseline. SER and AL were assessed at baseline and 3, 6 and 9 years prospectively. Between 6 and 16 years: latent growth mixture modelling identified four SER classes (Persistent Emmetropes-PEMM, Persistent Moderate Hyperopes-PMHYP, Persistent High Hyperopes-PHHYP and Emerging Myopes-EMYO) as optimal to characterise refractive progression and two classes to characterise AL. Between 12 and 22-years: five SER classes (PHHYP, PMHYP, PEMM, Low Progressing Myopes-LPMYO and High Progressing Myopes-HPMYO) and four AL classes were identified. EMYO had significantly longer baseline AL (≥ 23.19 mm) (OR 2.5, CI 1.05-5.97) and at least one myopic parent (OR 6.28, CI 1.01-38.93). More myopic SER at 6-7 years (≤ + 0.19D) signalled risk for earlier myopia onset by 10-years in comparison to baseline SER of those who became myopic by 13 or 16 years (p ≤ 0.02). SER and AL progressed more slowly in myopes aged 12-22-years (- 0.16D, 0.15 mm) compared to 6-16-years (- 0.41D, 0.30 mm). These growth trajectories and risk criteria allow prediction of abnormal myopigenic growth and constitute an important resource for developing and testing anti-myopia interventions.

Comparison of amblyopia in schoolchildren in Ireland and Northern Ireland: a population-based observational cross-sectional analysis of a treatable childhood visual deficit.

OBJECTIVES: This study reports the prevalence of persistent amblyopia (post-traditional treatment age) in schoolchildren in the Republic of Ireland (henceforth Ireland) and Northern Ireland (NI), UK; populations with broadly similar refractive and genetic profiles but different eye-care systems. DESIGN: This is a population-based observational study of amblyopia and refractive error. SETTING: Recruitment and testing in primary and post-primary schools in Ireland and NI. PARTICIPANTS: Two groups identified through random cluster sampling to represent the underlying population; Ireland 898 participants (12-13 years old) and NI 723 participants (295 aged 9-10 years old, 428 aged 15-16 years old). MAIN OUTCOME MEASURES: Monocular logMAR visual acuity (presenting and pinhole), refractive error (cycloplegic autorefraction), ocular alignment (cover test) and history of previous eye care. These metrics were used to determine prevalence and type of amblyopia and treatment histories. RESULTS: Children examined in NI between 2009 and 2011 had a significantly lower amblyopia prevalence than children examined in Ireland between 2016 and 2018 (two-sample test of proportions, p<0.001). Using a criteria of pinhole acuity 0.2logMAR (6/9.5 Snellen) plus an amblyogenic factor, 4 of 295 participants aged 9-10 years old (1.3%, 95% CIs 0.4 to 3.6) and 3 of 428 participants aged 15-16 years old (0.7%, 95%CIs 0.2 to 2.2) were identified in NI. The corresponding numbers in Ireland were 40 of 898 participants aged 12-13 years old (4.5%, 95% CI 3.2 to 6.1). In NI strabismic amblyopia was the most prevalent type of persistent amblyopia, whereas anisometropic was predominant in Ireland. In Ireland, amblyopia was associated with socioeconomic disadvantage (OR=2.2, 95%CIs 1.4 to 3.6, p=0.002) and poor spectacle compliance (OR 2.5, 95% CIs 2.0 to 3.2, p<0.001). CONCLUSIONS: Amblyopia prevalence persisting beyond traditional treatment ages was significantly lower among NI children compared with Ireland. Uncorrected anisometropia, compliance with spectacle wear and socioeconomic disadvantage were contributing factors in Ireland. Children without obvious visible eye defects were less likely to access eye care in Ireland, resulting in missed opportunities for intervention where necessary.

The Changing Profile of Astigmatism in Childhood: The NICER Study.

PURPOSE: We performed a prospective study of the changing profile of astigmatism in white school children in Northern Ireland. METHODS: Of the 399 6- to 7-year-old and 669 12- to 13-year-old participants in Phase 1 of the Northern Ireland Childhood Errors of Refraction (NICER) study, 302 (76%) of the younger and 436 (65%) of the older cohort were re-examined three years later (Phase 2). Stratified random cluster sampling was used. Following cycloplegia (cyclopentolate HCl 1%) refractive error was recorded by the Shin-Nippon-SRW-5000 autorefractor. Astigmatism is defined as ≥ 1.00 diopters cylinder (DC). Right eye data only are presented. RESULTS: The prevalence of astigmatism was unchanged in both cohorts: younger cohort 17.1% (95% confidence intervals [CIs], 13.3-21.6) were astigmatic at 9 to 10 years compared to 22.9% (95% CIs, 18.3-28.2) at 6 to 7 years; older cohort, 17.5% (95% CIs, 13.9-21.7) of participants were astigmatic at 15-16 years compared to 18.4% (95% CIs, 13.4-24.8) at age 12 to 13 years. Although prevalence remained unchanged, it was not necessarily the same children who had astigmatism at both phases. Some lost astigmatism (10.0%; CIs, 7.5-13.3 younger cohort and 17.4%; CIs, 13.5-22.2 older cohort); others became astigmatic (9.1%; CIs, 6.7-12.2 younger cohort and 11.6%; CIs, 8.4-15.8 older cohort). CONCLUSIONS: This study presents novel data demonstrating that the astigmatic error of white children does not remain stable throughout childhood. Although prevalence of astigmatism is unchanged between ages 6 and 7 to 15 to 16 years; during this time period individual children are developing astigmatism while other children become nonastigmatic. It is difficult to predict from their refractive data who will demonstrate these changes, highlighting the importance of all children having regular eye examinations to ensure that their visual requirements are met.

Comparison of refractive error measures by the IRX3 aberrometer and autorefraction.

PURPOSE: To compare the aberrometry-derived refractive error measurements from the IRX3 aberrometer (Imagine Eyes, Orsay, France) with a standardized measure of refractive error from the Shin-Nippon SRW-5000 (Japan) autorefractor in a large sample of school-aged children. METHODS: Participants were a subgroup of children from the Northern Ireland Childhood Errors of Refraction Study phase 2 (n = 161 9 to 10 years; n = 147 15 to 16 years). Refractive error was measured under cycloplegia (1.0% cyclopentolate HCl) with the IRX3 aberrometer followed by measurement with the Shin-Nippon autorefractor. Mean differences and 95% confidence intervals and limits of agreement were calculated for refractive vector components (M, J0, and J45). RESULTS: Participants had a wide range of refractive error ranging from -6.00 to +8.00 diopters (D) spherical equivalent refraction. Fixed measurement biases (±95% confidence interval) between instruments were small for both groups (9- to 10-year-olds: M, -0.20 ± 0.65 D; J0, -0.005 D; J45, 0.05 D; 15- to 16-year-olds: M, 0.03 ± 0.61 D; J0, -0.04 D; J45, -0.02 D). Statistically significant differences were found between instruments for M and J45 for the 9- to 10-year-old group (p < 0.0001) and for J0 for the 15- to 16-year-old group (p = 0.003). A statistically significant proportional measurement bias was found for the cylindrical components J0 and J45 for both groups (p < 0.0001), but no statistically significant proportional bias was found for M for either group. CONCLUSIONS: This is the first study to explore refractive error measurements from the IRX3 aberrometer in children. The differences between instruments for all refractive components (M, J0, and J45) were small for both groups (<0.25 D) and may not be considered clinically meaningful. Levels of agreement were also comparable to other studies investigating the validity of instruments measuring automated refraction in both adults and children. The results would suggest that these objective techniques produce similar results for assessment of refractive error in children.

Higher order ocular aberrations and their relation to refractive error and ocular biometry in children.

PURPOSE: The interaction between higher order ocular aberrations (HOA) and refractive error is not yet fully understood. This study investigated HOA in relation to refractive error and ocular biometric parameters in a population with a high prevalence of ametropia. METHODS: The HOA were investigated in two cohorts of Caucasian children aged 9 to 10 and 15 to 16 years (n = 313). These aberrations were measured for a 5-mm pupil with the IRX3 aberrometer. Cycloplegic refractive error and ocular biometry measures, including axial length and corneal curvature, also were assessed with the Shin-Nippon SRW-5000 auto-refractor and Zeiss IOLMaster, respectively. Participants were divided into refractive groups for analysis of HOA. RESULTS: The magnitude of total HOA was higher in this population at 0.27 µm (interquartile range [IQR], 0.22-0.32 µm) than other HOA reported in the literature. The profile of HOA was not significantly different across the two age cohorts or across refractive groups, nor did spherical aberration differ significantly with age (Z4° = 0.07 µm for both cohorts). Multivariate linear regression analysis demonstrated spherical aberration was significantly related to axial length (but not refractive grouping), with longer eyes having less positive values of fourth order and root mean square (RMS) spherical aberration. CONCLUSIONS: This study found no significant difference in HOA across refractive groups. The current study also highlights the importance of knowledge of axial length when analyzing HOA.

An investigation into the validity of self-reported classification of refractive error.

PURPOSE: To assess the validity of questionnaire use in the self-identification of refractive status. METHODS: Two hundred and forty adults (21-60 years of age) presenting for a routine eye examination at various optometric practices in Northern Ireland were asked to complete one of two questionnaires. Both questionnaires used identical questions to ascertain age, gender, current spectacle use, age of first spectacle use and level of education. For the identification of refractive status, Questionnaire 1 used layman's terminology whilst Questionnaire 2 combined optometric terminology with descriptive explanations. Current refractive status was identified by the examining optometrist who did not see the completed questionnaire. The spherical equivalent refractive error of the non-cycloplegic subjective refraction was used to categorise myopia as <0D and hyperopia as ≥+1.00D. Astigmatism was defined according to two different criteria: ≥0.50DC and ≥1.00DC. RESULTS: Questionnaire 1 had a sensitivity of 0.63 and a specificity of 0.90 for identifying myopia; a sensitivity of 0.58 and a specificity of 0.71 for identifying hyperopia; a sensitivity of 0.12 and a specificity of 0.98 for identifying astigmatism ≥0.50DC and a sensitivity of 0.19 and a specificity of 0.95 for identifying astigmatism ≥1.00DC. Questionnaire 2 had a sensitivity of 0.83 and a specificity of 0.93 for identifying myopia; a sensitivity of 0.45 and a specificity of 0.86 for identifying hyperopia; a sensitivity of 0.32 and a specificity of 0.88 for identifying astigmatism ≥0.50DC and a sensitivity of 0.50 and a specificity of 0.84 for identifying astigmatism ≥1.00DC. For both questionnaires, altering a positive self-identification of myopia to include only those who had worn spectacles prior to age 30 reduced the sensitivity and increased the specificity slightly. CONCLUSIONS: Questionnaires are a valid tool in self-identification of myopic refractive status. However, they are not an effective way of identifying hyperopia and astigmatism and objective or subjective refraction remains the most appropriate method of identifying such individuals.

A prospective study of spherical refractive error and ocular components among Northern Irish schoolchildren (the NICER study).

PURPOSE: To explore 3-year change in spherical refractive error and ocular components among white Northern Irish schoolchildren. METHODS: Baseline data were collected among 6- to 7-year-old and 12- to 13-year-old children. Three years after baseline, follow-up data were collected. Cycloplegic refractive error and ocular components measurements (axial length [AL], anterior chamber depth [ACD], corneal radius of curvature [CRC]) were determined using binocular open-field autorefraction and ocular biometry. Change in spherical equivalent refractive error (SER) and ocular components were calculated. RESULTS: A statistically significantly greater change in SER was found between 6 to 7 years and 9 to 10 years (younger cohort) compared to between 12 to 13 years and 15 to 16 years (older cohort) (-0.38 diopter [D] and -0.13 D, respectively) (P<0.001). A statistically significantly greater change in AL was found among the younger compared to the older cohort (0.48 mm and 0.14 mm, respectively) (P<0.001). Change in ACD was minimal across both groups (0.12 mm younger and 0.05 mm older cohort) as were changes in CRC. Change in SER was associated with change in AL in both age groups (both P<0.01). CONCLUSIONS: There is a greater change in both spherical refractive error and axial length in younger children when compared with teenagers. Although increase in axial length drives refractive change during childhood and teenage years, lens compensation continues to occur in an attempt to maintain emmetropia. White children living in Northern Europe demonstrate dramatically less change in spherical refractive error over a fixed period of time than their East Asian counterparts. In contrast, they appear to exhibit more rapid myopic progression than UK children studied in the mid-20th century.

The robustness of various forms of perimetry to different levels of induced intraocular stray light.

PURPOSE: To compare directly the robustness of standard automated perimetry (SAP), short-wavelength automated perimetry (SWAP), frequency-doubling perimetry (FDP), and grating-resolution perimetry (GRP) stimuli to different degrees of intraocular stray light induced by commercially available opacity-containing filters. METHODS: Five white opacity filters of increasing density were used to simulate the typical forward light scatter and stray light values associated with age-related lens opacification and significant cataract. The individually induced intraocular stray light value for each filter was quantified with a stray light meter and plotted against individual perimetric thresholds for the right eyes of three normally sighted trained observers for SAP, SWAP, FDP, and GRP. RESULTS: All tests were significantly but differently affected by increasing stray light. Overall average declines over a 1 log unit change in the stray light values were as follows: SAP, 4.85 dB; SWAP, 9.03 dB; FDP, 4.29 dB; and GRP, 1.36 dB. Standardized (z) scores were calculated after normalization to the spread of the normative data values for each instrument. These indicated that the standardized changes from baseline over the range of the five filters per log stray light unit were as follows: SAP, 2.177; SWAP, 1.96; FDP, 1.277; and GRP, 1.04. CONCLUSIONS: The increased stray light values induced by cataract-simulating filters has a significant effect on all tests. However, GRP, which is known to be limited by retinal sampling rather than contrast, remains the most robust of the tests to the effects of intraocular stray light. The degree to which the normative "sensitivity" range for different types of perimetry might incorporate a component caused by individual differences in intraocular stray light is discussed and requires further research.