Visual Acuity Screening in North Indian Schools: Testing Accuracy and Cost of Alternate Screening Models.

PURPOSE: Our study compares the sensitivity, specificity and cost of visual acuity screening as performed by all class teachers (ACTs), selected teachers (STs) and vision technicians (VTs) in north Indian schools. METHODS: Prospective cluster randomized control studies are conducted in schools in a rural block and an urban-slum of north India. Consenting schools, with a minimum of 800 students aged 6 to 17 years, within a defined study region in both locations, were randomised into three arms: ACTs, STs or VTs. Teachers were trained to test visual acuity. Reduced vision was defined as unable to read equivalent of 20/30. Optometrists, who were masked to results of initial screening, examined all children. Costs were measured for all three arms. RESULTS: The number of students screened were 3410 in 9 ACT schools, 2999 in 9 ST schools and 3071 in 11 VT schools. Vision deficit was found in 214 (6.3%), 349 (11.6%) and 207 (6.7%), (p < .001) children in the ACT, ST and VT arms, respectively. The positive predictive value of VT screening for vision deficit (81.2%) was significantly higher than that of ACTs (42.5%) and STs (30.1%), (p < .001). VTs had significantly higher sensitivity of 93.3% and specificity of 98.7%, compared to ACTs (36.0% and 96.1%) and STs (44.3% and 91.2%). The cost of screening children with actual visual deficit by ACTs, STs and VTs, was found to be $9.35, $5.79 and $2.82 per child, respectively. CONCLUSION: Greater accuracy and lower cost favours school visual acuity screening by visual technicians in this setting, when they are available.

Preliminary assessment of a standardized vision screening guideline in a pediatric inpatient rehabilitation unit.

OBJECTIVE: This study aimed to evaluate the impact of a standardized vision screen guideline on occupational therapy vision screens in a pediatric inpatient rehabilitation unit. METHODS: Charts of patients admitted to a pediatric inpatient rehabilitation before guideline implementation (n = 47) versus charts after implementation (n = 47) were randomly, retrospectively reviewed to explore differences in visual skills screened and use of standardized assessments. RESULTS: Significant improvements (p < = 0.05) were found in the number of visual skills screened (p = 0.034), use of standardized assessments (p = 0.005), and screening of the specific visual skills of accommodative amplitude (p = 0.05), suppression (p = 0.015), and double vision (p < 0.001). CONCLUSION: Implementation of a standardized vision screen guideline improved the frequency of vision screens during occupational therapy evaluations in a pediatric inpatient rehabilitation unit. The use of standardized assessments may also improve the quality of vision screens by encouraging staff to complete more comprehensive vision screens, including screening more visual skills, and by prompting use of standardized assessments, which can improve accuracy of screening procedures.

Photoscreening for amblyopia risk factors assessment in young children: A systematic review with meta-analysis.

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.

Cost-Effectiveness of photoscreeners in screening at-risk amblyopia in Indian children.

Objectives: Amblyopia is the most common cause of preventable vision impairment in children. This study tried to evaluate the cost-effectiveness of photoscreeners in identifying refractive errors making children at risk of amblyopia. Materials and Methods: This was designed as a prospective, open-label, randomized controlled study to compare the cost-effectiveness of photoscreeners (2WIN Adaptica and Plusoptix) versus autorefractor and Mohindra retinoscopy to identify the at-risk amblyopia. This study was conducted from October 2018 to December 2018 in coordination with Nanna Kannu school screening project and children in the age group of 5-11 years were included in the study. The photoscreening was done by lay screeners. A supervising ophthalmologist collated all data. Cost-effectiveness was calculated for the individual instruments and compared. The average time is taken for each instrument to record the refractive error was calculated and compared with the Mohindra retinoscopy. Results: Number of children included in this study was 2910. The mean age of the children was 7.82 + 0.65 years. The mean time taken for 2WIN Adaptica was 6 sec, Topcon -10 s, and Plusoptix -4 s. Plusoptix showed the minimal time for screening a child when compared to all other methods. The Plusoptix and 2WIN Adaptica were shown to be cost-effective when compared to Mohindra retinoscopy (P < 0.05). Conclusion: Photoscreening using Plusoptix and 2WIN Adaptica with lay screeners was < seven times the cost incurred and five times faster than the trained optometrists using either autorefractor or Mohindra retinoscopy and thus more cost-effective in screening a large number of young children with at-risk amblyopia at the community level.

Prediction and cost-effectiveness comparison of amblyopia screening methods at ages 3-4 years.

PURPOSE: Compare the performance of different amblyopia screening tests. METHODS: Based on exploratory factor analyses (EFA) of different screening tests performed in 3295 children, we created models of screening strategies in a matrix with: uncorrected visual acuity (UCVA), Plusoptix measurements (PO), Randot Stereo-test (SR), and Cover-Test (CT). Receiver Operating Characteristic (ROC) curves and confusion matrix were used to compare performance of different model's algorithm to predict new diagnosis of amblyopia. Estimated screening costs per screened and treated child were compared. RESULTS: Regression analyses revealed that, although all models predicted amblyopia (all p < 0.001), only models including PO or UCVA had higher prediction capacity (R2 > 0.4) and better discriminating ROC curves (AUC > 0.95; p < 0.001). For 96% sensitivity, UCVA + PO was the most cost-effective model, since the estimated average screening costs per treated child, almost doubled and tripled if using PO or UCVA alone, respectively, versus using both exams. When UCVA + PO is not possible to implement, adding SR to either UCVA or PO resulted in cost-savings of 28% and 18%, respectively. CONCLUSIONS: In a previous unscreened population, aged 3-4 years, screening programs using either UCVA or PO alone, should reconsider doing both tests simultaneously, since, for a high level of sensitivity, using simultaneously UCVA + PO is more cost-effective, per screened, and treated amblyopia. Concerns relating higher time-consuming exams for the combination of UCVA + PO should be surpassed, since costs per treated child drop considerably. When children benefit from good primary-care routine examinations since birth, no benefit was found for using CT in a screening setting. SR showed little benefit.

Teacher and school staff perspectives on their role in school-based vision programs.

OBJECTIVE: School-based vision programs (SBVPs) are one approach to increase access to vision care by providing vision screenings, eye examinations, and eyeglasses directly in schools. Few studies report on the perspectives of teachers and staff, who are important stakeholders, on SBVPs. We examined teacher and staff perspectives on their involvement in SBVPs. DESIGN: Qualitative study using focus groups. PARTICIPANTS: Teachers and staff at Baltimore and Chicago public schools served by SBVPs between 2016 and 2018. METHODS: We conducted 21 semistructured focus groups with 117 teachers and staff in 10 Baltimore and 11 Chicago public preK-12 schools that participated in SBVPs. Sessions were recorded, transcribed, and coded using inductive thematic analysis. RESULTS: Participants identified 2 main themes regarding teacher and staff involvement in SBVPs: (i) program outreach, including using multiple communication modalities to engage parents, explaining program details to families, and helping with program consent form return and (ii) promoting vision health, including identifying vision problems in the classroom, encouraging eyeglasses wear, and supporting eyeglasses maintenance. Participants also discussed limitations in capacity to partake in these activities. CONCLUSION: Teachers interact with parents and students throughout the SBVP process, undertaking important roles in outreach and health promotion to ensure uptake of SBVP services. SBVPs and other school-based health programs should explore strategies to support teachers in the roles they fill to optimize program impact.

Economic evaluations of vision screening to detect amblyopia and refractive errors in children: a systematic review.

OBJECTIVE: To synthesize and appraise economic evaluations of vision screening to detect vision impairment in children. METHODS: Literature searches were conducted on seven electronic databases, grey literature, and websites of agencies conducting health technology assessments. Studies were included if they (1) were full, comparative economic evaluations that used cost-utility, cost-benefit, cost-effectiveness, cost-consequence, or cost-analysis methods; (2) described screening services designed to detect amblyopia, strabismus, or uncorrected refractive errors in children under 6 years of age; and (3) published after 1994. High-quality studies were synthesized descriptively. Currencies were reported in 2019 Canadian dollars. Quality was assessed with the Pediatric Quality Appraisal Questionnaire (PQAQ). RESULTS: Vision screening services were conducted by paid staff, volunteers, or health care professionals in schools or clinics. Thirteen studies were published from five countries: China (n = 1), United States (n = 4), United Kingdom (n = 1), Canada (n = 1), and Germany (n = 6). Analytical techniques included cost-utility/cost-effectiveness combination (n = 2), cost-effectiveness analysis (n = 7), cost-utility analysis (n = 1), cost-benefit analysis (n = 1), cost-consequence analysis (n = 1), and cost analysis (n = 1). Incremental cost-effectiveness ratios ranged from C$1,056 to C$151,274 per additional case detected/prevented and from C$9,429 to C$30,254,703 per additional QALY gained, depending on the type of screening service and comparator. Six studies were determined to be of high quality. CONCLUSION: Vision screening to detect amblyopia for young children may be cost-effective compared with no screening if amblyopia reduced quality of life. Studies varied significantly in the type of screening services and comparators used. Methodological limitations were common. Future studies would be aided immensely by prospective studies on the impact of amblyopia on the health-related quality of life of young children and guidelines on the effective conduct of vision screening.

RéSUMé: OBJECTIF: Synthétiser et évaluer des évaluations économiques de dépistages visuels visant à détecter la déficience visuelle chez les enfants. MéTHODE: Nous avons interrogé sept bases de données électroniques, la littérature grise et les sites Web d'organismes effectuant des évaluations des technologies de la santé. Nous avons inclus les études correspondant aux critères suivants : (1) évaluations économiques comparatives exhaustives utilisant l'analyse coûts-utilité, coûts-bénéfices, coûts-efficacité ou coûts-conséquences ou l'analyse des coûts; (2) décrivant des services de dépistage visant à détecter l'amblyopie, le strabisme ou les anomalies de la réfraction non corrigées chez les enfants de moins de six ans; et (3) publiées après 1994. Nous avons fait la synthèse descriptive des études de haute qualité. Les devises ont été converties en dollars canadiens de 2019. Nous avons évalué la qualité des études à l'aide de l'outil PQAQ (Pediatric Quality Appraisal Questionnaire). RéSULTATS: Les services de dépistage visuel étaient offerts par du personnel rémunéré, des bénévoles ou des professionnels de santé dans des écoles ou des cliniques. Treize études ont été publiées dans cinq pays : Chine (n = 1), États-Unis (n = 4), Royaume-Uni (n = 1), Canada (n = 1) et Allemagne (n = 6). Les techniques d'analyse employées étaient la combinaison analyse coûts-utilité/analyse coûts-efficacité (n = 2), l'analyse coûts-efficacité (n = 7), l'analyse coûts-utilité (n = 1), l'analyse coûts-avantages (n = 1), l'analyse coûts-conséquences (n = 1) et l'analyse des coûts (n = 1). Les rapports coût-efficacité différentiels s'échelonnaient entre 1 056 $ CA et 151 274 $ CA par cas supplémentaire détecté/prévenu et entre 9 429 $ CA et 30 254 703 $ CA par année de vie pondérée par la qualité (AVPQ) supplémentaire gagnée, selon le type de service de dépistage et le comparateur. Six études ont été jugées être de haute qualité. CONCLUSION: Comparativement à l'absence de dépistage, les dépistages visuels pour détecter l'amblyopie chez les jeunes enfants peuvent être efficaces par rapport à leur coût lorsque l'amblyopie réduit la qualité de vie. Le type de services de dépistage et les comparateurs utilisés variaient considérablement d'une étude à l'autre. Les contraintes méthodologiques étaient courantes. Les études futures seraient grandement favorisées par des études prospectives des incidences de l'amblyopie sur la qualité de vie liée à la santé chez les jeunes enfants et par des lignes directrices sur l'exécution efficace des dépistages visuels.

Community-Based Hearing and Vision Screening in Schools in Low-Income Communities Using Mobile Health Technologies.

Introduction Globally, more than 50 million children have hearing or vision loss. Most of these sensory losses are identified late due to a lack of systematic screening, making treatment and rehabilitation less effective. Mobile health (mHealth), which is the use of smartphones or wireless devices in health care, can improve access to screening services. mHealth technologies allow lay health workers (LHWs) to provide hearing and vision screening in communities. Purpose The aim of the study was to evaluate a hearing and vision school screening program facilitated by LHWs using smartphone applications in a low-income community in South Africa. Method Three LHWs were trained to provide dual sensory screening using smartphone-based applications. The hearScreen app with calibrated headphones was used to conduct screening audiometry, and the Peek Acuity app was used for visual acuity screening. Schools were selected from low-income communities (Gauteng, South Africa), and children aged between 4 and 9 years received hearing and vision screening. Screening outcomes, associated variables, and program costs were evaluated. Results A total of 4,888 and 4,933 participants received hearing and vision screening, respectively. Overall, 1.6% of participants failed the hearing screening, and 3.6% failed visual acuity screening. Logistic regression showed that female participants were more likely to pass hearing screening (OR = 1.61, 95% CI [1.11, 2.54]), while older children were less likely to pass visual acuity screening (OR = 0.87, 95% CI [0.79, 0.96]). A third (32.5%) of referred cases followed up for air-conduction threshold audiometry, and one in four (25.1%) followed up for diagnostic vision testing. A high proportion of these cases were confirmed to have hearing (73.1%, 19/26) or vision loss (57.8%, 26/45). Conclusions mHealth technologies can enable LHWs to identify school-age children with hearing and/or vision loss in low-income communities. This approach allows for low-cost, scalable models for early detection of sensory losses that can affect academic performance.

Cost Analysis of Teleophthalmology Screening for Diabetic Retinopathy Using Teleophthalmology Billing Codes.

BACKGROUND AND OBJECTIVE: To evaluate the financial sustainability of teleophthalmology screening for diabetic retinopathy (DR) using telehealth billing codes. PATIENTS AND METHODS: The authors performed an Institutional Review Board-approved retrospective review of medical records, billing data, and quality metrics at the University of California Davis Health System from patients screened for DR through an internal medicine-based telemedicine program using CPT codes 92227 or 92228. RESULTS: A total of 290 patients received teleophthalmology screening over a 12-month period, resulting in an increase in the DR screening rate from 49% to 63% (P < .0001). The average payment per patient was $19.86, with an estimated cost of $41.02 per patient. The projected per-patient incentive bonus was $43.06 with a downstream referral revenue of $39.38 per patient. One hundred seventy-eight clinic visits were eliminated, providing an estimated cost savings of $42.53 per patient. CONCLUSION: Sustainable teleophthalmology screening may be achieved by billing telehealth codes but only with health care incentive bonuses, patient referrals, and by accounting for the projected cost-savings of eliminating office visits. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S26-S34.].

Validity and feasibility of a self-administered home vision examination in Yueqing, China: a cross-sectional study.

OBJECTIVE: To investigate the validity and feasibility of a self-administered home vision examination programme in China. DESIGN: Cross-sectional study. SETTING: Yueqing, China. PARTICIPANTS: A two-stage convenience sampling procedure was used to randomly select 600 households from 30 communities participating in the Yueqing Eye Study (YES). The aim of YES is to encourage home-based vision screening, reporting of visual acuity (VA) annually through social media and encouraging people to attend follow-up clinic appointments as a way to improve eye care access for adults with VA ≤+0.5 log of the minimum angle of resolution (logMAR). INTERVENTIONS: Household screeners (one per household) who tested other family members' VA completed a questionnaire on family structure, demographic information and knowledge about screening procedures. Other family members then underwent confirmatory VA testing by researchers. OUTCOME MEASURES: The completion rate of home-based VA screening, its sensitivity and specificity were used to evaluate validity. Factors that determined whether families participated in the self-VA screening were used to evaluate feasibility. RESULTS: 345 (66%) of the 523 (87.2%) households with valid data form their home-based vision examinations also were retested by researchers. There was no statistically significant difference in scores on the family-administerd or researcher-administerd VA test (VA≤+0.5 logMAR, p=0.607; VA >+0.5 logMAR, p=0.612). The sensitivity and specificity of home-based vision screening were 80.5% (95% CI 70.2% to 86.9%) and 95.1% (95% CI 92.6% to 96.8%), respectively. 14.7% (77/523) of tested respondents had VA ≤+0.5 logMAR. Predictors of performing home screening for VA remaining in regression models included higher economic status ('fair and above' vs 'poor': OR 1.74; 95% CI 1.08 to 2.76; p=0.022), age (<45 years vs ≥45 years: OR 0.46; 95% CI 0.25 to 0.85; p=0.014) and living in a nuclear (OR 5.17; 95% CI 2.86 to 9.36; p<0.001) or extended family (OR 8.37; 95% CI 4.93 to 14.20; p<0.001). CONCLUSION: Self-administered home vision screening is reliable and highly accepted by Chinese adults.

Cost-Minimization Analysis of Ranibizumab Versus Aflibercept for Treating Saudi Patients With Visual Impairment Owing to Age-Related Macular Degeneration or Diabetic Macular Edema.

OBJECTIVE: The standard-of-care treatment for age-related macular degeneration (AMD) and diabetic macular edema (DME) includes inhibiting blood vessel proliferation and reducing macular edema or swelling using anti-vascular endothelial growth factor therapies, such as ranibizumab and aflibercept. To conduct a cost-minimization analysis of ranibizumab and aflibercept for treating Saudi patients with visual impairment owing to AMD or DME. METHODS: Cost minimization was analyzed assuming that ranibizumab and aflibercept have equivalent clinical effectiveness. The third-party payer's perspective was used in several clinical scenarios. The base-case scenario was DME cases followed monthly using a protocol-specific follow-up. In scenario 1, AMD cases followed a treat-and-extend protocol over 2 years. In scenario 2, AMD cases followed the PRN (pro re nata) regimen over 2 years. In scenario 3, DME cases followed the PRN regimen for 1 year only. RESULTS: Aflibercept yielded cost savings of 25.75%, 31.54%, 51.30%, and 9.28% compared with ranibizumab for the base case, scenario 1, scenario 2, and scenario 3, respectively, which supports the premise that aflibercept is more cost saving than ranibizumab. CONCLUSIONS: From the third-party payer perspective, aflibercept is a cost-containment option that provides substantial savings over ranibizumab for treating Saudi patients with AMD or DME.

Development of a system based on artificial intelligence to identify visual problems in children: study protocol of the TrackAI project.

INTRODUCTION: Around 70% to 80% of the 19 million visually disabled children in the world are due to a preventable or curable disease, if detected early enough. Vision screening in childhood is an evidence-based and cost-effective way to detect visual disorders. However, current screening programmes face several limitations: training required to perform them efficiently, lack of accurate screening tools and poor collaboration from young children.Some of these limitations can be overcome by new digital tools. Implementing a system based on artificial intelligence systems avoid the challenge of interpreting visual outcomes.The objective of the TrackAI Project is to develop a system to identify children with visual disorders. The system will have two main components: a novel visual test implemented in a digital device, DIVE (Device for an Integral Visual Examination); and artificial intelligence algorithms that will run on a smartphone to analyse automatically the visual data gathered by DIVE. METHODS AND ANALYSIS: This is a multicentre study, with at least five centres located in five geographically diverse study sites participating in the recruitment, covering Europe, USA and Asia.The study will include children aged between 6 months and 14 years, both with normal or abnormal visual development.The project will be divided in two consecutive phases: design and training of an artificial intelligence (AI) algorithm to identify visual problems, and system development and validation. The study protocol will consist of a comprehensive ophthalmological examination, performed by an experienced paediatric ophthalmologist, and an exam of the visual function using a DIVE.For the first part of the study, diagnostic labels will be given to each DIVE exam to train the neural network. For the validation, diagnosis provided by ophthalmologists will be compared with AI system outcomes. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the principles of Good Clinical Practice. This protocol was approved by the Clinical Research Ethics Committee of Aragón, CEICA, on January 2019 (Code PI18/346).Results will be published in peer-reviewed journals and disseminated in scientific meetings. TRIAL REGISTRATION NUMBER: ISRCTN17316993.

[Vision screening in children: Review of the literature]. / Dépistage visuel de l'enfant : revue de la littérature.

In children, refractive errors and amblyopia are the two most common causes of avoidable visual impairment. Screening for these is essential, especially since there is a so-called "sensitive" period during which the maturation of the visual pathways is not complete. The child's visual prognosis will therefore depend on his or her age, the duration of the visual deprivation and the timing of management. Visual screening is part of a public health approach, but there are significant regional disparities regarding its organization and the means used. We conducted a review of the literature in order to establish an inventory of available resources and improve practices.

Hearing and vision screening for preschool children using mobile technology, South Africa.

OBJECTIVE: To implement and evaluate a community-based hearing and vision screening programme for preschool children in the Western Cape, South Africa, supported by mobile health technology (mHealth) and delivered by community health workers (CHWs). METHODS: We trained four CHWs to provide dual sensory screening in preschool centres of Khayelitsha and Mitchells Plain during September 2017-December 2018. CHWs screened children aged 4-7 years using mHealth software applications on smartphones. We used logistic regression analysis to evaluate the association between screening results and age, sex and test duration, and, for hearing, excessive background noise levels. RESULTS: CHWs screened 94.4% (8023/10 362) of eligible children at 271 centres at a cost of 5.63 United States dollars per child. The number of children who failed an initial hearing and visual test was 435 (5.4%) and 170 (2.1%), respectively. Hearing test failure was associated with longer test times (odds ratio, OR: 1.022; 95% confidence interval, CI: 1.021-1.024) and excessive background noise levels at 1 kilohertz (kHz) (e.g. OR for left ear: 1.688; 95% CI: 1.198-2.377). Visual screening failure was associated with longer test duration (OR: 1.003; 95% CI: 1.002-1.005) and younger age (OR: 0.629; 95% CI: 0.520-0.761). Of the total screened, 111 (1.4%) children were diagnosed with a hearing and/or visual impairment. CONCLUSION: mHealth-supported CHW-delivered hearing and vision screening in preschool centres provided a low-cost, acceptable and accessible service, contributing to lower referral numbers to resource-constrained public health institutions.

Development of core outcome sets for vision screening and assessment in stroke: a Delphi and consensus study.

OBJECTIVES: Visual impairment following stroke is common with a reported incidence of visual impairment in 60% of stroke survivors. Screening for visual impairment is neither routine nor standardised. This results in a health inequality where some stroke survivors receive comprehensive vision assessment to identify any existent visual problems while others receive no vision assessment leaving them with unmet needs from undiagnosed visual problems. The aim of this study was to define two core outcome sets (COS), one for vision screening and one for full visual assessment of stroke survivors. DESIGN: A list of potentially relevant visual assessments was created from a review of the literature. The consensus process consisted of an online 3-round Delphi survey followed by a consensus meeting of the key stakeholders. PARTICIPANTS: Stakeholders included orthoptists, occupational therapists, ophthalmologists, stroke survivors and COS users such as researchers, journal editors and guideline developers. SETTING: University. OUTCOME MEASURES: COS. RESULTS: Following the consensus process we recommend the following nine assessments for vision screening: case history, clinical observations of visual signs, visual acuity, eye alignment position, eye movement assessment, visual field assessment, visual neglect assessment, functional vision assessment and reading assessment. We recommend the following 11 assessments for full vision assessment: case history, observations, visual acuity, eye alignment position, eye movement assessment, binocular vision assessment, eye position measurement, visual field assessment, visual neglect assessment, functional vision assessment, reading assessment and quality of life questionnaires. CONCLUSIONS: COS are defined for vision screening and full vision assessment for stroke survivors. There is potential for their use in reducing heterogeneity in routine clinical practice and for improving standardisation and accuracy of vision assessment. Future research is required to evaluate the use of these COS and for further exploration of core outcome measures.

The diagnostic accuracy of an intelligent and automated fundus disease image assessment system with lesion quantitative function (SmartEye) in diabetic patients.

BACKGROUND: With the diabetes mellitus (DM) prevalence increasing annually, the human grading of retinal images to evaluate DR has posed a substantial burden worldwide. SmartEye is a recently developed fundus image processing and analysis system with lesion quantification function for DR screening. It is sensitive to the lesion area and can automatically identify the lesion position and size. We reported the diabetic retinopathy (DR) grading results of SmartEye versus ophthalmologists in analyzing images captured with non-mydriatic fundus cameras in community healthcare centers, as well as DR lesion quantitative analysis results on different disease stages. METHODS: This is a cross-sectional study. All the fundus images were collected from the Shanghai Diabetic Eye Study in Diabetics (SDES) program from Apr 2016 to Aug 2017. 19,904 fundus images were acquired from 6013 diabetic patients. The grading results of ophthalmologists and SmartEye are compared. Lesion quantification of several images at different DR stages is also presented. RESULTS: The sensitivity for diagnosing no DR, mild NPDR (non-proliferative diabetic retinopathy), moderate NPDR, severe NPDR, PDR (proliferative diabetic retinopathy) are 86.19, 83.18, 88.64, 89.59, and 85.02%. The specificity are 63.07, 70.96, 64.16, 70.38, and 74.79%, respectively. The AUC are PDR, 0.80 (0.79, 0.81); severe NPDR, 0.80 (0.79, 0.80); moderate NPDR, 0.77 (0.76, 0.77); and mild NPDR, 0.78 (0.77, 0.79). Lesion quantification results showed that the total hemorrhage area, maximum hemorrhage area, total exudation area, and maximum exudation area increase with DR severity. CONCLUSIONS: SmartEye has a high diagnostic accuracy in DR screening program using non-mydriatic fundus cameras. SmartEye quantitative analysis may be an innovative and promising method of DR diagnosis and grading.

Visual Acuity Assessment and Vision Screening Using a Novel Smartphone Application.

OBJECTIVES: To evaluate a smartphone-based application's (Peek Acuity) ability to assess visual acuity and screen for ocular conditions in children, we compared visual acuity assessment between Peek Acuity and the pediatric ophthalmology examination and evaluated Peek Acuity's ability to identify children with referable ocular conditions. STUDY DESIGN: We prospectively recruited 111 children age 3-17 years, presenting to a pediatric ophthalmology clinic, who could follow instructions. Monocular visual acuity assessments by Peek Acuity and standard clinical methods were performed in randomized order. We compared visual acuity assessments between methods using intraclass correlation coefficient (ICC) and evaluated Peek Acuity's ability to identify children with referable ocular conditions. RESULTS: ICC comparing visual acuity assessed between methods was 0.88 (95% CI 0.83-0.92) for first and 0.85 (95% CI 0.78-0.89) for second eyes examined. ICC among 3 to 5-year-olds (preschool-age children) was 0.88 (95% CI 0.77-0.94) for first and 0.45 (95% CI 0.13-0.68) for second eyes examined. Peek Acuity had a sensitivity of 83%-86% for decreased vision and 69%-83% for referable ocular disease. Sensitivity was highest among 3 to 5-year-olds with decreased vision, 93%-100%. CONCLUSIONS: Overall, Peek Acuity visual acuity assessment correlated well with visual acuity assessed by standard clinical methods, though preschool-age children appeared more susceptible to examination fatigue. Peek Acuity performed adequately as a screening tool and had the greatest sensitivity among those with decreased vision and preschool-age children. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03212222.

Evaluation of a Free Public Smartphone Application to Detect Leukocoria in High-Risk Children Aged 1 to 6 Years.

PURPOSE: To determine whether a white-eye detector smartphone application (app) can be used as a screening tool to detect early signs of leukocoria in a clinical practice. METHODS: A prospective, single-visit study of children aged 1 to 6 years presenting to the University Eye Clinic of Genova for a complete pediatric ophthalmologic examination was conducted. All children who met the enrollment criteria were screened by an orthoptist with the CRADLE (Computer Assisted Detector of Leukocoria) smartphone app for an iPhone operating system (iOS) (iPhone 7; Apple, Cupertino, CA). Cycloplegic retinoscopy and fundus examination were performed 30 minutes after one to two drops of a pediatric combination drop, comprising tropicamide 1% and phenylephrine 2.5%, were instilled. A comparison between the two methods yielded sensitivity, specificity, and negative likelihood ratio values. RESULTS: A total of 244 eyes of 122 children were included in the study. Nine eyes of 244 (3.6%) had leukocoria evaluable by penlight caused by amblyogenic cataract, 1 (0.4%) patient had retinopathy of prematurity stage 5, and 3 (1.2%) patients had retinoblastoma. The sensitivity of the white-eye detector app was 15.38% (95% confidence interval [CI]: 1.92% to 45.45%), the specificity was 100% (95% CI: 98.48% to 100.00%), and the negative likelihood ratio was 0.85 (95% CI: 0.67 to 1.07). CONCLUSIONS: A smartphone photoscreening app able to detect leukocoria may provide valuable support for children's parents. However, it cannot be considered an alternative to the ophthalmoscope for children. [J Pediatr Ophthalmol Strabismus. 2019;56(4):229-232.].

Effect of Instrument-Based Vision Screening for 3- to 5-Year-Old Children on Referrals to Eye Care Specialists.

Recently, several professional groups have recommended a change from chart-based to instrument-based screening for preschool-age children, but the effect of this change on health care utilization is unknown. We performed a secondary analysis of a site-randomized quality improvement project on transitioning from chart-based to instrument-based vision screening for 3- to 5-year-old children in primary care. We analyzed visit rates to ophthalmologists and optometrists and costs of such care before and after implementation of instrument-based vision screening with comparison to nonparticipating practices. The implementation of instrument-based vision screening resulted in a decrease in visits to eye care specialists from 83.1 visits per 1000 children per year to 55.0, a reduction of 33.8%; no comparable reduction was seen in nonparticipating practices. The cost of services by eye care specialists fell from $65 715 per 1000 children per year prior to $55 740, a decline of 15.2%; similar costs among control practices rose 13.4%.

Visual function assessment, ocular examination, and intervention in children with developmental delay: A systematic approach. Part 1.

Children with special needs form a unique subset with regards to visual function and examination techniques needed to assess them. With more awareness among the general public, neurologists, and pediatricians, these children are referred for assessment to the ophthalmologist or optometrist and sometimes even to the rehabilitation professional at an early age. This clinical practice guideline and review gives a systematic approach for examining the visual functions of a child with special needs. It outlines the procedures to be followed with equipment needed in clinical practice. Functional vision assessment guidelines are also included. This is the first part in a two-part series, with the first part presenting clinical examination guidelines and the second presenting intervention and vision enhancement techniques.