Pivotal Evaluation of an Artificial Intelligence System for Autonomous Detection of Referrable and Vision-Threatening Diabetic Retinopathy.

Importance: Diabetic retinopathy (DR) is a leading cause of blindness in adults worldwide. Early detection and intervention can prevent blindness; however, many patients do not receive their recommended annual diabetic eye examinations, primarily owing to limited access. Objective: To evaluate the safety and accuracy of an artificial intelligence (AI) system (the EyeArt Automated DR Detection System, version 2.1.0) in detecting both more-than-mild diabetic retinopathy (mtmDR) and vision-threatening diabetic retinopathy (vtDR). Design, Setting, and Participants: A prospective multicenter cross-sectional diagnostic study was preregistered (NCT03112005) and conducted from April 17, 2017, to May 30, 2018. A total of 942 individuals aged 18 years or older who had diabetes gave consent to participate at 15 primary care and eye care facilities. Data analysis was performed from February 14 to July 10, 2019. Interventions: Retinal imaging for the autonomous AI system and Early Treatment Diabetic Retinopathy Study (ETDRS) reference standard determination. Main Outcomes and Measures: Primary outcome measures included the sensitivity and specificity of the AI system in identifying participants' eyes with mtmDR and/or vtDR by 2-field undilated fundus photography vs a rigorous clinical reference standard comprising reading center grading of 4 wide-field dilated images using the ETDRS severity scale. Secondary outcome measures included the evaluation of imageability, dilated-if-needed analysis, enrichment correction analysis, worst-case imputation, and safety outcomes. Results: Of 942 consenting individuals, 893 patients (1786 eyes) met the inclusion criteria and completed the study protocol. The population included 449 men (50.3%). Mean (SD) participant age was 53.9 (15.2) years (median, 56; range, 18-88 years), 655 were White (73.3%), and 206 had type 1 diabetes (23.1%). Sensitivity and specificity of the AI system were high in detecting mtmDR (sensitivity: 95.5%; 95% CI, 92.4%-98.5% and specificity: 85.0%; 95% CI, 82.6%-87.4%) and vtDR (sensitivity: 95.1%; 95% CI, 90.1%-100% and specificity: 89.0%; 95% CI, 87.0%-91.1%) without dilation. Imageability was high without dilation, with the AI system able to grade 87.4% (95% CI, 85.2%-89.6%) of the eyes with reading center grades. When eyes with ungradable results were dilated per the protocol, the imageability improved to 97.4% (95% CI, 96.4%-98.5%), with the sensitivity and specificity being similar. After correcting for enrichment, the mtmDR specificity increased to 87.8% (95% CI, 86.3%-89.5%) and the sensitivity remained similar; for vtDR, both sensitivity (97.0%; 95% CI, 91.2%-100%) and specificity (90.1%; 95% CI, 89.4%-91.5%) improved. Conclusions and Relevance: This prospective multicenter cross-sectional diagnostic study noted safety and accuracy with use of the EyeArt Automated DR Detection System in detecting both mtmDR and, for the first time, vtDR, without physician assistance. These findings suggest that improved access to accurate, reliable diabetic eye examinations may increase adherence to recommended annual screenings and allow for accelerated referral of patients identified as having vtDR.

A Comprehensive Review of State Vision Screening Mandates for Schoolchildren in the United States.

SIGNIFICANCE: Methods and frequency of vision screenings for school-aged children vary widely by state, and there has been no recent comparative analysis of state requirements. This analysis underscores the need for developing evidence-based criteria for vision screening in school-aged children across the United States. PURPOSE: The purpose of this study was to conduct an updated comprehensive analysis of vision screening requirements for school-aged children in the United States. METHODS: State laws pertaining to school-aged vision screening were obtained for each state. Additional information was obtained from each state's Department of Health and Education, through their websites or departmental representatives. A descriptive analysis was performed for states with data available. RESULTS: Forty-one states require vision screening for school-aged children to be conducted directly in schools or in the community. Screening is more commonly required in elementary school (n = 41) than in middle (n = 30) or high school (n = 19). Distance acuity is the most commonly required test (n = 41), followed by color vision (n = 11) and near vision (n = 10). Six states require a vision screening annually or every 2 years. CONCLUSIONS: Although most states require vision screening for some school-aged children, there is marked variation in screening methods and criteria, where the screening occurs, and grade levels that are screened. This lack of standardization and wide variation in state regulations point to a need for the development of evidence-based criteria for vision screening programs for school-aged children.

12 Components of a Strong Vision Health System of Care: Part 3-Standardized Approach for Rescreening.

Strong school-based vision and eye health systems include 12 key components to be implemented before, during, and after the actual vision screening event. The National Center for Children's Vision and Eye Health (NCCVEH) at Prevent Blindness partnered with the National Association of School Nurses (NASN) to provide guidance for school nurses for each of the 12 key components via a Vision and Eye Health webpage on the NASN website ( https://www.nasn.org/nasn-resources/practice-topics/vision-health ). This online resource is designed to support school nurses accountable for vision screening and maintaining the eye health of preschool- and school-age children. This NCCVEH/NASN webpage addresses key activities that provide overall support for a child's vision and eye health-beginning with parent/caregiver education and ending with an annual evaluation of the school's vision and eye health system. NASN School Nurse is publishing information about each of these 12 components. The May 2019 installment provided details about the 12 Components approach as a whole and Components 1 and 2: Family Education and a Comprehensive Communication/Approval Process. The July 2019 edition described Components 3 and 4: Vision Screening Tools and Procedures and Vision Health for Children With Special Health Care Needs. This article describes Component 5: Standardized Approach for Rescreening.

Characteristics Associated with Adherence to Annual Dilated Eye Examinations among US Patients with Diagnosed Diabetes.

PURPOSE: To identify the characteristics that are associated with adherence to annual diabetic eye exams and patient awareness of retinopathy using a nationally representative sample from the United States. DESIGN: Cross-sectional, secondary analysis. PARTICIPANTS: National Health and Nutrition Examination Survey (NHANES) participants from 2005 to 2016 aged 20 years and older with diabetes mellitus. METHODS: The NHANES collected surveys every 2 years from 2005 to 2016, which contained demographic information, clinical information, and time to last dilated eye exam. From 2005 to 2008, retinal photographs were taken of all participants older than 40 years of age. We used univariate and multivariable logistic regression to determine the demographic and clinical factors associated with adherence to annual diabetic eye examinations and those associated with correctly reporting their retinopathy status. MAIN OUTCOME MEASURE: Factors associated with adherence defined as having an eye exam within the preceding 12 or 24 months. RESULTS: From 2005 to 2016, NHANES surveyed 4072 individuals who represent 20 million Americans aged 20 years and older with self-report of diabetes. By using the adherence definitions of 12 and 24 months, 63.4% and 78.7%, respectively, were adherent to diabetic eye examinations. The nonadherence rates of 36.6% and 21.3% for this national estimate did not change from 2005 to 2016 (P = 0.7, logistic regression). Insurance status, age, education, income, cholesterol levels, duration of diabetes, and self-reported retinopathy were all significantly associated with adherence with both definitions (all P < 0.05, logistic regression). Insurance status had the highest predictive value, with 76% of Americans on combination private-public insurance adherent compared with 36% of uninsured. Most Americans with retinopathy incorrectly denied having the diagnosis (2 727 144/3 896 093 or 70%). CONCLUSIONS: Multiple variables were associated with nonadherence to eye exams, with insurance status having the strongest association. Adherence with annual eye exams has not improved over the past decade. The majority of patients with retinopathy are unaware of this diagnosis, including the majority of those with a dilated funduscopic examination in the past year. Further improvements in education and adherence may reduce the visual morbidity caused by diabetes.

Transnational review of visual standards for driving: How Australia compares with the rest of the world.

IMPORTANCE: Driving is a highly visual task and a primary mode of transportation for many people around the world. BACKGROUND: There appears to be little uniformity of vision standards across the world for driving. We reviewed the basic screening visual requirements for obtaining standard private and commercial driving licences for a total of 70 jurisdictions, and reviewed the evidence behind these standards. DESIGN: Systematic review of basic screening vision standards worldwide for driving and literature review. SAMPLES: Published online documentation on visual acuity and field requirements for driving. METHODS: Journal articles, government reports and websites obtained via a Google search were used to review the regulations for driving. This was limited by the comprehensiveness of resources, and countries were excluded if the requirements were unclear or unattainable. A literature review was performed using Medline with keywords vision, driving and visual field. MAIN OUTCOME MEASURES: Visual parameters used for driving assessment. RESULTS: The results suggest significant variations across the world. The visual acuity requirements for a private licence range from a minimum of 6/9 to 6/60. The minimum binocular horizontal field requirement ranges from 110° to 150°. In general, standards for a commercial licence are stricter compared to a private licence. A literature review could not support the current driving standards as evidence-based. CONCLUSIONS AND RELEVANCE: The disunity of driving vision requirements worldwide likely reflects the inconclusive evidence base. Accounting for individual differences and the ability to predict individual risk is important in the context of determining driving licensure.

Diagnostic test accuracy of Spot and Plusoptix photoscreeners in detecting amblyogenic risk factors in children: a systemic review and meta-analysis.

PURPOSE: Amblyopia is a permanent visual impairment developed in early childhood. Recently, instrument-based photoscreeners have been widely used for vision screening to detect amblyopia risk factors, which is key for the prevention and treatment of amblyopia. This meta-analysis aims to evaluate the diagnostic test accuracy of Spot and Plusoptix photoscreeners in detecting risk factors for amblyopia in children. METHODS: An electronic literature search was performed in October 2018 using the MEDLINE, Embase, and Web of Science databases. Twenty-one publications with a total of 5022 subjects were included. Subjects given a comprehensive examination were considered to have amblyopia or amblyogenic risk factors based on the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria guidelines. RESULTS: The overall sensitivity for Spot and Plusoptix was 87.7% and 89.4%, respectively (p = 0.38); the specificity was 78.0% and 89.9%, respectively (p = 0.90). For subjects under 7 years old (preschool children), the overall sensitivity for Spot and Plusoptix was 91.7% and 90.2%, respectively (p = 0.81); the specificity was 82.6% and 93.0%, respectively (p = 0.46). CONCLUSION: Both Spot and Plusoptix photoscreeners demonstrated good sensitivity and specificity in detecting amblyopia risk factors in children, especially at preschool ages. There was no significant difference in diagnostic test accuracy between them.

Using Decision Curve Analysis to Evaluate Common Strategies for Myopia Screening in School-Aged Children.

Purpose: To evaluate common strategies for screening myopia. Methods: A total of 2,248 children aged 6 to 12 years from five randomly selected primary schools were included for the screening. Enrolled study participants underwent distant uncorrected visual acuity (UCVA, Standard Logarithmic Visual Acuity E Chart) and non-cycloplegic auto-refraction (NCAR, Topcon KR-8800). Among them, 1,639 children (72.9%) accepted cycloplegic auto-refraction. Taking rejection of cycloplegia into account, receiver operating characteristic curves were drawn to compare the accuracies of the four strategies (I, Cycloplegic auto-refraction; II, NCAR; III, UCVA; IV, Combination of UCVA and NCAR). Decision curve analysis (DCA) was used to compare net benefits. Tenfold cross-validation was used for statistical analyses. Results: For myopia (spherical equivalent refraction, SE ≤ -0.5D) screening, the mean sensitivities were 73.79% (SD: 5.40%), 85.57% (6.84%), 59.71% (13.49%), and 85.06% (6.68%) for Strategy I to IV; with mean specificities of 100% (0%), 87.43% (4.27%), 89.74% (10.25%), and 88.65% (5.07%), respectively. For screening early myopia (SE ≤ -0.5D and ≥-1.0D), the mean sensitivities were 73.44% (7.69%), 82.39% (5.32%), 54.27% (14.58%), and 81.76% (9.60%) for Strategy I to IV; with mean specificities of 100% (0%), 79.13% (4.86%), 85.48% (9.86%), and 81.17% (4.16%). Based on DCA, the net benefits of Strategy IV were the highest, with the probability thresholds ranging from 12% to 50%, after adjusting the TestHarms. For early myopia, the net benefits of Strategy IV were the highest with the probability threshold ranging from 5% to 34%. Conclusion: Combination of UCVA and NCAR produced the highest net benefits for myopia screening.

Approach of Family Physicians to Pediatric Eye Screening in Diyarbakir

Objectives: In Turkey, preventive medicine services are the responsibility of family physicians and vision screening is a key component of this responsibility. In this study, we aimed to investigate the approach of family physicians to vision screening in infants and children. Materials and Methods: Data were collected using a 16-item questionnaire administered to 100 family physicians working in the center and provinces of Diyarbakir. Results: The results indicated that 88 (88%) physicians declared knowing what the red reflex test was, while 12 physicians declared that they had never heard of it. Only 16 (16%) physicians performed the test routinely and 36 (36%) physicians performed it only in suspicious cases. Ten (10%) physicians indicated that they did not refer the patients to an ophthalmologist even though they did not perform the red reflex test. Moreover, 5 (5%) physicians did not have an ophthalmoscope and 12 (12%) physicians reported not knowing how to use an ophthalmoscope. Forty (40%) of the physicians measured preschool visual acuity at least once. Sixty-six (66%) physicians referred younger children who could not express their vision problems to an ophthalmologist. Four (4%) physicians declared that they would delay surgery in children with strabismus until they were old enough for surgery. Ninety-three (93%) physicians suggested that educational seminars about vision screening would be beneficial. Conclusion: Educational seminars about vision screening may have favorable outcomes. The medical devices in family medicine centers should be improved. Vision screening can be added to the negative performance-based compensation system in order to increase physicians' attention to vision screening. To implement detailed eye screening programs like those in developed countries, an infrastructure should be established for this screening program.

Vision screening in New Zealand: an audit of the B4 School Check.

AIMS: To assess the accuracy of the B4 School Check (B4SC) vision screening programme in two distinct regions of New Zealand. METHODS: A retrospective audit of all children who were screened for vision in the Southern and Tairawhiti District Health Boards, between 1 April and 30 September 2016. Results from the B4SC screening programme (n=2,109) were compared to records for all children who were screened and subsequently presented to an optometrist at a DHB eye clinic (n=116). RESULTS: The B4SC produced a sensitivity in the range of 54.7% to 94.7% and a specificity of 93.8% to 95.7%. There was a low positive predictive value (PPV), between 29.5% and 51.1%, with a relatively high number of false positive referrals. The negative predictive value (NPV) was higher, however, between 97.8% and 99.7%, meaning nearly all children who passed screening had no visual impairment. CONCLUSIONS: The high NPV is reassuring that very few children with visual impairment are missed by screening. The low PPV was consistent with the international literature and is related to a tendency for over-referral from the B4CS programme. Further work could evaluate increasing the threshold for referral to reduce the number of false positive cases.

Paediatric vision screening by non-healthcare volunteers: evidence based practices.

BACKGROUND: The purpose of this study was to test the sensitivity and specificity of eight undergraduate volunteer examiners conducting vision screening tests in a community setting, in order to determine if non-eye care professionals were able to be trained to an appropriate level of skill. METHODS: Eight undergraduate volunteer examiners were trained to conduct vision screening tests to address a gap in pediatric community eye care. Phase I of the study was implemented in the pediatric ophthalmology clinic, and phase II was conducted in nine local schools. Phase I consisted of 40 h of training for each volunteer regarding specific vision tests. Phase II consisted of screening children at nine local schools. RESULTS: A total of 690 children from nine local schools were screened by both the volunteer examiners and the optometrist during the course of this study. Volunteer examiners had a screening sensitivity of 0.80 (95%CI 0.66-0.90) and screening specificity of 0.75 (95%CI 0.71-0.78) when compared to the study optometrist. The overall accuracy of volunteer examiners was 75%. The resulting positive likelihood ratio was 3.24 (95%CI 2.6-3.9), indicating that a child with vision impairment was 3.2 times more likely to fail the vision test performed by the volunteer examiners compared to a child with no vision impairment. CONCLUSIONS: Non-healthcare professionals can be trained to an acceptable degree of accuracy to perform vision screening tests on children, which may assist in mitigating existing gaps in paediatric eye care.

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%.

Guidelines on Diabetic Eye Care: The International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings.

Diabetes mellitus (DM) is a global epidemic and affects populations in both developing and developed countries, with differing health care and resource levels. Diabetic retinopathy (DR) is a major complication of DM and a leading cause of vision loss in working middle-aged adults. Vision loss from DR can be prevented with broad-level public health strategies, but these need to be tailored to a country's and population's resource setting. Designing DR screening programs, with appropriate and timely referral to facilities with trained eye care professionals, and using cost-effective treatment for vision-threatening levels of DR can prevent vision loss. The International Council of Ophthalmology Guidelines for Diabetic Eye Care 2017 summarize and offer a comprehensive guide for DR screening, referral and follow-up schedules for DR, and appropriate management of vision-threatening DR, including diabetic macular edema (DME) and proliferative DR, for countries with high- and low- or intermediate-resource settings. The guidelines include updated evidence on screening and referral criteria, the minimum requirements for a screening vision and retinal examination, follow-up care, and management of DR and DME, including laser photocoagulation and appropriate use of intravitreal anti-vascular endothelial growth factor inhibitors and, in specific situations, intravitreal corticosteroids. Recommendations for management of DR in patients during pregnancy and with concomitant cataract also are included. The guidelines offer suggestions for monitoring outcomes and indicators of success at a population level.

Glaucoma referral refinement in Ireland: managing the sensitivity-specificity paradox in optometric practice.

PURPOSE: Glaucoma referral refinement (GRR) has proven a successful demand management strategy for glaucoma suspect cases in the United Kingdom (UK). A GRR clinic was established in Dublin, Ireland to investigate the clinical viability of this pathway outside the UK's National Health Service (NHS) structures, and away from the influence of National Institute for Clinical Excellence (NICE) guidance. METHODS: Glaucoma suspect patients were recruited into the scheme following referral from community optometrists in the greater Dublin area. The GRR exam protocol was designed in consultation with the participating ophthalmology department. The refinement scheme optometrist, trained through apprenticeship style experience at a hospital outpatient clinic, made a tentative management decision after carrying out the GRR exam. The final management decision was made in a 'virtual clinic' by a glaucoma specialist consultant ophthalmologist. RESULTS: Two hundred and twenty-five glaucoma suspect patients were seen in the scheme. After their first GRR visit, 28% were discharged back to their own optometrist, 42% were monitored in the GRR clinic, and 30% were referred to ophthalmology. After this monitoring cohort were further assessed, a total of 38% of the patients seen within the scheme required referral to ophthalmology. Sixteen percent of the total participant group (n = 225) were lost to follow up. Cohen's κ was used to determine the level of agreement between the scheme optometrist and ophthalmologist. There was substantial agreement, with κ = 0.63 for the first visit management decisions (n = 225). Agreement increased for subsequent monitoring visits with κ = 0.85 for second visits (n = 65), and κ = 0.69 for all management decisions within the scheme (n = 301). We received management outcomes for 44 of the 86 patients referred to ophthalmology. Of these 44, 57% received medical treatment for glaucoma, 34% were monitored without treatment, 2% were discharged, and 7% had comorbidities that were assessed and managed. CONCLUSION: Of the patients seen within the scheme, 62% did not require referral onward to ophthalmology, thus releasing the significant majority of hospital clinic slots that would previously have been required to examine such patients. The high level of inter-professional decision agreement likely reflects the benefits of pre-scheme apprenticeship style training and ongoing hospital clinic participation by the scheme optometrist. The rate of loss to follow up compares favourably with ophthalmology led, hospital based, glaucoma clinics. Nevertheless, the losses indicate that patient education remains a key priority for future planning.

Agreement and diagnostic accuracy of vision screening in children by teachers, community eye-health workers and vision technicians.

BACKGROUND: To compare the agreement and diagnostic accuracy of vision screening conducted by trained community eye-health workers (CEHWs) and teachers with reference to vision technicians in Movva Mandal (sub-district) in Krishna District in the Indian state of Andhra Pradesh. METHODS: As part of a large epidemiological study on visual impairment in children, vision screening was conducted in all the schools in a sub-district. The children were screened using a screening card with 6/12 tumbling E optotypes by trained CEHWs, teachers and a vision technician. Teachers were included if they had screened at least 100 children and had at least five children identified with visual impairment. RESULTS: Of a total 6,197 children from 75 schools, 4,929 children were screened by all three categories of examiners (one vision technician, five CEHWs and 79 teachers). The overall agreement between the vision technician and CEHWs was 0.84 (95 per cent CI: 0.79-0.9) with a range of 0.77-0.9. Overall sensitivity of CEHWs to detect visual impairment was 83.3 per cent (95 per cent CI: 73.6-90.6) with a range of 71.4-87.1 per cent. Overall agreement of the five teachers with the vision technician was 0.81 (95 per cent CI: 0.74-0.88) with a range of 0.32-0.92. The overall sensitivity of teachers to detect vision problem was 72.3 per cent (95 per cent CI: 61.4-81.6) with a range from 20 per cent to 85.7 per cent and specificity was near 100 per cent. CONCLUSION: There was no significant difference in the agreement and diagnostic accuracy of CEHWs and teachers compared to those of the vision technician. There was a large variability among teachers, which needs to be considered in school vision screening programs.

Evidence for the need for vision screening of school children in Turkey.

BACKGROUND: In many countries, access to general health and eye care is related to an individual's socioeconomic status (SES). We aimed to examine the prevalence of oculo-visual disorders in children in Istanbul Turkey, drawn from schools at SES extremes but geographically nearby. METHODS: Three school-based vision screenings (presenting distance visual acuity, cover test, eye assessment history, colour vision, gross stereopsis and non-cycloplegic autorefraction) were conducted on 81% of a potential 1014 primary-school children aged 4-10 years from two private (high SES) schools and a nearby government (low SES) school in central Istanbul. Prevalence of refractive errors and school-based differences were analysed using parametric statistics (ANOVA). The remaining oculo-visual aspects were compared using non-parametric tests. RESULTS: Of the 823 children with mean age 6.7 ± 2.2 years, approximately 10% were referred for a full eye examination (8.2% and 16.3% of private/government schools respectively). Vision had not been previously examined in nearly 22% of private school children and 65% of government school children. Of all children, 94.5% were able to accurately identify the 6/9.5 [LogMAR 0.2] line of letters/shapes with each eye and 86.6% the 6/6 line [LogMAR 0], while 7.9% presented wearing spectacles, 3.8% had impaired colour vision, 1.5% had grossly impaired stereo-vision, 1.5% exhibited strabismus, 1.8% were suspected to have amblyopia and 0.5% had reduced acuity of likely organic origin. Of the 804 without strabismus, amblyopia or organic conditions, 6.0% were myopic ≤ - 0.50DS, 0.6% hyperopic ≥ + 2.00DS, 7.7% astigmatic ≥1.00 DC and 6.2% anisometropic ≥1.00DS. CONCLUSIONS: The results highlight the need for general vision screenings for all children prior to school entry given the varied and different pattern of visual problems associated with lifestyle differences in two populations raised in the same urban locale but drawn from different socioeconomic backgrounds.

[Update on recommendations for screening for hydroxychloroquine retinopathy]. / Mise à jour des recommandations sur la toxicité rétinienne des antipaludéens de synthèse.

INTRODUCTION: Recommendations for screening for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy have recently been changed by the American Academy of Ophthalmology, taking into account new published data on toxicity prevalence, risk factors, location of onset in the retina and the efficacy of screening tests. METHODS: Literature review. RESULTS AND DISCUSSION: The risk of developing CQ or HCQ retinopathy depends on the daily dose and duration of treatment. At recommended doses, the risk is<1 % at 5 years, <2 % at 10years but increases to about 20 % after 20years of treatment. The maximum recommended daily dose is 5.0mg/kg for HCQ and 2.3mg/kg for CQ. The two main risk factors are the daily dose and duration of treatment. The presence of kidney failure and treatment with tamoxifen are also significant risk factors. A baseline examination should be performed at the initiation of treatment to rule out pre-existing maculopathy. The screening is then annual and starts from the 5th year of treatment. The two tests recommended for screening are the automated visual field and spectral domain OCT. Multifocal ERG and autofluorescence fundus imaging are only carried out secondarily to confirm the pathology.

The effect of omitting an early population-based vision screen in the Netherlands: A micro-simulation model approach.

Objective To estimate the effect of omitting an individual screen from a child vision screening programme on the detection of amblyopia in the Netherlands. A previous study (Rotterdam Amblyopia Screening Effectiveness Study) suggested that the three screens carried out between 6 and 24 months contributed little. Methods We developed a micro-simulation model that approximated the birth-cohort data from the previous study, in which 2964 children had completed follow-up at age 7, and 100 amblyopia cases were detected. Detailed data on screens, referrals, and orthoptic follow-up, including the cause of amblyopia, were available. The model predicted the number of amblyopia cases detected for each screen and for the entire screening programme, and the effect of omitting screens. Incidence curves for all types of amblyopia caused by strabismus, refractive anomalies or by both were estimated by approximation of the observational data, in conjunction with experts' estimations and the literature. Results We calculated mean actual sensitivity per screen per type of amblyopia, and the effect per screen. Screening at 24 months was found to be least effective. The impact on the screening programme, estimated by summing the effectiveness per screen, omitting the 24-month screen, was a reduction of 3.4% (57 vs. 59 cases) in the number of detected cases of amblyopia at age 5. Conclusion The effectiveness of the Dutch vision screening programme would hardly be affected by omission of the 24-month screening examination. A disinvestment study is warranted.