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Does Assessing Eye Alignment Along with Refractive Error Or Visual Acuity Increase Sensitivity for Detection of Strabismus in Preschool Vision Screening?

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Does Assessing Eye Alignment Along with Refractive Error Or Visual Acuity Increase Sensitivity for Detection of Strabismus in Preschool Vision Screening? Does Assessing Eye Alignment along with Refractive Error or Visual Acuity Increase Sensitivity for Detection of Strabismus in Preschool Vision Screening? The Vision in Preschoolers Study Group PURPOSE. Preschool vision screenings often include refractive the addition of Stereo Smile II to SureSight resulted in a error or visual acuity (VA) testing to detect amblyopia, as well statistically significant increase (21%) in sensitivity for de- as alignment testing to detect strabismus. The purpose of this tection of strabismus. study was to determine the effect of combining screening for CONCLUSIONS. The most efficient and low-cost ways to achieve eye alignment with screening for refractive error or reduced a statistically significant increase in sensitivity for detection of VA on sensitivity for detection of strabismus, with specificity strabismus were by combining the unilateral cover test with set at 90% and 94%. the autorefractor (Retinomax) administered by eye care pro- METHODS. Over 3 years, 4040 preschool children were fessionals and by combining Stereo Smile II with SureSight screened in the Vision in Preschoolers (VIP) Study, with administered by trained lay screeners. The decision of whether different screening tests administered each year. Examina- to include a test of alignment should be based on the screening tions were performed to identify children with strabismus. program’s goals (e.g., targeted visual conditions) and The best screening tests for detecting children with any resources. (Invest Ophthalmol Vis Sci. 2007;48:3115–3125) targeted condition were noncycloplegic retinoscopy (NCR), DOI:10.1167/iovs.06-1009 Retinomax autorefractor (Right Manufacturing, Virginia Beach, VA), SureSight Vision Screener (Welch-Allyn, Inc., Skaneateles, NY), and Lea Symbols (Precision Vision, LaSalle, trabismus has been reported to affect approximately 4% IL and Good-Lite Co., Elgin, IL) and HOTV optotypes VA Sof children.1–3 It can result in psychosocial, developmen- tests. Analyses were conducted with these tests of refractive tal, and psychological, as well as visual sequelae (e.g., am- error or VA paired with the best tests for detecting strabis- blyopia and/or loss of depth perception).2,4–6 Referral can mus (unilateral cover testing, Random Dot “E” [RDE] and be delayed due to the misconception that children will Stereo Smile Test II [Stereo Optical, Inc., Chicago, IL]; and outgrow strabismus.4,6 To promote early detection and MTI PhotoScreener [PhotoScreener, Inc., Palm Beach, FL]). treatment of vision problems such as amblyopia and strabis- The change in sensitivity that resulted from combining a test mus, the American Academy of Pediatrics (AAP) Committee of eye alignment with a test of refractive error or VA was on Practice and Ambulatory Medicine7 recommended a se- determined with specificity set at 90% and 94%. ries of eye evaluations, including infant fixation and cover RESULTS. Among the 4040 children, 157 were identified as test, leading to eye evaluations in children 3 years of age or having strabismus. For screening tests conducted by eye older to include “age-appropriate visual acuity measure- care professionals, the addition of a unilateral cover test to ment” and “ocular motility assessment.” The U.S. Preventive a test of refraction generally resulted in a statistically signif- Services Task Force8 recommends screening “to detect am- icant increase (range, 15%–25%) in detection of strabismus. blyopia, strabismus, and defects in visual acuity in children For screening tests administered by trained lay screeners, younger than 5 years.” Phase I of the Vision in Preschoolers (VIP) Study evaluated 11 preschool vision screening tests and showed that tests of From the Vision in Preschoolers Study Group. The members are refractive error and visual acuity (VA) performed best overall in listed in the Appendix. identifying preschool children with one or more targeted con- Supported by National Eye Institute Grants U10EY12534, ditions (amblyopia, strabismus, significant refractive error, U10EY12545, U10EY12547, U10EY12550, U10EY12644, U10EY12647, and/or unexplained reduced VA) as well as the most severe and U10EY12648. Paulette Schmidt was principal investigator for a grant 9,10 (Ͻ$20,000) issued to The Ohio State University Research Foundation conditions. Phase II of the VIP Study showed that combin- from Welch Allyn, Inc. for testing a prototype of the SureSight Vision ing a test of stereopsis with a test of VA or refractive error did Screener. Pennsylvania College of Optometry receives royalties Ͻ$10,000 not improve sensitivity for detecting one or more targeted annually on sales of the Stereo Smile Test. conditions.11 However, vision screenings currently used in Submitted for publication August 24, 2006; revised February 16, preschool children often include eye alignment testing to de- 2007; accepted May 21, 2007. tect strabismus and binocularity problems7,9,12–17 and the ef- Disclosure: P. Schmidt, Welch Allyn, Inc. (F); E. Ciner, Stereo Optical, Inc. (F); all others in The Vision in Preschoolers Study fect of including a test of ocular alignment on sensitivity for Group, None specifically detecting strabismus has not yet been determined. The publication costs of this article were defrayed in part by page Therefore, the purpose of this study was to determine the charge payment. This article must therefore be marked “advertise- effect of combining tests of eye alignment with tests of refrac- ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact. tive error or VA (which performed best overall in identifying Corresponding author: Marjean Taylor Kulp, The Ohio State Uni- preschool children with one or more targeted conditions) on versity College of Optometry, 338 West 10th Avenue, Columbus, Ohio sensitivity for detecting strabismus in preschool children. Ef- 43210-1280; [email protected]. Reprint requests: The Vision in Preschoolers Study Center, The fects on overall sensitivity for detection of one or more tar- Ohio State University, College of Optometry, 338 West Tenth Avenue, geted conditions and the most severe conditions are also con- Columbus, OH 43210-1280; [email protected]. sidered. Investigative Ophthalmology & Visual Science, July 2007, Vol. 48, No. 7 Copyright © Association for Research in Vision and Ophthalmology 3115 3116 VIP Study Group IOVS, July 2007, Vol. 48, No. 7 TABLE 1. Definition of VIP Targeted Disorders by Hierarchy Group 1: Very important to detect and treat early Amblyopia Presumed unilateral: Ն3 line interocular difference, a unilateral amblyogenic factor, and worse eye VA Յ 20/64 Suspected bilateral: a bilateral amblyogenic factor, worse eye VA Ͻ 20/50 for 3-year-olds or Ͻ 20/40 for 4-year-olds, contralateral eye VA worse than 20/40 for 3-year-olds or 20/30 for 4-year-olds Strabismus: constant in primary gaze Refractive error Severe anisometropia (interocular difference Ͼ 2 D hyperopia, Ͼ 3 D astigmatism, or Ͼ 6 D myopia) Hyperopia Ն 5.0 D Astigmatism Ն 2.5 D Myopia Ն 6.0 D Group 2: Important to detect early Amblyopia Suspected unilateral: 2-line interocular difference and a unilateral amblyogenic factor Presumed unilateral: Ն3 line interocular difference, a unilateral amblyogenic factor, and worse eye VA Ͼ 20/64 Strabismus: intermittent in primary gaze Refractive error Anisometropia (interocular difference Ͼ 1D hyperopia, Ͼ 1.5D astigmatism, or Ͼ 3D myopia)* Hyperopia Ͼ 3.25 D and Ͻ 5.0 D AND interocular difference in SE Ն0.5 D Astigmatism Ͼ 1.5 and Ͻ 2.5 D Myopia Ն 4.0 and Ͻ 6.0 D Group 3: Detection clinically useful Unexplained reduced VA Bilateral: no bilateral amblyogenic factor, worse eye VA Ͻ 20/50 for 3-year-olds or Ͻ 20/40 for 4-year-olds, contralateral eye VA worse than 20/40 for 3-year-olds or 20/30 for 4-year-olds Unilateral: no unilateral amblyogenic factor, worse eye VA Ͻ 20/50 for 3-year-olds or Ͻ 20/40 for 4-year-olds or Ն2 line difference between eyes (except 20/16 and 20/25) Refractive error Hyperopia Ͼ 3.25 and Ͻ 5.0 D AND interocular difference in SE Ͻ 0.5 D Myopia Ͼ 2.0 and Ͻ 4.0 D Modified from Ophthalmology, 111, The Vision in Preschoolers Study Group, Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision in Preschoolers Study, 637–650, Copyright 2004, with permission from American Academy of Ophthalmology. * Clarification of previous description of “Anisometropia, but not severe.”9,11 METHODS Subjects The methods of phases I and II of the VIP Study have been described Participants were 4040 preschool children who were enrolled in Head previously.9,11 Only the methodologic features with direct relevance Start near a VIP clinical center (Berkeley, CA; Boston, MA; Columbus, Ͻ for evaluating the results presented in this report are provided herein. OH; Philadelphia, PA; or Tahlequah, OK) and who were 3 to 5 years of age on September 1 of a data-collection year (2001, 2002, or 2003). All children who failed and a sample of children who passed the 9,11 TABLE 2. Characteristics of Strabismus in Years 1–3 routine Head Start visual screening were invited to participate. The research adhered to the tenets of the Declaration of Helsinki and was Year approved by the local institutional review board(s). Each child’s parent or guardian provided written informed consent. Each child was eligible .to participate only once (47 ؍ n) 3 (62 ؍ n) 2 (48 ؍ Characteristic 1(n Frequency Constant 26 (54%) 41 (66%) 31 (66%) Procedures Intermittent 22 (46%) 21 (34%) 16 (34%) Direction Vision Examination. Each child who participated received a Esotropia 29 (60%) 40 (65%) 33 (70%) standardized comprehensive eye examination by a licensed eye care Exotropia 18 (38%) 21 (34%) 14 (30%) professional (optometrist or ophthalmologist) who was experienced in Unknown 1 (2%) 1 (1%) 0 working with young children, was masked to the child’s screening Magnitude* Ͻ10⌬ 5 (10%) 13 (21%) 6 (13%) Ն ⌬ 10 42 (88%) 48 (77%) 40 (85%) TABLE 3.
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