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Original Investigation |

Beyond Screening for Risk Factors Objective Detection of Strabismus and Amblyopia FREE

Reed M. Jost, MS1; Susan E. Yanni, PhD1; Cynthia L. Beauchamp, MD2; David R. Stager Sr, MD2; David Stager Jr, MD3; Lori Dao, MD3; Eileen E. Birch, PhD1,4
[+] Author Affiliations
1Crystal Charity Ball Pediatric Vision Evaluation Center, Retina Foundation of the Southwest, Dallas, Texas
2Pediatric Ophthalmology & the Center for Adult Strabismus, Dallas, Texas
3Pediatric Ophthalmology & Adult Strabismus, Plano, Texas
4Department of Ophthalmology, UT Southwestern Medical Center, Dallas, Texas
JAMA Ophthalmol. 2014;132(7):814-820. doi:10.1001/jamaophthalmol.2014.424.
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Published online

Importance  Commercially available automated vision screening devices assess refractive risk factors, not amblyopia or strabismus, underreferring affected children and overreferring healthy children. Nearly half of affected children are not identified until after age 5 years, when treatment is less effective.

Objectives  To determine the diagnostic accuracy of the Pediatric Vision Scanner (PVS), a binocular retinal birefringence scanner, to objectively identify strabismus and amblyopia, and to compare retinal birefringence screening with a widely used automated pediatric screening device.

Design, Setting, and Participants  Three hundred consecutive preschool children (aged 2-6 years) were screened using the PVS and the SureSight Autorefractor at 2 pediatric ophthalmology private practices. A masked comprehensive pediatric ophthalmic examination provided the gold standard for determining sensitivity and specificity for each screening device.

Main Outcomes and Measures  The primary outcome was sensitivity and specificity of the PVS for detecting the targeted conditions, strabismus and amblyopia, in children aged 2 to 6 years. Secondary outcomes included the positive and negative likelihood ratios of the PVS for identifying the targeted conditions. In addition, sensitivity, specificity, and positive and negative likelihood ratios of the SureSight Autorefractor for the targeted conditions were assessed in the same cohort of children.

Results  Of the 300 patients, 188 had strabismus only, amblyopia only, or both, and 112 had no strabismus or amblyopia. The sensitivity of the PVS to detect strabismus and amblyopia (0.97; 95% CI, 0.94-1.00) was significantly higher than that of the SureSight Autorefractor (0.74; 95% CI, 0.66-0.83). Specificity of the PVS for strabismus and amblyopia (0.87; 95% CI, 0.80-0.95) was significantly higher than that of the SureSight Autorefractor (0.62; 95% CI, 0.50-0.73).

Conclusions and Relevance  The PVS identified children with strabismus and/or amblyopia with high sensitivity, outperforming the SureSight Autorefractor. Accurate, early detection of these conditions could improve long-term vision outcomes of affected preschool children.

Amblyopia is the leading treatable cause of monocular vision loss in childhood, with a mean prevalence of 2.2% for amblyopia and 2.8% for strabismus.14 Even children who make regular visits to their pediatricians may not be identified early, because the signs of amblyopia and strabismus can be subtle and preschool children may be uncooperative.512 Commercially available automated screening devices assess refractive error because hyperopia and anisometropia are risk factors for strabismus and amblyopia.13 However, screening for refractive risk factors fails to identify many children with amblyopia or strabismus and overrefers healthy children.1319 The consequences of not identifying and treating strabismus and amblyopia early include permanent visual impairment and adverse effects on school performance, fine motor skills, social interactions, and self-image.2028

Recently, a prototype device designed to detect strabismus and amblyopia directly has been described.29 Binocular retinal birefringence scans detect whether fixation of a target is foveal and steady in each eye by identifying the unique polarization signal created by the radially arranged Henle fibers (photoreceptor axons) that emanate from the fovea.2931 Specifically, when a circularly polarized spot of laser light is scanned as an annulus on both retinas, the differential polarization signal of the returning light results in a doubling of the input frequency. On the other hand, if the annulus does not surround each fovea due to strabismus, or if fixation is unsteady, as demonstrated in anisometropic amblyopia without strabismus,3236 the doubled frequency is reduced in amplitude or absent from the returned signal. In a pilot study of children aged 2 to 18 years conducted by the team that developed the prototype retinal birefringence scanner, dubbed the Pediatric Vision Scanner (PVS; REBIScan, Inc), sensitivity was 97% and specificity was 98% for strabismus and amblyopia, suggesting that the PVS could accurately identify children who need ophthalmic care and minimize overreferral.29 Since the pilot study, the bulky PVS was redesigned to be easily incorporated into routine pediatric care, with a reduced size and weight, an enhanced signal-to-noise ratio, the addition of a more child-friendly fixation target, and a “friendlier” look and feel.

The objective of this study was to independently evaluate the sensitivity and specificity of the redesigned PVS in the target preschool age range (ie, 2-6 years). In this initial study of the redesigned PVS, we sought to establish the accuracy of the PVS in identifying the targeted vision disorders, strabismus and amblyopia, in a clinical setting. For comparison, vision screening was also conducted with a device currently used by many for preschool vision screening, the SureSight Autorefractor (Welch Allyn). On the basis of the recent recommendations of Donahue et al13 on behalf of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Vision Screening Committee, we evaluated the sensitivity and specificity of each screening device using a complete eye examination performed by a fellowship-trained pediatric ophthalmologist (C.L.B., D.R.S., D.S., or L.D.) as the gold standard.

Participants

Three hundred consecutive boys and girls aged 2 to 6 years scheduled for a comprehensive medical eye examination, including cycloplegic refraction, were recruited from the Pediatric Ophthalmology & the Center for Adult Strabismus (private practice in Dallas, Texas) and Pediatric Ophthalmology & Adult Strabismus (private practice in Plano, Texas) 1 or 2 mornings per week between November 22, 2010, and July 22, 2013. Children with developmental delay, retinal disease, cataract, or eye muscle surgery in the past 6 months were excluded. Clinical staff identified eligible children during their visit and invited the parent(s) to discuss the study with the researcher (R.M.J. or S.E.Y.). Written informed consent was obtained from the parent(s) before participation in the study. The research protocol was approved by the institutional review board of the University of Texas Southwestern Medical Center and conformed to the requirements of the Health Insurance Portability and Accountability Act of 1996.

Acquisition of Data

Children were tested with the PVS and, for comparison, with the SureSight Autorefractor. Test order was varied according to a random-number table. Total test time was less than 5 minutes. Screening tests were performed by a trained examiner (R.M.J. or S.E.Y.) who was unaware of the results of the gold standard ophthalmic examination. Likewise, the pediatric ophthalmologist who performed the gold standard examination was unaware of the results of the screening test.

PVS

Children sat on their own or were seated on a parent's lap. Trained research staff (R.M.J. or S.E.Y.) performed all measurements. The PVS was held 40 cm from the child. Room lights were dimmed to enhance interest in the illuminated smiley face fixation target and to increase pupil size. A background measurement was obtained with eyes closed and subtracted from subsequent readings to improve the signal-to-noise ratio. If the child would not close his or her eyes, the background measurement was obtained with the device aimed at his or her forehead, arm, or the parent’s forehead. Data collection continued until 5 measurements were obtained (2.5 seconds). If 5 usable measurements could not be obtained, “unable” was recorded.

The PVS software performed a fast Fourier transform to analyze the power spectrum of the returning signals for each eye for each of the 5 scans. If more than 60% of the scans had predominantly 200 Hz power in both eyes (ie, simultaneous foveation), the child was categorized as “pass.” Otherwise, the outcome was “refer” (ie, either strabismus or amblyopia was present). This criterion was determined empirically in the developer’s pilot study.29

SureSight Autorefractor

The SureSight Autorefractor was used according to the manufacturer’s instructions with the child calibration setting. Briefly, it was held approximately 35 cm from the child. Data collection continued until at least 5 usable measurements (ie, reliability score ≥5) were obtained for each eye. If 5 measurements with reliability scores of 5 or higher could not be obtained, a “no measurement possible” result was reported. The refractive error obtained with the SureSight Autorefractor was compared with the age-based 2013 AAPOS Vision Screening Committee Guidelines for Automated Preschool Vision Screening13 to classify the test result as “refer” or “pass.”

Gold Standard Examination

A complete eye examination was performed by 1 of 4 fellowship-trained pediatric ophthalmologists (C.L.B., D.R.S., D.S., or L.D.) on the same day as the screening. Gold standard examiners did not have access to screening results. The examination included monocular distance visual acuity assessment, cover testing, ocular motility, cycloplegic retinoscopy, evaluation of the anterior segment, and binocular indirect ophthalmoscopy. If the child was too young to provide monocular distance visual acuity, amblyopia was assessed by fixation preference. With the parents’ written consent, a copy of medical records for the gold standard examination of each child was obtained 1 to 2 weeks after the screening visit.

Sample Size

On the basis of previous studies conducted at the same clinical sites, we estimated that 60% of children enrolled would be affected by strabismus and/or amblyopia. A sample size of 300 patients was chosen because the expected enrollment of 175 children with strabismus or amblyopia who should have a “refer” outcome and 125 children with no strabismus or amblyopia who should have a “pass” outcome would provide adequate 95% CIs for estimating sensitivity and specificity of retinal birefringence scanning over a reasonable range of expected outcomes (ie, 95% CIs of approximately ±0.04). Even if sensitivity or specificity were much lower than expected (eg, 0.90 or 0.80), the 95% CI would be only slightly larger, approximately ±0.06. Recruitment continued until the target enrollment of 300 was reached.

Primary Outcome

The primary outcome was sensitivity and specificity of the PVS for detecting the targeted conditions, strabismus and amblyopia, in children aged 2 to 6 years. Secondary outcomes included the positive and negative likelihood ratios of the PVS for detecting the targeted conditions. In addition, sensitivity, specificity, and positive and negative likelihood ratios of the SureSight Autorefractor for the targeted conditions were assessed in the same cohort of children.

Statistical Analysis

At the screening, eligibility characteristics, demographic information, and screening test order and results were recorded on a data form. Diagnosis of strabismus and amblyopia was extracted from the gold standard examination medical record 1 to 2 weeks after the screening visit. Children were classified as positive or negative for strabismus and/or amblyopia. Sensitivity, specificity, positive and negative likelihood ratios, and their 95% CIs were determined for each screening device. The rates of incomplete tests for the 2 screening devices were calculated as simple percentages and compared by z tests.

Between November 22, 2010, and July 22, 2013, a total of 300 consecutive eligible children were enrolled in the study. The mean (SD) age was 4.1 (1.4) years; 53.0% were girls and 83.7% were white. In the cohort, 62.6% had strabismus only, amblyopia only, or both, and 37.3% had neither strabismus nor amblyopia. Details of demographics and the frequency of targeted disorders (strabismus and amblyopia) by age are summarized in Table 1. Attempts to screen were unsuccessful for 1 child with the PVS and for 17 children with the SureSight Autorefractor (Table 2). Significantly fewer screening attempts were unsuccessful with the PVS than with the SureSight Autorefractor (z = 3.8; P < .001).

Table Graphic Jump LocationTable 1.  Demographics and Frequency Distribution of Targeted Disorders (Strabismus and Amblyopia) by Age
Table Graphic Jump LocationTable 2.  Unsuccessful Attempts to Screen With Each Device

Sensitivity and specificity of the PVS and SureSight Autorefractor for the targeted conditions of strabismus and amblyopia are summarized in Table 3, along with 95% CIs. Sensitivity of the PVS to detect strabismus and amblyopia (0.97) was significantly higher than that of the SureSight Autorefractor (0.74). Screening errors are summarized in Table 4. By the gold standard examination, the PVS failed to detect 1 of 131 strabismic children (0.8%) and 5 of 115 amblyopic children (4.3%). In comparison, the SureSight Autorefractor failed to detect 37 of 121 strabismic children (30.6%) and 17 of 104 amblyopic children (16.3%). Of the affected children, 37 of 44 (84.1%) who passed the SureSight Autorefractor screening were strabismic with a normal refractive error.

Table Graphic Jump LocationTable 3.  Sensitivity and Specificity of the Screening Devices for Detection of Strabismus and Amblyopia
Table Graphic Jump LocationTable 4.  Screening Errors by Gold Standard Examination Diagnoses and Cycloplegic Refractiona

Specificity of the PVS for strabismus and amblyopia (0.87) was significantly higher than that of the SureSight Autorefractor (0.62). False positives (12.6%) for the PVS included 7 children who had abnormal refractive errors in 1 or both eyes and 7 who had a normal refractive error. SureSight Autorefractor false positives (38.4%) included 28 children with an abnormal refractive error and 15 with a normal refractive error.

Because the current study was based in a clinic setting with a cohort enriched with affected children, statistical inference must be used to predict the performance of the screening devices in the general population. Therefore, positive and negative likelihood ratios for each screening device are also provided in Table 3. Positive likelihood ratios describe how many more times a “refer” result is likely to be observed in children with the target disorders than in unaffected children.37 The positive likelihood ratio of 7.7 for a “refer” outcome by the PVS was significantly higher than that for the SureSight Autorefractor and represents a moderate, but not conclusive, increase in the likelihood that the child has strabismus or amblyopia. The positive likelihood ratio of 1.9 for the SureSight Autorefractor denotes only a minimal increase in the likelihood that the child has one of these conditions. Negative likelihood ratios describe how many fewer times a “pass” result is likely to be observed in children with the target disorders than in unaffected children.37 The negative likelihood ratio of 0.03 for the PVS was significantly lower than that for the SureSight Autorefractor and represents the low probability that a child with the targeted condition of strabismus or amblyopia will receive a “pass” outcome (ie, affected children have a high probability of being correctly identified by the PVS device). The negative likelihood ratio of 0.42 for the SureSight Autorefractor reflects a moderate probability that children affected by the targeted conditions will be missed by SureSight Autorefractor screening.

Preschool vision screening with a binocular retinal birefringence scanning device, the PVS, had high sensitivity (0.97) and specificity (0.87) for detecting the targeted conditions of strabismus and amblyopia. The PVS outperformed screening for refractive risk factors using the SureSight Autorefractor, which had 8.8 times as many false negatives and 3.1 times as many false positives as the PVS.

Overall, PVS sensitivity to the targeted conditions did not differ from the 97% reported for the prototype PVS device, but specificity was significantly lower.29 This may be due to the age inclusion criterion of 2 to 6 years in the present study, while more than 50% of the participants in the prototype study were aged 7 to 18 years. Nonetheless, the PVS accurately identified 91.9% of children with anisometropic amblyopia in the absence of measurable strabismus and overreferred only 3 anisometropic children with orthophoria and no amblyopia. The sensitivity of the PVS to anisometropic amblyopia reported here matches that reported for the prototype.29 Many children with anisometropic amblyopia have fixation instability, but anisometropia alone does not have this association.32-36 As suggested by Loudon et al,29 the fixation instability that characterizes anisometropic amblyopia may be sufficient to reduce or eliminate the retinal birefringence signal detected by the PVS. Moreover, anisometropia in the absence of amblyopia will not disrupt the retinal birefringence signal.29

The success rate for PVS screening was more than 99%, which was significantly higher than the SureSight Autorefractor’s 94.3% success rate in the same cohort. Success rates for SureSight Autorefractor preschool screening of 76% to 89% in private practice and laboratory settings have been reported by numerous authors.3739 On the other hand, in multisite vision preschool screening studies, much higher SureSight Autorefractor success rates (>99%) have been described.16,40

One limitation of the present study is that fixation preference was used to diagnose amblyopia in some of the youngest members of the study cohort who were unable to cooperate with monocular distance visual acuity testing. Fixation preference is a less than ideal method to identify the presence or absence of amblyopia, particularly among children with orthotropia or microtropia.4147 In our cohort, 37 children (12.3%) had amblyopia diagnosed by fixation preference (5 amblyopic and 32 nonamblyopic), of whom 21 also had strabismus and, therefore, would have been categorized as affected by one of the targeted conditions regardless of the determination of visual acuity. Removing the remaining 16 children (2 amblyopic and 14 nonamblyopic) from the analysis of PVS sensitivity and specificity results in no change in sensitivity (0.97; 95% CI, 0.94-1.00) but a small improvement in specificity (0.88; 95% CI, 0.80-0.96).

A second limitation is that the present study was conducted in a clinical setting, with a cohort enriched in children affected by the targeted conditions of strabismus and amblyopia; therefore, this study cannot directly assess the performance of the PVS in a primary care screening setting. Nonetheless, calculation of the positive and negative likelihood ratios allowed us to compare the screening utility of the PVS and the SureSight Autorefractor. This analysis suggested that the use of the PVS in a screening setting would significantly change our knowledge of the probability that a child is affected by one of the targeted conditions. In comparison, use of the SureSight Autorefractor to screen children can provide only a minimal change in the probability that a child is affected by the targeted conditions. While the results of the likelihood ratio analysis are promising, the PVS needs further study in primary care settings before recommendations can be made about its regular use in that setting. Currently, we are evaluating the performance of the PVS in the setting of well-child visits at a private group pediatric practice.

One consequence of conducting this study in a clinical setting was that many of the children screened during a routine follow-up visit initially had been diagnosed with strabismus and/or amblyopia some time before. Therefore, it is possible that their strabismus and/or amblyopia had characteristics that differed from those typically seen in a screening setting or an initial office visit due to duration of the disease or to previous treatment. However, limiting the analysis to only the 56 children who were screened during their initial visit to the pediatric ophthalmologist, following a failed school or pediatric screening or due to parental concerns, provided estimates of sensitivity and specificity for both the PVS (sensitivity, 0.95 [95% CI, 0.83-1.00]; specificity, 0.86 [95% CI, 0.72-1.00]) and SureSight Autorefractor (sensitivity, 0.80 [95% CI, 0.52-1.00]; specificity, 0.64 [95% CI, 0.44-0.84]) that were similar to those derived from the entire study cohort.

The PVS does not calculate refractive error, which might be considered a disadvantage, but measurement of refractive error is not needed for the detection of amblyopia or strabismus. Devices such as the SureSight Autorefractor that do detect refractive error are more likely to generate false positives. By not detecting refractive error, false-positive referrals are reduced. No known medical harm comes from a lack of detecting nonamblyogenic refractive errors. Nonetheless, some have argued that it may be better to refer and treat all children with risk factors before amblyopia and strabismus develop.15

Because devices that screen for refractive risk factors cannot directly detect strabismus or amblyopia, children determined to be “at risk” due to a refractive error typically are referred by their primary care physician to an eye care professional for a comprehensive examination, with regularly scheduled follow-up visits, even though only 9% to 18% may eventually develop strabismus or amblyopia.13,14,17,48 The rationale for retinal birefringence screening with the PVS device is quite different. Namely, it is a simple, quick test that can be used to refer only affected children to eye care professionals or screen children at regular intervals in a primary care setting to provide early and accurate identification of those who develop strabismus or amblyopia. This strategy is in keeping with the 2013 AAPOS Vision Screening Committee recommendation that vision “screening should be viewed as a continuous process that occurs throughout visual development, beginning in infancy. We anticipate that vision screening of children will take place at several times during the formative years.”13(p5)

The failure to detect amblyopia during early childhood, when treatment may be most effective, is a serious public health problem. Amblyopia is the leading cause of monocular vision loss in children.49,50 Retinal birefringence scanning with the PVS is a novel approach that provides direct detection of strabismus and amblyopia, rather than the common approach of indirectly assessing refractive risk factors. The PVS is quick and simple to use, allows a long working distance (40 cm) that is comfortable for preschool children, provides an objective result of “pass” or “refer,” and is more accurate than risk factor assessment.

Submitted for Publication: October 2, 2013; final revision received December 19, 2013; accepted January 4, 2014.

Corresponding Author: Reed M. Jost, MS, Crystal Charity Ball Pediatric Vision Evaluation Center, Retina Foundation of the Southwest, 9600 North Central Expressway, Ste 200, Dallas, TX 75231 (reedjost@retinafoundation.org).

Published Online: May 29, 2014. doi:10.1001/jamaophthalmol.2014.424.

Author Contributions: Mr Jost had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Birch.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Jost, Yanni.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Jost, Birch.

Obtained funding: Yanni, Birch.

Administrative, technical, or material support: Yanni, D. Stager, Dao.

Study supervision: Yanni, Birch.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grant 9491 from the Thrasher Research Fund and by grant EY022313 from the National Institutes of Health National Eye Institute.

Role of the Sponsors: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Previous Presentations: This study was presented, in part, at the annual meeting of the American Association for Pediatric Ophthalmology and Strabismus; April 6, 2013; Boston, Massachusetts, and annual meeting of the Association for Research in Vision and Ophthalmology; May 9, 2013; Seattle, Washington.

Additional Information: The US Food and Drug Administration determined that the Pediatric Vision Scanner has an Investigational Device Exemption under 21 CFR 812.2(b) for devices with a nonsignificant risk.

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Hunter  DG, Nassif  DS, Piskun  NV, Winsor  R, Gramatikov  BI, Guyton  DL.  Pediatric Vision Screener 1: instrument design and operation. J Biomed Opt. 2004;9(6):1363-1368.
PubMed   |  Link to Article
Nassif  DS, Piskun  NV, Gramatikov  BI, Guyton  DL, Hunter  DG.  Pediatric Vision Screener 2: pilot study in adults. J Biomed Opt. 2004;9(6):1369-1374.
PubMed   |  Link to Article
Bedell  HE, Flom  MC.  Bilateral oculomotor abnormalities in strabismic amblyopes: evidence for a common central mechanism. Doc Ophthalmol. 1985;59(4):309-321.
PubMed   |  Link to Article
Bedell  HE, Yap  YL, Flom  MC.  Fixational drift and nasal-temporal pursuit asymmetries in strabismic amblyopes. Invest Ophthalmol Vis Sci. 1990;31(5):968-976.
PubMed
Birch  EE, Subramanian  V, Weakley  DR.  Fixation instability in anisometropic children with reduced stereopsis. J AAPOS. 2013;17(3):287-290.
PubMed   |  Link to Article
Simmers  AJ, Gray  LS, McGraw  PV, Winn  B.  Functional visual loss in amblyopia and the effect of occlusion therapy. Invest Ophthalmol Vis Sci. 1999;40(12):2859-2871.
PubMed
Zhang  B, Stevenson  SS, Cheng  H,  et al.  Effects of fixation instability on multifocal VEP (mfVEP) responses in amblyopes. J Vis. 2008;8(3):16.11-14.
PubMed   |  Link to Article
Harvey  EM, Dobson  V, Miller  JM,  et al.  Accuracy of the Welch Allyn SureSight for measurement of magnitude of astigmatism in 3- to 7-year-old children. J AAPOS. 2009;13(5):466-471.
PubMed   |  Link to Article
Rogers  DL, Neely  DE, Chapman  JB,  et al.  Comparison of the MTI Photoscreener and the Welch-Allyn SureSight autorefractor in a tertiary care center. J AAPOS. 2008;12(1):77-82.
PubMed   |  Link to Article
Kemper  A, Keating  L, Jackson  JL, Levin  E.  Comparison of monocular autorefraction to comprehensive eye examinations in preschool-aged and younger children .Arch Pediatr Adolesc Med. 2005;159(5):435-439.
PubMed
Silverstein  E, Lorenz  S, Emmons  K, Donahue  SP.  Limits on improving the positive predictive value of the Welch Allyn SureSight for preschool vision screening. J AAPOS. 2009;13(1):45-50.
PubMed   |  Link to Article
Cotter  SA, Tarczy-Hornoch  K, Song  E,  et al; Multi-Ethnic Pediatric Eye Disease Study Group.  Fixation preference and visual acuity testing in a population-based cohort of preschool children with amblyopia risk factors. Ophthalmology. 2009;116(1):145-153.
PubMed   |  Link to Article
Friedman  DS, Katz  J, Repka  MX,  et al.  Lack of concordance between fixation preference and HOTV optotype visual acuity in preschool children: the Baltimore Pediatric Eye Disease Study. Ophthalmology. 2008;115(10):1796-1799.
PubMed   |  Link to Article
Kothari  M, Bhaskare  A, Mete  D, Toshniwal  S, Doshi  P, Kaul  S.  Evaluation of central, steady, maintained fixation grading for predicting inter-eye visual acuity difference to diagnose and treat amblyopia in strabismic patients. Indian J Ophthalmol. 2009;57(4):281-284.
PubMed   |  Link to Article
Procianoy  L, Procianoy  E.  The accuracy of binocular fixation preference for the diagnosis of strabismic amblyopia. J AAPOS. 2010;14(3):205-210.
PubMed   |  Link to Article
Sener  EC, Mocan  MC, Gedik  S, Ergin  A, Sanaç  AS.  The reliability of grading the fixation preference test for the assessment of interocular visual acuity differences in patients with strabismus. J AAPOS. 2002;6(3):191-194.
PubMed   |  Link to Article
Wright  KW, Edelman  PM, Walonker  F, Yiu  S.  Reliability of fixation preference testing in diagnosing amblyopia. Arch Ophthalmol. 1986;104(4):549-553.
PubMed   |  Link to Article
Wright  KW, Walonker  F, Edelman  P.  10-Diopter fixation test for amblyopia. Arch Ophthalmol. 1981;99(7):1242-1246.
PubMed   |  Link to Article
Nathan  NR, Donahue  SP.  Modification of Plusoptix referral criteria to enhance sensitivity and specificity during pediatric vision screening. J AAPOS. 2011;15(6):551-555.
PubMed   |  Link to Article
Attebo  K, Mitchell  P, Cumming  R, Smith  W, Jolly  N, Sparkes  R.  Prevalence and causes of amblyopia in an adult population. Ophthalmology. 1998;105(1):154-159.
PubMed   |  Link to Article
National Eye Institute Office of Biometry and Epidemiology. Report on the National Eye Institute's Visual Acuity Impairment Survey Pilot Study. Washington, DC: Department of Health and Human Services; 1984.

Figures

Tables

Table Graphic Jump LocationTable 1.  Demographics and Frequency Distribution of Targeted Disorders (Strabismus and Amblyopia) by Age
Table Graphic Jump LocationTable 2.  Unsuccessful Attempts to Screen With Each Device
Table Graphic Jump LocationTable 3.  Sensitivity and Specificity of the Screening Devices for Detection of Strabismus and Amblyopia
Table Graphic Jump LocationTable 4.  Screening Errors by Gold Standard Examination Diagnoses and Cycloplegic Refractiona

References

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Friedman  DS, Repka  MX, Katz  J,  et al.  Prevalence of amblyopia and strabismus in white and African American children aged 6 through 71 months the Baltimore Pediatric Eye Disease Study. Ophthalmology.2009;116(11):2128-2134.e1-2.
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Donahue  SP, Arthur  B, Neely  DE, Arnold  RW, Silbert  D, Ruben  JB; POS Vision Screening Committee.  Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013;17(1):4-8.
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Colburn  JD, Morrison  DG, Estes  RL, Li  C, Lu  P, Donahue  SP.  Longitudinal follow-up of hypermetropic children identified during preschool vision screening. J AAPOS. 2010;14(3):211-215.
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Schmidt  P, Maguire  M, Dobson  V,  et al; Vision in Preschoolers Study Group.  Comparison of preschool vision screening tests as administered by licensed eye care professionals in the Vision in Preschoolers Study. Ophthalmology. 2004;111(4):637-650.
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Vision in Preschoolers Study Group.  Does assessing eye alignment along with refractive error or visual acuity increase sensitivity for detection of strabismus in preschool vision screening? Invest Ophthalmol Vis Sci. 2007;48(7):3115-3125.
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Cotter  SA, Varma  R, Tarczy-Hornoch  K,  et al; Joint Writing Committee for the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study Groups.  Risk factors associated with childhood strabismus: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies. Ophthalmology. 2011;118(11):2251-2261.
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Tarczy-Hornoch  K, Varma  R, Cotter  SA,  et al; Joint Writing Committee for the Multi-Ethnic Pediatric Eye Disease Study and the Baltimore Pediatric Eye Disease Study Groups.  Risk factors for decreased visual acuity in preschool children: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies. Ophthalmology. 2011;118(11):2262-2273.
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Chua  WH, Balakrishnan  V, Chan  YH,  et al.  Atropine for the treatment of childhood myopia. Ophthalmology. 2006;113(12):2285-2291.
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O’Connor  AR, Birch  EE, Anderson  S, Draper  H.  Relationship between binocular vision, visual acuity, and fine motor skills. Optom Vis Sci. 2010;87(12):942-947.
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O’Connor  AR, Birch  EE, Spencer  R.  Factors affecting development of motor skills in extremely low birth weight children. Strabismus. 2009;17(1):20-23.
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Packwood  EA, Cruz  OA, Rychwalski  PJ, Keech  RV.  The psychosocial effects of amblyopia study. J AAPOS. 1999;3(1):15-17.
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Rahi  JS, Cumberland  PM, Peckham  CS.  Does amblyopia affect educational, health, and social outcomes? findings from 1958 British birth cohort. BMJ. 2006;332(7545):820-825.
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Webber  AL, Wood  JM, Gole  GA, Brown  B.  The effect of amblyopia on fine motor skills in children. Invest Ophthalmol Vis Sci. 2008;49(2):594-603.
PubMed   |  Link to Article
Horwood  J, Waylen  A, Herrick  D, Williams  C, Wolke  D.  Common visual defects and peer victimization in children. Invest Ophthalmol Vis Sci. 2005;46(4):1177-1181.
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Webber  AL, Wood  JM, Gole  GA, Brown  B.  Effect of amblyopia on self-esteem in children. Optom Vis Sci. 2008;85(11):1074-1081.
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Loudon  SE, Rook  CA, Nassif  DS, Piskun  NV, Hunter  DG.  Rapid, high-accuracy detection of strabismus and amblyopia using the pediatric vision scanner. Invest Ophthalmol Vis Sci. 2011;52(8):5043-5048.
PubMed   |  Link to Article
Hunter  DG, Nassif  DS, Piskun  NV, Winsor  R, Gramatikov  BI, Guyton  DL.  Pediatric Vision Screener 1: instrument design and operation. J Biomed Opt. 2004;9(6):1363-1368.
PubMed   |  Link to Article
Nassif  DS, Piskun  NV, Gramatikov  BI, Guyton  DL, Hunter  DG.  Pediatric Vision Screener 2: pilot study in adults. J Biomed Opt. 2004;9(6):1369-1374.
PubMed   |  Link to Article
Bedell  HE, Flom  MC.  Bilateral oculomotor abnormalities in strabismic amblyopes: evidence for a common central mechanism. Doc Ophthalmol. 1985;59(4):309-321.
PubMed   |  Link to Article
Bedell  HE, Yap  YL, Flom  MC.  Fixational drift and nasal-temporal pursuit asymmetries in strabismic amblyopes. Invest Ophthalmol Vis Sci. 1990;31(5):968-976.
PubMed
Birch  EE, Subramanian  V, Weakley  DR.  Fixation instability in anisometropic children with reduced stereopsis. J AAPOS. 2013;17(3):287-290.
PubMed   |  Link to Article
Simmers  AJ, Gray  LS, McGraw  PV, Winn  B.  Functional visual loss in amblyopia and the effect of occlusion therapy. Invest Ophthalmol Vis Sci. 1999;40(12):2859-2871.
PubMed
Zhang  B, Stevenson  SS, Cheng  H,  et al.  Effects of fixation instability on multifocal VEP (mfVEP) responses in amblyopes. J Vis. 2008;8(3):16.11-14.
PubMed   |  Link to Article
Harvey  EM, Dobson  V, Miller  JM,  et al.  Accuracy of the Welch Allyn SureSight for measurement of magnitude of astigmatism in 3- to 7-year-old children. J AAPOS. 2009;13(5):466-471.
PubMed   |  Link to Article
Rogers  DL, Neely  DE, Chapman  JB,  et al.  Comparison of the MTI Photoscreener and the Welch-Allyn SureSight autorefractor in a tertiary care center. J AAPOS. 2008;12(1):77-82.
PubMed   |  Link to Article
Kemper  A, Keating  L, Jackson  JL, Levin  E.  Comparison of monocular autorefraction to comprehensive eye examinations in preschool-aged and younger children .Arch Pediatr Adolesc Med. 2005;159(5):435-439.
PubMed
Silverstein  E, Lorenz  S, Emmons  K, Donahue  SP.  Limits on improving the positive predictive value of the Welch Allyn SureSight for preschool vision screening. J AAPOS. 2009;13(1):45-50.
PubMed   |  Link to Article
Cotter  SA, Tarczy-Hornoch  K, Song  E,  et al; Multi-Ethnic Pediatric Eye Disease Study Group.  Fixation preference and visual acuity testing in a population-based cohort of preschool children with amblyopia risk factors. Ophthalmology. 2009;116(1):145-153.
PubMed   |  Link to Article
Friedman  DS, Katz  J, Repka  MX,  et al.  Lack of concordance between fixation preference and HOTV optotype visual acuity in preschool children: the Baltimore Pediatric Eye Disease Study. Ophthalmology. 2008;115(10):1796-1799.
PubMed   |  Link to Article
Kothari  M, Bhaskare  A, Mete  D, Toshniwal  S, Doshi  P, Kaul  S.  Evaluation of central, steady, maintained fixation grading for predicting inter-eye visual acuity difference to diagnose and treat amblyopia in strabismic patients. Indian J Ophthalmol. 2009;57(4):281-284.
PubMed   |  Link to Article
Procianoy  L, Procianoy  E.  The accuracy of binocular fixation preference for the diagnosis of strabismic amblyopia. J AAPOS. 2010;14(3):205-210.
PubMed   |  Link to Article
Sener  EC, Mocan  MC, Gedik  S, Ergin  A, Sanaç  AS.  The reliability of grading the fixation preference test for the assessment of interocular visual acuity differences in patients with strabismus. J AAPOS. 2002;6(3):191-194.
PubMed   |  Link to Article
Wright  KW, Edelman  PM, Walonker  F, Yiu  S.  Reliability of fixation preference testing in diagnosing amblyopia. Arch Ophthalmol. 1986;104(4):549-553.
PubMed   |  Link to Article
Wright  KW, Walonker  F, Edelman  P.  10-Diopter fixation test for amblyopia. Arch Ophthalmol. 1981;99(7):1242-1246.
PubMed   |  Link to Article
Nathan  NR, Donahue  SP.  Modification of Plusoptix referral criteria to enhance sensitivity and specificity during pediatric vision screening. J AAPOS. 2011;15(6):551-555.
PubMed   |  Link to Article
Attebo  K, Mitchell  P, Cumming  R, Smith  W, Jolly  N, Sparkes  R.  Prevalence and causes of amblyopia in an adult population. Ophthalmology. 1998;105(1):154-159.
PubMed   |  Link to Article
National Eye Institute Office of Biometry and Epidemiology. Report on the National Eye Institute's Visual Acuity Impairment Survey Pilot Study. Washington, DC: Department of Health and Human Services; 1984.

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