Ellipsoid Spectacle Comparison of Plusoptix, Retinomax and 2WIN Autorefractors.

BACKGROUND: Handheld devices can automatically give an estimate of refraction. The established method for refraction comparison using spherical equivalent (M) and J0, J45 vector transformations by Bland-Altman analysis is too complex for non-eye doctors involved with vision screening and remote vision clinics. Therefore, a simpler comparison technique was developed. METHODS: Based on the spectacle limit to resolve grade A 1 logMAR, B 3 logMAR and C 6 logMAR blur, J0, J45, and M are combined into the Alaska Blind Child Discovery (ABCD) composite ellipsoid GRADE system. Pediatric eye patients had confirmatory examination after dry refraction with three portable autorefractors: Plusoptix, 2WIN and Retinomax. The refractions were then compared using both Bland-Altman and ABCD composite. Performance to detect AAPOS amblyopia risk factors was also assessed. RESULTS: A total of 202 children, mean age seven years, 28% high spectacle need and 43% AAPOS 2013 amblyopia risk factors showed high correlation with cycloplegic refraction (intraclass correlation 0.49 to 0.90) for sphere, J0 and J45 spectacle components. Plusoptix had more (10%) inconclusives due to patients out-of-range. The Retinomax was unable to screen some younger children and was less reliable for sphere but gave more precise astigmatism estimates. The proportion of autorefractions expected to give GRADE A/B high-need patients acuity improvement to 20/40 would be 41% for Plusoptix, 39% for 2WIN and 65% for Retinomax. Sensitivity/specificity for amblyopia risk factor detection was 80%/83% for Plusoptix, 72%/88% for 2WIN and 84%/73% for Retinomax. CONCLUSION: The simplified spectacle comparison resembled Bland-Altman and could assist lay vision screeners and non-eye doctors attempting remote spectacle donation worldwide.

Oculocardiac Reflex During ROP Exams.

PURPOSE: Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery. PATIENTS AND METHODS: Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls. RESULTS: From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72-98%), kurtosis 1.60 and skewness -1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) - 11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34-240 seconds). CONCLUSION: Bradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.

The Impact of Re-Operation, Relatives and Race on the Oculocardiac Reflex During Strabismus Surgery.

PURPOSE: The oculocardiac reflex (OCR) is a trigeminovagal bradycardia elicited by tension on an extraocular muscle (EOM). Using three decades of observational data, we investigated whether or not individual strabismus patients are prone to oculocardiac reflex. PATIENTS AND METHODS: All patients undergoing strabismus surgery from 1992 to 2019 had deliberate 10-second, 200-gram square-wave tension on extraocular rectus muscles with anesthetic variables recorded. OCR was defined as the maximally tension-altered heart rate as a percent of stable baseline heart rate. RESULTS: OCR was compared in 2532 original cases with 323 re-operations. The 169 cases that used anticholinergics (99% OCR) were excluded from the analysis. The median OCR, a 15% drop, was found to be 85% (95% CI 39%, 102%,; range 5-151%). Factors that showed a significant effect on the OCR were the type of EOM with lateral rectus least (Kruskal-Wallis X2(3)=8, p<0.05), and adults had less OCR compared to the children (X2(2)=105, p<0.01). Factors that showed an augmenting effect on the OCR were peri-operative opioids (X2(6)=62, p<0.01) and Caucasian race (X2(4)=12, p<0.02). Gender and iris color were not found to have an impact on OCR. Re-operations and first-degree relatives did not differ from age-matched controls, but EOM- and opioid-adjusted re-operations correlated with their initial cases (r=0.37). CONCLUSION: We confirmed the previously published blocking effect of atropine, augmenting impact of opioids, and an inverse relationship of age on OCR. There was a weak proclivity for individuals to be prone to OCR. We found an impact of race with Caucasians having more OCR.

Direct OPTOS Nerve Size Determination of Prevalent Optic Nerve Hypoplasia in Alaska.

BACKGROUND: Optic nerve hypoplasia (ONH), one of the most common causes of pediatric blindness in developed countries, has been difficult to directly quantify. We sought to measure optic nerve size in Alaskan pediatric patients with optic nerve hypoplasia using ultra-widefield fundus imaging. METHODS: Adult and pediatric patients underwent conventional ultra widefield fundus imaging (OPTOS, Dunfermline, Scotland) with manual image processing to determine optic nerve size validated against refractive error and nystagmus and compared to optical spectral domain tomography. De-identified cases were then compared relative to visual acuity and birth prevalence. RESULTS: In Alaska's only pediatric ophthalmology outreach clinic, 108 cases of ONH less than 20 years old were clinically identified with 80 having ultra-widefield analysis. Median horizontal optic nerve diameter for 135 normals was 1.70 (95% C.I. 1.49, 2.14) whereas in patients clinically diagnosed with optic nerve hypoplasia was 1.23 (95% C.I 0.38, 1.45). Visual acuity (20/y) was related to horizontal optic nerve diameter (x) by y = 187 x-4.1. Horizontal nerve diameter h could be estimated from vertical nerve diameter v by h = 0.73v + 0.3 even in nystagmus patients. From 108 with ONH, 6 had threshold retinopathy of prematurity, 12 profound nystagmus, 32 legally blind, 6 with septo-optic dysplasia, and 5 with fetal alcohol syndrome. ONH is very prevalent in Alaska occurring at least 8-10 per 10,000 births. CONCLUSION: Compared to vertical diameter, horizontal diameter was more distinctive of optic nerve hypoplasia and more perturbed by nystagmus. Both were independent of refractive error. When hand-held, spectral domain OCT is not convenient, ultra-widefield fundus analysis is recommended for direct estimation of optic nerve size in children and adults. Optic nerve hypoplasia is prevalent in Alaskan children.

School bus accommodation-relaxing skiascopy.

OBJECTIVE: Accurate estimation of hyperopia and astigmatism is challenging in delayed children. Conventional skiascopy holds rows of increasing power ± lenses vertically in front of one eye. The school bus accommodation-relaxing skiascopy (SBA-RS) design holds child-friendly, lenses +1 to +10D horizontally so that a higher power fogs the nontested eye-relaxing accommodation without cycloplegia. METHODS: Design: Evaluation of diagnostic test. Subjects: Patients undergoing comprehensive eye examination in a pediatric ophthalmology practice. Cycloplegic (cyclopentolate 1%) retinoscopy was compared to dry SBA-RS and Retinomax (Righton, Japan) during pediatric eye examinations. Outcome measures: correlations, Chi-square and receiver operating characteristic (ROC) curve. RESULTS: Of 470 patients with a median age 6 years, 238 were under the age of 60 months and 110 had developmental delays. For those with cycloplegic spherical equivalent hyperopia over 0.7 D, median (90% CI) value for retinoscopy was +2.63 D (+0.75, +6.88), for SBA-RS was +2.50 D (+0.50, +6.75) and less for 184 with Retinomax +1.88 D (-1.56, +6.13) but similar despite delays. Astigmatic cylinder SBA-RS +1.50 D (+0.25, +4.00) lagged retinoscopy +1.75 D (+0.75,+4.50) but Retinomax was greater +2.00 D (+0.25, +4.64). Cycloplegic refractive components such as spherical equivalent, cylinder, and J0 and J45 power vectors correlated highly and were near unity with SBA-RS and Retinomax with the latter deviating greater. SBA-RS screened for amblyopia risk factors up to 92% sensitive and 94% specific. CONCLUSION: Accommodation-relaxing horizontal skiascopy very precisely estimates astigmatism power and axis and only lags cycloplegic refraction by about 0.15D in hyperopic patients fairly independent of neurodevelopmental delay. This technique can quickly estimate refraction even in delayed patients potentially reducing some need for cycloplegia. CLINICAL TRIALS REGISTRY: NCT03668067.

Performance of a Quick Screening Version of the Nintendo 3DS PDI Check Game in Patients With Ocular Suppression.

PURPOSE: To evaluate the ability of the PDI Check (PDI Check LLC, Anchorage, AK) near vision screening game to assess monocular acuity, stereopsis, suppression, and color. METHODS: Children and adults consented to perform the PDI Check Quick Screening game following conventional near testing of patched Rosenbaum acuity, Titmus Fly stereo, Worth 4-dot, and Ishihara color. Time to complete each test and preferred method were recorded. RESULTS: A total of 77 patients (5 to 63 years old) attempted all tests. There was a positive correlation between the PDI Check and conventional tests for all visual tasks. Using previously determined instrument referral criteria, sensitivity/specificity was determined for right acuity (67%/91%), left acuity (55%/94%), stereopsis (87%/95%), red-green color (80%/99%), and ocular suppression (58%/98%). Screening time was 202 ± 96 versus 99 ± 42 seconds for the PDI Check and the game was preferred by 87%. CONCLUSIONS: The PDI Check provided a valid assessment of near vision in less than half the time of conventional testing without patches or goggles. This Quick Screening version may help eye technicians and physicians with time efficiency in the frequent task of near visual assessment. [J Pediatr Ophthalmol Strabismus. 2019;56(4):234-237.].

Performance of the 2WIN Photoscreener With "CR" Strabismus Estimation in High-Risk Patients.

PURPOSE: Accurate estimation of refractive error and ocular alignment is critical for identifying amblyopia risk factors. The 2WIN photoscreener (Adaptica) uses a novel infrared-transmitting occluder wand to quickly estimate intermittent deviations. DESIGN: Reliability analysis. METHODS: 2WIN refraction was compared to dry and cycloplegic retinoscopy and Retinomax. 2WIN "CR" function with wand was compared to cover test. RESULTS: 371 patients aged 6 months to 63 years (median age 6 years) had refraction, and 2WIN yielded high degrees of correlation (Pearson product-moment) on linear regression for spherical equivalent (0.73-0.79), cylinder power (0.78-0.79), J0 vector (0.79-0.83), and J45 vector (0.64-0.67). Similar proportions of 2WIN and Retinomax were within target refraction values for spherical equivalent (70% [216/310] vs 69% [212/310]), cylinder power (94% [154/165] vs 90% [148/165]), and cylinder axis (69% [113/165] vs 71% [118/165]). 2WIN CR higher than 10 prism diopters (PD) correlated with cover test for constant and intermittent deviations (Pearson correlation 0.64-0.71). 2WIN + CR screened for 2003 American Association for Pediatric Ophthalmology and Strabismus amblyopia risk factors with 68% (965/96) sensitivity and 84% (70/83) specificity in preschool children with 53% (96/180) prescreening probability and 31% (55/177) developmental delays. CONCLUSION: The 2WIN correlated well with examination and Retinomax. The CR function reliably estimated constant and intermittent strabismus higher than 10 PD.

The Positive Predictive Value of Smartphone Photoscreening in Pediatric Practices.

PURPOSE: To compare smartphone photoscreening with other commercial objective screeners for amblyopia screening for young children. METHODS: Ten pediatricians in four practices employed Nokia 1020 smartphones (Espoo, Finland) with single-axis Gobiquity software (Scottsdale, AZ) during well-child visits. Outcomes of confirmatory pediatric ophthalmology examinations were prospectively compared using American Association for Pediatric Ophthalmology and Strabismus uniform standards. RESULTS: Five percent of 6,310 in-office screenings were referred: 25% for high anisometropia, 31% for hyperopia, and 15% for myopia. The positive predictive value (PPV) in 217 follow-up examinations was 68% (95% confidence interval: 62% to 74%) by 2013 age-stratified standards and 77% (confidence interval: 71% to 83%) by 2003 American Association for Pediatric Ophthalmology and Strabismus standards. The follow-up rate was 65%. CONCLUSIONS: Smartphone photoscreening had PPV comparable with other commercial objective screeners. Simple, valid photoscreeners should help pediatricians achieve widespread compliance with screening guidelines to reduce the burden of pediatric amblyopia vision impairment. [J Pediatr Ophthalmol Strabismus. 2018;55(6):393-396.].

Pediatric photoscreeners in high risk patients 2012: a comparison study of Plusoptix, Iscreen and SPOT.

BACKGROUND: New photoscreening models promise to detect amblyopia risk factors early in hopes of reducing permanent pediatric monocular and binocular vision impairment. The 3 commercially available interpreted photoscreeners had not yet been compared. METHODS: This is a prospective, observational screening study following AAPOS guidelines on pediatric patients with and without developmental delays. 270 patients in a pediatric eye practice aged 4.7 +/- 4 years with 7% special needs. From December 2011 through March 2012, the Plusoptix, the iScreen, and the Pediavision SPOT were applied before confirmatory exam in a clinical pediatric eye practice. RESULTS: The inconclusive rate ranged from 1-4% (iScreen) to 12% (Plusoptix). Sensitivity ranged from 72% (iScreen) to 84% (Plusoptix) and specificity ranged from 68% (SPOT) to 94% (Plusoptix). The iScreen can provide results in 99% of high risk patients. CONCLUSIONS: In this cohort with high pre-screening prevalence, the 2011 photoscreeners had favorable validation that is expected to improve with further clinical study. Pediatricians have practical technology with a recognized procedure code to assist in amblyopia reduction.

Lay Person Slit Lamp Detection of Iritis in Absence of an Eye MD: Test of a Portable Model of Cells and Flare.

BACKGROUND: Asymptomatic - or minimally so, eye conditions like uveitis, iritis, and glaucoma are silent stealthily blinding diseases, especially when present in children. The iritis that accompanies Juvenile Idiopathic or Rheumatoid Arthritis (JIA or JRA) is characteristically asymptomatic. Children with these must be examined regularly and routinely(see Reference 1 and Table) on an opthalmologic biomicroscopic slit lamp for the microscopic cells (and aqueous flare) which occurr in the anterior chamber of the eye, signaling the presence of iritis, and an immediate need for anti-inflammatory agents. Such an exam is also indicated when the so afflicted develop most any symptoms of a new or recurrent eye problem. Slit lamp iritis determination remains challenging. It virtually requires a major, not portable, table mounted and expensive biomicroscope. And the examiner designated in schedules (1) is a trained ophthalmolgist,, an "Eye M.D.". Both. There are times and places throughout the world where and when a slit lamp may be available but there is no Eye MD (or qualified ophthalmic technician or assistant) available in a timely manner to timely examine for iritis when such is needed as noted. However, there are theoretical advantages if a parent could detect iritis in their J I A child if a slit lamp were available, if they had been trained to use it and recognize iritis cells and flare. METHODS: A portable model of varying iritis severity was developed. Parents of JIA patients were instructed on slit lamp use and then attempted to match unknown models of iritis severity with known training models of varying concentrations of cells and flare. RESULTS: Twelve parents ranked the 5 unknowns with an average summed deviation from expected of 2.2 +/-2 grade levels (out of 12). This was a good and useful degree of training. CONCLUSION: We were able to teach lay adults to match a model of iritis severity on a slit lamp. We would suggest that where needed, they could provide urgent and more convenient and faster diagnosis and treatment of recurrent iritis and also augment recommended scheduled Eye MD screening for iritis in JIA patients providing an effectively higher level of care, quality of life, and reduction in loss of vision for JIA victims at lower cost and greater facility for the patients, their caregivers and society as a whole.

Validated portable pediatric vision screening in the Alaska Bush. A VIPS-like study in the Koyukon.

BACKGROUND: Photoscreening and remote autorefraction showed promise in the urban "Vision in PreSchoolers Study." We transported a comparative screening with confirmation program to a remote part of interior Alaska. METHODS: Eighty children from villages in the Koyukon region received onsite three-pronged vision screening followed by gold-standard confirmatory exams. Each had patched HOTV acuity, photoscreening and Suresight remote autorefraction. RESULTS: There was a high prevalence of amblyopia and vision disorders in these villages. Acuity testing was moderately valid but not useful for children under four years old. Suresight has specificity over 90 percent with sensitivity of 60 percent. Photoscreening had specificity over 95 percent and sensitivity of 70 percent and was better than Suresight for children under age four. CONCLUSION: The Welch Allyn Suresight had similar high validity in the Koyukon as in Vision in Preschoolers (VIPS) and provides immediate, onsite results. Photoscreening, particularly with commercial digital flash cameras and specific interpretation, is a cost effective screening tool particularly for younger children.

Amblyopia detection by camera: Gateway to portable, inexpensive vision screening (calibration and validation of inexpensive, pocket-sized photoscreeners).

BACKGROUND: Photoscreening can allow early detection of amblyopia. The Gateway DV-S20, and similar models of miniature, digital flash cameras, have similar optical dimensions to existing photoscreeners for less than $200. METHODS: These cameras were calibrated on known, threshold amblyogenic refractive errors induced by placing minus and toric contact lenses on a normal subject's left eye. The DV-S20 was then applied to known amblyopic patients. Students under age 7 were vision screened with patched acuity and sequential photoscreeners (MTI and Gateway). RESULTS: The digital cameras and the MTI photoscreeners produced similar magnitude interpretable crescents for amblyopiagenic refractive errors. They had very similar validation with sensitivities of 80-90% and specificities of 98% for serious eye disorders in known patients and school-aged children. CONCLUSION: Combined with careful interpretation, pocket-sized, digital flash cameras provide a portable and inexpensive digital alternative for pediatric photoscreening. A category 3 CPT code (0065T) can be used for this valid, public health technique: Amblyopia Detection By Camera (ADBC).