Unexpectedly high prevalence of asthenopia in Australian school children identified by the CISS survey tool.

BACKGROUND: To date there have been few systematic attempts to establish the general prevalence of asthenopia in unselected populations of school-aged children. Thus, the aim of this study was to determine whether the incorporation of Borsting et al's 2003 Revised Convergence-Insufficiency Symptom Survey (CISS) into a general school vision screening could aid in the identification of children with visual discomfort and indicate the need for further investigation. METHODS: Vision screening of an unselected middle school population investigated and analysed the incidence of self-reported nearwork-related visual discomfort via the CISS along with distance and near visual acuities plus non-cycloplegic autorefraction using a Shin-Nippon NVision-K 5001. RESULTS: Of the 384 unselected students approached in Grades 6-9, 353 participated (92.2%, mean 13.2 ± 1.4 years). The mean CISS score for the population without amblyopia and/or strabismus (96.0% of all students) was 16.8 ± 0.6, i.e., 45% of students in this cohort had CISS scores greater than one standard deviation above the mean found by Borsting et al. in 2003 during their validation study of the CISS on 9 to 18 year old children without binocular anomalies. Regression analyses indicated significantly higher (p < 0.001) mean CISS scores for the 3.2% who were hyperopes ≥ + 2.00D by non-cycloplegic autorefraction (27.7 ± 14.7) and for those who were amblyopic (24.3 ± 6.6) or strabismic (34.0 ± 9.8). The mean CISS score of 31.6 ± 9.0 for non-amblyopic/strabismic students having near vision poorer than 0.1 LogMAR was significantly higher (p < 0.001) than for those with good acuity. CONCLUSION: The most important finding of this study was the high incidence of asthenopia in an unselected population and that refractive status per se was not a major contributor to CISS scores. The results highlight the usefulness of the CISS questionnaire for assessment of visual discomfort in school vision screenings and the need for future exploration of near binocular vision status as a potential driver of asthenopia in school students, especially given current trends for frequent daily use of computers and handheld devices and necessarily prolonged accommodative-convergence effort at near, both at school and at home.

Populations Norms for "SLURP"-An iPad App for Quantification of Visuomotor Coordination Testing.

Currently the integrity of brain function that drives behavior is predominantly measured in terms of pure motor function, yet most human behavior is visually driven. A means of easily quantifying such visually-driven brain function for comparison against population norms is lacking. Analysis of eye-hand coordination (EHC) using a digital game-like situation with downloadable spatio-temporal details has potential for clinicians and researchers. A simplified protocol for the Lee-Ryan EHC (Slurp) Test app for iPad® has been developed to monitor EHC. The two subtests selected, each of six quickly completed items with appeal to all ages, were found equivalent in terms of total errors/time and sensitive to developmental and aging milestones known to affect EHC. The sensitivity of outcomes due to the type of stylus being used during testing was also explored. Populations norms on 221 participants aged 5 to 80+years are presented for each test item according to two commonly used stylus types. The Slurp app uses two-dimensional space and is suited to clinicians for pre/post-intervention testing and to researchers in psychological, medical, and educational domains who are interested in understanding brain function.

Does the virtual refractor patient-simulator improve student competency when refracting in the consulting room?

BACKGROUND: The use of patient simulators in ophthalmic education appears limited. This study examines the effects of the addition of the 'Virtual Refractor' patient simulator learning activity into a short unit preparing students to determine the power of the spectacle lenses required by patients in a clinic. METHODS: Twenty-four year one optometry students were randomly assigned to either the simulator-intervention group (n = 12) or the non-intervention group. All students attended tutorials on refraction and the use of a refractor-head. Simulator-intervention students additionally attended a tutorial on the Virtual Refractor. All answered a questionnaire concerning time spent studying, perceived knowledge and confidence. Twenty-four short-sighted patients were recruited. Two refractions per student were timed and the accuracy compared with that of an experienced optometrist. RESULTS: Ten students from each group completed the study. Students who used the simulator were significantly (p < 0.05) more accurate at a clinical level (within 0.22 ± 0.22 DS, 95 per cent CI 0.12-0.32) than those who did not (within 0.60 ± 0.67 DS, 95 per cent CI 0.29-0.92) and 13 per cent quicker (4.7 minutes, p < 0.05). Students who used the simulator felt more knowledgeable (p < 0.05) and confident (p < 0.05), but had spent more time reading about refraction and practised on the Virtual Refractor at home for 5.7 ± 1.3 hours. CONCLUSION: The Virtual Refractor has many features of high-fidelity medical simulation known to lead to effective learning and it also offers flexible independent learning without a concomitant increase in the student time-burden. The improved accuracy and speed on first patient encounters found in this study validates the use of this patient simulator as a useful bridge for students early in training to successfully transfer theoretical knowledge prior to entering the consulting room. The translational benefits resulting from compulsory learning activities on a patient simulator can lead to reduced demands on infrastructure and clinical supervision.

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.

Consensus statement on the immunohistochemical detection of ocular lymphatic vessels.

There is currently considerable controversy about existence and classification of "lymphatic vessels" in the eye. Some of the confusion is certainly caused by inappropriate use (or nonuse) of the correct immunohistochemical markers. Many experts in the field expressed the need for a consensus statement, and, in this perspective, authors offer arguments and solutions to reliably continue with immunohistochemical ocular lymphatic research.

Development of a novel approach to the assessment of eye-hand coordination.

BACKGROUND: Current methods to measure eye-hand coordination (EHC) have been widely applied in research and practical fields. However, some aspects of the methods, such as subjectivity, high price, portability, and high appraisal contribute to difficulties in EHC testing. NEW METHODS: The test was developed on an Apple iPad(®) and involves tracing up to 13 shapes with a stylus pen. The time taken to complete each trace and the spatial accuracy of the tracing is automatically recorded. The difficulty level for each shape was evaluated theoretically based on the complexity and length of outline. Ten adults aged 31.5±7.8 years and five children aged 9.4±1.1 years with normal vision participated. RESULTS: In adults, the time taken to trace and number of errors significantly decreased from the first to the second attempt (p<0.05) but not thereafter, suggesting a learning effect with repeatability after a practice attempt. Time taken and number of errors in children were both higher in monocular than binocular viewing conditions (p=0.02 and p<0.01, respectively) while adults' performance was similar in both viewing conditions. COMPARISON WITH EXISTING METHODS: Existing EHC tests are subjective in clinics and require higher skills and cost in research, and measure gross EHC. This novel test has been developed to address some of the limitations. CONCLUSIONS: The test is engaging for children and adults and is an objective method with potential for the assessment of fine EHC, suited to clinic-based and research use in ophthalmic or brain trauma settings, and in developmental disorders.

Refractive errors in students from Middle Eastern backgrounds living and undertaking schooling in Australia.

BACKGROUND: Environmental factors associated with schooling systems in various countries have been implicated in the rising prevalence of myopia, making the comparison of prevalence of refractive errors in migrant populations of interest. This study aims to determine the prevalence of refractive errors in children of Middle Eastern descent, raised and living in urban Australia but actively maintaining strong ties to their ethnic culture, and to compare them with those in the Middle East where myopia prevalence is generally low. METHODS: A total of 354 out of a possible 384 late primary/early secondary schoolchildren attending a private school attracting children of Middle Eastern background in Melbourne were assessed for refractive error and visual acuity. A Shin Nippon open-field NVision-K5001 autorefractor was used to carry out non-cycloplegic autorefraction while viewing a distant target. For statistical analyses students were divided into three age groups: 10-11 years (n = 93); 12-13 years (n = 158); and 14-15 years (n = 102). RESULTS: All children were bilingual and classified as of Middle Eastern (96.3 per cent) or Egyptian (3.7 per cent) origin. Ages ranged from 10 to 15 years, with a mean of 13.17 ± 0.8 (SEM) years. Mean spherical equivalent refraction (SER) for the right eye was +0.09 ± 0.07 D (SEM) with a range from -7.77 D to +5.85 D. The prevalence of myopia, defined as a spherical equivalent refraction 0.50 D or more of myopia, was 14.7 per cent. The prevalence of hyperopia, defined as a spherical equivalent refraction of +0.75 D or greater, was 16.4 per cent, while hyperopia of +1.50 D or greater was 5.4 per cent. A significant difference in SER was seen as a function of age; however, no significant gender difference was seen. CONCLUSIONS: This is the first study to report the prevalence of refractive errors for second-generation Australian schoolchildren coming from a predominantly Lebanese Middle Eastern Arabic background, who endeavour to maintain their ethnic ties. The relatively low prevalence of myopia is similar to that found for other metropolitan Australian school children but higher than that reported in the Middle East. These results suggest that lifestyle and educational practices may be a significant influence in the progression of myopic refractive errors.

Spatial and temporal dissociation of AQP4 and Kir4.1 expression during induction of refractive errors.

PURPOSE: Spatial co-localization of aquaporin water channels (AQP4) and inwardly rectifying potassium ion channels (Kir4.1) on the endfeet regions of glial cells has been suggested as the basis of functionally interrelated mechanisms of osmoregulation in brain edema. The aim of this study was to investigate the spatial and temporal changes in the expression of AQP4 and Kir4.1 channels in an avascular retina during the first week of the optical induction of refractive errors. METHODS: Three-day-old hatchling chicks were randomly assigned to three groups and either did not wear lenses or were monocularly goggled with +/-10D lenses for varying times up to 7 days before biometric assessment. Retinal tissue was prepared either for western blot analysis to show the presence of the AQP4 and Kir4.1 protein in the chick retina or for immunolocalization using AQP4 and Kir4.1 antibodies to determine the regional distribution and intensity of labeling during the induction of refractive errors. RESULTS: As expected, ultrasonography demonstrated that all eyes showed rapid elongation post hatching. Negative lens-wearing eyes elongated faster than fellow eyes or normal non goggled eyes and became progressively more myopic with time post lensing. Positive lens-wearing eyes showed reduced ocular growth compared to normal controls and developed a hyperopic refraction. Quantitative immunohistochemistry revealed the upregulation of AQP4 channel expression on Müller cells in the retinal nerve fiber layer during the first 2 days of negative lens wear. Kir4.1 channel upregulation in the inner plexiform layer was only found on day 4 of positive lens wear during the development of refractive hyperopia. CONCLUSIONS: These results indicate that the expression of AQP4 and Kir4.1 channels on Müller cells is associated with the changes in ocular volume seen during the induction of refractive errors. However, the sites of greatest expression and the temporal pattern of the upregulation of AQP4 and Kir4.1 were dissimilar, indicating a dissociation of AQP4 and Kir4.1 function during refractive error development. Increased AQP4 expression in the nerve fiber layer is suggested to contribute to the rapid axial elongation and movement of fluid into the vitreous cavity in the presence of minus lenses; whereas, upregulation of Kir4.1 channels appears to play a role in limiting axial elongation in the presence of plus lenses.

A role for aquaporin-4 in fluid regulation in the inner retina.

Many diverse retinal disorders are characterized by retinal edema; yet, little experimental attention has been given to understanding the fundamental mechanisms underlying and contributing to these fluid-based disorders. Water transport in and out of cells is achieved by specialized membrane channels, with most rapid water transport regulated by transmembrane water channels known as aquaporins (AQPs). The predominant AQP in the mammalian retina is AQP4, which is expressed on the Müller glial cells. Müller cells have previously been shown to modulate neuronal activity by modifying the concentrations of ions, neurotransmitters, and other neuroactive substances within the extracellular space between the inner and the outer limiting membrane. In doing so, Müller cells maintain extracellular homeostasis, especially with regard to the spatial buffering of extracellular potassium (K+) via inward rectifying K+ channels (Kir channels). Recent studies of water transport and the spatial buffering of K+ through glial cells have highlighted the involvement of both AQP4 and Kir channels in regulating the extracellular environment in the brain and retina. As both glial functions are associated with neuronal activation, controversy exists in the literature as to whether the relationship is functionally dependent. It is argued in this review that as AQP4 channels are likely to be the conduit for facilitating fluid homeostasis in the inner retina during light activation, AQP4 channels are also likely to play a consequent role in the regulation of ocular volume and growth. Recent research has already shown that the level of AQP4 expression is associated with environmentally driven manipulations of light activity on the retina and the development of myopia.

Orienteers with poor colour vision require more than cunning running.

BACKGROUND: Highly detailed colour coded maps are used in the sport of orienteering to enable competitors to navigate from one check point to another and to provide guidance on the nature of the terrain to be traversed. The colours are defined by the International Orienteering Foundation (IOF) and are said to have been chosen so they will not be confused by competitors who have abnormal colour vision. However, there are anecdotal reports that individuals with colour vision defects do have problems with the colour coding. METHOD: A Minolta Spectrophotometer CM-503i was used to measure the CIE x,y chromaticity co-ordinates and the reflectances of the standard colours recommended by the IOF for the colour coding of orienteering maps, as well as the colours on two maps used in orienteering events. RESULTS: Four pairs of IOF standard colours are likely to be confused by protan observers and four pairs by deutan observers. There were three pairs of colours likely to be confused by both deutan and protan observers on one of the competition maps and one pair likely to be confused by protan observers on the other map. Some of the colours on the actual competition maps differed noticeably from the standard IOF colours. DISCUSSION: Orienteers with more severe forms of abnormal colour vision are likely to be disadvantaged by their inability to differentiate some colours used on orienteering maps. The IOF should choose different colours that are less likely to be confused or should employ a redundant code (such as a pattern or texture). There is need for better quality control of the colours of competition maps to ensure they do conform to the IOF standard colours.

A role for aquaporin-4 during induction of form deprivation myopia in chick.

PURPOSE: Aquaporins (AQP) form a family of specialized water channels known to transport water across cell membranes and reduce osmotic gradients. The isoform AQP4 is highly expressed in the astroglia of the brain and Müller cells in the retina. In the brain, AQP4 play a role in the control of cerebral edema by shunting excess fluid into blood vessels and by upregulating during conditions of hyperosmolarity. Thus, on the basis of the hyperosmolarity seen across the retina and choroid of hatchling chickens made myopic by form deprivation (FD), we predicted an upregulation of retinal AQP4 expression during induction of myopia. METHODS: Two-day-old hatchling chicks were monocularly form-deprived for 48, 72, or 96 h, and then after biometric assessment, the eyes of these animals and the normal controls of the same age were enucleated. Retinal tissue was prepared either for western blot analysis to show the presence of the AQP4 protein in the chick retina or for immunolocalization using polyclonal AQP4 antibodies to determine regional distribution and intensity of labeling during the induction of form deprivation myopia (FDM). RESULTS: As expected, ultrasonography demonstrated that all post hatchling eyes showed rapid elongation with occluded eyes elongating faster than fellow eyes or normal controls and becoming progressively more myopic with the duration of visual deprivation. Western blot analyses revealed an approximately 30 kDa band immunoreactive for AQP4 protein and confirmed the presence of AQP4 in chicks. Immunohistochemical staining showed the greatest positive immunoreactivity for antibodies to AQP4 in the inner retina along the vitreoretinal interface, nerve fiber layer, ganglion cell layer, and inner plexiform layer in all animals. The control eyes showed relatively constant levels of AQP4 expression until day 5 after which the level appeared to decrease. By comparison, positive AQP4 immunoreactivity in the nerve fiber layer increased significantly over the first 48 h in form-deprived eyes and in fellow eyes and then decreased over the next 48 h but not to the level of expression in the normal untreated eyes. CONCLUSIONS: This is the first study to demonstrate the presence of AQP4 protein in the chick retina and to associate AQP4 expression in the inner retina with the initiation of form deprivation and the period of fastest axial elongation. This increased expression of AQP4 channels near the vitread border during the time of rapid growth suggests a role for AQP4 as a conduit for movement of retinal fluid into the vitreous in form-deprived chicks.

Ionic control of ocular growth and refractive change.

The physiological mechanisms underlying the abnormal vitreal and ocular growth and myopic refractive errors induced under conditions of visual form deprivation in many animal species, including humans, are unknown. This study demonstrates, using energy dispersive x-ray microanalysis, a systematic pattern of changes in the elemental distribution of K, Na, and Cl across the entire retina in experimental form deprivation myopia and in the 5 days required for refractive normalization after occluder removal. In our report we link the ionic environment associated with physiological activity of the retina under a translucent occluder to refractive change and describe large but reversible environmentally driven increases in potassium, sodium, and chloride abundances in the neural retina. Our results are consistent with the notion of ionically driven fluid movements as the vector underlying the myopic increase in ocular size. New treatments for myopia, which currently affects nearly half of the human population, may result.

Little evidence for an epidemic of myopia in Australian primary school children over the last 30 years.

BACKGROUND: Recently reported prevalences of myopia in primary school children vary greatly in different regions of the world. This study aimed to estimate the prevalence of refractive errors in an unselected urban population of young primary school children in eastern Sydney, Australia, between 1998 and 2004, for comparison with our previously published data gathered using the same protocols and other Australian studies over the last 30 years. METHODS: Right eye refractive data from non-cycloplegic retinoscopy was analysed for 1,936 children aged 4 to 12 years who underwent a full eye examination whilst on a vision science excursion to the Vision Education Centre Clinic at the University of New South Wales. Myopia was defined as spherical equivalents equal to or less than -0.50 D, and hyperopia as spherical equivalents greater than +0.50 D. RESULTS: The mean spherical equivalent decreased significantly (p < 0.0001) with age from +0.73 +/- 0.1D (SE) at age 4 to +0.21 +/- 0.11D at age 12 years. The proportion of children across all ages with myopia of -0.50D or more was 8.4%, ranging from 2.3% of 4 year olds to 14.7% of 12 year olds. Hyperopia greater than +0.50D was present in 38.4%. A 3-way ANOVA for cohort, age and gender of both the current and our previous data showed a significant main effect for age (p < 0.0001) but not for cohort (p = 0.134) or gender (p = 0.61). CONCLUSIONS: Comparison of our new data with our early 1990s data and that from studies of over 8,000 Australian non-clinical rural and urban children in the 1970's and 1980's provided no evidence for the rapidly increasing prevalence of myopia described elsewhere in the world. In fact, the prevalence of myopia in Australian children continues to be significantly lower than that reported in Asia and North America despite changing demographics. This raises the issue of whether these results are a reflection of Australia's stable educational system and lifestyle over the last 30 years.

Changes in ocular accommodation when shifting between global and local attention.

BACKGROUND: The link between cognitive changes in attentional focus and the physiological parameters of the eye is not well understood. The aim of the current work was to examine the role of ocular accommodation, that is, the process of changing the shape of the crystalline lens in order to focus an image onto the retina, in active shifts of visual attention between global and local information. METHOD: Ten adult participants (aged 19 to 27) viewed sequences of complex global/local figures presented at the same location. They were asked to identify either a global or local red target letter and to look for either a global or local letter x (probe) in the sequence following. Target and probe items were separated by a temporal gap of approximately one second. Refraction was measured using a Canon Autorefractor R1 at the time of target appearance and again at the time of probe presentation. Particular interest was paid to trials where participants were required to shift attention either from a local to global level or in the reverse direction. The difference between the two measurements of refraction gave a 'change score' which provided an indication of the change of accommodation. RESULTS: No significant change in refraction was observed when shifting from the local to the global condition. A mean change in refraction of -0.128 dioptres was observed for the global to local condition. The 95 per cent confidence interval for this difference did not overlap zero, indicating a significant change in refraction, which was attributed to an increase in accommodation. DISCUSSION: The results suggest that while a change in accommodation occurs in shifting attention from the global to the local aspect of the complex figures, a similar change is not observed in the reverse direction. These results are consistent with the hypothesis that it is more difficult to restrict attentional focus than it is to widen it.

Structural and elemental evidence for edema in the retina, retinal pigment epithelium, and choroid during recovery from experimentally induced myopia.

PURPOSE: The purpose of this study was to monitor temporal changes in the retina, retinal pigment epithelium (RPE), and choroid of chick eyes using biometric, ultrastructural, and elemental microanalysis techniques as a means of visualizing more detailed signs of the physiological processes underlying choroidal expansion and refractive normalization during recovery from form deprivation. METHODS: Axial dimensions and refractions were measured on form-deprived and fellow eyes of 117 experimental chickens reared with monocular translucent occlusion from days 1 to 15 and given different lengths of visual experience (T = 0-144 hours) before death. Tissue was analyzed ultrastructurally by electron microscopy and relative sodium (Na) and chloride (Cl) ion abundances, by using x-ray microanalysis to determine changes in the presence of these indicators of tissue hydration. RESULTS: Refractive error decreased from more than 20 D of myopia almost linearly over the first 144 hours after occlusion. Concurrent changes in thickness in the retina, RPE, and choroid were seen as a series of thickness increases and edema, which returned to normal thickness, first in the retina, and did not reach maximum until 3 days after occluder removal in the choroid. In freeze-dried tissue, Na and Cl ion concentrations were greatest in the RPE photoreceptor outer segments and extravascular choroid at T = 0, decreasing toward fellow eye levels by T = 48 in the RPE and choroid. Na and Cl ion abundances in the frozen lymph of choroidal lymphatics were nearly at control levels (T = 0) and increased later as the vessels became more distended after the extravascular edema became significant. CONCLUSIONS: The results suggest that occluder removal induces edema across the retina and choroid and that this fluid may be the vector eliciting choroidal expansion during recovery from form deprivation possibly driven by the hyperosmolarity in the choroid, RPE, and photoreceptor outer segments that accompanies deprivation.

Prevalence of myopia among primary school children in eastern Sydney.

BACKGROUND: Worldwide there is concern that the prevalence of myopia is increasing but the prevalence of myopia in Australian school children has not been analysed in detail. This study examines the prevalence of refractive errors in a large unselected population of primary school children in the eastern suburbs of Sydney. METHODS: Children visiting the Vision Education Centre at the School of Optometry and Vision Science, University of New South Wales, on a school excursion during the first half of the 1990s were refracted by non-cycloplegic retinoscopy. Spherical equivalents were computed and analysis of variance carried out. RESULTS: There were 1,459 boys and 1,076 girls in the study, a total of 2,535 children of whom approximately 40 per cent were born overseas or were first generation Australians. Overall, there was no significant difference in refractive error between girls and boys, although there were age/gender interactions with older girls exhibiting more hyperopia than boys. The refractive error ranged from -0.25 to +1.25 D spherical equivalent in 87.3 per cent of children. Mean spherical equivalent for the group was +0.50 +/- 0.82 D. There was a significant shift (p < 0.001) towards increasing myopia with age. The prevalence of myopia greater than -0.50 D rose from 1.0 per cent of four-year-olds to 8.3 per cent of 12-year-olds. CONCLUSIONS: The prevalence of myopia found in a large multi-ethnic group of non-clinical primary school children in eastern Sydney is lower than expected from other studies in the USA and Asia. Compared with Australian data from the 1970s and 1980s, only a weak increase in the prevalence of myopia is revealed.