Should tumbling E go out of date in amblyopia screening? Evidence from a population-based sample normative in children aged 3–4 years

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Abstract

Aims

To determine a normative of tumbling E optotype and its feasibility for visual acuity (VA) assessment in children aged 3-4 years.

Methods

A cross-sectional study of 1756 children who were invited to participate in a comprehensive non-invasive eye exam. Uncorrected monocular VA with crowded tumbling E with a comprehensive ophthalmological examination were assessed. Testability rates of the whole population and VA of the healthy children for different age subgroups, gender, school type and the order of testing in which the ophthalmological examination was performed were evaluated.

Results

The overall testability rate was 95% (92% and 98% for children aged 3 and 4 years, respectively). The mean VA of the first-day assessment (first-VA) and best-VA over 2 days’ assessments was 0.14 logMAR (95% CI 0.14 to 0.15) (decimal=0.72, 95% CI 0.71 to 0.73) and 0.13 logMAR (95% CI 0.13 to 0.14) (decimal=0.74, 95% CI 0.73 to 0.74). Analysis with age showed differences between groups in first-VA (F(3,1146)=10.0; p<0.001; η2=0.026) and best-VA (F(3,1155)=8.8; p<0.001; η2=0.022). Our normative was very highly correlated with previous reported HOTV-Amblyopia-Treatment-Study (HOTV-ATS) (first-VA, r=0.97; best-VA, r=0.99), with 0.8 to 0.7 lines consistent overestimation for HOTV-ATS as described in literature. Overall false-positive referral was 1.3%, being specially low regarding anisometropias of ≥2 logMAR lines (0.17%). Interocular difference ≥1 line VA logMAR was not associated with age (p=0.195).

Conclusions

This is the first normative for European Caucasian children with single crowded tumbling E in healthy eyes and the largest study comparing 3 and 4 years old testability. Testability rates are higher than found in literature with other optotypes, especially in children aged 3 years, where we found 5%–11% better testability rates.

Related collections

Most cited references 23

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The amblyopia treatment study visual acuity testing protocol.

, Raymond T Kraker, R. Blair … (2001)

To evaluate the reliability of a new visual acuity testing protocol for children using isolated surrounded HOTV optotypes. After initial pilot testing and modification, the protocol was evaluated using the Baylor-Video Acuity Tester (BVAT) to present isolated surrounded HOTV optotypes. At 6 sites, the protocol was evaluated for testability in 178 children aged 2 to 7 years and for reliability in a subset of 88 children. Twenty-eight percent of the 178 children were classified as having amblyopia. Using the modified protocol, testability ranged from 24% in 2-year-olds to 96% in 5- to 7-year-olds. Test-retest reliability was high (r = 0.82), with 93% of retest scores within 0.1 logMAR unit of the initial test score. The 95% confidence interval for an acuity score was calculated to be the score +/-0.125 logMAR unit. For a change between 2 acuity scores, the 95% confidence interval was the difference +/-0.18 logMAR unit. The visual acuity protocol had a high level of testability in 3- to 7-year-olds and excellent test-retest reliability. The protocol has been incorporated into the multicenter Amblyopia Treatment Study and has wide potential application for standardizing visual acuity testing in children.

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Visual acuity norms in pre-school children: the Multi-Ethnic Pediatric Eye Disease Study.

Rohit Varma, Stanley Azen, Martin S. Borchert … (2009)

To provide population-based normative data for monocular visual acuity (VA) and interocular differences in VA (IOD) in Black and Hispanic children 30 to 72 months of age without visually significant refractive errors or ophthalmic abnormalities. In a population-based cohort of children in the Multi-Ethnic Pediatric Eye Disease Study, monocular HOTV VA measurements using the Amblyopia Treatment Study protocol were analyzed using continuous and dichotomous outcomes for VA and IOD, after excluding subjects with ophthalmic abnormalities or refractive error. The analysis cohort consisted of 1722 Black and Hispanic children aged 30 to 72 months. Mean logMAR VA improved with age (p < 0.0001) and male gender (p = 0.0008). The proportion of children achieving VA 20/40 or better was associated with age (p < 0.0001), but not ethnicity or gender, and was 81, 94, 99, and virtually 100% in children aged 30 to 35, 36 to 47, 48 to 59, and 60 to 72 months of age, respectively. The most stringent VA threshold that excluded <5% of normal children was 20/63, 20/50, 20/32, and 20/32 for children aged 30 to 35, 36 to 47, 48 to 59, and 60 to 72 months, respectively. Children attending preschool or daycare achieved VA 20/32 more often than those not attending, after age adjustment (p = 0.01), as did children from higher-income families (p = 0.04). There was no association between mean absolute IOD and age (p = 0.45), ethnicity (p = 0.12), or gender (p = 0.19). The proportion of children with an IOD of 0 to 1 lines was higher in males than females (p = 0.02); it did not vary by age (p = 0.06) or ethnicity (p = 0.17). An IOD of 2 or more lines occurred in 6% of normal children. VA test performance in normal pre-school children improves with age. We propose new age-specific thresholds for defining abnormal monocular VA using HOTV optotypes in children between 2 and 5 years of age, for use in screening, clinical practice, and research.

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Whole-population vision screening in children aged 4–5 years to detect amblyopia

Ameenat Lola Solebo, Phillippa M Cumberland, Jugnoo Rahi (2015)

Amblyopia is a neurodevelopmental disorder that affects at least 2% of most populations and can lead to permanently reduced vision if not detected and treated within a specific period in childhood. Whole-population screening of children younger than 5 years is applied in many countries. The substantial diversity in existing programmes reflects their heterogeneous implementation in the absence of the complete evidence base that is now a pre-requisite for instituting screening. The functional importance of amblyopia at an individual level is unclear as data are scarce, but in view of the high prevalence the population-level effect might be notable. Screening of all children aged 4-5 years (eg, at school entry) confers most benefit and addresses inequity in access to timely treatment. Screening at younger ages is associated with increased risk of false-positive results, and at older ages with poor outcomes for children with moderate to severe amblyopia. We suggest that the real-life adverse effects of amblyopia should be characterised and screening and diagnosis should be standardised.

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Author and article information

Journal

Journal ID (nlm-ta): Br J Ophthalmol

Journal ID (iso-abbrev): Br J Ophthalmol

Journal ID (hwp): bjophthalmol

Journal ID (publisher-id): bjo

Title: The British Journal of Ophthalmology

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0007-1161

ISSN (Electronic): 1468-2079

Publication date (Print): June 2018

Publication date (Electronic): 7 October 2017

Volume: 102

Issue: 6

Pages: 761-766

Affiliations

[1 ] Department of Ophthalmology, Hospital de Braga , Braga, Portugal

[2 ] departmentSchool of Medicine , Life and Health Sciences Research Institute (ICVS), University of Minho , Braga, Portugal

[3 ] ICVS/3B’s—PT Government Associate Laboratory , Braga, Braga, Portugal

[4 ] Clinical Academic Center , Braga, Portugal

[5 ] Centro Cirúrgico de Coimbra , Coimbra, Portugal

[6 ] departmentIBILI, Faculty of Medicine , University of Coimbra , Coimbra, Coimbra, Portugal

[7 ] departmentDepartment of Ophthalmology , CHLN , Lisbon, Portugal

Author notes

[Correspondence to ] Dr Sandra Guimaraes, Department of Ophthalmology, Hospital de Braga, Sete Fontes- São Victor, 4710-243 Braga, Portugal; sandraguimaraes.eye@ 123456gmail.com

Article

Publisher ID: bjophthalmol-2017-310691

DOI: 10.1136/bjophthalmol-2017-310691

PMC ID: 5969336

PubMed ID: 28988161

SO-VID: 7f9f8bfc-28a5-4162-bb4e-9fc4a8098bf8

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/