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Age-based refinement of referral criteria for photoscreening
1Department of Ophthalmology and Visual Sciences, Vanderbilt University School of Medicine, 8000 Medical Center East, Nashville, TN 37232-8808, USA.
Insights
Preschool children under age 2 have low photoscreening pass rates due to high referral and unreadable rates, with rare treatment. Older children (≥2 years) referred for astigmatism have a higher likelihood of significant eye conditions.
Area of Science:
- Ophthalmology
- Pediatric Optometry
- Public Health Screening
Background:
- Photoscreening is widely used for early detection of vision impairments in preschool children.
- Astigmatism is a common refractive error that can lead to amblyopia if untreated.
- Current referral criteria may lead to over-referral of young children with low likelihood of significant pathology.
Purpose of the Study:
- To evaluate the examination outcomes of preschool children referred for suspected astigmatism via photoscreening.
- To determine the effectiveness of current referral criteria and explore adjustments for improved accuracy.
- To analyze the diagnostic yield of photoscreening in different age groups of preschool children.
Main Methods:
- A cross-sectional study and noncomparative case series involving 31,053 preschool children.
- Analysis of referral rates, unreadable photograph rates, and predictive value positive (PVP) of photoscreening referrals.
- Examination of treatment plans and outcomes for referred children, stratified by age and suspected condition.
Main Results:
- Referral rates were higher in younger children (6-11 months) compared to older children.
- Unreadable photograph rates decreased significantly with age, from 12.1% in 6-11 month olds to 1.1% in 4-year-olds.
- The PVP for astigmatism referrals was low in children under 1 year (25-30%), increasing to 67% for children ≥3 years examined by pediatric ophthalmologists. Conditions like strabismus and anisometropia were diagnosed in older children.
Conclusions:
- Photoscreening has a lower pass rate in children under 1 year due to higher referral and unreadable rates, with infrequent detection of significant pathology requiring intervention.
- Older children (≥2 years) referred for astigmatism demonstrate a higher probability of significant eye conditions.
- Adjusting referral criteria to de-emphasize astigmatism-only referrals in very young children (under 2 years) may be warranted, while maintaining referrals for other potentially amblyogenic factors.
Objective:
To evaluate examination results from preschool children referred from photoscreening, and to adjust referral criteria for suspected astigmatism.
Design:
Cross-sectional study and noncomparative case series.
Participants:
Thirty-one thousand fifty-three preschool children.
Methods:
Analysis of (1) referral rate and unreadable photograph rate for all children screened, (2) examination results and treatment plan for all children referred for suspected astigmatism, and (3) examination results and treatment for all referred children aged less than 1 year.
Main Outcome Measures:
Referral rate, unreadable photograph rate, predictive value positive, treatment plan.
Results:
The referral rate dropped from 7.8% for children 6 to 11 months to 5.3% for all other ages. The unreadable photograph rate declined exponentially from 12.1% for children aged 6 to 11 months to 1.1% for children aged 4 years. The predictive value positive of a photoscreen referral for all children in the 6- to 11-month age group was 30%, and only 12 of the 94 referred children were treated. The predictive value positive for children less than 1 year of age referred with suspected astigmatism was even lower (25%), and only one child in this age group was treated. The predictive value positive increased with age, and a higher percentage of older children were treated. For children at least 3 years old referred for suspected astigmatism, the predictive value positive was 67% when the examination was performed by a pediatric ophthalmologist. Strabismus, anisometropia, and high hypermetropia were diagnosed in such patients age 2 and older but never in younger children.
Conclusions:
Children less than 1 year of age have a much lower pass rate from photoscreening than do older children because of a higher referral rate and higher unreadable rate in this age group. When these children are examined, significant pathosis is usually absent, and intervention is rarely initiated. Most children age 2 and older who are referred for suspected astigmatism have a high likelihood of significant pathosis. It is probably unnecessary to examine children less than age 2 when their photoscreening suggests only astigmatism; conversely, referrals should still be provided for these children when their screening suggests other potentially amblyogenic factors.