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Updated: Aug 1, 2025
Author Spotlight: An Automated Method for Assessing Visual Acuity in Infants and Toddlers Using an Eye-Tracking System
Published on: March 17, 2023
Diagnostic Accuracy of Online Visual Acuity Testing of Paediatric Patients
Sally L Painter1, Ruth Hamilton2, Iain A T Livingstone3
1Birmingham Children's Hospital, UK.
Insights
Remote visual acuity testing in children showed good agreement with hospital tests, proving feasible even with smartphones. Further research is needed on home vision testing
Area of Science:
- Ophthalmology
- Pediatric Optometry
- Telemedicine
Background:
- The COVID-19 pandemic necessitated remote assessment of children's visual acuity.
- Traditional hospital-based eye services faced challenges in accessibility and continuity of care.
Purpose of the Study:
- To evaluate the agreement between hospital-based clinical visual acuity testing and clinician-led home-based visual acuity testing in children.
- To determine the feasibility and accuracy of remote visual acuity assessment methods.
Main Methods:
- Comparison of routine hospital-based acuities with online, orthoptist-supervised home-based visual acuities in 50 children (aged 2-16).
- Assessment of agreement using intra-class correlation and Bland-Altman plots.
- Evaluation of test-retest agreement for repeated home visual acuity tests.
Main Results:
- Good agreement was found between hospital and home testing for binocular acuity (LOA ±0.32 logMAR) and excellent agreement for monocular acuity (LOA ±0.35 logMAR).
- Test-retest agreement for monocular acuity at home was excellent (LOA ±0.14 logMAR).
- Smartphone testing was feasible, though limitations included inability to verify test distance and device calibration.
Conclusions:
- Clinician-supervised home-based visual acuity testing demonstrates good to excellent agreement with hospital-based testing.
- Remote visual acuity assessment is a feasible and accurate alternative, particularly for pediatric populations.
- Further investigation into the precision, acceptability, and economic/environmental impact of home vision testing is warranted.
Background/Objectives:
Remote assessment of children's visual acuity became necessary during the COVID-19 pandemic. This study aimed to assess the extent of agreement between hospital-based clinical testing and clinician-led home-based testing.
Subjects/Methods:
50 children aged 2-16 (median 8) years attending hospital eye services at two UK hospitals had routine hospital-based acuities compared with subsequent online, orthoptist-supervised home visual acuities. Agreement was assessed using intra-class correlation and Bland-Altman plots, as was test-retest (TRT) agreement of two, repeated home acuity tests.
Results:
Monocular acuities tested at hospital and at home were obtained from all 50 children; 33 also had binocular acuities in both settings and 35 had acuities retested immediately at home. Most children were tested at home using a computer or tablet; two were tested with a smartphone. No mean test differences were found for hospital vs home testing (-0.004 (95% CI -0.06-0.05) and -0.008 (95% CI -0.04-0.03) for binocular and monocular testing, respectively). Limits of agreement (LOAs) were ±0.32 and ±0.35 logMAR for binocular and monocular testing, respectively. LOAs for inter-ocular acuity differences (hospital vs home) were -0.15-0.25 logMAR. TRT monocular acuity agreement was excellent, with an LOA of ±0.14 logMAR.
Conclusions:
We found good (binocular) and excellent (monocular) agreement between hospital and home acuity testing. LOAs were in keeping with multiple changes between measures (test; setting; time; tester) and a cohort including patients as young as two years old. Even smartphone testing proved feasible. Inability of the supervising orthoptist to check test distance or device calibration/orientation was a limitation, likely contributing to the breadth of LOAs. Home vision testing is feasible and accurate, but its precision, acceptability, health economic impact and carbon impact require more attention.
