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Use of visual acuity to screen for significant refractive errors in preschool children
Mythili Ilango1, Felicia Christabelle Adinanto1, Kathryn Ailsa Rose1
1Discipline of Orthoptics, Graduate School of Health, Faculty of Health, University of Technology Sydney.
Insights
Visual acuity (VA) effectively detects myopia in preschoolers at the <6/7.5 cutoff. However, VA screening has low sensitivity for astigmatism and hyperopia, posing challenges for early detection of these refractive errors.
Area of Science:
- Ophthalmology
- Pediatric Optometry
- Vision Science
Background:
- Refractive errors are common in preschool children and can impact visual development.
- Early detection of refractive errors is crucial for timely intervention and preventing long-term vision problems.
- Visual acuity (VA) is a common screening tool, but its effectiveness in detecting various refractive errors in young children needs evaluation.
Purpose of the Study:
- To assess the sensitivity and specificity of visual acuity (VA) for detecting refractive errors in preschool children.
- To determine the optimal VA cutoff for identifying myopia, hyperopia, and astigmatism in this age group.
Main Methods:
- A cross-sectional study involving 2332 preschool children (aged 3-6 years) from the Sydney Pediatric Eye Disease Study.
- Comprehensive eye examinations included monocularly tested VA (HOTV test) and cycloplegic refraction.
- Clinically significant refractive errors were defined as myopia ≤-1.00D, hyperopia ≥+3.00D, and astigmatism ≥+1.00D.
Main Results:
- VA demonstrated high sensitivity (82.4%) and specificity (83.9%) for detecting myopia at the <6/7.5 cutoff.
- Sensitivity for detecting astigmatism and hyperopia was low across all VA cutoffs (<6/12, <6/9, <6/7.5), even for high hyperopia.
- Receiver Operating Characteristic (ROC) analysis showed the area under the curve (AUC) for detecting significant refractive error was highest for the <6/7.5 cutoff (0.708).
Conclusions:
- Visual acuity testing at a <6/7.5 cutoff is a valid method for detecting myopia in preschool children.
- Astigmatism and hyperopia, including high levels, are not consistently detected by VA screening in this age group.
- Screening preschool children for all types of significant refractive errors using VA alone presents a diagnostic challenge.
Abstract:
Purpose: To determine the sensitivity and specificity of visual acuity (VA) for the detection of refractive errors in preschool children from the Sydney Pediatric Eye Disease Study. Methods: Data from both eyes were pooled for a total of 2332 observations. Children aged 3-6 years had a comprehensive eye examination including VA (monocularly tested using the Electronic Visual Acuity HOTV test) and cycloplegic (cyclopentolate 1%) refraction using the table-mounted autorefractor (RK-F1 Auto Ref-Keratometer; Canon, Tokyo, Japan). Clinically significant refractive error was defined as: Myopia ≤-1.00D, Hyperopia ≥+3.00D (Moderate Hyperopia ≥+3.00D - <+5.00D, High Hyperopia ≥+5.00D) and Astigmatism ≥+1.00D. VA cutoffs used were <6/12, <6/9 and <6/7.5. Ethics approval was obtained by the Human Research Committee, University of Sydney and adheres to the tenants of the Declaration of Helsinki. Results: There was low sensitivity for detection of myopia at a cutoff of <6/12 (41.2%), with moderate sensitivity at <6/9 (58.8%), and high sensitivity (82.4%) and specificity (83.9%) at <6/7.5. Across the three cutoffs, there was low sensitivity for detection of astigmatism (<6/12: 14.7%, <6/9: 22.5%, <6/7.5: 54.3%) and hyperopia (<6/12: 13.8%, <6/9: 21.1%, <6/7.5: 52.3%). This was particularly true for those with moderate levels of hyperopia (sensitivity <6/12: 5.0%, <6/9: 8.8%, <6/7.5: 45.0%). High hyperopia was better detected, particularly at the <6/7.5 cutoff (72.4%); however, had low sensitivity at <6/12 (37.9%) and <6/9 (55.2%). ROC analysis for detection of clinically significant refractive error revealed an area under the curve (AUC) of 0.708 (p < .001) for <6/7.5. This was comparatively lower at <6/9 (AUC = .606) and <6/12 (AUC = .572, all p < .001). Conclusion: VA was valid for detecting myopia at the <6/7.5 cutoff for preschool children. Astigmatism and hyperopia, even at high levels, did not consistently impact VA. This remains a challenge for detecting significant refractive errors when screening in preschool children.
