The effect of mode of delivery on refractive errors in preschool children

Hartmann–Shack images taken from an archived collection of SureSight refractive measurements of pre-school children in Oxford County, Ontario, Canada were retrieved and re-analyzed. Higher-order aberrations were calculated over the age range of 3 to 6 years. These higher-order aberrations were compared with respect to magnitudes of ametropia. Subjects were classified as emmetropic (range −0.5 to + 0.5D), low hyperopic (+ 0.5 to +2D) and high hyperopic (+2D or more) based upon the resulting spherical equivalent. Higher-order aberrations were found to increase with higher levels of hyperopia (p < 0.01). The strongest effect was for children showing more than +2.00D of hyperopia. The correlation coefficients were small in all of the higher-order aberrations; however, they were significant (p < 0.01). These analyses indicate a weak association between refractive error and higher-order aberrations in pre-school children.

Early detection and treatment of amblyogenic conditions such as high refractive errors and anisometropia can help prevent the development of amblyopia. The traditional gold standard for the determination of refractive error in pre-school children is retinoscopy. Difficulties with retinoscopy in pre-school children have led to the development of autorefractors that can be free of operator bias and can be used by lay individuals. The Nikon Retinomax Plus handheld autorefractor has proven to be reliable for quick and accurate assessments of refractive errors in children. The Welch Allyn SureSight Vision Screener is a relatively new handheld autorefractor. The present study compares the results of measurements with the Retinomax Plus and the SureSight to the results of cycloplegic retinoscopy in pre-school children. Thirty-five children ranging in age from 3 to 5 years old were subjects. Any subjects with strabismus, amblyopia, nystagmus, or ocular disease were excluded. Refractive error was assessed 30 min after the application of a cycloplegic spray. Both autorefractors showed moderate agreement with cycloplegic retinoscopy results for measurement of spherical equivalent and cylinder power. In addition, the SureSight and the Retinomax Plus sphere and cylinder results showed moderate agreement with each other. Although the mean differences of the spherical equivalents determined were minimal, the 95% confidence intervals were large, which limits the value of the data obtained from each instrument. Even though the Retinomax Plus and the SureSight appear to agree with each other and with the results of cycloplegic retinoscopy for determining sphere and cylinder power, interpretation of the data should be considered as screening only because the actual magnitude of sphere and cylinder may vary from the actual magnitude. These results suggest that either device may be useful only as screening tools for assessing refractive error in pre-school children.

Preschool age is a critical phase in children's visual development. Refractive errors such as myopia, hypermetropia, and astigmatism often go undetected due to limited communication abilities in young children. Early detection is essential to prevent negative impacts on growth and learning achievement. The Lea Symbols Test is an effective visual screening method, especially for children who have not yet learned to read. Objective: This study aims to determine the prevalence and types of refractive errors in preschool children in Sawah Baru Subdistrict, South Tangerang, using the Lea Symbols Test. Method: This is a descriptive quantitative study using a survey approach. The sample consisted of 123 children aged 3–7 years from three kindergartens in the area. Visual acuity was assessed using the Lea Symbols chart, followed by subjective refraction using trial lenses. Data were analyzed univariately. Results: The findings showed that 38.2% of children had refractive errors in the right eye and 40.7% in the left eye. Myopia was the most common type (17.9%), followed by astigmatism (9.8%) and hypermetropia (8.1%). Most respondents were aged 5–6 years. The Lea Symbols Test proved effective in identifying visual acuity in early childhood. Conclusion: The prevalence of refractive errors in preschool children is relatively high, with myopia being the most common. Routine eye examinations and parental education are essential for early detection and management.

Purpose: The purpose of this study was to determine the prevalence of ocular morbidity in preschool children in Anganwadis of Pune. Methods: All preschool children from Anganwadi in the area of Vishrantwadi and Yerawada in Pune city, western India, in the age group 36 to &lt;72 months, underwent comprehensive eye examination in October 2019–February 2020: visual acuity estimation of each eye separately, slit-lamp examination, cycloplegic refraction, orthoptic evaluation, and fundoscopy. Prior to screening, an informed written consent form was taken from their parents and class teacher. All children needing optical or medical care were provided the same. Results: We examined 1341 children (aged 3 to &lt;6 years, mean: 3.85 ± 1.0) in 36 Anganwadis, and 693 (51.7%) were girls; 81 (6%) children were detected to have ocular morbidities. There were refractive error in 42 (3.1%), strabismus 8 (0.6%), disorder of lid and adnexa 11 (0.8%), allergic conjunctivitis 2 (0.15%), bacterial conjunctivitis 3 (0.2%), viral conjunctivitis 2 (0.15%), corneal opacity 3 (0.2%), nystagmus 4 (0.3%), convergence insufficiency 3 (0.2%), and cataract 2 (0.15%). There was no gender difference for any morbidity, but older children were more likely to have one (P &lt; 0.001). Out of 42 having refractive error, 5/42 (12%) had myopia, 1/42 (2%) hypermetropia, 11/42 (26%) myopic astigmatism, 3/42 (7%) compound myopic astigmatism, and 22/42 (52%) had mixed astigmatism. Conclusion: Refractive error in preschool children was not an insignificant problem. Most of the morbidities were treatable, and visual impairment was preventable.

Refractive Error in Preschool Children

The Vision in Preschoolers (VIP) Study Group conducted a multicenter, multidisciplinary, two-phase study to evaluate the performance of vision screening tests for identifying pre-school children with amblyopia, strabismus, significant refractive error, or unexplained reduced visual acuity (VA). The results of the VIP Study provide evidence-based guidelines for preschool vision screening. The best screening tests administered by eye care professionals were non-cycloplegic retinoscopy, Retinomax Autorefractor, SureSight Vision Screener, and linear, crowded Lea Symbols VA at 10 feet. The best screening tests administered by trained nurses and/or lay screeners were Retinomax, SureSight, and VIP single, crowded Lea Symbols VA screening test system at 5 feet. Eye care professionals can improve detection of strabismus by combining unilateral cover test with a refraction test and trained lay screeners can improve detection of strabismus by combining Stereo Smile II with SureSight. The best performing tests had high testability whether performed by trained eye care professionals, nurses, or lay screeners (>or=98%). Although very few children were unable to complete these tests, a child who was "unable" was much more likely to have a vision problem than a child who passed; therefore, children who are unable to complete one of these tests should be referred for further evaluation. When screening using the Retinomax, repeated testing to achieve the manufacturer's suggested confidence number is valuable and improves specificity. Federal initiatives to increase the number of pre-school children receiving vision screening or examination will increase the number of pre-school children identified with amblyopia, strabismus, and/or significant refractive error. Although there is general agreement regarding the importance of early detection of amblyopia, controversy exists regarding the importance of early detection of refractive error. Because of the high prevalence of significant refractive errors and lack of evidenced-based guidelines for correction of refractive error in pre-school children, future research is needed to evaluate the value of correcting refractive errors in preschoolers who do not have amblyopia and/or strabismus.

Background Myopia is a refractive error that is increasing dramatically all over the world. Early onset is associated with a significant visual burden later in life, but little is known about refractive errors in preschool children. The aim of this study was to assess prevalence of spectacle wear, visual acuity and refractive errors in young Dutch children and to make global comparisons. Methods We analyzed data of three prospective population-based studies: 99,660 3- to 5-year-olds undergoing vision screening at preventive child healthcare organizations, 6,934 6-year-olds from the Generation R study, and 2,974 7-year-olds from the RAMSES study. Visual acuity was measured with Landolt-C or LEA charts, spectacle wear was assessed, and refractive errors at age 6 and 7 were measured with cycloplegic refraction. Spectacle wear was compared with international studies. Results The prevalence of spectacle wear was 1.5%, 2.3%, 6.6%, 8.2% and 11.8% at 36, 45, 60, 72 and 84 months, respectively, with no major sex differences. Among children with spectacle wear at 72 months (N = 583) and 84 months (N = 351) 29.8% and 34.6% had myopia respectively, of which 21.1% and 21.6% combined with astigmatism, 19.6% and 6.8% had hyperopia, 37.2% and 11.1% hyperopia and astigmatism, and 12.5% and 33.3% astigmatism only. The prevalence of spectacle wear globally varied between 1.5% to 21%. Conclusions Spectacle wear in these European children started early in preschool and increased to substantial figures at school age. Among children with spectacle wear, &amp;gt;30% were already myopic, illustrating the urgency to implement myopia prevention strategies in child health centers. Key messages Early onset myopia is a public health issue. Of the 6- to 7-year-olds with spectacles 30-34% were already myopic. Monitoring of refractive errors and preventive lifestyle interventions are warranted.

We studied parental history, near work, and intraocular pressure as risk factors for eye size and refractive error in preschool children. This age group (3-6 years) was selected on the assumption that genetic influences on eye growth would outweigh environmental factors at this stage. A total of 527 children underwent cycloplegic refraction, keratometry, tonometry, and ultrasound biometry. They were asked to complete a near-work diary (MIRF Visual Exposure Index). The axial lengths of the children were found to be not correlated with parental myopia: No parents were myopic 21.72 mm; one parent was myopic 21.85 mm; both parents were myopic 21.75 mm. Near work was analyzed as the product of the working distance and time spent in various forms of near tasks. Although near work increased from 1.0 to 1.5 h with age from 3 to 5 years, there was no significant correlation of near work with either refractive error or axial length. The parental history of myopia and the amount of near work were thus not predictors of eye size in preschool children. A high prevalence of against-the-rule astigmatism was found, which did not decline with age from 3 to 5 years. Intraocular pressure (IOP) increased with age. Moreover, increasing IOP was correlated with increasing myopia. Similarly, the parental history of myopia was predictive of higher IOP in the child: no myopic parents 13.54 mmHg, one myopic parent 14.11 mmHg, two myopic parents 14.43 mmHg.

Objective To assess the value of the hand-held autorefractor Sure Sight in screening refractive errors in children 3 to 6 years old. Methods In a cross-sectional study, 321 children with lower visual acuity than normal participated in the Sure Sight and Topcon examinations, under cycloplegic and non-cycloplegic conditions respectively. Data were evaluated with Bland-Altman and ROC based on the prevalence study. Results In the comparison, it was found that the differences in spherical diopter, cylinder diopters and spherical equivalent (SE) between non-cycloplegia with Sure Sight (S1) and cycloplegia with Topcorn (T2) were significant. The correlation between S1 and T2 ranged from moderate (spherical diopter :r=0.59,P<0.05; SE :r=0.54,P<0.05) to high (cylinder diopter:r=0.89,P<0.05). The ROC curve found that myopia, hyperopia and astigmatism suspects with S1 were ≤+1.13 D, ≥+1.44 D and ≥ 0.88 D when compared to T2. The Yonden index also showed better sensitivity and specificity for astigmatism (0.679) than myopia (0.298) and hyperopia (0.270). Conclusion As a vision screening technique to detect refractive errors in preschool children, Sure Sight can help identify suspected astigmatism, but had limitations for myopia and hyperopia. Key words: Suresight examination; Children, preschool; Vision screening

BackgroundRefractive errors are relatively common all around the world. In particular, early onset myopia is associated with a significant burden in later life. Little is known about refractive errors in preschool children. The aim of this study was to assess the prevalence of spectacle wear, visual acuity and refractive errors in young Dutch children.MethodsWe analyzed data of three prospective population-based studies: 99,660 3- to 5-year-olds undergoing vision screening at preventive child healthcare organizations, 6934 6-year-olds from the Generation R study, and 2974 7-year-olds from the RAMSES study. Visual acuity was measured with Landolt-C or LEA charts, spectacle wear was assessed, and refractive errors at age 6 and 7 were measured with cycloplegic refraction.ResultsThe prevalence of spectacle wear ranged from 1.5 to 11.8% between 3 to 7 years with no significant gender differences. Among children with spectacle wear at 6 years (N = 583) and 7 years (N = 350) 29.8 and 34.6% had myopia respectively, of which 21.1 and 21.6% combined with astigmatism; 19.6 and 6.8% had hyperopia, 37.2 and 11.1% hyperopia and astigmatism, and 12.5 and 32.7% astigmatism only.ConclusionsSpectacle wear in European children starts early in preschool and increases to a relatively frequent visual aid at school age. Advocating early detection and monitoring of refraction errors is warranted in order to prevent visual morbidities later in life.

Many parents are concerned about their child's development. The purpose of this study is to determine whether parental concerns about overall development are associated with significant refractive errors among urban preschool children. A cross-sectional population-based study was conducted to evaluate the prevalence of ocular disorders in white and African American children aged 6 through 71 months in Baltimore, Maryland. A comprehensive eye examination with cycloplegic refraction was performed. Parental concerns about development were measured with the Parents' Evaluation of Developmental Status screening tool. Of 2546 eligible children 2381 (93.5%), completed the refraction and the parental interview. Parental concerns about development were present in 510 of the 2381 children evaluated [21.4%; 95% confidence intervals (CI): 9.8 to 23.1]. The adjusted odds ratios [OR] of parental concerns with hyperopia [≥3.00 diopters (D)] was 1.26 (95% CI: 0.90 to 1.74), with myopia (≥1.00 D) was 1.29 (95% CI: 0.83 to 2.03), with astigmatism (≥1.50 D) was 1.44 (95% CI: 1.08 to 1.93) irrespective of the type of astigmatism, and with anisometropia (≥2.00 D) was 2.61 (95% CI: 1.07 to 6.34). The odds of parental concerns about development significantly increased in children older than 36 months with hyperopia ≥3.00 D, astigmatism ≥1.50 D, or anisometropia ≥2.00 D. Parental concerns about general developmental problems were associated with some types of refractive error, astigmatism ≥1.50 D and anisometropia ≥2.00 D, in children aged 6 to 71 months. Parental concerns were also more likely in children older than 36 months with hypermetropia, astigmatism, or anisometropia. Parental concerns were not associated with myopia. Because of the potential consequences of uncorrected refractive errors, children whose parents have expressed concerns regarding development should be referred for an eye examination with cycloplegic refraction to rule out significant refractive errors.

BackgroundThis study aimed to investigate the difference between cycloplegic and noncycloplegic refraction and evaluate the pseudomyopia prevalence in Chinese preschool children during the outbreak of COVID-19.MethodsA cross-sectional study was conducted in the Tongzhou District of Beijing, China. Refractive error was measured under both noncycloplegic and cycloplegic conditions with autorefraction. The difference between noncycloplegic and cycloplegic spherical equivalent refraction (SER) and pseudomyopia prevalence were analyzed. Pseudomyopia was defined as SER ≤-0.50D in precycloplegic assessments and >-0.50D in post-cycloplegic assessments.ResultsOut of the 1487 participants who were enrolled in the study, 1471 individuals (98.92%) between the ages of 3–6 years completed all required procedures. A statistically significant difference in refraction was observed between noncycloplegic and cycloplegic measurements, the median of difference in spherical equivalent refraction (SER) of 0.88D (dioptre)(0.50,1.38). There was a high intraclass correlation (ICC) between these two methods for cylinders (ICC = 0.864; 95% CI, 0.850–0.877). The median DSE for myopia, emmetropia and hyperopia were 0.25D (0.00, 0.38),0.25D (0.06, 0.50) and 1.00D (0.62, 1.38), an hypermetropes showed considerably greater differences than myopes and emmetropes (Kruskal-Wallis test, H = 231.023, P = 0.000). Additionally, girls displayed a greater DSE than boys. Furthermore, when comparing against-the-rule (ATR) and oblique astigmatism, it was found that with-the-rule (WTR) astigmatism had the largest DSE. The study found varying prevalence rates of myopia, emmetropia, and hyperopia with and without cycloplegia, which were 1.90% vs. 10.06%, 11.49% vs. 50.31%, and 86.61% vs. 39.63%, respectively. Additionally, the overall prevalence of pseudomyopia was determined to be 8.29%. Participants with pseudomyopia had a significantly higher mean difference in SER (DSE) compared to non-pseudomyopic participants.ConclusionsCycloplegic refraction is more sensitive than a noncycloplegic one for measuring refractive error in preschool children. Pseudomyopia is prevalent in preschool children during the COVID-19 outbreak period. Our study indicates the possibility that cycloplegic refraction should be performed in preschool children routinely.

The Vision Screener® (Plusoptix) was developed for the recognition of amblyogenic refractive errors without cycloplegia. The aim of this study was to evaluate the sensitivity and specitifity for the detection of amblygenic refractive errors in preschool children. Furthermore it was investigated whether small angle strabismus as another cause for amblyopia could be detected by manual evaluation of corneal reflex images on printouts. 83 children aged between 0.5 and 6 years without strabismus had undergone 3 measurements without cycloplegia with the Vision Screener before cyclplegic retinoscopy was performed. In a second group of 72 children with orthotropia or a manifest strabismus < 10° the position of the eyes without correction was evaluated in a complete orthoptic and ophthalmological examination. Three measurements with the Vision Screener were performed in non-cycloplegic status. The centre of the "cloud of viewing directions" was determined on print-outs and the distance to the points of origin (middle of pupil) measured for each eye. The sum of distances of right and left eyes was taken for determination of total deviation and the assymetry was calculated by the difference of distances of the right and left eyes. There was a total sensitivity of 75% (specifity 91%) for amblyogenic refractive error (prevalence: astigmatism 22%, hyperopia 6%, anisometropia 6%). A change of threshold criteria increased the total sensitivity to 86% and 93%, whereas specifity was lowered to 80% and 76%, respectively. Eight children showed a manifest strabismus. In 75% of these cases the determined deviation of corneal reflex images in the horizontal direction was outside of the normal range; analysis of asymmetry showed an abnormal result in 37.5% of the cases. The examination using the Vision Screener may detect refractive errors and partially small angle strabismus as amblyogenic risk factors; however, additional tests should be added for screening examinations. An ophthalmological examination including cycloplegic retinoscopy cannot be replaced. Despite acceptable sensitivity and specifity the major portion of positively screened children will be without pathological findings at cycloplegic controls, because the amount of "false-positive" results exceeds the amount of "true-positive" results based on a prevalence of 5% for amblyopia.

Testability of the Retinomax Autorefractor and IOLMaster in Preschool Children: The Multi-ethnic Pediatric Eye Disease Study

The effect of mode of delivery on refractive errors in preschool children