Associations between visual function and magnitude of refractive error for emmetropic to moderately hyperopic 4‐ and 5‐year‐old children in the Vision in Preschoolers ‐ Hyperopia in Preschoolers Study

Abstract

Purpose To evaluate associations between visual function and the level of uncorrected hyperopia in 4‐ and 5‐year‐old children without strabismus or amblyopia. Methods Children with spherical equivalent (SE) cycloplegic refractive error of −0.75 to +6.00 on eligibility testing for the Vision in Preschoolers–Hyperopia in Preschoolers (VIP‐HIP) study were included. Children were grouped as emmetropic (<1D SE myopia or hyperopia), low hyperopic (+1 to <+3D SE) or moderate hyperopic (+3 to +6D SE). Children with anisometropia or astigmatism (≥1D), amblyopia or strabismus were excluded. Visual functions assessed were monocular distance visual acuity (VA) and binocular near VA with crowded HOTV charts, accommodative lag using the Monocular Estimation Method and near stereoacuity by ‘Preschool Assessment of Stereopsis with a Smile’. Visual functions were compared as continuous measures among refractive error groups. Results 554 children (mean age 58 months) were included in the analysis. Mean SE (SD) {N} for emmetropia, low and moderate hyperopia were +0.52D (0.49) {N = 270}, +2.18D (0.57) {N = 171} and +3.95D (0.78) {N = 113}, respectively. There was a consistent trend of poorer visual function with increasing hyperopia (p < 0.001). Although all children had age‐normal distance VA, logMAR (Snellen) VA of 0.00 (6/6) or better was achieved (distance, near) among more emmetropic (52%, 26%) and low hyperopic (47%, 15%) children than moderate hyperopes (25%, 9%). Mean (SD) distance logMAR VA declined from emmetropic 0.05 (0.10), to low hyperopic 0.06 (0.10) to moderately hyperopic children 0.12 (0.11) (p < 0.001); A mild progressive decrease in near VA also was observed from the emmetropic 0.13 (0.11) to low hyperopic 0.15 (0.10) to moderate hyperopic 0.19 (0.11) groups, (p < 0.001). Accommodative responses showed an increased lag with increasing hyperopia (ρ = 0.50, p < 0.001). Median near stereoacuity for emmetropes, low and moderate hyperopes was 40, 60 and 120 sec arc, respectively. The percentage of these groups with no reduced near visual functions was 83%, 61%, and 34%, respectively. Conclusions Decreasing visual function was associated with increasing hyperopia in 4‐ and 5‐year‐olds without strabismus or amblyopia. As hyperopia with reduced visual function has been associated with early literacy deficits, near visual function should be evaluated in these children.

The Impact of Hyperopia on Academic Performance Among Children: A Systematic Review

“…98 Because of the paucity of studies that have investigated visual attention 53,75 and visual-motor integration, 27,74,75,80 we could not explore the association between hyperopia and these domains in this review. However, 2 more recent studies 83,99 have reported poorer visual attention and visual-motor integration in those with hyperopia, and these higher functions are promising areas that warrant further investigation. Because fewer than 10 studies were included in our meta-analyses, we could not test for publication and reporting biases, which are likely in observational studies that do not require prior registration.…”

Vision Screening, Vision Disorders, and Impacts of Hyperopia in Young Children: Outcomes of the Vision in Preschoolers (VIP) and Vision in Preschoolers – Hyperopia in Preschoolers (VIP-HIP) Studies

“…39 The impact of increasing uncorrected hyperopia on visual function was further investigated in a secondary analysis of all 4and 5-year-old children who presented for VIP-HIP study eligibility testing (mean age 58 months). 40 Specifically, visual functions were compared among children classified as having emmetropia [<1 D spherical equivalent (SE) myopia or hyperopia], low hyperopia (þ1 to < þ3 D SE), or moderate hyperopia (þ3 to þ6 D SE). Children with amblyopia, strabismus, or 1 D or more of anisometropia or astigmatism were excluded.…”

“…The percentage of children in each group with 1 or more decreased visual functions increased with increasing hyperopia, from 17% of emmetropes, to 39% of low hyperopes, to 66% of moderate hyperopes. 40…”

“…37,38 Increasing magnitude of hyperopia was associated with worsening near visual function (near visual acuity, near stereoacuity, accommodative accuracy). 39,40 amblyopia (optically corrected interocular difference in visual acuity of 2 lines or more) (P < 0.0001 for each). Greater magnitude of astigmatism and bilateral hyperopia were independently associated with greater risk of bilateral vision reduction that is frequently described as bilateral amblyopia (optically corrected visual acuity in both eyes worse than 20/50 for 3-year-olds or worse than 20/40 for 4-to 5-year-olds) (P < 0.0001 for both).…”

Seeing beyond 2020: what next for refractive error care?

“…From a study in Aotearoa / New Zealand, Findlay et al 21 call for the Spot vision screener to be added to the current Parr vision test in the national programme to improve the sensitivity and specificity of amblyopia detection in 4-5 year olds. From the USA, Ciner et al 22 found that amongst 4-5 year old children without strabismus or amblyopia, visual acuity, accommodative lag and stereoacuity all reduced with increasing hyperopia; based on these findings, the authors call for near visual function to be routinely assessed in children with hyperopia. In India, Seelam et al 23 report results from a realist evaluation of a school-based eye health programme with a target population of 2 million children.…”