Choosing appropriate tools and referral criteria for vision screening of children aged 4–5 years in Canada: a quantitative analysis

Nishimura, Mayu; Wong, Agnes M. F.; Cohen, Ashley; Thorpe, Kevin E.; Maurer, Daphne

doi:10.1136/bmjopen-2019-032138

Cited by 17 publications

(19 citation statements)

References 67 publications

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“…Similarly, the United States Preventative Services Task Force 2017 guidelines recommend the use of multiple screening tests to identify preschool children at higher risk of vision problems 6 . In a Canadian study comparing five screening tests in a population of 4–5 year old children with a relatively high prevalence of astigmatism, the combination of a VA test with a photoscreener achieved higher sensitivity than use of a VA test alone 39 . Automated measures of refractive error are also quick to administer and require minimal cooperation from the child 14 .…”

Section: Discussionmentioning

confidence: 99%

“…6 In a Canadian study comparing five screening tests in a population of 4-5 year old children with a relatively high prevalence of astigmatism, the combination of a VA test with a photoscreener achieved higher sensitivity than use of a VA test alone. 39 Automated measures of refractive error are also quick to administer and require minimal cooperation from the child. 14 Targeting screening to detect significant refractive error by employing appropriate tests will ensure detection of amblyogenic factors, but also enable detection of smaller magnitude refractive errors that may reduce the performance of academic tasks.…”

Section: Discussionmentioning

confidence: 99%

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Diagnostic accuracy of the Parr vision test, single crowded Lea symbols and Spot vision screener for vision screening of preschool children aged 4–5 years in Aotearoa/New Zealand

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Goodman

et al. 2021

Ophthalmic Physiologic Optic

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Purpose Preschool children in New Zealand undergo vision screening to detect amblyopia at 4–5 years of age. The current test, the Parr vision test, does not meet international visual acuity chart guidelines and has not been validated against other commonly used paediatric vision tests. New Zealand vision screening protocols are also not targeted for detecting other eye conditions such as uncorrected refractive error, which may affect school performance. We compared the Parr vision test with the single crowded Lea symbols and the Spot vision screener for detecting ocular pathology, refractive error and amblyopic risk factors in preschool children. Methods A cross‐sectional diagnostic accuracy study recruited children aged 4–5 years via convenience sampling from the University of Auckland Optometry Clinic and through primary schools in Auckland, New Zealand. Participants received vision screening with the three different instruments administered by a lay screener. Comprehensive eye examinations were completed by a paediatric optometrist to determine the presence of vision disorders. Results Of 197 children who received a comprehensive eye examination, 14 (7.1%) had amblyopic risk factors and 43 (21.8%) had significant refractive error (15.7% with astigmatism, 9.1% with hyperopia). The sensitivity for detecting any ocular condition did not differ significantly between the tests (50.0% for Parr, 43.5% for Lea, 42.5% for Spot). Specificity was significantly lower for the Parr vision test (80.8%) than for the Lea symbols (93.4%) and Spot vision screener (98.0%). Adding the Spot vision screener to measurements of visual acuity significantly improved sensitivity in detecting any ocular condition with the Parr vision test (67.5% for Parr/Spot vs 50% for Parr alone), but not with the Lea symbols (52.5% for Lea/Spot vs 43.5% for Lea alone). Conclusion The sensitivity of the Parr vision test for detecting ocular conditions in preschool children does not vary significantly from that achieved by the Lea symbols or the Spot vision screener. However, current New Zealand vision screening protocols could be improved by expanding the target conditions to include significant refractive error and incorporating the use of the Spot vision screener to increase the accuracy with which children with refractive error are identified. Future research should include longitudinal studies to determine the effect of preschool vision screening on later ocular and academic outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Diagnostic accuracy of the Parr vision test, single crowded Lea symbols and Spot vision screener for vision screening of preschool children aged 4–5 years in Aotearoa/New Zealand

Findlay

Black

Goodman

et al. 2021

Ophthalmic Physiologic Optic

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“…Based on previous studies [35][36][37][38][39][40] and a concurrent study, 1 we used an acuity test (Cambridge Crowded Acuity Cards), 2 photoscreeners (Plusoptix S12 and Spot Vision Screener photoscreeners) and 2 measures of binocular vision (Preschool Randot Stereoacuity test and Pediatric Vision Scanner [PVS]) because they have high accuracy in identifying children with visual problems 1 (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503 /cmaj.191085/-/DC1).…”

Section: Study Participants and Designmentioning

confidence: 99%

“…or the central coordinator from our concurrent study. 1 We considered children who met any referral criterion (Table 1) as a "refer" and only children who passed all 5 tests as a "pass." We based referral criteria on the 2013 guidelines of the American Association of Pediatric Ophthalmology and Strabismus (AAPOS), 41 previously published norms 42 and our own data.…”

Section: Study Participants and Designmentioning

confidence: 99%

“…We based referral criteria on the 2013 guidelines of the American Association of Pediatric Ophthalmology and Strabismus (AAPOS), 41 previously published norms 42 and our own data. 1 Children who did not understand or were uncooperative were considered a refer, because such children have a higher risk of having a vision disorder, 43 and we reported the frequency for each screening test. In August 2018, the Ontario Ministry of Health and Long-Term Care (MOHLTC) released a protocol for vision screening in children in SK as part of the Ontario Public Health Standards (2017).…”

Section: Study Participants and Designmentioning

confidence: 99%

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Feasibility of a school-based vision screening program to detect undiagnosed visual problems in kindergarten children in Ontario

Nishimura

Wong

Dimaras

et al. 2020

CMAJ

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wo previous Canadian studies suggested that about 1 in 5 children aged 3-6 years have a visual problem such as amblyopia or clinically significant refractive errors (i.e., hyperopia, myopia, astigmatism or anisometropia). 1,2 Population-based studies in the United States and other countries have reported similar prevalence. 3-15 The United States Preventive Services Task Force recommends at least 1 vision screening in children between the ages of 3 and 5 years. 16 The Canadian Paediatric Society recommends screening for visual problems at well-child visits for children aged 3-5 years; 17 however, this often does not occur. 18 One report from Ontario showed that only 14% of children under 6 years of age had a comprehensive eye examination in 2013, even though examinations are paid for by provincial health insurance. 19 The underutilization of vision care means that children with amblyopia are not receiving treatment when it is most effective (i.e., before 8 yr of age). 20-22 In addition, early visual problems can negatively affect learning-children with amblyopia read more slowly than those with normal vision, 23,24 and refractive errors are associated with poor reading by grade 1. 25-31 We are unaware of any studies to date that have examined the scaling and implementation issues associated with a schoolbased, vision-screening program in kindergarten, or whether such a program could successfully identify and offer treatment (e.g., glasses) to children with previously undiagnosed visual problems. 32-34 In a study 1 in 1 school (n = 709 children), we investigated what combination of screening tools provided the highest sensitivity and specificity. In the current study, we used this information to test the feasibility of scaling up vision screening to multiple schools in diverse Ontario communities. We investigated whether screening should be offered in both junior kindergarten (JK) and senior kindergarten (SK), whether using an active or passive consent model makes a difference, whether offering follow-up eye examinations at the child's school can reduce barriers to access, and whether children are receptive to a screening program. These are practical details needed by funders to make decisions about implementing school-based vision screening.

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Cost-effectiveness of Universal School- and Community-Based Vision Testing Strategies to Detect Amblyopia in Children in Ontario, Canada

et al. 2023

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ImportanceScreening for amblyopia in primary care visits is recommended for young children, yet screening rates are poor. Although the prevalence of amblyopia is low (3%-5%) among young children, universal screening in schools and mandatory optometric examinations may improve vision care, but the cost-effectiveness of these vision testing strategies compared with the standard in primary care is unknown.ObjectiveTo evaluate the relative cost-effectiveness of universal school screening and mandated optometric examinations compared with standard care vision screening in primary care visits in Toronto, Canada, with the aim of detecting and facilitating treatment of amblyopia and amblyopia risk factors from the Ontario government’s perspective.Design, Setting, and ParticipantsAn economic evaluation was conducted from July 2019 to May 2021 using a Markov model to compare 15-year costs and quality-adjusted life-years (QALYs) between school screening and optometric examination compared with primary care screening in Toronto, Canada. Parameters were derived from published literature, the Ontario Schedule of Benefits and Fees, and the Kindergarten Vision Testing Program. A hypothetical cohort of 25 000 children aged 3 to 5 years was simulated. It was assumed that children in the cohort had irreversible vision impairment if not diagnosed by an optometrist. In addition, incremental costs and outcomes of 0 were adjusted to favor the reference strategy. Vision testing programs were designed to detect amblyopia and amblyopia risk factors.Main Outcomes and MeasuresFor each strategy, the mean costs per child included the costs of screening, optometric examinations, and treatment. The mean health benefits (QALYs) gained were informed by the presence of vision impairment and the benefits of treatment. Incremental cost-effectiveness ratios were calculated for each alternative strategy relative to the standard primary care screening strategy as the additional cost required to achieve an additional QALY at a willingness-to-pay threshold of $50 000 Canadian dollars (CAD) ($37 690) per QALY gained.ResultsSchool screening relative to primary care screening yielded cost savings of CAD $84.09 (95% CI, CAD $82.22-$85.95) (US $63.38 [95% CI, US $61.97-$64.78]) per child and an incremental gain of 0.0004 (95% CI, −0.0047 to 0.0055) QALYs per child. Optometric examinations relative to primary care screening yielded cost savings of CAD $74.47 (95% CI, CAD $72.90-$76.03) (US $56.13 [95% CI, $54.95-$57.30]) per child and an incremental gain of 0.0508 (95% CI, 0.0455-0.0561) QALYs per child. At a willingness-to-pay threshold of CAD $50 000 (US $37 690) per QALY gained, school screening and optometric examinations were cost-effective relative to primary care screening in only 20% and 29% of iterations, respectively.Conclusions and RelevanceIn this study, because amblyopia prevalence is low among young children and most children in the hypothetical cohort had healthy vision, universal school screening and optometric examinations were not cost-effective relative to primary care screening for detecting amblyopia in young children in Toronto, Canada. The mean added health benefits of school screening and optometric examinations compared with primary care screening did not warrant the resources used.

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Choosing appropriate tools and referral criteria for vision screening of children aged 4–5 years in Canada: a quantitative analysis

Cited by 17 publications

References 67 publications

Diagnostic accuracy of the Parr vision test, single crowded Lea symbols and Spot vision screener for vision screening of preschool children aged 4–5 years in Aotearoa/New Zealand

Diagnostic accuracy of the Parr vision test, single crowded Lea symbols and Spot vision screener for vision screening of preschool children aged 4–5 years in Aotearoa/New Zealand

Feasibility of a school-based vision screening program to detect undiagnosed visual problems in kindergarten children in Ontario

Cost-effectiveness of Universal School- and Community-Based Vision Testing Strategies to Detect Amblyopia in Children in Ontario, Canada

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