Intertester Agreement in Refractive Error Measurements

Abstract

Purpose To determine the inter-tester agreement of refractive error measurements between lay and nurse screeners using the Retinomax Autorefractor (Retinomax) and the SureSight Vision Screener (SureSight). Methods Trained lay and nurse screeners measured refractive error in 1452 preschoolers (3- to 5-years old) using the Retinomax and the SureSight in a random order for screeners and instruments. Inter-tester agreement between lay and nurse screeners was assessed for sphere, cylinder and spherical equivalent (SE) using the mean difference and the 95% limits of agreement. The mean inter-tester difference (lay minus nurse) was compared between groups defined based on child’s age, cycloplegic refractive error, and the reading’s confidence number using analysis of variance. The limits of agreement were compared between groups using the Brown-Forsythe test. Inter-eye correlation was accounted for in all analyses. Results The mean inter-tester differences (95% limits of agreement) were −0.04 (−1.63, 1.54) Diopter (D) sphere, 0.00 (−0.52, 0.51) D cylinder, and −0.04 (1.65, 1.56) D SE for the Retinomax; and 0.05 (−1.48, 1.58) D sphere, 0.01 (−0.58, 0.60) D cylinder, and 0.06 (−1.45, 1.57) D SE for the SureSight. For either instrument, the mean inter-tester differences in sphere and SE did not differ by the child’s age, cycloplegic refractive error, or the reading’s confidence number. However, for both instruments, the limits of agreement were wider when eyes had significant refractive error or the reading’s confidence number was below the manufacturer’s recommended value. Conclusions Among Head Start preschool children, trained lay and nurse screeners agree well in measuring refractive error using the Retinomax or the SureSight. Both instruments had similar inter-tester agreement in refractive error measurements independent of the child’s age. Significant refractive error and a reading with low confidence number were associated with worse inter-tester agreement.

Comparison of cycloplegic refraction between Grand Seiko autorefractor and Retinomax autorefractor in the Vision in Preschoolers–Hyperopia in Preschoolers (VIP-HIP) Study

“…Several studies found that the Retinomax had high repeatability and good agreement with cycloplegic retinoscopy. 5, 13, 15, 23 In fact, the cycloplegic Retinomax has been used for comparison to measure refractive error in large epidemiological pediatric eye disease studies, including the Multi-Ethnic Pediatric Eye Disease Study and Baltimore Pediatric Eye Disease Study. 24, 25 However, Wesemann and colleagues 15 found that Retinomax measurements in children under cycloplegia provided slightly more “plus” (by a mean of 0.25–0.50 D in spherical equivalent) than subjective refraction or retinoscopy in children and adults.…”

“…Although the repeatability and accuracy of these devices for measuring refractive error has been established in children and adults, 5–7, 10–15 prior research has not assessed their agreement in young children. Choong and colleagues 10 showed a mean sphere difference of 0.24 D (−0.07 D from the Grand Seiko vs −0.31 D from the Retinomax), a mean cylinder difference of −0.27 D (−0.73 D vs −0.46 D), and a mean SE difference of 0.10 D (−0.44 D vs −0.54 D) under cycloplegic conditions.…”

“…However, repeatability and accuracy of these devices for measuring refractive error has been previously established in children and adults. 5–7, 10–15 Finally, the children examined were limited to those believed to be candidates for the VIP-HIP study based on screening results consistent with emmetropia or moderate hyperopia (3–6 D); therefore, children with severe myopia or astigmatism were under-represented, limiting the generalization of our study findings to the general population of children.…”

“…4 Autorefractors have been widely used to assess the refractive error status of children in vision screening, clinical practice, and research settings because of their high repeatability and their ability to be successfully administered by trained lay individuals as well as nurses and eye care professionals. 5–8 The Retinomax (Righton, Tokyo, Japan) and Grand Seiko (Grand Seiko Co Ltd, Hiroshima, Japan) autorefractors are two commonly used devices for assessing refractive error in preschool children, each with different optical systems. The handheld Retinomax autorefractor uses an internal fixation target in conjunction with built-in automatic fogging mechanisms to minimize accommodation during measurement.…”

Comparison of the results of four different refraction measurement devices in children with retinoscopy

“…The detection of refractive error in the pediatric age group is one of the most important factors in the detection of amblyopia, which can be treated in this age group [9]. Due to their high reproducibility and successful application by trained ordinary people, nurses and eye care professionals, autorefractors and vision screening are widely used in clinical practice and research settings to assess the refractive error status of children [10]. In this study, we compared the results of two deskbound autorefractometers (Canon RK-F1 vs. TonoRef III), a handheld autorefractometer (Retinomax K-Plus-3) and a photoscreener (PlusOptix A09) with the gold standard cycloplegic retinoscopy, the four devices being both spherical equivalent, helping us find cylindrical value results compatible with retinoscopy.…”