Screening for abnormal levels of hyperopia in children: a non-cycloplegic method with a hand held refractor

Abstract

Aims-High hyperopia constitutes the majority of refractive errors in large scale visual screening at preschool ages. The authors aimed to assess the validity of the Retinomax hand held refractor to detect high hyperopia in a refractive screening performed without cycloplegia and carried out on children aged 9-36 months. They considered +1.5 D of manifest hyperopia to be the threshold value and abnormal absolute hyperopia to be above +3.5 D. Methods-Of the 897 children screened without cycloplegia, 220 were refracted with cycloplegia. The validity of several thresholds of manifest hyperopia was estimated by receiver operating characteristic (ROC) curves using cycloplegic measures as a reference. The reproducibility of Retinomax measurements was assessed. Normal and quick mode measurements were compared using the Wilcoxon test. Results-The manifest threshold of +1.5 D oVered the best combination of sensitivity (70.2%), specificity (94.6%), positive predictive value (78.6%), and negative predictive value (91.9%) to disclose abnormal absolute hyperopia. A good agreement was obtained between the various measurements using Retinomax on the same subject. In the results of this survey, there is no evidence that accommodation is minimised in the normal mode of measurement compared with the quick mode. Conclusion-The Retinomax hand held infrared autorefractor is a suitable instrument to diagnose abnormal hyperopia (manifest hyperopia >+1.5 D) in noncycloplegic refractive screening at preschool ages. It is suggested as the quick mode of measurement as it is more feasible in children (success rate 98.5%). (Br J Ophthalmol 1998;82:1260-1264 Amblyopia is the main cause of visual defects in children.1 Recent research tends to demonstrate that refractive anomalies are the leading cause of amblyopia.2 3 Refractive screening therefore constitutes an integral part of several large scale visual testing programmes in preschool children. [4][5][6][7][8][9][10] Among them, the Cambridge photoscreening programme 10 shows that an abnormal level of hyperopia (over +3.5 D in one or more meridians) is the most frequent refractive anomaly (5-6%) found in a population at 9 months of age. It is associated with a higher risk of amblyopia (37.5% versus 5.6% in the control group) and strabismus (21% versus 1.6%) at 4 years of age. This high prevalence of abnormal hyperopia together with its increased risk of amblyopia and strabismus implies that refractive screening should detect it with good sensitivity and specificity rates, preferably without cycloplegia. Cycloplegia is indeed time and energy consuming and, as an invasive act, is not suitable for a screening procedure. Cycloplegia could be avoided if there was a manifest (noncycloplegic) hyperopia threshold leading, with reasonably good sensitivity and specificity, to an absolute (cycloplegic) hyperopia greater than + 3.5 D. Atkinson et al 10 have already promoted non-cycloplegic videorefractive screening, choosing an accommodative lag of >1.5 D as a good predictor of hyperopic refrac...

Erros de refração como causas de baixa visual em crianças da rede de escolas públicas da regional de Botucatu - SP

“…A convivência diária com os alunos permite-lhes a detecção de mudanças de comportamento ou no rendimento escolar que podem estar vinculadas a distúrbios visuais (17) . Além da triagem bem feita, é necessário envolvimento das crianças e dos pais para que haja aderência ao tratamento (10,17) . Os estudos não apresentam homogeneidade entre os crité-rios para classificar as ametropias, assim como para selecionar os pacientes para exame oftalmológico (17) .…”

“…Ainda outros classificam os erros refracionais de hipermetropia e astigmatismo hipermetrópico em conjunto, considerando-os como os mais prevalentes (9)(10)(11) . Avaliando-se a acuidade visual dos portadores de ametropias observou-se que há maior ocorrência de baixa visão entre os portadores de astigmatismo, principalmente o hipermetrópico.…”

“…Estudos demonstram que erros refracionais hipermetrópicos (hipermetropia e astigmatismo hipermetrópico), em geral, são os mais prevalentes (9)(10)(11) . Reveste-se de grande importância o tratamento precoce destas ametropias, a fim de reduzir a incidência de ambliopia em crianças, uma vez que esta incide principalmente nos altos hipermétropes e quando existe anisometropia.…”

The usefulness of the Retinomax autorefractor for childhood screening validated against a Danish preterm cohort examined at the age of 4 years

“…A confidence value of at least 8 generally signifies good technical quality of measurement. [10][11][12][13] Overall, the spherical equivalent refraction (SER), calculated as sphere + 1 2 cylinder (in dioptres), could be given for 174 of 178 preterm children and 53 of 56 fullterm controls. The difference between pre-cycloplegic and cycloplegic values expressed the EIM.…”

“…High testability in non-cycloplegic cohorts was thus reported in several centres using the hand-held Retinomax autorefractometer (Nikon Inc, Tokyo, Japan), and positive findings were subsequently evaluated against cycloplegic paediatric ophthalmic examinations. [10][11][12][13][14][15][16][17][18] Between the ages of 2 and 4 years, the testability of single devices increased from about 50 to 90%; however, some conditions remain undetected. The Retinomax can identify significant ametropia immediately but poor cooperation from the child should further direct attention to deviations from normal.…”