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Alaska Blind Child Discovery

A cooperative, charitable research project to vision screen every preschool Alaskan

ABCD Publications


Arnold, R. W. (1993). Retinopathy of prematurity in Alaska: Treating the vast expanse. the International Conference on Retinopathy of Prematurity, Chicago, Illinois, USA, Kugler Publications (Amsterdam/New York).

Arnold, R. W. (1993). "Vision Screening in Alaska: Experience with Enhanced Brückner Test." Alaska Med 35(2): 204-208.

Arnold, R. W. (1994). "Posterior retinopathy of prematurity cryotherapy from a limbal reference." J Pediatr Ophthalmol Strabismus 31: 303-305.

Arnold, R. W. (2002). "Use of a consumer video system to enhance low vision in children and adults." JPOS 39(4): 245-247.

Arnold, R. W. (2003). "Highly specific photoscreening at the Alaska State Fair: Valid Alaska Blind Child Discovery photoscreening and interpretation." Alaska Med 45(2): 34-40.

Arnold, R. W. (2003). "The phoropter trapeze. A portable refractive support for remote clinics." Binocul Vis Strabismus Q 18(1): 26-7.
A trapeze was engineered using inexpensive pre-threaded commercial polyvinyl chloride ("PVC") plumbing pipe. This was suspended from a convenient overhead point and the phoropter was clamped to it. It was stabilized by the patient holding on two attached handles. Illustrated in photographs.

Arnold, R. W. (2004). "Pseudo-false positive eye/vision photoscreening due to accommodative insufficiency. A serendipitous benefit for poor readers?" Binoc Vis and Strabismus Quart 19(2): 75-80.
BACKGROUND: Children whose eyes and vision are otherwise normal and who should screen negatively as normals, but who fail to compensate for their normal mild hyperopia (i.e. by normally accommodating, or rather actually failing to accommodate) will generate hyperopic crescents in a photoscreen test that can be interpreted as "positive" (for pathology) because high and asymmetric levels of hyperopia are common risk factors for amblyopia. This would therefore usually be considered a "false positive" and no further care would be offered. However, this failure to compensate, may in fact be a pathological disorder, accommodative insufficiency, making this apparently "false positive" situation actually a actually a "false-positive-false- negative positive test", or more simply a "false- false positive test". METHODS: The Alaska Blind Child Discovery Project photoscreened just under 16,000 children referring 6% as "positive", of which, after examination, the false positive rate was just 6% of those referred (0.4% of the total number screened). RESULTS: Ten (42%) of the 24 false positives had evidence of accommodative insufficiency inspite of only average (for age) amounts of cycloplegic hyperopia and a lag of accommodation on dynamic retinoscopy. Eight of the 10 were boys of kindergarten age. Most of these subsequently benefitted from prescription and use of reading glasses of low plus sphere correction. CONCLUSION: About 0.15% of photoscreened children, or 2.5% of those screening positive, and 42% (10/24) found initially on exam to be falsely positive, yielding hyperopic interpretations despite low and usually acceptably normal for age amounts of hyperopia, are in fact suffering from a pathological accommodative insufficiency. Identification of such false- false positives by a combination of photoscreening and dynamic retinoscopy may be used to determine which students might be helped with enforced reading glasses. Confirmatory exams on photoscreen positive-hyperopia cases should include an assessment of accommodation to identify these children.
Arnold, R. W. (2004). "Vision in Preschoolers Study (letter)." Ophthalmol 111(12): 2313.

Arnold, R. W., M. D. Armitage, et al. (2005). "The cost and yield of photoscreening: Impact of photoscreening on overall pediatric ophthalmic costs." JPOS 42(2): 103-111.
Approximately 5% of preschool children suffer from amblyopia. Many of them have high or unequal hyperopia. Amblyogenic risk factors can frequently be detected by photoscreening.
MTI™ photoscreening was offered free-of-charge to a target group of children aged 1-4 from urban and rural screening hubs. Their parents provided a brief family and health history before consenting to the flash photography. Packets of screened images were mailed to the ABCD coordinating center for physician photoscreen interpretation, specifically seeking latent or anisometropic hyperopia. Parents and screeners were then mailed results and information about amblyopia. Follow-up exam data were then tallied. A Cost-Consequence Analysis was developed for vision screening and eye care.
In 1998 and 1999, 5166 screenings were performed with a “positive” interpretation rate of 4.5% in the 3046 urban children and 6.2% in the 2120 rural children. The penetrance of screening was 13% in urban communities and 49% in rural communities. The positive predictive value is estimated to be over 90%. From this, the average cost to screen and inform an Alaskan preschooler is about $10.50. The cost to detect by photoscreening an Alaskan with amblyogenic risk factors is about $225. Compared to AAP 1995 guidelines, implementing photoscreening adds 9% while mandating complete pre-Kindergarten exam adds 49% to overall eye care.
In some of the least accessible parts of America, MTI™ photoscreening with experienced physician interpretation achieved high community penetrance and high positive predictive value for latent hyperopia and other amblyogenic factors. The costs must be weighed against societal health goals. When the follow-up costs are considered, adding photoscreening to current AAP guidelines may add $112 per child over ten years, but probably would also assist in the reduction of amblyopia. We suspect that penetrance of urban photoscreening will remain low unless pediatric vision screening guidelines and reimbursement are revised.

Arnold, R. W., A. W. Arnold, et al. (2004). "Amblyopia detection by camera (ADBC): Gateway to portable, inexpensive, vision screening." Alaska Med 46(3): 63-72.

Arnold, R. W., G. R. Beauchamp, et al. (2005). "Compared value of amblyopia detection (letter)." Ophthalmology: (submitted) never published.

Arnold, R. W., L. Coon, et al. (1995). "Collaborative visual rehabilitation: High astigmatism, esotropia and elevator palsy." Alaska Med 37(3): 88-90.

Arnold, R. W. and S. P. Donahue (2006). "Compared value of amblyopia detection." Binocul Vis Strabismus Q 21(2): 78.

Arnold, R. W. and S. P. Donahue (2006). "The yield and challenges of charitable state-wide photoscreening." Binocul Vis Strabismus Q 21(2): 93-100.
INTRODUCTION: State-wide cooperative programs for pediatric vision screening utilizing the MTI photoscreener and centralized interpretation were established in Alaska (The Alaska Blind Child Discovery, ABCD) and in Tennessee (Tennessee Lions Outreach). METHODS: Details of setup, implementation and interpretation of the state-wide MTI photoscreening programs are compared through 2002. The absolute numbers of children screened and the breakdown in interpretation categories are presented. RESULTS: ABCD screened 14,000 children while Tennessee Lions screened 100,800. Similarities between ABCD and Tennessee programs were funded by Lions Clubs and other charitable and public health organizations, community screening and each had coordinated centralized image interpretation and notification. The programs differed by clinic focus (Tennessee Lions organized pre-schools while ABCD used village and community health fairs and schools), parent notification (Tennessee Lions communicated through pre- schools and ABCD mailed directly to parents), and image interpretation (Tennessee used VOIC age-based and pupil-size crescents while ABCD used "delta-center crescent"). Predictive value positive was 73% for Tennessee and 89% for ABCD. Tennessee achieved better followup on referrals after a specific coordinator was employed. Image interpretation breakdown for ABCD: Tennessee Lions Outreach were anisometropia (29%:34%), high hyperopia (33%:16%), astigmatism (18%:30%), strabismus (7%:15%), myopia (5%:2%), cataract (0.7%:0.2%). Two state-wide programs detected 3216 amblyopic children at a charity borne-cost of $1.5 million. If the parents persisted with appropriate amblyopia therapy, the expected societal value was estimated at $17 million. Lacking societal mandate and funding, these concerted charitable efforts only achieved a community penetration rate of 10% to 14%. CONCLUSION: National adoption of preschool vision screening by a method with similar or even better validity and cost effectiveness as MTI photoscreening, ideally in the pediatric medical home, is warranted.
Arnold, R. W. and K. F. Fierstein (2000). "Are vision screening devices accurate and reliable for use in pediatricians' offices to test children younger than 4 years old?: Con." Pediatric News: submitted.

Arnold, R. W., E. Gionet, et al. (2000). "The Alaska Blind Child Discovery project: Rationale, Methods and Results of 4000 screenings." Alaska Med 42: 58-72.
BACKGROUND: Photoscreening allows lay persons to adapt the Enhanced Bruckner Test to preschoolers in an attempt to identify refractive amblyopia. The Alaska Blind Child Discovery (ABCD) project is charitably funded and administered. METHODS: MTI photoscreening was offered to children in rural and urban communities in southern Alaska from 1996 through June 1999. Parents answered questions concerning the child's health, family ocular history and whether the child had any eye "Warning Signs." The MTI images were interpreted by two eye doctors using a modification in MTI published guidelines. RESULTS: Out of 4000 screenings performed on 3930 children, there was an overall "not normal" interpretation of 9% and an inconclusive rate of 1%. The mean S.D. age was 3.9 2 years. Only 6% had had a prior eye exam. The average number of Polaroid pictures per screening was 1.16. Follow-up data on "not normal" results was obtained on just over 50%. The positive predictive value during the first two years was 77% but improved to 92% from 1998-1999. Affirmative answers to the questions concerning previous eye exam, child's health, siblings eye health and positive "Warning Signs" were significantly associated with "not normal" interpretations but affirmative answers about eye health of mother, father and relatives were not. Community penetrance of photoscreening to the target age-group ranged from only 5% for Anchorage to almost 100% for the Bristol Bay public health nurses. Five percent of parents of "positive" results surveyed would not have recommended screening for their friends. Equipment functioned dependably even in remote Alaska. CONCLUSION: Charitable volunteer Polaroid photoscreening detected amblyopia and significant pediatric eye disease in over 300 children during the first 3.5 years of ABCD.
Arnold, R. W., E. G. Gionet, et al. (2003). "Duration and effect of single-dose atropine: paralysis of accommodation in penalization treatment of functional amblyopia." Binoc Vis and Strabismus Quart 19(2): 81-86.
BACKGROUND AND PURPOSE: Atropine dilates the pupil and paralyzes the ciliary muscle accommodation, blurring vision, and therefore is an effective penalization of the sound eye in the treatment of functional amblyopia of the other eye. The degree of blur induced is a function of the amount of the patient's uncorrected hyperopia and the distance from the eye of the viewed material or object. Another factor determining effectiveness of atropine penalization is the duration of the effect of the atropine. It is the purpose of this study to investigate these factors. METHODS: Six normal children underwent complete eye exam with cycloplegic refraction several days before deliberate instillation of atropine 1% in the sound, or right eye. Distance and near acuity was then tested after 30 minutes, and on subsequent days. Additional data points were derived by placing known minus lenses in front of the tested eye. In addition, we also studied one successfully treated amblyopic patient when he terminated chronic daily atropine in his normal, sound eye. RESULTS: Atropine initially produced a linear reduction in logMAR acuity (blur) at distance of about 0.2 logMAR lines per diopters of uncorrected hyperopia. The magnitude of the blur was greater for near, but the effect of increased hyperopia was slightly greater for distance measurements. This blurring of acuity lasted just less than 48 hours for normal subjects, and just over 48 hours following prompt cessation of chronic daily atropine in that one subject. Regression formulae were derived relating uncorrected hyperopia and time interval following atropine cessation on distance and near acuity in children of amblyopic age range. CONCLUSION: The degree of penalization is highly dependent on the uncorrected hyperopic refractive error. A significant penalization effect is present only for one day or so. Daily atropine is therefore indicated for penalization. To better tailor penalization therapy to target sound eye acuity blur, these formulae and graphs can be used, specifically, in addition, to determine the amount of deliberate spectacle hyperopic undercorrection to maximize the penalization effect.
Arnold, R. W., K. Kesler, et al. (1994). "Susceptibility to ROP in Alaskan Natives." J Pediatr Ophthalmol Strabismus 31: 192-194.

Arnold, R. W., J. B. Ruben, et al. (2005). "Korean kindergarten vision screen programme (letter)." Br J Ophthalmol 89(3): 392-393.

Arnold, R. W. and G. Sitenga (2000). "The detection of congenital glaucoma by photoscreen interpretation." Alaska Med 42(3): 73-77.
Photoscreening is designed to detect abnormalities in children's eye, particularly abnormal refractive errors, which can lead to amblyopia. An Alaska Bind Child Discovery MTI Polaroid photoscreen in one girl resulted in diagnosis and treatment of congenital glaucoma. Patients with known pediatric eye disease underwent photoscreening. Subtle non- refractive changes in photoscreen images may reveal eye disease even more serious than amblyopia. We suggest that human or computer interpretation of photoscreening images, particularly when retained, be done conscientiously with respect to the refractive state and alignment of the eyes, but also regarding other potentially serious ocular pathology.
Arnold, R. W., C. A. Stange, et al. (2006). "The compared predictive value of Bruckner, acuity and strabismus from pediatric referrals." Am Orthopt J 56(1): 15-21.
Although pediatric vision screening now passes evidence-based scrutiny, and has recent AAP guidelines, routine acuity testing in pediatric offices may still perform poorly.
From 6/2002 through 8/2005, all children aged 0-6 directly referred by pediatric care givers to one pediatric ophthalmologist were compared as to referral indication; failed acuity, strabismus and positive Bruckner test. AAPOS gold standard exam criteria was applied and compared to community photoscreening.
By referral indication, the following are numbers and predictive values: acuity (n=80, PPV 51%), Brückner (n=74, PPV = 89%), Strabismus (n=432, PPV = 81%). Community photoscreening referred n=392 with PPV = 91%. The objective tests and strabismus queries were not age-dependent.
The pediatric home best conforms to WHO guidelines due to case-continuous finding and assistance with treatment compliance particularly for strabismus. Objective tests outperform acuity testing in referral for refractive amblyopia including Brückner test in experienced hands. Observation and history best refers strabismus.

Arnold, R. W., L. Stark, et al. (2006). "Tent photoscreening and patched acuity by school nurses: Validation of ASD-ABCD." J AAPOS In press.

Donahue, S., R. Arnold, et al. (2003). "Preschool vision screening: What should we be detecting and how should we report it? Uniform guidelines for reporting results from studies of preschool vision screening." J AAPOS 7(5): 314-316.

Donahue, S. P., R. W. Arnold, et al. (2004). "Pediatric Photoscreening: Eye to Eye." J Pediatr Ophthalmol Strabismus 41(2): 72-6.

Kerr, N. and R. Arnold (2004). "Vision screening for children: current trends, technology and legislative issues." Curr Opin Ophthalmol 15: 454-459.

Kovtoun, T. A. and R. W. Arnold (2004). "Calibration of photoscreeners for threshold contact- induced hyperopic anisometropia: Introduction of the JVC photoscreeners." JPOS 41(3): 150-158.

Lang, D., J. Blackledge, et al. (2005). "Is Pacific Race a retinopathy of prematurity risk factor?" Arch Pediatr Adolesc Med 159(8): 771-773.
Background: Black race affords some protection from retinopathy of prematurity (ROP), but more ROP was previously found in another darkly pigmented race, the Alaskan natives.
Design: From fall 1989 through summer 2003, all Alaskan infants with a birth weight of 1500 g or less were examined, documenting mother’s stated race, prenatal care, and neonatal intensive care unit course.
Results: Retinopathy of prematurity was classified as to predefined threshold for peripheral ablative treatment (region of avascular retina and fibrovascular ridge and vessel tortuosity) in 873 infants. Threshold ROP was more prevalent in Alaskan natives (24.9%) and Asians (15.9%) (10% overall), with no significant difference between Alaskan natives and Asians (P=.24). Alaskan native males had more threshold ROP (69%) compared with non–Alaskan native males (51%). Compared with threshold nonnatives, Alaskan native threshold infants had greater birth weights (829±222 vs 704±186 g), required less time on ventilation (46±22 vs 70±75 days), and progressed to treatment at a younger age (35.5±2.2 vs 36.2±2.6 weeks’ gestational age) (data are given as mean±SD).
Conclusions: In this limited study, we find increased risk of threshold ROP in 2 northern Pacific races. Threshold Alaskan natives had similar or better prenatal and neonatal intensive care unit variables than did threshold nonnatives; however, Alaskan native males were still at a greater risk.

Lang, D. M., A. W. Arnold, et al. (2006). "Photoscreening, remote autorefraction and patched acuity testing in the Koyukon region of Alaska." Alaska Med 48: In Press.
Photoscreening and remote autorefraction showed promise in the urban “Vision in Preschoolers Study.” We transported a comparative screening with confirmation program to a remote part of interior Alaska.
80 children from villages in the Koyukon region received on-site three-pronged vision screening followed by gold-standard confirmatory exams. Each had patched HOTV acuity, photoscreening and Suresight remote autorefraction.
There was a high prevalence of amblyopia and vision disorders in these villages. Acuity testing was moderately valid but not useful for children less than 4 years old. Suresight has specificity over 90% with sensitivity of 60%. Photoscreening had specificity over 95% and sensitivity of 70% and was better than Suresight for children under age 4.
The Welch Allyn Suresight had similar high validity in the Koyukon as in VIPS and provides immediate, on-site results. We recommend that Welch Allyn adopt more specific VIPS referral guidelines. Photoscreening, particularly with commercial digital flash cameras and specific interpretation, is a cost effective screening tool particularly for younger children.

Leman, R. E., M. D. Armitage, et al. (2005). "The receiver-operator curve for flip-card surround HOTV in younger school children." Am Orthopt J 55(1): 128-135.
The AAP vision screening guidelines are not uniformly delivered. Moderate amblyopia can be successfully treated in children 7 year of age and older. The ideal method and threshold of vision and/or acuity testing in school is not known.
1700 students from first grade, Kindergarten and pre-K were screened with a flip-card, surround HOTV protocol with other eye patched combined with photoscreening. 234 had “Gold Standard” confirmatory exams from which AAPOS standards were validated.
Receiver Operator Curves were constructed by adjusting referral criteria by grade. A cut-off of 20/25 yielded fairly good (50%) sensitivity and 90% specificity for First and Kindergarten but many of the pre-K were unable to complete the testing.
Patched surround HOTV flip card acuity is useful in starting school children and a cut-off of 20/25 passing acuity suggested. Pre-K are not well acuity screened due to high inconclusive rate
Leman, R. E., M. M. Clausen, et al. (2006). "A comparison of patched HOTV visual acuity and photoscreening." J Sch Nurs 22(4): 237-243.
Early detection of significant vision problems in children is a high priority for pediatricians and school nurses. Routine vision screening is a necessary part of that detection and has traditionally involved acuity charts. However, photoscreening in which "red eye" is elicited to show whether each eye is focusing may outperform routine acuity testing in pediatric offices and schools. This study compares portable acuity testing with photoscreening of preschoolers, kindergarteners, and 1st-graders in 21 elementary schools. School nurses performed enhanced patched acuity testing and two types of photoscreening in a portable tent. Nearly 1,700 children were screened during spring semester 2004, and 14% had confirmatory exams by community eye care professionals. The results indicate that one form of photoscreening using a Gateway DV-S20 digital camera is significantly more sensitive to children with significant vision problems, as well as being the most cost effective (85% specificity and only $0.11 per child). This suggests that the adaptation of photoscreening into a routine vision screening protocol would be beneficial for efficiently detecting vision problems that could lead to amblyopia

Kirk VG, Clausen MM, Armitage MD, Arnold RW. Preverbal photoscreening for amblyogenic factors and outcomes in amblyopia treatment: early objective screening and visual acuities. Arch Ophthalmol 2008;125:489-492. BACKGROUND: Previous studies have suggested that infant photoscreening yields better results than visual acuity screening in preschool-aged children. With conventional vision screening, the patient must be able to provide monocular visual acuity cooperation, whereas objective screening for amblyogenic factors can be done at much younger ages. METHODS: From February 1996 through February 2006, Alaska Blind Child Discovery photoscreened 21 367 rural and urban Alaskan children through grade 2, with an 82% positive predictive value (ie, true number of those referred); 6.9% were referred for a complete eye examination and treatment. All "referred" interpreted images for children younger than 48 months who were then followed up and treated for more than 2 years were reviewed to determine whether treatment was successful. RESULTS: Of 411 "positive" screening photos from children younger than 4 years, 94 patients had more than 2 years follow-up. The 36 children photoscreened before age 2 years had a mean treated visual acuity of 0.17 logarithm of the minimum angle of resolution (logMAR), which was significantly better than that of 58 children screened between ages 25 and 48 months (mean, 0.26 logMAR). Despite similar levels of amblyogenic risk factors, the proportion of children failing to reach a visual acuity of 20/40 was significantly less among those screened before age 2 years (5%) than in those screened from ages older than 2.0 years and younger than 4.0 years (17%). CONCLUSION: Very early photoscreening yields better visual outcomes in amblyopia treatment compared with later photoscreening in preschool-aged children.


Arnold RW, Armitage MD, Limstrom SA. Sutured protective occluder for severe amblyopia. Arch Ophthalmol 2008;126:891-895. OBJECTIVE: To investigate the feasibility, acceptability, efficacy, and cost of a newly developed translucent shield that can be fixed by sutures to the orbital rim for a month of amblyopia therapy. METHODS: In an institutional review board-approved protocol for patients with amblyopia who do not adhere to the use of conventional patching, shield occluders were fashioned from heat-moldable sturdy black or translucent (20/4000) plastic with holes drilled for attachment. Under brief general anesthesia, patients aged 5 to 10 years had a thorough examination before the shield occluder was sewn to the brow and cheek of the nonamblyopic eye with 3-0 monofilament polypropylene sutures. RESULTS: Ten children completed this protocol from December 1999 through January 2002. All tolerated the occluder for 12 to 36 days. The resultant skin scars were acceptable to parents, patients, and investigators. The amblyopic eyes improved from a mean (SD) of 0.77 (0.30) logMAR (Snellen equivalent, 20/119) to 0.45 (0.29) logMAR (Snellen equivalent, 20/57), a change of 0.32 (0.16) logMAR lines. There was no damage to the sound (occluded) eye. CONCLUSION: Sew-on occluder shields are an alternative when adherence to the use of other types of patching (often referred to as compliance with patching) is not satisfactory.


Arch Ophthalmol. 2009 Dec;127(12):1591-5.
Comparison between the plusoptiX and MTI Photoscreeners.
Matta NS, Arnold RW, Singman EL, Silbert DI. CO, CRC, COT, Family Eye Group, 2110 Harrisburg Pike, Ste 215, Lancaster, PA 17601, USA.
OBJECTIVE: Both the Medical Technology and Innovations (MTI) and plusoptiX photoscreeners are used to objectively screen for amblyogenic risk factors in children. The MTI has been extensively studied, but the limited availability of film may render it obsolete. We compared the MTI with the plusoptiX, a newer digital photoscreener, for the ability to detect amblyogenic factors when compared with a comprehensive pediatric ophthalmic examination. We believe our results will help to guide community-based vision screening programs. METHODS: One hundred fifty-one children were examined consecutively in our office. Each patient was screened with the MTI and plusoptiX devices on the same day as part of a comprehensive pediatric ophthalmic examination. Results via MTI were evaluated by an expert masked examiner (R.W.A.), and the plusoptiX results were interpreted by the incorporated software. RESULTS: Sixty-five percent of patients were found to have amblyopia or amblyogenic risk factors during the pediatric ophthalmic examination conducted via the American Association of Pediatric Ophthalmology and Strabismus referral criteria. We found the MTI photoscreener to have a sensitivity of 83.6%, specificity of 90.5%, false- positive rate of 9.4%, false-negative rate of 16.3%, and positive predictive value of 94.2%. The plusoptiX demonstrated a sensitivity of 98.9%, specificity of 96.1%, false- positive rate of 3.7%, false-negative rate of 1.0%, and positive predictive value of 97.9%. CONCLUSION: The MTI and plusoptiX photoscreeners proved to be effective when compared with a comprehensive cycloplegic pediatric ophthalmic examination. The plusoptiX, however, was found to have a higher sensitivity and specificity than the MTI.

Clausen MM, Armitage MD, Arnold RW. Overcoming barriers to pediatric visual acuity screening through education plus provision of materials. J AAPOS 2009;13:151-4. PURPOSE: The American Academy of Pediatrics (AAP) recommends that LEA and HOTV optotypes be used for vision screening and that adhesive tape be used to occlude one eye during testing. We have developed an educational program designed to improve the quality and efficiency of vision screening. The purpose of this study was to ascertain the effectiveness of this program. METHODS: All 672 pediatric doctors and nurses in the state of Alaska were surveyed by mail to assess their screening protocol and the number of patients cared for annually. Respondents received educational material, including an instructional video, eye patches for visual acuity testing, and a critical line HOTV test box. Subjects were resurveyed 3 months later to determine whether the instructional intervention altered their established protocol. RESULTS: Of the 672 practitioners contacted for the survey, 239 (35.6%) responded, representing 31,000 patients, or 62% of all preschool children in Alaska. Use of recommended optotypes was rare (Lea, 3%, HOTV, 7%) compared with the use of nonrecommended optotypes (including use of the E test by 40% of respondents). The postintervention survey was answered by 107 (16%) practitioners. Of these, 24 (23%) reported that they had begun using an adhesive patch for visual acuity testing, whereas 19 (18%) had begun using AAP-recommended testing optotypes. CONCLUSIONS: In-office video education and provided adhesive eye patches increased the use of patches in primary care preschool vision screening. Mail delivery was less effective than anticipated.

Matta NS, Arnold RW, Singman EL, Silbert DI: Can a photoscreener help us remotely evaluate and manage amblyopia? Am Orthopt J 2011, 61:124-127. INTRODUCTION AND PURPOSE: To determine whether the plusoptiX(R) S04 photo-screener can assist in remotely managing amblyopia. METHODS: A retrospective chart review was performed on 103 children with amblyopia. All patients had a plusoptiX(R) screening performed while wearing their optical correction during a comprehensive pediatric ophthalmology examination. RESULTS: Children were classified as being fully treated in their glasses or needing further intervention to treat their amblyopia and / or strabismus. Further treatment was indicated if children were found to have abnormal alignment and / or best corrected visual acuity of 20 / 40 or worse in either eye with correction. Photoscreening results for these children demonstrated a sensitivity, specificity, false negative rate and false positive rate of 69%, 84%, 31%, and 16%, respectively. When visual acuity and photoscreening were combined for children who initially passed the plusoptiX(R) screen, these metrics improved to 97%, 89%, 2.7%, and 11%, respectively. CONCLUSION: Photoscreening combined with simple measurements of visual acuity may be a viable option for following efficacy of treatment in amblyopes. In some parts of the United States and in many areas of the world where telemedicine plays an increasingly important role, the plusoptiX(R) photoscreener could enhance vision care and may enhance telemedicine and the treatment of amblyopia


Arnold RW, Arnold AW, Eby E, Aleshire J: Lay Person Slit Lamp Detection of Iritis in Absence of an Eye MD: Test of a Portable Model of Cells and Flare. Binocular vision & strabology quarterly, Simms-Romano's 2012, 27(2):129-134. BACKGROUND: Asymptomatic - or minimally so, eye conditions like uveitis, iritis, and glaucoma are silent stealthily blinding diseases, especially when present in children. The iritis that accompanies Juvenile Idiopathic or Rheumatoid Arthritis (JIA or JRA) is characteristically asymptomatic. Children with these must be examined regularly and routinely(see Reference 1 and Table) on an opthalmologic biomicroscopic slit lamp for the microscopic cells (and aqueous flare) which occurr in the anterior chamber of the eye, signaling the presence of iritis, and an immediate need for anti-inflammatory agents. Such an exam is also indicated when the so afflicted develop most any symptoms of a new or recurrent eye problem. Slit lamp iritis determination remains challenging. It virtually requires a major, not portable, table mounted and expensive biomicroscope. And the examiner designated in schedules (1) is a trained ophthalmolgist,, an "Eye M.D.". Both. There are times and places throughout the world where and when a slit lamp may be available but there is no Eye MD (or qualified ophthalmic technician or assistant) available in a timely manner to timely examine for iritis when such is needed as noted. However, there are theoretical advantages if a parent could detect iritis in their J I A child if a slit lamp were available, if they had been trained to use it and recognize iritis cells and flare. METHODS: A portable model of varying iritis severity was developed. Parents of JIA patients were instructed on slit lamp use and then attempted to match unknown models of iritis severity with known training models of varying concentrations of cells and flare. RESULTS: Twelve parents ranked the 5 unknowns with an average summed deviation from expected of 2.2 +/-2 grade levels (out of 12). This was a good and useful degree of training. CONCLUSION: We were able to teach lay adults to match a model of iritis severity on a slit lamp. We would suggest that where needed, they could provide urgent and more convenient and faster diagnosis and treatment of recurrent iritis and also augment recommended scheduled Eye MD screening for iritis in JIA patients providing an effectively higher level of care, quality of life, and reduction in loss of vision for JIA victims at lower cost and greater facility for the patients, their caregivers and society as a whole.


Arnold RW, Tulip D, McArthur E, Shen J, Tappel J, Arnold LE, Winkle E, Armitage MD: Predictive value from pediatrician Plusoptix screening: Impact of refraction and binocular alignment. Binoc Vis and Strabismus Quart 2012, 27(4):227-232. ABSTRACT: Background: The positive predictive value (PPV) of conventional preschool acuity screening is about 50% whereas previous Polaroid photoscreening with experienced

interpretation can achieve PPV greater than 85%. The Plusoptix photoscreener has immediate

computer interpretation and a CPT code available to pediatricians.

Methods: Two Plusoptix S09 were used in two pediatric group practices with previously

validated refractive criteria and new manufacturer’s binocular alignment criteria. CPT billing

was monitored. Referred patients had prior gold-standard AAPOS examinations.

Results: 12% of 675 photoscreened preschoolers were referred. Of the 39 with AAPOS

gold-standard exams, the PPV from strabismus referrals was 17%, while 26 of 27 refractive

referrals had true amblyopia risk factors (PPV 96%). Screening CPT code 99174 reimbursement

rose from zero to half of insurers in 15 months.

Conclusion: Plusoptix photoscreening is valid after adjusting the binocular alignment

criteria. Such photoscreening should be employed by pediatric practices to detect and ultimately

to reduce amblyopia vision impairment in children.


Silbert DI, Matta NS, Arnold RW: Comparing The Iscreen To The Mti Photoscreener In Pediatric Vision Screening. IOVS 2012. Purpose: The iScreen digital photoscreener and the MTI photoscreener are both used to objectively screen for amblyopia risk factors in children. The MTI photoscreener is an analog model placing images on instant film and has been extensively tested, but limited availability of film may render it obsolete. The newly introduced iScreen digital photoscreener is a similar hand-held device, taking two rapid digital images, which are electronically transmitted for interpretation. In this study we compare the iScreen photoscreener with MTI for the ability to detect amblyopia risk factors compared to an ophthalmology exam and cycloplegic refraction in one cohort of children. We believe our results will help guide community-based screening programs in their selection of vision screening devices.

Methods: We performed a retrospective medical record review of patients who underwent iScreen and MTI photoscreening. 47 consecutive children were examined in our office. Each child was screened with both the iScreen as well as the MTI photoscreener in our office on the same day as part of a comprehensive pediatric ophthalmology examination. iScreen images were analyzed by the company and MTI images were analyzed by an expert masked examiner. Referral by either device was compared to the presence of amblyopia risk factors as determined by a cycloplegic examination as per the AAPOS referral criteria.

Results: 47 children were analyzed in total. 70% of children were found to have amblyopia risk factors. The iScreen was found to have a sensitivity of 81% and specificity of 79%. The MTI was found to have a sensitivity of 79% and specificity of 100%.

Conclusions: The iScreen and MTI performed similarly on this cohort of patients when compared to a comprehensive pediatric ophthalmology examination. Screening programs should feel comfortable substituting the iScreen photoscreener for the MTI.


Arnold RW: Amblyopia risk factor prevalence. J Pediatr Ophthalmol Strabismus 2013, 50(4):213-217. PURPOSE: In 2003, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) published a set of risk factors for amblyopia. The intent was to promote uniformity of reporting and development in screening. Because this prevalence is not yet known, this meta-analysis is an attempt to estimate it. METHODS: Major community preschool eye examination studies were reviewed and AAPOS cut-offs estimated. RESULTS: The approximate prevalence of anisometropia is 1.2%, hyperopia is 6%, astigmatism is 15%, myopia is 0.6%, strabismus is 2.5%, and visual acuity less than 20/40 is 6%. The mean combined prevalence is 21% +/- 2% compared to a prevalence of amblyopia 20/40 and worse of 2.5%. CONCLUSIONS: Knowing risk factor prevalence simplifies validation efforts. Amblyopia screening with a risk factor sensitivity less than 100% is expected and desirable. [J Pediatr Ophthalmol Strabismus 2013;50(4):213-217.].


Arnold RW, Arnold AW, Armitage MD, Shen JM, Hepler TE, Woodard TL: Pediatric photoscreeners in high risk patients 2012: A comparison study of Plusoptix, iScreen and SPOT. Binoc Vis and Strabismus Quart 2013, 28(1):20-28. Background: New photoscreening models promise to detect amblyopia risk

factors early in hopes of reducing permanent pediatric monocular and binocular vision

impairment. The 3 commercially available interpreted photoscreeners had not yet been


Methods: This is a prospective, observational screening study following AAPOS

guidelines on pediatric patients with and without developmental delays. 270 patients in a

pediatric eye practice aged 4.7 +/- 4 years with 7% special needs. From December 2011 through

March 2012, the Plusoptix, the iScreen, and the Pediavision SPOT were applied before

confirmatory exam in a clinical pediatric eye practice.

Results: The inconclusive rate ranged from 1-4% (iScreen) to 12% (Plusoptix).

Sensitivity ranged from 72% (iScreen) to 84% (Plusoptix) and specificity ranged from 68%

(SPOT) to 94% (Plusoptix). The iScreen can provide results in 99% of high risk patients..

Conclusions: In this cohort with high pre-screening prevalence, the 2011 photoscreeners

had favorable validation that is expected to improve with further clinical study. Pediatricians

have practical technology with a recognized procedure code to assist in amblyopia reduction.


Arnold RW, Davis B, Arnold LE, Rowe KS, Davis JM: Calibration and validation of nine objective vision screeners with contact lens-induced anisometropia. J Pediatr Ophthalmol Strabismus 2013, 50(3):184-190. PURPOSE: New objective photoscreeners are emerging with encouraging national guidelines and pediatric providers can be reimbursed for photoscreening. METHODS: Nine objective screeners were applied to two emmetropic subjects with or without known power contact lenses to induce spherical and cylindrical anisometropia close to American Association for Pediatric Ophthalmology and Strabismus (AAPOS) thresholds. RESULTS: The screeners produced near linear pupil crescents and estimated refractions for induced anisometropia. Most performed well with AAPOS 2003 validation; however, the iPhone (Apple, Cupertino, CA) was too sensitive, whereas the remote autorefractors using Vision in Preschoolers Study criteria were less sensitive. CONCLUSIONS: The new, interpreted objective screeners appear valid for detection of anismetropia.


Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB: Guidelines for automated preschool vision screening: A 10-year, evidence-based update. J AAPOS 2013, 17(1):4-8.SUMMARY: In 2003 the American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee proposed criteria for automated preschool vision screening. Recent literature from epidemiologic and natural history studies, randomized controlled trials of amblyopia treatment, and field studies of screening technologies have been reviewed for the purpose of updating these criteria. The prevalence of amblyopia risk factors (ARF) is greater than previously suspected; many young children with low-magnitude ARFs do not develop amblyopia, and those who do often respond to spectacles alone. High-magnitude ARFs increase the likelihood of amblyopia. Although depth increases with age, amblyopia remains treatable until 60 months, with decline in treatment effectiveness after age 5. US Preventive Services Task Force Preventative Services Task Force guidelines allow photoscreening for children older than 36 months of age. Some technologies directly detect amblyopia rather than ARFs. Age-based criteria for ARF detection using photoscreening is prudent: referral criteria for such instruments should produce high specificity for ARF detection in young children and high sensitivity to detect amblyopia in older children. Refractive screening for ARFs for children aged 12-30 months should detect astigmatism >2.0 D, hyperopia >4.5 D, and anisometropia >2.5 D; for children aged 31-48 months, astigmatism >2.0 D, hyperopia > 4.0 D, and anisometropia >2.0 D. For children >49 months of age original criteria should be used: astigmatism >1.5 D, anisometropia>1.5 D, and hyperopia >3.5 D. Visually significant media opacities and manifest (not intermittent) strabismus should be detected at all ages. Instruments that detect amblyopia should report results using amblyopia presence as the gold standard. These new American Association for Pediatric Ophthalmology and Strabismus Vision Screening Committee guidelines will improve reporting of results and comparison of technologies.


Silbert DI, Arnold RW, Matta NS: Comparison of the iScreen and the MTI photoscreeners for the detection of amblyopia risk factors in children. J AAPOS 2013, 17(1):34-37. BACKGROUND: The iScreen and Medical Technology and Innovations, Inc, (MTI) photoscreeners objectively screen for amblyopia risk factors in children. The MTI photoscreener has been extensively validated as a device that objectively screens for amblyopia risk factors in children, but limited availability of the instant film it uses may soon render it obsolete. More recently the iScreen photoscreener has been introduced. This device captures images digitally and transmits them electronically to be interpreted. We compared the newer iScreen's ability to detect amblyopia risk factors in children with the established MTI photoscreener. METHODS: The medical records of consecutive subjects screened by both the iScreen and MTI photoscreeners on the same day were retrospectively reviewed. The iScreen images were analyzed by the device's central interpretation center; MTI images were analyzed by an expert masked examiner using the delta crescent method. Referrals by both instruments were compared to the results of cycloplegic examination as per the American Association for Pediatric Ophthalmology and Strabismus 2003 referral criteria. RESULTS: A total of 169 children were included in the study. Of these, 107 (63%) were found to have amblyopia risk factors. The iScreen was found to have an accuracy rate of 81%, sensitivity of 87%, and specificity of 76%. The MTI was found to have an accuracy rate of 81%, sensitivity of 81%, and specificity of 81%. CONCLUSIONS: The iScreen and MTI performed similarly in detecting amblyopia risk factors when compared to a comprehensive pediatric ophthalmology examination.


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