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Salcido AA, Bradley J, Donahue SP. Predictive value of photoscreening and traditional screening of preschool children. J Aapos 2005;9(2):114-20.
PURPOSE: To compare the usefulness of traditional vision screening and photoscreening of 3- and 4-year-old children in the pediatrician's office. Methods: Following training of pediatricians and office staff, six pediatric clinics used both the MTI PhotoScreenertrade mark (Medical Technology Industries, LLC, Riviera Beach, FL) and traditional acuity and stereopsis screening materials (HOTV charts/Random Dot E tests as recommended by established AAP-MCHB-PUPVS guidelines) during well-child exams. Clinics used one testing method for a 6-month period and switched to the other for the following 6 months, in a randomized manner. Referred children received a complete eye examination with cycloplegic refraction by local ophthalmologists or optometrists who forwarded the results to Vanderbilt Ophthalmology Outreach Center. Amblyogenic factors were defined using standardized published criteria. Results: Six hundred five children were screened with the photoscreener and 447 were screened with traditional techniques. Mean time for screening was less with the photoscreener: 2.5 versus 5.9 minutes ( P < 0.01). Untestable rates were similar (18% vs 10%, respectively P = NS), but higher with the photoscreener due to one clinic's 70% unreadable rate. Referral rates were also similar: 3.8% versus 4.5%. The positive predictive value (PPV) rate differed greatly. With follow-up results obtained from 56% of referred children, 73% of photoscreening referred children (8/11 examined) had amblyogenic factors confirmed on formal eye exams, whereas all children referred using traditional screening methods (10/10 examined) were normal. Conclusion: Photoscreening is more time efficient than traditional screening and has a significantly higher PPV in 3- and 4-year-old children. This study was unable to validate traditional screening techniques in this preschool age group. If these results can be replicated, support for traditional vision screening must undergo intense scrutiny, and attention should be turned toward making photoscreening feasible for widespread implementation.

Leman R, Clausen MM, Bates J, Stark L, Arnold KK, Arnold RW. A comparison of patched HOTV visual acuity and photoscreening. J Sch Nurs 2006;22(4):237-43.
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.

Arnold RW, Stange CA, Ryan C. The compared predictive value of Bruckner, acuity and strabismus from pediatric referrals. Am Orthopt J 2006;56(1):15-21.
Background: Although pediatric vision screening now passes evidence-based scrutiny, and has recent AAP guidelines, routine acuity testing in pediatric offices may still perform poorly.
Methods: 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.
Results: 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.
Conclusion: 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.

Lang DM, Arnold AW, Leman RE, Arnold RW. Validated portable pediatric vision screening in the Alaska Bush: A VIPS-like study in the Koyukon. Alaska Med 2007;49(1):2-13.
Background: 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.
Methods: 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.
Results: 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.
Conclusion: 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.

Arnold RW, Stark L, Leman RE, Arnold KK, Armitage MD. Tent photoscreening and patched acuity by school nurses: Validation of ASD-ABCD. Binoc Vis and Strabismus Quart 2008;23(3):83-94.
Background: Photoscreening may outperform routine acuity testing in pediatric offices, however both have fairly good validity when performed by specialists in preschool vision screening.
Methods: School nurses performed patched HOTV surround acuity testing and two types of photoscreening (MTI and Gateway DV-S20) on 1700 children (696 1st grade, 710 Kindergarteners, and 271 special-needs pre-Kindergarten).  14% had comprehensive exams and another 65% had normal photoscreens combined with patched acuities of 20/25 or better OU.
Results: We estimate the overall sensitivity/specificity using AAPOS guidelines for the modalities to be 39%:99% for patched HOTV acuity, 77%:99% for MTI photoscreening, and 85%:98% for Gateway photoscreening.  The specificity of acuity testing was particularly low in pre-K due to 33% unable to complete the test.

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