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The Vision in PreSchoolers Study, a multicenter, NIH-funded multi-phase effort.

VIPS Phase 1 (enhanced prevalence Headstart, delivered by experienced pediatric optometrists and ophthalmologists, revised Suresight referral criteria, included photoscreening unreadables in failures, not reported with AAPOS vision screen criteria)

VIPS. Comparison of preschool vision screening tests as administered by licensed eye care professionals in the vision in preschoolers study. Ophthalmology. Apr 2004;111(4):637-650.
PURPOSE: To compare 11 preschool vision screening tests administered by licensed eye care professionals (LEPs; optometrists and pediatric ophthalmologists). DESIGN: Multicenter, cross-sectional study. PARTICIPANTS: A sample (N = 2588) of 3- to 5-year-old children enrolled in Head Start was selected to over-represent children with vision problems. METHODS: Certified LEPs administered 11 commonly used or commercially available screening tests. Results from a standardized comprehensive eye examination were used to classify children with respect to 4 targeted conditions: amblyopia, strabismus, significant refractive error, and unexplained reduced visual acuity (VA). MAIN OUTCOME MEASURES: Sensitivity for detecting children with >/=1 targeted conditions at selected levels of specificity was the primary outcome measure. Sensitivity also was calculated for detecting conditions grouped into 3 levels of importance. RESULTS: At 90% specificity, sensitivities of noncycloplegic retinoscopy (NCR) (64%), the Retinomax Autorefractor (63%), SureSight Vision Screener (63%), and Lea Symbols test (61%) were similar. Sensitivities of the Power Refractor II (54%) and HOTV VA test (54%) were similar to each other. Sensitivities of the Random Dot E stereoacuity (42%) and Stereo Smile II (44%) tests were similar to each other and lower (P<0.0001) than the sensitivities of NCR, the 2 autorefractors, and the Lea Symbols test. The cover-uncover test had very low sensitivity (16%) but very high specificity (98%). Sensitivity for conditions considered the most important to detect was 80% to 90% for the 2 autorefractors and NCR. Central interpretations for the MTI and iScreen photoscreeners each yielded 94% specificity and 37% sensitivity. At 94% specificity, the sensitivities were significantly better for NCR, the 2 autorefractors, and the Lea Symbols VA test than for the 2 photoscreeners for detecting >/=1 targeted conditions and for detecting the most important conditions. CONCLUSIONS: Screening tests administered by LEPs vary widely in performance. With 90% specificity, the best tests detected only two thirds of children having >/=1 targeted conditions, but nearly 90% of children with the most important conditions. The 2 tests that use static photorefractive technology were less accurate than 3 tests that assess refractive error in other ways. These results have important implications for screening preschool-aged children. {Note: photoscreeners used AAPOS pre-trial threshold criteria whereas Suresight and Retinomax were internally calibrated using this study's non-AAPOS GSE criteria.}

VIPS Phase 2 (eliminated most original screening modalities including photoscreening and HOTV, compared Suresight, Retinomax, crowded linear LEA and Stereo Smile, enhanced prevalence Headstart, screened by trained nurses and lay persons)

VIPS, Schmidt PP, Dobson V. Vision in Preschoolers (VIP) Study: Results of Phase II. IOVS. 2005 2005.
Abstract
Purpose: To compare the performance of nurse screeners and lay screeners in administering 4 vision screening tests to preschool children.
Methods: Nurse screeners and lay screeners, experienced in working with young children, completed training and certification procedures for all tests. Subjects were 1,452 3– to 5–year–old children enrolled in Head Start at the 5 VIP Clinical Centers. Approximately 2/3 of the children had failed the routine Head Start vision screening. Screening tests were the Retinomax Autorefractor, SureSight Vision Screener, crowded Linear Lea Symbols visual acuity (VA) test at 3 m, and Stereo Smile II test. Lay screeners also administered the crowded Single Lea Symbols (VA) test at 1.5 m. Screening results were compared to results from a standardized comprehensive eye examination that were used to classify children as having or not having amblyopia, strabismus, significant refractive error and/or unexplained reduced visual acuity.
Results: Screening results for each test were obtained on 98% of children for both nurse screeners and lay screeners. Completion times for each test were similar for both types of screeners. With specificity set at 0.90, sensitivities for detecting children with > 1 targeted condition differed for nurse screeners and lay screeners for the Retinomax (0.68 vs 0.62, p=0.004) and the crowded Linear Lea Symbols VA test (0.49 vs 0.37, p=0.0004), but not for the SureSight (0.64 vs 0.65, p=0.16) or the Stereo Smile II test (0.45 vs 0.40, p=0.06). However, sensitivity was significantly higher for lay screeners using the crowded Single Lea Symbols VA (1.5 m) compared to nurse screeners using the 3.0 m crowded Linear Lea Symbols visual acuity test (0.61 vs 0.49, p=0.0001). At 0.90 specificity, sensitivity for detection of the targeted conditions of greatest severity (e.g. severe anisometropia, constant strabismus, hyperopia > 4.75 D, astigmatism > 2.25 D, myopia > 6 D) did not differ between nurse screeners and lay screeners for any of the 4 tests.
Conclusions: Nurse screeners and lay screeners achieved similar sensitivity for detecting preschool children in need of a comprehensive eye examination when specificity is set at 0.90.

Compare: Donahue S, Arnold R, Ruben JB. 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. 2003;7(5):314-316.

Vision in Preschoolers (VIP) Study Group. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci. 2009 May 4. [Epub ahead of print]
The Vision in Preschoolers (VIP) Study Group conducted a multicenter, multidisciplinary, two-phase study to evaluate the performance of vision screening tests for identifying pre-school children with amblyopia, strabismus, significant refractive error, or unexplained reduced visual acuity (VA). The results of the VIP Study provide evidence-based guidelines for preschool vision screening. The best screening tests administered by eye care professionals were non-cycloplegic retinoscopy, Retinomax Autorefractor, SureSight Vision Screener, and linear, crowded Lea Symbols VA at 10 feet. The best screening tests administered by trained nurses and/or lay screeners were Retinomax, SureSight, and VIP single, crowded Lea Symbols VA screening test system at 5 feet. Eye care professionals can improve detection of strabismus by combining unilateral cover test with a refraction test and trained lay screeners can improve detection of strabismus by combining Stereo Smile II with SureSight. The best performing tests had high testability whether performed by trained eye care professionals, nurses, or lay screeners (>/=98%). Although very few children were unable to complete these tests, a child who was "unable" was much more likely to have a vision problem than a child who passed; therefore, children who are unable to complete one of these tests should be referred for further evaluation. When screening using the Retinomax, repeated testing to achieve the manufacturer's suggested confidence number is valuable and improves specificity. Federal initiatives to increase the number of pre-school children receiving vision screening or examination will increase the number of pre-school children identified with amblyopia, strabismus, and/or significant refractive error. Although there is general agreement regarding the importance of early detection of amblyopia, controversy exists regarding the importance of early detection of refractive error. Because of the high prevalence of significant refractive errors and lack of evidenced-based guidelines for correction of refractive error in pre-school children, future research is needed to evaluate the value of correcting refractive errors in preschoolers who do not have amblyopia and/or strabismus.

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