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Hudson, A. and S. Donahue (2005). "Review of results of pre-school vision screening." Invest Ophthalmol Vis Sci 46: Eabstract 686.
Purpose: Amblyopia is a common cause of vision loss and may be preventable by early detection and treatment of its underlining etiology. The vision in preschoolers study (VIP) recently evaluated several vision screening instruments and found that the Welch Allyn Sure Sight had the potential to be an effective screening instrument, providing that new referral criteria are incorporated into the instrument. However, the VIP study performed field testing using trained pediatric eye doctors rather than lay personnel, and the criteria proposed for referral were determined post hoc. Thus, it is unclear if the Welch Allyn Sure Sight can be effective when utilized by lay screeners and with the proposed referral criteria. We evaluated the effectiveness of the Welch Allyn Sure Sight under these conditions.
Methods: Over the past 7 years, volunteers from local Lions' Clubs have screened over 140,000 preschool children in Tennessee for amblyopia and other sight–threatening conditions. The participants, 2 to 5 year old pre–schoolers, were selected and screened with the Welch Allyn Sure Sight instrument at the local day cares, Mother’s Day Out programs, and preschools through the Tennessee Lion’s Outreach Program by their standard volunteer personnel. The new VIP criteria were programmed into the Sure Sight instrument and used for referral. Referred children were evaluated by local Optometrists or Ophthalmologists and the results of the formal examination, including cycloplegic refraction, were forwarded to Vanderbilt. Failure criteria were the standard criteria for "amblyogenic factors" proposed and published by the AAPOS Vision Screening Committee. Results: We have currently screened over 1200 children in an ongoing study. Ninety–nine percent of the children have been successfully screen tested. The current referral rate averages 8.0% and the reasons for referral includes 5.3% for astigmatism,1.3% for anisometropia, 1.1% for hyperopia, and 0.3% for high myopia. Although follow up of referred children has been limited, the predictive value positive is averaging 50%, with a higher PPV for suspected hyperopia and anisometropia, and a low PPV for astigmatism.
Conclusions: The Welch–Allyn Sure Site Vision Screening Instrument has a reasonable referral rate and PPV when used in the field, provided that the VIP referral criteria are used. Over-referrals are still a problem, primarily because patients referred for suspected astigmatism are often found to be normal. Further refinements of referral criteria will increase predictive value and should be investigated.

INTRODUCTION: The prospective Vision in Preschoolers (VIP) study evaluated 11 methods of screening and proposed referral criteria for the Welch Allyn SureSight(trade mark) Vision Screener with 90% and 94% specificity. The SureSight had a higher sensitivity than most other screening techniques when these criteria were applied. We evaluated the usefulness of these criteria in a field study of healthy preschool children. METHODS: The SureSight software was altered to recommend referral using the VIP referral criteria with 90% specificity. Lions Club volunteers screened preschool children throughout Tennessee. Referred children underwent comprehensive eye examinations with cycloplegic refraction. Examination failure criteria were based upon published standards. Reanalysis using the 94% specificity criteria was then performed. Outcomes included referral rate and positive predictive value. RESULTS: The SureSight was used to screen 4,733 children, and screening was successful in 99.7% of children. The referral rate using the 90% specificity criteria was 12.2%. Most children (73%) were referred for suspected astigmatism. The positive predictive value was 30%. Using the 94% specificity criteria from the VIP study decreased the referral rate to 7.9% and substantially decreased over referral for suspected astigmatism; however, several anisometropes went undetected. Higher specificity was achieved by raising astigmatism referral criteria to 2.2 diopters while leaving the anisometropia criteria unchanged. CONCLUSIONS: The SureSight can be used successfully for preschool screening in the field provided that criteria with high specificity are incorporated into the instrument's software program. Higher rates of positive predictive value can be achieved without jeopardizing sensitivity by raising astigmatism referral criteria to 2.2 diopters.1

1.         Rowatt AJ, Donahue SP, Crosby C, Hudson AC, Simon S, Emmons K. Field evaluation of the Welch Allyn SureSight vision screener: incorporating the vision in preschoolers study recommendations. J Aapos. Jun 2007;11(3):243-248.

Suresight References: 1.         Impact of Confidence Number on Accuracy of the SureSight Vision Screener. Optom Vis Sci. Feb;87(2):96-103.
2.         Harvey EM, Dobson V, Miller JM, et al. Accuracy of the Welch Allyn SureSight for measurement of magnitude of astigmatism in 3- to 7-year-old children. J AAPOS. Oct 2009;13(5):466-471.
3.         Kulp MT. Findings from the Vision in Preschoolers (VIP) Study. Optom Vis Sci. Jun 2009;86(6):619-623.
4.            Silverstein E, Lorenz S, Emmons K, Donahue SP. Limits on improving the positive predictive value of the Welch Allyn SureSight for preschool vision screening. J AAPOS. Feb 2009;13(1):45-50.
5.         Rogers DL, Neely DE, Chapman JB, et al. Comparison of the MTI Photoscreener and the Welch-Allyn SureSight autorefractor in a tertiary care center. J AAPOS. Feb 2008;12(1):77-82.
6.         Does assessing eye alignment along with refractive error or visual acuity increase sensitivity for detection of strabismus in preschool vision screening? Invest Ophthalmol Vis Sci. Jul 2007;48(7):3115-3125.
7.         Lang D, Leman R, Arnold AW, Arnold RW. Validated portable pediatric vision screening in the Alaska Bush. A VIPS-like study in the Koyukon. Alaska Med. Jan-Mar 2007;49(1):2-15.
8.            Maguire MG. Children unable to perform screening tests in vision in preschoolers study: proportion with ocular conditions and impact on measures of test accuracy. Invest Ophthalmol Vis Sci. Jan 2007;48(1):83-87.
9.         Rowatt AJ, Donahue SP, Crosby C, Hudson AC, Simon S, Emmons K. Field evaluation of the Welch Allyn SureSight vision screener: incorporating the vision in preschoolers study recommendations. J AAPOS. Jun 2007;11(3):243-248.
10.            Preschool vision screening tests administered by nurse screeners compared with lay screeners in the vision in preschoolers study. Invest Ophthalmol Vis Sci. Aug 2005;46(8):2639-2648.
11.       Ying GS, Kulp MT, Maguire M, Ciner E, Cyert L, Schmidt P. Sensitivity of screening tests for detecting vision in preschoolers-targeted vision disorders when specificity is 94%. Optom Vis Sci. May 2005;82(5):432-438.
12.            Kemper AR, Keating LM, Jackson JL, Levin EM. Comparison of monocular autorefraction to comprehensive eye examinations in preschool-aged and younger children. Arch Pediatr Adolesc Med. May 2005;159(5):435-439.
13.            Buchner TF, Schnorbus U, Grenzebach UH, Busse H. Examination of preschool children for ametropia: first experiences using a new hand-held autorefractor. Strabismus. Jun 2004;12(2):111-117.
14.       Iuorno JD, Grant WD, Noel LP. Clinical comparison of the Welch Allyn SureSight handheld autorefractor versus cycloplegic autorefraction and retinoscopic refraction. J AAPOS. Apr 2004;8(2):123-127.
15.            Schmidt P, Maguire M, Dobson V, et al. 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.
16.            Schimitzek T, Schworm HD. Wave-front analysis as screening technique for amblyogenic ametropia with and without cycloplegia. Strabismus. Sep 2003;11(3):133-143.
17.            Buchner TF, Schnorbus U, Grenzebach UH, Stupp T, Busse H. [Examination of preschool children for refractive errors. First experience using a handheld autorefractor]. Ophthalmologe. Nov 2003;100(11):971-978.
18.            Suryakumar R, Bobier WR. The manifestation of noncycloplegic refractive state in pre-school children is dependent on autorefractor design. Optom Vis Sci. Aug 2003;80(8):578-586.
19.       Steele G, Ireland D, Block S. Cycloplegic autorefraction results in pre-school children using the Nikon Retinomax Plus and the Welch Allyn SureSight. Optom Vis Sci. Aug 2003;80(8):573-577.
20.       Adams RJ, Dalton SM, Murphy AM, Hall HL, Courage ML. Testing young infants with the Welch Allyn suresight non-cycloplegic autorefractor. Ophthalmic Physiol Opt. Nov 2002;22(6):546-551.
21.            Schimitzek T, Wesemann W. Clinical evaluation of refraction using a handheld wavefront autorefractor in young and adult patients. J Cataract Refract Surg. Sep 2002;28(9):1655-1666.

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