PURPOSE:Currently, there are neither guidelines for school-based vision program operations nor a registry of programs that exist in the United States. We aim to describe the characteristics of school-based vision programs across the United States through a survey. METHODS:We identified 10 organizations that operated one or more school-based vision programs during the 2022-2023 school year. We developed and distributed an online survey form to collect information on program demographics, program components, and protocols for vision screenings and eye exams, as well as procedures for obtaining consent, dispensing glasses, and funding resources. Organizations were asked to complete a survey for each school district in which they operated, which we defined as an individual program. Programs that did not complete the survey were excluded. We used descriptive statistics to describe program characteristics. We compared grade levels that received vision screening by school-based vision programs and their respective screening mandate in the state where the programs operated. RESULTS:Seven organizations participated and provided data about 184 unique school-based vision programs. These programs operated in 19 states and the District of Columbia. All 184 programs provided vision screenings, eye exams, and eyeglasses. 94.6% of programs included instrument-based screening, with 46.7% using it exclusively. School-based vision programs most frequently screened elementary school grades. For eye exams, 81% of programs utilized opt-out consent; 21.7% of programs included dilation. Vision screenings were mostly conducted by program staff (164/184, 89.1%), and eye exams were performed by optometrists (183/184, 99.5%). Nine programs (5.0%) reported providing additional care beyond eyeglasses provision, while 135 (73.4%) reported having an established relationship with community eye care providers for students referred for additional evaluation and care. CONCLUSIONS:Many school-based vision programs operate in the United States. These programs focus on vision screening, eye exams, and eyeglasses provision. Establishing a registry of programs would help to disseminate lessons learned and track outcomes data. Future programs will benefit from guidelines to ensure they are operating according to best practices.

Here, we describe vision health in aging adults living with HIV (PLWH) and comparable people without HIV (PWOH) from the MACS/WIHS Combined Cohort Study (MWCCS). PLWH and PWOH aged 60 years and older were recruited from Baltimore/Washington, DC, from September 2021 to September 2023. Exact matching and sample weights were used to create age-balanced comparisons. Visual impairment (VA worse than 20/40 after refraction or CS worse than 1.50 logCS in the better eye) and the presence of eye pathology were assessed. We studied 74 PLWH (97% virally suppressed) and 65 PWOH, aged 61 to 79 years, 36% Black, and 87% male. For PLWH and PWOH, distance VA impairment was noted in 4% vs. 1%, respectively, and uncorrected refractive error in 15% vs. 5%. More than half had signs of dry eye disease (63% for PLWH and 51% for PWOH). About half of PLWH had developed at least an early stage of cataract, compared to 20% of PWOH. Posterior chamber abnormalities were observed in 4% and 0%, and glaucomatous changes in 19% and 25% of PLWH and PWOH, respectively. The need for eyecare was high among this sample of PLWH with viral suppression and PWOH.

PURPOSE:To evaluate rates of vision screening failure, eye exam completion, eyeglass prescribing, and follow-up recommendations from a school-based vision program (SBVP). DESIGN:Retrospective cross-sectional analysis. PARTICIPANTS:Pre-kindergarten through 5th grade students (ages 4-13) who underwent school-based screening in Fort Worth, Texas in 2022-2024. METHODS:Students who failed screening were offered school-based eye exams. Parent-reported demographics and school-level economic disadvantage (Free and Reduced-Price Meals; FARM%) were extracted. Mixed-effects logistic regression evaluated associations of grade, gender, race, ethnicity, eyeglass wear at screening, and FARM% for screening failure, eye exam after failure, and eyeglass prescription among exam completers. Associations between ocular diagnoses and follow-up interval, categorized as <6 months or ≥6 months, were tested using chi-square or Fisher's exact tests. MAIN OUTCOME MEASURES:Rates of screening failure, eye exam completion, eyeglass prescription, and follow-up interval. RESULTS:Among 41,236 students screened across 81 schools (median FARM%: 93.9%), 64.0% were Hispanic. Overall, 8,682 (21.1%) failed screening; 3,873 (44.6%) completed an eye exam. Hispanic and Black students had higher odds of screening failure (OR 1.35, 95% CI 1.25-1.46; 1.36, 95% CI 1.25-1.48, respectively) compared to non-Hispanic and non-Black students, respectively. After screening failure, Hispanic students had higher odds of completing an eye exam (OR 1.27, 95% CI 1.08-1.48), whereas Black students had lower odds (OR 0.82, 95% CI 0.69-0.97). Students with greater school-level economic disadvantage had higher odds of screening failure (OR 1.17 per 10% FARM increase, 95% CI 1.14-1.21) and completing an exam after failure (OR 1.24 per 10% increase, 95% CI 1.13-1.38). Among 3,767 students examined, 14.2% were recommended follow-up <6 months. Earlier follow-up was more common among those with amblyopia/amblyopia suspect (68.9% vs 6.6%) and strabismus (64.1% vs 13.3%) compared to those without (both p<0.001). CONCLUSIONS:In a predominantly Hispanic, economically disadvantaged district, this SBVP identified substantial unmet vision needs with disparities in screening failure and eye exam completion. Earlier follow-up recommendations were more common for high-risk diagnoses. Future work should focus on understanding whether students successfully connect to follow-up care after referral and developing guidelines to support children with ongoing eye care needs beyond SBVPs.

Purpose:To investigate progression rates of ocular biometry in various ocular shapes using three-dimensional magnetic resonance imaging (3D MRI). Methods:Highly myopic participants (spherical power ≤ -6 diopters [D]) of the prospective cohort study underwent ocular biometry, cycloplegic refraction and MRI examinations. Ocular shapes were classified using 3D MRI as spheroidal, ellipsoidal, conical, nasally distorted, temporally distorted, or barrel shaped. Spheroidal and ellipsoidal shapes were further categorized into non-deformed forms and other shapes were deformed. Mixed-effects model was used to assess the association between the change rate of spherical equivalent (SE) and ocular biometry and ocular shape. Machine learning models were developed to predict annual AL and SE progression rates. Results:A total of 150 eyes including 89 non-deformed eyes and 61 deformed eyes from 75 Participants (36 females [48.00%]) were followed up for 6.70 ± 2.66 years, with a mean age of 34.30 ± 13.43 years. Mean SE and axial length (AL) were -11.49 ± 3.76 D and 28.23 ± 1.72 mm. Eyes showed progressive myopic shift (-0.36 D/y; 95% confidence interval [CI], -0.45 to -0.26) and axial elongation (0.07 mm/y; 95% CI, 0.06-0.08). Deformed ocular (61 eyes) exhibited faster SE progression (β = -0.20, P < 0.001) and AL elongation (β = 0.05, P < 0.001) compared with non-deformed shapes (89 eyes). For annual AL progression, the random forest model achieved the lowest root mean square error (RMSE) (0.067; 95% CI, 0.048-0.087). For annual SE progression, the XGBoost model outperformed other algorithms with the lowest RMSE (0.644; 95% CI, 0.192-1.248). Conclusions:Ocular shapes continue to progress in SE and AL, with deformed ocular demonstrating higher rates of SE and AL than non-deformed shapes. Translational Relevance:A 3D MRI-based ocular shape identifies highly myopic eyes at increased risk of rapid biometric progression.

SIGNIFICANCE:School-based vision programs can improve children's access to vision care in underserved areas. Little is known about the need for eyeglasses among students not wearing them compared with the need for prescription updates. A greater understanding of prescription trends will help identify gaps in care and inform resource allocation. PURPOSE:We aim to describe the baseline eyeglasses-wearing status and the need for new and updated eyeglasses prescriptions for students participating in a large school-based vision program. METHODS:This cross-sectional analysis examined retrospective data from the 2016-2022 operations of the Helen Keller Intl's United States Vision Program. Included students were pre-kindergarten to grade 12 and had received a school-based eye examination after a failed vision screening. Data extracted included student demographics, self-reported eyeglasses-wearing status, lensometer measurement, refractive error, and eyeglasses prescription. Multivariate logistic regression models were implemented to understand the factors associated with eyeglasses prescription and prescription change, defined as at least 0.50 D spherical equivalent change or 0.75 D cylindrical change between lensometer measurement and final prescription. RESULTS:Of the 97,069 students included in the analysis, 27.3% of students were self-reported current wearers of eyeglasses, 30.5% were inactive wearers of eyeglasses, and 42.2% were nonwearers. Overall, 72,784 (75%) students were prescribed eyeglasses. Among them, 48,600/72,784 (67%) were not current wearers. On multivariate logistic regression, students were more likely to be prescribed eyeglasses if they were in higher grade levels (grades 11 to 12 compared with grades 1 to 2, odds ratio: 2.39, 95% confidence interval: 2.17 to 2.64) and were current wearers (odds ratio: 8.82, 95% confidence interval: 8.24 to 9.43). Among current wearers, students with at least 6 D myopia and at least 3 D astigmatism had the greatest likelihood of spherical equivalent and cylindrical prescription change, respectively. CONCLUSIONS:Within a large sample of students enrolled in a school-based vision program, more than half reported having eyeglasses. However, two in three students who needed eyeglasses were not wearing them. The need for eyeglasses was notable across all age groups, especially among higher grade levels and those with more severe refractive error. Most students who failed a vision screening while wearing eyeglasses needed an eyeglasses prescription update.

Obtaining parental consent is a crucial step for students to receive eye examinations in school-based vision programs (SBVPs). Using paper consent forms is challenging and may limit responses. We explored a novel, phased, multimodal consent approach in a Baltimore SBVP to increase program participation during the 2022-23 school year. Vision screenings were provided for all students as part of the program. Consent outreach was conducted for all students prior to vision screening (universal phase) and again after for students who failed a vision screening (targeted phase). Email consent only was used during the universal phase, whereas a tiered approach that combined email, paper, and telephone was used in the targeted phase. Of the 46 schools that implemented multimodal consenting, the mean overall consent response rate was 86% ± 9.3% (range, 62%-99%). Mean universal and targeted consent response rate was 15% (95% CI, 13%-18%) and 71% (95% CI, 68%-74%), respectively. Among targeted consent responses, 10% were obtained by email, 26% by paper, and 64% by telephone.

Purpose:To determine the impact of eye shape using three-dimensional magnetic resonance imaging on myopic maculopathy (MM) progression.Methods:At baseline, 67 participants with high myopia were selected. Eye shape was classified into spheroidal, ellipsoidal, temporally distorted, nasally distorted, conical, and barrel-shape identified from three-dimensional magnetic resonance imaging. Spheroidal and ellipsoidal shapes were defined as nondeformity; others were defined as eye deformity. Myopic maculopathy progression was determined through color fundus photography.Results:Within a 4-year follow-up, 17.1% (7/41) of patients with nondeformed eye shape had MM progression, whereas 69.2% (18/26) of patients with eye shape deformity had MM progression. In multivariable analysis, eye shape deformity (odds ratio, 4.35; 95% confidence interval, 1.10-17.29; P = 0.036) and axial length of >= 28 mm (odds ratio, 12.75; 95% confidence interval, 2.27-71.48; P = 0.004) significantly correlated with MM progression. The predictive discrimination of eye shape alone for MM progression did not differ from axial length (area under the curve: 0.765 vs. 0.750, P = 0.486). By incorporating age, sex, axial length, and eye shape, the prediction model achieved an area under the curve of 0.862 for discriminating MM progression.Conclusion:Eye shape deformity assessed by three-dimensional magnetic resonance imaging is a novel predictor for MM progression in high myopia.

BACKGROUND:School-based vision programs (SBVPs) can increase children's access to eye care services, yet some children have needs beyond the scope of SBVPs and require referral to community providers. We describe the referral practices of a large United States SBVP. METHODS:A retrospective, cross-sectional analysis was conducted using data from pre-Kindergarten through grade 12 students (5-22 years of age) who underwent an SBVP eye examination after a failed vision screening. Data on student demographics, refractive error, and school-level indicators of socioeconomic disadvantage were extracted. The proportion of students referred to community eye care was assessed. Mixed-effects logistic regression models were implemented to understand associations between referral status and student-or school-level characteristics. RESULTS:Of 97,107 students, 72,814 (75.0%) received eyeglasses and 13,884 (14.3%) were referred to community providers. Referrals were more common among younger students and those with greater school-level indicators of socioeconomic disadvantage. Compared with students with emmetropia, students with high hyperopia (OR = 7.21; 95% CI, 5.77-9.01) and high myopia (OR =3.70; 95% CI, 3.36-4.05) were more likely to be referred. Frequent referral reasons included refractive error (42.1%), amblyopia suspect (26.6%), and uncorrectable vision (26.1%). Nonreferred students were more likely to receive eyeglasses prescriptions (85.9% vs 9.4%). CONCLUSIONS:SBVPs can address most uncorrected refractive error within the school setting, but a substantial proportion of students need further evaluation. Young students and those with high refractive error are more likely to require referral. SBVPs may benefit from developing resources and community networks to support students' referral completion.

Purpose:Uncorrected visual impairment (VI) significantly impacts life quality and exacerbates age-related health issues. Social determinants of health (SDOH) are associated with uncorrected VI, but quantitative evidence is limited. This study investigated the link between SDOH and uncorrected VI among aging adults to identify disparities and improve vision care. Methods:We used data from the Atherosclerosis Risk in Communities (ARIC) study visits 4 and 6 and the ancillary Eye Determinants of Cognition (EyeDOC) study. We included subjects who were >70 years old and extracted their sex, race, residence, household income, education level, having an eye doctor, health insurance status, and Area Deprivation Index (ADI) and vision outcomes. Uncorrected VI was categorized into uncorrected distance (UDVI) or near visual impairment (UNVI). Associations between SDOH indicators and VI were evaluated using logistic regressions. Results:Among 967 adults (mean ± SD age, 78.6 ± 4.35 years; 37.9% male), UDVI was found in 293 and UNVI in 186. Living in Jackson, MS, was associated with lower odds for UNVI (adjusted odds ratio [aOR] = 0.36; 95% CI, 0.20-0.65). Higher odds for UNVI were associated with male sex (aOR = 2.01; 95% CI, 1.41-2.87), low educational attainment (aOR for not completing high school = 2.32; 95% CI, 1.37-3.92; aOR for high school only = 1.92; 95% CI, 1.26-2.92), no eye doctor (aOR = 1.58; 95% CI, 1.05-2.39), and having government health insurance only (aOR = 1.48; 95% CI, 1.00-2.17). Associations between SDOH factors and UDVI were weaker or non-existent. Conclusions:This study links SDOH factors to uncorrected VI among older adults. Translational Relevance:SDOH should be considered when designing interventions to reduce VI in vulnerable communities.

Aims To investigate the characteristics of myopic maculopathy among highly myopic Chinese children and adolescents and explore its associated risk factors. Methods Children and adolescents aged 7–17 years with spherical equivalent (SE) ≤ −6.00 dioptres (D) were recruited. Myopic maculopathy was categorised based on the International Meta-Analysis of Pathological Myopia Classification. The extent of diffuse choroidal atrophy (DCA) was classified using Early Treatment Diabetic Retinopathy Study grid (ETDRS). The area of DCA was categorised into three classes relative to optic disk area (DA): A1 (≤1 DA), A2 (1 to ≤5 DA) and A3 (5 to ≤10 DA). Logistic regression was used to identify risk factors associated with myopic maculopathy. Results Of the 425 participants aged 13.66±2.67 years, the proportions of tessellated fundus and DCA were 11.76% and 12.24%, and no more severe fundus lesions or ‘plus’ lesions. The proportion of DCA was 27.03% in children under 11, significantly higher than the 9.12% observed in those aged 11 and older (p<0.001). The percentages of DCA involving the outer, middle and central circles of the ETDRS grid were 42.31%, 55.77% and 1.92%. Myopic maculopathy was significantly associated with younger age (p<0.001), longer axial length (AL; p<0.001) and larger β-zone peripapillary atrophy (β-PPA; p=0.012). Conclusion In highly myopic children and adolescents, myopic maculopathy predominantly manifested as DCA (12.24%), with no cases of worse myopic maculopathy or ‘plus’ lesions. Younger age, longer AL and larger β-PPA were risk factors for myopic maculopathy.

PURPOSE:To describe refractive error findings and associated factors in students who received school-based eye exams following vision screenings. METHODS:Cross-sectional study of pre-kindergarten through 12th grade students who failed vision screening and underwent a school-based eye exam in the Northeast region of the United States during 2016-2022. Non-cycloplegic autorefraction and visual acuity measurements were used to categorize refractive error by type and severity. Main outcomes included any refractive error (at least -0.50D myopia, +0.50 hyperopia, 1.00D astigmatism, or 1.00D anisometropia), clinically significant refractive error (CSRE; more severe refractive error with decreased vision), and refractive amblyopia risk (RAR). Multivariable mixed-effects logistic regression was used to determine student- and school-level characteristics associated with refractive error outcomes. RESULTS:Of 103,159 included students who failed screening, 95,875 (92.9%) were analyzed. Overall prevalence of any refractive error was 94.2%, with 81.7% having CSRE. Pre-kindergarten & kindergarten students had the highest prevalence of CSRE (85.7%), which dropped to 77.0% by 3rd and 4th grade before rising with each higher grade level thereafter. Prevalence of RAR was 60.9% overall and highest in pre-kindergarten and kindergarten students (73.8%). Myopia was the most prevalent refractive error, followed by astigmatism, anisometropia, then hyperopia. The odds of hyperopia, astigmatism, and anisometropia decreased with higher grade level. CONCLUSION:Over 80% of students who failed vision screening at a large school-based vision program had CSRE, and over 60% had RAR. Pre-kindergarten and kindergarten students had an especially high prevalence of RAR. Refractive error remained common in every grade level.

Importance:Individuals with high myopia younger than 18 years are at relatively high risk of progressively worsening myopic maculopathy. Additional studies are needed to investigate the progression of myopic maculopathy in this age group, as well as the risk factors associated with progression. Objective:To investigate the 4-year progression of myopic maculopathy in children and adolescents with high myopia, and to explore potential risk factors. Design, Setting, and Participants:This hospital-based observational study with 4-year follow-up included a total of 548 high myopic eyes (spherical power -6.00 or less diopters) of 274 participants aged 7 to 17 years. Participants underwent comprehensive ophthalmic examination at baseline and 4-year follow-up. Myopic maculopathy was accessed by the International Photographic Classification and Grading System. The data analysis was performed from August 1 to 15, 2023. Main Outcomes and Measures:The progression of myopic maculopathy progression over 4 years and associated risk factors. Results:The 4-year progression of myopic maculopathy was found in 67 of 548 eyes (12.2%) of 274 participants (138 girls [50.4%] at baseline and 4-year follow-up) with 88 lesion changes, including new signs of the tessellated fundus in 16 eyes (18.2%), diffuse atrophy in 12 eyes (13.6%), patchy atrophy in 2 eyes (2.3%), lacquer cracks in 9 eyes (10.2%), and enlargement of diffuse atrophy in 49 eyes (55.7%). By multivariable analysis, worse best-corrected visual acuity (odds ratio [OR], 6.68; 95% CI, 1.15-38.99; P = .04), longer axial length (AL) (OR, 1.73; 95% CI, 1.34-2.24; P < .001), faster AL elongation (OR, 302.83; 95% CI, 28.61-3205.64; P < .001), and more severe myopic maculopathy (diffuse atrophy; OR, 4.52; 95% CI, 1.98-10.30; P < .001 and patchy atrophy; OR, 3.82; 95% CI, 1.66-8.80; P = .002) were associated with myopic maculopathy progression. Conclusions and Relevance:In this observational study, the progression of myopic maculopathy was observed in approximately 12% of pediatric high myopes for 4 years. The major type of progression was the enlargement of diffuse atrophy. Risk factors for myopic maculopathy progression were worse best-corrected visual acuity, longer AL, faster AL elongation, and more severe myopic maculopathy. These findings support consideration of follow-up in these individuals and trying to identify those at higher risk for progression.

PURPOSE:School-based vision programs (SBVPs) deliver care to students at school, addressing disparities in access to pediatric vision care. We aimed to evaluate the associations between SBVP outcomes and school-level characteristics. DESIGN:Retrospective cross-sectional data analysis. PARTICIPANTS:Public schools with at least 50 SBVP-enrolled students 5 to 22 years old with complete demographic data. Schools with less than 60% of total grade levels served by the SBVP were excluded, creating a sample of 410 schools. METHODS:Vision screening and eye examination data were extracted from 2016-2022 Helen Keller International's United States Vision Program dataset. Individual student data were aggregated to characterize each school's SBVP outcomes and were analyzed with schools' publicly available socioeconomic and demographic data (student body race and ethnicity composition, proportion of students qualifying for free and reduced-price meals [FARM], and proportion of English language learners). Fractional regression models were used to understand associations between SBVP outcomes and school characteristics. MAIN OUTCOME MEASURES:SBVP outcomes were rates of vision screening failure, prescriptions for eyeglasses, and community eye care referral among each school's SBVP-enrolled students. RESULTS:We evaluated 151 elementary schools (36.8%), 155 middle schools (37.8%), and 104 high schools (25.4%), with a median proportion of students qualifying for FARM of 87.4% and a plurality of Hispanic students in 61.0% of schools. Median rates of vision screening failure, eyeglasses prescription, and referral were 38.4%, 25.2%, and 5.4%, respectively. High schools were associated with increased screening failure and eyeglasses prescription rates and a decrease in referral rate compared with elementary schools. In multivariable analysis, each 10% increase in proportion of students qualifying for FARM was associated with a 2.6% (95% confidence interval [CI]: 1.54%-3.65%), 1.8% (95% CI, 0.87%-2.74%), and 0.86% (95% CI, 0.36%-1.36%) increase in screening failure, prescriptions for eyeglasses, and referral rates, respectively. CONCLUSIONS:Significant vision care demand exists among public schools, especially those with students from lower socioeconomic backgrounds. School-based vision programs are important in improving pediatric vision care access. Our findings demonstrated opportunities to allocate personnel and equipment resources according to schools' anticipated needs, thus maximizing SBVPs' impact. FINANCIAL DISCLOSURE(S):Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.