PURPOSE:Recent publications have proposed alternative retinopathy of prematurity (ROP) screening guidelines balancing efficiency with safety. We used the 28-hospital ROP CheckⓇ higher-risk, racially diverse database to perform external validation. ROP Check is neonatology/ophthalmology software that combines customizable, guideline-based screening and ophthalmology monitoring of staging ROP examinations and treatment. DESIGN:Retrospective analysis of screening guideline sensitivity. METHODS:We reviewed encounter volumes from 2010 to 2022 of infants whose entire hospital stay was monitored with ROP Check. Patients with primary laser or anti-vascular endothelial growth factor (anti-VEGF) therapy were compared with recent-encounter volume-reducing (2%-8.6%) proposals. RESULTS:A total of 5058 infants had 23,557 physician-patient encounters. Of these, 388 infants required ROP treatment, including 3 patients (1 of Pacific and 2 of non-Pacific race/ethnicity) with gestational age (GA) of 30.0 to 30.9 weeks. The 174 patients treated initially with laser had larger median bodyweight (BW) (706 g) than the 214 initially treated with anti-VEGF (620 g), older GA (25.1 vs 24.4 weeks), older GA at initial treatment (36.6 vs 35 weeks), fewer encounters (10 vs 13), and fewer examinations after treatment (3 vs 7). Six cases reached stage 4. We raise concerns that some of our treatment-warranted infants reached the threshold for treatment before the GA recommended by some recently proposed screening guideline modifications. However, cutting the last half-week GA screening guideline reduced encounters by 2.5%, whereas using ROP Check "if necessary" for BW <1400 and GA <30 weeks for infants of non-Pacific races/ethnicities cut encounters 7.8% without missing treatable infants. CONCLUSIONS:The proposed modifications of currently accepted screening guidelines for premature infants in the United States could reduce the volume of encounters, but must account for high-risk Pacific race/ethnicity infants, who require more sensitive screening.

Background: ROP Check® monitoring and documentation software from 28 American hospitals collected clinical data from 2010 to 2024 representing infants from a wide range of races and ethnicities. Methods: De-identified data compared gender to treatment status, race, birthweight (BW), gestational age (GA) and gestational age at first treatment. Results: From 7070 total patients, with 5060 having timely or early initial exams based on American Academy of Pediatrics (AAP) guidelines, 386 had treatment for ROP. Males constituted 54.3% of treated infants and 54.4% of all infants. There was no gender difference in gestational age or age at treatment, but males had greater birthweights (685 to 610 g). There were more females treated under 600 g. There were race-related birthweight differences in infants treated for ROP. Conclusion: There are more males screened and treated for ROP, but treatment rates are similar for both genders. Male preponderance reverses for infants with birthweight less than 600 g. Race has an influence on treated ROP.

Background:Extraocular muscle (EOM) tension during strabismus surgery produces trigemino-vagal bradycardia as a form of the oculocardiac reflex (OCR). Surface pain in the eye can cause bradycardia in premature infant eye examinations, so we evaluated the effect on the heart rate of different aspects of strabismus surgery. Methods:Electrocardiograph heart rate (H.R.) was monitored during outpatient strabismus surgery without anticholinergic or local anesthetic. The impact of limbus-based conjunctival incision was compared to 200 gram, 10-second tension on rectus muscles. Results:The 239 patients aged 0.6 to 83 years (16±20) during the limbal conjunctival incision had median change in H.R. from 100 bpm to 103 bpm, while initial rectus tension changed from 102 bpm to 75 bpm. Compared to median (and interquartile range) %HR with incision of 100% (100%, 101%) the corresponding first rectus tension 82% (65%, 98%) and subsequent rectus tension 80% (65%, 92%) were significantly greater (Kruskal-Wallis X2(2) = 251, p < 0.001) independent of gender, race, iris color, neurologic deficit, use of fentanyl or dexmedetomidine. Younger patients had greater percent heart rate drop with muscle tension but not conjunctival incision. Conclusion:Despite uninhibited pain receptors and general anesthesia in children and adults, conjunctival incision produced essentially no OCR compared to EOM rectus tension. Clinical Trials Registry:Clinical trial registration NCT04353960. Data Access:https://www.abcd-vision.org/references/OCR%20Incision%202025.pdf.

Background:Portable sphero-cylinder refraction is useful for remote medical missions and self-checking. A novel, inexpensive, handheld optical scope with an internal vision chart and adjustable diopter lens, called the Moptim MRT-200, was therefore validated. Methods:Young, capable patients from a pediatric eye practice had dry refraction estimates with the Moptim MRT-200, Adaptica 2WIN photoscreener, and Monocular Retinomax compared with actual refined retinoscopy. Vector-converted sphero-cylinder refractions and the univariate ABCD Ellipsoid were used for comparison as well as monocular visual acuity. Results:206 racially diverse, high-risk refractive patients with median "Ellipsoid-Gap" of 3.5 had high correlation spherical equivalent and similar ABCD Ellipsoid comparing Moptim MRT-200, 2WIN and Retinomax (Kruskal Wallis X2(5) = 4.2, p = 0.52) however the 61 patients with blur associated with Ellipsoid gap over 5.0 had better refractive accuracy with 2WIN and Retinomax than Moptim MRT-200 (p < 0.001). Visual acuity with Moptim MRT-200 had a weak correlation (ICC.41 AND.47) and a Bland-Altman mean difference of approximately 1 logMAR line less fine than the actual phoropter refraction. Conclusion:Precise sphero-cylinder estimation with the Moptim MRT-200 was too complex for lay screeners and many young patients, especially compared to 2WIN and Retinomax; however, rapid estimation of spherical refraction was feasible and valid.

Ophthalmic professional organizations such as the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) strive to support the optimal detection, prevention, and treatment of amblyopia to reduce the community burden of vision loss. To support population-level monitoring with regard to outcomes of childhood amblyopia screening and treatment, the AAPOS Vision Screening and the Research committees propose a set of guidelines for assessing population prevalence of persistent vision impairment due to amblyopia. The committees defined "residual amblyopia" as persistent vision impairment with best-corrected visual acuity worse than logMAR 0.3 (20/40) in one eye with an interocular difference, or visual acuity worse than logMAR 0.3 in both eyes, attributable to unilateral or bilateral amblyopia respectively, with visual acuity deficits not due to other organic causes. Epidemiological assessment of residual amblyopia should be made at an age when amblyopia should have already been detected and treated (8 years). A standardized assessment of residual amblyopia has the potential to promote public health interventions, including quality-improvement projects, for amblyopia screening and subsequent treatment.

Background:Isolated small-angle (< 20PD) strabismic amblyopia (is-asa) is not obvious to parents and pediatricians and can be missed by current photoscreeners. To improve early screening methods, the previously unknown prevalence and severity of is-asa is estimated from a twenty-year prospective observation. Methods:Published population data from the Multi-Ethnic and Baltimore Pediatric Eye Disease Studies (MEPEDS and BPEDS) were combined to estimate the cumulative prevalence. Then prospective, consecutive digital images of Brückner Test from 2003 to 2025 by one pediatric ophthalmologist were obtained with confirmatory exams. These were then compared to Alaska population and vision screening data. Results:From MEPEDS and BPEDS community screening data, patients with all strabismus, constant strabismus and strabismic amblyopia were stratified by strabismus angle suggesting that isolated small-angle strabismus (is-as) may occur in 1/200 children while is-asa may be 1/400 children. Over 22 years, 34 Alaska Brückner patients had isolated, constant strabismus less than 20 prism diopters of which 9 presented with amblyopia of which 4 had post-treatment residual amblyopia worse than 20/40. Considering population, doctors and referral rates, the Alaska prevalence of is-as is about 1 in 700 (0.03-0.24%) children while is-asa is about 1 in 7000 (0.006-0.024%) children. Conclusion:From two imperfect sources; review of large community screening studies and from prospective Brückner Test analysis, the prevalence of isolated small-angle strabismic amblyopia is so rare that future screening methods would require very high specificity. The Rebion blinq and 2WIN CR-function can identify is-asa in older children. Current photorefraction methods with early specific instrument referral criteria followed by sensitive acuity screening are still effective since is-asa is so rare.

To characterize racial disparities in retinopathy of prematurity (ROP) requiring treatment and to investigate specific treatment patterns across racial groups. Retrospective analysis of de-identified data from ROP Check®, a cloud-based electronic medical record system for neonatology screening and ophthalmology tracking ROP examinations and treatment. Data from 28 hospitals from 2011 to 2022 included 3631 surviving premature infants with recorded race. American Indian/Alaska Native (AI/AN), Asian, and Pacific Islander (PI) infants had the highest rates of ROP treatment at both early (21–25 weeks) and later gestational ages (26–30 weeks) while African American infants had the lowest and most pronounced at later gestational ages (26–30 weeks). AI/AN infants had earlier and more multiple treatments. Our study identifies PI race, alongside AI/AN and Asian backgrounds, as high-risk categories for treatment-warranted ROP. The inclusion of race to gestational age and birthweight enhances the prediction of treatment-warranted ROP.

Background:Seeking a quick way to estimate refractions for challenging pediatric patients, we studied two non-contact methods with particular attention to accuracy and level of stress in uncovering cycloplegic hyperopia.Methods:Newly referred and follow-up pediatric eye patients had timed school bus accommodation-relaxing skiascopy (SBARS) and Plusoptix A12 (Px) photoscreener testing before cyclopentolate 1% confirmatory examinations. The ABCD ellipsoid univariate method based on relative blur and vector components was used to compare dry sphero-cylinder refraction estimates with cycloplegic. Receiver operating characteristic (ROC) curves were used to determine screening value.Results:Three compared refractions were attempted in 191 racially diverse children of whom 100 were age 0.2-3.9 years and 91 were 4 to 14 years. Plusoptix failed to yield a result in 21 and an additional 21 were interpreted as an excess sphere. Median spherical equivalent did not differ between Px and SBARS for 149 with Px readings but in hyperopic patients, Plusoptix uncovered 27% less hyperopia. The ellipsoid for SBARS of 0.8 was better than 2.4 for Plusoptix (Mann-Whitney p<0.001). Plusoptix was fastest (3-15 seconds) followed by SBARS (15-30 seconds) compared to 30-45 minutes for cycloplegic exam.Conclusion:Non-contact quick refractive methods enhanced confirmatory cycloplegic pediatric exam in high-risk pediatric patients.

Introduction Photoscreeners have been shown to provide excellent measurements of the refractive error. However, whether they could be used for assessing cycloplegic refraction has not been examied. This study aimed to evaluate the agreement between cycloplegic and non-cycloplegic measurements obtained using a photoscreener and stationary autorefractor, respectively. Methods This study included all patients undergoing routine ophthalmic examination at the Hygeia Clinic (Poland) from June to July 2022. Each patient underwent non-cycloplegic and cycloplegic refraction assessments using the 2WIN photoscreener (Adaptica SRL, Padova, Italy) and an ARK-1 stationary autorefractor ARK-1 (Nidek Co Ltd., Tokyo, Japan), respectively. Each pair of assessments was conducted in random order, and all values were determined at a vertical distance of 12 mm. The agreement between cycloplegic and non-cycloplegic measurements was assessed using paired t -tests, Bland-Altman and ABCD ellipsoids. Results This analysis included 82 patients, of which 52 were female. Their mean age was 34.39 ± 13.13 years. The non-cycloplegic spherical equivalent (SE) did not differ significantly between the 2WIN (− 1.22 ± 2.45) and ARK-1 (− 1.19 ± 2.96) devices ( p = 0.580). However, the cycloplegic SE values demonstrated more negative values with the 2WIN device (− 1.13 ± 2.19) than with the ARK-1 device (− 0.75 ± 3.03; p = 0.007). The non-cycloplegic and cycloplegic measurements were strongly correlated between the devices ( r = 0.9473 and 0.9411, respectively). However, the correlation between their cycloplegic shifts in SE was low ( r = 0.2645). Ellipsoid refraction aligned better non-cycloplegic (ARK-1 = 1.00; 2WIN = 1.74) than with cycloplegic refraction (ARK-1 = 1.43; 2WIN = 1.90). Conclusion While the cycloplegic measurements obtained with the 2WIN photoscreener were strongly correlated with those obtained with the ARK-1 stationary autorefractor for most of the analyzed parameters, they should not be considered interchangeable.

Background:A new, portable computerized distance vision testing (screen plus remote) system called VisionKeys has been developed by the missions equipment developer EyeMobil so we validated it compared to conventional research testing devices. Methods:Using a standardized protocol of surround HOTV optotype presentation, the VisionKeys was compared to M&S for patched monocular distance visual acuity. A different VisionKeys function with anaglyph spectacle distance stereopsis was compared to near stereo on Titmus circles with Polaroid goggles and PDI Check on an autostereoscopic screen. Raw scores were converted to logarithm and compared with non-parametric and Bland Altman tests. Results:We recruited 145 ethnically diverse patients with range of acuity -0.4 to 2.6 (NLP) logMAR from a pediatric eye and adult strabismus practice showing median logMAR acuity of 0.0 with VisionKeys significantly finer resolution than 0.1 for M&S (Mann-Whitney z=2.6, p=0.01, n=290). VisionKeys acuity correlated very well with M&S and children under age 7 scored coarser than teens and young adults. Median distance log arc seconds stereo on VisionKeys (2.00) differed from near Titmus circles (1.78) and PDI Check (1.89, Kruskal-Wallis X2(2)=9.8, p=0.007) however they all correlated well by Bland Altman. Conclusion:The new, portable VisionKeys system gives valid distance visual acuity with slightly finer estimate compared to M&S and the distance stereo compared well with near Titmus and PDI Check. As such, it should be valuable for testing children and adults in remote locations.

Background:To be successful, amblyopia therapeutic techniques must respond when ingenious (shrewd) amblyopic children sabotage treatment effect by discovering ways(1) to alter those therapy aspects they find frustrating.Methods:Her guardian consented to IRB-approved study outside typical FDA enrollment guidelines for CureSight dichoptic therapy. Acuity (EVA) and stereopsis was by PEDIG protocols.Results:A 6-year-old rural Alaska native girl in foster care had previously been diagnosed with anisometropic amblyopia and treated with spectacles and patching but had poor compliance with BCVA 0.9-1.0 logMAR. She demonstrated exceptional creativity and hyperactivity but had no other medical issues. Atropine was prescribed in addition to her spectacles +5.50+1.00x90 and +0.50+1.00x90, but the patient discovered the rare "Spectacle Flip" method that sabotaged therapeutic impact. She had EVA enrollment acuities of logMAR 0.9 right and -0.1 left with stereo 400 seconds of arc. After just one month dichoptic therapy 1.5 hours 6 days per week, acuity improved to logMAR 0.7 and -0.1 with stereo up to 140 second of arc. Four months later acuity was 0.6 right and -0.2 left. Stereoacuity improved from 400 to 200 arc seconds.Conclusion:Even when conventional compliance methods fail, dichoptic therapy with eye-tracking has the novel and unique potential to improve amblyopia treatment compliance with real-time monitored fixation compliance and confirmation of correct spectacle wear.Clinical Trial Registration:NCT06165705.

https://youtu.be/f0dDGYGl2FM Purpose: Existing and emerging visual acuity methods like dynamic and dichoptic presentation, prefer-ential looking and eye tracking promise to afford better and earlier assessment in children with and without amblyopia so we propose methods needed to easily evaluate and compare their metrics. Subjects and Methods: Patients older than 8 years with treated amblyopia and superb vision (logMAR -0.1 to -0.3) normals performed timed, patched eETDRS with Sloan matching card at 3.00 m and PDI Check dichoptic near rivalry dynamic test to demonstrate test re-Test and compared disparate acuity with intraclass correlation (ICC) and Bland Altman 95% limits of agreement (LOA) to generate a simple method of qualifying acuity test matching.Results: 26 amblyopic patients and 11 superb-vision normals performed eETDRS retest, PDI Check retest and combined ICC of 0.98, 0.60 and 0.27, respectively, and Bland Altman LOA of 0.24, 2.06 and 2.28 logMAR. The time to test one eye with eETDRS had median (interquartile range; IQR) duration of 280 (205 to 346) seconds, while the PDI Check autostereoscopic dichoptic for both eyes only took 39 (30 to 47) seconds. Optimum ICC and LOA for visual acuity comparison should be >0.95 and <0.3 logMAR, whereas "good" ICC and should be 0.75-0.89 ICC and 1.0-1.49 logMAR LOA.Conclusion: Superb vision subjects (logMAR < -0.1) and treated amblyopic patients confirmed optimum comparable eETDRS, and fair test re-Test PDI Check but suppression on near dichoptic testing confirmed disparity compared to optimized eETDRS distance acuity.

Goldstein et al1Goldstein J.E. Guo X. Boland M.V. Smith K.E. Visual acuity: assessment of data quality and usability in an electronic health record system.Ophthalmol Sci. 2023; 3100215https://doi.org/10.1016/j.xops.2022.100215Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar from Johns Hopkins have performed an elegant and important analysis of their data quality associated with ophthalmology’s most important variable, visual acuity (VA). They concluded that direct analysis of electronic medical record (EMR) data at their institution was less than ideal, and even reconstructed data had limited reliability. The problem may be due in part to sloppy direct data entry, but is primarily a result of historically incorrect EMR formatting of VA data. After decades of EMR evolution, is quality VA data dead? Encouragingly, the study noted that my subspecialty of pediatric ophthalmology, which directly deals with non-numeric classification of VA, still had one of the lowest levels of VA unusability (4.5%). Perhaps there is hope. You mention computer-adaptive VA testing and predefined VA-structured fields. How would the authors suggest concrete solutions to the otherwise dismal VA direct data reliability? What solutions are quick, simple, and efficient for the technician while also providing reasonable reliability? Age-based, physiological evidence has recently been employed to provide unique digital equivalents for both pediatric fixation-based VA and low-vision designations similar to your “internal data dictionary” for VA.2Arnold R.W. Digital values for alpha acuities.J Pediatr Opthalmol Strabismus. 2021; 58: 132-135https://doi.org/10.3928/01913913-20210111-02Crossref PubMed Scopus (3) Google Scholar The publication provides formulae that convert such digital or descriptive visual acuities from United States customary units and metrics to logarithm of the minimum angle of resolution (logMAR) and back. What level of logMAR would the authors assign to no light perception blindness? What would it take for all the ophthalmology EMR systems to abandon the alpha character formatting for VA and convert to a uniform, digitally useful version? The sooner, the better. Researchers, policy-makers, physicians, taxpayers, and patients deserve it. Visual Acuity: Assessment of Data Quality and Usability in an Electronic Health Record SystemOphthalmology ScienceVol. 3Issue 1PreviewTo examine the data quality and usability of visual acuity (VA) data extracted from an electronic health record (EHR) system during ophthalmology encounters and provide recommendations for consideration of relevant VA end points in retrospective analyses. Full-Text PDF Open Access

Pediatric Anesthesiology, Central Penninsula Hospital, Soldotna, Alaska, [email protected] Pediatric Ophthalmology and Strabismus, Alaska Children’s Eye and Strabismus, Anchorage, Alaska