Prevalence and Causes of Visual Impairment in Asian and Non-Hispanic White Preschool Children: Multi-Ethnic Pediatric Eye Disease Study

doi:10.1016/j.ophtha.2012.12.029

Ophthalmology

Volume 120, Issue 6, June 2013, Pages 1220-1226

https://doi.org/10.1016/j.ophtha.2012.12.029 Get rights and content

Purpose

To determine the prevalence and causes of decreased visual acuity (VA).

Design

Population-based cross-sectional study.

Participants

Multi-ethnic sample of children 30 to 72 months of age identified in Los Angeles.

Methods

All eligible children underwent a comprehensive ophthalmic evaluation including monocular VA testing, cover testing, cycloplegic autorefraction, fundus evaluation, and VA retesting with refractive correction. Decreased VA was defined as presenting or best-measured VA worse than 20/50 in children 30 to 47 months of age and worse than 20/40 for children 48 months of age and older. The prevalence and causes of decreased VA were determined, for both presenting and best-measured VA, in the better-seeing and the worse-seeing eyes.

Main Outcome Measures

Prevalence and causes of decreased vision.

Results

Presenting VA was assessed in 1840 children and best-measured VA was assessed in 1886 children. Presenting VA was decreased in the worse eye of 4.2% of Asian children and of 3.6% of non-Hispanic white (NHW) children. Close to one-fourth of these cases had no identifiable cause, and 81% of these resolved on retesting. Decreased presenting VA in the worse eye with an identifiable ophthalmic cause was present in 3.4% of Asian children and in 2.6% of NHW children. Decreased presenting VA attributable to simple refractive error (myopia ≥0.5 diopters [D]; hyperopia ≥3.0 D; astigmatism ≥2.0 D or ≥1.5 D for children older than 36 months) was present in the worse eye of 2.3% of Asian children and of 1.4% of NHW children and in the better eye of 0.5% of Asian children and of 0.3% of NHW children. Decreased best-measured VA attributable to a cause was present in the worse eye of 1.2% of both Asian children and NHW children and in the better eye of 0.2% of Asian and of 0.3% of NHW children. Amblyopia related to refractive error was the most common cause, and was 10 times as common as ocular disease. Severe visual impairment was rare.

Conclusions

Seventy percent of all decreased VA in Asian and NHW preschool children and more than 90% of decreased VA with an identifiable cause is related to refractive error—either uncorrected refractive error or amblyopia resulting from refractive error.

Financial Disclosure(s)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Section snippets

Patients and Methods

Details of the methods are published in an accompanying article.3, 4 The visual acuity (VA) testing protocol1, 5 (summarized in Fig 1) was as follows. Presenting single-surround HOTV VA6, 7 was tested with correction, if worn, in children 30 months of age and older. A subsample of children also underwent quality control (QC) retesting of presenting VA. Taking the best result obtained so far for each eye, if VA was decreased in either eye (<20/50, or <20/40 in children 48 months of age or older)

Results

Of 3039 Asian and non-Hispanic white children examined (52% male), 2063 (1018 Asian, 1045 non-Hispanic white) were 30 months of age or older. Of these, 912 Asian children (90%) were able to undergo VA testing for both eyes on the first attempt, as were 927 non-Hispanic white children (89%). One additional non-Hispanic white child with unmeasurable VA (worse than 20/800) in 1 eye resulting from ocular disease also was considered testable in both eyes for the purposes of analysis. These 1840

Discussion

Visual impairment resulting from ocular disease, unilateral or bilateral amblyopia, or probable bilateral ametropic amblyopia was seen in the worse eye of 1.2% of Asian and non-Hispanic white children and in the better eye of 0.2% to 0.3% of Asian and non-Hispanic white children. In addition, correctable presenting VI associated with unmet need for refractive correction was seen in the worse eye of 2.3% of Asian children and of 1.4% of non-Hispanic white children and in the better eye of 0.5%

Acknowledgments

The Multi-Ethnic Pediatric Eye Disease Study investigators thank the following members of the National Eye Institute's Data Monitoring and Oversight Committee for their substantial contributions through critical review and advice: Jonathan M. Holmes, MD (Chair), Eileen E. Birch, PhD, Karen J. Cruickshanks, PhD, Natalie Kurinij, PhD, Maureen G. Maguire, PhD, Joseph M. Miller, MD, MPH, Graham E. Quinn, MD, and Karla Zadnik, OD, PhD.

References (18)

S.A. Cotter et al.
Visual acuity testability in African-American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study
Am J Ophthalmol
(2007)
P.S. Moke et al.
Computerized method of visual acuity testing: adaptation of the Amblyopia Treatment Study visual acuity testing protocol
Am J Ophthalmol
(2001)
P.G. Steinkuller et al.
Childhood blindness
J AAPOS
(1999)
A.S. Pai et al.
Prevalence and risk factors for visual impairment in preschool children: the Sydney Paediatric Eye Disease Study
Ophthalmology
(2011)
D. Robaei et al.
Visual acuity and the causes of visual loss in a population-based sample of 6-year-old Australian children
Ophthalmology
(2005)
A.D. Negrel et al.
Refractive Error Study in Children: sampling and measurement methods for a multi-country survey
Am J Ophthalmol
(2000)
R. McKean-Cowdin et al.
Risk factors for astigmatism in preschool children: the Multi-Ethnic Pediatric Eye Disease and Baltimore Pediatric Eye Disease Studies
Ophthalmology
(2011)
A. Fozailoff et al.
Prevalence of astigmatism in 6- to 72-month-old African American and Hispanic children: the Multi-Ethnic Pediatric Eye Disease Study
Ophthalmology
(2011)
Prevalence and causes of visual impairment in African-American and Hispanic preschool children: the Multi-Ethnic Pediatric Eye Disease Study
Ophthalmology
(2009)

There are more references available in the full text version of this article.

Cited by (52)

Disparities in Vision Health and Eye Care
2022, Ophthalmology
Citation Excerpt :
For example, Black and Hispanic children are more likely to be myopic than White children,161 whereas White and Hispanic children are more likely to be hyperopic than Black children;161 racial and ethnic differences exist for astigmatism as well.27,161–164 The Multi-Ethnic Pediatric Eye Disease Study found a higher prevalence of presenting refractive error–related VI in both Black children and Hispanic children than in either Asian American or non-Hispanic White children.156 Approximately 95% of first-grade students in low-income areas, 95% of whom identified as minority race or ethnicity, did not have glasses to address their decreased visual acuity, and Black and Hispanic students were less likely than non-Hispanic White students to have glasses.165
Wait, what are we screening for again?
2022, Journal of AAPOS
AAPOS uniform guidelines for instrument-based pediatric vision screen validation 2021
2022, Journal of AAPOS
As instrument-based pediatric vision screening technology has evolved, the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) has developed uniform guidelines (2003, updated 2013) to inform the development of devices that can detect specified target levels of amblyopia risk factors (ARFs) and visually significant refractive error. Clinical experience with the established guidelines has revealed an apparent high level of over-referral for non-amblyopic, symmetric astigmatism, prompting the current revision.
The revised guidelines reflect the expert consensus of the AAPOS Vision Screening and Research Committees.
For studies of automated screening devices, AAPOS in 2021 recommends that the gold-standard confirmatory comprehensive examination failure levels include anisometropia >1.25 D and hyperopia >4.0 D. Astigmatism >3.0 D in any meridian and myopia < −3 D should be detected in children <48 months, whereas astigmatism >1.75 D and myopia < −2 D should be detected after 48 months. Any media opacity >1 mm and manifest strabismus of >8^Δ should also be identified. Along with performance in detecting ARFs and refractive error, validation studies should also report screening instrument performance with regard to presence or absence of amblyopia. Instrument receiver operating characteristic curves and Bland-Altman analysis are suggested to improve comparability of validation studies.
Examination failure criteria have been simplified and the threshold for symmetric astigmatism raised compared to the 2013 guidelines, whereas the threshold for amblyogenic anisometropia has been decreased. After age 4 years, lower magnitudes of symmetric astigmatism and myopia are also targeted despite a low risk of amblyopia, because they can influence school performance and may warrant consideration of myopia prevention therapy.
Socioeconomic Status and Vision Care Services in Ontario, Canada: A Population-Based Cohort Study
2022, Journal of Pediatrics
To test the association of material deprivation and the utilization of vision care services for young children.
We conducted a population-based, repeated measures cohort study using linked health and administrative datasets. All children born in Ontario in 2010 eligible for provincial health insurance were followed from birth until their seventh birthday. The main exposure was neighborhood-level material deprivation quintile, a proxy for socioeconomic status. The primary outcome was receipt of a comprehensive eye examination (not to include a vision screening) by age 7 years from an eye care professional, or family physician.
Of 128 091 children included, female children represented 48.7% of the cohort, 74.4% lived in major urban areas, and 16.2% lived in families receiving income assistance. Only 65% (n = 82 833) had at least 1 comprehensive eye examination, with the lowest uptake (56.9%; n = 31 911) in the most deprived and the highest uptake (70.5%; n =19 860) in the least deprived quintiles. After adjusting for clinical and demographic variables, children living in the least materially deprived quintile had a higher odds of receiving a comprehensive eye examination (aOR 1.43; 95% CI 1.36, 1.51) compared with children in the most materially deprived areas.
Uptake of comprehensive eye examinations is poor, especially for children living in the most materially deprived neighborhoods. Strategies to improve uptake and reduce inequities are warranted.
Vision Screening, Vision Disorders, and Impacts of Hyperopia in Young Children: Outcomes of the Vision in Preschoolers (VIP) and Vision in Preschoolers - Hyperopia in Preschoolers (VIP-HIP) Studies
2022, Asia-Pacific Journal of Ophthalmology
This review summarizes clinically relevant outcomes from the Vision in Preschoolers (VIP) and VIP–Hyperopia in Preschoolers (VIP-HIP) studies. In VIP, refraction tests (retinoscopy, Retinomax, SureSight) and Lea Symbols Visual Acuity performed best in identifying children with vision disorders. For lay screeners, Lea Symbols single, crowded visual acuity (VA) testing (VIP, 5-foot) was significantly better than linear, crowded testing (10-foot). Children unable to perform the tests (<2%) were more likely to have vision disorders than children who passed and should be referred for vision evaluation. Among racial/ethnic groups, the prevalence of amblyopia and strabismus was similar while that of hyperopia, astigmatism, and anisometropia varied. The presence of strabismus and significant refractive errors were risk factors for unilateral amblyopia, while bilateral astigmatism and bilateral hyperopia were risk factors for bilateral amblyopia. A greater risk of astigmatism was associated with Hispanic, African American, and Asian race, and myopic and hyperopic refractive error. The presence and severity of hyperopia were associated with higher rates of amblyopia, strabismus, and other associated refractive error. In the VIP-HIP study, compared to emmetropes, meaningful deficits in early literacy were observed in uncorrected hyperopic 4- and 5-year-olds [≥+4.0 diopter (D) or ≥+3.0 D to ≤+6.0 D associated with reduced near visual function (near VA 20/40 or worse; stereoacuity worse than 240”)]. Hyperopia with reduced near visual function also was associated with attention deficits. Compared to emmetropic children, VA (distance, near), accommodative accuracy, and stereoacuity were significantly reduced in moderate hyperopes, with the greatest risk in those with higher hyperopia. Increasing hyperopia was associated with decreasing visual function.
Causes of vision loss at China's largest blind school during a period of significant economic growth: 2008-2016
2020, Journal of AAPOS
To investigate the different causes of vision loss and school-based treatment regimens at Quanzhou Blind School (QBS), China's largest blind school, in 2008 and 2016.
In 2008, 144 students received comprehensive eye examinations along with a complete family and ophthalmic history; in 2016, 125 students were examined. Vision loss was categorized into visual impairment and blindness classifications based on WHO guidelines. The etiologies of impairment and blindness in 2008 were compared to those in 2016 using the Fisher exact test. The prevalence and type of visual aids were also analyzed during this period.
The leading cause of visual impairment significantly shifted from corneal scarring in 2008 to retinopathy of prematurity (ROP) in 2016 (P = 0.020). Congenital cataracts remained the leading cause of blindness in 2008 and 2016. In 2016 there was a significant increase in the use of visual aids, with 63.2% of students using them in 2016 compared to 8.3% in 2008 (P = 0.0001).
Between 2008 and 2016, the leading cause of visual impairment shifted from corneal scarring to ROP, while congenital cataracts remained the leading cause of blindness.

View all citing articles on Scopus

: Manuscript no. 2012-559.

: *A full listing of the Multi-Ethnic Pediatric Eye Disease Study Group is available in Appendix 1 at http://aaojournal.org.

: Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

: Supported by the National Eye Institute, National Institutes of Health, Bethesda, Maryland (grant nos.: EY14472 and EY03040); and an unrestricted grant from the Research to Prevent Blindness, Inc, New York, New York. Dr. Varma is a Research to Prevent Blindness Sybil B. Harrington Scholar.

^⁎: Group members listed online in Appendix 1 (available at http://aaojournal.org).

View full text

Original articlePrevalence and Causes of Visual Impairment in Asian and Non-Hispanic White Preschool Children: Multi-Ethnic Pediatric Eye Disease Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Financial Disclosure(s)

Section snippets

Patients and Methods

Results

Discussion

Acknowledgments

Am J Ophthalmol

Am J Ophthalmol

J AAPOS

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Prevalence and causes of visual impairment in African-American and Hispanic preschool children: the Multi-Ethnic Pediatric Eye Disease Study

Ophthalmology

Original article
Prevalence and Causes of Visual Impairment in Asian and Non-Hispanic White Preschool Children: Multi-Ethnic Pediatric Eye Disease Study