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BackgroundTo investigate the feasibility of using the Stopping Elderly Accidents, Deaths and Injuries (STEADI) Falls Risk Tool Kit during community-based eye health screenings to assess falls risk of participants enrolled in the Manhattan Vision Screening and Follow-Up Study (NYC-SIGHT).MethodsCross-sectional analysis of data from a 5-year prospective, cluster-randomised clinical trial conducted in affordable housing developments in New York City in adults age 40 years and older. Prescreening questions determined whether participants were at risk of falling. STEADI tests classified participants at low, moderate or high risk of falling. Multivariate logistic regression determined odds of falls risk of all enrolled participants.Results708 participants completed the eye health screening; 351 (49.6%) performed STEADI tests; mean age: 71.0 years (SD±11.3); 72.1% female; 53.6% Black, non-Hispanic, 37.6% Hispanic/Latino. Level of falls risk: 32 (9.1%) low, 188 (53.6%) moderate and 131 (37.3%) high. Individuals age >80 (OR 5.921, 95% CI (2.383 to 14.708), p=0.000), had blurry vision (OR 1.978, 95% CI (1.186 to 3.300), p=0.009), high blood pressure (OR 2.131, 95% CI (1.252 to 3.628), p=0.005), arthritis (OR 2.29876, 95% CI (1.362 to 3.875), p=0.002) or foot problems (OR 5.239, 95% CI (2.947 to 9.314), p=0.000) had significantly higher odds of falling, emergency department visits or hospitalisation due to falling.ConclusionThis study detected a significant amount of falls risk in an underserved population. The STEADI Falls Risk screening questions were easy for eye care providers to ask, were highly predictive of falls risk and may be adequate for referral to occupational health and/or physical therapy.

Purpose The relationship between refractive error at age 1 and the risk of developing amblyopia or accommodative esotropia, and the protection offered by early glasses, is unknown. These are determined in the Early Glasses Study, a prospective, population-based, longitudinal, randomized controlled study. We report baseline findings. Methods Healthy children aged 12–18 months were recruited at Children’s Healthcare Centres (CHCs) and received an entry orthoptic examination followed by cycloplegic retinoscopy. Children with amblyopia, strabismus, ophthalmic disease or very high refractive error were excluded. Those exceeding the AAPOS 2003 Criteria (> + 3.5D spherical equivalent (SE), > 1.5D astigmatism, > 1.5D anisometropia) were randomized into wearing glasses or not, and are followed-up by research orthoptists. Other children are followed-up by regular vision screening at CHCs and visual acuity is measured in all children at age 4. Results Parents of 865 children were called, 123 were excluded. Of 742 children enrolled, 601 underwent the entry orthoptic examination at age 14.5 ± 1.7 months. Mean SE was + 1.73 ± 1.18D, astigmatism -0.70 ± 0.44D, anisometropia 0.21D (IQR: 0–0.25). Of 62 (10.3%) children exceeding the Criteria, 52 were randomized into wearing glasses or not. Of 539 other children, 522 are followed up at CHCs. In total, 31 were excluded: 2 had strabismus and amblyopia, 7 strabismus, 2 amblyopia suspect, 1 strabismus suspect, 1 squinting during sinusitis, 4 excessive refractive error, 9 myopia, 2 ptosis, 1 oculomotor apraxia, 1 Duane syndrome, 1 congenital nystagmus. Conclusion Prevalence of strabismus (10/601) was as expected, but prevalence of amblyopia (2/601) was low, suggesting that common amblyopia develops later than generally thought. Key messages What is known High refractive errors cause amblyopia, but no study has determined the exact relationship between the kind and size of refractive error at age 1 and the risk to develop amblyopia, and assessed the protective effect of glasses in a controlled, population-based, longitudinal study. What is new At baseline, 601 children received a full orthoptic examination followed by retinoscopy in cycloplegia at the age of 14.5 ± 1.7 months; 10.3% had high refractive error exceeding spherical equivalent > + 3.5D, > 1.5D astigmatism, > 1D oblique astigmatism or > 1.5D anisometropia. The prevalence of amblyopia was lower (0.3%) than expected, suggesting that most amblyopia develops after the first year of life. The prevalence of anisometropia, associated with amblyopia in older children, was low (0.8%).

To report the 5-year results of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative. Infants requiring retinopathy of prematurity (ROP) screening at six neonatal intensive care units from December 1, 2005, to November 30, 2010, were evaluated with remote retinal photography by an ROP specialist. Every infant received outpatient binocular indirect ophthalmoscope examinations until termination criteria were achieved or until treatment. Outcomes were treatment-warranted ROP (TW-ROP, ETROP type 1) and adverse anatomical events. Five hundred eleven infants (1,022 eyes) were screened. Fifteen infants had TW-ROP and underwent laser photocoagulation. The TW-ROP cohort had significantly lower birth weight and gestational age (both P < .001). No patient progressed to adverse anatomical outcomes and no case of TW-ROP was missed. Tele-medicine had 100% sensitivity, 99.8% specificity, 93.8% positive predictive value, and 100% negative predictive value for detection of TW-ROP. Telemedicine demonstrates high diagnostic accuracy for detection of TW-ROP and can complement ROP screening.

Young children's vision screening, as part of a preventative health care service, produces great value for developing regions. Besides yielding a high return on investment from forestalling surgeries using a low-cost intervention at a young age, it improves school performance and thus boosts future labor force quality. Leveraging low-skilled health care workers with smartphones and automated diagnosis to offer such programs can be a scalable model in resource-limited areas. This study aimed to develop and evaluate an effective, efficient, and comprehensive vision screening solution for school children in resource-limited areas. First, such an exam would need to cover the major risk factors of amblyopia and myopia, 2 major sources of vision impairment effectively preventable at a young age. Second, the solution must be integrated with digital patient record-keeping for long-term monitoring and popular statistical analysis. Last, it should utilize low-skilled technicians and only low-cost tools that are available in a typical school in developing regions, without compromising quality or efficiency. A workflow for the screening program was designed and a smartphone app was developed to implement it. In the standardized screening procedure, a young child went through the smartphone-based photoscreening in a dark room. The child held a smartphone in front of their forehead, displaying pre-entered personal information as a quick response code that duplexed as a reference of scale. In one 10-second procedure, the child's personal information and interpupillary distance, relative visual axis alignment, and refractive error ranges were measured and analyzed automatically using image processing and artificial intelligence algorithms. The child's risk for strabismus, myopia, and anisometropia was then derived and consultation given. A preliminary evaluation of the solution was conducted alongside yearly physical exams in Luoyang, Henan, People's Republic of China. It covered 20 students with suspected strabismus and 80 randomly selected students, aged evenly between 8 and 10. Each examinee took about 1 minute, and a streamlined workflow allowed 3 exams to run in parallel. The 1-shot and 2-shot measurement success rates were 87% and 100%, respectively. The sensitivity and specificity of strabismus detection were 0.80 and 0.98, respectively. The sensitivity and specificity of myopia detection were 0.83 and 1.00, respectively. The sensitivity and specificity of anisometropia detection were 0.80 and 1.00, respectively. The proposed vision screening program is effective, efficient, and scalable. Compared with previously published studies on utilizing a smartphone for an automated Hirschberg test and photorefraction screening, this comprehensive solution is optimized for practicality and robustness, and is thus better ready-to-deploy. Our evaluation validated the achievement of the program's design specifications.

The Influence of Age, Duration of Diabetes, Cataract, and Pupil Size on Image Quality in Digital Photographic Retinal Screening Peter Henry Scanlon , MRCP 1 , Chris Foy , MSC 2 , Raman Malhotra , FRCO, PHTH 3 and Stephen J. Aldington , DMS 4 1 Department of Ophthalmology, Cheltenham General Hospital, Cheltenham, U.K. 2 R&D Support Unit, Gloucester Hospitals National Health Service Trust, Gloucester, U.K. 3 Oxford Eye Hospital, Oxford, U.K. 4 Retinopathy Grading Centre, Imperial College, London, U.K. Address correspondence and reprint requests to Dr. Peter Scanlon, Gloucestershire Eye Unit, Cheltenham General Hospital, Sandford Road, Cheltenham, GL53 7AN, U.K. E-mail: peter.scanlon{at}glos.nhs.uk Abstract OBJECTIVE —To evaluate the effect of age, duration of diabetes, cataract, and pupil size on the image quality in digital photographic screening. RESEARCH DESIGN AND METHODS —Randomized groups of 3,650 patients had one-field, nonmydriatic, 45° digital retinal imaging photography before mydriatic two-field photography. A total of 1,549 patients were then examined by an experienced ophthalmologist. Outcome measures were ungradable image rates, age, duration of diabetes, detection of referable diabetic retinopathy, presence of early or obvious central cataract, pupil diameter, and iris color. RESULTS —The ungradable image rate for nonmydriatic photography was 19.7% (95% CI 18.4–21.0) and for mydriatic photography was 3.7% (3.1–4.3). The odds of having one eye ungradable increased by 2.6% (1.6–3.7) for each extra year since diagnosis for nonmydriatic, by 4.1% (2.7–5.7) for mydriatic photography irrespective of age, by 5.8% (5.0–6.7) for nonmydriatic, and by 8.4% (6.5–10.4) for mydriatic photography for every extra year of age, irrespective of years since diagnosis. Obvious central cataract was present in 57% of ungradable mydriatic photographs, early cataract in 21%, no cataract in 9%, and 13% had other pathologies. The pupil diameter in the ungradable eyes showed a significant trend ( P < 0.001) in the three groups (obvious cataract 4.434, early cataract 3.379, and no cataract 2.750). CONCLUSIONS —The strongest predictor of ungradable image rates, both for nonmydriatic and mydriatic digital photography, is the age of the person with diabetes. The most common cause of ungradable images was obvious central cataract. Footnotes A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. Accepted June 23, 2005. Received February 9, 2005. DIABETES CARE

Background Uncorrected refractive errors are the commonest cause of visual loss in children despite spectacle correction being highly cost-effective. Many affected children do not benefit from correction as a high proportion do not wear their spectacles. Reasons for non-wear include parental attitudes, overprescribing and children being teased/bullied. Most school programmes do not provide health education for affected children, their peers, teachers or parents. The Portable Eye Examination Kit (Peek) will be used in this study. Peek has applications for measuring visual acuity with software for data entry and sending automated messages to inform providers and parents. Peek also has an application which simulates the visual blur of uncorrected refractive error (SightSim). The hypothesis is that higher proportion of children with uncorrected refractive errors in schools allocated to the Peek educational package will wear their spectacles 3–4 months after they are dispensed, and a higher proportion of children identified with other eye conditions will access services, compared with schools receiving standard school screening. Methods/Design Cluster randomized, double-masked trial of children with and without uncorrected refractive errors or other eye conditions. Government schools in Hyderabad, India will be allocated to intervention (Peek) or comparator (standard programme) arms before vision screening. In the intervention arm Peek will be used for vision screening, SightSim images will be used in classroom teaching and will be taken home by children, and voice messages will be sent to parents of children requiring spectacles or referral. In both arms the same criteria for recruitment, prescribing and dispensing spectacles will be used. After 3–4 months children dispensed spectacles will be followed up to assess spectacle wear, and uptake of referrals will be ascertained. The cost of developing and delivering the Peek package will be assessed. The cost per child wearing their spectacles or accessing services will be compared. Discussion Educating parents, teachers and children about refractive errors and the importance of wearing spectacles has the potential to increase spectacle wear amongst children. Innovative, potentially scalable mobile technology (Peek) will be used to screen, provide health education, track spectacle wear and adherence to follow-up amongst children referred. Trial registration Controlled-Trials.com, ISRCTN78134921 . Registered on 29 June 2016.

Purpose In this study, we explored different statistical approaches to identify the best algorithm to predict EQ-5D utility scores from the NEI-VFQ 25 in patients with agerelated macular degeneration (AMD). Methods Ordinary least squares (OLS), Tobit, and censored least absolute deviation (CLAD) approaches were compared using cross-sectional data (primary dataset, n = 151) at screening from a phase I/II clinical trial in patients with AMD. Three models were specified in this study: full (includes all 12 dimensions of the NEI-VFQ 25), short (includes only the general health dimension and the composite score), and reduced model (using stepwise regression). To evaluate the predictive accuracy of the models, the mean absolute prediction error (MAPE), mean error, and root means squared error were calculated using in-sample cross-validation (within the primary dataset) and out-of-sample validation using an independent dataset (n = 393). The model that provided the lowest prediction errors was chosen as the best model. Results In-sample cross-validation and out-of-sample validation consistently demonstrated that, compared to other approaches, heteroscedasticity-adjusted OLS produced the lowest MAPE (mean values were 0.1400, 0.1593, respectively) for the full model, while CLAD performed best for the short and reduced models (mean values were 0.1299, 0.1483, respectively). The normality and homoscedasticity assumptions of both OLS and Tobit were rejected. CLAD, however, can accommodate these particular violations. Conclusions The CLAD-short model is recommended for producing the EQ-5D utility scores when only the NEIVFQ 25 data are available.

Diabetic retinopathy (DR) is a leading cause of blindness in adults worldwide. Early detection and intervention can prevent blindness; however, many patients do not receive their recommended annual diabetic eye examinations, primarily owing to limited access. To evaluate the safety and accuracy of an artificial intelligence (AI) system (the EyeArt Automated DR Detection System, version 2.1.0) in detecting both more-than-mild diabetic retinopathy (mtmDR) and vision-threatening diabetic retinopathy (vtDR). A prospective multicenter cross-sectional diagnostic study was preregistered (NCT03112005) and conducted from April 17, 2017, to May 30, 2018. A total of 942 individuals aged 18 years or older who had diabetes gave consent to participate at 15 primary care and eye care facilities. Data analysis was performed from February 14 to July 10, 2019. Retinal imaging for the autonomous AI system and Early Treatment Diabetic Retinopathy Study (ETDRS) reference standard determination. Primary outcome measures included the sensitivity and specificity of the AI system in identifying participants' eyes with mtmDR and/or vtDR by 2-field undilated fundus photography vs a rigorous clinical reference standard comprising reading center grading of 4 wide-field dilated images using the ETDRS severity scale. Secondary outcome measures included the evaluation of imageability, dilated-if-needed analysis, enrichment correction analysis, worst-case imputation, and safety outcomes. Of 942 consenting individuals, 893 patients (1786 eyes) met the inclusion criteria and completed the study protocol. The population included 449 men (50.3%). Mean (SD) participant age was 53.9 (15.2) years (median, 56; range, 18-88 years), 655 were White (73.3%), and 206 had type 1 diabetes (23.1%). Sensitivity and specificity of the AI system were high in detecting mtmDR (sensitivity: 95.5%; 95% CI, 92.4%-98.5% and specificity: 85.0%; 95% CI, 82.6%-87.4%) and vtDR (sensitivity: 95.1%; 95% CI, 90.1%-100% and specificity: 89.0%; 95% CI, 87.0%-91.1%) without dilation. Imageability was high without dilation, with the AI system able to grade 87.4% (95% CI, 85.2%-89.6%) of the eyes with reading center grades. When eyes with ungradable results were dilated per the protocol, the imageability improved to 97.4% (95% CI, 96.4%-98.5%), with the sensitivity and specificity being similar. After correcting for enrichment, the mtmDR specificity increased to 87.8% (95% CI, 86.3%-89.5%) and the sensitivity remained similar; for vtDR, both sensitivity (97.0%; 95% CI, 91.2%-100%) and specificity (90.1%; 95% CI, 89.4%-91.5%) improved. This prospective multicenter cross-sectional diagnostic study noted safety and accuracy with use of the EyeArt Automated DR Detection System in detecting both mtmDR and, for the first time, vtDR, without physician assistance. These findings suggest that improved access to accurate, reliable diabetic eye examinations may increase adherence to recommended annual screenings and allow for accelerated referral of patients identified as having vtDR.

Background/aimsThe purpose of the study was to evaluate patients' ease of understanding of Damato campimetry assessment and to determine the sensitivity and specificity of the results compared with Humphrey automated perimetry.MethodsPatients underwent Humphrey perimetry and Damato campimetry on the same day. Patients were excluded if they were unable to undergo Humphrey perimetry. Results were graded as matched, partially matched and not matched with those of Humphrey perimetry.ResultsOne hundred patients (197 eyes) were assessed: 62 women and 38 men with mean age of 62.8 (SD 15.98) years. It was not possible to plot Damato campimetry in 19 eyes (6.5%): 13 due to lack of understanding and six due to low vision. In total 178 eyes were tested with both methods. Results showed 94 eyes as true positives, 45 as true negatives, 22 as false negatives and 17 as false positives. Ninety-five eyes had matched visual field results, five eyes had partial matches and 78 eyes (36%) were not matched. The extent of agreement was 0.216 (95% CI 0.073 to 0.36) with κ analysis.ConclusionsWe found Damato campimetry to be a useful portable device to assess the visual field, with an optimal sensitivity of 81% and a specificity of 72% based on comparison with a Humphrey 24-2 programme. Of the patients studied, 6.5% were unable to do the test and 64% had matched or partially matched results from both assessments. Further study is required to compare complete results with a Humphrey 30-2 programme and also to study populations where patients do not have access to outpatient formal visual field assessments.

To evaluate a combined hearing and eye screening model for newborns attending immunization clinics in Cameroon. We analysed data from a screening project that took place between November 2021 and February 2024, which assessed both the hearing and eyes of newborns using otoacoustic emission and fundal reflex tests, respectively. We then evaluated sensitivity, specificity and predictive values of screening conducted by trained auxiliary staff versus specialists. We screened 1807 newborns, of which 54% (976) were female. The median age at screening was 13 days. Eight percent of newborns (141/1807) did not pass the otoacoustic emission test; screeners scheduled these newborns for a second-line otoacoustic emission test within three months. Only 28% (39/141) returned for the repeat otoacoustic emission test. Of the returning babies, 33% (13/39) still did not pass, and screeners referred them for an auditory brainstem response threshold test. Screeners detected an absent fundal reflex in 2% (27) of babies. Compared to specialists, trained auxiliary staff showed 82% sensitivity and 99% specificity in hearing screening; predictive values were 90% (positive) and 99% (negative). For eye screening, sensitivity was 67% and specificity 99%, with predictive values of 86% (positive) and 98% (negative). Combined screening performed by trained auxiliary staff in immunization clinics offers a promising approach to screening newborns' hearing and eyes, enabling broader population coverage with fewer resources. Combined screening conducted at immunization clinics includes both hospital- and community-born babies and is therefore suitable for countries with a high number of out-of-hospital births.