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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

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.

Amblyopia is a neurodevelopmental disorder that affects at least 2% of most populations and can lead to permanently reduced vision if not detected and treated within a specific period in childhood. Whole-population screening of children younger than 5 years is applied in many countries. The substantial diversity in existing programmes reflects their heterogeneous implementation in the absence of the complete evidence base that is now a pre-requisite for instituting screening. The functional importance of amblyopia at an individual level is unclear as data are scarce, but in view of the high prevalence the population-level effect might be notable. Screening of all children aged 4–5 years (eg, at school entry) confers most benefit and addresses inequity in access to timely treatment. Screening at younger ages is associated with increased risk of false-positive results, and at older ages with poor outcomes for children with moderate to severe amblyopia. We suggest that the real-life adverse effects of amblyopia should be characterised and screening and diagnosis should be standardised.

The nonmydriatic, noncontact, and rapid acquisition features of ultra-widefield fundus (UWF) imaging create an invaluable tool for pediatric retinal screening in primary care. This review assesses the landscape of pediatric eye screening, identifies gaps in diagnosing a range of pediatric retinal conditions, and discusses potential uses of UWF imaging for retinal screening. The standards for pediatric eye screening in primary care include red reflex testing, direct ophthalmoscopy, external ocular exam, instrument-based screening, and visual acuity testing. These tests fail to diagnose several treatable retinal diseases. In this gap, UWF retinal imaging provides a panoramic view of the retinal landscape, allowing for a more comprehensive examination. For several pediatric retinal conditions (eg, retinal detachment, retinopathy of prematurity, Coats' disease, familial exudative vitreoretinopathy, Stargardt disease, ocular toxocariasis), UWF retinal imaging provides the high spatial resolution necessary for reliable diagnosis, expediting time to treatment while maintaining low false positive rates. [Ophthalmic Surg Lasers Imaging Retina 2025;56:XX–XX.]

Background To evaluate the stability and predictive ability of uncorrected visual acuity (UCVA), non-cycloplegic refraction (NCR), and axial length (AL) as indicators in non-cycloplegic school vision screening for myopia. Methods This retrospective cohort study is based on the Shanghai Child and Adolescent Large-scale Eye Study (SCALE). Participants included students who failed school screenings and were referred for follow-up cycloplegic refractions at eye hospitals within three months. We evaluated the differences in UCVA, spherical equivalent (SE), and AL between school screenings and hospital re-evaluations. Furthermore, we assessed the validity of using UCVA in combination with NCR as predictive metrics for myopia referral. Results Among the 8,492 children, 4,357 (51.3%) were boys, with a mean age of 8.26 years (SD = 2.77). AL was identified as a reliable myopia screening indicator across all age groups (ICC = 0.981; 95% CI: 0.978–0.984), outperforming UCVA (ICC = 0.791) and SE (ICC = 0.806). The estimated prevalence of myopia using UCVA and NCR was 76.10%, significantly higher than 58.37% observed with cycloplegic testing. Sensitivity was 96.93% and specificity was 53.13% (Youden index = 0.5). In preschoolers, myopia rates decreased from 50.17% before to 19.82% after cycloplegia, while school-aged children exhibited better consistency. Decision curve analysis showed that the full model incorporating AL did not significantly benefit school-aged children, but may offer greater net benefits for preschoolers. Conclusions AL should be integrated into screening programs for preschoolers. For school-aged children, the combination of UCVA and NCR suffices for myopia prediction, potentially eliminating the need for cycloplegia.

Aim: To report the Karnataka Internet Assisted Diagnosis of Retinopathy of Prematurity (KIDROP) program for retinopathy of prematurity (ROP) screening in underserved rural areas using an indigenously developed tele-ROP model. Materials and Methods: KIDROP currently provides ROP screening and treatment services in three zones and 81 neonatal units in Karnataka, India. Technicians were trained to use a portable Retcam Shuttle (Clarity, USA) and validated against ROP experts performing indirect ophthalmoscopy. An indigenously developed 20-point score (STAT score) graded their ability (Level I to III) to image and decide follow-up based on a three-way algorithm. Images were also uploaded on a secure tele-ROP platform and accessed and reported by remote experts on their smart phones (iPhone, Apple). Results: 6339 imaging sessions of 1601 infants were analyzed. A level III technician agreed with 94.3% of all expert decisions. The sensitivity, specificity, positive predictive value and negative predictive value for treatment grade disease were 95.7, 93.2, 81.5 and 98.6 respectively. The kappa for technicians to decide discharge of babies was 0.94 (P < 0.001). Only 0.4% of infants needing treatment were missed.The kappa agreement of experts reporting on the iPhone vs Retcam for treatment requiring and mild ROP were 0.96 and 0.94 (P < 0.001) respectively. Conclusions: This is the first and largest real-world program to employ accredited non-physicians to grade and report ROP. The KIDROP tele-ROP model demonstrates that ROP services can be delivered to the outreach despite lack of specialists and may be useful in other middle-income countries with similar demographics.

Background and Objectives: Children with autism spectrum disorder (ASD) often experience visual problems, yet their ophthalmic health remains underexplored due to testability challenges and limited-service access. This study evaluated ophthalmic screening outcomes in children with ASD and examined whether autism severity influenced ocular findings or cooperation during examinations. Materials and Methods: This cross-sectional study included 210 children with ASD (mean age 8.18 ± 4.99 years; 83.3% male). Examinations were conducted in an autism education center using non-contact methods: stereopsis (LANG I stereotest; LANG-STEREOTEST AG, Küsnacht, Switzerland), cover–uncover, and Hirschberg tests for strabismus, Spot Vision Screener (Welch Allyn Inc., Skaneateles Falls, NY, USA) for refractive errors, and Brückner test for red reflex. Autism severity was assessed with the Turkish version of the Adapted Autism Behavior Checklist (AABC). Results: Refractive errors were identified in 22.3% of participants: astigmatism in 15.2%, myopia in 5.2% (including 3 high myopia), and hyperopia in 1.9%. Strabismus was present in 11.9%, most commonly intermittent exotropia. Nearly half (49.5%) could not complete stereopsis testing, and a weak positive correlation was observed between AABC scores and the higher absolute spherical equivalent (SE) value between the two eyes (r = 0.173, p = 0.044). Children unable to complete stereopsis testing had significantly higher AABC scores (22.66 ± 9.69 vs. 13.39 ± 9.41, p < 0.001). Notably, 50 children (23.8%) had never undergone an eye examination prior to this study. Conclusions: Ophthalmic findings, particularly astigmatism and strabismus, are common in children with ASD. Greater autism severity was associated with reduced testability and modestly worse refractive error status. These findings suggest that tailored, accessible eye-care approaches and systematic vision screening may help to reduce overlooked visual problems and support more equitable care for children with ASD.

Purpose To report the summary characteristics of operational models associated with Student Led Free Vision Screening Programs (SLFVSP) and to identify opportunities for program optimization. Methods An 81-question mixed methods survey was distributed to SLFVSP leaders nationwide and Medical Student Educators within the American University Ophthalmology Professors (AUPO) Association. Survey responses were analyzed using Mann Whitney U and Fisher’s Exact tests. Themes considering the assets and liabilities of SLFVSPs were summarized using self-reported qualitative data from survey responses. Qualitative and quantitative themes considering were then synthesized into a Strengths, Weaknesses, Opportunities, & Threats (SWOT) analysis for a collective appraisal of SLFVSP operations. Finally, drivers were identified to generate change ideas to improve SLFVP operations through a collaborative, quality improvement model. Results A total of 16 survey responses were included from programs operational for a median of 6 years. Most respondent programs ( n  = 9) reported year-long operations; no preference between weekday ( n  = 8) and weekend ( n  = 7) screening activities was identified. Programs obtained funding from a diverse array of internal and external sources. There was no significant difference in wait time for scheduled appointments compared to a walk-in strategy; overall door-to-door visit times ranged from 15 min to 120 min. Screenings were held in several locations, most commonly in Federally Qualified Health Centers ( n  = 8) and religious centers ( n  = 6). Most screening event volunteers were first- and second-year medical students. The qualitative thematic analysis demonstrated that the most commonly self-reported asset was improving access to scarce vision screening services ( n  = 7) while the most commonly self-reported liability was difficulty recruiting faculty and/or resident for oversight ( n  = 5). The SWOT analysis revealed while the participant SLFVSPs were bolstered by site experience, community and corporate partnerships for glasses and space to hold vision screening, and institutional support from academic ophthalmology departments, limitations included difficulty with recruitment, space limitations, and poor follow-up care infrastructure. Conclusion Collaborative standardization of SLFVSP operations can promote targeted staff training, organizational stewardship, and consensus building to ensure SLFVSP can offer sustainable vision screening programs that build vision equity at the community level.

Background/Aims The high prevalence of visual defects among children with special needs is well reported and guidelines for vision screening are in place. However, recent research has suggested that vision care for such children is neglected. This study set out to evaluate the current status of vision screening and eye care in special schools in Wales. Methods In phase 1, all 44 special schools in Wales received a questionnaire on current vision screening practices. In phase 2, full eye examinations were conducted with 173 pupils of five schools with no screening service; the pupils were aged 2–21 years. In phase 3, feedback about the service was obtained from all schools and from 15 parents whose children took part. Results In phase 1, vision screening was patchy and inconsistent among the 39 schools responding. In phase 2, there is a high proportion of pupils (42%) reporting no previous eye examination. Overall, 17% of the pupils in the five schools presented with low vision (WHO definition, poorer than 0.3 LogMAR), 50% needed a first-time or updated spectacle prescription and 51% had some ocular abnormality that was either sight-limiting or warranted action to prevent risk to sight. In phase 3, school staff and parents reported that school-based eye examinations were valuable and, for those children with previous experience, likely to be more successful than clinic-based or practice-based examinations for this particular population. Conclusions There is an urgent need for a school-based optometric service for this vulnerable group of children and young people.

BackgroundVery premature infants screened for retinopathy of prematurity (ROP) that do not develop ROP still experience serious visual developmental challenges, and while it is recommended that all children in the UK are offered preschool visual screening, we aimed to explore whether this vulnerable group requires dedicated follow-up.MethodsWe performed a real-world retrospective observational cohort study of children previously screened for ROP in NHS Greater Glasgow and Clyde (Scotland) between 2013 and 2015. We excluded those with any severity of ROP identified during screening. Electronic patient records were searched for preschool orthoptic visual screening (See4School) results and results of referral to the hospital eye service (HES).Results222 children met the inclusion criteria. Their median birth weight was 1200 g and median gestational age was 31 weeks. A total of 111 (50%) of these children had been referred to HES nationally. 103 were referred within the health board where ROP screening took place; of these, 47% (48/103) were referred from the See4School programme, 31% (31/103) from paediatric clinics, 13% (13/103) from primary care and 11% (11/103) from community optometrists. 42 of these 103 referrals (41%) to HES had occurred before the age (3½ years) when children became eligible for See4School screening. At hospital review, 55% (55/99) patients had a glasses prescription issued for refractive error, 22% were estimated to have amblyopia and 30% had a diagnosis of strabismus.ConclusionIn this non-controlled study we found premature infants that do not develop ROP still face considerable visual morbidity and dedicated follow-up may be warranted.