School bus accommodation-relaxing skiascopy

Andrew W Arnold, Stephanie L Arnold, Jacob H Sprano, Robert W Arnold, Andrew W Arnold, Stephanie L Arnold, Jacob H Sprano, Robert W Arnold

Abstract

Objective: Accurate estimation of hyperopia and astigmatism is challenging in delayed children. Conventional skiascopy holds rows of increasing power ± lenses vertically in front of one eye. The school bus accommodation-relaxing skiascopy (SBA-RS) design holds child-friendly, lenses +1 to +10D horizontally so that a higher power fogs the nontested eye-relaxing accommodation without cycloplegia.

Methods: Design: Evaluation of diagnostic test. Subjects: Patients undergoing comprehensive eye examination in a pediatric ophthalmology practice. Cycloplegic (cyclopentolate 1%) retinoscopy was compared to dry SBA-RS and Retinomax (Righton, Japan) during pediatric eye examinations. Outcome measures: correlations, Chi-square and receiver operating characteristic (ROC) curve.

Results: Of 470 patients with a median age 6 years, 238 were under the age of 60 months and 110 had developmental delays. For those with cycloplegic spherical equivalent hyperopia over 0.7 D, median (90% CI) value for retinoscopy was +2.63 D (+0.75, +6.88), for SBA-RS was +2.50 D (+0.50, +6.75) and less for 184 with Retinomax +1.88 D (-1.56, +6.13) but similar despite delays. Astigmatic cylinder SBA-RS +1.50 D (+0.25, +4.00) lagged retinoscopy +1.75 D (+0.75,+4.50) but Retinomax was greater +2.00 D (+0.25, +4.64). Cycloplegic refractive components such as spherical equivalent, cylinder, and J0 and J45 power vectors correlated highly and were near unity with SBA-RS and Retinomax with the latter deviating greater. SBA-RS screened for amblyopia risk factors up to 92% sensitive and 94% specific.

Conclusion: Accommodation-relaxing horizontal skiascopy very precisely estimates astigmatism power and axis and only lags cycloplegic refraction by about 0.15D in hyperopic patients fairly independent of neurodevelopmental delay. This technique can quickly estimate refraction even in delayed patients potentially reducing some need for cycloplegia.

Clinical trials registry: NCT03668067.

Keywords: cycloplegia; hyperopia; retinoscopy; skiascopy.

Conflict of interest statement

Robert W Arnold coordinates the Alaska Blind Child Discovery which has received discounted vision screen technology from several vendors. He serves unpaid on advisory boards for several photoscreeners. He is on the boards of PDI Check that makes vision screen game for Nintendo 3DS and also for Glacier Medical Software that markets ROP Check NICU cloud-based monitoring software. He is also an investigator and protocol developer for PEDIG. Dr Arnold also has a patent pending with PDI Check. No author has a financial stake in SBA-RS from Eye Care and Cure. The authors report no other conflicts of interest in this work.

© 2019 Arnold et al.

Figures

Figure 1
Figure 1
The school bus accommodation-relaxing skiascopy (SBA-RS) technique being utilized by author RWA in a remote Burma clinic demonstrating a higher plus lens over the nonstreaked eye to produce fogging effect (written informed parental consent given to share photo).
Figure 2
Figure 2
Linear regression for spherical equivalent comparing two screening methods (abscissa) SBA-RS (open black circles and solid black regression line) and Retinomax (solid gray diamonds with dashed gray regression line) compared to cycloplegic refraction in diopters (ordinate).
Figure 3
Figure 3
Linear regressions for SBA-RS versus cycloplegic spherical equivalent refraction for patients with and without developmental delays separating those with hyperopia (spherical equivalent greater than 0.7 D).
Figure 4
Figure 4
Linear regression for astigmatism cylinder power comparing two screening methods (abscissa) SBA-RS (open black circles and solid black regression line) and Retinomax (solid gray diamonds with dashed gray regression line) compared to cycloplegic refraction in diopters (ordinate).
Figure 5
Figure 5
Linear regression for astigmatism J0 vector comparing two screening methods (abscissa) SBA-RS (open black circles and solid black regression line) and Retinomax (solid gray diamonds with dashed gray regression line) compared to cycloplegic refraction in diopters (ordinate).
Figure 6
Figure 6
Linear regression for astigmatism J45 vector comparing two screening methods (abscissa) SBA-RS (open black circles and solid black regression line) and Retinomax (solid gray diamonds with dashed gray regression line) compared to cycloplegic refraction in diopters (ordinate).
Figure 7
Figure 7
Bland–Altman plot comparing patients with astigmatism 0.75 and greater measured by school bus accommodation relaxing skiascopy (SBA-RS) and cycloplegic refraction for J0 vector.
Figure 8
Figure 8
Bland–Altman plot of J45 vector for patients with astigmatism 0.75 diopters and greater measured with SBA-RS compared to cycloplegic refraction.
Figure 9
Figure 9
Receiver operating characteristic (ROC) curve for screening cycloplegic refractive amblyopia risk dactors (ARF) with school bus accommodation-relaxing skiascopy (SBA-RS, black) and Retinomax (gray). Two published uniform gold-standard guidelines from the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 2003 (solid squares) and age-stratified from 2013 (dashed circles).

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