Automated vision screening devices that use eccentric photorefraction often miss significant hyperopia or provide false-positive referrals in preschool-aged children, according to findings published in Optometry and Vision Science.

Researchers performed screenings on children from the Vision in Preschoolers (VIP) study (N=1430, mean age 54.5±6.8 years, 50.7% boys, 47.1% Black). Participants included children who failed a local vision screening and a random sample (approximately 20%) of those who did not. Investigators randomly assigned children to 1 of 2 automated vision screening methods; a handheld autorefractor or tabletop photorefractor. They switched screening methods for the groups after initial analysis and performed a comprehensive eye examination at least 1 day after screening. Investigators were masked to the results of the screening tests. VIP researchers defined referral criteria as ≥1.50 and ≥3.50 D for hyperopia,  ≥2.75 and ≥3.00 D for myopia, ≥1.50 and ≥2.00 D for astigmatism, and ≥1.75 and ≥1.50 D for anisometropia for the autorefractor and photorefractor, respectively.

Researchers detected significant hyperopia in 132 of the children according to the American Association of Pediatric Ophthalmology and Strabismus (AAPOS) standards (>+4.0 D in any meridian for children 48 months of age or younger and >+3.5 D in any meridian for children 49 months or older). The sensitivity for detecting hyperopia was 80.3% for the autorefractor compared with 69.7% for the photorefractor (95% CI, 7.0-20.5%, P =.04) and the specificity was 78.4% and 80.6% (P =.07), respectively. The proportion of children who failed the screening due to lack of results was 19.6%.

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Investigators detected significant hyperopia in 166 children according to VIP standards (>+3.25 D in any meridian). The sensitivity for detecting hyperopia was 77.7% for the autorefractor and 65.7% for the photorefractor devices (P =.009) and specificity was 79.6% and 81.4% (P =.15), respectively. The proportion of children who failed the screening due to lack of results was 16.5%.

Researchers compared the magnitude of the sphere (most positive meridian) from each of the screening devices with the magnitude of the sphere from cycloplegic refraction for each eye of the cohort. The magnitude of the sphere for the autorefractor was ~1.75 D less hyperopic than cycloplegic refraction magnitudes when the magnitude was >1.00D from cycloplegic refraction. The photorefractor had similar magnitudes from cycloplegic refraction until ~4.00 D. When sphere magnitudes from cycloplegic refraction reached values of >4.00 D, the sphere magnitudes of the photorefractor plateaued at ~3.50 D.

“Because of the association of moderate to high hyperopia with amblyopia, strabismus, lower preschool literacy, reduced near visual acuity, worse stereopsis, and inaccurate accommodation, detecting children with moderate to high hyperopia is important.” according to the researchers. “When developing a vision screening program, the potential for automated devices that use eccentric photorefraction to miss significant hyperopia or to increase false-positive referrals must be taken into consideration.”

The study was limited by the inclusion of children from primarily low-income families, which provided limited data from other income groups, and a low sample size of children with significantly high hyperopia.


Maguire MG, Ying G-S, Ciner EB, Kulp MT, Candy TR, Moore B. Detection of significant hyperopia in preschool children using two automated vision screeners. Optom Vis Sci. 2022;99(2):114-120. doi:10.1097/OPX.0000000000001837