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A novel smartphone App to support the clinical practice of pediatric ophthalmology and strabismus: the validation of visual acuity tests

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  • Azienda Provinciale per i Servizi Sanitari (APSS) di Trento
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Abstract and Figures

This study is aimed at describing the TreC Oculistica novel smartphone App that facilitated the clinical practice of pediatric ophthalmology and strabismus during the COVID-19 pandemic and at reporting on the validation of visual acuity tests in a home setting. The Trec Oculistica smartphone App was prescribed to eligible patients at the Pediatric Ophthalmology and Strabismus Clinic, Ophthalmology Unit of Rovereto Hospital, between September 2020 and March 2022. Four key indicators were identified for monitoring visual and visuo-motor functions remotely: visual acuity, ocular motility, head posture, and color vision. Clinicians selected few mobile applications (iOS, Android) and printable materials within the Trec Oculistica App: the Snellen Chart Visual Acuity App, the 9Gaze App, the eyeTilt App, the Color Blind test App, the LEA Symbols pdf, and the Snellen Chart pdf. All patients, aged 4 and older, were screened at home for visual acuity at 3 m and later in the clinic (LEA Symbols cabinet or Snellen computerized optotype). The 9Gaze, the eyeTilt, and the Color Blind test Apps were only recommended to a subset of patients based on clinical suspicion or diagnosis. The Wilcoxon signed rank sum test and weighted Cohen’s kappa coefficient were applied to compare pairs of scores from different settings. The Trec Oculistica App was downloaded and activated by 97 patients or their caregiver. 40 patients were tested at home using the 9Gaze App, 7 used the eyeTilt App, and 11 used the Color-Blind test App. Families reported that all the Apps were easy and intuitive to use; clinicians reported that measurements were reliable. 82 eyes of 41 patients (mean age 5.2 years, SD ± 0.4, range 4.4–6.1) were tested for visual acuity using the self-administered LEA Symbols pdf. 92 eyes of 46 patients (mean age 11.6 years, SD ± 5.2, range 6–35) were evaluated using the self-administered Snellen Chart Visual Acuity App or the Snellen Chart pdf. Home median visual acuity score was statistically different from that registered in clinical setting for both the LEA Symbols pdf (P-value = 0.0074) and the Snellen Chart App and pdf (P-value = 0.0001). The strength of agreement was 0.12 (slight) for the LEA Symbols pdf, 0.50 (moderate) for the Snellen Chart Visual Acuity App, and 0.69 (substantial) for the Snellen Chart pdf. Conclusion: The novel TreC Oculistica smartphone App was a useful tool for facilitating the clinical practice of pediatric ophthalmology and strabismus during the COVID-19 pandemic. In the follow-up of strabismus patients and patients with suspected inherited retinal diseases, the 9Gaze, eyeTilt, and Color Blind test applications were deemed to be intuitive and easy to use by families and were considered reliable by clinicians. In a home setting, visual acuity tested by means of Snellen Charts was moderately congruent with the in-office examination. On the contrary, agreement was poor in younger children tested with the LEA Symbols pdf. What is Known: • Teleophthalmology enables clinicians to evaluate patients’ ocular diseases remotely and various tools are helpful for screening, follow-ups and treatment. • Smartphones can currently be used to obtain ocular images and vision measurements of patients’ eyes and this information can be shared with the ophthalmologist for further evaluations and medical management (mhealth). What is New: • Smartphone Apps can be successfully used in a hybrid teleophthalmology service concerning first visits and follow-ups. • Apps and printable materials are easy, intuitive to use for patients and also reliable for clinicians.
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European Journal of Pediatrics (2023) 182:4007–4013
https://doi.org/10.1007/s00431-023-05058-1
RESEARCH
A novel smartphone App tosupport theclinical practice ofpediatric
ophthalmology andstrabismus: thevalidation ofvisual acuity tests
ElisabettaRacano1 · GiuliaMalfatti3 · RiccardoPertile2 · RobertaDelleSite1· FedericaRomanelli1·
AndreaNicolini3
Received: 20 February 2023 / Revised: 8 May 2023 / Accepted: 6 June 2023 / Published online: 29 June 2023
© The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023
Abstract
This study is aimed at describing the TreC Oculistica novel smartphone App that facilitated the clinical practice of pediatric ophthal-
mology and strabismus during the COVID-19 pandemic and at reporting on the validation of visual acuity tests in a home setting.
The Trec Oculistica smartphone App was prescribed to eligible patients at the Pediatric Ophthalmology and Strabismus Clinic,
Ophthalmology Unit of Rovereto Hospital, between September 2020 and March 2022. Four key indicators were identified for moni-
toring visual and visuo-motor functions remotely: visual acuity, ocular motility, head posture, and color vision. Clinicians selected
few mobile applications (iOS, Android) and printable materials within the Trec Oculistica App: the Snellen Chart Visual Acuity
App, the 9Gaze App, the eyeTilt App, the Color Blind test App, the LEA Symbols pdf, and the Snellen Chart pdf. All patients, aged
4 and older, were screened at home for visual acuity at 3m and later in the clinic (LEA Symbols cabinet or Snellen computerized
optotype). The 9Gaze, the eyeTilt, and the Color Blind test Apps were only recommended to a subset of patients based on clinical
suspicion or diagnosis. The Wilcoxon signed rank sum test and weighted Cohen’s kappa coefficient were applied to compare pairs
of scores from different settings. The Trec Oculistica App was downloaded and activated by 97 patients or their caregiver. 40 patients
were tested at home using the 9Gaze App, 7 used the eyeTilt App, and 11 used the Color-Blind test App. Families reported that all the
Apps were easy and intuitive to use; clinicians reported that measurements were reliable. 82 eyes of 41 patients (mean age 5.2years,
SD ± 0.4, range 4.4–6.1) were tested for visual acuity using the self-administered LEA Symbols pdf. 92 eyes of 46 patients (mean
age 11.6years, SD ± 5.2, range 6–35) were evaluated using the self-administered Snellen Chart Visual Acuity App or the Snellen
Chart pdf. Home median visual acuity score was statistically different from that registered in clinical setting for both the LEA Sym-
bols pdf (P-value = 0.0074) and the Snellen Chart App and pdf (P-value = 0.0001). The strength of agreement was 0.12 (slight) for
the LEA Symbols pdf, 0.50 (moderate) for the Snellen Chart Visual Acuity App, and 0.69 (substantial) for the Snellen Chart pdf.
Conclusion: The novel TreC Oculistica smartphone App was a useful tool for facilitating the clinical practice of pediatric
ophthalmology and strabismus during the COVID-19 pandemic. In the follow-up of strabismus patients and patients with
suspected inherited retinal diseases, the 9Gaze, eyeTilt, and Color Blind test applications were deemed to be intuitive and
easy to use by families and were considered reliable by clinicians. In a home setting, visual acuity tested by means of Snellen
Charts was moderately congruent with the in-office examination. On the contrary, agreement was poor in younger children
tested with the LEA Symbols pdf.
What is Known:
Teleophthalmology enables clinicians to evaluate patients’ ocular diseases remotely and various tools are helpful for screening, follow-ups
and treatment.
Smartphones can currently be used to obtain ocular images and vision measurements of patients’ eyes and this information can be shared with
the ophthalmologist for further evaluations and medical management (mhealth).
What is New:
Smartphone Apps can be successfully used in a hybrid teleophthalmology service concerning first visits and follow-ups.
Apps and printable materials are easy, intuitive to use for patients and also reliable for clinicians.
Keywords Smartphone Apps· Pediatric ophthalmology and strabismus· Visual acuity
Communicated by Peter de Winter
Extended author information available on the last page of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Various digital tools have emerged in recent years to monitor patients' VA [13] including smartphone-based applications such as V@home [14], Peek Acuity [15], GoCheck Kids [1], Sightbook [16], TreC Oculistica [17], the web-based index test [18], the Pocket Vision Screener [19], self-administered tests as Early Treatment Diabetic Retinopathy Study (ETDRS) home VA test [2] and the Accustat ® [20] and even the first smart TV-based VA test, the Democritus Digital Visual Acuity Test (DDiVAT) [21]. However, though a low mean difference between digital tools to the standard charts and clinical equivalence indication was previously reported, the wide 95% limits of agreement revealed lower precision of the digital self-assessments, especially in patients with decreased VA [22]. ...
... Furthermore, as long as the self-administered at home test follows a standardized protocol, it is equivalent to a standard technician-administered VA test in the clinic in the examined population [2]. There is a broad agreement that both smartphone apps and printable materials assessing VA are easy, intuitive to use for patients and also reliable for clinicians [17]. ...
Preprint
Full-text available
Background: Visual acuity (VA) assessments are crucial in ophthalmology but traditionally rely on in-clinic evaluations. The emergence of telemedicine has spurred interest in creating dependable self-administered VA tests for use beyond standard clinical environments. This study evaluates the practicality and validity of a self-administered Near VA card test against traditional Snellen and Rosenbaum Pocket Vision Screener (RPVS) methods for home monitoring and enhancing clinical workflow. Methods: In a cross-sectional study a near VA card (Hadassah Self-Visual Acuity Screener-HSVA) was developed with written and videotaped instructions for self-use. Patients with a minimal best corrected VA (BCVA) of 1.0 LogMAR in at least one eye were recruited from Ophthalmology and Optometry clinics. Outcomes included mean BCVA difference between the self-administered and those obtained by the examiner, and correlations among BCVA values obtained by Snellen, RPVS, HSVA and previous distance BCVA according to the patient electronic medical records. Results: A total of 275 participants (mean age: 42.5±19.4 years, range: 18-89 years, 47% female) were included. Test-retest reliability analysis for the HSVA demonstrated very good correlation and repeatability (n=38 patients.; Rs=1.0, P
... Various digital tools have emerged in recent years to monitor patients' VA [12], including smartphone-based applications such as V@home [13], Peek Acuity [14], GoCheck Kids [1], Sightbook [15], TreC Oculistica [16], the web-based index test [17], the Pocket Vision Screener [18], self-administered tests, such ad as the Early Treatment Diabetic Retinopathy Study (ETDRS) home VA test [2] and the Accustat ® [3], and even the first smart TV-based VA test, the Democritus Digital Visual Acuity Test (DDiVAT) [19]. However, though a low mean difference between digital tools and the standard charts and clinical equivalence indications were previously reported, the wide 95% limits of agreement revealed the lower precision of the digital self-assessments, especially in patients with decreased VA [20]. ...
... Furthermore, as long as the self-administered at-home test follows a standardized protocol, it is equivalent to a standard technician-administered VA test in a clinic in the examined population [2]. There is a broad agreement that both smartphone apps and printable materials assessing VA are easy, intuitive to use for patients, and reliable for clinicians [16]. Investigating the feasibility of remote testing and its value in enhancing patient convenience and healthcare accessibility, future research is setting up a framework for the remote application of the HSVA test. ...
Article
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Background: Visual acuity (VA) assessments are crucial in ophthalmology but traditionally rely on in-clinic evaluations. The emergence of telemedicine has spurred interest in creating dependable self-administered VA tests for use beyond standard clinical environments. This study evaluated the practicality and validity of a self-administered near VA card test against traditional Snellen and Rosenbaum Pocket Vision Screener (RPVS) methods for home monitoring and enhancing clinical workflow. Methods: In a cross-sectional study, a near VA card (Hadassah Self-Visual Acuity Screener (HSVA)) was developed with written and videotaped instructions for self-use. Patients with a minimal best-corrected VA (BCVA) of 1.0 LogMAR in at least one eye were recruited from ophthalmology and optometry clinics. Outcomes included the mean BCVA difference between the self-administered values and those obtained by the examiner, and correlations between BCVA values obtained by the Snellen, RPVS, HSVA, and previous distance BCVA methods according to the patients’ electronic medical records. Results: A total of 275 participants (mean age: 42.5 ± 19.4 years; range: 18–89 years; 47% female) were included. Test–retest reliability analysis of the HSVA demonstrated a very good correlation and repeatability (n = 38 patients; Rs = 1.0; p < 0.001). Accuracy analysis revealed the mean LogMAR BCVA values of an additional 237 patients obtained by the Snellen, RPVS, and HSVA methods were similar (p = 0.10). The self-test BCVA results obtained by the HSVA agreed with the masked examiner-tested VA results (n = 67 patients; p = 0.17; Rs = 0.87; ICC = 0.96). Similar results were obtained when stratification by median age (42 years) was performed. Bland–Altman analysis of the HSVA and RPVS methods demonstrated a good agreement. To assess whether the HSVA could predict the VA results in the clinically used charts, multivariate analysis was used and revealed that the HSVA predicted the RPVS results (β = 0.91; p = 0.001; R² = 0.88), and the self-test HSVA predicted the Snellen VA results within two lines (β = 0.93; p = 0.01; R² = 0.36). Conclusions: The home-based HSVA assessment exhibited high test–retest reliability, accuracy, and alignment with clinical-standard VA tests. Its efficacy in self-testing mirrored examiner-conducted VA assessments and accurately predicted Snellen VA outcomes, indicating the HSVA’s suitability for self-monitoring in chronic ocular conditions or when access to conventional examinations is limited. The utility of self-administered VA tests may extend beyond ophthalmology and optometry, potentially benefiting primary care, emergency medicine, and neurology. Further research is needed to explore and validate the practical applications of remote VA testing.
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This article provides recommendations for screening children aged 36 to younger than 72 months for eye and visual system disorders. The recommendations were developed by the National Expert Panel to the National Center for Children's Vision and Eye Health, sponsored by Prevent Blindness, and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, United States Department of Health and Human Services. The recommendations describe both best and acceptable practice standards. Targeted vision disorders for screening are primarily amblyopia, strabismus, significant refractive error, and associated risk factors. The recommended screening tests are intended for use by lay screeners, nurses, and other personnel who screen children in educational, community, public health, or primary health care settings. Characteristics of children who should be examined by an optometrist or ophthalmologist rather than undergo vision screening are also described. There are two current best practice vision screening methods for children aged 36 to younger than 72 months: (1) monocular visual acuity testing using single HOTV letters or LEA Symbols surrounded by crowding bars at a 5-ft (1.5 m) test distance, with the child responding by either matching or naming, or (2) instrument-based testing using the Retinomax autorefractor or the SureSight Vision Screener with the Vision in Preschoolers Study data software installed (version 2.24 or 2.25 set to minus cylinder form). Using the Plusoptix Photoscreener is acceptable practice, as is adding stereoacuity testing using the PASS (Preschool Assessment of Stereopsis with a Smile) stereotest as a supplemental procedure to visual acuity testing or autorefraction. The National Expert Panel recommends that children aged 36 to younger than 72 months be screened annually (best practice) or at least once (accepted minimum standard) using one of the best practice approaches. Technological updates will be maintained at http://nationalcenter.preventblindness.org.
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Purpose With the recent rise of teleophthalmology due to coronavirus disease, we are in need of accurate and reliable methods of checking visual acuity remotely. We compare the visual acuity as measured by the GoCheck Kids application, HOTV with the amblyopia treatment study (ATS), and our clinic protocol. Design This is a prospective, comparison of visual acuity assessment methods. Methods Established patients (aged 3-18) in the practice of a single pediatric ophthalmologist were eligible. Visual acuity was measured by: 1) GoCheck Kids mobile application (by patient’s family member), 2) HOTV-ATS (by study personnel), and 3) regular clinic protocol (by ophthalmic technician). To assess agreement between measures of acuity, intraclass correlations with 95% confidence intervals were computed. Results Fifty-three children participated. The mean difference between GoCheck Kids and HOTV-ATS acuities (0.094) was significantly different (p<0.001); the intraclass correlation (ICC) was 0.55 (95% CI: 0.40, 0.68). The mean difference between GoCheck Kids and chart acuities (0.010) was not significantly different (p=0.319); ICC: 0.59 (95% CI: 0.45, 0.71). The mean difference between HOTV-ATS and chart acuities (0.084) was significantly different (p<0.001); ICC: 0.66 (95% CI: 0.53, 0.76). The percent of eyes with visual acuity as measured by GoCheck Kids that was within 1 line of the HOTV-ATS and chart acuity was 65.3% and 86.7%, respectively. Conclusions GoCheck Kids as checked by a family member provides a modest correlation of visual acuity compared to the chart screen and a fair correlation of visual acuity compared to HOTV-Amblyopia Treatment Study protocol, though a vast majority are within 1 line.
Article
Purpose. This article provides recommendations for screening children aged 36 to younger than 72 months for eye and visual system disorders. The recommendations were developed by the National Expert Panel to the National Center for Children's Vision and Eye Health, sponsored by Prevent Blindness, and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, United States Department of Health and Human Services. The recommendations describe both best and acceptable practice standards. Targeted vision disorders for screening are primarily amblyopia, strabismus, significant refractive error, and associated risk factors. The recommended screening tests are intended for use by lay screeners, nurses, and other personnel who screen children in educational, community, public health, or primary health care settings. Characteristics of children who should be examined by an optometrist or ophthalmologist rather than undergo vision screening are also described. Results. There are two current best practice vision screening methods for children aged 36 to younger than 72 months: (1) monocular visual acuity testing using single HOTV letters or LEA Symbols surrounded by crowding bars at a 5-ft (1.5 m) test distance, with the child responding by either matching or naming, or (2) instrument-based testing using the Retinomax autorefractor or the SureSight Vision Screener with the Vision in Preschoolers Study data software installed (version 2.24 or 2.25 set to minus cylinder form). Using the Plusoptix Photoscreener is acceptable practice, as is adding stereoacuity testing using the PASS (Preschool Assessment of Stereopsis with a Smile) stereotest as a supplemental procedure to visual acuity testing or autorefraction. Conclusions. The National Expert Panel recommends that children aged 36 to younger than 72 months be screened annually (best practice) or at least once (accepted minimum standard) using one of the best practice approaches. Technological updates will be maintained at http://nationalcenter.preventblindness.org.
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