• Mayu Nishimura, Agnes Wong, Ashley Cohen, Kevin Thorpe, and Daphne Maurer.
• Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada mayu.nishimura@sickkids.ca.
• BMJ Open. 2019 Sep 26; 9 (9): e032138.

ObjectivesTo assess the diagnostic accuracy of five vision screening tools used in a school setting using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).DesignWe compared the results of the five best evidence-based screening tools available in 2014 to the results of a comprehensive eye exam with cycloplegic refraction by a licenced optometrist. Screening included Cambridge Crowded Acuity Cards, Plusoptix S12 and Spot photoscreeners, Preschool Randot Stereoacuity Test and the Pediatric Vision Scanner (PVS). Referral criteria followed AAPOS (2013) guidelines and published norms.SettingA large school in Toronto, Canada, with 25 split classrooms of junior kindergarten (JK: 4 year olds) and senior kindergarten (SK: 5 year olds) children.ParticipantsOver 2 years, 1132 eligible children were enrolled at the school. After obtaining parental consent, 832 children were screened. Subsequently, 709 children had complete screening and optometry exam data.Main Outcome MeasuresThe presence/absence of a visual problem based on optometrist's assessment: amblyopia, amblyopia risk factors (reduced stereoacuity, strabismus and clinically significant refractive errors) and any other ocular problem (eg, nystagmus).ResultsOverall, 26.5% of the screened children had a visual problem, including 5.9% with amblyopia. Using all five tools, screening sensitivity=84% (95% CI 78 to 89), specificity=49% (95% CI 44 to 53), PPV=37% (95% CI 33 to 42), and NPV=90% (95% CI 86 to 93). The odds of having a correct screening result in SK (mean age=68.2 months) was 1.5 times those in JK (mean age=55.6 months; 95% CI 1.1 to 2.1), with sensitivity improved to 89% (95% CI 80 to 96) and specificity improved to 57% (95% CI 50 to 64) among SK children.ConclusionsA school-based screening programme correctly identified 84% of those kindergarten children who were found to have a visual problem by a cyclopleged optometry exam. Additional analyses revealed how accuracy varies with different combinations of screening tools and referral criteria.© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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