Comparison of the amblyopia treatment study hotv and electronic-early treatment of diabetic retinopathy study visual acuity protocols in children aged 5 to 12 years

doi:10.1016/j.ajo.2003.08.016

American Journal of Ophthalmology

Volume 137, Issue 2, February 2004, Pages 278-282

This study was presented in part at the Annual Meeting of the American Academy of Optometry, San Diego, California, December 8, 2002.

https://doi.org/10.1016/j.ajo.2003.08.016 Get rights and content

Abstract

Purpose

To compare two established visual acuity protocols: the Amblyopia Treatment Study HOTV (ATS HOTV) visual acuity protocol and the Electronic-Early Treatment of Diabetic Retinopathy Study (E-ETDRS) protocol, in children aged 5 to 12 years.

Design

Prospective cohort study.

Methods

Crowded HOTV optotypes and crowded ETDRS optotypes were presented to 236 consecutive children aged 5 to 12 years using an electronic visual acuity tester (Palm handheld, personal computer, and monitor). Twenty-three percent of the children were classified as amblyopic, 35% as having uncorrected refractive error, 36% as normal, and 6% as other. Visual acuity test results were converted to logarithm of minimal angle of resolution (logMAR) units for analysis.

Results

In developmentally normal children (n = 230), testability was 100% for HOTV in 5- to 12-year-olds and 100% for E-ETDRS in 7- to 12-year-olds. The E-ETDRS testing could be completed in 52% of 5-year-olds and in 87% of 6-year-olds. Visual acuity performance was better when measured by HOTV compared with E-ETDRS (median difference 0.06 logMAR [three letters on a chart with five letters/line], P = .0001), and the difference was found in normal eyes, eyes with refractive error, and amblyopic eyes.

Conclusions

The ATS HOTV protocol yields slightly better visual acuity performance compared with E-ETDRS in 5- to 12-year-olds, but on average by less than a logMAR level. This systematic difference is important when a physician changes testing modality as a child matures and should be considered when interpreting the results of recent and ongoing clinical trials in amblyopia.

Section snippets

Methods

Single surrounded HOTV optotypes and single surrounded Sloan letters were both presented to 236 consecutive children between 5 and 12 years of age at a single site, using the electronic visual acuity (EVA) tester.6 The HOTV letters were presented using the ATS HOTV visual acuity protocol4 and the Sloan letters using the E-ETDRS protocol.10 The details of each protocol have been previously described.4, 10 In brief, the ATS HOTV visual acuity protocol has a screening phase where single optotypes

Results

There were 236 subjects between 5 and 12 years of age with the median age of 9 years. One-hundred and twenty-five subjects (53%) were female, 218 (92%) were Caucasian, and 6 (3%) had developmental delay. Eighty-six (36%) of the subjects were considered to be normal. Amblyopia was present in 54 subjects (23%), uncorrected refractive error in 82 (35%), and other causes for decreased visual acuity in 14 (6%; Table 1).

All developmentally normal children aged 5 to 12 years could successfully

Discussion

In our comparison of two visual acuity protocols, we found excellent testability for both the ATS HOTV protocol4 and the E-ETDRS protocol10 among children aged 5 to 12 years. The ATS HOTV protocol yielded slightly better visual acuity performance than E-ETDRS, but less than one logMAR level on average (only about three letters on a standard logMAR chart with five letters per line).

Our results of testability with ATS HOTV are similar to previous reports in the literature. We had previously shown

Supplementary files

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We found statistically significant differences between the records of VA obtained with FSVA and ETDRS, resulting in a better VA of 0.06 logMAR with our test. This result is coincident with the outcomes reported by Rice et al. [34] who found an MD of 0.06 logMAR between ATS and ETDRS. Leone et al. [35] also found a better VA with the ATS procedure than with HOTV and ETDRS charts even though the latter ones incorporated a staircase method that improves the VA results.
We present a new iPad application (app) for a fast assessment of Visual Acuity (VA) and Contrast Sensitivity (CS) whose reliability and agreement was evaluated versus a commercial screening device (Optec 6500). The measurement of VA was programmed in the app in accordance with the Amblyopia Treatment Study protocol. The CS was measured with sinusoidal gratings of four different spatial frequencies: 3, 6, 12 and 18 cpd at the same contrast values of the Functional Acuity Contrast Test (FACT) included in the Optec 6500. Forty-five healthy subjects with monocular corrected visual acuities better than 0.2 logMAR participated in the agreement study. Bland-Altman analyses were performed to assess the agreement and Deming regressions to calculate Mean Differences (MDs) and Limits of Agreement (LoAs). Coefficients of reliability were 0.15 logMAR for our method and 0.17 logMAR for the ETDRS testing protocol. For testing the CS, our test showed no statistically significant differences compared with the FACT at any spatial frequency (p > 0.05). The MDs were lower than 0.05 log units for all spatial frequencies.
Reliability and validity of an automated computerized visual acuity and stereoacuity test in children using an interactive video game
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This may reduce the effectiveness of the test, which gives no guarantee of reliability or validity when administered to children. The electronic visual acuity (EVA) test and computerized logMAR visual acuity measurement system (COMPlog) are the most commonly used computerized visual acuity tests.4,5,7,11,12,16,17 A comprehensive MEDLINE literature search found no study evaluating the validity of EVA and COMPlog in preschool-aged subjects compared with the standard tests.
To evaluate the test-retest reliability and validity of the new automated computerized distance visual acuity and stereoacuity test for children, which uses an interactive video game.
Retrospective, observational case series.
A total of 102 children aged between 3 and 7 years underwent the Snellen visual acuity test, the Distance Randot Stereotest, and the new automated computerized distance visual acuity and stereoacuity test. The test-retest reliability and validity of the automated computerized tests were assessed and compared with the Snellen visual acuity test and the Distance Randot Stereotest with frequency distributions of the differences, Bland-Altman plots, and Deming regression.
The automated computerized distance visual acuity test had high test-retest reliability (95% limits of agreement ±0.18 logMAR, 90.0% of the differences within 0.2 logMAR) and acceptable validity as compared with the Snellen visual acuity chart (95% limits of agreement ±0.27 logMAR, 81.3% of the differences within 0.2 logMAR). The automated computerized distance stereoacuity test had high test-retest reliability (95% limits of agreement ±0.29 log arc second, 95.1% of the differences within 0.3 log arc second) and acceptable validity as compared with the Distance Randot Stereotest (95% limits of agreement ±0.35 log arc second, 93.9% of the differences within 0.3 log arc second).
The new automated computerized distance visual acuity and stereoacuity test, which uses an interactive video game, has good reliability and acceptable validity compared with the Snellen visual acuity chart and the Distance Randot Stereotest.
Development of visual acuity in preschool children as measured with Landolt C and Tumbling e charts
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In a study of primary school children in the United Kingdom, Simmers and colleagues21 found that visual acuity measurements obtained by Sheridan-Gardiner test significantly differed from those obtained by Glasgow acuity cards. In a comparison of HOTV and ETDRS tests, Rice and colleagues22 also found that the use of HOTV produced a greater visual acuity score than ETDRS did in children between 5 to 12 years of age. The Vision in Preschoolers study group reported that visual acuity obtained by HOTV was greater than that obtained with the use of Lea symbols in children between 3 and 3.5 years of age.7
To investigate the visual acuity development as measured by Landolt C and Tumbling E charts (“C chart” and “E chart”) in preschool children.
Visual acuity measurements of healthy children ages 3-6 years who had been evaluated with the use of E charts (during kindergarten screening) and C charts (in a hospital setting) from 2005 to 2007 were studied. Inclusion criteria were hyperopia <4.5 D, myopia <3.0 D, astigmatism <2.0 D, and anisometropia <2.0 D. The best-corrected visual acuity (BCVA) in each group was analyzed.
There were 821 children in the E chart group and 212 in the C chart group (mean age, 5 years). The mean BCVA improved from between age 3-4 years and age 5-6 years in both groups (P < 0.001). Children in the C chart group had significantly greater astigmatism compared with those in the E chart group (0.66 D ± 0.47 vs 0.28 D ± 0.39; P < 0.001). The BCVA obtained by E chart was greater than that obtained by C chart at age 3-4 years (logMAR 0.0246 ± 0.0646 vs 0.1158 ± 0.1462, P < 0.001), but not at age 5-6 years.
When children reach 5-6 years of age, visual acuity values obtained by C and E charts approach those observed in adults. In younger patients, the E chart obtains a greater visual acuity score than the C chart. Thus, thresholds for normal visual acuity in preschool children ages 3-6 years should be both age specific and test specific.
Comparison of the Amblyopia Treatment Study HOTV and the Electronic-Early Treatment of Diabetic Retinopathy Study visual acuity protocols in amblyopic children aged 5 to 11 years
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On average, the ATS-HOTV interocular difference was 0.42 lines (95% CI: 0.22-0.61) smaller than the E-ETDRS interocular difference. Similar to the study by Rice et al,6 we found that the ATS-HOTV protocol resulted in a slight mean overestimate of visual acuity relative to the E-ETDRS protocol (0.68 lines, equivalent to 3.4 letters). Our novel finding is that most of the discrepancy was due to overestimation by ATS-HOTV of amblyopic eye visual acuity when the E-ETDRS visual acuity was ≥0.3 logMAR (ie 20/40 or worse).
As part of the long-term follow-up of amblyopic children who were enrolled in the Amblyopia Treatment Study, we tested visual acuity in both eyes of 142 patients by using 2 established visual acuity protocols, the Amblyopia Treatment Study HOTV (ATS HOTV) visual acuity protocol and the Electronic-Early Treatment of Diabetic Retinopathy Study (E-ETDRS) protocol, at one of the annual visits. Mean age at the time of testing was 9.0 years (range, 5.6-11.9 years). The ATS-HOTV protocol resulted in a slight mean overestimate of visual acuity relative to the E-ETDRS protocol (0.68 lines for amblyopic eyes; 0.25 lines for fellow eyes). The overestimation occurred primarily when the E-ETDRS visual acuity was poorer than 0.3 logMAR. ATS-HOTV acuity also underestimated interocular visual acuity differences by 0.42 lines. When one uses the ATS-HOTV protocol, it may be wise to exercise caution when interpreting “near-normal” visual acuity or interocular differences as “within normal” because the ATS-HOTV method may have a slight bias toward better performance of amblyopic eyes than E-ETDRS.
Amblyopia
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Results from recent randomised clinical trials in amblyopia should change our approach to screening for and treatment of amblyopia. Based on the current evidence, if one screening session is used, screening at school entry could be the most reasonable time. Clinicians should preferably use age-appropriate LogMAR acuity tests, and treatment should only be considered for children who are clearly not in the typical range for their age. Any substantial refractive error should be corrected before further treatment is considered and the child should be followed in spectacles until no further improvement is recorded, which can take up to 6 months. Parents and carers should then be offered an informed choice between patching and atropine drops. Successful patching regimens can last as little as 1 h or 2 h a day, and successful atropine regimens as little as one drop twice a week. Intense and extended regimens might not be needed in initial therapy.
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Biosketches and/or additional material at www.ajo.com doi:10.1016/j.ajo.2003.08.016

This study was supported in part by the National Institutes of Health (EY11751), by Research to Prevent Blindness, New York, New York (to J.M.H. as Olga Keith Weiss Scholar and an unrestricted grant to the Department of Ophthalmology, Mayo Clinic), and by the Mayo Clinic, Rochester, Minnesota.

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Comparison of the amblyopia treatment study hotv and electronic-early treatment of diabetic retinopathy study visual acuity protocols in children aged 5 to 12 years☆

Abstract

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Supplementary files

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol