Risk factors for decreased visual acuity in preschool children: the multi-ethnic pediatric eye disease and Baltimore pediatric eye disease studies

Abstract

Objective: To investigate risk factors associated with unilateral or bilateral decreased visual acuity (VA) in preschool children.

Design: Population-based, cross-sectional prevalence study.

Participants: Population-based samples of 6504 children ages 30 to 72 months from California and Maryland.

Methods: Participants were preschool African-American, Hispanic, and non-Hispanic white children from Los Angeles, California, and Baltimore, Maryland. Data were obtained by a parental interview and a detailed ocular examination. Logistic regression models were used to evaluate the independent associations between demographic, behavioral, and clinical risk factors with unilateral and bilateral decreased VA.

Main outcome measures: Odds ratios (ORs) for various risk factors associated with interocular difference (IOD) in VA of ≥2 lines with ≤20/32 in the worse eye, or bilateral decreased VA <20/40 or <20/50 if <48 months of age.

Results: In multivariate logistic regression analysis, 2-line IOD with a VA of ≤20/32 was independently associated with Hispanic ethnicity (OR, 2.05), esotropia (OR, 8.98), spherical equivalent (SE) anisometropia (ORs ranging between 1.5 and 39.7 for SE anisometropia ranging between 0.50 to <1.00 diopters [D] and ≥2.00 D), and aniso-astigmatism in J0 or J45 (ORs ranging between 1.4 and ≥5.3 for J0 or J45 differences ranging between 0.25 to <0.50 D and ≥1.00 D). Bilateral decreased VA was independently associated with lack of health insurance (OR, 2.9), lower primary caregiver education (OR, 1.7), astigmatism (OR, 2.3 and 17.6 for astigmatism 1.00 to <2.00 D and ≥2.00 D), and SE hyperopia ≥4.00 D (OR, 10.8).

Conclusions: Anisometropia and esotropia are risk factors for IOD in VA. Astigmatism and high hyperopia are risk factors for bilateral decreased VA. Guidelines for the screening and management of decreased VA in preschool children should be considered in light of these risk associations.

Financial disclosure(s): The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Figure 1

Participant flowchart highlighting those children who were included and excluded from the final analysis sample for both outcomes – inter-ocular difference of 2 or more lines with visual acuity (VA) of 20/32 or worse in worse eye, and bilateral decreased VA, in preschool children from both the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) and the Baltimore Pediatric Eye Disease Study (BPEDS).

Figure 2

Locally weighted regression line illustrating the independent relationship between level of overall anisometropia and the estimated prevalence of inter-ocular visual acuity (VA) difference of 2 or more lines with VA 20/32 or worse in the worse eye, in preschool children in the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) and the Baltimore Pediatric Eye Disease Study (BPEDS), after controlling for other risk factors. The estimated prevalence of having an inter-ocular VA difference of 2 or more lines with VA 20/32 or worse in the worse eye was obtained using the stepwise logistic regression procedure. VA: visual acuity.

Figure 4

(A) Locally weighted regression lines illustrating the independent relationship between level of spherical equivalent refractive (SE) error ; (B) or absolute cylindrical power (astigmatism) and the estimated prevalence of bilateral decreased visual acuity (VA) in preschool children in the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) and the Baltimore Pediatric Eye Disease Study (BPEDS) after controlling for other risk factors. The estimated prevalence of having any bilateral decreased VA was obtained using the stepwise logistic regression procedure. The plot for Figure 3a excludes 2 children with highly hyperopic refractions (>11.00 D SE in both eyes) due to aphakia. VA: visual acuity. SE: spherical equivalent.

Figure 4

(A) Locally weighted regression lines illustrating the independent relationship between level of spherical equivalent refractive (SE) error ; (B) or absolute cylindrical power (astigmatism) and the estimated prevalence of bilateral decreased visual acuity (VA) in preschool children in the Multi-Ethnic Pediatric Eye Disease Study (MEPEDS) and the Baltimore Pediatric Eye Disease Study (BPEDS) after controlling for other risk factors. The estimated prevalence of having any bilateral decreased VA was obtained using the stepwise logistic regression procedure. The plot for Figure 3a excludes 2 children with highly hyperopic refractions (>11.00 D SE in both eyes) due to aphakia. VA: visual acuity. SE: spherical equivalent.