Effectiveness of the Spot Vision Screener using updated 2021 AAPOS guidelines

Abstract

Purpose: To evaluate the Spot Vision Screener according to updated 2021 AAPOS Vision Screening Committee guidelines for instrument-based pediatric vision screen validation.

Methods: As part of an IRB-approved ongoing prospective study, children were screened with the Spot prior to a complete examination.

Results: Spot screening was successful in 1,036 of 1,090 children (95%). Forty-eight percent of participants were referred for further screening using the Spot manufacturer guidelines, and 40% of all children were found to have a 2021 amblyopia risk factor or visually significant refractive error by gold standard examination. The Spot recommendation compared reasonably well to the 2021 criteria, with an overall sensitivity of 0.88 and a specificity of 0.78. Applying updated guidelines to the Spot for hyperopia, anisometropia, and astigmatism yielded moderate-to-poor sensitivity (0.27-0.77) but excellent specificity (>0.9). The area under the curve of the receiver operating characteristic analysis demonstrates overall good prediction performance for the Spot for each diagnosis-myopia, hyperopia, astigmatism, anisometropia (range, 0.87-0.97). Results of our study suggest increasing the instrument referral criterion for astigmatism from 1.5 D (manufacturer thresholds of the screener used in this study) to 2 D in older children. Decreasing the anisometropia cut-off from 1 D to 0.75 D would improve sensitivity from 0.59 to >0.8.

Conclusions: In our study population, the overall predictive ability of the Spot is good, with a sensitivity of 0.88 and a specificity of 0.78. We recommend specific device refractive referral criteria to maximize screening effectiveness using the updated AAPOS guidelines.

FIG 1.

Bland-Altman plots comparing Spot measurements to physician-reported measurements. The x-axis represents the mean of the Spot and physician measures for each child; the y-axis, the difference between the Spot and physician measures. The gray middle line represents the mean difference between the Spot and physician measures; the bottom and top gray lines represent the 95% agreement interval, that is the interval within which 95% of the differences between the first and second method fall.

FIG 2.

Receiver operating characteristics (ROC) curves for the Spot criterion for physician diagnosed myopia, hyperopia, anisometropia, and astigmatism. The three ROC curves in each panel represent the ROC across all patients (light gray solid line), in children under 4 years of age (black dashed line), and in children 4 years or older (dotted-gray line).