Keenan, Jeremy D

Kumar, Rajesh S

Moe, Caitlin A

Nagaraj, Sriharsha

Rackenchath, Mahalakshmi V

Sathidevi, AV

Stamper, Robert L

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UCSFUC San Francisco Previously Published WorksTitleAccuracy of pinhole visual acuity at an urban Indian hospitalPermalinkhttps://escholarship.org/uc/item/5m14s8z7JournalEye, 33(2)ISSN0950-222XAuthorsKumar, Rajesh SRackenchath, Mahalakshmi VSathidevi, AVet al.Publication Date2019-02-01DOI10.1038/s41433-018-0237-6Copyright InformationThis work is made available under the terms of a Creative Commons Attribution License, available at https://creativecommons.org/licenses/by/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaAcknowledgements We thank the Thames Valley Macular GroupRapid Access Guidelines developed by SM Downes, C Moorman, SLWatson and L Jenkins in collaboration with the Oxfordshire LOC.Compliance with ethical standardsConflict of interest Susan Downes Disclosure: PI on relevant com-mercially sponsored trials in last 5 years: Novartis, Bayer, andAlcon. Prof Susan Downes has received honoraria in the past15 years from Novartis and Bayer for speaking at educationalmeetings, as well as travel expenses from Ely Lilly as chair fordiabetic retinopathy screening meetings, and Novartis to attendeducational meetings in Medical Retina pre 2010. She is a PI on anumber of commercial trials (Novartis, Roche, Bayer, Allergen,among others), and has received a bursary for a research nursepractitioner, and equipment (visudyne pump for photodynamictherapy) and funding to carry out genetic testing for a researchproject from Novartis. She also has has been a co-PI or Pl on grantsfrom Wellcome, UK Fighting Blindness RP, Fight for Sight and UKNIHR/CRN funding. The remaining authors declare that they haveno conflict of interest.References1. The Royal College of Ophthalmologists. Age-Related MacularDegeneration: Guidelines for Management 2013. https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-SCI-318-RCOphth-AMD-Guidelines-Sept-2013-FINAL-2.pdf2. The Royal College of Ophthalmologists. Wet AMD Rapid AccessReferral Form 2010. https://www.rcophth.ac.uk/wp-content/uploads/2015/04/2010-SCI-048-AMD-Electronic-Referral-Form-edited.pdfEye (2019) 33:335–337https://doi.org/10.1038/s41433-018-0237-6Accuracy of pinhole visual acuity at an urban Indian hospitalRajesh S. Kumar1,2 ● Mahalakshmi V. Rackenchath1 ● A. V. Sathidevi1 ● Sriharsha Nagaraj1 ● Caitlin A. Moe3 ●Robert L. Stamper4 ● Jeremy D. Keenan 3,4Received: 16 August 2018 / Accepted: 7 September 2018 / Published online: 19 October 2018© The Royal College of Ophthalmologists 2018The World Health Organization-endorsed rapid assessmentof avoidable blindness (RAAB) survey employs pinholeacuity to distinguish between refractive error versus con-ditions not correctable with eyeglasses, but few studies havevalidated this approach [1].MethodsEthical committees at the University of California, SanFrancisco and Narayana Nethralya Eye Hospital approvedthis study. A consecutive series of patients aged ≥50 yearsvisiting the refraction clinic at Narayana Nethralaya EyeHospital (Bangalore, India) in September 2015 had pre-senting vision and pinhole vision assessed using an ETDRSchart in a fully illuminated room, and then had a manifestrefraction by an experienced optometrist. Analyses arereported with bootstrapped 95% confidence intervals withresampling at the participant level to account for non-independence of eyes.Fig. 2 Delay between referral and specialist review by diagnosis* Jeremy D. Keenanjeremy.keenan@ucsf.edu1 Narayana Nethralaya Eye Hospital, Bangalore, India2 Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE3 Francis I Proctor Foundation, University of California,San Francisco, CA, USA4 Department of Ophthalmology, University of California,San Francisco, CA, USACorrespondence 335ResultsWe assessed 204 eyes from 104 individuals (mean age63.4 ± 7.8 years, 51.9% female). Mean spherical equivalentafter manifest refraction was –0.31 (95% confidence inter-val [CI]: –0.07 to –0.60). Mean uncorrected visual acuitywas 0.43 logMAR units (95% CI: 0.38–0.49), mean bestcorrected visual acuity (BCVA) was 0.16 (95% CI: 0.13–0.19) and mean pinhole acuity was 0.15 (95% CI: 0.12–0.18). Pinhole acuity had high agreement with BCVA(intraclass correlation coefficient 0.97, 95% CI: 0.96–0.98;Fig. 1). On average, pinhole acuity was less than a letterdifferent from BCVA (mean 0.4 letters better, 95% limits ofagreement by Bland–Altman method: four letters worse tofive letters better). The magnitude of improvement on pin-hole testing was correlated with the magnitude of sphericalequivalent from refraction (Spearman’s rho= 0.68, P <0.001; Fig. 2).Of 204 eyes, 21 (10.3%) had visual impairment evenafter subjective refraction (BCVA worse than 20/60). Whentreated as a diagnostic test for visual impairment not cor-rectable with eyeglasses, pinhole acuity provided high dis-criminative ability, with an area under the receiver operatingcharacteristics (ROC) curve of 0.99 (95% CI: 0.97–1.0).Pinhole acuity worse than 20/60 was 85.7% sensitive(95% CI: 59.1–100%) and 100% specific (98.0–100%)for detecting visual impairment not correctable withglasses, and had a positive predictive value of 100%(95% CI: 81.4–100%).ConclusionsPrevious studies of patients with diabetic retinopathy or lowvision found that pinhole acuity was biased relative toBCVA, with pinhole acuity ~1 line worse than BCVA[2, 3]. In contrast, we found essentially no bias in thispopulation from a refraction clinic in India. The reason forthe discrepancy is unclear, but the pinhole occluder maycause more visual degradation in those with retinalpathology than in a general population like ours [2]. Theestimates of sensitivity and specificity of pinhole acuity as atest for visual impairment are consistent with prior reports,and suggest that estimates of refractive error based onpinhole occlusion should not overestimate the prevalence ofdisease [4].In summary, pinhole acuity agreed well with BCVA andwas a specific test for visual impairment not correctablewith eyeglasses. These results suggest that pinhole occlu-sion is a valid gauge of refractive error in the RAAB surveyor other community-based surveys.Funding This work was funded by the Fortisure Foundation, ThatMan May See, and Research to Prevent Blindness.Compliance with ethical standardsConflict of interest The authors declare that they have no conflictof interest.Fig. 2 Relationship between improvement with pinhole occlusion andrefractive error. Eyes were stratified according to how many lines ofimprovement were achieved with pinhole occlusion. The distributionof spherical equivalent for each stratum is depicted as a box-and-whiskers plotFig. 1 Correlation between measurements of best spectacle correctedvisual acuity and pinhole acuity. Points are weighted; the area of thecircles represents the number of observations at each coordinate336 CorrespondenceReferences1. Kuper H, Polack S, Limburg H. Rapid assessment of avoidableblindness. Community Eye Health. 2006;19:68–9.2. Eagan SM, Jacobs RJ, Demers-Turco PL. Study of luminanceeffects on pinhole test results for visually impaired patients. OptomVis Sci. 1999;76:50–8.3. Sun JK, et al. Visual acuity testing using autorefraction or pinholeoccluder compared with a manual protocol refraction in individualswith diabetes. Ophthalmology. 2011;118:537–42. https://doi.org/10.1016/j.ophtha.2010.07.0224. Loewenstein JI, Palmberg PF, Connett JE, Wentworth DN. Effec-tiveness of a pinhole method for visual acuity screening. ArchOphthalmol. 1985;103:222–3.Eye (2019) 33:337–338https://doi.org/10.1038/s41433-018-0246-5Time to drop the phenylephrine from the paediatric cycloplegiaprotocol: informing practice through auditSue Llewellyn1,2 ● Payal Khandelwal2,3 ● Selina Glaze2,3 ● Peter Thomas2,4,5 ● Annegret Dahlmann-Noor 2,4,5Received: 25 September 2018 / Accepted: 4 October 2018 / Published online: 23 October 2018© The Royal College of Ophthalmologists 2018Cycloplegic retinoscopy is the gold standard refractionapproach in children. Various protocols are in use toachieve cycloplegia during outpatient appointments. Manyuse not only the muscarinergic antagonist, cyclopentolate(CP), which paralyses the ciliary muscle, but also the alpha-adrenergic agonist, phenylephrine (PE), which as amydriatic paralyses the iris constrictor, but has no effect onthe ciliary muscle. Whilst mydriasis facilitates visualisationof the retinoscopy reflex, there is a risk of underestimatinghypermetropia. Published evidence suggests that repeatedinstillation of CP only is effective even for brown and verydark irides [1–3].To develop a Patient Group Directive (PGD) we carriedout a two-cycle audit (CA18/PA/02). The first round eval-uated our current protocol: blue iris, CP 1% once (0.5% ifage < 3 months); brown iris, CP/PE 2.5% once; very darkiris, CP/PE twice, 10–15 min apart; repeated if pupils stillconstrict on pentorch illumination. As standard, we set fulldilation in 90% within 30 min, i.e. the level expected forblue irides with a single CP drop [4].In the second round, we only included children withbrown or very dark iris, administering CP twice or threetimes, respectively, 10–15 min apart.Table 1 Ethnic background and iris colour of children assessed in thisauditRound 1 Round 2n % n %EthnicityAfro-Caribbean 5 9 10 20Asian 7 13 19 37Caucasian 44 79 20 39Chinese 1 2Other 1 2Iris colourBlue 32 57Brown 11 20 14 27Very dark 13 23 37 73This work was presented at the annual meeting of the British IslesPaediatric Ophthalmology and Strabismus Association, Manchester,October 3–5, 2018.* Annegret Dahlmann-Noorannegret.dahlmann-noor@nhs.net1 Bedford Hospital Trust, Kempston Road, Bedford, UK2 Moorfields at Bedford Hospital, Children’s Eye Clinic, EnhancedServices Centre, Kimbolton Road, Bedford, UK3 Cambridgeshire Community Services NHS Trust, Unit 3, MeadowLane, St Ives PE27 4LG, UK4 Paediatric Service, Moorfields Eye Hospital, 162 City Road,London EC1V 2PD, UK5 NIHR Biomedical Research Centre at Moorfields Eye Hospital andUCL Institute of Ophthalmology, 162 City Road, London EC1V2PD, UKCorrespondence 337

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Accuracy of pinhole visual acuity at an urban Indian hospital

Accuracy of pinhole visual acuity at an urban Indian hospital

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