Can PlusoptiX Replace Cycloplegic Exams in Young Children?

Undilated PlusoptiX Exams Less Traumatic for Very Young Patients

Ron Zimmerman

May 16, 2012

May 16, 2012 (San Antonio, Texas) — Do children who have had undilated plusoptiX exams also need to have dilated exams to make sure that abnormalities have not been overlooked?

That is the fundamental question researchers David Silbert, MD, and Noelle S. Matta, MD, from the Family Eye Group in Lancaster, Pennsylvania, set out to answer. In a retrospective study presented here at the American Association for Pediatric Ophthalmology and Strabismus 38th Annual Meeting, they identified children who had had an undilated plusoptiX exam and reviewed their records.

"Dilation is traumatic for kids. They are screaming and are disrupting things, and that's traumatic for me," said Dr. Silbert. "We wanted to know if technological advances have made the need for lengthy exams unnecessary in select patients."

Pupil dilation not only lengthens exams (requiring additional time from the ophthalmologist and staff), but also increases the cost of the exams.

The plusoptiX photoscreener is a noninvasive digital infrared device linked to software. It takes multiple photographs in 3 different meridians in just a few seconds. The plusoptiX screens both eyes simultaneously for refractive errors, pupil size, and gaze deviation in patients as young as 6 months. Results are displayed immediately as a "pass" or "refer." Pupil size, corneal reflexes, and refraction are measured and compared with referral criteria; if readings are outside age-based limits, a refer recommendation is displayed, indicating that patient's ocular issues should be further investigated. The public policy implication is that the use of this device "may allow us as pediatric ophthalmologists to see larger numbers of patients," said Dr. Silbert.

In all, 451 children whose records were reviewed were found to have had plusoptiX exams on their first visit and were included in the study. Of these, 222 children (49%) were found to have normal undilated plusoptiX results, but 32 were excluded because they had abnormal vision or a medical condition requiring a further dilated exam. In 186 (98%) of the remaining 190 children, a subsequent cycloplegic examination did not provide any other information.

The cycloplegic exam provided additional medical information in only 4 patients (2%) — 2 verbal and 2 nonverbal. Of the verbal children, 1 had cupping without glaucoma and 1 had normal alignment but the parents felt that the eyes crossed. One nonverbal child had a nonvisually significant congenital cataract and the other had borderline astigmatism and refractive amblyopia and was fitted with corrective glasses.

The researchers conclude that a normal plusoptiX result, combined with normal alignment/motility evaluation and normal visual acuity, has a 98% negative predictive value for ophthalmologic pathology.

Traumatic dilating drops are unnecessary, according to the researchers, and can be replaced with the plusoptiX photoscreener and an abbreviated eye exam.

Joseph Miller, MD, from the University of Arizona in Phoenix, said that he personally feels that plusoptiX is very effective, and that it is the closest thing to putting the skill of a retinoscopist in an instrument that combines automation with good optical methods.

However, he explained, "many [ocular conditions] are rare; they may occur at a prevalence of 1 in 5000 to 1 in 10,000 patients.... If you're only looking at 200 subjects [as in this study], you're not going to see those the way we do over the course of a career."

Dr. Miller posed some fundamental questions: "Does anyone really question the value of a cycloplegic examination? Is [plusoptiX] a step toward improved efficiency, where we're working smarter? Or is it a degradation of quality, where we're doing less because we're being paid less?"

Robert Arnold, MD, an ophthalmologist in private practice in Anchorage, Alaska, who advises statewide community vision screening programs, believes that the researchers are arguing that scarce public health resources should be spread to more of America through greater use of the plusoptiX screener.

"We have children without insurance going blind next to our practices, not because they're not getting full cycloplegic exams, but because they're not getting anything at all. I think [Dr. Silbert] was saying that it takes quite a bit of effort to screen your whole community, and he's asking where that [funding] is going to come from."

Dr. Arnold suggests that both a full exam, at a higher cost, and plusoptiX screening, at lower cost, be offered to parents at their option. "Dr. Silbert seems to be saying that we can check your child's acuity with a patch, then do the plusoptiX exams; if your child passes those and you aren't complaining about any other ocular issue, you have a 98% chance that your child is going to do well," he said. "I think that you're not a bad parent if you haven't gone for the full-blown exam at the higher cost, because if something develops later, however small that possibility, you can always come in at that time for the cycloplegic exam."

Dr. Silbert and Dr. Mata have disclosed no relevant financial relationships. Dr. Miller reports receiving an NIH grant (NIH EYE 13153). Dr. Arnold reports receiving an unrestricted grant from Walmart.

American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 38th Annual Meeting: Paper 22. Presented March 27, 2012.