Rotterdam Amblyopia Meeting

Transcription

1 Rotterdam Amblyopia Meeting Towards a uniform European guideline for populationbased screening Erasmus MC University Medical Center Rotterdam The Auditorium of the Erasmus MC (second floor Erasmus MC, North side of the H-building) Thursday, 27th October 2011

2 Dear Delegate, It is our pleasure to welcome you to the Fourth Rotterdam Amblyopia Meeting. This years theme is towards a uniform European guideline for population-based screening. This meeting offers invaluable insights into the various screening methods in the European countries: several international speakers will highlight their screening programmes. It will give you the opportunity to evaluate, share your ideas, and discuss the programmes. This will hopefully lead to a more uniform and successful vision screening programme for children. In the morning session the focus lies on screening for amblyogenic factors such as hypermetropia and strabismus. At the end, these papers will be discussed by Rikard Juttmann, leader of the Rotterdam amblyopia screening effectiveness study (RAMSES) and many other cost-effectiveness studies. After lunch, more papers will be presented on amblyopia with speakers from the UK, Germany and the Netherlands A dinner will conclude the meeting. We hope you will have a fruitful scientific day! The organising committee Huib Simonsz Sjoukje Loudon Jan Roelof Polling 2

3 8:00 9:00 Registration The Auditorium of the Erasmus MC (Second floor Erasmus MC, North side of the H-building A-206) 9:00 Welcome 9:10 9:30 Implementation of triage in 5-year olds in the Netherlands: vision test in a population based screening at primary schools Paul Kocken (Leiden, Netherlands) 9:30 9:50 Current guideline for early detection of amblyopia and amblyogenic factors in school-aged children by Pupil Guidance Centres teams in Flanders Cecile Guérin (Leuven, Belgium) 9:50 10:10 Screening of amblyopia in Flanders: the Kind en Gezin programme Ilse de Veurster (Antwerp, Belgium) 10:00 10:20 Infant and preschool screening for refractive error, strabismus and cataract with the Plusoptix A09 Oliver Ehrt (Munich, Germany) 10:20 10:40 Should we be screening for hypermetropia? What does the evidence tell us? Anna O'Connor (Liverpool, United Kingdom) 10:40 11:00 Coffee break 11:00 11:20 Prevalence of refractive errors and the association of refractive error with visual acuity, quality of visual functioning and axial length in 8 year- old school children in Warsaw Alicja Krawczyk (Warsaw, Poland) 11:20 11:40 Results of screening Vision test I can see? " in the group of Polish students aged 6 to 15 years Anna Zaleska- Zmijewska (Warsaw, Poland) 11:40 12:00 The value of early detection of visual problem must be weighed against the time and resources required to conduct the screening Very well, but how to compare the efficiency of screening programs in EU-member states? Huib Simonsz (Rotterdam, Netherlands) 3

4 12:00 12:45 Panel discussion chaired by Rikard Juttmann (The Rotterdam AMblyopia Screening Effectiveness Study RAMSES) 13:00 14:00 Lunch 14:00 14:20 Amblyopia Treatment: an update of recent studies Catherine Stewart (London, United Kingdom) 14:20 14:40 The development of the CAT-QOL (Children s Amblyopia Treatment Quality of Life Questionnaire) Jill Carlton (Sheffield, United Kingdom) 14:40 14:55 Implementation of an educational cartoon that improves compliance with occlusion therapy for amblyopia - Angela Tjiam (Rotterdam, Netherlands) 14:55-15:10 Utility analysis of bilateral visual impairment caused by insufficiently treated amblyopia and contra-lateral age-related macular degeneration Elizabeth van de Graaf (Rotterdam, Netherlands) 15:10 15:30 Recognizability of equally sized and spaced optotypes from Amsterdam picture chart, tumbling-e, Lea symbols, EDTRS and Landolt-C in healthy and amblyopic individuals Dominiek Despriet (Rotterdam, Netherlands) 15:30 16:00 Vision Screening in toddlers - Jürgen Schmidt (Nuremberg, Germany) 16:00 16:30 Discussion 16:30 Closing Drinks 4

5 Janine Bezem, Esther Coenen, Kitty van der Ploeg, Paul Kocken Implementation of triage in 5-year olds in the Netherlands: vision test in a population based screening at primary schools The main focus of the Preventive Child Health Care (PCH) in the Netherlands is the protection and promotion of the health of 0-19 year olds. As part of this service, all children are examined on defined ages by a PCH doctor or nurse using Preventive Health Examinations (PHE). Thus PCH doctors and nurses spend much time at children without health risks. An innovative triage method was developed to provide more efficient health care, enabling PCH doctors and nurses to give more attention and care to children that might be at risk. 5/6 old children are preselected during schools hours by the doctor s assistant based on their care needs. These care needs are assessed using a questionnaire for parents, signals of the child s teacher, and risk assessment conducted by the trained doctors assistant. The doctor s assistant strictly follows a protocol which guides her decisions taken in the process of the risk assessment and the triage of high risk children. The protocol for the conduct of the vision test is based on the Dutch guideline for vision screening in PCH. Children with underperformance on the vision test are referred to the PCH physician for further examination. After this physicians examination the child is referred to external services for specialized eye care if needed. The triage method used in Dutch PCH will be presented and the study of this innovative method that is currently conducted will be explained. paul.kocken@tno.nl 5

6 Cecile Guérin, Karel Hoppenbrouwers Current guideline for early detection of amblyopia and amblyogenic factors in school-aged children by Pupil Guidance Centres teams in Flanders Since 2000, and on the authority of the Ministry of Health of Flanders, the Flemish Scientific Society for Youth Health Care has been engaged in the development of evidence-based guidelines for school health care. Since 2003, the first completed guideline - which is related to the early detection of visual impairments in schoolchildren (3-18 years) - is officially accepted as the standard for good visual screening practice in School Health Care and implemented in all Pupil Guidance Centres in Flanders. One of the core aims of this guideline is the early detection of amblyopia and amblyogenic factors. Therefore all children are screened for visual acuity deficiency at ages 3, 4, 6 & 8 years (monocular visual acuity measured at a distance of 3 metres with a Kay pictures crowded logmar book or a Keeler LogMAR crowded test, depending on the age and maturity of the child) and for ocular alignment deviation by means of Hirschberg test at the age of 3 years and by cover-uncover test and alternate cover test at 4 and 6 years. Test characteristics and rationale for the choice of these tests will be highlighted, as well as referral criteria and recommendations for specific high risk groups. cecile.guerin@med.kuleuven.be 6

7 Ilse De Veuster, Erwin Van Kerschaver Screening of amblyopia in Flanders: the Kind en Gezin programme Screening of amblyopia is started in Flanders at the age of 12 and 24 months by the nurse at the consultation bureau of «Kind en Gezin» with a binocular automated infrared video-refractometer. Amblyogenic factors are searched for. The Eye Screener gives automatically a pass or refer conclusion. An ophthalmologist sees the referred children no more than two months after the referral. A standardised report has to be filled in. At the moment this programme is running in 1 province of Flanders. van.de.velde-de.veuster@telenet.be 7

8 Oliver Ehrt Infant and preschool screening for refractive error, strabismus and cataract with the Plusoptix A09 The Plusoptix A09 is a binocular video refractor which measures from 1m distance and also analyzes the corneal reflex for ocular alignment. Most previous studies did not clearly differentiate between strabismus, ametropia and other amblyogenic factors. Method: We performed repeated measurements with the A09, cycloplegic refraction, orthoptic exam and calculated sensitivity and specificity for the detection of amblyogenic ametropia and strabismus on 296 children age 0.5 to 6 years from 6 paediatricians' offices. 42 children with variable forms of cataract were screened at the paediatric ophthalmology service of the Muenchen University Eye Hospital. Results: Sensitivity and specificity to detect amblyogenic refractive errors (>+3dpt hyperopia, >1 dpt astigmatism or anisometropia) was 80% and 95% respectively. Repeat measurements showed that the second was slightly better than the first with no further improvement with the third. Sensitivity for detecting strabismus 5 was 32% and 88% for strabismus 8 when specificity was set at 95%. Cata racts were detected in 97%. Conclusion: Screening for amblyogenic ametropia and cataracts with the Plusoptix A09 is fast, reliable and children of all age groups showed very good compliance. So it can easily be used to screen in the first two years of live when visual acuity screening is not yet possible. To detect small angle strabismus screening must be supplemented by a random dot stereo test, e.g. the Lang-Test. oliver.ehrt@med.uni-muenchen.de 8

9 Anna O'Connor Should we be screening for hypermetropia? What does the evidence tell us? Aim: Review of the literature to determine whether it is beneficial to screen for hypermetropia. Summary: The presence of low to moderate degrees of hypermetropia may not be detected by routine screening procedures in the UK. Current guidelines do not include direct assessment of refractive errors and rely on visual acuity testing to detect any resultant deficit. However, if a child passes a distance acuity test due to their ability to accommodate, it could be argued that low to moderate levels of hypermetropia, in the absence of strabismus or amblyopia, do not need to be prescribed. This assumes that there is no resultant detriment to the child, though research has demonstrated a link between hypermetropia and a range of deficits such as poorer performance on visual and literacy tasks, reduced reading and writing skills and lower IQ. A number of questions remain therefore, such as whether additional testing should be incorporated to detect moderate hypermetropia, if so what should that test be and when it should be undertaken. If a test is performed, this raises an additional question as to what levels of hypermetropia require correction in children, of which there is currently no consensus. annaoc@liv.ac.uk 9

10 Alicja Krawczyk Prevalence of refractive errors and the association of refractive error with visual acuity, quality of visual functioning and axial length in 8 year- old school children in Warsaw Purpose of our study was to describe the prevalence of spherical equivalent refraction and assosciation of refractive error and visual acuity, visual functioning and axial length in 8 years old population of school children. Materials and Methods: year- old children from 27 primary schools were examined. Monocular logmar near and distance visual acuity, non- and cycloplegic refractive error and axial length were measured. Spherical equivalent refraction was defined as follows: non significant hyperopia >+0.75 D <+2.0 D, significant hyperopia >+2.25 D, emmetropia >-0.5 D <+0.5D, myopia >-0,5 D. Results: This 8 year- old population was predominantly mildly hyperopic. Nonsignificant hyperopia occured in 70,29 %, significant hyperopia- 16,63%, emmetropia- 9,6%, myopia in 3,27% of children. Most eyes with normal visual acuity occured among the emmetropic and non significantly hyperopic eyes. Conclusions: Emmetropia not always is equivalent to the normal visual acuity and lack of visual difficulties. Children with normal visual acuity, complaining of visual discomfort need refractive error examination as they can have significant hyperopia. Children with emmetropia and nonsignificant hyperopia need further refractive error screening. ala@yeti.com.pl 10

11 Anna Zaleska- Zmijewska, Jerzy Szaflik Results of screening Vision test I can see..." in the group of Polish students aged 6 to 15 years The aim of the study was to asses the prevalence of refractive errors in school children examined with screening program I can see.. to confirm the diagnosis during ophthalmic examination. Material and methods: children from randomly chosen primary schools and high schools passed the screening test at schools. Methods: 1. stage- screening program I can see a part of the SENSE EXAMINATION PLATFORM (Designed by the International Centre of Hearing and Speech), which consisted of color vision test (Ishihara charts) and contrast determination test (VCTS Vistech chart), 2. stage: objective ophthalmic examination after cycloplegia done in the group of children who failed screening test. Results: Stage I screening tests: positive results in 2972 children (29,7%), Stage II- ophthalmic examination: 1002 children = 33,7% from the risk group were examined. Colour vision defects were observed 8 times more often in boys. For 23,5% of all examined the ophthalmic examination was the first visit at specialist. Conclusions: Positive results of the screening test were confirmed in almost 70 % of examined children. Over 30% of school children need refractive error correction aniazaleska-zmijewska@wp.pl 11

12 Huib Simonsz, Frans-Willem Goudsmit, Rikard Juttmann, Edward Steyerberg, Harry de Koning, The value of early detection of visual problem must be weighed against the time and resources required to conduct the screening Very well, but how to compare the efficiency of screening programs in EU-member states? The Consensus Statement on Vision Screening of School Age Children signed in Warsaw in June, that is now being discussed in the European Public Health Alliance, says that ( 6) The objective of a vision screening program is to identify children with visual defects at the earliest possible stage, however the value of early detection of visual problem must be weighed against the time and resources required to conduct the screening. In the Netherlands, sufficient studies have been carried out on vision screening and the treatment of amblyopia to permit an estimate of its efficiency. Population-based vision screening takes per child for all 6 exams (Korfage, 2003), at a price of 400,000 per minute annually, at a birth rate of 180,000, hence vision screening in the Netherlands may cost 4,253,333 annually (2003 s). Treatment of amblyopia caused by strabismus costs 2472, of amblyopia caused by anisometropia costs 2052 (König et al., 2003), hence treatment of amblyopia in the Netherlands may cost 3.2% x x ( )/2 = 13,029,120. In the RAMSES birth-cohort study (Groenewoud et al, 2010) a quarter of all children with amblyopia had insufficiently treated amblyopia (visual acuity < 0.5) at age 7, approximately another quarter reaches visual acuity 0.5 without treatment, hence screening and treatment in the Netherlands preserves a visual acuity of 0.5 in the amblyopic eye of 180,000 x (3.2% - 0.8% - 0.8%) = 2880 children annually, at 5858 per child. Decrease of utility in patients with insufficiently treated amblyopia has been measured (van de Graaf et al, 2010), and in elderly among these patients who loose vision in their better eye. The latter patients may cost an additional 2500 or 5000 annually for magnifiers and other aid measures. 12

13 But how to compare the efficiency of screening programs in EU-member states? How to assess the efficacy of a single screen of a screening programme? Screening is done in Germany by paediatricians, in Skandinavia by district nurses, in the UK by school nurses or by orthoptists and in the Netherlands by doctors at Youth Health Care Offices. In most countries, visual acuity is measured in 3- to 6-year-olds to detect amblyopia and the RAMSES study found that "Most cases of amblyopia were detected by vision screening with visual acuity measurement. Preverbal screening contributed little to the detection of refractive amblyopia. But increasingly, expensive screening devices are promoted that allow identification of conditions that predispose to amblyopia, like hypermetropia, before age 3. Increasing hypermetropia, more than hypermetropia itself, leads to amblyopia (Simonsz et al., 1992). Comparison between prescription of glasses to treat conditions predisposing to amblyopia at age 1, with detection of amblyopia itself at age 4 will be a complex challenge. One of us (FWG) has made a micro-simulation model to calculate the efficacy of a screening program based on estimates of age-specific incidence of amblyopia, age-specific sensitivity of examination technique and age-specific effect of occlusion treatment, derived from observational data (RAMSES and other studies), using a discrete quasi maximum likelihood approach. Monte Carlo simulations were applied with various incidence, sensitivity and treatment-effect combinations to approach the observational data. The effect per screen and the optimal interval between screens could be calculated. A new schedule for vision screening in the Netherlands was designed containing fewer screens and an almost equal overall effectiveness. This model should be expanded with observational data from all EU-member states to allow comparison of screening programs. simonsz@compuserve.com 13

14 Catherine Stewart, Merrick Moseley, Alistair Fielder Amblyopia Treatment: an update of recent studies We review the findings of trials of mainstay amblyopia treatment conducted within the last 5 years. These have confirmed that an initial period of full-time refractive correction is beneficial for all types of amblyopia. Adopting this practice may allow up to 30% of children to avoid any further treatment. Studies that have investigated the role of atropine occlusion as a first-line treatment for amblyopia have shown weekend atropine to be as effective as patching for children with both moderate or severe amblyopia. Where patching is prescribed, 2-4 hours/day occlusion appears sufficient to provide an optimum outcome for the majority of children, although those over 6 years tend to require a larger dose to achieve best outcome; their amblyopia being more resistant to treatment. Educational interventions such as cartoons, written and video explanations of treatment aimed at improving compliance appear to raise it to a therapeutic level in those who may otherwise have poor compliance or drop out from treatment. Formal, evidence-based practice guidelines for the management of amblyopia have emerged although their adoption by practitioners, at least in the UK, has been questioned. c.e.stewart@city.ac.uk 14

15 Jill Carlton The development of the CAT-QOL (Children s Amblyopia Treatment Quality of Life Questionnaire) The use of Patient Reported Outcome Measures (PROMs) to inform clinical decision-making and resource allocation is increasingly common. Existing generic measures of quality of life are often ineffective in detecting health-related quality of life (HRQoL) implications of visual impairment. This paper will describe the development of the CAT-QOL (Children s Amblyopia Treatment Quality of Life Questionnaire); a paediatric disease-specific HRQoL measure for amblyopia. The CAT-QOL differs from other amblyopia questionnaires, in that the development of the instrument adopted a bottom-up approach. The items were identified from patients, rather than parents or clinicians. A review of the development stages of the instrument will be given. This will include the results of a systematic literature review 1 ; analysis of focus groups conducted with clinicians 2 ; and analysis of interviews with children with amblyopia. The questionnaire has been pre-piloted in a clinical setting. The results will be presented and the first version of the CAT-QOL will be shown. The CAT-QOL is being piloted at sites across England throughout summer It is hoped that some pilot data may be available to demonstrate the validity of the instrument. The development of a disease-specific measure of HRQoL in amblyopia will allow future research to determine the long-term effects of therapy upon the social and emotional well-being of the child. This work was produced under the terms of the Personal Development Award research training fellowship issued by the NIHR. 1. Carlton J, Kaltenthaler E. Health-related quality of life measures (HRQoL) in patients with amblyopia and strabismus: a systematic review. Br J Ophthalmol 2011;95: , 2. Carlton J. Clinicians perspectives of health related quality of life (HRQoL) implications of amblyopia: a qualitative study. British and Irish Orthoptic Journal. In press j.carlton@sheffield.ac.uk 15

16 Angela Tjiam, Gerdien Holtslag, Elizabet Vukovic, Wijnanda Asjes, Marianne Sinoo, Jan Roelof Polling, Sjoukje Loudon, Huib Simonsz Implementation of an educational cartoon that improves compliance with occlusion therapy for amblyopia Purpose: In an RCT in The Hague, we demonstrated that an educational cartoon explaining amblyopic children why they should wear their eye patch, was very effective in improving compliance. Electronically measured compliance, was low especially among children of immigrants with low fluency in Dutch. In a pre- and postimplementation study, we evaluated the adoption of this cartoon among orthoptists and its effect in daily orthoptic practice. Methods: Orthoptists in low SES areas (n=9) and orthoptists working elsewhere in NL (n=23) were recruited. They provided standard orthoptic care during the first year. Prior to the implementation, they attended a course on compliance. Together with the educational cartoon, several additional measures, conceived both by us and by the orthoptists themselves, were implemented, like calling parents who missed appointments, use of translators, etc. In the second year, they supplemented their standard orthoptic care with the educational cartoon. Pre- and post-implementation, we used observation (2x), interviews (2x) and questionnaires (4x) to compare orthoptists awareness, attitudes and activities in dealing with noncompliance. A survey was sent to all Dutch orthoptists (n=325) annually. Additionally, integration of the course on compliance into the School of Orthoptics was assessed. Lastly, three-to-six-year old newly-diagnosed amblyopic children which were treated by the recru ited orthoptists participated the study: orthoptic data were collected of each child s visit to the orthoptist. Outcome measures were acuity-difference reduction rate (ADR), outpatient attendance rate, and, in low-ses areas, electronically measured compliance. Results: Courses on compliance given to orthoptists participating in the study were successful, but are suspended temporarily because of lack of interest from other orthoptists and lack of reimbursement by the employing hospitals. Pre- and post-implementation, only a quarter of orthoptists suspected noncompliance in a single patient on one day of 16

17 observation; the others never did. None of the additional measures that cost the hospital extra time or money were realized. Although the Dutch School of Orthoptics was participating in the study from the onset, teachings about compliance have not been included in the curriculum in a systematic fashion. In low-ses areas, 114 children participated preand 65 children post-implementation. Elsewhere in NL, 335 children participated pre- and 249 children post-implementation. The cartoon was again very effective in improving compliance in the low-ses areas: mean electronically measured compliance was 52.0% pre- vs. 62.3% post-implementation (P=0.146); 41.8% vs. 21.6% (P=0.043) occluded less than 30% of prescribed occlusion time, respectively. Also the attendance rates at appointments improved. ADR was log/year in the pre- and log/year in the post-implementation group (P=0.051), in low-ses areas; elsewhere in NL, that was and log/year, respectively (P=0.009). Conclusion: Non-compliance seems less of a problem for most orthoptists; it is possible that noncompliance is masked by the high effectiveness of patching the healthy eye: a child with 30% compliance may still reach good vision in both eyes, it just takes longer. In the interpretation of these results the differences between the interests of public health and the interests in running a hospital or a practice seem pertinent. Nonetheless, implementation of the educational cartoon for occlusion therapy accelerates visual acuity increase, attendance rate and electronically measured compliance. amtjiam@gmail.com 17

18 Elizabeth van de Graaf, Huib Simonsz Utility analysis of bilateral visual impairment caused by insufficiently treated amblyopia and contra-lateral age-related macular degeneration. Background: To measure the patient-perceived decrease in quality of life in insufficiently treated amblyopia patients who recently became visually impaired in the better eye. Cost-effectiveness of childhood amblyopia screening partly depends on the perceived decreased quality of life due to bilateral visual impairment in amblyopes. Methods: Subjects from the ophthalmology outpatient clinic, Erasmus MC: Patients with insufficiently treated amblyopia (visual acuity <0.5) with a recent acuity decrease to <0.5 in the better eye. Controls had age-related macular degeneration (visual acuity <0.5) with a recent acuity decrease to <0.5 in the better eye. Health-related quality of life instruments used during interviews with subjects were: Visual Function Questionnaire-25, Amblyopia & Strabismus Questionnaire, Health Utilities Index Mark III, and Low Vision Quality-of-Life Questionnaire. Utility values were derived face-to-face during interviews by Time Trade- Off (TTO) and Standard Gamble (SG) method by top-down search procedure while following-up subjects' visual acuity for approx. 1 year. Results: Eight and seven subjects from patient and control group were interviewed. TTO mean utility values were 0.87 (i.e. 13 % decrease in quality of life) for patient-group and 0.89 for control-group. SG mean utility value was 0.99 for both groups (for bilateral blindness TTO utility value was reported as 0.35, SG 0.49). No correlation was found between visual acuity and decrease in quality of life, due to subjects varying circumstances. Subjects over age 80 either were trading more lifetime when acuity decrease occurred in the second eye shortly after decreased visual acuity in the first eye or were not trading lifetime when being alive was the most important to them. Conclusion: The measured decrease in quality of life was rather small and its relation with visual acuity unclear. e.vandegraaf@erasmusmc.nl 18

19 Dominiek Despriet, Özlem Engin, Angela Tjiam, Helma van der Meulen- Schot, Annemarie Romers, Xanne Slot, Mari Gutter, M Prost, M Tjon Fo Sang, M Rijneveld, Maria Fronius, Huib Simonsz Recognisability of equally sized and spaced optotypes from Amsterdam picture chart, tumbling-e, Lea symbols, EDTRS and Landolt-C in healthy and amblyopic individuals Purpose: Visual acuity (VA) is highly dependent on the type of chart used. The Landolt-C and Lea Symbols are the only charts that are standardized; most picture charts are calibrated only for the age group they are used for. Our goal was to measure the recognizability of the different optotypes, while other influences remained the same, in healthy students and amblyopic patients. Methods: Logarithmic charts were made with Landolt-C (LC), Lea Symbols (Lea), Tumbling-E (TE), Amsterdam Picture Chart (APK) and ETDRS optotypes with identical size and distance between optotypes. We recruited 100 healthy students and 59 amblyopic patients with 2 LogMAR acuity difference. Charts were randomly presented under DIN EN ISO 8596 and 8597 conditions. A row was passed if 3/5 or 6/10 optotypes were read correctly. Thresholds with Lea, TE, APK and ETDRS relative to that with LC were calculated. Results: In the control group, the VA was LogMAR with LC. The Log Relative Recognizability (LogRR) compared to LC was for APK, for TE, for ETDRS and for Lea. In the amblyopic eyes, we measured a VA of LogMAR with LC. The LogRR was for APK, for TE, for ETDRS and for Lea. In the healthy eyes of amblyopes, we measured a VA of LogMAR with LC. The LogRR was for APK, for TE, for ETDRS and for Lea. Discussion & Conclusions: Recognisability was low for Lea and APK optotypes. The complex pictures of the APK were least recognizable. This discrepancy was larger in the amblyopic eyes as well as the healthy eyes of amblyopic patients. We hypothesize that this is due to the crowding phenomenon which occurs within the APK optotypes. 19

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21 Jürgen Schmidt Vision Screening in toddlers Whenever we meet amblyopic patients it's important to remember that most of them could have been saved from amblyopia if their amblyogenic factors were detected and treated in early childhood. This presentation introduces a vision screener that enables you to detect most amblyogenic factors in toddlers, one year and older, already. In the past decades infants typically received a vision acuity test age 4 to 5 years. Looking at prevalence of Amblyopia today, this method has proven in-effective. To improve the situation, vision screening has to be performed much earlier. This implies that new methods for vision screening are necessary. These methods must not require patient cooperation and need to be affordable. Our vision screener is a binocular, hand-held autorefractor that measures refraction in un-dilated pupils from one meter away. A measurement takes one second only and provides sphere, cylinder and axis as well as eye alignment and pupil size information. Based on these readings a "pass" or "refer" screening result is displayed on screen automatically. Therefore Plusoptix vision screeners can be used by lay vision screening personnel. Many studies have determined sensitivity, specificity and positive predictive value of Plusoptix vision screeners so far. Results vary, depending on patient ages and referral criteria chosen. The bottom line is that Plusoptix vision screeners improve early detection of amblyogenic factors considerably. In 2010, based on a multi center study over at two year time period, Kind & Gezin, a governmental health care organization in Flanders/Belgium, has chosen to incorporate Plusoptix vision screeners within their well baby visit exams. j.schmidt@plusoptix.de 21

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23 Parkeren Erasmus MC Beperkte parkeermogelijkheid Het Erasmus MC is het beste bereikbaar met het openbaar vervoer. Parkeerautomaten In de garage kunt u contant betalen, chippen of pinnen. Het tarief is 1,50 per uur. De parkeerautomaten staan bij Ingang 2, in de hal van Sophia en op de begane grond bij de trappen en lift naar de faculteit. Parkeren minder validen Bij Ingang 2 en Sophia/faculteit zijn een aantal parkeerplaatsen voor minder validen. Te bereiken via de parkeergarage. K&R Parkeerplaats voor afzetten/ophalen (maximaal 20 minuten). Doorrijdhoogte De parkeergarage heeft een maximale doorrijdhoogte van 2.30 m. Mocht uw vervoersmiddel hoger zijn, kunt u zich melden bij de Hoofdingang (1). Head entrance (1) Follow our signs to Auditorium Erasmus MC, 2 nd floor of H-North Building (A-206) 23

24 Auditorium Erasmus MC, 2 nd floor of H-North Building (A-206) 24

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26 Congress dinner after the meeting. 18:00 hours - 19:00 hours Please contact the organising committee. Restaurant Jonge de Jong Delistraat ZL Rotterdam Katendrecht