This prospective study is covered by Institutional Review Board at Providence Hospital with Clinical Trial Registry (NCT03668067) and de-identified data access from
www.ABCD-Vision.org. The study complies with HIPAA and the Declaration of Helsinki. Images and video of children examined by this technique are included. Written parental informed consent with appropriate translation was obtained.
The SBA-RS rack (Eye Care and Cure: 22 cm × 6 cm × 0.5 cm) has one row of convex (plus) lenses from 1 to 10 diopters arranged continuously so extra plus lens can be placed horizontally over the nonretinoscoped eye to achieve fogging. The rack appears like a yellow school bus with a millimeter ruler (
Figure 1). One “wheel” has a −5 concave lens and the other a translucent occluder.
The retinoscopy technique presented the previously hidden school bus as a surprise (brought forward from a back pocket) and handed to the child asking if any older siblings ride a bus. Then, sitting behind the windows was demonstrated by the retinoscopist gently transferring the bus toward the child’s eye covering the nonscoped eye with adjacent, higher plus “windows.” The desired response was more “with” retinoscopy reflex 1–3 seconds looking through the skiascopy lens, and sliding the bus back and forth toward higher plus lenses watching for more “with” reflex and mydriasis accompany-relaxed accommodation. Neutralization required confirmation of astigmatism power and axis for the first eye. Then, the “bus” was reversed “to come home from school.” Often accommodation was already relaxed for the second eye as soon as the reversed-direction bus was in place (
Supplementary video).
Since SBA-RS has just one row of integer-value plus spherical lenses, retinoscopy made liberal use of 1) adjusting the working distance to determine fractional refractive values for sphere and cylinder power and 2) sliding the bus back and forth to relax more accommodation uncovering more hyperopia. For higher myopic patients, the concave −5 lens in one of the “bus wheels” was utilized. Utilizing this simple device, the single −5 lens and the +1 through +10 convex lenses, sphero-cylinder refraction could be determined with a range from −10D to +8.5D. For the extremely high hyperopic patients, the SBA-RS was checked by holding an additional +12 lens to allow fogging when refracting through the +10 lens.
Patients undergoing initial or follow-up comprehensive ophthalmic examination were screened with SBA-RS before retinoscopy with our “gold-standard” cycloplegia at least 20 mins following instillation of cyclopentolate 1%. For objective comparison, many of the patients also had Retinomax automated refraction before cycloplegic refraction. Data were collected regarding age, indication for examination and neurodevelopmental delay such as autism, syndrome, attention-deficit hyperactivity disorder (ADHD), fetal alcohol syndrome (FAS), etc. The clinician performing the cycloplegic examination mainly used phoropter with refinement and was usually not aware of the Retinomax findings at the time of the refraction.
Refractive values were organized to afford the best comparison. Spherical equivalent was sphere plus 0.5× cylinder power in plus format. Power vectors for astigmatism (J0 Horizontal Jackson-Cross and J45 oblique Jackson-Cross) were calculated by (J
0) = [−(K
steep−K
flat)/2] × cos2α and (J
0) = [−(K
steep−K
flat)/2] × cos2α where K represents cylinder power and alpha (α) the axis in radians.18 (
link) We classified cases of hyperopia as those whose cycloplegic spherical equivalent exceeded 0.7 diopters and those with astigmatism as those whose plus cylinder power exceeded 0.7 diopters. Bland-Altman analysis and interclass correlation coefficient (ICC) were determined for these refractive values.
Correlations were assessed by linear regression with Spearman product moment coefficient. Medians between groups were compared with Mann–Whitney test. Proportions were compared with Chi-square test. A probability of 0.05 was considered significant.
Sample size calculation for linear regression with 2 predictors: statistical power level 0.9, probability level 0.01, and the anticipated effect size of 0.05 indicate a minimal sample size of 351.
Arnold A.W., Arnold S.L., Sprano J.H, & Arnold R.W. (2019). School bus accommodation-relaxing skiascopy. Clinical Ophthalmology (Auckland, N.Z.), 13, 1841-1851.