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Intertester Agreement in Refractive Error Measurements

Huang, Jiayan*; Maguire, Maureen G.; Ciner, Elise; Kulp, Marjean T.; Quinn, Graham E.; Orel-Bixler, Deborah**; Cyert, Lynn A.**; Moore, Bruce; Ying, Gui-Shuangfor the Vision In Preschoolers (VIP) Study Group

doi: 10.1097/OPX.0000000000000025
Original Articles

Purpose To determine the intertester agreement of refractive error measurements between lay and nurse screeners using the Retinomax Autorefractor and the SureSight Vision Screener.

Methods Trained lay and nurse screeners measured refractive error in 1452 preschoolers (3 to 5 years old) using the Retinomax and the SureSight in a random order for screeners and instruments. Intertester agreement between lay and nurse screeners was assessed for sphere, cylinder, and spherical equivalent (SE) using the mean difference and the 95% limits of agreement. The mean intertester difference (lay minus nurse) was compared between groups defined based on the child’s age, cycloplegic refractive error, and the reading’s confidence number using analysis of variance. The limits of agreement were compared between groups using the Brown-Forsythe test. Intereye correlation was accounted for in all analyses.

Results The mean intertester differences (95% limits of agreement) were −0.04 (−1.63, 1.54) diopter (D) sphere, 0.00 (−0.52, 0.51) D cylinder, and −0.04 (1.65, 1.56) D SE for the Retinomax and 0.05 (−1.48, 1.58) D sphere, 0.01 (−0.58, 0.60) D cylinder, and 0.06 (−1.45, 1.57) D SE for the SureSight. For either instrument, the mean intertester differences in sphere and SE did not differ by the child’s age, cycloplegic refractive error, or the reading’s confidence number. However, for both instruments, the limits of agreement were wider when eyes had significant refractive error or the reading’s confidence number was below the manufacturer’s recommended value.

Conclusions Among Head Start preschool children, trained lay and nurse screeners agree well in measuring refractive error using the Retinomax or the SureSight. Both instruments had similar intertester agreement in refractive error measurements independent of the child’s age. Significant refractive error and a reading with low confidence number were associated with worse intertester agreement.






**OD, PhD

Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania (JH, MGM, G-SY); Salus University, Elkins Park, Pennsylvania (EC); College of Optometry, Ohio State University, Columbus, Ohio (MTK); The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (GEQ); School of Optometry, University of California, Berkeley, Berkeley, California (DO-B); College of Optometry, Northeastern State University, Tahlequah, Oklahoma (LAC); and New England College of Optometry, Boston, Massachusetts (BM).

Gui-Shuang Ying 3535 Market Street, Suite 700 Philadelphia, PA 19104 e-mail:

© 2013 American Academy of Optometry