Alaska Blind Child Discovery

ABCD Publications

Arnold, R. W. (1993). Retinopathy of prematurity in Alaska: Treating the vast expanse. the International Conference on Retinopathy of Prematurity, Chicago, Illinois, USA, Kugler Publications (Amsterdam/New York).

Arnold, R. W. (1993). "Vision Screening in Alaska: Experience with Enhanced Brückner Test." Alaska Med 35(2): 204-208.

Arnold, R. W. (1994). "Posterior retinopathy of prematurity cryotherapy from a limbal reference." J Pediatr Ophthalmol Strabismus 31: 303-305.

Arnold, R. W. (2002). "Use of a consumer video system to enhance low vision in children and adults." JPOS 39(4): 245-247.

Arnold, R. W. (2003). "Highly specific photoscreening at the Alaska State Fair: Valid Alaska Blind Child Discovery photoscreening and interpretation." Alaska Med 45(2): 34-40.

Arnold, R. W. (2003). "The phoropter trapeze. A portable refractive support for remote clinics." Binocul Vis Strabismus Q 18(1): 26-7.
A trapeze was engineered using inexpensive pre-threaded commercial polyvinyl chloride ("PVC") plumbing pipe. This was suspended from a convenient overhead point and the phoropter was clamped to it. It was stabilized by the patient holding on two attached handles. Illustrated in photographs.

Arnold, R. W. (2004). "Pseudo-false positive eye/vision photoscreening due to accommodative insufficiency. A serendipitous benefit for poor readers?" Binoc Vis and Strabismus Quart 19(2): 75-80.
BACKGROUND: Children whose eyes and vision are otherwise normal and who should screen negatively as normals, but who fail to compensate for their normal mild hyperopia (i.e. by normally accommodating, or rather actually failing to accommodate) will generate hyperopic crescents in a photoscreen test that can be interpreted as "positive" (for pathology) because high and asymmetric levels of hyperopia are common risk factors for amblyopia. This would therefore usually be considered a "false positive" and no further care would be offered. However, this failure to compensate, may in fact be a pathological disorder, accommodative insufficiency, making this apparently "false positive" situation actually a actually a "false-positive-false- negative positive test", or more simply a "false- false positive test". METHODS: The Alaska Blind Child Discovery Project photoscreened just under 16,000 children referring 6% as "positive", of which, after examination, the false positive rate was just 6% of those referred (0.4% of the total number screened). RESULTS: Ten (42%) of the 24 false positives had evidence of accommodative insufficiency inspite of only average (for age) amounts of cycloplegic hyperopia and a lag of accommodation on dynamic retinoscopy. Eight of the 10 were boys of kindergarten age. Most of these subsequently benefitted from prescription and use of reading glasses of low plus sphere correction. CONCLUSION: About 0.15% of photoscreened children, or 2.5% of those screening positive, and 42% (10/24) found initially on exam to be falsely positive, yielding hyperopic interpretations despite low and usually acceptably normal for age amounts of hyperopia, are in fact suffering from a pathological accommodative insufficiency. Identification of such false- false positives by a combination of photoscreening and dynamic retinoscopy may be used to determine which students might be helped with enforced reading glasses. Confirmatory exams on photoscreen positive-hyperopia cases should include an assessment of accommodation to identify these children.
Arnold, R. W. (2004). "Vision in Preschoolers Study (letter)." Ophthalmol 111(12): 2313.

Arnold, R. W., M. D. Armitage, et al. (2005). "The cost and yield of photoscreening: Impact of photoscreening on overall pediatric ophthalmic costs." JPOS 42(2): 103-111.
Background
Approximately 5% of preschool children suffer from amblyopia. Many of them have high or unequal hyperopia. Amblyogenic risk factors can frequently be detected by photoscreening.
Method
MTI™ photoscreening was offered free-of-charge to a target group of children aged 1-4 from urban and rural screening hubs. Their parents provided a brief family and health history before consenting to the flash photography. Packets of screened images were mailed to the ABCD coordinating center for physician photoscreen interpretation, specifically seeking latent or anisometropic hyperopia. Parents and screeners were then mailed results and information about amblyopia. Follow-up exam data were then tallied. A Cost-Consequence Analysis was developed for vision screening and eye care.
Result
In 1998 and 1999, 5166 screenings were performed with a “positive” interpretation rate of 4.5% in the 3046 urban children and 6.2% in the 2120 rural children. The penetrance of screening was 13% in urban communities and 49% in rural communities. The positive predictive value is estimated to be over 90%. From this, the average cost to screen and inform an Alaskan preschooler is about $10.50. The cost to detect by photoscreening an Alaskan with amblyogenic risk factors is about $225. Compared to AAP 1995 guidelines, implementing photoscreening adds 9% while mandating complete pre-Kindergarten exam adds 49% to overall eye care.
Conclusion
In some of the least accessible parts of America, MTI™ photoscreening with experienced physician interpretation achieved high community penetrance and high positive predictive value for latent hyperopia and other amblyogenic factors. The costs must be weighed against societal health goals. When the follow-up costs are considered, adding photoscreening to current AAP guidelines may add $112 per child over ten years, but probably would also assist in the reduction of amblyopia. We suspect that penetrance of urban photoscreening will remain low unless pediatric vision screening guidelines and reimbursement are revised.
Arnold, R. W., A. W. Arnold, et al. (2004). "Amblyopia detection by camera (ADBC): Gateway to portable, inexpensive, vision screening." Alaska Med 46(3): 63-72.

Arnold, R. W., G. R. Beauchamp, et al. (2005). "Compared value of amblyopia detection (letter)." Ophthalmology: (submitted) never published.

Arnold, R. W., L. Coon, et al. (1995). "Collaborative visual rehabilitation: High astigmatism, esotropia and elevator palsy." Alaska Med 37(3): 88-90.

Arnold, R. W. and S. P. Donahue (2006). "Compared value of amblyopia detection." Binocul Vis Strabismus Q 21(2): 78.

Arnold, R. W. and S. P. Donahue (2006). "The yield and challenges of charitable state-wide photoscreening." Binocul Vis Strabismus Q 21(2): 93-100.
INTRODUCTION: State-wide cooperative programs for pediatric vision screening utilizing the MTI photoscreener and centralized interpretation were established in Alaska (The Alaska Blind Child Discovery, ABCD) and in Tennessee (Tennessee Lions Outreach). METHODS: Details of setup, implementation and interpretation of the state-wide MTI photoscreening programs are compared through 2002. The absolute numbers of children screened and the breakdown in interpretation categories are presented. RESULTS: ABCD screened 14,000 children while Tennessee Lions screened 100,800. Similarities between ABCD and Tennessee programs were funded by Lions Clubs and other charitable and public health organizations, community screening and each had coordinated centralized image interpretation and notification. The programs differed by clinic focus (Tennessee Lions organized pre-schools while ABCD used village and community health fairs and schools), parent notification (Tennessee Lions communicated through pre- schools and ABCD mailed directly to parents), and image interpretation (Tennessee used VOIC age-based and pupil-size crescents while ABCD used "delta-center crescent"). Predictive value positive was 73% for Tennessee and 89% for ABCD. Tennessee achieved better followup on referrals after a specific coordinator was employed. Image interpretation breakdown for ABCD: Tennessee Lions Outreach were anisometropia (29%:34%), high hyperopia (33%:16%), astigmatism (18%:30%), strabismus (7%:15%), myopia (5%:2%), cataract (0.7%:0.2%). Two state-wide programs detected 3216 amblyopic children at a charity borne-cost of $1.5 million. If the parents persisted with appropriate amblyopia therapy, the expected societal value was estimated at $17 million. Lacking societal mandate and funding, these concerted charitable efforts only achieved a community penetration rate of 10% to 14%. CONCLUSION: National adoption of preschool vision screening by a method with similar or even better validity and cost effectiveness as MTI photoscreening, ideally in the pediatric medical home, is warranted.
Arnold, R. W. and K. F. Fierstein (2000). "Are vision screening devices accurate and reliable for use in pediatricians' offices to test children younger than 4 years old?: Con." Pediatric News: submitted.

Arnold, R. W., E. Gionet, et al. (2000). "The Alaska Blind Child Discovery project: Rationale, Methods and Results of 4000 screenings." Alaska Med 42: 58-72.
BACKGROUND: Photoscreening allows lay persons to adapt the Enhanced Bruckner Test to preschoolers in an attempt to identify refractive amblyopia. The Alaska Blind Child Discovery (ABCD) project is charitably funded and administered. METHODS: MTI photoscreening was offered to children in rural and urban communities in southern Alaska from 1996 through June 1999. Parents answered questions concerning the child's health, family ocular history and whether the child had any eye "Warning Signs." The MTI images were interpreted by two eye doctors using a modification in MTI published guidelines. RESULTS: Out of 4000 screenings performed on 3930 children, there was an overall "not normal" interpretation of 9% and an inconclusive rate of 1%. The mean S.D. age was 3.9 2 years. Only 6% had had a prior eye exam. The average number of Polaroid pictures per screening was 1.16. Follow-up data on "not normal" results was obtained on just over 50%. The positive predictive value during the first two years was 77% but improved to 92% from 1998-1999. Affirmative answers to the questions concerning previous eye exam, child's health, siblings eye health and positive "Warning Signs" were significantly associated with "not normal" interpretations but affirmative answers about eye health of mother, father and relatives were not. Community penetrance of photoscreening to the target age-group ranged from only 5% for Anchorage to almost 100% for the Bristol Bay public health nurses. Five percent of parents of "positive" results surveyed would not have recommended screening for their friends. Equipment functioned dependably even in remote Alaska. CONCLUSION: Charitable volunteer Polaroid photoscreening detected amblyopia and significant pediatric eye disease in over 300 children during the first 3.5 years of ABCD.
Arnold, R. W., E. G. Gionet, et al. (2003). "Duration and effect of single-dose atropine: paralysis of accommodation in penalization treatment of functional amblyopia." Binoc Vis and Strabismus Quart 19(2): 81-86.
BACKGROUND AND PURPOSE: Atropine dilates the pupil and paralyzes the ciliary muscle accommodation, blurring vision, and therefore is an effective penalization of the sound eye in the treatment of functional amblyopia of the other eye. The degree of blur induced is a function of the amount of the patient's uncorrected hyperopia and the distance from the eye of the viewed material or object. Another factor determining effectiveness of atropine penalization is the duration of the effect of the atropine. It is the purpose of this study to investigate these factors. METHODS: Six normal children underwent complete eye exam with cycloplegic refraction several days before deliberate instillation of atropine 1% in the sound, or right eye. Distance and near acuity was then tested after 30 minutes, and on subsequent days. Additional data points were derived by placing known minus lenses in front of the tested eye. In addition, we also studied one successfully treated amblyopic patient when he terminated chronic daily atropine in his normal, sound eye. RESULTS: Atropine initially produced a linear reduction in logMAR acuity (blur) at distance of about 0.2 logMAR lines per diopters of uncorrected hyperopia. The magnitude of the blur was greater for near, but the effect of increased hyperopia was slightly greater for distance measurements. This blurring of acuity lasted just less than 48 hours for normal subjects, and just over 48 hours following prompt cessation of chronic daily atropine in that one subject. Regression formulae were derived relating uncorrected hyperopia and time interval following atropine cessation on distance and near acuity in children of amblyopic age range. CONCLUSION: The degree of penalization is highly dependent on the uncorrected hyperopic refractive error. A significant penalization effect is present only for one day or so. Daily atropine is therefore indicated for penalization. To better tailor penalization therapy to target sound eye acuity blur, these formulae and graphs can be used, specifically, in addition, to determine the amount of deliberate spectacle hyperopic undercorrection to maximize the penalization effect.
Arnold, R. W., K. Kesler, et al. (1994). "Susceptibility to ROP in Alaskan Natives." J Pediatr Ophthalmol Strabismus 31: 192-194.

Arnold, R. W., J. B. Ruben, et al. (2005). "Korean kindergarten vision screen programme (letter)." Br J Ophthalmol 89(3): 392-393.

Arnold, R. W. and G. Sitenga (2000). "The detection of congenital glaucoma by photoscreen interpretation." Alaska Med 42(3): 73-77.
Photoscreening is designed to detect abnormalities in children's eye, particularly abnormal refractive errors, which can lead to amblyopia. An Alaska Bind Child Discovery MTI Polaroid photoscreen in one girl resulted in diagnosis and treatment of congenital glaucoma. Patients with known pediatric eye disease underwent photoscreening. Subtle non- refractive changes in photoscreen images may reveal eye disease even more serious than amblyopia. We suggest that human or computer interpretation of photoscreening images, particularly when retained, be done conscientiously with respect to the refractive state and alignment of the eyes, but also regarding other potentially serious ocular pathology.
Arnold, R. W., C. A. Stange, et al. (2006). "The compared predictive value of Bruckner, acuity and strabismus from pediatric referrals." Am Orthopt J 56(1): 15-21.
Background
Although pediatric vision screening now passes evidence-based scrutiny, and has recent AAP guidelines, routine acuity testing in pediatric offices may still perform poorly.
Methods
From 6/2002 through 8/2005, all children aged 0-6 directly referred by pediatric care givers to one pediatric ophthalmologist were compared as to referral indication; failed acuity, strabismus and positive Bruckner test. AAPOS gold standard exam criteria was applied and compared to community photoscreening.
Results
By referral indication, the following are numbers and predictive values: acuity (n=80, PPV 51%), Brückner (n=74, PPV = 89%), Strabismus (n=432, PPV = 81%). Community photoscreening referred n=392 with PPV = 91%. The objective tests and strabismus queries were not age-dependent.
Conclusion
The pediatric home best conforms to WHO guidelines due to case-continuous finding and assistance with treatment compliance particularly for strabismus. Objective tests outperform acuity testing in referral for refractive amblyopia including Brückner test in experienced hands. Observation and history best refers strabismus.
Arnold, R. W., L. Stark, et al. (2006). "Tent photoscreening and patched acuity by school nurses: Validation of ASD-ABCD." J AAPOS In press.

Donahue, S., R. Arnold, et al. (2003). "Preschool vision screening: What should we be detecting and how should we report it? Uniform guidelines for reporting results from studies of preschool vision screening." J AAPOS 7(5): 314-316.

Donahue, S. P., R. W. Arnold, et al. (2004). "Pediatric Photoscreening: Eye to Eye." J Pediatr Ophthalmol Strabismus 41(2): 72-6.

Kerr, N. and R. Arnold (2004). "Vision screening for children: current trends, technology and legislative issues." Curr Opin Ophthalmol 15: 454-459.

Kovtoun, T. A. and R. W. Arnold (2004). "Calibration of photoscreeners for threshold contact- induced hyperopic anisometropia: Introduction of the JVC photoscreeners." JPOS 41(3): 150-158.

Lang, D., J. Blackledge, et al. (2005). "Is Pacific Race a retinopathy of prematurity risk factor?" Arch Pediatr Adolesc Med 159(8): 771-773.
Background: Black race affords some protection from retinopathy of prematurity (ROP), but more ROP was previously found in another darkly pigmented race, the Alaskan natives.
Design: From fall 1989 through summer 2003, all Alaskan infants with a birth weight of 1500 g or less were examined, documenting mother’s stated race, prenatal care, and neonatal intensive care unit course.
Results: Retinopathy of prematurity was classified as to predefined threshold for peripheral ablative treatment (region of avascular retina and fibrovascular ridge and vessel tortuosity) in 873 infants. Threshold ROP was more prevalent in Alaskan natives (24.9%) and Asians (15.9%) (10% overall), with no significant difference between Alaskan natives and Asians (P=.24). Alaskan native males had more threshold ROP (69%) compared with non–Alaskan native males (51%). Compared with threshold nonnatives, Alaskan native threshold infants had greater birth weights (829±222 vs 704±186 g), required less time on ventilation (46±22 vs 70±75 days), and progressed to treatment at a younger age (35.5±2.2 vs 36.2±2.6 weeks’ gestational age) (data are given as mean±SD).
Conclusions: In this limited study, we find increased risk of threshold ROP in 2 northern Pacific races. Threshold Alaskan natives had similar or better prenatal and neonatal intensive care unit variables than did threshold nonnatives; however, Alaskan native males were still at a greater risk.
Lang, D. M., A. W. Arnold, et al. (2006). "Photoscreening, remote autorefraction and patched acuity testing in the Koyukon region of Alaska." Alaska Med 48: In Press.
Background
Photoscreening and remote autorefraction showed promise in the urban “Vision in Preschoolers Study.” We transported a comparative screening with confirmation program to a remote part of interior Alaska.
Methods
80 children from villages in the Koyukon region received on-site three-pronged vision screening followed by gold-standard confirmatory exams. Each had patched HOTV acuity, photoscreening and Suresight remote autorefraction.
Results
There was a high prevalence of amblyopia and vision disorders in these villages. Acuity testing was moderately valid but not useful for children less than 4 years old. Suresight has specificity over 90% with sensitivity of 60%. Photoscreening had specificity over 95% and sensitivity of 70% and was better than Suresight for children under age 4.
Conclusion
The Welch Allyn Suresight had similar high validity in the Koyukon as in VIPS and provides immediate, on-site results. We recommend that Welch Allyn adopt more specific VIPS referral guidelines. Photoscreening, particularly with commercial digital flash cameras and specific interpretation, is a cost effective screening tool particularly for younger children.
Leman, R. E., M. D. Armitage, et al. (2005). "The receiver-operator curve for flip-card surround HOTV in younger school children." Am Orthopt J 55(1): 128-135.
Background
The AAP vision screening guidelines are not uniformly delivered. Moderate amblyopia can be successfully treated in children 7 year of age and older. The ideal method and threshold of vision and/or acuity testing in school is not known.
Methods
1700 students from first grade, Kindergarten and pre-K were screened with a flip-card, surround HOTV protocol with other eye patched combined with photoscreening. 234 had “Gold Standard” confirmatory exams from which AAPOS standards were validated.
Results
Receiver Operator Curves were constructed by adjusting referral criteria by grade. A cut-off of 20/25 yielded fairly good (50%) sensitivity and 90% specificity for First and Kindergarten but many of the pre-K were unable to complete the testing.
Conclusion
Patched surround HOTV flip card acuity is useful in starting school children and a cut-off of 20/25 passing acuity suggested. Pre-K are not well acuity screened due to high inconclusive rate.
Leman, R. E., M. M. Clausen, et al. (2006). "A comparison of patched HOTV visual acuity and photoscreening." J Sch Nurs 22(4): 237-243.
Early detection of significant vision problems in children is a high priority for pediatricians and school nurses. Routine vision screening is a necessary part of that detection and has traditionally involved acuity charts. However, photoscreening in which "red eye" is elicited to show whether each eye is focusing may outperform routine acuity testing in pediatric offices and schools. This study compares portable acuity testing with photoscreening of preschoolers, kindergarteners, and 1st-graders in 21 elementary schools. School nurses performed enhanced patched acuity testing and two types of photoscreening in a portable tent. Nearly 1,700 children were screened during spring semester 2004, and 14% had confirmatory exams by community eye care professionals. The results indicate that one form of photoscreening using a Gateway DV-S20 digital camera is significantly more sensitive to children with significant vision problems, as well as being the most cost effective (85% specificity and only $0.11 per child). This suggests that the adaptation of photoscreening into a routine vision screening protocol would be beneficial for efficiently detecting vision problems that could lead to amblyopia

Kirk VG, Clausen MM, Armitage MD, Arnold RW. Preverbal photoscreening for amblyogenic factors and outcomes in amblyopia treatment: early objective screening and visual acuities. Arch Ophthalmol 2008;125:489-492. BACKGROUND: Previous studies have suggested that infant photoscreening yields better results than visual acuity screening in preschool-aged children. With conventional vision screening, the patient must be able to provide monocular visual acuity cooperation, whereas objective screening for amblyogenic factors can be done at much younger ages. METHODS: From February 1996 through February 2006, Alaska Blind Child Discovery photoscreened 21 367 rural and urban Alaskan children through grade 2, with an 82% positive predictive value (ie, true number of those referred); 6.9% were referred for a complete eye examination and treatment. All "referred" interpreted images for children younger than 48 months who were then followed up and treated for more than 2 years were reviewed to determine whether treatment was successful. RESULTS: Of 411 "positive" screening photos from children younger than 4 years, 94 patients had more than 2 years follow-up. The 36 children photoscreened before age 2 years had a mean treated visual acuity of 0.17 logarithm of the minimum angle of resolution (logMAR), which was significantly better than that of 58 children screened between ages 25 and 48 months (mean, 0.26 logMAR). Despite similar levels of amblyogenic risk factors, the proportion of children failing to reach a visual acuity of 20/40 was significantly less among those screened before age 2 years (5%) than in those screened from ages older than 2.0 years and younger than 4.0 years (17%). CONCLUSION: Very early photoscreening yields better visual outcomes in amblyopia treatment compared with later photoscreening in preschool-aged children.

 

Arnold RW, Armitage MD, Limstrom SA. Sutured protective occluder for severe amblyopia. Arch Ophthalmol 2008;126:891-895. OBJECTIVE: To investigate the feasibility, acceptability, efficacy, and cost of a newly developed translucent shield that can be fixed by sutures to the orbital rim for a month of amblyopia therapy. METHODS: In an institutional review board-approved protocol for patients with amblyopia who do not adhere to the use of conventional patching, shield occluders were fashioned from heat-moldable sturdy black or translucent (20/4000) plastic with holes drilled for attachment. Under brief general anesthesia, patients aged 5 to 10 years had a thorough examination before the shield occluder was sewn to the brow and cheek of the nonamblyopic eye with 3-0 monofilament polypropylene sutures. RESULTS: Ten children completed this protocol from December 1999 through January 2002. All tolerated the occluder for 12 to 36 days. The resultant skin scars were acceptable to parents, patients, and investigators. The amblyopic eyes improved from a mean (SD) of 0.77 (0.30) logMAR (Snellen equivalent, 20/119) to 0.45 (0.29) logMAR (Snellen equivalent, 20/57), a change of 0.32 (0.16) logMAR lines. There was no damage to the sound (occluded) eye. CONCLUSION: Sew-on occluder shields are an alternative when adherence to the use of other types of patching (often referred to as compliance with patching) is not satisfactory.

 

Arch Ophthalmol. 2009 Dec;127(12):1591-5.
Comparison between the plusoptiX and MTI Photoscreeners.
Matta NS, Arnold RW, Singman EL, Silbert DI. CO, CRC, COT, Family Eye Group, 2110 Harrisburg Pike, Ste 215, Lancaster, PA 17601, USA. NoelleMatta@gmail.com
OBJECTIVE: Both the Medical Technology and Innovations (MTI) and plusoptiX photoscreeners are used to objectively screen for amblyogenic risk factors in children. The MTI has been extensively studied, but the limited availability of film may render it obsolete. We compared the MTI with the plusoptiX, a newer digital photoscreener, for the ability to detect amblyogenic factors when compared with a comprehensive pediatric ophthalmic examination. We believe our results will help to guide community-based vision screening programs. METHODS: One hundred fifty-one children were examined consecutively in our office. Each patient was screened with the MTI and plusoptiX devices on the same day as part of a comprehensive pediatric ophthalmic examination. Results via MTI were evaluated by an expert masked examiner (R.W.A.), and the plusoptiX results were interpreted by the incorporated software. RESULTS: Sixty-five percent of patients were found to have amblyopia or amblyogenic risk factors during the pediatric ophthalmic examination conducted via the American Association of Pediatric Ophthalmology and Strabismus referral criteria. We found the MTI photoscreener to have a sensitivity of 83.6%, specificity of 90.5%, false- positive rate of 9.4%, false-negative rate of 16.3%, and positive predictive value of 94.2%. The plusoptiX demonstrated a sensitivity of 98.9%, specificity of 96.1%, false- positive rate of 3.7%, false-negative rate of 1.0%, and positive predictive value of 97.9%. CONCLUSION: The MTI and plusoptiX photoscreeners proved to be effective when compared with a comprehensive cycloplegic pediatric ophthalmic examination. The plusoptiX, however, was found to have a higher sensitivity and specificity than the MTI.

Clausen MM, Armitage MD, Arnold RW. Overcoming barriers to pediatric visual acuity screening through education plus provision of materials. J AAPOS 2009;13:151-4. PURPOSE: The American Academy of Pediatrics (AAP) recommends that LEA and HOTV optotypes be used for vision screening and that adhesive tape be used to occlude one eye during testing. We have developed an educational program designed to improve the quality and efficiency of vision screening. The purpose of this study was to ascertain the effectiveness of this program. METHODS: All 672 pediatric doctors and nurses in the state of Alaska were surveyed by mail to assess their screening protocol and the number of patients cared for annually. Respondents received educational material, including an instructional video, eye patches for visual acuity testing, and a critical line HOTV test box. Subjects were resurveyed 3 months later to determine whether the instructional intervention altered their established protocol. RESULTS: Of the 672 practitioners contacted for the survey, 239 (35.6%) responded, representing 31,000 patients, or 62% of all preschool children in Alaska. Use of recommended optotypes was rare (Lea, 3%, HOTV, 7%) compared with the use of nonrecommended optotypes (including use of the E test by 40% of respondents). The postintervention survey was answered by 107 (16%) practitioners. Of these, 24 (23%) reported that they had begun using an adhesive patch for visual acuity testing, whereas 19 (18%) had begun using AAP-recommended testing optotypes. CONCLUSIONS: In-office video education and provided adhesive eye patches increased the use of patches in primary care preschool vision screening. Mail delivery was less effective than anticipated.