School performance and undetected and untreated visual problems in schoolchildren in Ireland; a population-based cross-sectional study

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School performance and undetected and untreated visual School performance and undetected and untreated visual

problems in schoolchildren in Ireland; a population-based cross-problems in schoolchildren in Ireland; a population-based cross-

sectional study sectional study

Síofra Harrington

Technological University Dublin

, [email protected]

Peter Davison

Technological University Dublin

, Peter[email protected]

Veronica O'Dwyer

Technological University Dublin

, [email protected]

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Siofra Harrington, Peter A. Davison & Veronica O'Dwyer (2021): School performance and undetected and

untreated visual problems in schoolchildren in Ireland; a population-based cross-sectional study, Irish

Educational Studies, DOI: 10.1080/03323315.2021.1899024

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Irish Educational Studies

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School performance and undetected and

untreated visual problems in schoolchildren in

Ireland; a population-based cross-sectional study

Siofra Harrington, Peter A. Davison & Veronica O'Dwyer

To cite this article: Siofra Harrington, Peter A. Davison & Veronica O'Dwyer (2021):

School performance and undetected and untreated visual problems in schoolchildren

in Ireland; a population-based cross-sectional study, Irish Educational Studies, DOI:

10.1080/03323315.2021.1899024

To link to this article: https://doi.org/10.1080/03323315.2021.1899024

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School performance and undetected and untreated visual problems in

schoolchildren in Ireland; a population-based cross-sectional study

Siofra Harrington

, Peter A. Davison and Veronica O’Dwyer

School of Physical and Clinical and Optometric Sciences, Technological University Dublin,

Dublin, Ireland

(Received 17 February 2020; accepted 10 December 2020)

This study explored the association between children’s vision and their school

academic progress as reported by parents/guardians. Participants were 1,612

schoolchildren (722 6-7-year-olds, 890 12-13-year-olds) in randomly selected

schools in Ireland. In advance of data collection, parents/guardians reported

school performance as (a) much better than classmates (high-performance) (b)

about the same as classmates (average-performance) (c) not as well as

classmates (low-performance). Measurements included logMAR monocular

visual acuities (with spectacles if worn, and pinhole) in the distance (3 m) and

near (40 cm); the amplitude of accommodation; stereoacuity, colour vision

assessment, and cyclopleged autorefraction.

Controlling for confounders, children presenting with visual impairment

(vision poorer than 0.3logMAR (6/12) in the ‘better eye’), amblyopia (‘lazy

eye’), uncorrected refractive error (hyperopia ≥+3.50D and astigmatism

≥1.50DC), reduced for age ability to adjust focus from distance to near tasks

(accommodation), impaired three-dimensional vision (stereoacuity), and

defective colour vision were more likely to report low-performance in school.

The majority of low-performing participants (68%) did not have an eye

examination within the 12 months before data collection. Children with

academic performance challenges ought to have a comprehensive eye

examination, to detect potential vision problems for early intervention

minimising any negative impact they may have on educational outcomes.

Keywords: School performance; vision; visual impairment; amblyopia; refractive

error

Introduction

Research suggests that up to 80% of what children learn in school is acquired visually

(Ehri 2005; Scheiman and Rouse 2006; Sylva 1997). For example, 70-80% of a typical

school day involves visual-based tasks, of which half are sustained near visual tasks

(Narayanasamy et al. 2016; Negiloni, Ramani, and Sudhir 2017). Good vision is

essential to learn efﬁciently and succeed in school. Untreated, visual impairments

in childhood, can result in developmental delay; limiting educational achievement,

reducing employment opportunities and social engagement (Skarzyn

ski and Pio-

trowska 2012). Schoolchildren need many visual skills to learn including adequate

visual acuity (VA) to distinguish details on blackboards or whiteboards (distance),

* Corresponding author. Email: [email protected]

Irish Educational Studies, 2021

https://doi.org/10.1080/03323315.2021.1899024

computer screens (intermediate), and written material/books (near) and to quickly

and accurately adjust the eyes focus between these tasks (Li 2004). Other visual abil-

ities required include coordinating the use of two eyes together when moving eyes

across a page or judging depth and distances (Taylor-Kulp 1999). Moreover, learning

requires the ability to make sense of what we see (visual perception) which involves

recognition, comprehension and retention (Goldstand, Koslowe, and Parush 2005).

Accordingly, the link between vision and academic performance has been observed

in many studies which addressed speciﬁc aspects of visual function such as VA

(Kulp and Schmidt 1996), stereoacuity (three-dimensional image) (Ponsonby et al.

2013), uncorrected refractive error (myopia (nearsightedness), hyperopia (longsight-

edness) and astigmatism (distorted vision due to irregular cornea or lens) (VIP-HIP

Study Group 2016)), inadequate binocular vision status and delayed visual processing

(Christian et al. 2018; Hopkins et al. 2019). However, no study has examined the col-

lective inﬂuence of these and other factors such as colour vision deﬁciency on school

performance.

Vision appears to be strongly associated with learning in the “learn to read’ stage

(<8-years-old) where there is a signiﬁcant demand on the visual system when decod-

ing text (Chen, Bleything, and Lim 2011). Whereas visual requirements change

during the ‘read to learn’ stage (>8-years-old); print size decreases, the amount of

time spent reading and studying increases, thus increasing visual demand (Legge

and Bigelow 2011; Wilkins et al. 2009), and fast, automatic decoding is required as

the emphasis is on comprehension. Children with special educational needs beneﬁt

measurably from in-school comprehensive eyecare and spectacle provision (Black

et al. 2019). However, results regarding the association between vision and school per-

formance in typically developing children have been inconsistent; some studies have

found an association (Bruce et al. 2016; Wood et al. 2018), while other studies have

not (Dirani, Shekar, and Baird 2008; Helveston et al. 1985).

Many studies established an association between myopia and intelligence

measures (Onal et al. 2007; Williams, Miller, and Saw 2008 ), however, in contrast,

hyperopia is associated with reading difﬁculties (Ip et al. 2008), educational underper-

formance (Stewart-Brown, Haslum, and Butler 2008; Williams, Miller, and Saw

2008), and developmental de ﬁcits (Atkinson et al. 2002). Children with amblyopia

(‘lazy eye’) read more slowly (Kelly et al. 2015), and take signiﬁcantl

y longer to com-

plete a multiple-choice form despite being provided with the correct answers when

compared to a control group (Kelly et al. 2018). Academic challenges in school

due to defective colour vision (Gallo et al. 2003), and amblyopia (Carlton and Kal-

tenthaler 2011) can result in low self-esteem and feelings of inferiority. Unaddressed

visual issues have negative consequences for both the individual, in ter ms of dimin-

ished educational opportunities (Khalaj et al. 2011), and reduced quality of life

(Carlton and Kaltenthaler 2011), with implications beyond school years affecting

employment options; additionally impacting the broader community in terms of

higher healthcare expenditure and lost output (Rahi and Gilbert 2012).

Therefore, addressing vision disorders in early childhood, ideally in advance of

commencing school (Roch-Levecq 2008), is essential to prevent them from impacting

on children’s education, social and physical development (Birch et al. 2018; Webber

2018). This is the ﬁrst study in Ireland to examine the relationship between

parents/guardians’ perception of their children’s school academic progress in main-

stream school and various aspects of vision. The present study examined the

2 S. Harrington et al.

collective inﬂuence of a wide range of vision variables on parent-reported school per-

formance using multinomial logistic regression.

Methodology

Sampling, recruitment protocols, participation rates, experimental techniques and

methods employed are previously described in detail (Harrington et al. 2019a). The

present study adopted protocols and sampling measures used in population-based

international studies (Negrel et al. 2000; Ojaimi et al. 2005;O’Donoghue et al.

2010, Logan et al. 2011), designed to assess refractive error and visual impairment

in children, where sample sizes were based on estimating the age-speciﬁc myopia

prevalence in the study population. In summary, sample size calculations, using

G*Power

analysis, were based on a 3-5% myopia prevalence with a 1.0% standard

error for 6-7-year-olds and 10% prevalence with 1.5% standard error for 12-13-

year-olds. The sample was inﬂated to allow for clustering within schools and a 75%

participation rate. Therefore, a minimum of seven hundred 6-7-year-old and eight

hundred 12-13-year-old children was required. Stratiﬁed random sampling was

used to obtain representative samples of children in mainstream schools in Ireland.

Schools were categorised by primary/post-primary status, urban/rural status and

socioeconomic status. The Irish state supports schools designated as Delivering

Equality of opportunity In School (DEIS). This study categorised socioeconomic

status by DEIS status: DEIS schools were deﬁ ned as socioeconomically disadvan-

taged, other schools were deﬁned as advantaged. The Technological University

Dublin Research Ethics Committee granted ethical approval, and the study was

carried out in compliance with the tenets of the Declaration of Helsinki.

Public involvement: During the design stage of the study, focus groups assessed the

burden associated with, and the time to complete the study questionnaire (Collins

2003). Focus group feedback, to improve the study accessibility, shortened the ques-

tionnaire, simpliﬁed the wording, and added a statement advising parents/guardians

to skip any questions they felt uncomfortable answering. Furthermore, a storyboard,

outlining the examination, was designed to make the study clear to children. Addition-

ally, focus group feedback revealed objectively measured academic scores and teacher-

reported ﬁndings of participants’ school performance would not be acceptable to some

parents of low-performing children. This could have compromised the questionnaire

response rate and negatively impacted on participants engaging with the study.

Hence, the study used parent/guardian reports as a proxy for school performance. Pre-

vious research found parental reports are as accurate as standardised testing or pro-

fessional opinion (Diamond 1987; Diamond and Squires 1993; Glascoe 1997).

Children with written inf ormed consent and child assent were examined on their

school premises within school hours. Data collection was conducted between June

2016 and Janu ary 2018 by the ﬁrst author (Dr Síofra Harrington), a trained optometrist.

Participants wer e 1,626 schoolchildren in Ireland: 728 participants aged 6-7-years-old

(377 bo ys and 351 girls) and 898 participants aged 12-13-years-old (504 bo ys and 394

girls). Ethnicity was as follo ws: White (1290 participants), Traveller (156 participants)

or non-White (combined: Black 80, East Asian 51, and South Asian 49). The Traveller

community is Ireland’s largest indigenous ethnic minority (Gilbert et al. 2017).

Participants’ parents/guardians completed a standardised questionnaire reporting

inter-alia, eye and vision problems, medical and previous eye examination and

Irish Educational Studies 3

parent-reported school performance. They returned it to the ﬁrst author in advance

of data collection. The questionnaire parent-reported school performance response

options were: (a) much better than classmates; (b) about the same as classmates;

performance and low-performance in line with the Programme for International

Student Assessment (PISA) worldwide study by the Organisation for Economic

Co-operation and Development (OECD) categories (OECD 2016).

Examinations

Distance vision (3 m): monocular logMAR presenting (with spectacles if worn) VA

was measured and scored by-letter with and without a pinhole using the Good-Lite

(Elgin, Illinois) Sloan letters logMAR chart. A matching card was available for par-

ticipants unable to name the letters. Near vision (40 cm): monocular logMAR pre-

senting VA was measured using the Sonsken logMAR near test chart (Novomed

limited, Maidstone, ME199AG, UK). Stereovision: The TNO anaglyph stereo-test

(Richmond products, South San Francisco, CA 94080, USA) was used to quantify

the degree of stereoacuity. Amplitude of accommodation (this is the maximum

measure of accommodative function (the ability of the eye to change its focus from

distant to near objects) that can be observed) was measured binocularly using the

Royal-Air-Force rule push-up method; participants reported when the target

brought gradually nearer their eyes became blurred. Ocular alignment was evaluated

to check for the presence of strabismus (misaligned eyes) using a cover-uncover test,

and an alternating cover test, using an accommodative target with and without spec-

tacle correction (if worn) at 3m and 40cm. The Richmond Hardy-Rand-Rittler fourth

edition, colour-vision test was performed with the habitual prescription in place at a

distance of 70 cm in natural daylight. Cycloplegic autorefraction was performed at

least 20 min and not more than 45 min post instillation of anaesthetic (Minims Prox-

ymetacaine Hydrochloride 0.5% w/v, Bausch & Lomb, UK) and cycloplegic eye drops

(Minims Cyclopentolate Hydrochloride 1% w/v, Bausch & Lomb, UK). Cycloplegic

refraction is the gold standard for measuring refractive errors in children; the eye

drops temporarily paralyse the focusing system of the eye. Non-cycloplegic refraction

can result in overdiagnosis of short-sightedness and underestimation of long-sighted-

ness (Li et al. 2019). The representative value for SER - sphere plus half the cylindrical

value - was used in subsequent analysis.

Deﬁnitions: Presenting visual impairment (PVI) was presenting VA

>0.30logMAR (worse than 6/12 Snellen) in the ‘better eye ’ (Smith et al. 2009).

Amblyopia was deﬁned as pinhole acuity≥0.3logMAR in the affected eye, plus the

presence of an amblyogenic factor (Xiao et al. 2015). Clinically signiﬁcant refractive

errors were: myopia SER≤−1.00 dioptre

(D), hyperopia≥3.50D, astigmatism≥1.50

dioptre cylinder (DC)

(O’Donoghue et al. 2012). Follow up: Subsequent to the

examination, all parents/guardians received a detailed report advising them of

study ﬁndings and the necessity of any further treatment if required.

Statistical methodology

Multinomial logistic regression analysis, with participants who reported average-per-

formance as the reference category, was employed to examine the relationship of

4 S. Harrington et al.

parent-reported school performance with categorical variables (myopia, hyperopia,

astigmatism, amblyopia, stereoacuity status, PVI and colour-vision) while controlling

for confounders (ethnicity, socioeconomic status and gender). Presenting vision

(logMAR), stereoacuity (arc-seconds) and amplitude of accommodation (D) were

analysed as continuous variables in the multiple linear regression models. The distri-

bution of right and left eye data were signiﬁcantly correlated for distance VA (Pearson

correlation: 6-7-years-old r = 0.77, 12-13-years-old r = 0.65, overall r = 0.71 (all

p<0.001)), and near VA (Pearson correlation: 6–7 years r = 0.85, 12-13-years-old

r = 0.55, overall r = 0.76 (all p < 0.001)). Hence, data are presented for the right eye

only unless otherwise stated; amblyopia means amblyopic in either eye or both. P-

values ≤0.05 were regarded as signiﬁcant. Throughout, 95% conﬁdence intervals

(CI) were used.

Results

Statistical analysis of study questionnaires and examination results included

722 of the 728 6-7-year-olds (response-rate = 99.2%) and 890 of the 898 12-

13-year-olds (response-rate = 99.1%). Their parents/guardians reported 9%

(67/722) of 6-7-year-old and 6% (55/890) of 12-13-year- old participants as

low-performing.

Sociodemographic Factors associated with school performance

Logistic regression analysis showed high-performance was associated with older

age-group (OR = 1.5, CI:1.1-1.9, p = 0.006), urban living (OR = 1.8, CI:1.3-2.5,

p < 0.001), but not ethnicity (p = 0.84), or socioeconomic status (p = 0.45) or

gender (p = 0.81).

Low-performance was associated with: socioeconomic disadvantage (OR = 2.0,

CI:1.3-3.0, p = 0.003); 10.7% (37/345) of socioeconomically disadvantaged partici-

pants reported low-performance compared to 6.6% (85/1286) of advantaged partici-

pants; Male gender (OR = 1.7, CI:1.1-2.5, p = 0.01); 9.1% (79/872) of males reported

low-performance compared to 5.8% (43/741) of females; and Traveller ethnicity

(OR = 3.0, CI:1.3-7.0, p = 0.008); 14.0% (21/151) of Traveller participants reported

low-performance, the corresponding percentages for White and non-White were

7.0% (92/1282) and 5.0% (9/182) respectively. Low-performance was not associated

with urban/rural living (p = 0.66).

Over two-thirds of low-performing participants (67% of 6-7-year-olds and 69% of

12-13-year-olds) had no eye examination within 12 months of data collection. Unless

otherwise stated the 6-7-year-olds and 12-13-year-olds are herewith analysed

separately.

Distance vision (3 m)

Distance vision was signiﬁcantly better amongst high-performing than average-per-

forming and low-performing 6-7-year-olds (p < 0.001); similarly among 12-13-year-

old (p = 0.02) participants (Table 1 and Figure 1 in which a higher value indicates

poorer vision).

Irish Educational Studies 5

Table 1. The relationship between school-performance in 722 6-7-years-old and 890 12-13-

years-old participants and presenting vision (distance 3 m and near 40 cm), presenting

stereovision and the presenting amplitude of accommodation.

Presenting vision†

High-

performance

Average-

performance

Low-

performance

P-

value

6–7 years

mean ± SD mean ± SD mean ± SD

Distance vision

(logMAR)

−0.01 ± 0.15 0.00 ± 0.15 0.15 ± 0.25 <0.001

Near vision (logMAR) 0.07 ± 0.18 0.08 ± 0.22 0.23 ± 0.35 <0.001

Stereovision

(arcseconds)

150.4 ± 217.7 135.9 ± 202.6 282.0 ± 325.8 <0.001

Accommodation

(Dioptres)

14.0 ± 4.2 13.7 ± 3.8 11.4 ± 4.9 <0.001

12–13 years

mean ± SD mean ± SD mean ± SD

Distance vision

(logMAR)

−0.05 ± 0.23 −0.03 ± 0.19 0.00 ± 0.24 0.03

Near vision (logMAR) 0.03 ± 0.12 0.04 0.07 ± 0.18 0.02

Stereovision

(arcseconds)

87.6 ± 163.9 95.1 ± 190.0 149.4 ± 252.3 0.001

Accommodation

(Dioptres)

12.2 ± 3.2 12.1 ± 3.8 11.1 ± 3.4 0.24

†Measurements taken with participants spectacles if worn; Boldface indicates statistically signiﬁcant P <

0.05; standard deviation (SD).

Figure 1. The distribution of distance vision (presenting with spectacles if worn) in 6-7-year-

olds (top image) and 12–13 year-olds (bottom image) by parent-reported school performance

category. On average, distance vision in low-performing 6-7-year-olds was signiﬁcantly poorer

than average-performing and high-performing 6-7-year-olds.

6 S. Harrington et al.

Near vision (40 cm)

Near vision was signiﬁcantly better amongst high-performing, than average-perform-

ing, and low-performing 6-7-year-olds (p < 0.001); similarily in 12-13-year-olds (p <

0.001) (Table 1).

Stereovision

Stereovision was signiﬁcantly better amongst high-performing than average-perform-

ing and low-performing 6-7-year-olds (p < 0.001); correspondingly in 12-13-year-olds

(p = 0.001) (Table 1 and Figure 2 in which a higher value indicates poorer

stereovision).

Amplitude of accommodation

Poorer accommodation was associated with low-performance in the 6-7-year-olds (p

< 0.001), but not the 12-13-year-olds (p = 0.24) (Table 1).

Presenting visual impairment

Six-seven-year-olds: PVI was associated with low-performance (OR = 11.2, CI:4.8-27,

p < 0.001) (Figure 3). Of the 67 low-performing 6-7-years-olds, 11 (16.4%) had PVI;

seven (10.5%) of which reported no history of spectacle wear; two (3.0%) required

updated spectacles, and two (3%) did not have their spectacles at school.

Twelve-thirteen-year-olds: PVI was associated with low-performance (OR = 3.3,

CI:1.5-9.1, p = 0.02) (Figure 3); of the 55 low-performing 12-13-year-olds ﬁve (9%)

had PVI, of which two reported no history of spectacle wear, two were at school

without their spectacles, and one required updated spectacles.

Figure 2. The distribution of stereoacuity (arcseconds) in 6-7-year-olds (top image) and 12–

13 year-olds (bottom image) by parent-reported school performance category. Low-perform-

ing participants had signiﬁ cantly poorer stereoacuity than average-performing and high-per-

forming participants in both age-groups.

Irish Educational Studies 7

Spectacle wear compliance

Amongst low-performing participants, four (6.3%) 6–7-year-olds and eight (14.8%)

12-13-year-olds did not have their spectacles in school.

Eye examinations

All low-performing 6-7-year-olds with PVI (11 participants) reported not having had

their eyes tested during the 12 months before data collection. The corresponding

numbers in the older cohort were three of ﬁve participants.

Uncorrected clinically signiﬁcant refractive error

Emmetropia (absence of clinically signiﬁcant refractive error) (OR = 1.4, CI:1.1-

1.8, p < 0.001) was associated with high perfor mance in both age-groups.

Myopia (OR = 1.8, CI:1.2-2.7, p = 0.003) was associated with h igh-performance

in 12-13-year-olds but not in 6-7-year-olds (p = 0.27). Uncorrected hyperopia

was associated with low-perfor man ce (OR = 2.7, CI:1.1-7.0, p = 0.04); amongst

uncorrected 6-7-year-old hyperopic participants, 23.8% (5/21) reported low-per-

formance compared to 9.5% (2/21) low-perfor mance in c orrected hyperopic 6-7-

year-olds.

Uncorrected astigmatism was associated with low-performance (OR = 2.1,

CI:1.1-3.1, p < 0.001) in both age cohorts. Amongst uncorrected astigmatic 6-7-

year-olds, 37% (10/27) reported low-performance compared to 10.7% (3/28) of cor-

rected astigmatic participants. Amongst 12-13-year-olds, 11% (4/38) with uncorrected

astigmatism reported low-performance in school, there were no low-performing 12-

13-year-old participants with corrected astigmatism.

Figure 3. The relationship between presenting visual impairment and low-performance in

school. Amongst participants with presenting visual impairment, 40.7% of 6-7-year-olds and

16.7% of 12-13-year-olds reported low-performance. The corresponding percentages for par-

ticipants without visual impairment were 6.8% and 5.6% respectively.

8 S. Harrington et al.

Amblyopia

Amblyopia was associated with low-performance in 6-7-year-olds (OR = 7.7, CI:4.0-

14.3, p < 0.0001) and 12-13-year-olds (OR = 5.6, CI:1.7-17.5, p = 0.002) (Figure 4).

Fitting a logistic regression model relating parent-reported school performance to

the amblyopia and stereoacuity categories jointly (abnormal stereoacuity≥240 arc-

seconds otherwise normal) revealed both amblyopia (OR = 3.5, CI:1.7-6.7, p =

0.001) and stereoacuity (OR = 2.3, CI:1.4-4.0, p = 0.002) remained signiﬁcantly

related to low-performance.

The effect of amblyopia treatment on parent-reported school performance was

also investigated. Controlling for age, participants with amblyopia (never treated)

were 3.7 times (CI:1.5-8.3, p = 0.004) more likely to report low-performance than

those without amblyopia (never treated), and 3.6 times (CI:1.1-12.5, p = 0.04) more

likely to report low-performance than participants successfully treated for amblyopia

(Figure 5).

Strabismus

Strabismus (misaligned eyes) was associated with low-performance (OR = 2.1,

CI:1.1-4.0, p = 0.03). All low-performing strabismic participants were esotropic.

Fitting a logistic regression model relating parent-reported school performance to

the amblyopia and strabismus jointly revealed strabismus was no longer associated

with low-performance (p = 0.44), whereas amblyopia remained strongly associated

with low-perfor mance (OR = 5.0, CI:2.9-8.8, p < 0.0001).

Figure 4. The relationship between amblyopia prevalence and low-performance in school. Of

the 6-7-year-olds: 50% (4/8) of participants with bilateral amblyopia, 39.5% (15/38) with uni-

lateral amblyopia and 6.9% (47/682) of non-amblyopic 6-7-year-olds reported low-perform-

ance. Of the 12-13-year-olds: 52% (4/7) with bilateral amblyopia, 15.2% (5/33) with

unilateral amblyopia and 5.7% (49/858) without amblyopia reported low-performance.

Irish Educational Studies 9

Colour vision

Controlling for gender, defective colour-vision was associated with low-performance

(OR = 4.7, CI:1.5-14.3, p = 0.01).

Discussion

This study i s the ﬁrst to explore the relationship between parent-reported school

performance and vision in children attending mainstream schools in Ireland.

Study ﬁndings demonstrate an association between uncorrected ref ractive error

(long-sightedness and astigmatism), untreated amblyopia (lazy eye), PVI (inability

to see half of a standard eye test chart with either eye in the distance and near),

diminished stereoacuity (three-dimensional vision), and defective colour vision

with low-perfor mance in school. Following focus-group feedback, school academic

perfor mance data was based on how parents/guardians perceived their child’sper-

formance in school when compared to their peers. Therefo re, children in socioeco-

nomically disadvantaged schools we re compared to children in the same

environment and children attending other schools were compared to their peers.

Hence, the present study addressed the association between how parents/guardians

perceived their child’s performance in school (qualitative analysis) and various

aspects of vision (quantitative analysis). Quan titative analysis provides the empi ri-

cal evidence necessary for clinical practitioners. Whereas, qualitative analysis sup-

ports the personal and experiential ‘knowing’ which is critical to the

interpretation of study ﬁndin gs and their application to clinical practice (Malterud

2001). Furthermore, qualitative assessment methods are crucial to understanding

community needs and issues, providing researchers with a better understanding of

Figure 5. Percentage of participants who reported low-performance, average-performance,

and high-performance in each of the following categories: not amblyopic with no history of

treatment (1,453 participants), successfully treated amblyopes (79 participants), unsuccessfully

treated amblyopes (31 participants), and amblyopic and no history of amblyopia treatment (40

participants).

10 S. Harrington et al.

the meaning and implications of quantitative study ﬁndings (Malterud 2001). As

patient-recorded outcome measures are now routinely used in health settings and

essential when updating health policy (Tadic

et al. 2013), feedback from parents/

guardians regarding their child’s school academic perfor mance provides useful

information that may be more context-speciﬁc than test scores of mathematical

ability or reading speed.

In line with previous studies, including with the PISA worldwide study (OECD

2016), the present study found low-performance associated with male gender

(Weaver-Hightower 2003), socioeconomic disadvantage (Bruce et al. 2016), and eth-

nicity (Hoff 2013).

Presenting vision

Concurring with previous studies (Goldstand, Koslowe, and Parush 2005; Maples

2003), reduced distance VA was associated with low-performance in both age-

groups. Distance VA demand in classrooms varies depending on the position in the

classroom, level of illumination and whether the material is presented on a board/

smart-board (Narayanasamy et al. 2016; Negiloni, Ramani, and Sudhir 2017;

2019). However, the mean distance VA in low-performing 6-7-year-olds was poorer

than the VA threshold level (0.3logMAR) reported in the literature (Narayanasamy

et al. 2016; Negiloni, Ramani, and Sudhir 2017). Additionally, PVI was associated

with low-performance in both age-cohorts; children with PVI do not have the ade-

quate vision threshold (0.3LogMAR) in either eye required to read material from a

board/smart-board (Langford and Hug 2010; Narayanasamy et al. 2016). Thus, high-

lighting the importance of routine assessment of visual task demands and the visual

skill levels required by children in school classrooms to inform educators of their stu-

dent’s visual requirements (Negiloni, Ramani, and Sudhir 2017).

Reduced near VA was associated with low-performance in both age-groups, which

is unsurprising given the importance of near vision in the learning environment (Nar-

ayanasamy et al. 2016); over half of the school day involves sustained vision at 20-

25 cm. Moreover, the VA demand for children aged 10–12 years to sustain ﬂuent

reading was previously reported at 0.33 ± 0.09 logMAR (Narayanasamy et al.

2016); hence, many low-performing participants (mean vision at near 0.23 ±

0.35logMAR) may not have adequate acuity to maintain sustained near work. Fur-

thermore, in-school vision screening in Ireland is limited to a measurement of dis-

tance vision (Health Service Executive 2005); hence, children with reduced near

vision may miss an opportunity for early intervention if their distance vision meets

the screening cut-off (0.2logMAR).

Refractive error

The association established in the present study between uncorrected hyperopia

(long-sightedness) and academic underperformance aligns with the Vision in Pre-

schoolers Study and the Child Health and Education Study (Stewart-Brown,

Haslum, and Butler 2008; VIP-HIP Study Group 2016). Traditionally, hyperopia

≤+3.00 D is rarely corrected in children aged 6-7-years as they are considered to

have adequate accommodation to compensate for near visual tasks (Arnold 2004).

However, the present study demonstrated low-performing children had signiﬁcantly

Irish Educational Studies 11

lower mean amplitude of accommodation, especially in the 6-7-year-old cohort. Prior

research involving 10-12-year-olds reported the average reading distance at 23 cm

(range 20 cm to 25 cm) hence 4-5D of accommodation are required to see at near,

and, as accommodative amplitude should be twice the dioptric demand, 8-10D of

accommodation is necessary during near work in the classroom (Narayanasamy

et al. 2016). Thus, low-performing participants may not have adequate accommo-

dation (mean (SD):11.4 ± 4.9D) required to sustain near ﬁxation. Indeed, objectively

measured accommodation may be lower than the subjectively measured push-up test

used in the present study (Anderson et al. 2008). Furthermore, accommodation is

rarely routinely checked in childhood as children are presumed to have adequate

accommodation to see at near (Woodhouse et al. 1993), given accommodation

decreases with age in the typical population and symptoms associated with difﬁculty

reading are usually ﬁrst experienced in middle age (45-years-old). Based on the results

of the current study near VA and objectively measured accommodation (such as

dynamic retinoscopy) ought to be routinely checked in schoolchildren.

Uncorrected astigmatism was associated with low-performance in the present

study in agreement with the literature. For example, Harvey et al. (2016) reported

reading ﬂuency signiﬁcantly reduced in students with uncorrected bilateral astigma-

tism, but not when corrected, compared to their non-astigmatic peers. Likewise, Nar-

ayanasamy et al. (2015) demonstrated simulated bilateral astigmatic blur resulted in

reduced comprehension, reading speed and accuracy in 10-year-old Australians high-

lighting the challenges uncorrected astigmats experience in school, which has impor-

tant implications for schoolchildren in Ireland, where signiﬁcant amounts of

uncorrected astigmatism exist (Harrington et al. 2019a).

Of further concern was the substantial number of children at school without their

prescribed spectacles, many of whom were socioeconomically disadvantaged (Har-

rington et al. 2019a). Prescribing spectacles to children who need them can

improve academic performance (Ma et al. 2014; Slavin et al. 2018;Yietal.2015),

which is essential for children with special educational needs (Black et al. 2019),

resulting in increased classroom engagement and reduced ‘off-task’ behaviour

(Black et al. 2019). Moreover, cognitive ability in low-income preschoolers with

uncorrected refractive error signiﬁcantly improved following just six-weeks of specta-

cle wear (Roch-Levecq et al. 2008).

Furthermore, the prevalence of myopia is increasing globally; one in ﬁve 12-13-

year-olds in Ireland are myopic (Harrington et al. 2019a). Children with myopia

will not have the threshold level of VA needed to see detail on the white or blackboard

in school. Hence, compliance with spectacle wear in school requires coordinated

public health policy responses at both the child and parental level (Harrington et

al. 2019b).

Amblyopia, strabismus and binocular vision

Overall, proportionally more parents/guardians of 6-7-year-olds with strabismus

(misaligned eyes) reported their children were low-performing than parents/guar-

dians of orthotropic (straight-eyed) participants, in agreement with previous

studies (Reed, Kraft, and Buncic 2004; Woodhouse, Grifﬁths, and Gedling 2000).

Furthermore, similar to Reed, Kraft, and Buncic (2004), strabismus was associated

with low-performance in the younger cohort and not the older group in the present

12 S. Harrington et

al.

study. Hence, its possible children may adapt or develop coping strategies for their

strabismus. Interestingly, controlling for amblyopia, the association between strabis-

mus and school-performance was no longer signiﬁcant, suggesting the presence of

strabismus (a cosmetically visible eye defect) alone is not a marker for academic dif-

ﬁculties; instead it is the relationship between strabismus and amblyopia which was

strongly associated with low-performance. Indeed, Narayanasamy et al. (2014)

demonstrated simulated monocular hyperopic blur was signiﬁcantly associated with

impaired academic performance, particularly when the 11-year-old participants

were involved in sustained near visual tasks.

The association found between amblyopia and low-performance aligns with

Khalaj et al. (2011) and Kugathasan et al. (2019). Moreover, the reduced levels of

low-performance amongst participants successfully treated for amblyopia reinforce

the importance of early detection and compliance with amblyopia treatment. This

ﬁnding is crucial in Ireland where persistent amblyopia (post-traditional treatment

age) prevalence is high (4.5% in children aged 12–13 years) and associated with socio-

economic disadvantage and poor compliance with spectacle wear (Harrington et al.

2019b).

Previous studies demonstrated a relationship between amblyopia and reading

speed (Kelly et al. 2015), transcribing (Kelly et al. 2018), and disrupted reading

ability and accuracy (Kugathasan et al. 2019). Kugathasan et al. (2019) proposed chil-

dren with amblyopia, may beneﬁt from using texts with reduced crowding and from

time allowances for tasks involving reading. In contrast, Rahi, Cumberland, and

Peckham (2006) attributed quality of life issues associated with amblyopia to amblyo-

pia treatment (wearing an eyepatch) and not the visual disruption. For example,

Carlton and Kaltenthaler (2011) reported low self-esteem, negative self-image, bully-

ing and teasing are associated with amblyopia treatment. However, successful

amblyopia treatment to improve VA was associated with signiﬁcantly reduced levels

of low-performance in the present study. Hence, addressing amblyopia and complet-

ing amblyopia treatment early in childhood when treatment is more likely to be suc-

cessful (Holmes 2011), and during a period before children become increasingly more

self-aware and susceptible to ridicule and feelings of inferiority (Erikson’s psychoso-

cial stage 4 (5-12-years-old): industry versus inferiority) (Erikson 1968) is essential.

Thus, it is necessary to integrate vision, educational and psychosocial implications

of amblyopia treatment (Koklanis, Abel, and Aroni 2006).

The association between reduced/abnormal stereoacuity and low-performance

concurs with Taylor-Kulp (1999). Controlling for amblyopia, the relationship

between abnor mal stereoacuity and low-performance remained. Stereoacuity is a

measure of binocular vision (three-dimensional vision), which is affected by

reduced VA, inaccurate accommodation and ocular alignment (Li et al. 2016). Fur-

thermore, Ponsonby et al. (2013) demonstrated orthoptic interventions (a programme

of eye exercises) to improve stereoacuity improved literacy in children to a greater

extent than providing parental literacy support alone.

Colour vision deﬁciency

Controlling for gender, participants with defective colour vision performed less well

than classmates in the current study, aligning with ﬁndings in Italian schoolchildren

(Gallo et al. 1998). In contrast, Cumberland, Rahi, and Peckham (2004) reported

Irish Educational Studies 13

children with defective colour vision did as well as their peers educationally, and the

authors queried the rationale for colour-vision screening in schools. Indeed, as per the

Best Health Revisited HSE guidelines, colour vision is not routinely checked in

schoolchildren in Ireland (HSE 2005). However, colour is used extensively as a didac-

tic tool in education, and more recent research demonstrated defective colour vision

associated with slow learning (Gallo et al. 2003). Additionally, Steward and Cole

(1989) and Gallo et al. (2003) established many individuals are unaware of their defec-

tive colour vision. Hence, early screening is vital to inform teaching staff and assist

children in developing adaptive strategies to support learning and inform career

choice, which is limited by defective colour vision (Cole 2004).

Public awareness

The majority of participants (68%) reported by their parents/guardians as low-per-

forming in school had not had an eye examination within the 12 months before

data collection. Furthermore, focus-group feedback revealed parents/guardians of

low-performing children might be uncomfortable about sharing speciﬁc academic

data. However, many low-performing children had PVI, a level of vision too poor

to obtain a driving licence, demonstrating a possible lack of public awareness as to

the importance of clear and accurate vision in children’s development (Sharma

et al. 2012). Whether parents were unaware of the association between school-per-

formance and a child’s ability to see clearly or unaware of how to access an eye exam-

ination for their child was not investigated in the present study. Furthermore, parents

may have other commitments such as work or dependants in the home, which mean

they are unable to bring their child for an eye examination (Sharma et al. 2012). As

both PVI and low-performance were associated with socioeconomic disadvantage in

the present study, some families may have been unable to afford private eyecare for

their child. In Ireland, children without a medical card are not entitled to free eye

tests with a high street optometrist. The waiting lists for publically funded eye tests

is currently over two years in Ireland (Power et al. 2017), the consequence is many

children are not accessing an eye examination either before commencing school or

when a child is performing below average in school.

Early vision testing requires parental knowledge of the importance of vision testing

for children. Early childhood interventions enhance children’s wellbeing, as demon-

strated by the Chicago longitudinal (18 years) study where, every $1.00 invested in

health, social services and preschool education to low-income children in public

schools returned $7.50 to society (Reynolds, Temple, and Ou 2003). Membreno et al.

(2002) estimated economic beneﬁt of amblyopia treatment was $22 return to the

Gross Domestic Product for every $1 invested; this return is especially enhanced due

to the early intervention of amblyopia treatment and the subsequent lifelong impact

on income. Thus, the impact of poor vision, on children’s educational performance

is a public health issue (Black et al. 2019), which has ﬁnancial implications for the com-

munity due to lost earnings (Membreno et al. 2002), and a range of associated health

issues such as anxiety and depression (Hayes et al. 2019; Leo et al. 1999). Notably, Tra-

veller and socioeconomically disadvantaged participants were disproportionately

affected in this study with higher levels of both PVI and low-performance. While

this paper does not seek to investigate the impact of speciﬁc policies on academic per-

formance, the results do suggest that both parent-reported school performance and

14 S. Harrington et al.

PVI are complex issues that require a coordinated approach including recognition of

interrelated determinants of health. O’Donnell et al. (2016) demonstrated culturally-

speciﬁc policy responses, including innovative ways of accessing primary care for mar-

ginalised groups, are vital to address existing inequalities. Likewise, novel ways of enga-

ging constructively with marginalised groups are needed to address existing eye-health

and educational inequalities in Ireland.

The high number of low-performing children with PVI and no history of primary

eyecare identiﬁed in the present study, highlight the gaps and the possible lack of

optimal integration with current childhood health services in Ireland. Additionally,

the acknowledged delays in eyecare follow up of over two years in Ireland

(Murphy 2017) from when issues are reported, may be a contributor to the level of

unaddressed vision issues identiﬁed in the study. Thus, study ﬁndings highlight the

importance of earlier testing of children’s vision, ideally in advance of starting

school, which will allow the development of adaptive policies to assist those children

in school in achieving their academic potential generating consequential societal

beneﬁts by increasing the number of better-performing students in school.

The strengths of this study include the large sample size, random school selection

and the high questionnaire completion rate (>99%). Parent-reported outcomes of

school performance instead of objectively measured academic scores is a study limit-

ation. Standardised outcome measures to assess the relationship between academic

achievement and vision are essential (Hopkins et al. 2019); however, public engage-

ment during the design stage of the present study revealed the difﬁculties and sensi-

tivities associated with that aim. Hence, gaps remain concerning speciﬁc aspects of

vision and their relationship with particular aspects of academic achievement.

Further research is therefore required to examine what level of visual impairment

is likely to interfere with various aspects of learning. To address these limitations,

increasing public awareness of the importance of vision in children’s education is

imperative, as is involving public representatives and relevant stakeholders at the

design stage of any future study to prevent participation bias and provide data to

inform clinical decision-making. Furthermore, due to the cross-sectional nature of

the data, it is not possible to conclude that unaddressed visual issues are responsible

for low-performance in school. Hence, further studies, including longitudinal studies,

are recommended to assess the extent and magnitude of the relationship between

vision and how well children perform academically in school.

Conclusion

This study revealed low-performance in children in mainstream schools in Ireland

was associated with undetected or untreated visual impairment due to uncorrected

refractive error and amblyopia, with marginalised communities disproportionally

affected. Poor stereoacuity and defective colour vision were additional factors with

schoolchildren aged 6–7 years, particularly affected by unaddressed visual issues.

Children presenting with academic performance challenges ought to have a compre-

hensive eye examination, to detect potential vision problems for early intervention,

thus minimising any negative impact they will have on educational outcomes.

Study ﬁndings suggest that addressing vision and academic performance inequalities

requires coordinated policy responses at both the child and community level. Speciﬁ c

and culturally-appropriate public education programmes highlighting the importance

Irish Educational Studies 15

of comprehensive eye examinations for all children, including the consequences of

untreated and undetected visual problems, ideally in advance of starting school is a

study recommendation. Reporting of visual outcomes will create better awareness

of vision issues such as defective colour vision in school-age children to determine

educational requirements speciﬁc to children with these visual issues, thereby

enabling teachers and parents/guardians to develop adaptive teaching strategies to

help susceptible children achieve their academic potential while progressing

through school.

Patient and public involvement

The study was supported by a patient advisory group, which provided input to the

programme of research. Parents/legal guardians of participants collaborated with

us for the design of the study, the informational material to support the data collec-

tion and participant and school involvement, and assess the burden of participation

from the patient’s perspective. At the end of the study, results and ﬁndings were pro-

vided to all participants.

Data availability statement: No additional unpublished data from the study are

available.

Notes

1. G*Power software is used to calculate statistical power to determine the appropriate sample

size to detect a "true" effect when it exists

2. A unit of measurement of the optical power of a lens- reciprocal of the lens focal length in

metres

3. The difference in dioptres between the steepest and shallowest curvature of the lens/cornea.

Acknowledgement

The authors would like to express their appreciation to Dr Jim Stack (Waterford Institute of

Technology, Ireland), Professor John Kearney (Epidemiology, School of Biological Sciences,

Technological University Dublin, Ireland), and Professor Kathryn Saunders (School of Biome-

dical Sciences, Ulster University, Northern Ireland) for their valuable input in the Ireland Eye

Study. The authors would also like to acknowledge the support and participation of the

schools, the children and their parents and guardians in the Ireland Eye Study.

Disclosure statement

The authors report no conﬂicts of interest.

Funding

This work was supported by Technological University Dublin Fiosraigh Scholarship: [Grant

Number N/A]; Association of Optometrists Ireland: [Grant Number N/A]; Irish Opticians

Board: [Grant Number N/A].

Notes on contributors

Dr Siofra Harrington, PhD, lecturer in Optometry and clinical tutor in Technological Univer-

sity Dublin, principal investigator Ireland Eye Study, research interests include ametropia,

16 S. Harrington et al.

amblyopia and visual impairment in children, public health and vision screening, myopia man-

agement, binocular vision, colour vision, sports vision and school vision.

Dr Peter Davison, PhD, formerly Senior Lecturer in Optometry at Technological University

Dublin. National Optometry Centre Colour Vision Assessment Unit head. His research inter-

ests include evaluating colour vision tests, macular pigment density effects on visual functions,

cataract patients postoperative vision prediction, night-vision, and road trafﬁ c accidents visual

correlations.

Dr Veronica O’Dwyer, PhD, lecturer and clinical tutor in Optometry in Technological Univer-

sity Dublin, research interests include schoolchildren ametropia, amblyopia and vision impair-

ment; diet/macular pigment in age-related macular degeneration; Demodex folliculorum and

dry eye and contact lens wear impact on refractive surgery outcomes.

ORCID

Siofra Harrington

http://orcid.org/0000-0003-2667-1796

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