- Design
- Cross-sectional study within a national multicentre cohort, randomised test order
- Population
- 995 children aged 3–15, Shanghai
- Primary outcome
- Mean uncorrected visual acuity by chart
- Effect
- Preschool referral 18.6% (HOTV) vs 31.2% (tumbling E); specificity 0.93 vs 0.79
This cross-sectional study, part of a national Chinese cohort, tested 995 children aged 3 to 15 in Shanghai with both HOTV and tumbling E logMAR charts in random order, 30 minutes apart, and compared the results with cycloplegic refraction and full eye examination.
Overall, measured acuity was better with HOTV (logMAR 0.15 vs 0.20). The gap was largest in the youngest — about one line at age 3 — and narrowed to a letter or less from age 8. Among 183 preschool children, HOTV referred 18.6% against 31.2% with tumbling E, with a higher true positive rate (0.68 vs 0.44) and better specificity (0.93 vs 0.79) for amblyopia and refractive error.
Tumbling E asks a young child to indicate direction, a cognitive task that many cannot do reliably; HOTV asks them to match a letter. In school and community screening programmes where tumbling E is used, switching to HOTV for younger children could cut false referrals and catch more true problems. For children 8 and older, either chart performs similarly.
- Use an HOTV matching chart rather than tumbling E for vision screening in children under 8.
- Expect tumbling E to under-read acuity in 3- and 4-year-olds by about a line.
- For children aged 8 and over, either chart gives similar results.
- Train screeners to use a matching card so the child can point rather than name letters.
- Confirm abnormal screens with cycloplegic refraction before prescribing.
Why it matters
The chart choice itself was changing who got referred, especially among preschoolers.
Don't overread it
A single-city cross-sectional study — it does not show that switching charts improves long-term visual outcomes.
The statistics, in plain English
Specificity of 0.93 vs 0.79 means HOTV wrongly flagged about 7 in 100 children without disease, against about 21 in 100 with tumbling E. The true positive rate of 0.68 vs 0.44 means HOTV caught a larger share of children who truly had a problem. These results come from one city's children.
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