Purpose: To determine the testability, performance, and test-retest variability (TRV) of visual acuity (VA) assessment using the Freiburg Visual Acuity Test (FrACT) compared to the LEA Symbols Test (LEA) in preschool children.
Methods: In 134 preschool children aged 3.0 to 6.8 years, monocular VA of each eye was measured twice with a four-orientation Landolt C version of the FrACT and once with the LEA. FrACT runs were preceded by a binocular run for explanatory purposes. Test order alternated between subjects. Optotypes were presented on a computer monitor (FrACT) or on cards (LEA) at a distance of 3 m.
Results: Overall, 68% completed the FrACT (91/134 children) and 88% completed the LEA (118/134 children). Testability depended on age: FrACT, 19% (<4 years) and 87% (≥4 years); LEA, 70% (<4 years) and 95% (≥4 years). Mean ± SD VA difference between tests was 0.11 ± 0.19 logarithm of the minimum angle of resolution [logMAR], with LEA reporting better acuity. The difference depended on age (0.27 ± 0.23 logMAR [<4 years], 0.09 ± 0.18 logMAR [≥4 years], P < 0.001) and on test sequence (higher age dependence of FrACT VAs for LEA first, P < 0.001). The 95% limits of agreement for the FrACT TRV were ±0.298 logMAR.
Conclusions: The examiner-independent FrACT, using international reference Landolt C optotypes, can be used to assess VA in preschool children aged ≥4 years, with reliability comparable to other pediatric VA tests.
Translational relevance: Use of the automated FrACT for VA assessment in preschool children may benefit objectivity and validity as it is a computerized test and employs the international reference Landolt C optotype.