The EUscreen study – How cost-effective is photorefraction?

Scope and costs of autorefraction and photoscreening for childhood amblyopia – a systematic narrative review in relation to the EUSCREEN project data.    Horwood A, Griffiths HJ, Carlton J, Mazzone P, Channa A, Nordmann M, Simonsz H, on behalf of The EUSCREEN Foundation Eye 2020 Epub 30.11.2020  Eye

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  • Photoscreening for refractive risk factors for amblyopia is widely reported but rarely compared with alternatives such as VA screening
  • Photoscreening may result in early detection and treatment of amblyopia, but evidence of better long term outcomes is surprisingly weak
  • Early referral from photoscreening increases costs (and so reduces cost-effectiveness) due to longer treatment and observation time and more false referrals
  • Later VA screening seems the most cost-effective option



Amblyopia screening can target reduced visual acuity (VA), its refractive risk factors, or both. VA testing is imprecise under 4 years of age, so automated risk-factor photoscreening appears an attractive option. This review considers photoscreening used in community services, focusing on costs, cost-effectiveness and scope of use, compared with EUSCREEN project Country Reports describing how photo- and automated screening is used internationally.


A systematic narrative review was carried out of all English language photoscreening literature to September 10th 2018, using publicly available search terms. Where costs were considered, a CASP economic evaluation checklist was used to assess data quality.


Of 370 abstracts reviewed, 55 reported large-scale community photoscreening projects. Five addressed cost-effectiveness specifically, without original data. Photoscreening was a stand-alone, single, test event in 71% of projects. In contrast, 25 of 45 EUSCREEN Country Reports showed that if adopted, photoscreening often supplements other tests in established programmes and is rarely used as a stand-alone test. Reported costs varied widely and evidence of cost-effectiveness was sparse in the literature, or in international practice. Only eight (13%) papers compared the diagnostic accuracy or cost-effectiveness of photoscreening and VA testing, and when they did, cost-effectiveness of photoscreening compared unfavourably.


Evidence that photoscreening reduces amblyopia or strabismus prevalence or improves overall outcomes is weak, as is evidence of cost-effectiveness, compared to later VA screening. Currently, the most cost-effective option seems to be a later, expert VA screening with the opportunity for a re-test before referral.