In vision screening in Flanders (part of Belgium), visual acuity (VA) is measured at age 3, 4 and 6. In 2013, the PlusOptix photoscreener, which measures refractive error and alignment, was added at age 1 and 2.5. In vision screening in Iran VA is measured 1-3 times between ages 3-6. In 2011, the PlusOptix was first added, now with full coverage. We intend to explore its cost-effectiveness.

A questionnaire was developed with six domains: Vision screening policy, attendance, practice of screening, costs of screening, orthoptic diagnosis and treatment, and quality and costs of the device. Stakeholders in vision screening in Flanders and Iran were interviewed in person. A literature search preceded the interviews.

In Flanders, 80% of children aged 0-3 years participated at least once. After PlusOptix screening at age one, 8% of children were referred. Of these children, 44.1% had astigmatism, anisometropy, hyperopia, myopia or amblyopia. Thirteen percent of these (1% of all children) was treated, mostly with glasses. Costs per screen were € 5.40- € 7.20. Device costs were €7.000 every 4 years. In Iran, more than 90% of children aged 3-6 years participated at least once. Sensitivity of this screening program is 89%, with a positive predictive value of 51%. Costs per screen were € 0.50. Device costs were €7.000. The PlusOptix is used mainly when VA measurement fails.

Data on benefits of early prescription of glasses are still lacking. Refractive error and misalignment are risk factors for amblyopia and early glasses could prevent the development of amblyopia, but the relation between magnitude of refractive error and increase of odds to develop amblyopia is unknown and would require large studies comparing children with and without glasses. The use of PlusOptix when VA measurement fails in Iran requires a different cost-effectiveness analysis but is an interesting alternative option.