title: Evaluation of visual acuity measurements after autorefraction vs manual refraction in eyes with and without diabetic macular edema.
abstract: OBJECTIVE
  To compare visual acuity (VA) scores after autorefraction vs manual refraction in eyes of patients with diabetes mellitus and a wide range of VAs.
  
  
  METHODS
  The letter score from the Electronic Visual Acuity (EVA) test from the electronic Early Treatment Diabetic Retinopathy Study was measured after autorefraction (AR-EVA score) and after manual refraction (MR-EVA score), which is the research protocol of the Diabetic Retinopathy Clinical Research Network. Testing order was randomized, study participants and VA examiners were masked to refraction source, and a second EVA test using an identical supplemental manual refraction (MR-EVAsuppl score) was performed to determine test-retest variability.
  
  
  RESULTS
  In 878 eyes of 456 study participants, the median MR-EVA score was 74 (Snellen equivalent, approximately 20/32). The spherical equivalent was often similar for manual refraction and autorefraction (median difference, 0.00; 5th-95th percentile range, -1.75 to 1.13 diopters). However, on average, the MR-EVA scores were slightly better than the AR-EVA scores, across the entire VA range. Furthermore, the variability between the AR-EVA scores and the MR-EVA scores was substantially greater than the test-retest variability of the MR-EVA scores (P < .001). The variability of differences was highly dependent on the autorefractor model.
  
  
  CONCLUSIONS
  Across a wide range of VAs at multiple sites using a variety of autorefractors, VA measurements tend to be worse with autorefraction than manual refraction. Differences between individual autorefractor models were identified. However, even among autorefractor models that compare most favorably with manual refraction, VA variability between autorefraction and manual refraction is higher than the test-retest variability of manual refraction. The results suggest that, with current instruments, autorefraction is not an acceptable substitute for manual refraction for most clinical trials with primary outcomes dependent on best-corrected VA.
authors.affiliation: Beetham Eye Institute and Research Section, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Jennifer K
authors.initials: JK
authors.lastname: Sun
authors.forename: Haijing
authors.initials: H
authors.lastname: Qin
authors.forename: Lloyd Paul
authors.initials: LP
authors.lastname: Aiello
authors.forename: Michele
authors.initials: M
authors.lastname: Melia
authors.forename: Roy W
authors.initials: RW
authors.lastname: Beck
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Andreoli
authors.forename: Paul A
authors.initials: PA
authors.lastname: Edwards
authors.forename: Adam R
authors.initials: AR
authors.lastname: Glassman
authors.forename: Michael R
authors.initials: MR
authors.lastname: Pavlica
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D003930:Diabetic Retinopathy / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008269:Macular Edema / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D012029:Refraction, Ocular / Q000502:physiology*; D041623:Tomography, Optical Coherence; D014787:Vision Tests; D014792:Visual Acuity / Q000502:physiology*; D055815:Young Adult