Undiagnosed visual disorders among first-grade children in Türkiye: a school-based photoscreening cross-sectional study with cost analysis

Türkiye’s national vision screening programme relies on LEA Symbol acuity testing by family health workers at primary-care centres, with no instrument-based or school-based component and was formalised only months before the COVID-19 pandemic (March 2020) disrupted preventive services. This study evaluated the clinical yield and cost implications of school-based photoscreening among first-grade children. A two-phase, district-wide, school-based cross-sectional study was conducted in Devrek district, Zonguldak Province, Türkiye (May 2022). All 509 first-grade students across seven primary schools were targeted for screening with the Plusoptix S12R photoscreener. Screen-positive children underwent comprehensive ophthalmic examination including cycloplegic refraction and best-corrected visual acuity assessment. Confirmatory examination failure levels followed the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 2021 guidelines; amblyopia was defined according to American Academy of Ophthalmology Preferred Practice Pattern criteria. A provider-perspective cost analysis was performed using opportunity costs in euros. Of 509 children, 467 were screened (91.7% coverage). Eighty-seven (18.6%) met referral criteria; 55 (63.2%) completed comprehensive examination. Nineteen (34.5% of examined) met AAPOS-2021 criteria for at least one target condition, with astigmatism > 1.75 D being the most prevalent condition (20.0%). Spectacles were prescribed to 45 children (81.8%), of whom 39 (86.7%) had no prior spectacle history. Three children (5.5%) met criteria for confirmed amblyopia and an additional 11 (20.0%) were classified as having subnormal visual acuity below the national age-norm (not meeting amblyopia criteria). All three confirmed cases were newly detected. Total programme cost was €1,844 (€3.95/child screened; €47.3/newly identified treatable condition). School-based photoscreening at school entry revealed a substantial burden of previously undiagnosed visual disorders in a Turkish district where, amid post-pandemic disruption to preventive services, national-programme delivery and outcomes were not retrievable for the cohort. More than six in seven children requiring spectacles (86.7%) were previously unknown to the healthcare system. Because no individual national-programme results were available, the incremental yield over routine care could not be quantified. These findings support evaluating instrument-based screening within Türkiye’s school health framework.