HOTV Vision Test Compared With Tumbling E for Pediatric Vision Screening

Importance: Accurate assessment of uncorrected visual acuity (UCVA) is fundamental to pediatric vision screening. Although the HOTV letter-matching test is recommended for pediatric vision screening, the tumbling E test remains widely used globally despite its higher cognitive demands for young children. Evidence directly comparing UCVA outcomes between the 2 tests across pediatric age groups is limited. Objective: To compare UCVA outcomes from HOTV and tumbling E vision tests and evaluate their suitability for pediatric vision screening. Design, Setting, and Participants: In this cross-sectional observational study, each participant underwent UCVA testing with both HOTV and tumbling E logMAR charts in a randomized sequence, with a 30-minute rest period between tests to minimize fatigue. The study was conducted in Shanghai as part of a national multicenter cohort study in China. Participants included 995 children aged 3 to 15 years who completed both vision tests, cycloplegic refraction, and comprehensive ophthalmic examinations. These data were analyzed from January 2025 to June 2026. Exposure: UCVA assessments using HOTV and tumbling E logMAR tests. Main Outcomes and Measures: The primary outcome was mean UCVA (logMAR). Secondary outcomes included referral rates for reduced UCVA, screening performance for amblyopia and refractive errors, testability, and time required for vision test. Results: Overall, mean (SD) UCVA was 0.15 (0.22) (20/25) with HOTV and 0.20 (0.20) (20/32) with tumbling E (95% CI, -0.07 to -0.02; P < .001). The difference between the 2 tests decreased with age, initially 1 logMAR line in children aged 3 to younger than 4 years, more than 3 letters in those younger than 8 years, and reducing to 1 or less letters by age 8 years or older. Among 183 preschool children, HOTV test showed a lower referral rate (n = 34 [18.6%]) than tumbling E (n = 57 [31.2%]) (mean difference, -12.6%; 95% CI, -19.2% to -5.9%; P < .001), along with a higher true positive rate (0.68 vs 0.44; P < .001) and better specificity (0.93 vs 0.79; P < .001), with similar measures in older children. Conclusions and Relevance: These findings support the use of the HOTV test for children younger than 8 years. Its use could reduce unnecessary referrals, especially in the context of growing global emphasis on pediatric vision screening and early detection of myopia. Trial Registration: ClinicalTrials.gov Identifier: NCT05770661.