Peer-reviewed article

HOTV Vision Test Compared With Tumbling E for Pediatric Vision Screening.

Wu H, Wang Y, Ni Z, Liu Y, Liu Z et al. · 1 Oct 2026

Abstract

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.