Dr. Alison Bruce studied the impact of vision and amblyopia on early literacy skills in the Born in Bradford cohort. She found that for every 1 line reduction in visual acuity, a child's literacy score decreased by 2%. Two percent of children studied had poor vision and 2% had visual impairment. Lower visual acuity was significantly associated with lower literacy scores, even after adjusting for social and biological factors. The results provide evidence that amblyopia negatively affects early literacy development. Further research is needed to better understand amblyopia and develop interventions to improve screening attendance and literacy outcomes.

1. Dr Alison Bruce
Bradford Teaching Hospitals NHS Foundation Trust

2. Funding Acknowledgement:
Dr Alison Bruce is funded by the National Institute
for Health Research Post-doctoral fellowship
Programme (NIHR PDF).
This presentation presents independent research.
The views expressed are those of the author(s) and
not necessarily those of the NHS, the NIHR or the
Department of Health.

4. Normal vision
Untreated
Amblyopia
Vision age 1
Vision age 7
Age in years
Treated
Amblyopia

5. Bruce and Outhwaite Br Ir Orth J 2013

6.  “Need for more precise estimates of the
prevalence of amblyopia”
 Evidence of impact on everyday life

7.  What factors associated with amblyopia?
 What are the reasons for failing to attend?
 What impact of amblyopia on educational
attainment ?
Study nested in
“Born in Bradford Cohort”

8.  Bradford 5th
largest
 8th
most deprived city in UK
 Children born 2007 – 2010
 Approx 13,000
 60% children born
 50% South Asian origin

9.  Predictor of reading ability & educational
attainment
 Letter identification & decoding essential prior to
reading
 Woodcock Reading Mastery Tests: Letter ID

10.  Household income
 Mothers education
 Spoken Language

11. School
screening
Visual
outcome
BiB
profile of
non-
attenders
Eye clinics
Attendance
rates

13.  BiB epidemiological data (mothers & babies)
(n=11000)
 Vision screening in school @ 4-5 years
(n=17000)
 Literacy (BiB Starting Schools programme)
(n=6000)

14. Summary of data
c = complete cohort, s = subgroup
Pregnancy Birth 4-5yrs
Ethnicity C
Mothers SE class C
Mothers education C
Housing tenure C
Money problems C
Smoked in pregnancy C
Alcohol in pregnancy C
Gestational age C
Birth weight C
Visual acuity (logMAR) C
Strabismus C
Auto-refraction C
Literacy (letter identification) S
Cognitive ability (receptive vocabulary) S

15. Impact of vision on literacy
FACTOR FULLY ADJUSTED MODEL*** (n=2025)
PVA - difference in literacy score per 1 line (0.1 log unit) -1.65 (-2.17 to -1.13) p<0.001
BPVS - difference in literacy score per 1 unit 0.25 (0.21 to 0 .28) p<0.001
Ethnicity (ref - White British)
Pakistani -0.14 (-1.86 to 1.58) p= 0.872
Other 2.85 (0.88 to 4.82) p=0.005
Sex at birth (ref – Male)
Female 3.06 (2.09 to 4.04) p<0.001
Birth weight (g) 0.001 (0.0001 to 0.002) p=0.036
Gestational age (weeks) -0.01 (-0.37 to 0.34) p=0.937
Questionnaire Language (ref – English)
Other language -1.61 (-3.18 to -0.04) p= 0.045
UK born (ref – No)
Yes -0.97 (-0.49 to 2.43) p= 0.192
Receiving Benefits
Yes -1.03 (-2.04 to -0.03) p=0.045
Level of Education (ref – Low)
Medium (5 GCSE & A level equivalent) 1.13 (-0.04 to 2.3) p=0.059
High (higher than A-level) 3.20 (1.71 to 4.70) p<0.001
Smoked in pregnancy (ref – No)
Yes -1.82 (0.25 to 3.39) p=0.023

16. Impact of vision on literacy
FACTOR FULLY ADJUSTED MODEL*** (n=2025)
PVA - difference in literacy score per 1 line (0.1 log unit) -1.65 (-2.17 to -1.13) p<0.001
BPVS - difference in literacy score per 1 unit 0.25 (0.21 to 0 .28) p<0.001
Ethnicity (ref - White British)
Pakistani -0.14 (-1.86 to 1.58) p= 0.872
Other 2.85 (0.88 to 4.82) p=0.005
Sex at birth (ref – Male)
Female 3.06 (2.09 to 4.04) p<0.001
Birth weight (g) 0.001 (0.0001 to 0.002) p=0.036
Gestational age (weeks) -0.01 (-0.37 to 0.34) p=0.937
Questionnaire Language (ref – English)
Other language -1.61 (-3.18 to -0.04) p= 0.045
UK born (ref – No)
Yes -0.97 (-0.49 to 2.43) p= 0.192
Receiving Benefits
Yes -1.03 (-2.04 to -0.03) p=0.045
Level of Education (ref – Low)
Medium (5 GCSE & A level equivalent) 1.13 (-0.04 to 2.3) p=0.059
High (higher than A-level) 3.20 (1.71 to 4.70) p<0.001
Smoked in pregnancy (ref – No)
Yes -1.82 (0.25 to 3.39) p=0.023

17. Impact of vision on literacy
FACTOR FULLY ADJUSTED MODEL*** (n=2025)
PVA - difference in literacy score per 1 line (0.1 log unit) -1.65 (-2.17 to -1.13) p<0.001
BPVS - difference in literacy score per 1 unit 0.25 (0.21 to 0 .28) p<0.001
Ethnicity (ref - White British)
Pakistani -0.14 (-1.86 to 1.58) p= 0.872
Other 2.85 (0.88 to 4.82) p=0.005
Sex at birth (ref – Male)
Female 3.06 (2.09 to 4.04) p<0.001
Birth weight (g) 0.001 (0.0001 to 0.002) p=0.036
Gestational age (weeks) -0.01 (-0.37 to 0.34) p=0.937
Questionnaire Language (ref – English)
Other language -1.61 (-3.18 to -0.04) p= 0.045
UK born (ref – No)
Yes -0.97 (-0.49 to 2.43) p= 0.192
Receiving Benefits
Yes -1.03 (-2.04 to -0.03) p=0.045
Level of Education (ref – Low)
Medium (5 GCSE & A level equivalent) 1.13 (-0.04 to 2.3) p=0.059
High (higher than A-level) 3.20 (1.71 to 4.70) p<0.001
Smoked in pregnancy (ref – No)
Yes -1.82 (0.25 to 3.39) p=0.023

18. Impact of vision on literacy
FACTOR FULLY ADJUSTED MODEL*** (n=2025)
PVA - difference in literacy score per 1 line (0.1 log unit) -1.65 (-2.17 to -1.13) p<0.001
BPVS - difference in literacy score per 1 unit 0.25 (0.21 to 0 .28) p<0.001
Ethnicity (ref - White British)
Pakistani -0.14 (-1.86 to 1.58) p= 0.872
Other 2.85 (0.88 to 4.82) p=0.005
Sex at birth (ref – Male)
Female 3.06 (2.09 to 4.04) p<0.001
Birth weight (g) 0.001 (0.0001 to 0.002) p=0.036
Gestational age (weeks) -0.01 (-0.37 to 0.34) p=0.937
Questionnaire Language (ref – English)
Other language -1.61 (-3.18 to -0.04) p= 0.045
UK born (ref – No)
Yes -0.97 (-0.49 to 2.43) p= 0.192
Receiving Benefits
Yes -1.03 (-2.04 to -0.03) p=0.045
Level of Education (ref – Low)
Medium (5 GCSE & A level equivalent) 1.13 (-0.04 to 2.3) p=0.059
High (higher than A-level) 3.20 (1.71 to 4.70) p<0.001
Smoked in pregnancy (ref – No)
Yes -1.82 (0.25 to 3.39) p=0.023

19. Impact of vision on literacy
FACTOR FULLY ADJUSTED MODEL*** (n=2025)
PVA - difference in literacy score per 1 line (0.1 log unit) -1.65 (-2.17 to -1.13) p<0.001
BPVS - difference in literacy score per 1 unit 0.25 (0.21 to 0 .28) p<0.001
Ethnicity (ref - White British)
Pakistani -0.14 (-1.86 to 1.58) p= 0.872
Other 2.85 (0.88 to 4.82) p=0.005
Sex at birth (ref – Male)
Female 3.06 (2.09 to 4.04) p<0.001
Birth weight (g) 0.001 (0.0001 to 0.002) p=0.036
Gestational age (weeks) -0.01 (-0.37 to 0.34) p=0.937
Questionnaire Language (ref – English)
Other language -1.61 (-3.18 to -0.04) p= 0.045
UK born (ref – No)
Yes -0.97 (-0.49 to 2.43) p= 0.192
Receiving Benefits
Yes -1.03 (-2.04 to -0.03) p=0.045
Level of Education (ref – Low)
Medium (5 GCSE & A level equivalent) 1.13 (-0.04 to 2.3) p=0.059
High (higher than A-level) 3.20 (1.71 to 4.70) p<0.001
Smoked in pregnancy (ref – No)
Yes -1.82 (0.25 to 3.39) p=0.023

20. @BiBresearch, @BiBparents
Conference #BiB15
Born in Bradford
Registered charity no: 1061753
Prevalence
of PVA
1.0 (6/60)
2 % 0.8 (6/36)
0.5 (6/24)
2 % 0.4 (6/18)
0.3 (6/12)
4 % 0.2 (6/9)
92 % 0.0 (6/6)

21.  Reduced vision effects early literacy
(score 2% every 1 line reduction in vision: CI -2.17 to -1.13 p<0.001)
 2% children “poor vision”
 2% children “visual impaired”

22.  Better understanding of amblyopia
 Evidence of effect on early literacy in children
 Proposed service re-design to improve uptake
 Platform for further research

23.  Insight from parents & carers
 Develop interventions
 Trial

25. Acknowledgments
•Orthoptic Dept. Bradford Teaching Hospitals NHS
Trust
•Born in Bradford
•Institute for Effective Education - University of York
alison.bruce@bthft.nhs.uk