Why HOTV May Be a Better Fit for Preschool Vision Screening

Choosing a visual acuity test for a preschool child involves more than selecting optotypes that are large enough to see. The child also needs to understand the task and respond reliably, which means the demands of the testing method can influence the result.

That distinction is at the center of research published in JAMA Ophthalmology comparing HOTV letter matching with the tumbling E test in children ages 3 to 15. The differences between the two approaches were most noticeable in younger children, suggesting that developmental demands built into the task can affect measured visual acuity. For preschool vision screening programs, that matters because the method used can influence which children meet criteria for referral.

HOTV and Tumbling E Ask Children to Do Different Things

Both HOTV and tumbling E tests allow visual acuity to be assessed without asking a young child to read a conventional alphabet chart, but the response required by each test is different. With HOTV, children identify or match one of four letters: H, O, T, or V. The tumbling E test asks the child to recognize the orientation of the letter E and indicate which direction it is facing.

For younger children, that difference may be important. The researchers suggested that the directionality and visuospatial skills needed to complete a tumbling E test may not yet be fully developed in some preschool-aged children. As those abilities develop with age, the difference between HOTV and tumbling E results appears to become smaller.

The issue was not simply whether children could complete the tests. Testability was high with both approaches, but the findings suggest that the response demands of the task may still affect the visual acuity that is measured.

The Largest Differences Were Seen Before Age 8

The study evaluated children ages 3 to 15 who completed HOTV and tumbling E visual acuity testing as well as cycloplegic refraction and comprehensive ophthalmic examinations. The order of the two visual acuity tests was randomly assigned.

Among the 980 children included in the comparison of first-test results, mean uncorrected visual acuity was 0.15 logMAR with HOTV and 0.20 logMAR with tumbling E. The difference became smaller as children grew older. In children ages 3 through 7, the average difference exceeded three letters, while among the youngest children the difference reached approximately one line of visual acuity. By age 8 and older, the difference between the tests had narrowed to about one letter.

That age pattern is especially relevant for professionals working with younger children. The findings do not suggest that HOTV should replace tumbling E testing across every pediatric age group. Rather, the clearest differences appeared among preschool and younger primary-school children.

HOTV Resulted in Fewer Preschool Referrals

The choice of test also affected referral rates. Among 183 preschool children, 34 met referral criteria for reduced uncorrected visual acuity when tested with HOTV, compared with 57 when tested with tumbling E.

The researchers also reported a higher true-positive rate with HOTV in the preschool group. The true-positive rate was 0.68 with HOTV compared with 0.44 with tumbling E, while specificity was also higher with HOTV in this group.

These findings do not mean that HOTV, or any other visual acuity screening test, diagnoses an eye condition. Vision screening is intended to identify children who may need further evaluation by an eye care professional. What the study shows is that test selection can affect screening performance and referral outcomes in younger children.

For larger preschool or school screening programs, that difference can have practical consequences. A testing method that is better aligned with the child's developmental abilities may help reduce referrals associated with difficulty performing the task rather than reduced visual acuity itself.

Screening Performance Depends on More Than Optotype Size

The researchers also addressed the assumption that HOTV might simply be easier than tumbling E. Their interpretation was different. Rather than concluding that HOTV optotypes are inherently easier to see, they suggested that the tumbling E task may place additional developmental demands on younger children because it requires an understanding of direction and spatial orientation.

A younger child may therefore perform differently because of the response demands of the task, not only because of what they can see. That distinction is important in pediatric vision screening because the aim is to measure visual acuity without allowing an unrelated developmental skill to have an unnecessary influence on the result.

Choosing an age-appropriate response method can help reduce those additional demands. For professionals working with preschool-aged children, that means considering not only which optotypes appear on the chart, but also what the child is being asked to do with them.

A Good-Lite HOTV Chart Was Used in the Research

The study has a direct connection to Good-Lite. Researchers identified the HOTV chart used in the study as Good-Lite model 500025. The current Good-Lite product is Chart(Distance): ESV3000™ and ESC2000™ - HOTV ETDRS (13ft/4m), a proportionally spaced logMAR chart designed for testing at 13 feet, or 4 meters.

The use of this specific chart in the research should not be interpreted as validation of every HOTV product or every pediatric screening protocol. The findings relate to the study's testing procedures, population, and conditions, but they provide useful comparative evidence about how HOTV and tumbling E testing can perform differently in younger children.

The Study Also Had Important Limitations

The findings need to be considered alongside the study design. Although the order of HOTV and tumbling E testing was randomly assigned, both tests were completed on the same day. Children tended to perform worse on whichever visual acuity test they completed second, despite having a rest period between tests.

The researchers considered fatigue a likely explanation and therefore used the first visual acuity test for their primary comparison. Testing the two methods on separate days may have provided a stronger within-child comparison and reduced the potential influence of fatigue.

Neither approach identified every child with an ocular condition. False-negative results occurred with both tests, including among children with refractive errors, so the findings should not be interpreted to mean that HOTV eliminates missed referrals or replaces comprehensive eye examinations.

Matching the Vision Test to the Child

The practical message from this research is less about declaring one optotype universally superior and more about choosing a visual acuity task that fits the developmental abilities of the child being screened. In this study, HOTV produced better measured uncorrected visual acuity and fewer referrals among preschool children, while the difference between HOTV and tumbling E became much smaller as children grew older.

For professionals screening preschool and younger school-aged children, the findings provide another reason to consider both the optotype and the response method. The closer the testing task fits what a young child can reliably understand and perform, the better chance the result has of reflecting visual acuity rather than difficulty with the task itself.

Sources

Wu H, Wang Y, Ni Z, et al. HOTV Vision Test Compared With Tumbling E for Pediatric Vision Screening. JAMA Ophthalmology. Published online August 27, 2026. Read the original study.

Stroka M. HOTV Exam More Appropriate for Preschool Aged Children Than Tumbling E Test. Optometry Advisor. Published August 31, 2026.