Systematic review and meta-analysis on the agreement of non-cycloplegic and cycloplegic refraction in children

The effect of cycloplegia in the accuracy of autorefraction, keratometry and axial length using the Myopia Master

BACKGROUND

Assessing refractive errors under cycloplegia is recommended for paediatric patients; however, this may not always be feasible. In these situations, refraction has to rely on measurements made under active accommodation which may increase measurements variability and error. Therefore, evaluating the accuracy and precision of non-cycloplegic refraction and biometric measurements is clinically relevant. The Myopia Master, a novel instrument combining autorefraction and biometry, is designed for monitoring refractive error and ocular biometry in myopia management. This study assessed its repeatability and agreement for autorefraction and biometric measurements pre- and post-cycloplegia.

METHODS

A prospective cross-sectional study evaluated a cohort of 96 paediatric patients that underwent ophthalmologic examination. An optometrist performed two repeated measurements of autorefraction and biometry pre- and post-cycloplegia. Test-retest repeatability (TRT) was assessed as differences between consecutive measurements and agreement as differences between post- and pre-cycloplegia measurements, for spherical equivalent (SE), refractive and keratometric J0/J45 astigmatic components, mean keratometry (Km) and axial length (AL).

RESULTS

Cycloplegia significantly improved the SE repeatability (TRT, pre-cyclo: 0.65 D, post-cyclo: 0.31 D). SE measurements were more repeatable in myopes and emmetropes compared to hyperopes. Keratometry (Km) repeatability did not change with cycloplegia (TRT, pre-cyclo: 0.25 D, post-cyclo:0.27 D) and AL repeatability improved marginally (TRT, pre-cyclo: 0.14 mm, post-cyclo: 0.09 mm). Regarding pre- and post-cycloplegia agreement, SE became more positive by + 0.79 D, varying with refractive error. Myopic eyes showed a mean difference of + 0.31 D, while hyperopes differed by + 1.57 D. Mean keratometry, refractive and keratometric J0/J45 and AL showed no clinically significant differences.

CONCLUSIONS

Refractive error measurements, using the Myopia Master were 2.5x less precise pre-cycloplegia than post-cycloplegia. Accuracy of pre-cycloplegic refractive error measurements was often larger than the clinically significant threshold (0.25 D) and was refractive error dependent. The higher precision compared to autorefraction measurements, pre- and post-cycloplegia agreement and refractive error independence of AL measurements emphasize the superiority of AL in refractive error monitoring.

Myopia management algorithm. Annexe to the article titled Update and guidance on management of myopia. European Society of Ophthalmology in cooperation with International Myopia Institute

Myopia is becoming increasingly common in young generations all over the world, and it is predicted to become the most common cause of blindness and visual impairment in later life in the near future. Because myopia can cause serious complications and vision loss, it is critical to create and prescribe effective myopia treatment solutions that can help prevent or delay the onset and progression of myopia. The scientific understanding of myopia's causes, genetic background, environmental conditions, and various management techniques, including therapies to prevent or postpone its development and slow its progression, is rapidly expanding. However, some significant information gaps exist on this subject, making it difficult to develop an effective intervention plan. As with the creation of this present algorithm, a compromise is to work on best practices and reach consensus among a wide number of specialists. The quick rise in information regarding myopia management may be difficult for the busy eye care provider, but it necessitates a continuing need to evaluate new research and implement it into daily practice. To assist eye care providers in developing these strategies, an algorithm has been proposed that covers all aspects of myopia mitigation and management. The algorithm aims to provide practical assistance in choosing and developing an effective myopia management strategy tailored to the individual child. It incorporates the latest research findings and covers a wide range of modalities, from primary, secondary, and tertiary myopia prevention to interventions that reduce the progression of myopia.

Myopia management -A survey of optometrists and ophthalmologists in Israel

PURPOSE

Myopia management is practiced by ophthalmologists and optometrists. This study evaluated the approach and standard of myopia management among eye-care practitioners (ECPs) in Israel. The findings may ultimately affect the quality of care.

METHODS

A questionnaire was sent to 954 optometrists and 365 ophthalmologists, including demographic questions; whether they owned any devices to monitor myopia progression; the lowest progression they considered significant; various questions pertaining to myopia management and treatment methods.

RESULTS

Responses from 135 optometrists and 126 ophthalmologists were collected, the majority practicing more than five years; 94% of optometrists, and 64% of ophthalmologists. Around 53% of optometrists and 27% of the ophthalmologists proclaimed to practice myopia management. ECPs primary parameters influencing risk assessment for progression were age, genetic background and history of progression. Time outdoors, during daylight hours, is advised by ophthalmologists (97%) and optometrists (78%). Limiting screentime is encouraged by 87% of ophthalmologists and 69% of optometrists. Myopia progression of 0.50D-0.75D after six months is regarded to require intervention by 93% of ophthalmologists and 83% of optometrists. Optometrists selected multiple myopia management treatments, primarily optical (ophthalmic myopia management lenses 40%, multifocal ophthalmic lenses 24%, peripheral blur contact lenses 38%, orthokeratology 11%), while 95% of ophthalmologists chose atropine and only 3-11% selected any additional treatments to consider.

CONCLUSION

This study highlighted ECPs' agreement on the principles, importance of, and timeline of intervention with myopia management. The disconnect between the two professions lies in management methods. Genuine dialogue and co-management should be encouraged for maximum implementation, benefit and effectiveness of available patient treatments.

Comparison between cycloplegic and noncycloplegic refraction in young adult myopes

SIGNIFICANCE

This study explores the difference between cycloplegic and noncycloplegic refraction in young adult myopes.

PURPOSE

From the available literature, it is unclear whether cycloplegia is necessary when refracting young adults. This study investigates the agreement between noncycloplegic autorefraction and cycloplegic autorefraction and investigates factors affecting the agreement between the two methods.

METHODS

In total, 125 myopes with ages ranging between 18 and 26 years were included from Australia and Vietnam. Each participant underwent noncycloplegic autorefraction and cycloplegic autorefraction. Cycloplegia was induced with 1% ophthalmic tropicamide.

RESULTS

The mean spherical equivalent difference (95% confidence interval) between noncycloplegic autorefraction and cycloplegic autorefraction was -0.20 D (-0.25 to -0.14 D; t124 = -7.18, p<0.0001 ) . A mean difference of >0.25 D was seen in 46.8% of eyes. The lower and upper limits of agreement were -0.80 and 0.41 D, respectively. With univariate analysis, factors including age, degree of refractive error, accommodation amplitude, and distance phorias showed no impact on the average difference between cycloplegic autorefraction and noncycloplegic autorefraction. Yet, eyes with near exophoria ( F2,120 = 6.63, p=0.0019) and Caucasian eyes ( F3,121 = 2.85, p=0.040) exhibited the smallest paired differences. However, in the multivariate analysis, only near exophoria was associated with a lower mean difference. A significantly smaller proportion (34.9%) of eyes with near exophoria had a paired difference of -0.25 D or more compared with esophoria (50%) and orthophoria (65%; χ2 = 6.6, p=0.038).

CONCLUSIONS

Noncycloplegic autorefraction results in more myopic refractive error than cycloplegic autorefraction in young adults.

The CroMyop study: myopia progression in Croatian children and adolescents-a 15-year retrospective analysis

Purpose

Myopia is a major global health issue, especially among children and adolescents. Understanding its traits and progression is vital for proper management and prevention. This study aimed to fill a gap in research by analyzing demographic and refractive data concerning myopia among children and adolescents in Croatia, with the goal of providing insights into myopia prevalence, progression rates, and associated risk factors within the Croatian population.

Design

This retrospective study utilized a comprehensive dataset from pediatric ophthalmology clinics at the University Eye Department, University Hospital "Sveti Duh," Zagreb, Croatia. The dataset included electronic medical records spanning from January 2008 to July 2023, encompassing demographic and refractive data.

Methods

Data analysis focused on individuals aged 4 to 18 years who were diagnosed with primary myopia and/or compound myopic astigmatism. Ophthalmic examinations, including visual acuity tests, cycloplegic refraction, and assessments for eye comorbidities, were conducted by experienced pediatric ophthalmologists. Statistical analysis, including t-tests, survival analysis, and logistic regression, was performed to assess myopia prevalence, progression rates, and associated factors. These analyses were adjusted for covariates such as age, parental myopia, and gender.

Results

The study included 895 individuals, 51 premyopes, 813 low myopes, and 31 high myopes. The average age of diagnosis was 11.37 ± 3.59 years for premyopes, 11.18 ± 3.53 years for low myopes, and 11.44 ± 4.35 years for high myopes. The fastest progression occurred in 2021 and 2022, -0.5 ± 0.12 D/y for premyopes and - 0.45 ± 0.1 D/y for low myopes. Premyopic progression to low myopia was associated with age 7-9 years (HR 2.42, 1.53 to 3.21) and both parents being myopic (HR 920.27. 850.16 to 950.53). Low myopic individuals with both myopic parents displayed the fastest 11-24 months after first visit progression rates, -0.69 (-0.52 to -0.87) D/y, while the 7-9 age group demonstrated -0.36 (-0.24 to -0.45) D/y. Low myopes aged 7-9 years with baseline SE between -6 D and -4 D were more strongly associated with ≤ - 0.5 D progression (OR = 2.0, 95% CI -1.00 to 2.39).

Conclusion

This study highlights the importance of environmental factors, genetics, and age in addressing myopia progression among Croatian youth, urging further research for effective local intervention strategies.

Myopia prevalence and ocular biometry in children and adolescents at different altitudes: a cross-sectional study in Chongqing and Tibet, China

OBJECTIVE

To investigate the differences in myopia prevalence and ocular biometry in children and adolescents in Chongqing and Tibet, China.

DESIGN

Cross-sectional study.

SETTING

The study included children and adolescents aged 6-18 years in Chongqing, a low-altitude region, and in Qamdo, a high-altitude region of Tibet.

PARTICIPANTS

A total of 448 participants in Qamdo, Tibet, and 748 participants in Chongqing were enrolled in this study.

METHODS

All participants underwent uncorrected visual acuity assessment, non-cycloplegic refraction, axial length (AL) measurement, intraocular pressure (IOP) measurement and corneal tomography. And the participants were grouped according to age (6-8, 9-11, 12-14 and 15-18 years group), and altitude of location (primary school students: group A (average altitude: 325 m), group B (average altitude: 2300 m), group C (average altitude: 3250 and 3170 m) and group D (average altitude: 3870 m)).

RESULTS

There was no statistical difference in mean age (12.09±3.15 vs 12.2±3.10, p=0.549) and sex distribution (males, 50.4% vs 47.6%, p=0.339) between the two groups. The Tibet group presented greater spherical equivalent (SE, -0.63 (-2.00, 0.13) vs -0.88 (-2.88, -0.13), p<0.001), shorter AL (23.45±1.02 vs 23.92±1.19, p<0.001), lower prevalence of myopia (39.7% vs 47.6%, p=0.008) and flatter mean curvature power of the cornea (Km, 43.06±1.4 vs 43.26±1.36, p=0.014) than the Chongqing group. Further analysis based on age subgroups revealed that the Tibet group had a lower prevalence of myopia and higher SE in the 12-14, and 15-18 years old groups, shorter AL in the 9-11, 12-14 and 15-18 years old groups, and lower AL to corneal radius of curvature ratio (AL/CR) in all age subgroups compared with the Chongqing group, while Km was similar between the two groups in each age subgroup. Simple linear regression analysis showed that SE decreased with age in both the Tibet and Chongqing groups, with the Tibet group exhibiting a slower rate of decrease (p<0.001). AL and AL/CR increased with age in both the Tibet and Chongqing groups, but the rate of increase was slower in the Tibet group (p<0.001 of both). Multiple linear regression analysis revealed that AL had the greatest effect on SE in both groups, followed by Km. In addition, the children and adolescents in Tibet presented thinner corneal thickness (CCT, p<0.001), smaller white to white distance (WTW, p<0.001), lower IOP (p<0.001) and deeper anterior chamber depth (ACD, p=0.015) than in Chongqing. Comparison of altitude subgroups showed that the prevalence of myopia (p=0.002), SE (p=0.031), AL (p=0.001) and AL/CR (p<0.001) of children at different altitudes was statistically different but the Km (p=0.189) were similar. The highest altitude, Tengchen County, exhibited the lowest prevalence of myopia and greatest SE among children, and the mean AL also decreased with increasing altitude.

CONCLUSIONS

Myopia prevalence in Tibet was comparable with that in Chongqing for students aged 6-8 and 9-11 years but was lower and myopia progressed more slowly for students aged 12-14 and 15-18 years than in Chongqing, and AL was the main contributor for this difference, which may be related to higher ultraviolet radiation exposure and lower IOP in children and adolescents at high altitude in Tibet. Differences in AL and AL/CR between Tibet and Chongqing children and adolescents manifested earlier than in SE, underscoring the importance of AL measurement in myopia screening.

Distribution and correlation of refractive parameters in children with different corneal curvatures in southeast China

AIM

To analyze the distribution of refractive status in school-age children with different corneal curvatures (CC) and the correlation between CC and refractive status.

METHODS

A total of 2214 school-aged children of grade 4 in Hangzhou who were screened for school myopia were included. Uncorrected distance visual acuity (UCDVA), non-cycloplegic refraction, axial length (AL), horizontal and vertical corneal curvature (K1, K2) were measured and spherical equivalent (SE), corneal curvature radius (CCR) and axial length/corneal radius of curvature ratio (AL/CR) were calculated. UCDVA<5.0 and SE≤-0.50 D were classified as school-screening myopia. According to the different CCRs, the patients were divided into the lower corneal curvature (LCC) group (CCR≥7.92) and the higher corneal curvature (HCC) group (CCR<7.92). Each group was further divided into the normal AL subgroup and the long AL subgroup. The refractive parameters were compared to identify any differences between the two groups.

RESULTS

Both SE and AL were greater in the LCC group (P=0.013, P<0.001). The prevalence of myopia was 38% in the LCC group and 44% in the HCC group (P<0.001). The proportion of children without screening myopia was higher in the LCC group (62%) than in the HCC group (56%). Among these children without screening myopia, the proportion of long AL in the LCC group (24%) was significantly higher than that in the HCC group (0.012%; P<0.001). The change of SE in the LCC group was less affected by the increase of AL than that in the HCC group.

CONCLUSION

School-aged children in the LCC group have a lower incidence of screening myopia and longer AL. Low CC can mask SE reduction and AL growth to some extent, and the change of AL growth change more in children with low CC than high CC. Before the onset of myopia, its growth rate is even faster than that after the onset of myopia.

Method comparison and overview of refractive measurements in children: implications for myopia management

OBJECTIVE

This study investigated the agreement between objective wavefront-based refraction and subjective refraction in myopic children. It also assessed the impact of cyclopentolate and refraction levels on the agreement.

METHODS

A total of 84 eyes of myopic children aged 6-13 years were included in the analysis. Non-cycloplegic and cycloplegic objective wavefront-based refraction were determined and cycloplegic subjective refraction was performed for each participant. The data were converted into spherical equivalent, J0 and J45, and Bland-Altman plots were used to analyse the agreement between methods.

RESULTS

Linear functions were used to determine the dependency between the central myopic refractive error and the difference between the method of refraction (=bias). The influence of central myopia was not clinically relevant when analysing the agreement between wavefront results with and without cyclopentolate (comparison 1). The bias for wavefront-based minus subjective spherical equivalent refraction (comparison 2) was ≤-0.50 D (95% limits of agreement -0.010 D to -1.00 D) for myopia of -4.55 D and higher when cycloplegia was used (p<0.05). When no cyclopentolate was used for the wavefront-based refraction (comparison 3), the bias of -0.50 D (95% limits of agreement -0.020 D to -0.97 D) was already reached at a myopic error of -2.97 D. Both astigmatic components showed no clinically relevant bias.

CONCLUSION

The spherical equivalent, measured without cycloplegic agents, led to more myopic measurements when wavefront-based refraction was used. The observed bias increased with the amount of myopic refractive error for comparisons 2 and 3, which needs to be considered when interpreting wavefront-refraction data.

TRIAL REGISTRATION NUMBER

NCT05288335.

Two different autorefractors for vision screening in children and adolescents

AIM

To compare the consistency of two autorefractors (Tianle RM-9000 and Topcon KR-800) for school-age myopia children, and to provide a basis for largescale data analysis and comparison.

METHODS

The refractive error in 909 subjects (age 4-18y) were measured using both autorefractors without cycloplegia. The data were analyzed using Fourier decomposition and the correlation coefficients, intraclass correlation coefficients (ICC), and Bland-Altman limits of agreement (LoA) for each parameter were calculated.

RESULTS

There was a strong correlation between the spherical equivalent (SE), sphere diopter (DS), and cylinder diopter (DC) readings of the Tianle RM-9000 and those of the Topcon KR-800, with correlation coefficient values of 0.98, 0.98 and 0.83 and ICC values of 0.99, 0.99 and 0.93, respectively. However, the correlation coefficients and ICC values of J0 and J45 were unreliable (R=-0.004, -0.034; both ICC<0.10). Bland-Altman analysis revealed that SE, DS, and DC measured by the Tianle RM-9000 were significantly biased toward myopia compared with the Topcon KR-800, and the mean differences were -0.072, -0.026, -0.091 D, respectively (all P<0.01). The minimum absolute value of the difference within the 95% LoA for SE, DS, and DC was 0.63 D, 0.50 D, 0.62 D, respectively; all these values were in the clinically acceptable range. For J0 and J45, the mean differences were close to zero (P=0.43, 0.84); however, the 95% LoA were relatively wide (J0 SD: 0.53; 95%CI: -1.00, 1.10; J45 SD: 0.52; 95%CI: -1.00, 1.00).

CONCLUSION

The two autorefractors are consistent with each other, as the differences in SE, DS, and DC were within the clinically acceptable range. Readers can compare the data measured by either device in different studies and use the two devices in the same study to generate a dataset that can be analyzed together. However, the J0 and J45 vectors are unreliable and should not be used to assess astigmatism.

Accuracy and precision of automated subjective refraction in young hyperopes under cycloplegia

PURPOSE

To assess the agreement between the Eye Refract, an instrument to perform subjective automated refraction, and the traditional subjective refraction, as the gold standard, in young hyperopes under noncycloplegic and cycloplegic conditions.

METHODS

A cross-section and randomized study was carried out, involving 42 participants (18.2 ± 7.7 years, range 6 to 31 years). Only one eye was chosen for the analysis, randomly. An optometrist conducted the refraction with the Eye Refract, while another different optometrist conducted the traditional subjective refraction. Spherical equivalent (M), cylindrical components (J0 and J45), and corrected distance visual acuity (CDVA) were compared between both refraction methods under noncycloplegic and cycloplegic conditions. A Bland-Altman analysis was performed to assess the agreement (accuracy and precision) between both refraction methods.

RESULTS

Without cycloplegia, the Eye Refract showed significantly lower values of hyperopia than the traditional subjective refraction (p < 0.009), the mean difference (accuracy) and its 95% limits of agreement (precision) being -0.31 (+0.85, -1.47) D. Conversely, there were no statistical differences between both refraction methods under cycloplegic conditions (p ≥ 0.05). Regarding J0 and J45, both refraction methods manifested no significant differences between them under noncycloplegic and cycloplegic conditions (p ≥ 0.05). Finally, the Eye Refract significantly improved CDVA (0.04 ± 0.01 logMAR) compared with the traditional subjective refraction without cycloplegia (p = 0.01).

CONCLUSIONS

The Eye Refract is presented as a useful instrument to determine the refractive error in young hyperopes, the use of cycloplegia being necessary to obtain accurate and precise spherical refraction.

The rate of orthokeratology lens use and associated factors in 33,280 children and adolescents with myopia: a cross-sectional study from Shanghai

OBJECTIVES

To investigate the rate of orthokeratology lens (ortho-k lens) use and its associated factors in children and adolescents with myopia.

METHODS

Cross-sectional study. Children from 104 primary and middle schools in Shanghai were enrolled by cluster sampling. Ophthalmic examinations were conducted and information was obtained using questionnaires for associated factors analysis.

RESULTS

A total of 72,920 children and adolescents were included, among which 32,259 were the potential population for ortho-k lens use. A total of 1021 participants used ortho-k lenses, equating to a use rate of 1.4% in the total population and 3.1% in the potential population. Age (OR 0.91, 95% CI: 0.88-0.95, p < 0.001), BMI (≥95th percentile: OR 0.48, 95% CI: 0.35-0.66, p < 0.001), age at initiation of refractive correction (≤12 years: OR 1.75, 95% CI: 1.31-2.33, p < 0.001), and parental myopia (either: OR 2.09, 95% CI: 1.58-2.75, p < 0.001; both: OR 3.94, 95% CI: 3.04-5.11, p < 0.001) were independently associated with ortho-k lens use. Of the ortho-k lenses users, 12.4% had a logMAR CVA of ≥0.3. A correction target (SE) of ≤-3.0 D (OR 2.05, 95% CI: 1.38-3.05, p < 0.001) and a sleeping duration of ≤6 h (OR 4.19, 95% CI: 2.03-8.64, p < 0.001) were factors independently associated with CVA ≥ 0.3.

CONCLUSIONS

A certain proportion of children and adolescents in Shanghai chose to wear ortho-k lenses, related to the situation of parents and children themselves. Health education and follow-ups should be strengthened to ensure orthokeratology application quality.

Comparability of the Retinomax K-plus 3 handheld autorefractometer in quick mode versus on-table autorefractometer in standard mode

INTRODUCTION

This study analyzes the comparability of measurements taken by a Retinomax K-plus 3 handheld autorefractometer in Quick mode and a Topcon KR-800 on-table autorefractometer in standard mode on the pediatric population, and establishes their correlation.

METHODS

It is a retrospective comparative study. Spherical diopter power (SPH), cylindrical diopter power (CYL), angle of cylindrical axis (AX), and spherical equivalent (SE) were measured with the Retinomax in Quick mode and with the Topcon in standard mode. Each patient was evaluated in cycloplegic and non-cycloplegic conditions by both autorefractometers. Student's t-test was performed between the two instruments for SPH, CYL, and SE. The Pearson correlation coefficient was calculated and the dispersion was represented using Bland-Altman graphs, also evaluating the subgroup of patients under 4 years of age. A descriptive analysis of the percentages of measures that differed was performed.

RESULTS

It included 98 eyes of 49 subjects (age range: 3-16 years). The data for HPS without cycloplegia are virtually identical, whereas with cycloplegia there is a hyperopic bias of +0.5 diopters measured with Retinomax. CYL results are very similar with and without cycloplegia. There is a high Pearson correlation for both instruments (>0.91) and a low degree of dispersion in the Bland-Altman plots under cycloplegia.

CONCLUSION

The Retinomax data were consistent with those obtained by Topcon. The Retinomax is a useful instrument for detecting refractive errors in children between 3 and 16 years of age.