Cycloplegic Refraction in Hyperopic Children: Effectiveness of a 0.5% Tropicamide and 0.5% Phenylephrine Addition to 1% Cyclopentolate Regimen

Retinoscopes: Past and present

BACKGROUND

Retinoscopy is arguably the most important method in the eye clinic for diagnosing and managing refractive errors. Advantages of retinoscopy include its non-invasive nature, ability to assess patients of all ages, and usefulness in patients with limited cooperation or communication skills.

AIM

To discuss the history of retinoscopes and examine current literature on the subject.

METHODS

A search was conducted on the PubMed and with the reference citation analysis (https://www.referencecitationanalysis.com) database using the term “Retinoscopy,” with a range restricted to the last 10 years (2013-2023). The search string algorithm was: "Retinoscopy" (MeSH Terms) OR "Retinoscopy" (All Fields) OR "Retinoscopes" (All Fields) AND [(All Fields) AND 2013: 2023 (pdat)].

RESULTS

This systematic review included a total of 286 records. Publications reviewed iterations of the retinoscope into autorefractors, infrared photo retinoscope, television retinoscopy, and the Wifi enabled digital retinoscope.

CONCLUSION

The retinoscope has evolved significantly since its discovery, with a significant improvement in its diagnostic capabilities. While it has advantages such as non-invasiveness and broad applicability, limitations exist, and the need for skilled interpretation remains. With ongoing research, including the integration of artificial intelligence, retinoscopy is expected to continue advancing and playing a vital role in eye care.

Ultrasound biomicroscopy analysis of ciliary muscle dynamics and its relation to intra-ocular pressure after phacoemulsification in dogs

Introduction

This study investigates the relationship between ciliary muscle dynamics, thickness, and the regulation of intraocular pressure (IOP), focusing on the progression of cataracts and changes post-phacoemulsification. It explores how these factors impact canine ocular health, particularly in the context of cataract development and subsequent surgical intervention.

Materials and methods

Data was collected using Ultrasound Biomicroscopy (UBM) from dogs at the Veterinary Medical Teaching Hospital of Chungbuk National University, Korea. The study involved 57 eyes from 35 dogs, categorized into five groups: 13 normal eyes, 14 with incipient cataracts, 12 with immature cataracts, 6 with mature cataracts, and 12 post-phacoemulsification. UBM measurements assessed various ciliary muscle parameters including ciliary body axial length (CBAXL), ciliary process-sclera angle (CPSA), longitudinal fibers of ciliary muscle thickness (Lf-CMT), and longitudinal and radial fibers of ciliary muscle thickness (LRf-CMT).

Results

Findings indicated a decrease in CBAXL and an increase in Lf-CMT as cataracts progressed in severity. Post-phacoemulsification, there was a notable increase in CBAXL and a decrease in CPSA, Lf-CMT, and LRf-CMT, compared to both cataractous and normal eyes. Regression analysis revealed a significant positive association between CBAXL and IOP, alongside a negative association between Lf-CMT and IOP. These findings suggest that variations in ciliary muscle dynamics and thickness, as influenced by cataract progression and phacoemulsification, have distinct impacts on intraocular pressure.

Discussion

The study proposes that phacoemulsification leads to ciliary muscle contraction, causing an inward and anterior movement of the ciliary muscle. This movement results in the narrowing of the ciliary cleft and constriction of the unconventional outflow pathway, potentially causing an increased risk of glaucoma post-surgery. Our research contributes to understanding the anatomical and physiological changes in the canine eye following cataract surgery and underscores the importance of monitoring IOP and ciliary muscle dynamics in these patients.

Understanding accommodative control in the clinic: Modeling latency and amplitude for uncorrected refractive error, presbyopia and cycloplegia

Accommodation is the process of adjusting the eye's optical power so as to focus at different distances. Uncorrected refractive error and/or functional presbyopia mean that sharp focus may not be achievable for some distances, so observers experience sustained defocus. Here, we identify a problem with current models of accommodative control: They predict excessive internal responses to stimuli outside accommodative range, leading to unrealistic adaptation effects. Specifically, after prolonged exposure to stimuli outside range, current models predict long latencies in the accommodative response to stimuli within range, as well as unrealistic dynamics and amplitudes of accommodative vergence innervation driven by the accommodative neural controller. These behaviors are not observed empirically. To solve this issue, we propose that the input to blur-driven accommodation is not retinal defocus, but correctable defocus. Predictive models of accommodative control already estimate demand from sensed defocus, using a realistic "virtual plant" to estimate accommodation. Correctable defocus can be obtained by restricting this demand to values physically attainable by the eye. If we further postulate that correctable defocus is computed using an idealized virtual plant that retains a young accommodative range, we can explain why accommodative-convergence responses are observed for stimuli that are too near-but not too far-to focus on. We model cycloplegia as a change in gain, and postulate a form of neural myopia to explain the additional relaxation of accommodation often seen with cycloplegia. This model produces plausible predictions for the accommodative response and accommodative convergence signal in a wide range of clinically relevant situations.

Efficacy of 3D-printed eye model to enhance retinoscopy skills

We conducted a prospective study to evaluate the efficacy of simulation-based education using a three-dimensional (3D)-printed schematic eye model in improving the retinoscopy refraction skills of medical students. A schematic eye model was printed using a fused deposition modeling-based 3D printer. Twenty medical students randomized into 3D (n = 10) and control (n = 10) groups received a 1-h lecture on the principles and methods of manifest refraction and were shown how to use the retinoscope and sciascope bars. The 3D group additionally attended a tutorial on the schematic eye. Both groups performed refractive examinations on four eyes of volunteer patients, and the results were recorded as a baseline. Instructor feedback and refraction practice was provided with the 3D group or with control group. To account for subject fatigue, patients spent no more than 8 min on the examination. After a 1-h break to allow for fatigue and familiarity, refraction tests were repeated on four randomly selected eyes of patients. Students' refraction readings were compared with the autorefractor values using a spherical equivalent value and blur strength. All participants measured the time required to complete the refraction test and reported their subjective confidence in the results of each refraction test. Refractive errors before and after training did not differ between the control and 3D groups, with a significant improvement in errors observed in both groups (p = 0.005 and 0.008, respectively). The time to complete refraction before and after training did not differ between the two groups, both of which showed a significant reduction in time (p = 0.005 and 0.028, respectively). Pre- and post-training confidence scores for the accuracy of each refraction on a 10-point Likert scale were not significantly different. However, when comparing score changes between pre- and post-training, only the control group showed a significant increase in confidence (p = 0.005). Tests for the non-inferiority of refractive errors after training indicated that the 3D group was non-inferior to the control group. In conclusion, training in retinoscopy refraction skills using a 3D-printed eye model resulted in significant improvement in accuracy and speed compared to practice with real patients. Except for better confidence in the control group, schematic eye model training was not inferior to practice with real patients.

Comparison of the new self-contained darkroom refractive screener versus table-top autorefractor and cycloplegia retinoscopy in detecting refractive error

PURPOSE

By comparing the results of the new self-contained darkroom refractive screener (YD-SX-A) versus table-top autorefractor and cycloplegic retinoscopy, to evaluate the performance of the YD-SX-A in detecting refractive error in children and adolescents and then judge whether it can be used in refractive screening.

METHODS

Cross-sectional study. 1000 participants between the ages of 6 and 18 who visited the Optometry Center of the People's Hospital of Guangxi Zhuang Autonomous Region from June to December 2022 were selected. First, participants were instructed to measure their diopter with a table-top autorefractor (Topcon KR8800) and YD-SX-A in a noncycloplegic setting. After cycloplegia, they were retinoscopy by a professional optometrist. The results measured by three methods were collected respectively. To avoid deviation, only the right eye (1000 eyes) data were used in the statistical analysis. The Bland-Altman plots were used to evaluate the agreement of diopters measured by the three methods. The receiver operating characteristic (ROC) curves was used to analysis effectiveness of detecting refractive error of YD-SX-A.

RESULTS

The average age of participants was 10.77 ± 3.00 years, including 504 boys (50.4%) and 496 girls (49.6%). When YD-SX-A and cycloplegia retinoscopy (CR) were compared in the myopia group, there was no statistical difference in spherical equivalent (SE) (P > 0.05), but there was a statistical difference in diopter spherical (DS) and diopter cylinder (DC) (P < 0.05). Comparing the diopter results of Topcon KR8800 and CR, the difference between each test value in the myopia group was statistically significant (P < 0.05). In the hyperopia group, the comparison between YD-SX-A and CR showed no statistically significant differences in the DC (P > 0.05), but there were significant differences in the SE and DS (P < 0.05). In the astigmatism group, the SE, DS, and DC were statistically different, and the DC of YD-SX-A was lower than that of CR and Topcon KR8800. Bland-Altman plots indicated that YD-SX-A has a moderate agreement with CR and Topcon KR8800. The sensitivity and specificity of YD-SX-A for detecting myopia, hyperopia and astigmatism were 90.17% and 90.32%, 97.78% and 87.88%, 84.08% and 74.26%, respectively.

CONCLUSION

This study has identified that YD-SX-A has shown good performance in both agreement and effectiveness in detecting refractive error when compared with Topcon KR8800 and CR. YD-SX-A could be a useful tool for large-scale population refractive screening.

Comparison of Self Refraction accuracy with Cycloplegic Subjective Refraction in Young Adults

Background

Uncorrected refractive error is one of the major causes of blindness. Self-refraction methods are currently practiced to correct refractive error. Self-adjustable eyeglasses are available easily in the present online buying era. Hence this study aimed to compare the visual and refractive outcomes between Self-refraction (SR) eyeglasses and Cycloplegic subjective Refraction (CSR).

Methodology

This observational cross-sectional study included 59 participants (21 males and 38 females) within the age of 18 to 30yearsand refractive error between +3.00D to -6.00D took part in this study. Subjects with a previous history of non-strabismic binocular vision anomaly, astigmatic error, pathological eye problems, ocular surgery or trauma were excluded from the study. The subjects were allowed to estimate their refractive error with DialVision eyeglasses followed by CSR, which was performed by a single examiner. The visual and refractive outcomes of SR and CSR were collected and analyzed.

Result

The study participants mean age was 22(2) years.The comparison of visual acuity and duochrome between SR and CSR using Paired T test showed a statistically significant difference (P<0.01). Visual acuity attained from SR resulted in a mean acuity of 0.14(0.05) logMAR compared to CSR 0.002(0.007) logMAR. Duochrome test identified 92% of participants being under corrected with SR. No statistically significant difference was observed in contrast sensitivity and cover test (P>0.01).

Conclusion

Visual acuity with SR was acceptable but wasn't better than CSR. Appreciable under correction of refractive error with SR raises concern. Encouraging a patient to correct their own refractive error without a comprehensive eye examination can lead to various adverse effects. Even though SR might bring a brief relief towards the burden of uncorrected refractive error, dispensing spectacle based on standard refraction procedure is imperative for good visual performance.

Ocular Cyclopentolate: A Mini Review Concerning Its Benefits and Risks

Cycloplegic and mydriatic agents are essential in ophthalmological clinical practice since they provide the means for diagnosing and treating certain eye conditions. In addition, cyclopentolate has proven to possess certain benefits compared to other available cycloplegics and mydriatics. Still, the incidence of some adverse drug reactions related to this drug, especially in susceptible patients, has created interest in reviewing the literature about the benefits and risks of using cyclopentolate. A literature search was conducted in Medline/PubMed and Google Scholar, focusing on identifying cyclopentolate's benefits and risks; the most important benefit was its usefulness for evaluating refractive errors, especially for hyperopic children, pseudomyopia, anterior uveitis, treatment of childhood myopia, idiopathic vision loss, and during examinations before refractive surgery, with particular advantages compared to other cycloplegics. While the risks were divided into local adverse drug reactions such as burning sensation, photophobia, hyperemia, punctate keratitis, synechiae, and blurred vision, which are relatively frequent but mild and temporary; and systemic adverse drug reactions such as language problems, visual or tactile hallucinations and ataxia, but unlike ocular, systemic adverse drug reactions are rare and occur mainly in patients with risk factors. In addition, six cases of abuse were found. The treatment with cyclopentolate is effective and safe in most cases; nevertheless, special care must be taken due to the potential severe ADRs that may occur, especially in susceptible patients like children, geriatrics, patients with neurological disorders or Down's syndrome, patients with a low blood level of pseudocholinesterase, users of substances with CNS effects, and patients with a history of drug addiction. The recommendations are avoiding the use of 2% cyclopentolate and instead employing solutions with lower concentrations, preferably with another mydriatic such as phenylephrine. Likewise, the occlusion of the nasolacrimal duct after instillation limits the drug's absorption, reducing the risk of systemic adverse events.

Lag of accommodation predicts clinically significant change of spherical equivalents after cycloplegia

AIM

To evaluate related factors with the change of spherical equivalents (ΔSE) and determine the suitable predictor of clinically significant ΔSE (≥0.50 D) with cyclopentolate hydrochloride on Chinese children.

METHODS

A total of 145 right eyes of 145 children aged 4 to 15y were enrolled. Intraocular pressure, axial length and lag of accommodation (LOA) were assessed before cycloplegia induced by 3 drops of 1% cyclopentolate at 5-minute intervals. SE was measured before and 1h after the first drop of cyclopentolate. ΔSE was compared between different gender groups and among refractive groups. Multivariate linear regression analysis was performed to find related factors with ΔSE. ROC analysis was used to figure out the suitable predictor of clinically significant ΔSE.

RESULTS

For the total 145 eyes, the mean SE reached up to -0.70±1.86 D from -1.30±1.62 D, with the mean ΔSE of 0.60±0.55 D. The mean ΔSE were 0.63±0.55 D and 0.57±0.56 D respectively in the male and female group (P=0.40). The mean ΔSE was significantly different among different refractive groups (P<0.0001), with the ΔSE of hyperopia group (1.12±0.64 D) larger than that of the emmetropia (0.56±0.43 D, P=0.001) and myopia group (0.32±0.28 D, P<0.0001). The ΔSE was correlated with LOA (B=-0.54, P<0.0001), cycloplegic SE (B=0.10, P<0.0001) and age (B=-0.04, P=0.015). ROC curve indicated that LOA predicted clinically significant ΔSE by 82% [area under the curve (AUC)=0.82] alone, while the value was slightly improved to 85% (AUC=0.85) in combination with axial length and 86% (AUC=0.86) in association with axial length as well as age.

CONCLUSION

After cycloplegia with cyclopentolate, the ΔSE decreases with larger LOA, longer axial length and older age. Specifically, LOA plays a more vital role in predicting clinically significant ΔSE.

Agreement Between Retinoscopy, Autorefractometry and Subjective Refraction for Determining Refractive Errors in Congolese Children

OBJECTIVE

To assess the agreement between retinoscopy and autorefractometry and between subjective refraction and both retinoscopy and autorefractometry in Congolese children.

PATIENTS AND METHODS

Fifty-four children (6-17 years old) were enrolled consecutively in this cross-sectional study. Refraction was evaluated before and after cycloplegia (1% cyclopentolate) with retinoscopy and autorefractometry. Readings were compared (paired t-test) and agreement assessed with Bland-Altman plots. Subjective refraction was compared with the two methods to determine which one provides better reference estimates for subjective refraction.

RESULTS

Under cycloplegia, the spherical power was comparable between retinoscopy and autorefractometry (1.12 ± 1.37 D vs 1.22 ± 1.06D, P = 0.70), cylinder power was significantly more myopic on retinoscopy than autorefractometry (0.80 ± 1.10D vs -0.62 ± 0.66, P = 0.019), and SE was greater on autorefractometry than retinoscopy (0.91 ± 1.10D vs 0.72 ± 1.00D, P = 0.014). Retinoscopy and autorefractometry overestimated the power of spherical (P = 0.022 and 0.002, respectively) and cylindrical components (all P < 0.001). There was an agreement between retinoscopy and autorefractometry in measuring spherical (bias: 0.09 ± 0.16D; limit of agreement, LoA: -0.40 to 0.22D) and cylindrical power (bias: -0.18 ± 0.20D; LoA: -0.57 to 0.21D). Subjective refraction agreed with cycloplegic retinoscopy for determining SE power (bias: 0.11D; LoA: -0.51 to 0.73D).

CONCLUSION

Retinoscopy and autorefractometry can be used interchangeably in children for determining the power of spherical and cylindrical components. Cycloplegic retinoscopy is better than autorefractometry to obtain SE reference values for subjective refraction in children.

Analysis of the potential impact of strabismus with and without amblyopia on visual-perceptual and visual-motor skills evaluated using TVPS-3 and VMI-6 tests

PURPOSE

To investigate the potential impact of strabismus and amblyopia on visual-perceptual skills (VPS) and visual-motor skills (VMS) of patients according to the type of strabismus, visual acuity (VA), state of binocularity, and sex.

METHODS

This observational, transverse, prospective study analyzed a sample of 146 children with strabismus (88 male and 58 female) aged 5-15 years from Querétaro, México. To determine the strabismus type, we considered the deviation direction, frequency, binocularity state, and associated and dissociated elements. VPS and VMS were evaluated using the Test of Visual-Perceptual Skills 3rd ed. (TVPS-3) and Visual-Motor Integration Test of Beery 6th ed. (VMI-6).

RESULTS

Sex was the main variable associated with the performance of the analyzed patients on TVPS-3 and VMI-6 (p<0.05); boys obtained better scores than girls in all evaluated aspects. Stereopsis was not a determinant of the patients' performance level but was associated with the far and near angles of deviation in both types of strabismus, esotropia and exotropia. Amblyopia was associated with the spatial relationship (p=0.001) and visual closure abilities (p=0.044). Form constancy skill scores diminished in both types of strabismus (esotropia: p=0.011; exotropia: p=0.004), and VMS were the most affected in patients with strabismus.

CONCLUSIONS

The performance of patients with strabismus with and without amblyopia on TVPS-3 and VMI-6 suggests that they adopt a mechanism to compensate for the impact of strabismus on their VPS and VMS.

Efficacy in myopia control

There is rapidly expanding interest in interventions to slow myopia progression in children and teenagers, with the intent of reducing risk of myopia-associated complications later in life. Despite many publications dedicated to the topic, little attention has been devoted to understanding 'efficacy' in myopia control and its application. Treatment effect has been expressed in multiple ways, making comparison between therapies and prognosis for an individual patient difficult. Available efficacy data are generally limited to two to three years making long-term treatment effect uncertain. From an evidence-based perspective, efficacy projection should be conservative and not extend beyond that which has been empirically established. Using this principle, review of the literature, data from our own clinical studies, assessment of demonstrated myopia control treatments and allowance for the limitations and context of available data, we arrive at the following important interpretations: (i) axial elongation is the preferred endpoint for assessing myopic progression; (ii) there is insufficient evidence to suggest that faster progressors, or younger myopes, derive greater benefit from treatment; (iii) the initial rate of reduction of axial elongation by myopia control treatments is not sustained; (iv) consequently, using percentage reduction in progression as an index to describe treatment effect can be very misleading and (v) cumulative absolute reduction in axial elongation (CARE) emerges as a preferred efficacy metric; (vi) maximum CARE that has been measured for existing myopia control treatments is 0.44 mm (which equates to about 1 D); (vii) there is no apparent superior method of treatment, although commonly prescribed therapies such as 0.01% atropine and progressive addition spectacles lenses have not consistently provided clinically important effects; (viii) while different treatments have shown divergent efficacy in the first year, they have shown only small differences after this; (ix) rebound should be assumed until proven otherwise; (x) an illusion of inflated efficacy is created by measurement error in refraction, sample bias in only treating 'measured' fast progressors and regression to the mean; (xi) decision to treat should be based on age of onset (or refraction at a given age), not past progression; (xii) the decreased risk of complications later in life provided by even modest reductions in progression suggest treatment is advised for all young myopes and, because of limitations of available interventions, should be aggressive.

Cycloplegia in Children: An Optometrist's Perspective

PURPOSE

To determine the current scope of practice with regards to cycloplegic examinations, specifically in the pediatric population.

METHODS

A comprehensive literature review was conducted using PubMed, ScienceDirect, Elsevier, and Google Scholar databases using keywords such as "cyclopentolate"; "tropicamide"; "pediatric"; "cycloplegia"; "atropine"; and "cycloplegic" from inception to October 2019.

RESULTS

Atropine has the strongest cycloplegic effect and is recommended for cases of large accommodative esotropia. Because of the undesired side effects and risks from atropine, cyclopentolate has been found to offer a very effective cycloplegia even for moderate to high hyperopia and has become the standard of care for traditional pediatric cycloplegic exams. Tropicamide has also been shown to offer adequate cycloplegia with less toxicity and side effects. Of all agents, tropicamide presents the least side effects and toxicity, whereas atropine presents the greatest. Cyclopentolate is a very safe cycloplegic agent that has risk of toxicity which increases with higher doses and concentrations.

CONCLUSION

The American Optometric Association's current pediatric cycloplegic guidelines have proven both safe and effective, as they recommend a conservative approach of using cyclopentolate 0.5% in infants and cyclopentolate 1% in those older than one-year old to avoid undesired side effects. Topical ophthalmic drops and spray instillation have both proved equally efficacious and therefore each have their place within a clinical setting. Using Cycolmydril under six months old and cyclopentolate 1% over 6 months old as recommended by the AAO, also provides a safe and effective guideline for cycloplegic examinations within the pediatric population.

Anterior Segment Biometry During Accommodation and Effects of Cycloplegics by Swept-Source Optical Coherence Tomography

Purpose

We analyzed changes in the crystalline lens during accommodation and the effects of cycloplegics by swept-source anterior-segment optical coherence tomography (AS-OCT).

Materials and Methods

Twenty healthy volunteers (7 males and 13 females, aged 22–34 years), with no history of eye disease except for refractive errors, were recruited. Biometric parameters, including anterior chamber depth (ACD), lens thickness (LT), and anterior and posterior curvature of the lens (ACL and PCL), were measured using AS-OCT (CASIA2). The measurements were performed with or without an accommodative demand of 5.0 diopters (D). The same tests were repeated following the topical administration of 1% cyclopentolate or a compounding agent comprising 0.5% tropicamide and 0.5% phenylephrine.

Results

The AS-OCT system was capable of simultaneous visualization of all optical components of the anterior segment in a single frame. ACD, LAC, and LPC decreased and LT increased significantly during 5.0 D accommodative stimulation in both eyes. Both cyclopentolate and tropicamide/phenylephrine eyedrops led to deeper ACD, thinner LT, and flatter LAC. There were no significant differences in all lens parameters despite having 5.0 D accommodative stimulation in both eyes with cycloplegia.

Conclusion

Our results suggest that both tropicamide/phenylephrine and cyclopentolate eyedrops have enough cycloplegic effects in young adults.

An UPLC-MS/MS Method for Simultaneous Determination of Tropicamide and Phenylephrine in Rabbit Ocular Tissues and Plasma

Purpose: Mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine are commercially available for cycloplegic refraction. Determining the pharmacokinetics (PK) and distribution of tropicamide and phenylephrine simultaneously in ocular tissues is an important but challenging issue. Herein, we developed a sensitive and selective ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method for simultaneous determination of tropicamide and phenylephrine concentrations in rabbit ocular tissues and plasma. Methods: The two analytes were extracted with ethyl acetate using etofesalamide as an internal standard and separated using a chromatographic C₈ column with isocratic elution. Mass spectrometry analysis was performed with positive electrospray ionization and data were acquired in a multiple reaction monitoring mode. Results: We validated this method over a concentration range of 5-1,600 ng/mL for tropicamide and 1-320 ng/mL for phenylephrine in ocular tissues, as well as 0.5-64 ng/mL for both compounds in plasma. Inter- and intraday precisions in all samples were both <12.9% and the accuracy was within 92.1%-108.4%. The highest concentration of tropicamide was found in aqueous humor (C_max: 29430 ng/g), while was in cornea for phenylephrine (C_max: 3465 ng/g). All the ocular tissues concentrations were much higher than those of blood. Conclusion: This UPLC-MS/MS method allowed us to determine the PK and distribution of tropicamide and phenylephrine in rabbit ocular tissue, which may be helpful in the future development and application of mydriatic agents.

Ametropia prevalence of primary school students in Chinese multi-ethnic regions

Introduction: To explore the prevalence of visual impairment due to uncorrected ametropia from primary students in multi-ethnic regions of Yunnan (Southern China).Methods: Primary school students of 7 ~ 12 years old from 5 multi-ethnic regions were screened. Cycloplegic refraction and subjective trial lens visual acuity were measured in all children with distance unaided visual acuity < 20/20. Gender, ages, ethnics, and regions were assessed with analysis of difference and Odds Ratio (OR) respectively, by statistics software R.Results: Of all 24296 children, the incidence rate for visual impairment from ametropia was 19.18% (myopia accounted for 94.31%) for 7 ~ 12 years old in Yunnan primary schools in a multi-ethnic region. Myopia prevalence differed significantly among gender, ages, ethnics, and regions (P = .0003, P < .00001, P < .00001, P < .00001, respectively). Girls were more prone to have myopia (OR = 1.19, 95%, CI = 1.11-1.27) than boys; the risk of myopia increased with age: 9-10 years OR = 2.6 (95% CI = 2.62-3.2), 11-12 years OR = 6.6 (95% CI = 6-7.26). Three ethnic minorities surveyed were less prone to myopia than Han: Dai OR = 0.62 (95% CI = 0.47-0.8) Hani OR = 0.56 (95%CI = 0.41-0.76) Buyi OR = 0.50 (95% CI = 0.4-0.62).Conclusions: Myopia, not corrected by glasses, was the most frequent cause of visual impairment in Yunnan primary schools, in a muli-ethnic region. Boys, young children and certain ethnic minorities were less prone to myopia.

Clinical Performance of the Spot Vision Photo Screener before and after Induction of Cycloplegia in Children

Aim

To compare the clinical performance of the Spot Vision Screener used to detect amblyopia risk factors (ARFs) in children before and after induction of cycloplegia; the children were referred because they met the screening criteria of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS).

Methods

The Spot Vision Screener and a standard autorefractometer were used to examine 200 eyes of 100 children aged 3–10 years, before and after cycloplegia induction, in terms of ARFs. Sensitivity, specificity, and positive and negative predictive values for the detection of significant refractive errors were measured using the AAPOS referral criteria. It was explored that Spot Screener data were affected by cycloplegia. The extent of agreement between cycloplegic/noncycloplegic photoscreening data and cycloplegic autorefraction measurements was assessed using Wilcoxon and Spearman correlation analyses.

Results

The Spot's sensitivity was improved from 60.9% to 85.3% and specificity from 94.9% to 87.4% with cycloplegia compared to cycloplegic standard autorefractometer results. The positive predictive value of Spot was 75.7%, and the negative predictive value was 90.4% without cycloplegia. With cycloplegia, the positive predictive value of Spot was 63.6% and the negative predictive value was 95.8%.

Conclusions

The Spot Screener afforded moderate sensitivity and high specificity prior to cycloplegia. The sensitivity and negative predictive value improved after induction of cycloplegia. Examiners should be aware of the effects of cycloplegia on their findings.

Tropicamide has limited clinical effect on cycloplegia and mydriasis when combined with cyclopentolate and phenylephrine

PURPOSE

To examine the cycloplegic and mydriatic effect of tropicamide omission from a common pediatric eye drop combination.

METHODS

Consecutive children examined at the Ann & Robert H. Lurie Children's Hospital of Chicago from June 8, 2017 to September 6, 2017 were enrolled prospectively. Tropicamide, cyclopentolate, and phenylephrine (TCP) was instilled in one eye; cyclopentolate and phenylephrine (CP), in the other. Spherical equivalent, maximum pupil size, and pupillary constriction in response to photostimulation were measured before and 30 minutes after instillation using an autorefractor and pupillometer. Iris pigmentation was examined as a between-subjects variable.

RESULTS

A total of 75 children 4-11 years of age were included. Mean differences in spherical equivalent between TCP and CP were not statistically significant (P = 0.95). Significant interactions between eye drop regimen and iris pigmentation were observed for pupil size (P = 0.001) and constriction percentage (P = 0.02). Among only patients with dark irides, TCP yielded slightly larger pupils (7.70 vs 7.31 mm [P < 0.001]) that were less responsive to light (5.75% vs 8.07% [P = 0.002]). All pupils dilated to ≥6.0 mm, with equivalent proportions achieving ≥7.0 mm for TCP and CP (P = 0.18).

CONCLUSIONS

TCP and CP elicited equivalent cycloplegic effects. Mydriatic differences between the regimens, although statistically significant in dark irides, were of limited clinical magnitude, and all pupils achieved sufficient dilation for funduscopy.