Cycloplegic refraction more accurate than noncycloplegic in school-aged children
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Most school-aged children demonstrated less than 1 D of myopic spherical equivalent difference between noncycloplegic and cycloplegic refractions, although hyperopia, age and race contributed to observed differences, according to research.
“Although cycloplegic refraction is considered the gold standard in epidemiologic assessment of refractive error in pediatric populations, data on the systematic differences in refractive error measurements obtained with and without cycloplegia among school-aged individuals in the United States are limited,” Xinxing Guo, MD, PhD, research associate at Wilmer Eye Institute at Johns Hopkins University School of Medicine, and colleagues wrote in Ophthalmology. “Furthermore, refractive error may affect schoolchildren of different race and ethnicity disproportionately.”
In a cross-sectional, retrospective study, Guo and colleagues assessed 11,119 children (mean age, 10.8 years; 52.4% girls; 62.9% Black; 32.3% Hispanic) who were evaluated from 2016 to 2019 at the Illinois College of Optometry Princeton Vision Clinic. Participants underwent visual acuity testing and noncycloplegic and cycloplegic autorefraction.
Researchers defined myopia as at least –0.50 D spherical equivalent (SE), hyperopia as at least +0.50 D SE and astigmatism as at least 1.00 D, and measured differences between noncycloplegic and cycloplegic autorefraction.
According to study results, SE noncycloplegic autorefraction measured 0.65 ± 1.04 D more myopic than cycloplegic SE. In addition, mean SE difference decreased from –0.75 ± 1.82 D in participants younger than 5 years to –0.47 ± 0.76 D in those 15 years and older.
Researchers also reported significant differences between noncycloplegic and cycloplegic SE and cylindrical measurements across all age, sex and racial/ethnic subgroups, as well as in all refractive error type and severity groups, except for astigmatism in white students and in severe hyperopia.
Additionally, a greater proportion of individuals over all age groups were found to have myopia using noncycloplegic autorefraction than with cycloplegic autorefraction.
After adjusting for demographics and retractive error, researchers further reported that individuals who had at least 1.00 D more myopic SE refraction by noncycloplegic autorefraction (n = 2,879) were more likely to be younger than 5 years (OR = 1.45; 95% CI, 1.18-1.79) and 5 to younger than 10 years (OR = 1.32; 95% CI, 1.18-1.48). This difference of at least 1 D more myopic SE also was reported more in Hispanic participants (OR = 1.23; 95% CI, 1.1-1.36) and in those with hyperopia (OR, 4.2-13.31).
Individuals with at least 0.75 D cylindrical difference between refractions (n = 561) were more likely be younger than 5 years (OR = 2.42; 95% CI, 1.75-3.35), male (OR = 1.34; 95% CI, 1.13-1.59) and have mild myopia or moderate to high hyperopia.
“By assessing the magnitude of the measurement differences between noncycloplegic and cycloplegic autorefraction, the current study helps to inform clinicians and epidemiologists of the population-specific implications of noncycloplegic autorefraction,” Guo and colleagues wrote. “Our findings may be helpful to studies or programs that rely on noncycloplegic refraction measurements in school-aged children.”
They added, “More research is warranted to understand better the appropriate use and limitations of noncycloplegic refraction in school-based vision programs.”
Perspective
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In a busy clinical practice, we often see autorefractions performed without cycloplegia in children. In many cases, we may have a good estimation of refractive error with noncycloplegic autorefraction, but how often is it not a good estimate? Based on this study, which had a large sample size (N = 11,119) and a wide range of ages (3-22 years old) including both myopia and hyperopia, this question was answered: In three-fourths of cases, the estimation is within 1.00 D.
The authors found that, comparing noncycloplegic with cycloplegic autorefraction, one-fourth of school-aged individuals had at least 1.00 D higher myopic SE. Particularly, there is the higher probability of myopic overestimation with noncycloplegic autorefraction for children younger than 10 years or those with a hyperopic refractive error. In their example, when using noncycloplegic autorefraction, children with moderate and high hyperopia were at significantly higher risk of having up to 6.00 D SE more myopic (less hyperopic) measurements, presumably due to accommodation. The study indicates that cycloplegic refraction is recommended for those young children with hyperopia.
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