Comparison of photorefraction by Plusoptix A12 and cycloplegic autorefraction in children.

BACKGROUND: Plusoptix photoscreeners are capable of measuring refractive errors of children from 1 meter distance, without cyloplegia. We aimed to compare refractive data obtained from the newest version of Plusoptix (model 12) with cycloplegic autorefraction. METHODS: We examined 111 consecutive children aged 3-7 years first by Plusoptix A12C under manifest condition and subsequently for cycloplegic refraction by Topcon KR-1 tabletop autorefractometer. Sphere, spherical equivalent, cylinder and axis of astigmatism measured by the two methods were analyzed to determine correlation, agreement and differences. RESULTS: Binocular examination of 111 children aged 4.86±1.27 years revealed good agreement between refractive data obtained by Plusoptix and cycloautorefraction, according to Bland-Altman plots. Significant (p < 0.001) and strong correlation was found between all refractive measurements (Pearson's r value of 0.707 for sphere, 0.756 for pherical equivalent, and 0.863 for cylinder). Plusoptix mean sphere, spherical equivalent and cylinder were 1.22, 0.56, and -1.32 D, respectively. Corresponding values for cycloautorefraction were 1.63, 1.00, and -1.26 D. The difference between axis of cylinder measured by the two methods was < 10° in 144 eyes (64.9%). CONCLUSIONS: Considering the significant agreement and correlation between Plusoptix photoscreener and cycloplegic autorefraction, the need for cycloplegic drops in refractive examination of children may be obviated. The mean difference between cylinder measurements are considerably trivial (0.06 D), but sphere is approximately 0.4 D underestimated by Plusoptix compared to cycloautorefraction, on average.

Comparison of Spot Vision Screener and Tabletop Autorefractometer with Retinoscopy in the Pediatric Population.

Objectives: Determining the accuracy of cycloplegic refractive error measurements made with the Spot Vision Screener (SVS, Welch Allyn Inc, Skaneateles Falls, NY, USA) is important for refractive assessment of uncooperative patients during optometric examinations. This study compared cycloplegic refractive errors measured by SVS and tabletop autorefractometer to cycloplegic retinoscopy in children. Materials and Methods: Eighty-eight eyes of 44 subjects were examined in the study. Refractive error measurements were obtained under cycloplegia using retinoscopy, SVS, and Nidek ARK-530 tabletop autorefractometer (ARK-530, Nidek, Japan). Spherical and cylindrical values, spherical equivalents (SE), and Jackson cross-cylinder values at axes of 0° (J0) and 45° (J45) were recorded. Correlations between methods were analyzed using intraclass correlation coefficient (ICC) and Bland-Altman analysis. Results: The mean age was 7 years (range: 6 months-17 years). Sixteen (36%) of the subjects were female and 28 (64%) were male. For SE there was excellent agreement between retinoscopy and SVS (ICC: 0.924) and between retinoscopy and tabletop autorefractometer (ICC: 0.995). While there was a moderate correlation between retinoscopy and SVS for cylindrical values (ICC: 0.686), excellent correlation was detected between retinoscopy and autorefractometer (ICC: 0.966). J0 and J45 crosscylinder power values were not correlated between retinoscopy and SVS (ICC: 0.472) or retinoscopy and tabletop autorefractometer (ICC: 0.442). Retinoscopy was correlated with both SVS and tabletop autorefractometer for all parameters within ±1.96 standard deviations in Bland-Altman analysis. Conclusion: Cycloplegic retinoscopy is the gold standard for refractive error measurement in the pediatric population. However, it requires time and experienced professionals. This study revealed moderate to good agreement between SVS and retinoscopy, with better agreement in spherical errors than cylindrical errors. Although the SVS is intended for screening programs, it may also be useful in the pediatric eye office to estimate spherical refractive error in uncooperative patients.

Agreement in non-cycloplegic and cycloplegic refraction between a photoscreener and a calibrated autorefractor.

INTRODUCTION: Photoscreeners have been shown to provide excellent measurements of the refractive error. However, whether they could be used for assessing cycloplegic refraction has not been examied. This study aimed to evaluate the agreement between cycloplegic and non-cycloplegic measurements obtained using a photoscreener and stationary autorefractor, respectively. METHODS: This study included all patients undergoing routine ophthalmic examination at the Hygeia Clinic (Poland) from June to July 2022. Each patient underwent non-cycloplegic and cycloplegic refraction assessments using the 2WIN photoscreener (Adaptica SRL, Padova, Italy) and an ARK-1 stationary autorefractor ARK-1 (Nidek Co Ltd., Tokyo, Japan), respectively. Each pair of assessments was conducted in random order, and all values were determined at a vertical distance of 12 mm. The agreement between cycloplegic and non-cycloplegic measurements was assessed using paired t-tests, Bland-Altman and ABCD ellipsoids. RESULTS: This analysis included 82 patients, of which 52 were female. Their mean age was 34.39 ± 13.13 years. The non-cycloplegic spherical equivalent (SE) did not differ significantly between the 2WIN (- 1.22 ± 2.45) and ARK-1 (- 1.19 ± 2.96) devices (p = 0.580). However, the cycloplegic SE values demonstrated more negative values with the 2WIN device (- 1.13 ± 2.19) than with the ARK-1 device (- 0.75 ± 3.03; p = 0.007). The non-cycloplegic and cycloplegic measurements were strongly correlated between the devices (r = 0.9473 and 0.9411, respectively). However, the correlation between their cycloplegic shifts in SE was low (r = 0.2645). Ellipsoid refraction aligned better non-cycloplegic (ARK-1 = 1.00; 2WIN = 1.74) than with cycloplegic refraction (ARK-1 = 1.43; 2WIN = 1.90). CONCLUSION: While the cycloplegic measurements obtained with the 2WIN photoscreener were strongly correlated with those obtained with the ARK-1 stationary autorefractor for most of the analyzed parameters, they should not be considered interchangeable.

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.

Low-dose atropine 0.01% for the treatment of childhood myopia: a pan-India multicentric retrospective study.

OBJECTIVE: The objective of this study was to assess the efficacy of low-dose atropine 0.01% in controlling myopia progression among Indian children over a 2-year period. METHODS: This retrospective study, conducted across 20 centres in India, monitored the progression of myopia over 2 years after initiating treatment with 0.01% atropine eye drops. This included children between 6 and 14 years with baseline myopia ranging from -0.5 D to -6 D, astigmatism≤-1.5 D, anisometropia ≤ -1 D and documented myopia progression of ≥0.5 D in the year prior to starting atropine. Subjects with any other ocular pathologies were excluded. RESULTS: A total of 732 children were included in the data analysis. The mean age of the subjects was 9.3±2.7 years. The mean myopia progression at baseline (1 year before starting atropine) was -0.75±0.31 D. The rate of myopia progression was higher in younger subjects and those with higher baseline myopic error. After initiating atropine, myopia progression significantly decreased to -0.27±0.14 D at the end of the first year and -0.24±0.15 D at the end of the second year (p<0.001). Younger children (p<0.001) and higher baseline myopia (p<0.001) was associated with greater myopia progression and poor treatment response (p<0.001 for both). CONCLUSION: Low-dose atropine (0.01%) effectively reduces myopia progression over 2 years in Indian children.

Topographic and surgical risk factors for high postoperative residual astigmatism after small incision lenticule extraction in patients with different degrees of myopia: a retrospective cohort study.

BACKGROUND: To evaluate the possible topographic and surgical risk factors for high postoperative residual astigmatism in patients who undergo small-incision lenticule extraction (SMILE) surgery and have different myopia degrees. METHODS: A retrospective cohort study was conducted, and patients who underwent SMILE surgery were enrolled. A total of 80 and 150 eyes from 40 to 75 individuals, respectively, were selected as the low myopia and high myopia groups. The demographic data, visual acuity, refraction, topographic parameters and surgical settings were recorded. Multiple linear regression with interaction tests were performed to survey the risk factors for high postoperative residual astigmatism in each group. RESULTS: Five (6.25%) and 9 (6.00%) eyes presented with high postoperative residual astigmatism in the low myopia and high myopia groups, respectively, but these differences were not significant (P = 0.569). A steep corneal curvature was correlated with a greater risk of high postoperative residual astigmatism in the low myopia group (P = 0.015), while a higher degree of cycloplegic cylinder power, steeper corneal curvature, greater topographic cylinder power, smaller optic zone and longer incision length were associated with a high rate of postoperative residual astigmatism in the high myopia group (all P < 0.05). In addition, the interaction effects of cycloplegic and topographic cylinder power and longer incision length on the incidence of high postoperative residual astigmatism development were more evident in the high myopia group than in the low myopia group (all P < 0.05). CONCLUSIONS: A steep corneal curvature correlates with a high risk of high postoperative residual astigmatism after SMILE surgery, and a higher degree of cycloplegic and topographic cylinder and longer incision are associated with high postoperative residual astigmatism in individuals with high myopia.

Cutoff values of axial length/corneal radius ratio for determining myopia vary with age among 3-18 years old children and adolescents.

PURPOSE: To investigate the effectiveness and cutoffs of axial length/corneal radius (AL/CR) ratio for myopia detection in children by age. METHODS: Totally, 21 kindergartens and schools were enrolled. Non-cycloplegic autorefraction (NCAR), axial length (AL), horizontal and vertical meridian of corneal radius (CR1, CR2), and cycloplegic autorefraction were measured. Receiver operating characteristic (ROC) curve was used to obtain the effectiveness and cutoff for myopia detection. RESULTS: Finally, 7803 participants aged 3-18 years with mean AL/CR ratio of 2.99 ± 0.16 were included. Area under the ROC curve (AUC) of AL/CR ratio for myopia detection (0.958 for AL/CR1, 0.956 for AL/CR2, 0.961 for AL/CR) was significantly larger than that of AL (0.919, all P < 0.001), while AUCs of the three were similar with different cutoffs (> 2.98, > 3.05, and > 3.02). When divided by age, the ROC curves of AL/CR ratio in 3- to 5-year-olds showed no significance or low accuracy (AUCs ≤ 0.823) in both genders. In ≥ 6-year-olds, the accuracies were promising (AUCs ≥ 0.883, all P < 0.001), the cutoffs basically increased with age (from > 2.93 in 6-year-olds to > 3.07 in 18-year-olds among girls, and from > 2.96 in 6-year-olds to > 3.07 in 18-year-olds among boys). In addition, boys presented slightly larger cutoffs than girls in all ages except for 16 and 18 years old. For children aged 3-5 years, AL/CR ratio or AL combined with NCAR increased AUC to > 0.900. CONCLUSION: AL/CR ratio provided the best prediction of myopia with age-dependent cutoff values for all but preschool children, and the cutoffs of boys were slightly larger than those of girls. For preschool children, AL/CR ratio or AL combined with NCAR is recommended to achieve satisfactory accuracy. AL/CR ratio calculated by two meridians showed similar predictive power but with different cutoffs.

Low concentration atropine and myopia: a narrative review of the evidence for United Kingdom based practitioners.

The prevalence of myopia is increasing across the world. Controlling myopia progression would be beneficial to reduce adverse outcomes such as retinal detachment and myopic maculopathy which are associated with increased axial length. Pharmacological control of myopia progression with atropine has been investigated since the 19th century and the benefits of slowing myopia progression are considered against the side-effects of near blur and photophobia. More recently, randomised trials have focused on determining the optimum concentration of atropine leading to low-concentration atropine being used to manage myopia progression by practitioners across the world. Currently, in the United Kingdom, there is no licensed pharmacological intervention for myopia management. The aim of this review is to interpret the available data to inform clinical practice. We conducted a narrative review of the literature and identified peer-reviewed randomised controlled trials using the search terms 'myopia' and 'atropine', limited to the English language. We identified two key studies, which were the Atropine in the Treatment Of Myopia (ATOM) and Low-concentration Atropine for Myopia Progression (LAMP). Further studies were identified using the above search terms and the references from the identified literature. Atropine 0.01% has a modest effect on controlling axial length progression. Atropine 0.05% appears to be superior to atropine 0.01% in managing myopia progression. There is a dose-dependent rebound effect when treatment is stopped. Atropine is a well-tolerated, safe, and effective intervention. Treatment would be needed for several years and into adolescence, until axial length progression is stable.

Juvenile-onset myopia-who to treat and how to evaluate success.

The risk of eye diseases such as myopic macular degeneration increases with the level of myopia, but there is no safe level of myopia and the burden of lower degrees of myopia remains considerable. Effective treatments are available that slow progression and thus limit the final degree of myopia. In this review, the rationale for slowing progression is summarized, and a case made for treating all myopic children. Measurement of refractive error and axial length is reviewed, stressing the precision of optical biometry, but also the need for cycloplegic autorefraction. The factors influencing progression are considered and the available tools for interpretation of progression rate are discussed. Finally, the need to set attainable treatment goals is emphasized.

Intracameral phenylephrine for surgical mydriasis and intraoperative floppy-iris syndrome: systemic adverse effects and optimal dose.

Phenylephrine, a potent sympathomimetic, induces mydriasis via iris dilator muscle contraction. Intracameral (IC) phenylephrine has been successfully used in cataract surgery for initial mydriasis, maintaining mydriasis, and management of intraoperative floppy-iris syndrome. Serious systemic adverse events (mainly cardiovascular) have been described with topical phenylephrine drops, but we found very little evidence of such adverse events associated with IC phenylephrine use. However, we suspect under-reporting of such adverse events, as they may instead be ascribed to anxiety, positioning, anesthesia, etc. Optimal dosage/concentrations for IC phenylephrine use in different purposes have not been fully studied. In the absence of robust evidence, we suggest that lower but effective IC phenylephrine concentrations are used: a lower concentration (0.31%), in conjunction with an anticholinergic and lidocaine, may be used for initial mydriasis. For management of intraoperative floppy-iris syndrome, 0.31% may be effective, though a higher concentration (1% to 1.25%) may be required.

Short-term effects of cyclopentolate and tropicamide eye drops on macular choroidal thickness in myopic children.

BACKGROUND: To investigate the short-term effects of cyclopentolate and tropicamide eyedrops on choroidal thickness (ChT) in myopic children using placebo or low-dose atropine eyedrops. METHODS: The analysis included 242 myopic individuals (7-19 years) enrolled in two randomised placebo-controlled clinical trials of low-dose atropine eyedrops. Cycloplegia was induced using either one drop of 1% cyclopentolate (n = 161), two drops of 1% cyclopentolate (n = 32) or two drops of 1% tropicamide (n = 49). ChT measurements were taken using swept-source optical coherence tomography before and 30 min after administering the cycloplegic eye drops. A subset of 51 participants underwent test-retest measurements prior to cycloplegia. RESULTS: Mean changes in subfoveal ChT after two drops of tropicamide and one and two drops of cyclopentolate were -2.5 µm (p = 0.10), -4.3 µm (p < 0.001) and -9.6 µm (p < 0.001), respectively. Subfoveal ChT changes after one and two drops of cyclopentolate were significantly greater than the test-retest changes (test-retest mean change: -3.1 µm; p < 0.05), while the tropicamide group was not significantly different (p = 0.64). Choroidal thinning post-cyclopentolate was not significantly different between atropine and placebo treatment groups (p > 0.05 for all macular locations). The coefficient of repeatability (CoR) in the tropicamide group (range: 8.2-14.4 µm) was similar to test-retest (range: 7.5-12.2 µm), whereas greater CoR values were observed in the cyclopentolate groups (one drop: range: 10.8-15.3 µm; two drops: range: 12.2-24.6 µm). CONCLUSIONS: Cyclopentolate eye drops caused dose-dependent choroidal thinning and increased variation in pre- to post-cycloplegia measurements compared with test-retest variability, whereas tropicamide did not. These findings have practical implications for ChT measurements when cyclopentolate is used, particularly for successive measurements.

Preservatives and pH in low-dose atropine formulations for clinical trials.

Over a century ago, atropine has been tested to arrest myopia progression with good results. In recent years, many randomized clinical trials have tested different concentrations against placebo. Three recent such studies with low-dose atropine showed that it was less effective than previous studies, even the last one showing no difference in myopia progression between the treated and control group. Previous randomized studies had been performed in Asian populations, and these last three were extended to Western Caucasian populations, based on the initial observation that differences in iris pigmentation could be a factor for a difference in effectiveness. We have noticed that the three last studies in the West have used the same patented formulation, while previous studies have preferred compounded low-dose atropine. Here we review how the power of hydrogen (pH) and preservatives could account for differences in drug penetration to the eye, possibly explaining the differences between studies.

Tropicamide Versus Cyclopentolate for Cycloplegic Refraction in Pediatric Patients With Brown Irides: A Randomized Clinical Trial.

PURPOSE: To compare the final cycloplegic refraction of tropicamide 1% and cyclopentolate 1% in children 3-16 years of age with brown irides. DESIGN: Randomized, controlled, multicenter prospective clinical trial. METHODS: Included patients were randomized to either cyclopentolate 1% or tropicamide 1% in the first visit with autorefraction measurements. Each subject underwent a second cycloplegic refraction using the other agent on a separate visit with a minimum of 1-week interval and a maximum of 12 weeks. We measured the change in SE (ΔSE) for each eye by deducting the SE before cycloplegia from the SE after cycloplegia. RESULTS: A total of 185 eyes from 94 children aged 3-16 years (average= 8.79 ±3.11 years) were included. The average SE of both eyes before cycloplegia was -0.082 ± 4.8 diopters. The SE after instillation of cyclopentolate and tropicamide in both eyes was 1.07±5.2 and 0.96±5.1, respectively (P value < .001). The average ΔSE after cycloplegia was 1.15±1.2 for cyclopentolate and 1.04±1.2 for tropicamide (P value < .001). The difference between ΔSE of cyclopentolate and tropicamide was found statistically significant at 0.11±1.2 (P < .001), although clinically insignificant. The ΔSE between the 2 drops before and after cycloplegia in both eyes for all refractive error groups was clinically insignificant. The greatest effect of cyclopentolate and tropicamide was in hyperopic eyes with ΔSE of 1.54±1.4 and 1.39±1.4, respectively. CONCLUSIONS: Tropicamide might be an effective and safe replacement for cyclopentolate in the refracting nonstrabismic pediatric population 3-16 years of age regardless of their refractive error status.

Quality assessment of non-mydriatic fundus photographs for glaucoma screening in primary healthcare centres: a real-world study.

BACKGROUND: This study assessed the quality distribution of non-mydriatic fundus photographs (NMFPs) in real-world glaucoma screening and analysed its influencing factors. METHODS: This cross-sectional study was conducted in primary healthcare centres in the Yinzhou District, China, from 17 March to 3 December 2021. The quality distribution of bilateral NMFPs was assessed by the Digital Reading Department of the Eye Hospital of Wenzhou Medical University. Generalised estimating equations and logistic regression models identified factors affecting image quality. RESULTS: A total of 17 232 photographs of 8616 subjects were assessed. Of these, 11.9% of images were reliable for the right eyes, while only 4.6% were reliable for the left eyes; 93.6% of images were readable in the right eyes, while 90.3% were readable in the left eyes. In adjusted models, older age was associated with decreased odds of image readability (adjusted OR (aOR)=1.07, 95% CI 1.06~1.08, p<0.001). A larger absolute value of spherical equivalent significantly decreased the odds of image readability (all p<0.001). Media opacity and worse visual acuity had a significantly lower likelihood of achieving readable NMFPs (aOR=1.52, 95% CI 1.31~1.75; aOR=1.70, 95% CI 1.42~2.02, respectively, all p<0.001). Astigmatism axes within 31°~60° and 121°~150° had lower odds of image readability (aOR=1.35, 95% CI 1.11~1.63, p<0.01) than astigmatism axes within 180°±30°. CONCLUSIONS: The image readability of NMFPs in large-scale glaucoma screening for individuals 50 years and older is comparable with relevant studies, but image reliability is unsatisfactory. Addressing the associated factors may be vital when implementing ophthalmological telemedicine in underserviced areas. TRIAL REGISTRATION NUMBER: ChiCTR2200059277.