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Comparison of retinoscopy results with and without 1% cyclopentolate in school-aged children
Sue E Doherty1, Lesley A Doyle1, Sara J McCullough1
1Optometry and Vision Science Research Group, School of Biomedical Sciences, Biomedical Sciences Research Institute, University of Ulster, Coleraine, UK.
Insights
Cycloplegic retinoscopy reveals more hyperopia in children aged 6-13 years than non-cycloplegic methods. While a non-cycloplegic sphere of +1.50DS can indicate significant hyperopia, cycloplegia is needed for accurate spherical error assessment.
Area of Science:
- Ophthalmology
- Pediatric Optometry
- Clinical Refraction
Background:
- Accurate refractive error assessment in children is crucial for timely intervention and management of visual development.
- Cycloplegic retinoscopy is considered the gold standard for determining refractive error by paralyzing accommodation, but its necessity in all pediatric cases is debated.
- Understanding the differences between cycloplegic and non-cycloplegic retinoscopy across age groups can optimize clinical decision-making.
Purpose of the Study:
- To establish an evidence base for practitioners regarding the necessity of cycloplegic retinoscopy in pediatric eye examinations.
- To determine the age at which the difference between cycloplegic and non-cycloplegic retinoscopy becomes clinically insignificant.
- To investigate the influence of age, refractive error, spectacle wear, and accommodation on the disparity between the two retinoscopy methods.
Main Methods:
- A single examiner performed both cycloplegic and non-cycloplegic retinoscopy on 128 children aged 6-13 years, stratified into four age groups.
- Cycloplegia was induced using 1% cyclopentolate, with retinoscopy performed 30 minutes post-instillation.
- Accommodation was assessed using dynamic retinoscopy, and the examiner was masked to habitual spectacle wear and lenses used.
Main Results:
- A significant difference was found in the spherical component between cycloplegic and non-cycloplegic retinoscopy across all age groups (p < 0.0001).
- This difference decreased with increasing age but remained statistically significant.
- The disparity was greater in cases of high hyperopia (≥+2.50DS) and increased proportionally with the degree of hyperopia. Astigmatic error measures did not differ significantly.
- A non-cycloplegic sphere of ≥+1.50DS demonstrated 87% sensitivity and 96% specificity for identifying clinically significant hyperopia (≥+2.50DS) via cycloplegic retinoscopy.
Conclusions:
- 1% cyclopentolate does not affect the astigmatic component but significantly increases the measured hyperopia in the spherical component for children aged 6-13 years.
- The difference between cycloplegic and non-cycloplegic spherical measurements increases with the degree of hyperopia, irrespective of spectacle wear or accommodation.
- While a non-cycloplegic retinoscopy result of ≥+1.50DS can help identify children at risk of significant hyperopia, cycloplegic retinoscopy remains essential for precise determination of the full spherical refractive error.
Purpose:
This study was designed with the aim of providing practitioners with an evidence base to inform their clinical decision making as to when cycloplegic retinoscopy is necessary and when it might be appropriate to forgo. The study aimed to determine the age at which there ceases to be a clinically significant difference between cycloplegic and non-cycloplegic retinoscopy and whether age, refractive error, habitual spectacle wear and accommodation influence the relationship.
Methods:
A single examiner carried out cycloplegic and non-cycloplegic retinoscopy on 128 children stratified into four age groups (6-7, 8-9, 10-12 and 12-13 years). Cycloplegia was achieved using 1% cyclopentolate and retinoscopy carried out after 30 min. The examiner was masked to the lenses used and to habitual spectacle wear. Accommodation was assessed using dynamic retinoscopy prior to cycloplegia.
Results:
Cycloplegic and non-cycloplegic sphere differed significantly (z = -9.18, p < 0.0001). Although the difference decreased significantly as age increased (χ2 = 16.57, p = 0.0009), cycloplegic retinoscopy revealed more hyperopia than non-cycloplegic retinoscopy in all age groups (p < 0.0001). The difference between cycloplegic and non-cycloplegic results was greater where 'high' hyperopia (≥+2.50DS) was present (F1,6 = 12.86, p = 0.0005), and as hyperopia increased the difference increased (Spearman's ρ = 0.55, p < 0.0001). Neither spectacle wear (p = 0.74) nor accommodation (p = 0.08) influenced the difference between spherical measures. Measures of astigmatic error did not differ significantly (z = -1.59, p = 0.11). A non-cycloplegic sphere ≥+1.50DS was relatively sensitive (87%) and specific (96%) at indicating clinically significant hyperopia (≥+2.50D) as revealed by cycloplegic retinoscopy.
Conclusions:
Cyclopentolate 1% does not impact the cylindrical component of the retinoscopy result, but reveals significantly more hyperopia in the spherical component, both statistically and clinically in children aged 6-13 years. Differences between cycloplegic and non-cycloplegic sphere increase significantly with increasing hyperopia, independent of spectacle wear and accommodation. A non-cycloplegic retinoscopy result of ≥+1.50DS may be used by practitioners wishing to identify children aged 6-13 years at risk of clinically significant hyperopia (≥+2.50DS), but cycloplegia is required to accurately ascertain the full spherical error.
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