Purpose: To study the need of post mydriatic test (PMT) in children with mild to moderate compound

myopic astigmatisma.
Materials and Methods: The children having mild to moderate compound myopic astigmatism
presenting to the pediatric ophthalmology department underwent subjective refraction before,
immediately after cycloplegia and 3 days after cycloplegia. The refractive error was analyzed using two-
tailed paired t test by dividing the refractive-errors into sphere, cylinder and axis. Spherical equivalent
was analyzed separately.

Result: Eighty four eyes of 42 children aged 3 to16 years (Mean 9.6, SD 3.2) were included. Mean sphere
was -0.9 diopter sphere (DS) (± 1.9) without cycloplegia and -0.4 DS (± 2.0) with cycloplegia compared
to -0.9 DS (± 1.8) in the PMT. Mean cylinder was -1.3 diopter cylinder (DC) (± 1.2) without cycloplegia
and -1.0 DC (± 1.5) with cycloplegia compared to -1.14 DC (± 1.3) in PMT. Mean spherical equivalent
was -1.5 DS (± 1.6) without cycloplegia and -0.9 DS (± 1.8) with cycloplegia compared to -1.5 DS (± 1.6)
in PMT. For spherical equivalent, the correlation coefficient (r) between non-cycloplegic refraction and
cycloplegic refraction; non-cycloplegic refraction and PMT; cycloplegic refraction and PMT was 0.9.
However, in comparison to cycloplegic refraction, PMT was closer to non-cycloplegic refraction and
differed by only 0.01 DS (± 0.9) in sphere and 0.2 D (± 0.7) in cylinder. Conclusion: PMT is not
warranted in children with compound myopic astigmatism.

Cycloplegia helps to uncover the latent component in hypermetropes and relaxes

accommodative spasm in myopes thereby reducing undercorrections in hyperopes and
overcorrections in myopes.[1-3] Most investigators recommend cycloplegic refraction
to correct ametropia in children.[4] Adequate cycloplegia in pigmented races often
require multiple topical application of cyclopentolate, homatropine or atropine eye
drops.[5] Although it is agreed that cycloplegia is necessary for refraction in
children, despite the attendant side effects (such as prolonged difficulty in near
work, photophobia and other systemic adverse effects)[6] and increase in the patient
waiting time, same is not true for post mydriatic test (PMT). For PMT, a patient is
recalled for subjective refraction, usually three or four days later, when the effect
of cycloplegia and mydriasis has completely disappeared. Despite a lack of evidence
that PMT adds any value to the spectacle prescription of the myopic children, it is
performed as a routine (read as tradition) in older children in many eye hospitals
and eye clinics in India. PMT increases the cost of eye care and the inconvenience to
the patient because of the extra visit needed. In this study, we have compared the
refraction of myopic children before and after cycloplegia with PMT and conclude that
the traditional practice of doing routine PMT for every patient is not warranted.

Materials and Methods

This prospective, observational cohort study was done in the Department of
Pediatric-Ophthalmology, at a tertiary teaching eye care center in western India.
Children cooperative for subjective and objective refraction aged between 4-16 years
with myopia between -0.25 DS and -6 DS, astigmatism ≥0.50 D and spherical equivalent
≥ −1.50 D were included in the study. Children aged 3 years or less and those with
the best corrected visual acuity less than 20/20, media opacity, nystagmus, squint or
any other ocular comorbidity were excluded. Patients were examined on Topcon
Autorefractometer RM-6000B (Topcon Corporation, Japan). The patient was seated on an
ophthalmic chair (Plantech PO-EU, Gujarat, India). Care was taken to stabilize the
head on the chin rest while the forehead touched the forehead band and eyes leveled
to the eye level marker. Children were allowed to keep both their eyes open while the
optometrist took 3 readings manually according to the standard operating protocol
mentioned in the user’s manual. An average of three readings was used for
refraction. Readings with standard deviation of more than 0.12 were excluded and a
repeat of three readings was taken. The subjective refraction was started with the
autorefractor readings.
Cycloplegia was attained with three instillation of cyclopentolate eye drops
(Cyclopent 1%, Sun Pharmaceutical Ltd, India), in the inferior cul de sac every 15
minutes. Cycloplegic autorefraction was done after 45 minutes again repeating the
subjective refraction starting from the autorefractor readings. The final spectacle
prescription was given after performing the subjective refraction (PMT) performed at
least 3 days later starting with the prior autorefractor reading obtained under
cycloplegia. The final prescription was balanced with the duochrome test to refine
the spherical monocular end point.[7]
The non-cycloplegic refraction was defined as the subjectively refined
spectacle prescription from the values obtained from the autorefraction under non-
cycloplegic condition. The cycloplegic refraction was defined as the subjectively
refined spectacle prescription obtained under cycloplegic condition from the values
obtained from the autorefraction under cycloplegic condition. PMT was defined as the
subjectively refined spectacle prescription obtained under non-cycloplegic condition
from the values obtained from the cycloplegic autorefraction. It was performed at
least 3 days after the cycloplegic autorefraction was performed. The data was entered
in MS Excel, version Windows 2000 (Microsoft Corporation (I) Pvt. Ltd., Gurgaon,
India). The refractive error was analyzed by dividing it into three components
(sphere, cylinder, and axis). The spherical equivalent was analyzed separately. The p
value for the difference of mean was calculated using two-tailed paired t test. The
Pearson correlation coefficient (r) was calculated for the set of data obtained from
cycloplegic verses noncycloplegic refraction and the final spectacle prescription
after PMT. Sample size calculation[8] was done for continuous paired variable using
the Formula: Z1-/2 – Z [1-]2 Sc 2 /d2 with 5% significance level i.e., Z1-/2 =
1.96, standard normal variate as 80% (Z 1-= –0.84), the standard deviation of the
controlled group (Sc) was 1.63, and the effect size (d) was 50. By this calculation,
we were require

Results
Eighty-four eyes of 42 children aged between 3 and 16 years (Mean 9.60, SD
3.18) of which 20 were males were included in the study. The spherical equivalent and
the sphere were significantly reduced after cycloplegia [Tables 1 and 2]. The
correlation coefficient between the non-cycloplegic refraction, cycloplegic
refraction and PMT for the spherical equivalent and sphere was 0.9. There was no
significant difference between non-cycloplegic refraction and PMT.d to recruit 83.32
eyes for this study.

Discussion
 The refractive surgeons have questioned the routine use of strong cycloplegics
in young adult ametropes undergoing refractive surgery for the correction of
ametropia.[9] The refraction obtained in the myopic children with tropicamide 1% was
similar to 1% topical cyclopentolate.[10] There is an increasing trend toward using
faster-acting and less-potent cycloplegics in children. Nevertheless, cycloplegic
refraction remains a gold standard to obtain the baseline refractive status of an eye
and to negate the effect of accommodation despite associated difficulty to perform
near work, photophobia and other adverse effects.[6]

In a typical pediatric eye clinic, a large number of ametropic children aged

above 6 years have myopia ranging between –1 diopter sphere (DS) and –6 DS.
Cycloplegic refraction in such a situation is routinely practiced. However, the
practice of calling the patient back for a PMT may not be feasible or cost-effective
especially if it does not add any further information that improves the final
spectacle prescription. The autorefractometers are generally condemned for inducing
the accommodation. However, autorefractometers such as Topcon RM 6000B use the
technique of continuous fogging and hence it negates the accommodative urge giving
more accurate readings even in the absence of cycloplegia. It is important to note
that, in the present study we did not use the autorefraction without subjectively
refining the sphere and cylinder obtained from the standard technique of subjective
refraction (fogging, cross cylinder evaluation and a duochrome test). Previous
investigators have reported good reproducibility with cycloplegic retinoscopy and
cycloplegic autorefraction.[11] However, there may be little agreement between the
two different objective refraction methods.[12] Hence, it is recommended to perform
subjective refinement of the objective refraction whether obtained by autorefraction
or retinoscopy. Despite employing the fogging and duochrome
test in the study, we found that PMT and non-cycloplegic refraction tend to
over-estimate a myopic refractive error. The mean difference between the cycloplegic
and non-cycloplegic sphere was 0.4 (±0.7) and cylinder was 0.3 (±1.1). In keeping
with the past study, in the present study, the cylinder axis did not vary
significantly between both cycloplegic and noncycloplegic refraction.[13]
Ophthalmologists follow differing prescription guidelines for children; one group
prescribes least correction in myopes (subjective refraction obtained under
cycloplegic condition with red better response on duochrome test) while another group
prescribes what patient subjectively accepts under non-cycloplegic correction. To
whichever group the reader belongs to, as there was no significant difference in pre-
cycloplegia refraction and PMT, both the groups do not need PMT. For the later group,
they do not even need a cycloplegic refraction! In conclusion, a PMT is not warranted
for prescribing spectacles in children with mild to moderate myopia.