C L I N I C A L A N D E X P E R I M E N T A L

OPTOMETRY
RESEARCH PAPER

Comparison of objective refraction in darkness to cycloplegic refraction:

a pilot study

Clin Exp Optom 2016; 99: 168–172 DOI:10.1111/cxo.12367

Balamurali Vasudevan* BSOptom OD Background: The aim was to assess non-cycloplegic objective refraction in darkness using an
Kenneth J Ciuffreda† OD PhD open-field auto-refractor, and furthermore to compare it with distance cycloplegic subjective
Kelly Meehan* OD refraction and distance cycloplegic retinoscopy in the light, in children and young adults.
Dejana Grk* OD Methods: Twenty-three, visually-normal, young-adults (46 eyes) ages 23 to 31 years, and five
Misty Cox* OD children (10 eyes) ages five to 12 years, participated in the study. The spherical component
*Midwestern University, Glendale, Arizona, USA of their refraction ranged from -2.25 D to +3.75 D with a mean of +1.80 D, and a mean cylin-
†
Optometry - Vision Science, SUNY, New York, New der of 0.70 D. Three techniques were used to assess refractive error. An objective measure of
York, USA
the non-cycloplegic refractive state was obtained using an open-field autorefractor
E-mail: drmurali@gmail.com
(WAM-5500) after five minutes in the dark to allow for dissipation of accommodative transients
and relaxation of accommodation. In addition, both distance retinoscopy and subjective
distance refraction were performed following cycloplegia (Cyclopentolate, 1%) using conven-
tional clinical procedures. All measurements were obtained on the same day within a single
session. The spherical component of the refraction was compared among the three tech-
niques in both the children and adults.
Results: There was no significant difference in spherical refraction among the three tech-
niques: non-cycloplegic objective refraction in the dark, distance cycloplegic retinoscopy and
distance cycloplegic subjective refraction, in either the adults (F[2, 137] = 0.79, p = 0.45) or
the children (F[2, 27] = 0.47, p = 0.62). Mean difference in the spherical component between
refraction in the dark and the cycloplegic distance retinoscopy was -0.34 D (r = 0.89) in the
adults and +0.14 D (r = 0.96) in the children. The mean difference in spherical component
between refraction in the dark and the cycloplegic distance subjective refraction was -0.25 D
(r = 0.92) in the adults and -0.05 D (r = 0.95) in the children.
Conclusion: Comparison of the spherical refractive component between the three techniques
was not significantly different and furthermore, they were highly correlated in both the chil-
Submitted: 15 December 2014 dren and adults in this pilot study. Non-cycloplegic refraction in the dark may provide a reli-
Revised: 1 July 2014 able adjunct or alternative to conventional cycloplegic refraction in both children and
Accepted for publication: 7 July 2015 young adults.

Key words: accommodation, children’s vision, cycloplegia, refraction

Techniques for determining refractive error
of the eye can be broadly divided into either
objective or subjective methods.1 Objective
techniques involve less interaction with the
patient, and the automated refractive mea-
surements are obtained from one or both
eyes using either an open-field or closed-field
system. The benefits include convenience, ra-
pidity and ease of use in children and adults,
especially in the presence of any cognitive or
attentional impairment. In contrast, subjec-
tive methods involve interacting more with
the patient and obtaining the refraction
based on explicit instructions provided to
the patient and the responses obtained.
While hyperfocal-based, subjective refraction
may be more time consuming and require
an experienced practitioner to perform the
procedure in young children, it frequently
produces a more accurate and acceptable re-
sult.2 Thus, it remains the ‘gold standard.’
One of the important goals of clinical re-
fraction is to ensure that the final prescrip-
tion does not stimulate accommodation,
thereby avoiding potential iatrogenically-
induced asthenopia.2 This is a relatively
time-consuming process when performed in
adults, and even more demanding in many
young children. When measuring refractive
error in young children, especially those
who are unco-operative, conventional refrac-
tion may not be optimal. In addition, accu-
rate estimation of refractive error is
important in very young children with high
hyperopia, as it could lead to the develop-
ment of strabismus and/or amblyopia.3
There has been an effort to develop tech-
niques and instrumentation that permit
detection of refractive error with minimal re-
quirement for co-operation in young chil-
dren. Photorefraction is one such example.
It has been a common technique for
assessing refraction in both infants and chil-
dren for decades;4,5 however, the results have
been equivocal, when compared with
cycloplegic retinoscopy.6,7 There is also evi-
dence suggesting that non-cycloplegic
autorefraction has reasonable accuracy and
repeatablity when compared with cycloplegic
retinoscopy and cycloplegic subjective refrac-
tion8–11 For example, a recent study12

Clinical and Experimental Optometry 99.2 March 2016 © 2016 Optometry Australia
168
 Objective refraction in darkness and cycloplegic refraction Vasudevan, Ciuffreda, Meehan, Grk and Cox
compared three autorefractors, the Reti-
nomax K-plus 2 (Nikon Corp, Japan), Canon
RK10 Autorefractor (Canon, Japan) and
Grand Seiko WR-5100K (Shin-Nippon,
Japan) to conventional subjective refrac-
tion, both with and without cycloplegia,
in children. They found that the three
autorefractors produced a higher myopic re-
fraction as compared to the non-cycloplegic
subjective refraction. In contrast, there were
no significant differences with cycloplegia.
This suggested that blur-driven accommoda-
tion was not controlled and/or an undesir-
able proximal accommodative contribution
was present.13 A more recent investigation in-
volving the screening of refractive error
in children using the Retinomax K-plus 2
and the plusoptiX S08, both with and
without cycloplegic and with comparison to
cycloplegic retinoscopy, revealed that sensi-
tivity was much higher with cycloplegia, as
the accommodative component was elimi-
nated in the children.14
When using an autorefractor without the
application of a cycloplegic agent in these
populations, the accommodative blur drive
is never completely absent, thus likely
resulting in reduced accuracy and increased
variability, as well as the presence of a refrac-
tive bias producing myopic over-correction.13
This is especially pertinent in children, who
have high accommodative reserve.14,15 This
blur-driven accommodative component can
be reduced, when performing autorefraction
with a binocular open-field device, such as
the WAM-5500 (Shin-Nippon, Japan),16,17
with interaction and modulation of the addi-
tion of the blur-driven component by
vergence accommodation.1 The WAM en-
ables the patient to focus and fixate at far
through a half-silvered mirror, while the re-
fractive measurements are obtained. Another
possible technique to relax accommodation
involves the concept of testing in total dark-
ness, which we discovered serendipitously
years ago in an unrelated experiment. Here,
the subject was asked to sit in complete dark-
ness with eyes closed for five minutes followed
by autorefraction in total darkness. This tech-
nique minimises any reflex, proximal and
vergence components of accommodation.1
with the exception of tonic accommodation,
which is small (~0.50 D), and the individual’s
baseline distance refractive error. This tech-
nique avoids the need for a cycloplegic agent,
if proven to be reliable.
There are no published investigations com-
paring traditional clinical procedures to in-
dark testing of the eye’s refractive state. Thus,
© 2016 Optometry Australia
the aim of the present pilot study was to assess
non-cycloplegic objective refraction in dark-
ness using an open-field auto-refractor and
furthermore, to compare it with cycloplegic
distance subjective refraction and the
cycloplegic distance retinoscopy in the light,
in a sample of both children and young
adults.
METHODS
Twenty-three, visually-normal, young-adults
(46 eyes) between the ages of 23 and 31 years
and five children (10 eyes) between the ages
of five and 12 years, participated in the pilot
study. All had monocular and binocular vi-
sual acuity of 6/6 or better. The spherical re-
fractive component ranged from -2.25 to
+3.75 D, with a mean of +1.80 D. The cylindri-
cal refractive component ranged from
emmetropia to -1.00 D, with a mean of
-0.70 D. Subjects with anisometropia of
2.00 D or higher and/or with amblyopia
and/or strabismus were excluded, as well as
those with any history of ocular, neurological
or systemic disorders. In addition, subjects
with a spherical refractive component of
more than ±4.00 D and/or a cylindrical com-
ponent of more than 1.00 D were also ex-
cluded. This spherical refractive range
encompasses approximately 90 per cent of
the population in both children and
adults.18,19
Three different procedures were used to
assess and compare refractive error. These
included:
1. Objective assessment of the non-
cycloplegic refractive state using an open-
field, infrared autorefractor (WAM-5500,
AIT Industries, Illinois, USA) after five mi-
nutes in total darkness,
2. Cycloplegic distance static retinoscopy in
conventional reduced clinical room illu-
mination (20 lux), and
3. Subjective distance cycloplegic refraction
in conventional reduced clinical room
illumination (20 lux). One drop of
cycloplentolate (1%) was administered,
and all measurements were obtained 20
minutes later.20
The subject’s residual accommodation was
assessed using the push-up technique to en-
sure that the accommodative response was
significantly reduced (less than 2.00 D) and
with visual acuity of 6/18 or worse. Twenty mi-
nutes after the instillation of cycloplegia was
found to be sufficient to achieve this goal.
Retinoscopy and subjective refraction were
performed by the same optometrist in all
subjects. Standard clinical testing procedures
and conditions were used for these tech-
niques1 employing the hyperfocal, refractive
criterion of ‘maximum plus for maximum
visual acuity’ at a distance1 of six metres. All
measurements were obtained on the same
day within one session, with all measurements
performed in a counter-balanced manner.
Refraction was performed in the
dark using the WAM-5500 open-field
autorefractor.17 Subjects were initially seated
in a completely darkened room (six metres
length and three metres width) with their
eyes closed for five minutes to allow dissipa-
tion of any accommodative transients and re-
laxation of accommodation,1,21 and without
any prior knowledge of the room dimensions
to avoid any possible effects of proximal ac-
commodation.13 They were instructed to
gaze straight ahead, relax and try to ‘look’
far and not to move their eyes. The small dis-
play monitor of the WAM facing the experi-
menter was covered with a shear black cloth
to prevent stray light from illuminating the
otherwise totally-darkened room. Open-field
measurements of the accommodative re-
sponse were obtained in the right eye with
both eyes open. The mean of five measure-
ments was calculated and used in the analysis.
Periodically, eye alignment was monitored
through the black cloth to ensure that the
measurements were obtained through the
centre of the pupil. With any significant eye-
alignment error, the WAM gave either an
error message or a very high (~ -8.00 D)
and transient refractive value, which was
discarded in the analysis.
Repeatability of the WAM refraction in the
dark was assessed in five adults from the same
study population. These subjects were asked
to return on another day within the same
week and the above procedures were re-
peated by the same experimenter under the
same test conditions.
Sphero-cylindrical refraction was per-
formed for each technique; however, only
the spherical component of the refraction
was compared among the three techniques
to simplify the analysis, especially as the cylin-
drical components were small (less than 1.00
D). In the current study, no compensation
was made for the accommodative component
for any of the parameters tested. Thus, all
were reported as ‘raw’/uncompensated re-
fractive values. A one-way ANOVA was per-
formed for the factor of spherical
component of the refraction. In addition,
Pearson correlations were performed. For
repeatability assessment, an intra-class
Clinical and Experimental Optometry 99.2 March 2016
169
Objective refraction in darkness and cycloplegic refraction Vasudevan, Ciuffreda, Meehan, Grk and Cox
correlation (ICC) was performed to assess the
relationship between each device. An intra-
class correlation of less than 0.40 indicates
poor reproducibility; between 0.40 and 0.75
indicates fair-to-good reproducibility and
greater than 0.75 indicates excellent repro-
ducibility. The SPSS (version 20, IBM) statisti-
cal software was used for all data analysis and
graphical displays.
RESULTS
Adults
A one-way ANOVA was performed for the
factor of refractive technique. There was no
significant difference in mean refraction
among the three techniques, namely, non-
cycloplegic WAM refraction in the dark,
cycloplegic retinoscopy at distance and
cycloplegic subjective refraction at distance
(F[2,137] = 0.79, p = 0.45; Figure 1 A and B).
Figure 1. (A) Comparison of mean spheri-
cal refraction between in-dark WAM-refrac-
tion, cycloplegic distance retinoscopy, and
cycloplegic distance subjective refraction
in the adults. Subjects have been ordered
based on their refractive error. (B) Compar-
ison of mean spherical refraction between
in-dark WAM-refraction, cycloplegic dis-
tance retinoscopy and cycloplegic distance
subjective refraction in the children. Sub-
jects have been ordered based on their re-
fractive error.
Clinical and Experimental Optometry 99.2 March 2016
170
Children Non-cyloplegic WAM dark Cycloplegic retinoscopy Cycloplegic subjective
Mean (D) 1.98 1.84 1.93
SE (D) 0.37 0.42 0.36
Table 1. Summary of the group mean and standard error of the spherical component of
refraction for children with each of the three techniques (n = 10 eyes). D: dioptres
Adults Non-cyloplegic WAM dark Cycloplegic retinoscopy Cycloplegic subjective
Mean (D) 0.12 0.42 0.39
SE (D) 0.30 0.33 0.35
Table 2. Summary of the group mean and standard error of the spherical component of
refraction for adults with each of the three techniques (n = 46 eyes). D: dioptres
Mean difference in the spherical component
between the WAM refraction in the dark and
the cycloplegic distance retinoscopy was
-0.34 D, whereas it was -0.25 D between the
WAM refraction in the dark and the
cycloplegic subjective distance refraction.
Group mean and standard error of the mean
for the adults and children within the same
technique are summarised in Tables 1 and 2.
A Pearson correlation was performed to
compare the relationship between the three
refractive techniques. There was a high corre-
lation among them: WAM refraction versus
cycloplegic distance retinoscopy (p < 0.01;
r = 0.89; Figure 2), WAM refraction versus
Figure 2. Correlation of spherical refraction cycloplegic distance subjective refraction
between the in-dark WAM refraction and dis- (p < 0.01, r = 0.92; Figure 3) and cycloplegic dis-
tance cycloplegic retinoscopy in the adults tance retinoscopy versus cycloplegic distance
subjective refraction (p < 0.01, r = 0.96;
Figure 4).
Figure 3. Correlation of spherical refrac- Figure 4. Correlation of spherical refrac-
tion between the in-dark WAM refraction tion between cycloplegic distance retinos-
and distance cycloplegic subjective refrac- copy and distance cycloplegic subjective
tion in the adults refraction in the adults
© 2016 Optometry Australia
 Objective refraction in darkness and cycloplegic refraction Vasudevan, Ciuffreda, Meehan, Grk and Cox
Intra-class correlation was performed to as-
sess repeatability in five of the subjects for the
WAM refraction in the dark. The intra-class
correlation was 0.82 (p < 0.01) between the
first and second set of measurements, which
suggested excellent repeatability.
Children
A one-way ANOVA was performed for the fac-
tor of refractive technique. There was no sig-
nificant difference in refraction among the
three techniques: non-cycloplegic WAM re-
fraction in the dark, cycloplegic distance reti-
noscopy and cycloplegic subjective distance
refraction (F[2, 27] = 0.47, p = 0.62). Mean
Figure 5. Correlation between spherical re-
fraction with in-dark WAM refraction and
distance cycloplegic retinoscopy in the
children.
Figure 6. Correlation between spherical re-
fraction with in-dark WAM-refraction and
distance cycloplegic subjective refraction
in the children.
© 2016 Optometry Australia
difference in the spherical component be-
tween the in-dark WAM refraction and the
distance cycloplegic retinoscopy was +0.14
D, while the mean difference in the spherical
component between the in-dark WAM refrac-
tion and the cycloplegic distance subjective
refraction was -0.05 D.
A Pearson correlation was performed to
compare the relation between the three re-
fractive techniques. There was a high
correlation among them: in-dark WAM
refraction versus distance cycloplegic retinos-
copy (p < 0.01; r = 0.95; Figure 5), in-dark
WAM refraction versus distance cycloplegic
subjective refraction (p < 0.01, r = 0.96;
Figure 6) and cycloplegic distance retinos-
copy versus cycloplegic distance subjective
refraction (p < 0.01, r = 0.91; Figure 7).
DISCUSSION
There are several interesting findings in the
present study. First, the mean spherical re-
fractive values between the three techniques
were very similar. Second, the mean differ-
ence in spherical component between the
three techniques was no greater than -0.34 D
in the adults and +0.14 D in the children.
Thus, most differences were within the resolu-
tion limit of clinical refraction, that is, 0.25 D.1
Third, the three techniques were very highly
correlated.
There has been a long-term effort to
develop a quick and accurate way to perform
distance refraction with a subjective tech-
nique in children. Mohindra22 reported on
a non-cycloplegic refractive technique to be
used in young children and infants that
Figure 7. Correlation of spherical refrac-
tion between the distance cycloplegic reti-
noscopy and the distance cycloplegic
subjective refraction in the children.
involves dynamic retinoscopy at near (for ex-
ample, 40 cm) in a darkened room. In this
technique, the retinoscopy light is fixated
with one eye at near and the other eye is oc-
cluded. Hand-held trial lenses are rapidly in-
terposed to ascertain the retinoscopic
neutral point. The outcome of this technique
is dependent on quickly and carefully
performing retinoscopy in a darkened envi-
ronment with the child fixating on the near
target. It has been reported that retinoscopy
obtained using the Mohindra technique is
comparable to that of cycloplegic refraction,
with a ±0.50 D mean difference.23 Interest-
ingly, the present study makes the process
easier and objective by using an auto-
refraction. In addition, elimination of effec-
tively all possible light in the room enables a
better estimate of refraction in the absence
of any possible distractions and undesirable
accommodative changes. Liang et al.24
compared refractive error between the
hand-held Retinomax and table-top Topcon
autorefractors in 114 cyclopleged (mean
age: 6.7 years) and 156 non-cyclopleged
(mean age: 8.5 years) children in a cross-
sectional study. They reported that the
Retinomax exhibited a mean myopic bias
(0.59 D) under non-cycloplegic conditions,
but effectively none was observed with
cycloplegia. Later, Iuorno, Grant and
Noël25compared the Welch Allyn SureSight
autorefractor under non-cycloplegic condi-
tions to both the Nidek AR-20 autorefractor
and distance retinoscopy with cycloplegia
in 91 children (mean age: 8.1 years). They
reported that the Welch Allyn device often
produced a more myopic refraction than
the other techniques, thus making it a less
preferred option for the visual screening
of young children.
More recently,12 refraction was compared
in 117 children (ages seven to 12 years)
between three autorefractors, the Retinomax
K Plus 2, the Canon RF10, and the Grand
Seiko WR5100K. Subjective refraction with
and without cycloplegia was performed.
Under the non-cycloplegic conditions, the
three autorefractors again produced a more
myopic correction in the children without
cycloplegia than that found with cycloplegia.
Under cycloplegic conditions, the auto-
refractors were accurate and in agreement
with the cycloplegic clinical findings. All of
the above results suggest an undesirable and
intrusive accommodative component, thus
frequently resulting in an inaccurate and
biased refraction, without cycloplegia in
children.
Clinical and Experimental Optometry 99.2 March 2016
171
Objective refraction in darkness and cycloplegic refraction Vasudevan, Ciuffreda, Meehan, Grk and Cox
The Grand Seiko (WR-5100K) has
very good overall accuracy. The mean intra-
session repeatability has been found to be
0.09 D for the spherical component and
0.14 D for the cylindrical component.17 This
high level of performance may be attributed
to its binocular, open field-of-view design,
which allows the aggregate accommodative
response to be better controlled and
minimised, when one focuses upon a physical
target positioned at distance (for example, six
metres). It differs from the Retinomax K plus
2 and the Canon RK 10, both of which use
‘fogging techniques’ to attempt to control ac-
commodation.16,17 Such fogging approaches
may be inadequate, as there are other factors,
such as proximal accommodation induced by
gazing and focusing into the enclosed near
system,16 which can be up to 1.00 D or more.
While ease of use and ability to obtain
rapid measurements are important, accurate
refractive measurements in children are ever
more relevant. In children following
cyclopegia, a good estimate of any latent hy-
peropia is essential to assess their risk of stra-
bismus and/or amblyopia,3 and also to
provide them with an appropriate refractive
correction for clarity of vision. In addition,
children wearing spectacles that have myopic
overcorrection need to exert additional ac-
commodative effort for clear vision, which
may result in asthenopia. If they do not do
so, the resultant uncompensated and in-
creased retinal defocus may contribute to
the development and/or progression of myo-
pia.26 The prescription of spectacles based
solely on the non-cycloplegic autorefraction
may predispose them to myopic progres-
sion.26 Therefore, the practice of using one’s
non-cycloplegia autorefraction should be
subjected to closer scrutiny, especially if the
spectacle prescription is determined solely
on such measurements.
The current pilot study investigated an ad-
ditional way to assess refractive error in both
adults and children without the use of
cycloplegia. Both cycloplegic refraction and
non-cycloplegic WAM refraction in the dark
values incorporate the tonic component of
approximately 0.50 D. In contrast, for the
dry retinoscopy/subjctive refraction values, a
compensation of approximately 0.50 D
should be deducted from the WAM vlaue
for appropriate comparison. In current clini-
cal settings, many practitioners use
autorefractors to obtain an initial estimate of
Clinical and Experimental Optometry 99.2 March 2016
172
the distance refraction. This is followed by
its subjective refinement. Together, conven-
tional objective autorefraction and subse-
quent subjective refraction have provided a
good protocol in most patients to determine
the refractive state accurately; however, it
does not completely eliminate any accommo-
dative component in the young adult or
child. Tonic accommodation will be present
in the cycloplegic refraction. Our proposed
new technique of employing WAM distance
refraction in the dark serves as an adjunct or
even an alternative, to cycloplegic refraction
in these populations. While similar results
have been obtained between autorefraction
and subjective refraction,13 the WAM in dark-
ness concept is the only clinical technique
that is both safe and comparable to
cycloplegic retinoscopy and cycloplegic sub-
jective refraction. In summary, refraction in
the dark offers a quick, safe and reliable alter-
native to cycloplegic subjective refraction in
both young adults and children.
There are some limitations to the present
pilot study. First, the samples were relatively
small. Second, moderate-to-large cylinders
were not incorporated into the sample.
Third, a larger range of overall refraction
was not assessed. Further investigation is
required on a larger population of children
over a wide range of both spherical and cylin-
drical refractive errors to validate and extend
this technique in these populations, as well as
others (for example, those with brain injury
and cognitive impairment).
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