CYCLOPLEGIC REFRACTION

IN ADULT

MD SHAHID MANZOOR
FELLOW NEI
 Manifest refraction: A refraction without
cycloplegic drops (which dilate the pupils and
prevent accommodation); it is also called a "dry"
refraction

 Cycloplegic refraction: A refraction done with

cycloplegic drops given to dilate the pupils and
prevent accommodation; it is also called a "wet"
refraction.
 Post-cycloplegic refraction( PMT):
A "dry" refraction performed on a visit at least several
days after a "wet" refraction.

 The purpose is to see how much of the full cycloplegic

refraction found on the previous visit can be tolerated.
 The precision of refraction is affected by
accommodation which leads to a myopic shift,
especially in children, who have a wider
accommodative range.

 Therefore, cycloplegic refraction is common

practice in children to ensure accurate
assessment of refractive error [1, 2].

 1) Fotedar R, Rochtchina E, Morgan I,Wang JJ, Mitchell P, Rose KA (2007) Necessity of cycloplegia
for assessing refractive error in 12- year-old children: a population-based study. Am J Ophthalmol
144:307–309
 2. Chen J, Xie A, Hou L, Su Y, Lu F, Thorn F (2011) Cycloplegic and noncycloplegic refractions of
Chinese neonatal infants. Invest Ophthalmol Vis Sci 52:2456–2461
 Conflicting evidence exists regarding the need for
cycloplegic measurement in adolescents and
young adults.

 While the data from the Tehran Eye Study [3, 4]

and Beaver Dam Offspring Study [5] both
support the notion that cycloplegia is necessary
in young adults, a recent study by Sanfilippo et
al. concluded that cycloplegia is warranted for
adolescents but not for young adults [6]

 3. Fotouhi A, Morgan IG, Iribarren R, Khabazkhoob M,Hashemi H (2012) Validity of

noncycloplegic refraction in the assessment of refractive errors: the Tehran Eye Study. Acta
Ophthalmol 90:380–386
 4. Hashemi H, Fotouhi A, Mohammad K (2004) The ageand gender-specific prevalences of
refractive errors in Tehran: the Tehran Eye Study. Ophthalmic Epidemiol 11: 213–225
 5. Krantz EM, Cruickshanks KJ, Klein BE, Klein R, Huang GH, Nieto FJ (2010) Measuring refraction
in adults in epidemiological studies. Arch Ophthalmol 128:88–92
 6. Sanfilippo PG, Chu BS, Bigault O, Kearns LS, Boon MY, Young TL, Hammond CJ, Hewitt AW,
Mackey DA (2014) What is the appropriate age cut-off for cycloplegia in refraction? Acta
Ophthalmol 92:e458–e462
 INDICATION
 Hyperopia.
 Asthenopia with near work.

 Accommodative Spasm.

 Anisometropia.

 Esotropia.
 CONTRAINDICATION
 Absence of pt consent .
 Hypersensitivity.

 H/o angle closure attack.

 Practical inconvenience.
 1) HYPERMETROPIA

 TOTAL HYPERMETROPIA
=LATENT + MANIFEST (facultative + absolute)
 LATENT V/S MANIFEST HYPEROPIA

 The condition in which all or part of a patient’s

hyperopia is compensated for by the tonicity of
the ciliary muscle, is known as latent hyperopia.

 The hyperopia which can be revealed in a

objective refraction represents the patient’s
manifest hyperopia.

 Latent Hyperopia can only be revealed in a

cycloplegic refraction
 As people age and their amplitude of
accommodation decreases, latent hyperopia tends
to become manifest

 For this reason some low hyperopes not requiring

glasses (and not having enough latent hyperopia
to cause symptoms of eyestrain) find that, as
amplitude of accommodation decreases with age,
glasses are eventually required for clear and
comfortable vision.
ABSOLUTE V/S FACULTATIVE HYPEROPIA
 The hyperopia which can be revealed in a
objective refraction represents the patient’s
manifest hyperopia.(Absolute + Facultative )

 Absolute Hyperopia is that hyperopia that cannot

be compensated for by accommodation

 The additional dioptres of Hyperopia that can be

overcome by accommodation is Facultative
Hyperopia
 RE-

 AR- + 1.5 DS
 ST- + 1.0 DS
 DR- + 3.00 DS
 DA- + 2.50

 Find manifest hyperopia, latent hyperopia, absolute

hyperopia, facultative hyperopia and total hyperopia
 manifest= +1.50 D
 latent = +3.00 D – (+1.50 D) = +1.50 D

 absolute = +1.00 D

 facultative = +1.50 D –(+1.00 D) = +0.50 D

 Total = +1.50 D + (+1.50 D) = +3.00 D

 2) ASTHENOPIA WITH NEAR WORK

 Asthenopia with near work.

 This applies for children and young adults.
A study of young adults 18-21 years old showed
that they possessed +1 to +2 D of latent
hypermetropia.

 Should they complain of headaches with near

work and asthenopia, cycloplegic refraction is
indicated.
 3) ACCOMMODATIVE SPASM

Accommodative Spasm. In older children and

young adults, cycloplegic refraction can confirm
the diagnosis of accommodative spasm, which is a
constant or intermittent, involuntary increase in
ciliary contraction.

 Patients with low hyperopia may present as

myopic during examination; this so-called
pseudomyopia can be identified by cycloplegic
evaluation.
 PSEUDOMYOPIA
 Pseudomyopia has been defined as a reversible
form of myopia that results from a spasm of the
ciliary muscle.

 The excessive accommodative response produces

an apparent myopic shift that will disappear
when a cycloplegic agent is administered to
produce relaxation of accommodation.
 History of a reduction in distance visual acuity,
particularly toward the end of a working day .

 These patients are frequently detected by the

presence of a significantly greater (more than 1
D) amount of relative plus power (i.e., more
hyperopia or less myopia) on retinoscopy
compared with the subjective refractive .
 4) ANISOMETROPIA
 Anisometropia is a very powerful amblyogenic
risk factor. Over +1.00ds difference between two
eyes can put a child at risk of developing
anisometropic amblopia.

 It is not surprising to find a much larger

difference in refractive error between the two
eyes after cyclodilation.
 5)ESOTROPIA

 Esotropia. New onset or previously well-

controlled accommodative esotrope is an
indication for cycloplegic refraction.

 This allows us to determine whether the eye

turn has an accommodative component.
 HYPEROPIA CASE 1
 A 25-year-old patient was recently given a
glasses somewhere.
They are now complaining that they cannot
tolerate the new glasses. What should be done?
 Cycloplegic refraction is required, If a significant
amount of plus sphere, not previously worn, is
found on a cycloplegic refraction, it is best to
bring the patient back for a post-cycloplegic
refraction before writing the final prescription.

 The purpose is to determine

how much of the full cycloplegic refraction they
can tolerate.
 A lesser amount than the full hyperopic
correction may need to be prescribed because the
long-standing accommodative tone, which has
been present to self-correct the latent hyperopia,
can be quite resistant to relaxation.
 Over time, this tone will decrease and,
subsequently, additional plus can be added until
the full hyperopic correction is accepted.
HYPEROPIA CASE 2
 Always think of uncorrected or undercorrected
hyperopia in young patients who have presbyopic
symptoms.
 HYPEROPIA CASE 3
 A 35-year-old patient without glasses is seeing
well at distance, but is having difficulty reading.

 Is this presbyopia?
 The patient most likely has hyperopia that is not
being fully corrected by their glasses.

 They are therefore using their accommodative

ability to correct the latent hyperopia, leaving an
insufficient amount of accommodation for
reading.
 When measuring to uncover latent hyperopia,
one may perform a cycloplegic refraction or "push
plus," that is, during a noncycloplegic refraction,
give as much plus spherical power as the patient
will tolerate without causing blurring or
discomfort.
 If a large amount of latent hyperopia is found

with a cycloplegic refraction, it is often best for

the patient to return for a post-cycloplegic
refraction to make sure they can tolerate the
additional plus.
 It may be necessary to give them the full
hyperopic correction in stages if the
accommodative tone, probably present for many
years to correct the latent hyperopia, is not able
to relax readily.

 Latent hyperopia can commonly, be present in

individuals who see well at distance without
glasses and are not known to be hyperopic
HYPEROPIA CASE 4
 MYOPIA CASE 1

 A 24-year-old myope who, although seeing

reasonably well at distance without correction, is
"soaking up" minus spherical power during
subjective refraction. Why is this happening, and
what can be done to determine if it is needed?
- It is important, when performing subjective
refraction, to be concerned about giving the
patient too much minus spherical correction.
Over-minusing occurs as a result of the patient
accommodating during the refraction.
-This is especially a concern with a younger
patient, for they have a great deal of
accommodative ability.
- There is a tendency for the extra minus power
to be preferred by the patient because, when
offset by accommodation, the letters on the acuity
chart will look smaller and darker, and thus
"better."
 A cycloplegic refraction can be performed

 The red-green duochrome test can be used.

 Fogging techniques can be employed so that the

patient begins from a position of extra plus.
 MYOPIA CASE 2
 A 37-year-old myope seeing well at distance with
their glasses is having trouble reading.

 Is this presbyopia?
-
 For someone 37 years of age, presbyopia is not
the most likely diagnosis.
 It is much more likely the patient is over-

minused at distance. Their trouble reading is,

most probably, the result of having to use their
accommodative ability to offset the excessive
minus in their glasses.
 They therefore do not have enough

- accommodation left to use for reading.

 Let the patient know that the new glasses you
will be giving them, with less minus sphere, may
require a little adjustment period for seeing
clearly at distance, as their accommodative tone
may take a little time to relax.
MYOPIA CASE 3
 ASTHENOPIA CASE NO 1
 A young adult (27-year-old) who does not wear
glasses is having difficulty reading.

What are the considerations?

 Reading difficulty in a 27-year-old is not due to
presbyopia. Three primary considerations are:

 1. If the patient has a significant amount of

latent hyperopia, their accommodative ability
is being used to correct their hyperopic
refractive error, leaving an insufficient amount
for reading.
 2. Convergence insufficiency:
The near point of convergence should be no
farther away than 8 cm. Patients with
convergence insufficiency typically complain of
headache and eye strain (asthenopia) which
occur very soon after they begin reading. Often
words will begin to swim together, and they
should be asked whether they have observed
this, for this symptom is quite diagnostic.
 Convergence exercises are a very effective

treatment for these patients, with great success

in eliminating their symptoms.
 3. Medication:
Medicines used for colds, motion sickness, and
some central nervous system diseases are among
those that can make reading more difficult by
their effect on the pupils and accommodation.
History is important in identifying this etiology.
 POST MYDRIATIC TEST
 The reason most likely to be cited for omitting a
cycloplegic examination is the need for a post
cycloplegic refraction.

 But is a second visit really necessary?

 The only candidates who will be qualified for
PMT are those who exhibit a significant
difference between their manifest and cycloplegic
refractive errors.

 This will not include more than 15- 20 % of

cycloplegic refractions.
 1) Adolescents –who are myopic under
cycloplegic will never reveal any less myopia with
a post-cycloplegic test; therefore they a may be
exused. For them you simply prescribe the
cycloplegic findings.

 2) Adult- Their cycloplegic refractions are

usually preceded by a manifest refraction. If the
two yield compatible data, as happens in the
majority of patients, no post- cycloplegic test is
required.
 3) Pre – prebyopes and presbyopes;
- A difference from manifest is found in pre-
presbyopes, then a post- examination is
mandatory.

- Cycloplegia is rarely necessary after age 55(

mydriatics alone will suffice for ophthalmoscopy),
so post- cycloplegic examinations are even less
common.