CYCLOPLEGIC REFRACTION

EXAMINATION IN CHILDREN
dr. Tia Afelita
dr. Kemala Sayuti

2nd STAGE
Ophtalmology Department
Medical Faculty Andalas University
M. Djamil General Hospital
.
1 INTRODUCTION

ANATOMY AND PHYSIOLOGY OF THE

2 IRIS AND CILIARY BODY

3 GROWTH AND DEVELOPMENT

4 CYCLOPLEGIC REFRACTION EXAMINA-

TION

5 CONCLUSION
INTRODUCTION
INTRODUCTION
Cycloplegic Refraction Examination in Children
19 Million
Children globally have visual
impairment
Mahayana, etc
in Yogjakarta and Central
Java, the prevalence of un-
corrected refractive errors
in elementary school chil-
dren in urban and suburban
areas was 10.1% and
12.3% respectively.
12 Million
of them due to uncorrected
refractive errors
Halim, etc
the prevalence of refractive
errors in children aged 11-15
years in suburban areas in
Bandung is 15.9% with un-
corrected cases 12.1%
 INTRODUCTION
Refractive errors in Children

Refractive errors in children are important to treat because they can

cause amblyopia, visual disturbances, and blindness. In addition, it
will have an impact on low academic performance at school, impaired
intelligence development, and barriers to children's social life
INTRODUCTION

Examination with cycloplegics is an important component

of the examination of refraction in children, especially in
young children, high hypermetropia, or with
strabismus

“ Cyclopegic refraction is the gold standard

for measuring refraction in children because
of its ability to prevent accommodation

“
INTRODUCTION

In uncooperative children, an alternative

examination with:
- restriction of physical movement
- further examination under sedation
and anesthesia.
ANATOMY AND
PHYSIOLOGY OF
THE IRIS AND CIL-
IARY BODY
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
IRIS
- Thin, pigmented contractile circular structure, analogous to the
diaphragm of a camera
- Anterior extensive of uveal tract
- Extends from iris root to iris margin that forms the pupil
- Central aperture is called pupil (3-4 mm)
- Lies on anterior lens surfaces, surrounded by aqueous humour
- Posteriorly, central portion of iris is in contact with lens which
give characteristic conical configuration

- Function:
- The diaphragm regulates the amount of light entering the
eye
- controls optical aberrations
- depth of focus
- plays a role in the flow of aqueous humor.
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
IRIS
The layers of the iris are:
- Anterior limiting layer
- Stroma of iris and Ciliary muscle,
- Anterior epithelium
- Posterior epithelium
Epitel

Anterior limiting layer Pigmen

Iris

- Thin, discontinuous (cryptic) condensed ante-

rior stroma
- Composed of collagen fibrils & fibroblasts
- It contains number of melanocytes regardless
of iris color-in darker iris melanin granules are
dense & numerous
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY

Stroma of Iris
- Loose, pigmented, highly vascular connective tissue
- Composed of pigmented & non-pigmented cells,
muscles, collagen fibrils & extensive ground sub-
stance
- Pigmented: melanocytes & clump cells (pig-
mented cell)
- Non-pigmented: fibroblast, lymphocyte,
macrophage, mast cells
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
Ciliary muscle
- Two type of iris muscle located in the stromal layer of iris:
Sphincter muscle in pupillary zone and dilator muscle in
the ciliary zone
- Sphincter muscle:
- Oriented parallel to the pupillary margin
- Measure 0,75mm in diameter and has thickness of
0,1-1,7mm
- Contractions causes constriction (miosis)
- Supplied by parasympathetic nerve
- Dilator muscle:
- 4μm in thickness
- Located in ciliary zone
- Oriented radially from iris root toward the pupil
- Contraction cuase  dilatation of pupil
- Supplied by sympathetic nerve
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY

Anterior epithelium & dilator muscle

- Composed of unique myoepithelial cells

Posterior epithelium
- Single layer of heavily pigmented simple colum-
nar cells
- At posterior, continuous with inner non-pig-
mented epithelial layer of ciliary body
- Curled to anterior surface at pupil margin 
Pupillary ruff
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
Ciliary Body
- layer of the uvea that functions in the process of
accommodation and production of aqueous hu-
mor
- Dimension:
- 5,9 mm nasally (From limbus)
- 6,7 mm wide temporally
- Its is triangular shape in cross section-base facing
anterior chamber and apex at ora serrata
- It extends from the posterior limit of limbus (s-
cleral spur & iris root) to Ora serrata

- It consists two parts

- Pars plicata – 2mm - anterior vascular part
- Pars plana – 4mm – posterior flat avascular
part
 ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
Ciliary muscle
3 groups of smooth muscle fibers which function as
unit:
1. Longitudinal muscle (outer)
- Attached anteriorly to scleral spur, outer
trabecular meshwork
2. Radial muscle/oblique
- Attached to the inner uveal mesh work
3. Circular muscle (inner muscle)
- Primarily attached to the ciliary and iris
stroma

Posteriorly muscle are attached to elastic structure

of par planna vessels and bruch’s elastic
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
Iris nerve supply
- Efferent presynaptic parasympathetic nerve begins
oculomotorius nucleus  Edinger Westhpal Nucleus
(EWN) in Midbrain
- Axons of EWN extend into N III (Oculomotorius
nerve)
- Leaves at dorsomedial aspects of brain stem
- Enters orbit via the inferior divisions of N III
- Terminates in Ciliary ganglion
- Axons from ciliary ganglion extends as post synaptic
fiber via short ciliary nerve to innervate the sphincter
pupillae
ANATOMY AND PHYSIOLOGY OF THE IRIS AND
CILIARY BODY
GROWTH AND
DEVELOPMENT
 Changes in children's eyes
occur in 3 phases

First phase Second Phase Third Phase

(Birth – 2 years)
period of rapid growth axial length
increases by about 4 mm in the first
6 months of life and increases by 2
mm over the next 6 months
(ages 2 – 5 (ages 5 – 13 years)
years)
Growth begins to slow down,
and the axial length increases
by 1 mm in each phase.
GROWTH AND DEVELOPMENT
Eyeball dimension development

 Eyeball Dimensions in Newborns and Adults

Newborn Adult
Axial Length 14.5 – 15.5 mm 23.0 – 24.0
Horizontal Corneal 9.5 – 10.5 mm 12.0 mm
Diameter
K Value 52.00 D 42.00 – 44.00 D
GROWTH AND DEVELOPMENT
Progression of Refraction and Emmetropization Status
- Newborns have hyperopic eyes of about 3 D.
- In the first months of life, this hyperopia in-
creases slightly, but decreases to about 1 D by the
end of the first year of life due to:
- changes in the strength of the cornea and
lens,
- the axial length of the eyeball,
By the end of the second year of life, the anterior
segment reaches adult proportions,

- Emmetropia occurs around the age of 6-8 years,

but if myopia occurs before the age of 10 years,
the risk of developing progressive myopia or my-
opia > 6 D will be higher.
Visual Acuity Development in Children
GROWTH AND DEVELOPMENT
Accommodation
Accommodation is the eye's ability to dynamically increase the diopter
power of the lens to keep the image focused on the retina as it changes from
far to near vision
GROWTH AND DEVELOPMENT

Accommodation for newborns

- the accommodation process has been there since
birth but the mechanism is not accurate until the
age of 4 months of life
- At the age of 2-3 months, babies are usually able to
fixate on objects at close range and are able to fol-
low moving objects and try to reach objects they
see.
- At the age of 3-4 months, full accommodation has
occurred with the lens starting to flatten and the cil-
iary muscles starting to strengthen.
GROWTH AND DEVELOPMENT

Etiology of Refractive Errors in Children

CYCLOPLEGIC
REFRACTION EX-
AMINATION
CYCLOPLEGIC REFRACTION EXAMINA-
TION
- Examination with cycloplegics is an important compo-
nent of the examination of refraction in children, espe-
cially in younger children, high hypermetropia, or ac-
companied by strabismus.

- Maximum cycloplegia in children is needed to get an ac-

curate measurement of refractive errors because the
tone of accommodation in children is higher than adults.

- Cycloplegic drugs work to temporarily paralyze the cil-

iary muscle and pupillary sphincter

- The ideal cycloplegic can be identified by full hyperme-

tropia, rapid onset, short duration, painless drip and
minimal side effects.
CYCLOPLEGIC REFRACTION EXAMINATION
Cycloplegic drugs
 Retinoscopy
examination
- Retinoscopy is an objective examination to as-
sess the patient's refractive status.
- There are two types of retinoscopy, namely:
- by using cycloplegic
- without cycloplegics
- The principle of retinoscopy examination with cy-
cloplegic and without cycloplegic is basically the
same, the difference lies in the procedure.
- The tool that is often used is the steak
retinoscope
The steps of objective refraction exam-
ination using streak retinoscopy in-
clude:
- Give cycloplegic drugs according to the
route of administration.

- The patient sits opposite the examiner at a

working distance of 50 cm and wears a
+2.00 D lens.

- The examiner uses the right eye to perform

a retinoscopy examination of the patient's
right eye, and the examiner's left eye to ex-
amine the patient's left eye.
The steps of objective refraction exam-
ination using streak retinoscopy in-
clude:
- Drop the retinoscope beam on the pupil and move it
perpendicular to the axis and the value of the light
reflex on the pupil. Move it on different meridians.
Seen whether the movement is opposite or in the di-
rection of the light.

- In emmetropia the fundal reflex does not move,

which is called neutralization

- If the light reflected from the eye that appears in the

pupil moves in the direction of the retinoscope (with
movement), then add a positive lens slowly so that
the light does not move or until it appears stationary.
The steps of objective refraction exam-
ination using streak retinoscopy in-
clude:
- If the light reflected from the eye appears in the
pupil moving in the opposite direction to the
retinoscope (against movement), then add the neg-
ative lens slowly so that the light does not move or
until it appears still.

- If the streak shows broken and broken rays, the ex-

amination is carried out on both perpendicular axes
to see the strength of the cylindrical lens or its
astigmatism.

- Record the results of the examination and the value

then if possible make corrections for refraction.
Eye Position Affects Refractive Correction
- The position of the eye in children such as esotropia or exotropia affects
the correction of refraction in children.

- In refractive accommodative esotropia where esotropia is caused by ex-

cessive convergence arising from accommodation to overcome hyperme-
tropia.
- The clinical picture generally appears at 2-3 years
of age, starting with an intermittent phase of 1-3
years (amblyopia is usually absent) and then pro-
gressing to constant esotropia (amblyopia is
present).

- So in patients with uncorrected hypermetropia,

accommodation will occur to get a clear image
and will cause convergence.
Eye Position Affects Refractive Correction
- If there is insufficient fusional divergence, an esodeviation will occur.

- Correction in this patient is to immediately provide full correction for hy-

permetropia with the principle of reducing esotropia to 8 PD or less and
given to children aged less than 6 years.

- In exotropia, the development of exodeviation can

be intermittent or constant

- Intermittent exotropia usually occurs in infancy and

childhood, and usually occurs at several months of
age

- Correction of refractive error by overcorrection for

myopia (usually 2-4 D) with minus lenses or bifocals
can control deviation effectively.
 Examination of Non-Cooperative
Children
- In infants and young children, a brief physical move-
ment restriction (restraint) may be necessary.

- Depending on the severity of the eye problem, exam-

ination under sedation or under anesthesia may be
the best solution

- Examination under anesthesia is indicated in children

who have developmental delays or children who are
aggressive and strong enough to be held safely and
require further evaluation.
CONCLUSION
CONCLUSION
Cycloplegic Refraction Examination in Children

1. Refractive status in children changes as the length of the eye-

ball axis increases and the cornea and lens become flatter.
2. Examination of cycloplegic refraction is the gold standard ex-
amination for examination of refractive errors in children.
3. The working principle of streak retinoscopy is that when light
from the retinoscope enters the eye, the light is reflected from
the retina which is called the retinoscopy reflex or red reflex
and the value of the direction of the light movement, if it is in
the same direction, it means that there is a hyperopia refractive
disorder and if it is in the opposite direction, it means that there
is myopia. neutralization.
4. In children who are less cooperative, physical motion restric-
tion (restraint) examinations can be carried out by administer-
ing anesthesia or sedation.
 Thank you
Cycloplegic Refraction Examination in Children