CYCLOPLEGIC REFRACTION

IN STRABISMUS

R. Haryo Yudono
Pediatric Ophthalmology and Strabismus
Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas
Gadjah Mada
History
• Cycloplegic refraction was put in scientific basis
by Donders
• It was universally accepted after the publication
of the donders “Anomalies of accommodation
and refraction of the eye” in 1864

Franciscus Cornelis Donders

INTRODUCTION

• Refractive error most common cause of visual disturbance worldwide

• Vitale et al: in the US, most common refractive error is astigmatism
(36.2%), myopia (33.1%), hyperopia (3.6%)
• 2 methods of evaluation of refractive error: cycloplegic and non-
cycloplegic
• Cycloplegic refraction (CR) is a crucial procedure for strabismus
evaluation ; esotropia (ET)
• The principle steps in the diagnosis and treatment of ET are determine
of full amount of hyperopia, whether hyperopia correction will correct
ET
INTRODUCTION

Cyclo = ciliary, plegic = paralysis

To determine a person’s complete refractive error by temporarily

paralyzing the ciliary body body by using cycloplegic eye drops.
The accommodation of lens is fully relaxed.

Gold standard for children and adults with active accommodation

Cycloplegic vs Non cycloplegic refraction
No Characteristic Cycloplegic Noncycloplegic
1 Pupil dilatation Dilated Undilated
2 Accommodation Lost Intact
3 Time Need more time Need less time
4 Drugs Atropine, Cyclopentolate, Not needed
Tropicamide,  Homatropine
5 Types - Retinoscopy, Autorefractor,
Objective and Subjective
retinoscopy

6 Cost Costly Less costly

7 Patient convenience Less More
Kaur K, Gurnani B. Cycloplegic And Noncycloplegic Refraction. [Updated 2022 May 10]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK580522/
Principle of cycloplegic refraction

Determination of total refractive error during

temporary paralysis of ciliary muscles as an
instillation of cycloplegic drugs & it is objective
methods which is also known as wet retinoscopy
Parasympathetic action in eye
Cholinergic receptors

• found in the iris sphincter and the ciliary body.

• It is of the muscarinic type also found in the skeletal
muscles.
• Five sub types of muscarinic receptors(M1-M5)
• The muscarinic agonist action at the receptor constricts
the pupil and contracts the ciliary muscles.
• causes pupillary dilatation & paralysis of
accommodation
Cholinergic receptors
Cycloplegic agents

• Atrophine sulphate
• Homatropine hydrobromide
• Cyclopentolate hydrochloride
• Tropicamide
Cycloplegic agents
No Drug  Age Group Dose Peak effect Timing of Duration of Cycloplegic Tonus
Retinoscopy action effect allowance
1 Atropine Below 5 Three times x 3 2-3 days 4 day 10-20 days After 3 weeks of 1 D
Sulfate (1% ointment) years days retinoscopy

2 Homatropine 5-8 years One drop for 1-1.5 hours After 90 2-3 days After 3 weeks of 0.5 D
hydrobromide every 10 mins minutes of retinoscopy
(2% drops) ( 6 times) drug
administration
3 Cyclopentolate 8-20 years One drop every 80-90 After 90 6-18 hours After 3 days of 0.75 D
hydrochloride (1% drops) 15 mins (3 minutes minutes of retinoscopy
times) drug
administration
(Havener's
recommende
d dose)
4 Tropicamide (0.5%, 1% Above 15 One drop every 20-40 - 4-6 hours - -
drops) years, used 15 mins (3-4 minutes
as a times)
mydriatic
Cycloplegic Refraction (CR)

Ocular
Accomodation
Convergence

CR is important test in the evaluation of any patient who has

issues relating to binocular vision and ocular motility
Indication of cycloplegic refraction
(CR)

• Determination of objective refractive error by relaxing

accommodation
a.    Young or uncooperative patients
b.    Strabismus
c.    Suspected malingerer
d.    Accommodative spasm/pseudo myopia
e.    Infantile glaucoma (surrogate for axial length)
 Indication of cycloplegic refraction
(CR)
Mandatory to do CR Accomodative
ET

Refractive Nonrefractive Partially

(Normal AC/A) (High AC/A) Accomodative

Accommodative ET is defined as a convergent deviation of the eyes

associated with activation of the accommodative reflex
Indication of cycloplegic refraction
(CR)

Acquired
Nonaccomodative ET

Divergence Spasm of
Basic Cyclic Sensory Consecutive
Insuf near reflex
Mandatory to do CR
Indication of cycloplegic refraction
(CR)
For patients with
accommodative ET,
repeated cycloplegic
examination are essentials
whe control of strabismus is
precarious
When is cycloplegia ready for refraction?

Determined by
Mydriasis and
Asses residual
cycloplegia do not
Cycloplegia accommodation by
complete at the
push up test
same time
Contraindication of cycloplegic
refraction (CR)

1. Previous adverse effects

2. All drugs have possibility of anticholinergic
side-effects
• Central nervous system changes
• Flushing
• Dry mouth and eyes
• Fever
Side effects of cycloplegic drugs
• Atropine: fever, dry mouth, decrease sweating, allergic reactions
of eyelid and conjunctiva, elevation of IOP, tachycardia,
convulsions, death
• Homatropine: incoherent speech, hallucinations, disorientation,
psychosis, visual disturbances
• Cyclopentolate: lacrimation, blurred vision, hallucinations, ataxia,
disorientation, disturbance in speech, restlessness
• Tropicamide: foreign body sensation, dry mouth, mood changes,
tachypnea
References
• AAO, Basic and Clinical Science Course. Section 6: Pediatric Ophthalmology and Strabismus, 2021-2022
• Kenneth Wright. Handbook of Pediatric Strabismus and Amblyopia. 2003. Section 6: Sensory Aspects of Strabismus.
• Nelson LB, Catalano RA. 2014. Wills Eye Strabismus Atlas. 2014.
• Lambert SR, Lyons CJ. 2014. Taylor and Hoyt’s Pediatric Ophthalmology and Strabismus : Fifth Edition. Elsevier.
THANK YOU