Abstract
CONTEXT:
Uncorrected refractive errors are the most common cause of visual impairment and global blindness.
AIMS:
This study aims to assess the accuracy of refractive error measurements using streak retinoscopy and autorefraction, both with and without administering cycloplegics, in children aged 4–10 years.
SETTINGS AND DESIGN:
This study is an analytical observational research with a cross-sectional design.
SUBJECTS AND METHODS:
This study was conducted at an eye clinic from January 2020 to August 2020, with 90 subjects. The examination utilized 1% cyclopentolate cycloplegia administered twice within 1 h, along with retinoscopy and autorefractors.
STATISTICAL ANALYSIS USED:
The data were analyzed using the Wilcoxon signed-rank test.
RESULTS:
The study results indicate that (1) there was no significant difference in the mean spherical equivalent (SE) before cycloplegia between the two instruments (P = 0.630); (2) a significant difference in mean SE after cycloplegia was observed for both instruments (P < 0.001); (3) significant differences in mean SE after cycloplegia were noted for both instruments in cases of compound myopic astigmatism (P < 0.001), compound hyperopic astigmatism (P = 0.007), and mixed astigmatism (P = 0.001); and (4) examination of all subjects showed undercorrection of autorefractometry results compared to those of retinoscopy.
CONCLUSIONS:
Retinoscopy and autorefractors yield different results for refractive error correction after cycloplegia. Therefore, autorefractor examination with cycloplegia cannot be considered a substitute for retinoscopy with cycloplegia.
Keywords: Autorefractor, cycloplegia, refractive errors, retinoscopy
Introduction
Refractive errors, or ametropia, are optical defects that disrupt the formation of a focus on the retina by the incoming light rays. These disorders are classified into myopia, hyperopia, and astigmatism.[1] Uncorrected refractive errors are the most common cause of visual impairment and a significant contributor to global blindness. According to the World Health Organization, approximately 45 million individuals are blind worldwide, and an estimated 135 million suffer from low vision.[2] It is estimated that approximately 1.4 million cases of childhood blindness exist, with around 500,000 new cases occurring each year.[2] The prevalence of refractive errors among children in Indonesia is 22.1%. These disorders affect about 10% of the 66 million children aged 5–19 years.[3] In Makassar, the rates of blindness and eye disorders among children have not been previously reported.[2] Rimayanti et al. indicated that refractive errors in children accounted for 13.87% of 245 children aged 2–6 years in playgroups and kindergartens in Makassar and Gowa, Indonesia.[4]
If this condition is not addressed comprehensively, it will continue negatively impacting children’s cognitive development and learning processes. Children may struggle to concentrate during learning and other activities, ultimately affecting their academic performance.[5]
Refractive errors assessment is essential for screening, diagnosis, and appropriate management evaluation. Eye accommodation significantly influences this examination in children, necessitating cycloplegics to control eye accommodation during the assessment. However, the potential side effects of cycloplegics must be carefully considered.[6]
Assessing visual acuity in children can be challenging; therefore, appropriate examination methods are essential.[6] This study was conducted using objective examination methods. Refractive errors in children are often evaluated using tools such as retinoscopes and autorefractors. Retinoscopy using cycloplegia is considered the gold standard for examination in children.[7,8] The autorefractor is an instrument for assessing refractive status. It is widely used due to its efficiency in time utilization and ability to comfort children during the examination.[9]
In this study, we aimed to compare the results of refractive error examinations using streak retinoscopy and an autorefractor, both with and without cycloplegia, in pediatric patients who visited the Eye Clinic of Hasanuddin University Hospital and the Orbita Eye Clinic with complaints of refractive disorders.
Subjects and Methods
This study is an analytical observational research with a cross-sectional design. It was conducted at the Eye Clinic of Hasanuddin University Hospital and the Orbita Eye Clinic in Makassar, South Sulawesi, Indonesia, from January 2020 to August 2020. The study employed a consecutive sampling technique. The study subjects consisted of pediatric patients aged 4–10 years who presented to the eye clinic with complaints of refractive errors that met the inclusion criteria for the study. The inclusion criteria were pediatric patients aged 4–10 years who were cooperative during the examination, were willing to undergo examination and refraction testing using cycloplegia, and whose parents signed an informed consent form before the examination. The exclusion criteria included patients with blurred vision accompanied by media opacities, a history of head trauma, a history of eye surgery, and congenital eye anomalies. The classification of refractive errors in this study followed the guidelines of the American Academy of Ophthalmology 2018 (AAO, 2018),[10] which divides refractive errors into emmetropia and ametropia (myopia, hyperopia, and astigmatism). Astigmatism is further classified into simple myopic astigmatism, simple hyperopic astigmatism, compound myopic astigmatism, compound hyperopic astigmatism, and mixed astigmatism. Emmetropia was set for 0.00 D, while ametropia condition was not classified into any specific dioptric range. We also did not determine any dioptric range for the inclusion criteria of our study subjects.
The subjects of this study consisted of 90 eyes of children with refractive errors. All subjects underwent a comprehensive ophthalmic evaluation, which included visual acuity assessment using a Snellen chart for fixation, retinoscopy with a Neitz retinoscope (Neitz Instruments Co., Ltd., Tokyo, Japan), autorefraction using a TOPCON autorefractor (Topcon, Tokyo, Japan), and a Topcon slit-lamp biomicroscope. Cyclopentolate 1% eye drops were instilled twice within 1 h for cycloplegic refraction, after which both retinoscopy and autorefraction were repeated under cycloplegic conditions. To minimize the examiner-related subjective bias during retinoscopy, all examinations were conducted by an ophthalmologist using a standardized protocol.[11]
The procedures followed the principles outlined in the Declaration of Helsinki and received approval from the Biomedical Research Ethics Committee for Humans at the Faculty of Medicine (No: 363/UN4.6.4.5.31/PP36/2020) on July 13, 2020.
The study subjects received an explanation and signed an informed consent form before undergoing the examination. The variables were analyzed and reported in terms of percentage, mean, and standard deviation. The comparison of refraction before and after cycloplegia was analyzed using the Wilcoxon signed-rank test. A statistically significant P value was set at <0.05. All data were analyzed using version 22 of the Statistical Package for the Social Sciences (SPSS; IBM Corporation, Armonk, New York, USA).
Results
The study subjects consisted of 90 eyes with no exclusions, and all participants agreed to sign the informed consent form. The collected data were then processed and presented in Table 1.
Table 1.
Subject characteristics by gender and age
| Characteristics | Frequency, n (%) |
|---|---|
| Gender | |
| Male | 44 (48.9) |
| Female | 46 (51.1) |
| Age (years) | |
| 4 | 8 (8.9) |
| 5 | 12 (13.3) |
| 6 | 10 (11.1) |
| 7 | 26 (28.9) |
| 8 | 18 (20) |
| 9 | 8 (8.9) |
| 10 | 8 (8.9) |
Table 1 shows more female children (51.1%) than male children (48.9%). The age group most affected by refractive errors was 7 years (28.9%), while the age groups with the least prevalence of refractive errors were 4, 9, and 10 years (8.9% each).
Table 2 shows that the most prevalent diagnosis of refractive errors without cycloplegia, as measured by retinoscopy, was compound myopic astigmatism, which accounted for 42 eyes, representing 46.7%. In contrast, the least common diagnosis of refractive errors without cycloplegia measured by retinoscopy was simple hyperopic astigmatism, with only one case, corresponding to 1.1%.
Table 2.
Subject characteristics by diagnosis before and after cycloplegia based on retinoscopy and autorefractor measurement
| Diagnosis | Retinoscopy | Autorefractor | ||
|---|---|---|---|---|
|
|
|
|||
| Before cycloplegia, n (%) | After cycloplegia, n (%) | Before cycloplegia, n (%) | After cycloplegia, n (%) | |
| Emmetropia | 6 (6.7) | 1 (1.1) | 3 (3.3) | 1 (1.1) |
| Myopia | 1 (1/1) | 0 | 0 | 1 (1.1) |
| Hyperopia | 2 (2.2) | 2 (2.2) | 0 | 2 (2.2) |
| Simple myopic astigmatism | 18 (20.0) | 14 (15.6) | 2 (2.2) | 0 |
| Compound myopic astigmatism | 42 (46.7) | 46 (51.1) | 53 (58.9) | 45 (50.0) |
| Simple hyperopic astigmatism | 1 (1.1) | 3 (3.3) | 1 (1.1) | 0 |
| Compound hyperopic astigmatism | 5 (5.6) | 10 (11.1) | 13 (14.4) | 26 (28.9) |
| Mixed astigmatism | 15 (16.7) | 14 (15.6) | 18 (20.0) | 15 (16.7) |
The highest diagnosis of refractive errors without cycloplegia, as measured by an autorefractor, is compound myopic astigmatism, occurring in 53 eyes, which corresponds to a percentage of 58.9%. The lowest diagnosis of refractive errors without cycloplegia using an autorefractor is simple hyperopic astigmatism, recorded in 1 eye, with a rate of 1.1%.
Figure 1a illustrates the changes in subject size for the conditions before and after cycloplegia using an autorefractor. The most significant change is observed in the diagnosis of compound hyperopic astigmatism.
Figure 1.
Graph of subject characteristics according to refractive error before and after cycloplegia based on measurements from autorefraction (a) and retinoscopy (b)
Following cycloplegia, the highest refractive error diagnosis using the autorefractor is compound myopic astigmatism, recorded in 45 eyes with a 50% percentage. Conversely, after cycloplegia, emmetropia and myopia were each diagnosed in 1 eye, corresponding to a rate of 1.1%.
Figure 1b illustrates the changes in diagnosis before and after cycloplegia using retinoscopy. The range of change indicates that no significant differences were observed.
After cycloplegia was administered, the most prevalent diagnosis of refractive errors using retinoscopy was compound myopic astigmatism, with 46 eyes representing 51.1%. Conversely, the least common diagnosis following cycloplegia was simple hyperopic astigmatism, with only 3 cases accounting for 3.3%.
Table 3 shows a significant change (P = 0.001) following cycloplegia. As measured by both instruments, the refractive changes before cycloplegia yield a mean of − 3.20 ± 5.72 for retinoscopy and − 3.25 ± 5.88 for the autorefractor, with P = 0.630. After cycloplegia, the mean values are − 3.23 ± 5.98 for retinoscopy and − 2.57 ± 5.91 for the autorefractor, with P < 0.001. There was a statistically significant difference in the results of refractive errors examination with cycloplegic between the autorefractometer and the retinoscopy (P < 0.001).
Table 3.
Changes in refraction results for all study subjects using retinoscopy and autorefractor before and after cycloplegia
| Variables | n | Mean SE±SD | P |
|---|---|---|---|
| Before sikloplegik | |||
| Retinoscopy | 90 | −3.20±5.72 | 0.630 |
| Autorefractor | 90 | −3.24±5.87 | |
| After sikloplegik | |||
| Retinoscopy | 90 | −3.23±5.98 | <0.001 |
| Autorefractor | 90 | −2.57±5.91 |
Using the Wilcoxon signed-rank test, P<0.05. SE: Standard error, SD: Standard deviation
In Table 4, the diagnosis of emmetropia before cycloplegia is represented by 6 eye subjects, yielding a mean of 0.00 for retinoscopy and 0.08 for the autorefractor, with a nonsignificant P = 0.461. The diagnosis of hyperopia includes 2 subjects, with means of + 6.00 for the retinoscopy and + 5.81 for the autorefractor, resulting in a nonsignificant P = 0.317. The diagnosis of simple myopic astigmatism comprises 18 subjects, with means of − 0.66 for retinoscopy and − 0.95 for the autorefractor, also showing a nonsignificant P = 0.711. The diagnosis of compound myopic astigmatism includes 42 subjects, with a mean of − 7.67 for retinoscopy and a decrease to − 7.79 for the autorefractor, resulting in a nonsignificant P = 0.139. The diagnosis of compound hyperopic astigmatism consists of 5 subjects, showing a mean of 7.99 for retinoscopy and a decrease to 8.71 for the autorefractor, with a nonsignificant P = 0.225. The diagnosis of mixed astigmatism includes 15 subjects, with a mean of − 0.33 for retinoscopy and a decrease to − 0.78 for the autorefractor, yielding a nonsignificant P = 0.164.
Table 4.
Comparison of mean spherical equivalent before and after cycloplegia based on retinoscopy and autorefraction diagnostic group
| Groups based on retinoscopy diagnosis before cycloplegia | Before cycloplegia | After cycloplegia | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
| n | Variable | Mean SE±SD | P a | n | Variable | Mean SE±SD | P a | |
| Emmetropia | 6 | Retinoscopy | 0.00 | 0.461 | 1 | Retinoscopy | NAb | NAb |
| Autorefractor | +0.08±0.55 | Autorefractor | ||||||
| Myopia | 1 | Retinoscopy | NAb | NAb | 0 | Retinoscopy | NAb | NAb |
| Autorefractor | Autorefractor | |||||||
| Hyperopia | 2 | Retinoscopy | +6.00±1.41 | 0.317 | 2 | Retinoscopy | +1.00±0.00 | 0.180 |
| Autorefractor | +5.81±1.14 | Autorefractor | +1.34±0.22 | |||||
| Simple myopic astigmatism | 18 | Retinoscopy | −0.66±0.42 | 0.711 | 14 | Retinoscopy | −0.57±0.42 | 0.109 |
| Autorefractor | −0.95±1.12 | Autorefractor | −0.22±1.24 | |||||
| Compound myopic astigmatism | 42 | Retinoscopy | −7.67±4.77 | 0.139 | 46 | Retinoscopy | −7.43±4.95 | <0.001* |
| Autorefractor | −7.79±4.82 | Autorefractor | −6.70±4.85 | |||||
| Simple hyperopic astigmatism | 1 | Retinoscopy | NAb | NAb | 3 | Retinoscopy | +0.66±0.14 | 0.109 |
| Autorefractor | Autorefractor | +1.57±0.68 | ||||||
| Compound hyperopic astigmatism | 5 | Retinoscopy | +7.99±2.04 | 0.225 | 10 | Retinoscopy | +5.72±3.94 | 0.007* |
| Autorefractor | +8.71±2.04 | Autorefractor | +6.42±3.74 | |||||
| Mixed astigmatism | 15 | Retinoscopy | −0.33±0.66 | 0.164 | 14 | Retinoscopy | −0.17±0.29 | 0.001* |
| Autorefractor | −0.78±0.75 | Autorefractor | +0.55±0.54 | |||||
aUsing the Wilcoxon signed-rank test, *P<0.05, bThe groups of myopia and simple hyperopic astigmatism could not be analyzed statistically due to insufficient subject sizes. NA: Not available, SE: Standard error, SD: Standard deviation
The comparison of mean spherical equivalent (SE) after cycloplegia in the retinoscopy groups shows significant changes (P < 0.05) for compound myopic and mixed astigmatism diagnoses. Conversely, the diagnoses of hyperopia, simple myopic astigmatism, simple hyperopic astigmatism, and compound hyperopic astigmatism are not statistically significant (P > 0.05). In addition, the diagnosis of emmetropia and myopia cannot be assessed due to insufficient subject sizes for statistical analysis.
Discussion
This study was conducted on 90 eyes of children aged 4–10 years to compare refractive errors with and without cycloplegia using retinoscopy and an autorefractor. The findings revealed that refractive errors were more commonly observed in girls (51.1%) than in boys (48.9%). Among the 61 children, there were 38 females (62.3%). Similarly, a study in China involving 224 children reported that over 50% of the participants were female.[12] The results of refractive errors found by Miharti in Bali differ, indicating a higher prevalence in male children, at 53.3%.[2] However, Ejup Mahmudi (2013) and Li et al. in Shanghai asserted that gender is not a significant factor in developing refractive errors.[12,13]
Refractive errors were observed to be more prevalent among children aged 7 years. This prevalence may be attributed to the fact that children at this age are in school, which increases their likelihood of experiencing refractive errors.[13] This study is consistent with the statement made by Guha et al. (2017).[7] Guha (2017) noted that children aged ≤14 in India experience refractive errors. Meanwhile, Mihartari’s et al.’s research in Bali indicated that children around 9–12 years are more likely to experience refractive errors.[2]
The study found that the most common refractive errors identified through retinoscopy, without and with cycloplegia, are compound myopic astigmatism. This finding aligns with the research by Mihartari et al., who reported that myopic astigmatism is the most frequently observed refractive error.[2]
The most common refractive errors identified through retinoscopy, without and with cycloplegia, are compound myopic astigmatism (58.9%). This finding is consistent with Asharlous (2016),[15] who noted a decrease in cases of astigmatism following cycloplegia. However, this result contrasts with a study in Shanghai, where hyperopia was more prevalent after cycloplegia.[13]
This study observed changes in the prevalence of compound myopic astigmatism before and after administering cycloplegia during retinoscopy and autorefractor assessments. The administering of cycloplegic drops diminishes accommodation ability, as indicated by alterations in lens power.[14] Lens thickness also decreases following the administration of cycloplegia, leading to increased spherical aberration.[14] Using cycloplegia during examination can enhance visual clarity and assist in identifying latent hyperopia, which can result in strabismus and/or amblyopia. Older children generally need less cycloplegia, as their dioptric changes tend to be less pronounced.[13]
In refractive errors such as astigmatism, changes after cycloplegia can occur due to several factors, including accommodative effects, variations in the patient’s head position during examination, pupil dilation leading to differences in visual axis, increased aberrations, lenticular astigmatism, changes in the elasticity of the crystalline lens, and alterations in astigmatism influenced by centrifugal rings during dilation.[15] The size of the cylinder value in the absence of cycloplegia is affected by accommodation. This study concludes that cycloplegic retinoscopy is the most effective method for evaluating refractive errors.
In full-term babies, the elevated levels of hyperopia and astigmatism are commonly observed, but these refractive errors tend to decrease markedly within the 1st year of life. The cornea is more convex during infancy, resulting in higher levels of astigmatism, generally with a with-the-rule astigmatism. However, this condition decreases as the eye develops until age 18, often evolving into with-the-rule astigmatism.[16]
Refractive examination without cycloplegia using retinoscopy is still more accurate than an autorefractor. Changes in refractive errors [Table 3] before and after cycloplegia show different results between retinoscopy and autorefractor, with significant differences observed after cycloplegia. Research conducted by Ira Aldyta found meaningful changes in refraction post-cycloplegia using retinoscopy, with simple myopic astigmatism showing substantial results in the 1–6 year age group (P = 0.047).[17]
Refraction assessment with an autorefractor without cycloplegia tends to result in overcorrection, leading to overestimating the myopia prevalence in children.[18] Furthermore, the results indicate that refractive measurements with negative spherical values are higher with cycloplegia, while positive spherical cases are lower without cycloplegia. Nonetheless, the use of an autorefractor without cycloplegia in children often underestimates hyperopia and overcorrects myopia.[18]
Several studies indicate that refraction using cycloplegia yields more accurate results than assessments conducted without cycloplegia.[19] A study in China found that, without the administration of cycloplegia, school-aged children exhibited greater levels of myopia compared to those measured with cycloplegia.[13] This difference may be attributed to the effects of uncontrolled accommodation. Therefore, cycloplegia is used in children because it effectively controls accommodation.
After the administration of cycloplegia, refractive errors predominantly shift toward hyperopia. Changes in refractive errors before and after administering cycloplegia are due to a greater accommodative response in preschool-aged children. However, no significant changes in refractive errors were observed in cases of astigmatism.[13]
Excessive accommodation in children can interfere with refractive errors. However, retinoscopy can provide accurate measurements despite the influence of accommodation, whereas autorefractor assessments are still affected by accommodative power.[18] Accommodation during refractive assessments can shift toward negative values (overestimating myopia and underestimating hyperopia). In some instances, hyperopia or emmetropia may even be misidentified as myopia.[19] Refraction measurements conducted without cycloplegia can result in measurement errors for myopia, hyperopia, and emmetropia in children and adults.[20]
This study found no significant differences in refractive errors before cycloplegia when comparing retinoscopy and autorefractor assessments. This lack of difference may be due to the children’s strong accommodative power and the lack of cooperation during autorefractor use. For example, some children may find it difficult to position their chin on the chin rest correctly.[7] This finding is consistent with Mukash et al., who reported no significant difference in refractive error before cycloplegia between retinoscopy and autorefractors.[21]
This study found significant differences in the refractive errors after administering cycloplegia when comparing retinoscopy and autorefraction measurements. Cycloplegia reduces the ciliary muscle contraction, resulting in corneal flattening. Cycloplegic administration diminishes accommodative function, as reflected by changes in lens power, while lens thickness reduction after cycloplegia leads to increased spherical aberration.[14] These results contrast with the findings of Guha’s et al.’s study,[7] which showed no significant differences between retinoscopy and autorefractor after cycloplegia.
In myopia, there is a decrease in the depth of the anterior segment and an increase in the refractive errors of hypermetropia and emmetropia, so that there will be a weakness of accommodation after administration of cycloplegics and changes in the structure of the anterior segment.[22] Children with hyperopia tend to use more accommodation when focusing on a target compared to children with myopia. Increased accommodative effort can significantly affect the refractive error measurements obtained after cycloplegia using an autorefractor.[23]
Astigmatism is more commonly detected with an autorefractor than with retinoscopy. Differences in refractive error measurements can be influenced by factors such as compliance, head positioning to align the eye with the measurement point, difficulty in fixation in younger children, high-order aberrations, and variations in pupil dilation, along with different vectors of astigmatism on the centrifugal rings along the visual axis during dilation.[24]
Refraction assessments in young children and infants are more effectively conducted with autorefractors. This approach is influenced by factors such as patient compliance and the capabilities of the examination, which can impact the changes in refractive errors that result from cycloplegia.[25]
In cases of hyperopia, the results obtained with cycloplegia do not align with those from retinoscopy and subjective refraction. Conversely, in myopia, the findings from retinoscopy, autorefractor, and subjective refraction show no differences in mean values and standard deviations after cycloplegia. Guha’s study indicates a correlation between retinoscopy and autorefractor measurements following cycloplegia.[7]
Retinoscopy is the best method for objective refraction assessment, although some current studies suggest that autorefractors can yield good results without cycloplegia.
The limitations of this study include a highly varied size distribution and uneven allocation of subjects. Even though we used the nonparametric test to compare the differences between groups, it was still challenging to analyze differences in refractive results between the two instruments due to insufficient subjects in some groups. In addition, there was no analysis of corrected visual acuity based on measurements from both instruments, preventing an assessment of changes in visual acuity. The refractive errors without and with cycloplegia were analyzed solely using SEs, which means changes in spherical, cylindrical, or axis values could not be determined. Moreover, as the study was conducted within a few centers, the applicability of the results to a broader population may be limited.
Conclusions
Compound myopic astigmatism is the most common refractive error detected with and without cycloplegia during retinoscopy and autorefractor examinations. There was a statistically significant difference in the results of refractive error examinations with cycloplegic between the autorefractometer and the retinoscopy (P < 0.001). Autorefractor examination with cycloplegia cannot be considered a substitute for retinoscopy with cycloplegia.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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