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This study compared the near retinoscopy technique for determining refractive error to the standard cycloplegic refraction method in infants and children. There was a significant difference found between the two techniques for both sphere and cylinder power. The difference tended to be larger for infants than children. No significant effects were found for monocular vs binocular testing, gender, or eye tested. The findings suggest caution in substituting near retinoscopy for cycloplegic refraction, even with a correction factor, when determining refractive error in infants and young children.
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Pediatric Optometry
Titlu original
A Comparison of Cycloplegic Refraction to the Near Retinoscopy
This study compared the near retinoscopy technique for determining refractive error to the standard cycloplegic refraction method in infants and children. There was a significant difference found between the two techniques for both sphere and cylinder power. The difference tended to be larger for infants than children. No significant effects were found for monocular vs binocular testing, gender, or eye tested. The findings suggest caution in substituting near retinoscopy for cycloplegic refraction, even with a correction factor, when determining refractive error in infants and young children.
This study compared the near retinoscopy technique for determining refractive error to the standard cycloplegic refraction method in infants and children. There was a significant difference found between the two techniques for both sphere and cylinder power. The difference tended to be larger for infants than children. No significant effects were found for monocular vs binocular testing, gender, or eye tested. The findings suggest caution in substituting near retinoscopy for cycloplegic refraction, even with a correction factor, when determining refractive error in infants and young children.
M Ohindra described a near retinoscopic technique as a substitute
for cycloplegic procedures determining refractive error.I - 2 This tech - MICHAEL D. WESSON, 0 .0 ., M.S.- nique will be referred to herein as the "near retinoscopy technique." KELLI R. MANN, O . D .~ The basic technique requires occlusion of one eye while retinoscopy NORMAN W. BRAY, Ph .D.c is performed on the open eye at a distance of 50 cm in a totally dark room. In this manner the subject will presumably fixate on ABSTRACT: The near retinoscopy technique the light of the retinoscope along the visualaxis.3 An adjustment in of refractive error determination was compared lens power for both tonus of accommodation a nd working distance to the standard method of cycloplegic refraction from the retinoscope light is estimated to be 1.25 diopters. T his using 10 "infants" (3-1 2 months of age) and 10 "children" (32- 109 months of age). There was a value was empirically derived from a study co nducted on 27 adult significant difference between the techniques for subjects 2 and again determined experime ntally by measuring accom- both sphere and cylinder power. Although there modative responses in adults. The 1.25 diopters is subtracted from was no interaction of refractive technique and the gross retinoscopy to yield t he final noncycloplegic value. age group, the difference between near retinos Since its inception, the near ret inoscopy technique has been copy and cycloplegic refractive error tended to promoted for use with infants and young children to provide a be larger for infanta than for children. No sig- consistent refractive determination that compares favorably with nificant difference was found when the average cycloplegic techniques. Mohindra originally reported that the tech- refractive values were compared for monocular nique had good reliability with infants using a comparison between or binocular conditions and no significant effect two examiners.' There were several aspects of Mohindra's study, was found for either gender or laterality (right however, t hat were not clear. First, the age range of the subjects versus left eye). Based on these findings, it is was not. given. T his is important since variability in age may be a suggested that caution be used in substituting the near retinoscopy technique for cycloplegic factor in determining the efficacy of the procedure. Second, al- refraction even utili:l.ing a "correction" factor fo r though all subsequent studies of t his technique used monocular the diopt ric difference between techniques. occlusion, this one did not. However, it is possible that occlusion was used but not described in the procedure. Finally, although KEY WORDS: near retinoscopy technique, cy inspection of the published graphs appears to display good correia cloplegic refraction, infanta, children, refractive tion between the two exam iners, no statistical analysis was per- error formed to verify this observation. The apparent variability of the hyperopic values may have reduced any statistical correlation to a Weuon MD, Mann KR, Bray NW. A comperilon or much greater extent tha n can be deduced by a visual comparison of cydoplegic refr.ction to the near retinollCOPY tech nique for rerractiva e rror determination. J Am Optom the graphs. A.IIOC 1990; 61:680-4. To confirm t.he accuracy of this technique as a reliable substi- tute for cycloplegic retinoscopy, Mohindra and Molinari compared t he near ret.inoscopy method to cycloplegic refraction utilizing 3 1 subjects, 3- 7 years of age .~ Their results provided good interexam- iner reliability fo r spherical and cylindrical power (r=+0.S3 and +0.75, respectively) and good correlation between techniques for spherical power (r=+0. 75) . Unfortunately, the drugs used were 1% tropicamide (Mydriacyl) and 10% phenylephrine hydrochloride (Neo-Synephrine). Tropi- camide is not an appropriate agent for cycloplegic refraction since it has been shown to leave an average 3.500. of residual accommo- dation with as much as 6.250 . of accommodation in a sample ra ngi ng from infancy to 9 years of age.s-1 Alt hough it has a rapid onset, wit.h muimum cycloplegia occurring in 20-30 min, the effect quickly diminishes.s Of course, phenylephrine hydrochloride has no cycloplegic action. One other problem with Mohindra and Moli
680 Journal or the American Optometric Association
nari's study was that it did not include infants, the literature suggests that this may be the case. Variability group that this refractive technique was designed to may be less for the older population resulting in smaller evaluate. differences between the near retinoscopy technique and In a comparison study, Maino et aL evaluated a cycloplegic retinoscopy. The present study was designed much Jarger (3 11 subjects) and younger sample (18-48 to investigate these possibilities. monthsl.1I Their method of cycloplegia incorporated 0.75% tropicam ide combined with 2.5% phenylephrine. Method The participants were first examined using the near A total of 20 infants and young children from t he retinoscopy technique of Mohindra and Molinari.s Re- pediatric population at the Chauncey Sparks Center fo r tinoscopy was performed 20 min after instillation of the Developmental and Learning Disorders were used as drops. Results indicated that t here was little agreement subjects after obtaining the parents' informed consent. between the two procedures in preschool children. Us- The mean age for the overall group was 43.6 months ing the 1.25 diopter correction factor, there was only a (range: 3- 109 months; SD=42.4 months). There were 35.7 percent agreement between the cycloplegic values nine males and 11 females. For purposes of further and the adjusted near retinoscopy values. Other modi- analysis the participants were grouped into two age fications of the correction factor were attempted with groups of 10 subjects: "i nfant s~ (range 3- 12 months; only a marginal improvement in agreement. When they mean==7 months, SO=3 months) and "child ren~ (range evaluated children with larger refractive errors (>+3.00 32- 109 months; mean 80.2. SD=30.1 months). O.S. or > -1.00 cylinder), there was even less agree- The near retinoscopy technique was performed first ment. There was agreement only 27 percent of the time fo r all participants. Each participant was randomly within + / -0.50 D.S. Although a large sample was used, assigned to a counterbalanced order of binocular/ mo- infants were not evaluated and the drugs used for nocular or monocular/binocular procedures. Near reti- cycloplegia suffered from the same problems as the noscopy was rendered at a 50 cm test distance in a dark Mohindra and Molinari study. room by one examiner (KM) . Lens bars were used to Borghi and Rouse addressed the issue of using a find the neutral point which indicated a change from better cycloplegic agent in t heir 1985 study. 1O They "with" to "against." The fin al recorded value was ad- compared the near retinoscopy met hod to cycloplegic justed by subtracting the empirically derived value of retinoscopy utilizing an older sample of 21 subjects 1.25 diopters used by Mohindra. u whose ages ranged from 3.5- 10 years. One percent Following the near retinoscopy technique, cyclople- cyclopentolate was employed (2 drops in each eye re- gia was achieved with 1 drop of 1% cyclopentolate peated at 5 min intervals) . Cycloplegic refraction was (Cyclogyl) in each eye fo llowed by a waiting period of performed 35 to 40 min following the instillation of 45 min (+/ -5 min). Retinoscopy followed in the same drops. On the average, 0.630 more plus power was order as the near retinoscopy technique and was per- measured by the cycloplegic method and these results fo rmed at 66 cm. The final recorded value was adjusted were significantly different for t he vertical, horizontal by subtracting 1.50 diopters, the working distance cov- and combined meridians (p=0.005; 0.0005; and 0.0001 ered to dioptric value. respectively). The authors indicated that if one were to "cut~ the cycloplegic findin g by +0.500. to + 1.000 . Results before prescribing, the results between the two proce- duted would be in close agreement. Refractive comparison There are a nu mber of issues which remain to be resolved. First, the technique would have its greatest Each eye of every subject in the two age groups was utility with infants, but this age group has not been refracted a total of four times: Under monocular con- studied directly. Although infants were evaluated fo r ditions with the near retinoscoy and cycloplegic tech- interexaminer reliability in Mohindra's earliest study, niques, and under binocular conditions with the near infants were not evaluated fo r cycloplegic/near retinos- retinoscopy and cycloplegic tech niques. Thus, on each copy comparison in later studies. The Maino study age group, 80 refractive measurements were available included children in the 18-48 month age range while for the right eye and for the left eye (10 subjects x 4 the Borghi and Rouse study included children 42- 120 refractions/eye/subject) for both sphere and cylinder mont hs. measures. When considering the two refractive tech- Second, it is possible that covering one eye is not a niques separately, a total of 40 refractive measurements necessary component of t he procedure. The original were obtai ned for each technique. paper did not use occlusion. I Further, Griffin aJludes to Sphe rical values were analyzed in a mixed analysis t he possibility that occlusion does not make a differ- of variance (ANOVA) using t he P4V programs of ence. 1I Finally, it is possible that the technique has BMDP. 12 The variables included age group (infants and greater merit with older children than with infants. The children), gender, technique (near retinoscopy and cy-
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cloplegic), ocular condition (monocula r and binocular), no statistically significant effect for gender for either eye (right and left), with repeated measures on the last age group. t hree factors. There was a significant effect fo r t ech- T here was no difference between the right and left nique, F(1 ,16)-13.58, p<.002, M8.-1.95, with means eye as indicated by the nonsignifica nt main effect for of +0.53 (80:2.19) and +1.97 (80- 1.89) for t he near eye, F(1,lS)=.48, p>.49, M5.""'2.S1, with meansoC + 1.38 retinoscopy a nd cycloplegic techniques, respectively. (80 =2.25) and + 1.12 (50 =2.07) for the right and left This result indicates that when the data from all par- eye, respectively. The interaction of eye and age was ticipants are considered (infants and children com - not significant, F(l,16 )=.88, p>.3S, M8. =2.Sl. T he bined) , the near retinoscopy technique resulted in less means fo r the right and left eyes for the infants were refractive error than the cycloplegic technique. There + 1.16 (80=2.47) and + 1.63 (50= 2.62), respectively, was no s ignificant difference between age groups, and for the children the corresponding means were F(1, 16):1.22, p>.28, M5.:27.71 , with means of +1.62 +1.14 (5 0 =2.00) and +0.S1 (80=1.14). This nonsig- (80:2.53), and +0.88 (80 =1.64) for the infants and nificant main effect and interaction indicates that there children, respectively. were no differences between eyes for either age group. As indicated by a nonsignificant interaction of tech- There were no other significant effects or higher order nique a nd age group, F(1,16) = 2.93. p>. l O, MS. =1.95, interactions with the spherical measures. the same pattern holds fo r both infants and children. The means were +0.56 (8 0 =2 .67) and +2.68 (SO: 1.89) for near retinoscopy and cycloplegic for t he infant s and Cylinde r powe r compa rison +0.50 (80 :1.60) and +1.26 (SO=1.S2) for the near Cylinder power was used as t he dependent variable in retinoscopy and cycloplegic Cor t he children. a second mixed ANOVA with the same variables as The main effect for ocular condition was not stat is- used in t he a nalysis of the spherical refractive error t ically significant, F(l,16)=0.49, p>.49, M8. =.09, with data. As with spherical refractive error comparison, means of +1.23 (80=2. 18) and +1/ 27 (80= 2.15) for there was an overall significant difference between the monocular and binocular conditions, respectively. two techn iques for cylinder power F(l,16)=10.25, There was no interactions with ocular condition a nd p<.OO5, M5.:: 1.25. The mean cylinder value for the age, F(1,IS)=.06, p>.81 , MS. =.09, with means of +1.59 near retinoscopy method was -0.20 (50 =.36) while for (80 ""'2.57) and + 1.64 (50=2.52) for the monocular and the cycloplegic it was -0.36 (50=.49). There was no binocular condit ions for the infants and +0.87 mean effect for age F(l,16):0.04, p>.85, MS. =1.25, (50=1.64) and +0.89 (80=1.66) Cor the monocular and ocular condition (monocular and binocular), binocular conditions for the children. These results F(l ,16)= 0.07, p>.79, MS e =.02, gender F(l ,16)=2.04, indicate that t he effect oC covering one eye during the p>. 17, M8.=1.25, and eye F(l,IS)=3.49, p>.08, objective refract ion does not influence the measures for M5.= .15. All inte ractions were nonsignificant. either age group. One might speculate that there may be difference if the data for the ocular conditions were treated sepa- Discussion rately Cor the near retinoscopy and cycloplegic tech The results indicate that 1) there is a significant differ niques. However, the interaction oC ocu lar condit ion ence for both sphere and cylinder powe r between the a nd technique was not statistically significant, cycloplegic and near retinoscopy technique; 2) it makes F(l,lS)=.14, p>.71, MS.=.004, with means Cor the mo no difference whether the techniques a re performed nocular and binocular conditions of >0.52 (50=2.22) monocula rly or binocularly as Griffin has suggested,l l and +0.54 (50=2.18) with the near retinoscopy tech- 3) there appears to be no significant difference as the nique and +1.94 (50= 1.90) and +1.99 (50 =1.89) fo r result of gender, age or eye tested. the cycloplegic technique. This is an indication that Borghi and Rouse's results suggest little difference t here is no efCect due to ocular condition for either the (0.630 more plus in the cycloplegic than the near reti near retinoscopy or cycloplegic technique. noscopy method) between t echniques for their sample The main effect for gender was not significant, although the differences were statistically significant. F(1 ,16)=.25, p> .S2, M5. =27.71, with means of +1.3 1 This may be explained by the age of the subjects whose (50 =2.15) and +1.20 (50=2. 17) for the males and ages ranged from 42- 120 months. The average age of females, respectively. T here was no interaction of gen- our total sample of 20 was 43.S months (80 =42.4) with der and age, F(l,IS)=1.21 , p>.28, M5.=27.71, with a maximum age of 109 months. Ten of those subject s means for the males and females of +2.60 (SO=2.20 were 12 months or less with an average age of 7 months and + 1.19 (80=2.5S), respectively, for the inCants and (50=3), while the older children had an average age of + 0.67 (50=1.83) a nd +1.20 (50=1.26), respectively, 80.2 months (8D=30.1). Thus, any comparison between for the children. T hese results indicate that there was our study a nd that of Borghi and Rouse should be
682 Journal of the American Optometric Association
Table I: Correlation coefficients: near 5.000 , - -- - -- - -- - 4.500 retinoscopy versus cycloplegic refraction 000 J.500 condition N correlation (R) P ....Iue J ooo 2.500 00 sphere 7.000 ~ 1.500 monocular 20 .74 < .001 rtl 1,000 binocular 20 .75 <.001 ::. 0.500 ("I 0,000 " 05 sphere tI 0.500 monocular 20 .63 <.002 1000 -1.500 binocular 20 .67 < .001 :rooo 00 cylinder monocular binocular 20 20 .90 .86 < .001 <.00 1 -:;1.500 O5.OOO'-::-::-:!::---:,-::--::- -05.500 ~~ , ------t -1.000 0 ,000 1000 2.000 05,000 4.000 ,J 5.000 OS cylinder COMBSC monocular 20 .80 <.001 FilfUre I : Spberical va lue. to r tbe le l't and rigbt eye unde r monoc ul a r a nd b lnoc ul.r eon dition a were c omb ined binocular 20 .03 <.001 (CQ MBS M:ane.r point retin oaoo py; COMBSCEClyc1opJegie r e_ tinOlCOpy). Their ....erage v.lues for each of tbe 20 aubjecta ror th e two refrac ti ve metboda were tben co mpa red in th is confined to the older group. For these children, we IlCaUerplo t. The co rrelation between me thod. wa. 0.68. The found more plus in the cycloplegic refract.ion than ob- regreat;ion line Willi ploued witb a s lope of 0.1'\2 a nd the Y served wit.h the near ret.inoscopy method (0.820). T his intercept , -1 .070. is very similar to Borghi and Rouse's value of 0.630. However, for our infant group, t.he difference between t ive correlations, this means that individuals who tend the near retinoscopy and t.he cycloplegic technique was to display large values with cycloplegic agents also tend 2.120, nearly three times greater than the older popu- to display large values with the near retinoscopy tech- lation, even t hough the interaction of age group and nique. Conversely, those with low cycloplegic values techn ique failed to reach conventional levels of statis- will tend to be low with the near retinoscopy technique. tical significance. Adding a correction constant such as +0.50 to +0.750 This suggests that using the near retinoscopy tech- to the near retinoscopy value will not change an indi- nique for anything but a gross indication of refractive viduals ranking. After the correction factor, those with error can lead to very tenuous conclusions concerning the greater values on one measure will still be relatively refractive error. With this in mind, we reanalyzed this greater on the other measure while those low on one data using all 20 subjects to see if the differences measure will also be low on the other. The average between techniques reveal greater differences for my- scores fo r the group will be more similar with such a opes or hyperopes. Difference calculations were made correction, but the correlation between measures will only on t hose subjects displaying either myopia on all not change. This means t hat the error in prediction will measures (n::8) or hyperopia on all measures (n=12). not change, only t he group average. These problems are The average difference between techniques for myopia of even greater importance with the moderate correla- was +2.61 (SO=1.79) while the difference for hyperopia tions which have a higher error of prediction. It is the was +0.65 (50::.78). T his difference between myopia sphere measures that are utilized most, and fo r t hese and hyperopia proved to be statistically significant there are only moderate correlations between t he near F(1,16)=8.89, p<.009. However, due to the small sample retinoscopy and cycloplegic techniques. Figure 1 pro- size under the constraint mentioned above, we were vides a scatterplot of combined measures comparing unable to evaluate infants and ch ildren separately fo r near retinoscopy with cycloplegia for spherical values these differences. under monocular and binocular conditions. A moderate T he final point to be made from this data concerns correlation of 0.68 is obtained. T he square of t he cor- the interpretation of the correlation between the near relation is.47 which means that the two methods have retinoscopy values and those of cycloplegic refraction. only 47 percent of their variance in common, leaving Table 1 displays the correlation between the techniques 53 percent unaccounted. for sphere and cylinder values under monocular and One other complication is t hat we know that if the binocular conditions. The correlations between the near retinoscopy results increase in magnitude over an techniques range from moderate (.63) to high (.90) and age range, then the cycloplegic results also will increase. all are sign ificantly greater than zero. Therefore, why However, the magnitude of the change depends on age can the two techniques not be utilized interchangeably'? and t here is a t rend for t his difference to be greater fo r The reason is that correlation only indicates the degree infants than for older children. Therefore, it is not of consistency between individuals, not the magnitude appropriate to state that "on t he average" the cyclo- of t he difference between measures. With st rong posi- plegic refraction will be +0.500 to +0.750 more plus
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than the near retinoscopy technique. Using the regres- 5. Mohindra I, Moli nlri J f.'. Near retinoteopy and cyeloplellic reti- sion equations generated by these data will not be valid nOllCOpy in early primary grade IChoo lchildren. Am J Optom Phyaiol Opt 1979: 56:34-8. because there is a significant difference in values be 6. Cett.es BC. T ropicamide, a new cycloplegic mydriat ic. Arch tween techniques and there is a trend for the magnitude Ophthalmol l96 1; 65:632- 5. of this difference to be larger for infants than for 7. Milder B. T ropica mide 118 I cycloplegic agent. Arch Ophthalmol 1961: 66:70-2. younger children. It should be noted, however, that the 8. AmOfl OM. Cycloplegic refraction. In: Bartlett JD , Jaanu s SO interaction of age group and technique failed to reach eca. Clinical ocular pharmacology. 2nd ed. Bosto n: Butterworth" conventional levels of statistical significance. 1989:42.5. 9. ,,"18ioo J H, Cibi, CW, Creu P, do .1. Noncycloplegic ..... cyclo plegic retinOllCOpy in pre-Khool children. Ann Ophthalmol 1984; 16:880- 2. Conclusion 10. Borghi RA , Rouse MW. ComperilOn of refraction obtained by ~ near retin OllCOpY and retinoteopy under cycloplegi . Am J Contrary to other publis hed reports, our data indicates Opt.om Phy,io] Opt 1985: 62: 169-72. that the near retinoscopy and cycloplegic techniques It. Griffin JR. Binocular Anom.li": Pl"QCedure. for Vision Therapy. yield significantly different values and can not be used. 2nd ed. Chic'go: proreuional Pre.., 1982:436. 12. Dizon W A (Ed.). BMDP Statistical Softw'n! . Berkely, CA: Uni interchangeably. There appears to be a trend towards versity or C.lifornil Pre.., 1985. less difference in older children but the size of our sample is too s mall to conclusively establis h th is trend. We suggest that until much larger studies of infants Footnotes and young children a re carefu lly conducted, the refrac a. A!I$OCi.te Proresso r ofOpto melry/Directo r, Di ... i, ion of Optometry, tive results of the near retinoscopy technique should be Chauny Sperks Center for De ...elopmental .nd Leuning Di, interpreted with caution. orden:, F.A.A.O.b. Optometrill./Residenl, Pedietric Optomet.ry.c. Profeuor of J>.ychology/Director, Di... ision of P$yc hoIOl)', Chauncey Sparks Ce n!.!! for De ... elopmental .nd Learn ing Di,- References orde rs
I. Mohindrll I. A te<:hnique for infant e:lllminalion.t. Am J Optom
Ph)'lliol Opt 1975: 52:867-70. Submitted 11/89; accepted 5/90 2. Mohindra I. Compari!l(ln of Mn ear retinOKopyR . nd IUbjecti... e refraction in adults. Am J Opt.om Phyaiol Ollt 1977; 54:3 19-22. University o( Alabama at Birmingham 3. Mohindrl I. A non-cydoplegic refraction tl'( hnique for inflnu Department of Optometry .nd young children. J Am Optom Assoc 1977; 48:518-23. 4. Owens DA, Mohindra I, Held R. The effl'(li"'eness of I retino School of Optometryl ICope beam 118 I n .etommodllti ... e stimulus. Inve$t Ophthalmol Medical Center Vii Sci 1980; 19:942-9. Birmingham, AL 35294
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