Comparison of non-cycloplegic photorefraction, cycloplegic photorefraction and cycloplegic retinoscopy in children

Impacts of environments on school myopia by spatial analysis techniques in Wuhan

The prevalence of myopia in China has increased significantly in recent years, and the age of onset has become younger. Previous studies have indicated that various environmental factors can influence the development of school myopia. However, the environmental impacts on school myopia remains to be investigated. Discoveries in this field may contribute to better urban planning. This study involved 7,610 students (aged 6-12 years, 4084 boys and 3526 girls) from six primary schools in Wuhan, China. We evaluated the associations between school myopia and the environment by analyzing the geographical distribution of myopic children. We utilized the spatial statistical analysis model. The Normalized Difference Vegetation Index (NDVI) risk coefficient for a 5,000-m radius around target schools was 0.379 (p = 0.008), while the NDVI risk coefficient for a 100-m radius around target schools was 0.241 (p = 0.047). The sports area risk coefficient for a 5,000-m radius around target schools was 0.234 (p = 0.016). We found that the specific buffers of NDVI and sports area around schools were associated with the prevalence of school myopia in schools, which worth further research to guide future initiatives on school myopia from an environmental perspective.

Retinoscopes: Past and present

BACKGROUND

Retinoscopy is arguably the most important method in the eye clinic for diagnosing and managing refractive errors. Advantages of retinoscopy include its non-invasive nature, ability to assess patients of all ages, and usefulness in patients with limited cooperation or communication skills.

AIM

To discuss the history of retinoscopes and examine current literature on the subject.

METHODS

A search was conducted on the PubMed and with the reference citation analysis (https://www.referencecitationanalysis.com) database using the term "Retinoscopy," with a range restricted to the last 10 years (2013-2023). The search string algorithm was: "Retinoscopy" (MeSH Terms) OR "Retinoscopy" (All Fields) OR "Retinoscopes" (All Fields) AND [(All Fields) AND 2013: 2023 (pdat)].

RESULTS

This systematic review included a total of 286 records. Publications reviewed iterations of the retinoscope into autorefractors, infrared photo retinoscope, television retinoscopy, and the Wifi enabled digital retinoscope.

CONCLUSION

The retinoscope has evolved significantly since its discovery, with a significant improvement in its diagnostic capabilities. While it has advantages such as non-invasiveness and broad applicability, limitations exist, and the need for skilled interpretation remains. With ongoing research, including the integration of artificial intelligence, retinoscopy is expected to continue advancing and playing a vital role in eye care.

The Performance of Spot Photoscreener in 6 to 10 Weeks Infants in China: A Cross-Sectional Study

Purpose

To compare the refractive errors measured by the Spot photoscreener (with or without cycloplegia) to cycloplegic retinoscopy in 6- to 10-week-old infants.

Materials and Methods

101 right eyes from 101 healthy infants aged 6 to 10 weeks were recruited for this cross-sectional observational study. Refractive errors were measured using Spot photoscreener before and after cycloplegia, as well as cycloplegic retinoscopy. Comparisons between the refractive measurements were performed using one-way ANOVA with the post hoc Tukey HSD test or Kruskal-Wallis test with the Steel-Dwass test according to the data normality. Pearson's correlation test and 95% confidence intervals were calculated. The agreement was evaluated using a Bland-Altman plot with 95% limits of agreement of the differences.

Results

Spot photoscreener was found to underestimate the spherical equivalent by 2.33 Diopters (D) in these infants. Following the induction of cycloplegia, the spherical equivalent measured by Spot photoscreener was in excellent agreement with cycloplegic retinoscopy with the mean difference of 0.01 D. Spot photoscreener overestimated cylindrical parameter by 0.2 D with poor agreement with cycloplegic retinoscopy no matter whether cycloplegia was induced. It had good agreement with cycloplegic retinoscopy in the J0 vector than the J45 vector measurement.

Conclusions

With the induction of cycloplegia, Spot photoscreener can accurately evaluate spherical equivalent in hyperopic infants with mild-to-moderate astigmatism. While it may provide valuable measurements of astigmatism, discrepancies in cylinder and axis should be taken into account.

Neutral Density Filters as a Tool for Cycloplegic Plusoptix-Photorefractor Measurements: An Explorative Study

Purpose:

The purpose of this study is to investigate the usefulness of neutral-density (ND) filters in cycloplegic-Plusoptix-photorefractor measurements.

Methods:

No-filter and ND-filter 0.04, 0.1 and 0.2 cycloplegic-Plusoptix-photorefractor measurements were made in 42 hypermetropic eyes. Sphere, cylinder, spherical equivalent (SEQ), J0, and J45 values were compared.

Results:

Mean Plusoptix-photorefractor pupil sizes were 7.7±0.68 and 7.7±0.72 mm The no-filter failure rate was 16%, with 87% in pupils >7.8 mm. Mean no-filter sphere, cylinder, SEQ, J0 and J45 values were +0.34±0.35D, -0.29±0.22D, +0.20±0.36, -0.00±0.15, and +0.02±0.11, respectively. Only ND-filter-0.04 provided 5% more successful measurements and a clinically significant alteration in the percentage of values exceeding 0.5D for sphere and SEQ (-10% and -20%), but not for cylinder (+5%). Despite the increased accuracy, 21% of the spherical outcome exceeded 0.50D. Furthermore, the single-measure-intraclass-correlation-coefficient between no-filter and ND-filter-0.04 outcome was moderate (sphere 0.78 (0.62-0.87), cylinder 0.59 (0.35-0.75), SEQ 0.68 (0.48-0.82), J0 0.73 (0.54-0.84) and J45 0.57 (0.50-0.86)) and indicated significant individual variation. Bland-Altman-analyses indicated significant bias for sphere and SEQ; p=0.038 and p=0.030.

Conclusion:

ND-filter-0.04 resulted in a larger proportion of successful measurements and an increased accuracy. However, an unacceptable percentage of inaccuracy was still present compared to retinoscopy. There could be validity issues with the ND-filter 0.04 or the baseline no-filter readings at the start. We conclude that cycloplegic Plusoptix-photorefraction, even with the use of a 0.04 ND filter, is not a suitable method for exact objective refraction purposes in children.

Comparison of Adult Refractive Disorder Measurements Using HandyRef-K, Retinomax, Plusoptix, and Table-top Autorefractometer Devices

OBJECTIVES

This study was conducted to compare refractive error measurements recorded using the Nidek HandyRef-K handheld autorefractometer (HDY; Nidek Co. Ltd., Tokyo, Japan), Plusoptix A09 photorefractor (PO; Plusoptix GmbH, Nuremberg, Germany), Retinomax K-plus 3 (RTX; Right Mfg. Co. Ltd., Tokyo, Japan), and a table-mounted autorefractometer/keratometer (TTR; URK 800, Unicos Co. Ltd., Daejeon, Republic of Korea).

METHODS

Patients aged ≥18 years underwent measurement of refraction without cycloplegia using 4 devices and the spherical power (SP), cylindrical power (CP), and spherical equivalent (SE) values were analyzed and compared.

RESULTS

A total of 181 eyes of 181 patients were enrolled in the study. The mean age of the patients was 33.08±0.95 years (range: 18-79 years). There was a significantly significant difference in the SP, CP, and SE values determined by the devices (p<0.001). The SP and SE values of the RTX and the HDY were similar, while the other device results were different (Wilcoxon signed-rank test, p=0.004). The CP values of the PO and the TTR, the HDY and the TTR were also comparable.

CONCLUSION

The HDY, RTX, and the PO are suitable for screening in clinical practice, but the findings strongly suggest that they should be used with caution.

Agreement Between Retinoscopy, Autorefractometry and Subjective Refraction for Determining Refractive Errors in Congolese Children

OBJECTIVE

To assess the agreement between retinoscopy and autorefractometry and between subjective refraction and both retinoscopy and autorefractometry in Congolese children.

PATIENTS AND METHODS

Fifty-four children (6-17 years old) were enrolled consecutively in this cross-sectional study. Refraction was evaluated before and after cycloplegia (1% cyclopentolate) with retinoscopy and autorefractometry. Readings were compared (paired t-test) and agreement assessed with Bland-Altman plots. Subjective refraction was compared with the two methods to determine which one provides better reference estimates for subjective refraction.

RESULTS

Under cycloplegia, the spherical power was comparable between retinoscopy and autorefractometry (1.12 ± 1.37 D vs 1.22 ± 1.06D, P = 0.70), cylinder power was significantly more myopic on retinoscopy than autorefractometry (0.80 ± 1.10D vs -0.62 ± 0.66, P = 0.019), and SE was greater on autorefractometry than retinoscopy (0.91 ± 1.10D vs 0.72 ± 1.00D, P = 0.014). Retinoscopy and autorefractometry overestimated the power of spherical (P = 0.022 and 0.002, respectively) and cylindrical components (all P < 0.001). There was an agreement between retinoscopy and autorefractometry in measuring spherical (bias: 0.09 ± 0.16D; limit of agreement, LoA: -0.40 to 0.22D) and cylindrical power (bias: -0.18 ± 0.20D; LoA: -0.57 to 0.21D). Subjective refraction agreed with cycloplegic retinoscopy for determining SE power (bias: 0.11D; LoA: -0.51 to 0.73D).

CONCLUSION

Retinoscopy and autorefractometry can be used interchangeably in children for determining the power of spherical and cylindrical components. Cycloplegic retinoscopy is better than autorefractometry to obtain SE reference values for subjective refraction in children.

Comparison between Plusoptix A09 and gold standard cycloplegic refraction in preschool children and agreement to detect refractive amblyogenic risk factors

BACKGROUND:

The preschool children hardly complain about their vision problems. It is of paramount importance to screen them with an objective tool and compare with the gold standard technique.

AIM:

To compare the values obtained with Plusoptix A09 and cycloplegic refraction in 3–6 years children and agreement to detect refractive amblyogenic risk factors.

SUBJECTS AND METHODS:

A cross-sectional study was conducted in the Outpatient Department of Ophthalmology in a tertiary care hospital. Informed consent from parents and verbal assent from children were obtained. Each subject had monocular vision assessment with Lea symbol chart, stereo acuity measurement with Frisby, refractive screening with Plusoptix A09, squint assessment, and anterior segment evaluation before administering Homatropine hydrobromide (homide) 2% eye drops. Cycloplegic refraction and posterior segment evaluation were performed for final diagnosis.

STATISTICAL ANALYSIS:

Descriptive statistics were used to summarize the data. Spearman correlation coefficient and kappa statistics were also employed.

RESULTS:

In total, data of 94 children were analyzed. The correlation values obtained between plusoptix and cyclorefraction values for spherical, cylindrical, spherical equivalent were 0.508 (P < 0.0001), 0.779 (P < 0.0001), and 0.407 (P < 0.0001), respectively. Refractive errors were seen in 32% and amblyopia in 17% of eyes. Kappa value was κ = 0.974 in detecting refractive amblyogenic risk factors.

CONCLUSION:

Good correlation was found between the plusoptix and cyclorefraction values. Cylindrical values showed a better correlation. Refractive errors and amblyopia were the major ocular disorders observed. There was significant agreement between the refractive techniques in detecting amblyogenic risk factors.

Analysis of suspected visual impairment risks based on objective refraction in 3-year-old children

PURPOSE

To evaluate the relationship between uncorrected visual acuity and non-cycloplegic refractive value among 3-year-old children in a vision screening program in Japan.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

The participants were 1746 Japanese children screened from April 2009 to July 2018, and ranged in age from 36 to 47 months. Visual acuity and handheld refractive values were collected from the clinical records of 3-year-old children in a vision screening program. Multiple logistic regression analysis was used to evaluate the association between 0.3 logarithm of the minimum angle of resolution (logMAR) and > 0.3 logMAR. Correlation analysis was also performed for the presence of myopic shift.

RESULTS

Among the 1746 children (aged [mean ± standard deviation], 37.6 ± 1.6 months; percentage of boys, 50.4%), representing 3492 eyes, 116 eyes (3.3%) had > 0.3 logMAR. Multiple logistic regression analysis revealed that the risk factors for 1.75-2.00 diopter (D) spherical power (odds ratio [OR], 2.51; 95% confidence interval [CI] 1.12-5.64; P = 0.026) and 1.25-1.50 D cylindrical power (OR, 5.66; 95% CI 1.58-20.40; P < 0.01) were increased in eyes with > 0.3 logMAR. There was no myopic shift for 10 years (Spearman's rank correlation coefficient; P = 0.65).

CONCLUSION

It is important to set a threshold that comprises the characteristics of the autorefractor used in screening, and to ensure that, to help prevent amblyopia a thorough eye examination in ophthalmic institutions will be conducted taking into account population-based refractive values.

Performance of Plusoptix A09 Photo Screener in Refractive Error Screening in School Children Aged between 5 and 15 Years in the Southern Part of India

Purpose:

To evaluate the performance of Plusoptix A09 in detecting ametropia, warranted against frequently-used technique of retinoscopy in children attending school (5–15 years) and its probability as a screening tool.

Methods:

This study was the subset of a larger epidemiological study visual acuity refractive error squint conducted in schools to determine the prevalence of ocular morbidity among the 5–15 years' school children population. Every 7^th student in the class (each school had mean value of 100 students) was randomly selected for this study after ascertaining their eligibility as per the inclusion criteria. A cohort of a total of 150 children within the age group of 5–15 (mean, 10.21 ± 2.83) years were recruited from 11 schools of Udupi district. Students with best corrected visual acuity of 20/20, refractive error within ±5.00 diopter (D), without any eccentric fixation, and no history of ocular pathology or seizures were recruited. Refractive error was tested by Plusoptix photorefractor followed by non-cycloplegic and cycloplegic retinoscopic techniques. The examiners performing these tests were masked and unware of the findings. Bland Altman plotted the agreement between the techniques, followed by the receiver operating characteristic curve (ROC), and sensitivity of Plusoptix.

Results:

One-way analysis of variance calculated statistical differences among Plusoptix, objective retinoscopy, and cycloplegic retinoscopy for mean spherical value (1.12 ± 1.16 D, 0.65 ± 0.69 D, and 0.8 ± 0.82 D), cylindrical value (−0.83 D ± 1.27, −0.32 D ± 0.86, and −0.34 D ± −0.93), and spherical equivalent value (0.71 D ± 1.06, 0.45 D ± 0.7, and 0.61 D ± 0.81), with P = 0.0001, 0.0001, and 0.097, respectively. Bland Altman plots showed good agreement for spherical equivalent values of Plusoptix and objective retinoscopy. However, the area under the ROC curve (0.386) suggests that lower diagnostic ability of this device in this age group population in comparison to retinoscopy (0.575) with the sensitivity and specificity of Plusoptix was 69.2% and 84.8%.

Conclusions:

This study fails to report ideal sensitivity mandated for a screening tool, although good specificity and agreement are observed. Along with retinoscopy, this tool will be effective in screening a children's population aged between the age group of 5 and 15 years.

Are the results of handheld auto-refractometer as valid as the result of table-mounted refractometer?

Purpose

To determine the agreement of table-mounted and handheld auto-refractometers and to evaluate the effect of age and different types of refractive errors on this comparison.

Methods

In this cross-sectional study conducted in 2015 using multi-stage cluster sampling, two underserved villages were selected randomly in the north and southwest of Iran. All the selected participants underwent optometric and ophthalmic examinations. Refraction was measured using handheld and table-mounted auto-refractometers in 652 subjects.

Results

The mean age of the subjects was 32.7 ± 18.72 years, and 58.3% of them were female. A significant difference was observed in the results of sphere, spherical equivalent (SE), and J45 vector between the two devices (P < 0.012), but there was no significant difference in J0 vector. There was a significant difference in the results of sphere between the two devices in all age groups under 50 years (P = 0.005), but there was no difference in age groups above 50 years. Correlation coefficients of the two devices were 0.989, 0.986, 0.908, and 0.951 for the results of sphere, SE, J0 vector, and J45 vector, respectively (P < 0.0001). The 95% limit of agreement (LOA) of the two devices was -0.31 to +0.53 for sphere, -0.27 to +0.63 for SE, -0.27 to +0.27 for J0 vector, and -0.16 to -0.17 for J45 vector.

Conclusions

According to our findings, the spherical error and cylindrical power measurements of the two devices have a significant correlation. Although there is a significant difference in the mean values between the two devices, this difference may be considered clinically insignificant, and considering the narrow 95% LOA between the two devices, the results may be used interchangeably.

Comparison of Autorefraction and Photorefraction with and without Cycloplegia Using 1% Tropicamide in Preschool Children

Purpose

We aimed to investigate whether the accuracy of the Plusoptix A09 photorefractor in children with ametropia is enhanced by cycloplegia with 1% tropicamide.

Methods

A total of 70 eyes (70 children) were retrospectively reviewed. Noncycloplegic photorefraction, cycloplegia with 1% tropicamide, cycloplegic photorefraction, and cycloplegic refraction with a tabletop autorefractometer were performed on all subjects in this order. Measurements were compared statistically.

Results

The mean age was 45.9 ± 11.4 months. The mean spherical equivalent (0.61 ± 1.03 diopters (D); range, −2.38 to 3.63 D) and mean spherical power (1.16 ± 0.92 D; range, −1.25 to 3.75 D) values that were acquired from the photorefraction without cycloplegia showed statistically significant differences from those of the autorefraction with cycloplegia (mean spherical equivalent = 1.00 ± 1.27 D; range, −1.50 to 4.25 D, mean spherical power = 1.60 ± 1.14; range, −1.25 to 4.50 D). The mean difference for the spherical equivalent was −0.39 ± 0.93 D (P=0.021; 95% limits of agreement (LoA) = −2.22 D to 1.44 D) and for spherical power was −0.44 ± 1.02 D (P=0.016; LoA = −2.44 D to 1.56 D). Without cycloplegia, Plusoptix A09 showed myopic shift, while after cycloplegia, it showed hyperopic shift. Spherical equivalent (mean difference (MD) ± SD = 0.78 ± 1.00 D, P < 0.001; LoA = −1.17 D to 2.72 D) and spherical power (MD ± SD = 0.73 ± 1.04 D, P < 0.001; LoA = −1.31 D to 2.77 D) values were significantly different from those of autorefraction with cycloplegia. Cylindrical power values obtained by photorefraction both with and without cycloplegia were not statistically different from those of autorefraction with cycloplegia (P > 0.05).

Conclusion

Cycloplegia with 1% tropicamide did not improve the accuracy of photorefraction using Plusoptix A09 in preschool children. The spherical equivalent and spherical power values obtained by photorefraction with cycloplegia were significantly higher from those obtained by autorefraction with cycloplegia.

Ocular residual and corneal astigmatism in a clinical population of high school students

Purpose

Total refractive astigmatism is usually the first consideration that guides the selection of contact lens type (e.g., spherical or toric), while the ocular source of the astigmatism is a second, but more important consideration, for the final clinical decision. This study was conducted to provide detailed data on this topic by evaluating astigmatic components in Chinese adolescents.

Methods

Participants were recruited from healthy high school students undergoing an annual ocular examination at a local hospital. Total astigmatism (TA), corneal astigmatism (CA), and ocular residual astigmatism (ORA) were determined by a Hartmann-Shack wavefront analyzer system (KR-1W, Topcon) with the natural pupil. The axis relationship between CA and ORA was placed into three categories: on-axis, defined as an axis with a difference of 0 ± 10°; opposite-axis, a difference of 90 ± 10°; and the rest defined as oblique-axis.

Results

The study consisted of 1,466 students (57.84% girls, age: 16.49 ± 1.05 years). ORA was present in 83.97%, 66.64%, and 45.23% of participants, according to the various criteria for astigmatism (≥ 0.50 D, ≥ 0.75 D, and ≥ 1.00 D, respectively). While with-the-rule was the most common axis orientation for both TA (76.28%) and CA (89.94%), against-the-rule predominated in ORA (93.82%; χ² = 1688.544, p < 0.001). Opposite-axis was the major type of axis difference (90.96%) of clinical significance (i.e., ≥ 1.00 D) between CA and ORA, which also prevailed in all levels of TA (range: 56.25–82.26%).

Conclusions

ORA is common in high school students and usually demonstrates a compensation relationship with CA, which should be taken into consideration when determining the design of contact lenses to correct refractive error.

Pediatric vision screening using the plusoptiX A12C photoscreener in Chinese preschool children aged 3 to 4 years

This study evaluated the performance of plusoptiX A12C in detecting amblyopia risk factors (ARFs) in Chinese children aged 3-to-4-year. PlusoptiX examination was successfully conducted among 1,766 subjects without cycloplegia to detect refractive error, asymmetry and media opacity. Cycloplegic retinoscopy (CR) was conducted on 357 children suspected of having vision abnormalities. Statistical differences between CR and the device were confirmed using the mean spherical value (+1.41 ± 0.87 D versus +1.14 ± 0.81 D), cylindrical value (−0.47 ± 0.64 versus −0.84 ± 0.78) and spherical equivalent (SE) value (+1.17 ± 0.84 D versus +0.72 ± 0.64 D) (all P < 0.0001). In the emmetropia group, the differences were statistically significant for the cylinder and SE (all P < 0.0001) but not the sphere (P = 0.33). In the hyperopia group, the differences were statistically significant for the sphere, cylinder and SE (all P < 0.0001). For refractive and strabismic ARFs detection, the sensitivity, specificity, positive predictive value, and negative predictive value were calculated, respectively.

Difference of refraction values between standard autorefractometry and Plusoptix

Aim: Comparison between the objective refraction measurement results determined with Topcon KR-8900 standard autorefractometer and Plusoptix A09 photo-refractometer in children. Material and methods: A prospective transversal study was performed in the Department of Ophthalmology of "Sf. Spiridon" Hospital in Iași on 90 eyes of 45 pediatric patients, with a mean age of 8,82 ± 3,52 years, examined with noncycloplegic measurements provided by Plusoptix A09 and cycloplegic and noncycloplegic measurements provided by Topcon KR-8900 standard autorefractometer. The clinical parameters compared were the following: spherical equivalent (SE), spherical and cylindrical values, and cylinder axis. Astigmatism was recorded and evaluated with the cylindrical value on minus after transposition. The statistical calculation was performed with paired t-tests and Pearson's correlation analysis. All the data were analyzed with SPSS statistical package 19 (SPSS for Windows, Chicago, IL). Results: Plusoptix A09 noncycloplegic values were relatively equal between the eyes, with slightly lower values compared to noncycloplegic auto refractometry. Mean (± SD) measurements provided by Plusoptix AO9 were the following: spherical power 1.11 ± 1.52, cylindrical power 0.80 ± 0.80, and spherical equivalent 0.71 ± 1.39. The noncycloplegic auto refractometer mean (± SD) measurements were spherical power 1.12 ± 1.63, cylindrical power 0.79 ± 0,77 and spherical equivalent 0.71 ± 1.58. The cycloplegic auto refractometer mean (± SD) measurements were spherical power 2.08 ± 1.95, cylindrical power 0,82 ± 0.85 and spherical equivalent 1.68 ± 1.87. 32% of the eyes were hyperopic, 2.67% were myopic, 65.33% had astigmatism, and 30% eyes had amblyopia. Conclusions: Noncycloplegic objective refraction values were similar with those determined by autorefractometry. Plusoptix had an important role in the ophthalmological screening, but did not detect higher refractive errors, justifying the cycloplegic autorefractometry.