Comparison of Subjective Refraction under Cycloplegia Versus Post Mydriatic Refraction in Pediatric Population Comparison Of Subjective Refraction Under Cycloplegia Versus Post Mydriatic Refraction In Pediatric Population: Subjective Refraction under Cycloplegia Versus Post Mydriatic Refraction.

throughout due to of . Objective: To compare refractive status in (age to 15 checked with subjective refraction under cycloplegia versus post mydiatric test (PMT). Methods: Comparative cross-sectional study was conducted in clinic of College of Allied vision sciences /Mayo Lahore including 120 non-pathological eyes of 60 subjects. Individuals with nystagmus and deviation of were excluded. Power of SE (P1) was taken as proposed number of glasses to be dispensed. After three days PMT was done and prescription of glasses with BCVA (P2) was noted and prescribed. At PMT (P2-P1) was noted and evaluated. All data entered and analyzed by using SPSS-23. P-value equal or less than 0.05 was taken as signi�cant. Two-way and measures �xed. a. estimator interaction effect not. b. correlation coe�cients consistency The between-measure predicted from SRC with 98% accuracy in both myopic and hyperopic cases. With following given formula. PMT = 0.77*CR.sph - 0.03 r=0.98. (Hyperopia)(Myopia) PMT= 0.96*CR.sph - 0.03 r=0.99. This study strongly negates the need for PMT as PMT can be strongly predicted from SRC.


I N T R O D U C T I O N
Reduced vision throughout early childhood is typically due to errors of refraction. Objective: To compare refractive status in children (age 5 to 15 years) checked with subjective refraction under cycloplegia versus post mydiatric test (PMT). Methods: Comparative cross-sectional study was conducted in pediatric ophthalmic clinic of College of ophthalmology and Allied vision sciences /Mayo hospital Lahore including 120 non-pathological eyes of 60 subjects. Individuals with nystagmus and deviation of eyes were excluded. Power of SE (P1) was taken as proposed number of glasses to be dispensed. After three days PMT was done and prescription of glasses with BCVA (P2) was noted and prescribed. At PMT (P2-P1) was noted and evaluated. All data entered and analyzed by using SPSS-23. P-value equal or less than 0.05 was taken as signi cant. Results: Among 120 eyes (n=120), the distribution of myopia was 57.5% and hyperopia was 42%. The mean age of 60 individuals (female: 35% and male: 65%) was 9.47 ± 2.50 years. Among 120 eyes (n=120), the distribution of myopia was 57.5% (n = 69 eyes) and hyperopia was 42% (n = 51 eyes). Interclass correlation: Two-way mixed effects model where people effects are random and measures effects are xed. a. The estimator is the same, whether the interaction effect is present or not. b. Type C intraclass correlation coe cients using a consistency de nition. The between-measure variance is excluded from the denominator variance. c. This estimate is computed assuming the interaction effect is absent, because it is not estimable otherwise. Conclusion: There was statistically signi cant difference of SE of SRC and PMT_SE in both myopic and hyperopic children in both cases. PMT was signi cantly less as compared to SRC, in hyperopic patients, this difference increases with the amount of hyperopia. PMT can be predicted from SRC with 98% accuracy in both myopic and hyperopic cases. With following given formula. PMT = 0.77*CR.sph -0.03 r=0.98. (Hyperopia) PMT= 0.96*CR.sph -0.03 r=0.99. This study strongly negates the need for PMT as PMT can be strongly predicted from SRC.

A R T I C L E I N F O A B S T R A C T
distinguish numerous complaints causing visual imperfections [8]. Though calculation of refractive error in pediatric populace is right challenging even for a practiced optometrist [9]. Selection for amblyopia and amblyogenic hazards in youngsters, monitored by proper management, is effective in decreasing the incidence and severity of optical damage in grown person [10]. Cycloplegic refraction is a method that permits evaluation of an accurate refractive error by preventing accommodation [11]. Cycloplegia is compulsor y; for satisfactor y modi cation of refractive error, mainly in young kids and patients with accommodative esotropia or high hypermetropia demanding more accommodative power [12]. Lack of cycloplegia is related to slight overestimation of myopia and obvious mistakes in evaluation of incidence of emmetropia and hyperopia [13]. There is no consistent method of regulating non-cycloplegic refraction to approximate cycloplegic refractions as the amount of refractive error varies from individual to individual as well as the type of cycloplegic refractive error. Non-cycloplegic refraction is therefore tricky [14]. Cautious choice of cycloplegic drug is signi cant as it is harder to attain complete cycloplegia in kids with darker irides, so usually cyclopentolate 1% is suggested to bring about adequate cycloplegia [15]. Other drugs like, Tropicamide is also introduced, and however it does not fully obstruct accommodation in children [16]. Test performed after three days of cycloplegic refraction when the effect of cycloplegia and mydriasis is completely disappeared, is termed as PMT (post mydriatic test) which is subjectively re ned spectacle prescription obtained under noncycloplegic condition from the values obtained from cycloplegic refraction. As for PMT an additional appointment is required, patients assume it very di cult for them [17,18].

M E T H O D S
prescription and actual required prescription at PMT (P2-P1) was noted and evaluated. The participants were distributed into myopic and hyperopic categories and data was analyzed for the both groups. All data entered and analyzed by using SPSS-23. Normality of quantitative facts was inspected with Shapiro Wilk test and paired sample ttest was done. Interclass correlation was nd out in myopic and hyperopic patients. Bland-Altman plot was drawn. Pvalue equal or less than 0.05 was taken as signi cant.
Comparative cross-sectional study was conducted on 120 non-pathological eyes of 60 subjects. Individuals with nystagmus and deviation of eyes were excluded. Refractive status was measured by cycloplegic retinoscopy. At the time of cycloplegic refraction the SE of retinoscopy was calculated. The eye was labeled as myopic if the SE was less than zero and hyperopic if it was more than zero. Patient came for cycloplegic refraction cycloplegia was done with cyclopentolate 1% eye drop, instilled thrice with the gap of 15 minutes. After 1 hour of last drop cycloplegic refraction was done, and SE was calculated. Power of SE (prescription 1, P1) was taken as proposed number of glasses to be dispensed. Three days after, PMT was done and prescription of glasses with BCVA (prescription 2, P2) was noted and prescribed. The difference between proposed R E S U L T S The mean age of 60 individuals (female: 35% and male: 65%) was 9.47 ± 2.50 years. Among 120 eyes (n=120), the distribution of myopia was 57.5% (n = 69 eyes) and hyperopia was 42% (n = 51 eyes). Interclass correlation: Two-way mixed effects model where people effects are random and measures effects are xed. a. The estimator is the same, whether the interaction effect is present or not. b. Type C intraclass correlation coe cients using a consistency de nition. The between-measure variance is excluded from the denominator variance. c. This estimate is computed assuming the interaction effect is absent, because it is not estimable otherwise.

D I S C U S S I O N
and management of important ophthalmic disorders a through cycloplegic investigation is a fundamental procedure speci cally in children as they are going through a critical process of visual maturation and have high amplitude of accommodation due to which actual refractive error is masked. Ciliary muscles are temporarily paralyzed by using different cycloplegic agents and actual refractive error is determined this process is called cycloplegic refraction. Overcorrection and under correction is also experienced if in uence of cycloplegia is insu cient. For an ideal cycloplegic agent time is an important factor to minimize adverse reaction and achieve good results. However, some practitioners follow dilated refraction and PMT as part of their regular refraction procedure, thus unduly increasing time for the prescription process. Considering that dilatation is performed as part of a comprehensive eye examination, we proposed subjective refraction under cycloplegia after performing cycloplegic retinoscopy as an alternative to avoid PMT visit in prescribing refractive corrections. Hashemi et al., conducted a research in Iranian children in 2018. According to their results Auto refractometer can be used dependably in Iranian children above six years of age, if led in cycloplegic state [20]. In contrast Cycloplegic retinoscopy was preferred in this study for children age 5 to 15 years. Supporting this study, another research also concluded that auto refraction can be performed in children but gold standard technique is cycloplegic retinoscopy [21]. In the present study, the change in spherical equivalent among the refractive groups of myopia and hyperopia was compared. Evaluated 60 participants with a mean (±SD) age of 9.47 (±2.50) years, with female: 35% and male: 65% participated in the study. Among them, the distribution of myopia was 57.5% (n = 69 eyes) and hyperopia was 42% (n = 51 eyes). The results showed a statistically signi cant difference in myopic and hypermetropic children. In hypermetropic children difference between SE increases as refractive error increases. Many parents nd it di cult to visit for PMT as it requires an extra appointment which is mutually burdensome for parents and examiner as well. Because pediatric refraction requires attention and is time consuming, it is much easy for examiner to perform retinoscopy and subjective refraction (under cycloplegia) on the same day to avoid PMT. A research showed if arti cial pupil is used under cycloplegic state and subjective refraction was done, PMT can be avoided [18].
Consequently, according to this study subjective refraction under cycloplegia can be performed on the same day following cycloplegic retinoscopy in myopic and hypermetropic patients. Although there was a statistically signi cant difference in proposed and prescribed number in both type of errors. By help of given formula PMT_SE can Visual damage in children is most commonly produced by refractive errors and that visual loss is reversible. Therefore for better outcomes and to reduce occurrence and brutality of visual complaints in children timely recognition and management of refractive errors is necessary. Principal objective for vision assessment is for early declaration to lessen the burden of ocular diseases in young age. Ciliary muscles are essential in the process of accommodation. The movement of ciliary body and ciliary muscles causes zonular relaxation due to which lens shape becomes more curved and its refractive power increases that procedure is labelled as accommodation. Cycloplegic agents are the drugs that are instilled to inhibit accommodation for refractive error evaluation. For precise evaluation of actual refractive error the best proposed method is cycloplegic refraction [19]. In the identi cation .000 .000 .000