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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 4  |  Page : 256-258

Does cycloplegia have a role in accurate estimation of refraction in highly myopic children


1 Department of Ophthalmology, Faculty of Medicine, AlAzhar University, Damietta, Cairo, Egypt
2 Department of Ophthalmology, Faculty of Medicine, AlAzhar University, Cairo, Egypt

Date of Submission30-Apr-2018
Date of Acceptance31-Jul-2018
Date of Web Publication20-Dec-2018

Correspondence Address:
Mohamed Altaher A AbdelAtty
15 AboDawood AlZahiry Street, 6th District, Nasr City 11765
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DJO.DJO_21_18

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  Abstract 


Aim The aim of this study was to determine whether there is any difference between manifest and cycloplegic refractions in highly myopic children.
Patients and methods This prospective study was carried out on 250 children aged 6–14 years with a refractive error higher than −6D. Both manifest and cycloplegic refractions were measured and compared for the difference in spherical equivalent.
Results Our study showed no statistically significant difference in the spherical equivalent between manifest and cycloplegic refraction in highly myopic children.
Conclusion This study suggests that cycloplegia has no significant value in accurate estimation of refraction in children with high myopia.

Keywords: children, cycloplegia, high myopia, refraction


How to cite this article:
Ghali AA, AbdelAtty MA. Does cycloplegia have a role in accurate estimation of refraction in highly myopic children. Delta J Ophthalmol 2018;19:256-8

How to cite this URL:
Ghali AA, AbdelAtty MA. Does cycloplegia have a role in accurate estimation of refraction in highly myopic children. Delta J Ophthalmol [serial online] 2018 [cited 2021 Dec 3];19:256-8. Available from: http://www.djo.eg.net/text.asp?2018/19/4/256/248083




  Introduction Top


Myopia is one of the most common visual diseases, affecting about 25% of the population [1],[2]. A high myopia of −6.00 D or more represents the minority of myopic individuals; it is associated with an increased risk of ocular pathologies such as glaucoma, cataract, and retinal detachment [3],[4],[5],[6].

It is generally believed that myopia has a multifactorial etiology [7]. It has been suggested that environmental factors such as increasing educational pressures and urbanization might be important factors. The high visual demands of near work including reading, and other near work have been considered to be a potential cause of myopia development [8],[9],[10],[11],[12],[13],[14]. The mode of inheritance may be autosomal dominant, recessive, or X-linked, but it can also appear sporadically.

Sustained accommodation and intraocular pressure are suspected to influence axial elongation in eyes that have decreased scleral resistance, yet no longitudinal studies have confirmed this [15]. Myopic individuals can be classified into two groups: those with a low amount, sometimes referred to as ‘school myopia’, and those having greater than −6D, often called ‘pathologic’ or high myopia [15].

Some authors confirmed previous findings demonstrating a significant axial elongation associated with accommodation. This elongation persists for a short time in myopic subjects and has also shown that accommodation is accompanied by a thinning of the choroid [16]. Cycloplegic agents are frequently used to inhibit accommodation during estimation of refractive error. The cycloplegic refraction has been reported to provide a more accurate estimate of the true refractive error [17]. According to some authors, the maximal effect of Cyclopentolate 1% is around 45 min and continues for 90 min. The data of refractive power did not change significantly after Cyclopentolate drops in myopic children between −1.5 D and −6 D [18].

The contribution of the ciliary muscle to the development and progression of myopia has been studied. A thickened ciliary muscle in myopia has been suggested as an internal equatorial growth restriction, possibly due to hypertrophy with potentially poor contractility, which may result in the development and progression of myopia [19].

The OCT anterior segment has been used to determine whether there is a relationship between refractive error and ciliary muscle thickness in different muscle regions in children.

The results stated that the posterior ciliary muscle fibers are thicker in myopia, but the apical ciliary muscle fibers are thicker in hyperopia [20].


  Patients and methods Top


In total, 250 children were enrolled in the study; their age ranged from 6 to 14 years; 128 were girls and 122 were boys ([Table 1]).
Table 1 Demographic aspects of the patients

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Inclusion criteria

  1. Age ranged between 6 and 14 years.
  2. Myopic refractive error higher than −6D spherical equivalent.


Exclusion criteria

  1. Systemic or ocular disease.
  2. Previous eye surgery.


All patients were submitted to autorefraction with the use of Topcon RM8000 Autorefractor (Topcon, Tokyo, Japan) before and after cycloplegia.

Cycloplejico eye drops (Alcon, Fort Worth, Texas, USA; imported by United Company of Pharmacists UCP, Cairo, Egypt) was used to obtain the cycloplegic refraction in all children, in three doses, 5 min apart and autorefraction 30 min after the last dose.

Statistical package for social sciences software, version 24, was used to analyze the data (2017, SPSS; IBM SPSS Statistics, New York, New York, USA).


  Results Top


In myopia with manifest refraction ranging between −11.25D and −16D, five children of the 67 children showed the difference between manifest and cycloplegic refractions as follows:
  1. In children with manifest refraction ranging between −11.25D and −12D, two children of seventeen children showed a difference of −0.5D between manifest and cycloplegic refraction.
  2. In children with manifest refraction ranging between −13.25D and −14D, three children of 21 children showed a difference between manifest and cycloplegic refraction, two of the three showed a difference of − 0.75D, while the third showed a difference of −1.5D ([Table 2]).
    Table 2 Differences between manifest and cycloplegic refraction and their statistical significance

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At the end of our study, we found that there was no statistically significant difference between manifest and cycloplegic refraction in children with myopia higher than −6D.


  Discussion Top


The role of the ciliary muscle in the accommodative process has been extensively studied. Accommodation occurs when the ciliary muscle and ciliary body move forward and inward, releasing zonular tension at the attachment to the lenticular capsule [21],[22]. Cycloplegic agents are frequently used to inhibit accommodation during the estimation of refractive error. The cycloplegic refraction has been reported to provide a more accurate estimate of the true refractive error [17]. In our study, we found no statistically significant difference in refraction, in particular in the myopic group (high myopic children), before and after cycloplegia. The results of our study are supported by the results of some authors who suggested that a thickened ciliary muscle in myopia may be an internal equatorial growth restriction, possibly due to hypertrophy with potentially poor contractility, which may result in the development and progression of myopia. These results concluded that accentuated ciliary muscle thickness, associated with muscular hypertrophy, may account for the inherent dysfunction in myopia [19].

OCT anterior segment has been used to determine whether there is a relationship between the refractive error and the ciliary muscle thickness in different muscle regions in children.

The results stated that the posterior ciliary muscle fibers are thicker in myopia, but the apical ciliary muscle fibers are thicker in hyperopia [20]. These results can play an important role in explanations of our findings. The current study also supports the idea that suggests the negative relationship, between refractive error and posterior ciliary muscle thickness, as referenced by Jeon et al. [19] and Pucker et al. [20].

It has been clearly reported that ciliary muscle thickness is related to refractive error, but there may be other factors that influence its dimensions as well [19],[20].It has been reported that the data of refractive power did not change significantly after administration of cyclopentolate drops in myopic children with a refraction between −1.5 D and −6 D [18]. This is comparable to the results of our study despite the difference in the degree of myopia.

Up until now, it is unclear why the ciliary muscle is thicker in myopic patients. Thickened ciliary muscle prevents excessive growth in the equatorial diameter, possibly a matter of hypertrophy with potentially poor contractility [20].

In conclusion, with regard to high myopia in children, it may be acceptable in practice to rely on the results of autorefraction without cycloplegia in spectacle prescription in highly myopic children, although the general consensus is on the importance of cycloplegia for accurate estimation of refractive error.

We recommend excluding ciliary spasm at the first instance of refractive error estimation by using cycloplegic eye drops.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Mutti DO, Mitchell GL, Moeschberger ML, Jones LA, Zadnik K. Parental myopia, near work, school achievement, and children’s refractive error. Invest Ophthalmol Vis Sci 2002; 43:3633–3640.  Back to cited text no. 14
    
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Curtin B. The myopias. Basic science and clinical management. Philadelphia: Harper & Row; 1985. 91–97  Back to cited text no. 15
    
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Woodman EC, Read SA, Collins MJ. Axial length and choroidal thickness changes accompanying prolonged accommodation in myopes and emmetropes. Vision Res 2012; 72:34–41.  Back to cited text no. 16
    
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Robb RM, Petersen RA. Cycloplegic refractions in children. J Pediatr Ophthalmol 1968; 5:110–114.  Back to cited text no. 17
    
18.
Lin LLK, Shin Y-F., Hsiao C-H., Su T-C., Chen C-J., Hung PT. The cycloplegic effects of cyclopentolate and Tropicamide on myopic children. J Ocul Pharmacol Ther 1998; 14:331–335.  Back to cited text no. 18
    
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Jeon S, Lee WK, Lee K, Moon NJ. Diminished ciliary muscle movement on accommodation in myopia. Exp Eye Res 2012; 105:9–14.  Back to cited text no. 19
    
20.
Pucker AD, Sinnott LT, Kao C-Y., Bailey MD. Region-specific relationships between refractive error and ciliary muscle thickness in children. Invest Ophthalmol Vis Sci 2013; 54:4710–4716.  Back to cited text no. 20
    
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Tamm E, Lütjen-Drecoll E, Jungkunz W, Rohen JW. Posterior attachment of ciliary muscle in young, accommodating old, presbyopic monkeys. Invest Ophthalmol Vis Sci 1991; 32:1678e1692.  Back to cited text no. 21
    
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Croft MA, McDonald JP, James RJ, Heatley GA, Lin TL, Lütjen-Drecoll E, Kaufman PL. Surgical intervention and accommodative responses, I: centripetal ciliary body, capsule, and lens movements in rhesus monkeys of various ages. Invest Ophthalmol Vis Sci 2008; 49:5484e5494.  Back to cited text no. 22
    



 
 
    Tables

  [Table 1], [Table 2]



 

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Introduction
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