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    Cycloplegic Refraction in Strabismus: R. Haryo Yudono

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    albaaza
    This document discusses cycloplegic refraction in strabismus. Cycloplegic refraction involves temporarily paralyzing the ciliary muscles using cycloplegic eye drops to fully relax accommodation and determine a person's complete refractive error. It is the gold standard for evaluating children and adults with active accommodation. The document outlines the history of cycloplegic refraction and indications for its use, such as in strabismus evaluation. It describes commonly used cycloplegic agents like atropine, homatropine, and cyclopentolate and provides details on their dosing, onset of action, and duration. Contraindications and potential side effects are also discussed.

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    Cycloplegic Refraction in Strabismus: R. Haryo Yudono

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    albaaza
    33 views22 pages
    This document discusses cycloplegic refraction in strabismus. Cycloplegic refraction involves temporarily paralyzing the ciliary muscles using cycloplegic eye drops to fully relax accommodation and determine a person's complete refractive error. It is the gold standard for evaluating children and adults with active accommodation. The document outlines the history of cycloplegic refraction and indications for its use, such as in strabismus evaluation. It describes commonly used cycloplegic agents like atropine, homatropine, and cyclopentolate and provides details on their dosing, onset of action, and duration. Contraindications and potential side effects are also discussed.

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    This document discusses cycloplegic refraction in strabismus. Cycloplegic refraction involves temporarily paralyzing the ciliary muscles using cycloplegic eye drops to fully relax accommodation and determine a person's complete refractive error. It is the gold standard for evaluating children and adults with active accommodation. The document outlines the history of cycloplegic refraction and indications for its use, such as in strabismus evaluation. It describes commonly used cycloplegic agents like atropine, homatropine, and cyclopentolate and provides details on their dosing, onset of action, and duration. Contraindications and potential side effects are also discussed.

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    33 views22 pages

    Cycloplegic Refraction in Strabismus: R. Haryo Yudono

    Uploaded by

    albaaza
    This document discusses cycloplegic refraction in strabismus. Cycloplegic refraction involves temporarily paralyzing the ciliary muscles using cycloplegic eye drops to fully relax accommodation and determine a person's complete refractive error. It is the gold standard for evaluating children and adults with active accommodation. The document outlines the history of cycloplegic refraction and indications for its use, such as in strabismus evaluation. It describes commonly used cycloplegic agents like atropine, homatropine, and cyclopentolate and provides details on their dosing, onset of action, and duration. Contraindications and potential side effects are also discussed.

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    CYCLOPLEGIC REFRACTION

    IN STRABISMUS

    R. Haryo Yudono
    Pediatric Ophthalmology and Strabismus
    Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing, Universitas
    Gadjah Mada
    History
    • Cycloplegic refraction was put in scientific basis
    by Donders
    • It was universally accepted after the publication
    of the donders “Anomalies of accommodation
    and refraction of the eye” in 1864

    Franciscus Cornelis Donders


    INTRODUCTION

    • Refractive error most common cause of visual disturbance worldwide


    • Vitale et al: in the US, most common refractive error is astigmatism
    (36.2%), myopia (33.1%), hyperopia (3.6%)
    • 2 methods of evaluation of refractive error: cycloplegic and non-
    cycloplegic
    • Cycloplegic refraction (CR) is a crucial procedure for strabismus
    evaluation ; esotropia (ET)
    • The principle steps in the diagnosis and treatment of ET are determine
    of full amount of hyperopia, whether hyperopia correction will correct
    ET
    INTRODUCTION

    Cyclo = ciliary, plegic = paralysis

    To determine a person’s complete refractive error by temporarily


    paralyzing the ciliary body body by using cycloplegic eye drops.
    The accommodation of lens is fully relaxed.

    Gold standard for children and adults with active accommodation


    Cycloplegic vs Non cycloplegic refraction
    No Characteristic Cycloplegic Noncycloplegic
    1 Pupil dilatation Dilated Undilated
    2 Accommodation Lost Intact
    3 Time Need more time Need less time
    4 Drugs Atropine, Cyclopentolate, Not needed
    Tropicamide,  Homatropine
    5 Types - Retinoscopy, Autorefractor,
    Objective and Subjective
    retinoscopy

    6 Cost Costly Less costly


    7 Patient convenience Less More
    Kaur K, Gurnani B. Cycloplegic And Noncycloplegic Refraction. [Updated 2022 May 10]. In: StatPearls
    [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
    https://www.ncbi.nlm.nih.gov/books/NBK580522/
    Principle of cycloplegic refraction

    Determination of total refractive error during


    temporary paralysis of ciliary muscles as an
    instillation of cycloplegic drugs & it is objective
    methods which is also known as wet retinoscopy
    Parasympathetic action in eye
    Cholinergic receptors

    • found in the iris sphincter and the ciliary body.


    • It is of the muscarinic type also found in the skeletal
    muscles.
    • Five sub types of muscarinic receptors(M1-M5)
    • The muscarinic agonist action at the receptor constricts
    the pupil and contracts the ciliary muscles.
    • causes pupillary dilatation & paralysis of
    accommodation
    Cholinergic receptors
    Cycloplegic agents

    • Atrophine sulphate
    • Homatropine hydrobromide
    • Cyclopentolate hydrochloride
    • Tropicamide
    Cycloplegic agents
    No Drug  Age Group Dose Peak effect Timing of Duration of Cycloplegic Tonus
    Retinoscopy action effect allowance
    1 Atropine Below 5 Three times x 3 2-3 days 4 day 10-20 days After 3 weeks of 1 D
    Sulfate (1% ointment) years days retinoscopy

    2 Homatropine 5-8 years One drop for 1-1.5 hours After 90 2-3 days After 3 weeks of 0.5 D
    hydrobromide every 10 mins minutes of retinoscopy
    (2% drops) ( 6 times) drug
    administration
    3 Cyclopentolate 8-20 years One drop every 80-90 After 90 6-18 hours After 3 days of 0.75 D
    hydrochloride (1% drops) 15 mins (3 minutes minutes of retinoscopy
    times) drug
    administration
    (Havener's
    recommende
    d dose)
    4 Tropicamide (0.5%, 1% Above 15 One drop every 20-40 - 4-6 hours - -
    drops) years, used 15 mins (3-4 minutes
    as a times)
    mydriatic
    Cycloplegic Refraction (CR)

    Ocular
    Accomodation
    Convergence

    CR is important test in the evaluation of any patient who has


    issues relating to binocular vision and ocular motility
    Indication of cycloplegic refraction
    (CR)

    • Determination of objective refractive error by relaxing


    accommodation
    a.    Young or uncooperative patients
    b.    Strabismus
    c.    Suspected malingerer
    d.    Accommodative spasm/pseudo myopia
    e.    Infantile glaucoma (surrogate for axial length)
    Indication of cycloplegic refraction
    (CR)
    Mandatory to do CR Accomodative
    ET

    Refractive Nonrefractive Partially


    (Normal AC/A) (High AC/A) Accomodative

    Accommodative ET is defined as a convergent deviation of the eyes


    associated with activation of the accommodative reflex
    Indication of cycloplegic refraction
    (CR)

    Acquired
    Nonaccomodative ET

    Divergence Spasm of
    Basic Cyclic Sensory Consecutive
    Insuf near reflex
    Mandatory to do CR
    Indication of cycloplegic refraction
    (CR)
    For patients with
    accommodative ET,
    repeated cycloplegic
    examination are essentials
    whe control of strabismus is
    precarious
    When is cycloplegia ready for refraction?

    Determined by
    Mydriasis and
    Asses residual
    cycloplegia do not
    Cycloplegia accommodation by
    complete at the
    push up test
    same time
    Contraindication of cycloplegic
    refraction (CR)

    1. Previous adverse effects


    2. All drugs have possibility of anticholinergic
    side-effects
    • Central nervous system changes
    • Flushing
    • Dry mouth and eyes
    • Fever
    Side effects of cycloplegic drugs
    • Atropine: fever, dry mouth, decrease sweating, allergic reactions
    of eyelid and conjunctiva, elevation of IOP, tachycardia,
    convulsions, death
    • Homatropine: incoherent speech, hallucinations, disorientation,
    psychosis, visual disturbances
    • Cyclopentolate: lacrimation, blurred vision, hallucinations, ataxia,
    disorientation, disturbance in speech, restlessness
    • Tropicamide: foreign body sensation, dry mouth, mood changes,
    tachypnea
    References
    • AAO, Basic and Clinical Science Course. Section 6: Pediatric Ophthalmology and Strabismus, 2021-2022
    • Kenneth Wright. Handbook of Pediatric Strabismus and Amblyopia. 2003. Section 6: Sensory Aspects of Strabismus.
    • Nelson LB, Catalano RA. 2014. Wills Eye Strabismus Atlas. 2014.
    • Lambert SR, Lyons CJ. 2014. Taylor and Hoyt’s Pediatric Ophthalmology and Strabismus : Fifth Edition. Elsevier.
    THANK YOU

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