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Purpose: To compare pupil dynamics after using premixed intracameral anesthetic mydriatic combination (ICAM) of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) versus topical mydriatic (TM) drops consisting of tropicamide 0.8%, phenylephrine 5%, and cyclopentolate 0.5% in pediatric cataract surgery., Design: Randomized, masked, fellow eye-controlled trial., Setting: Tertiary eye care facility., Study Population: Children ≤12 years of age with bilateral cataracts planned for surgery. One eye was randomized to receive ICAM and the other eye (control) TM drops., Intervention: Commercially available ICAM that was injected at the beginning of surgery or TM 3 times at an interval of 30 minutes, 1 hour before the scheduled time of surgery. The other treatment was administered for the second eye cataract surgery., Main Outcome Measure: Pupil dynamics at various points of surgery were studied by a masked observer., Results: Sixty-three patients (126 eyes) were randomized to receive ICAM in 1 eye (group 1) or TM drops (group 2). The mean age of the children in the study was 15.7 ± 24.3 months (range 3 months to 5 years). Adequate mydriasis with a single injection was achieved in 93.5% of patients in group 1 and 88.8% of patients in group 2 without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.78 mm to 5.1 mm after injection of 1 unit of ICAM and from 1.75 mm to 6.06 mm with TM drops (P < .0001). The maximum pupillary dilation achieved was 6.06 ± 1.17 mm in group 1 and 6.75 ± 1.07 mm in group 2 (P = .004). The average change in pupillary size from injection of drug until the end of surgery was positive in group 1 (0.75 ± 0.98 mm) and negative in group 2 (-0.3348 ± 2.57 mm), ie, there was a relative miosis in group 2 toward the end of surgery (P = .001)., Conclusions: Topical drugs achieved a larger maximum pupil size compared with ICAM. However, ICAM provided adequate and stable mydriasis without the need for augmentation compared with topical drops in children undergoing cataract surgery., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)-guided intravitreal injections., Design: Comparative cost analysis., Methods: Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models., Results: Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient., Conclusion: Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To determine the effect of dilating drops on strabismus measurements in adults., Design: Prospective cohort study., Methods: Patients aged 18 and older with strabismus underwent a standard evaluation of ocular motility, stereopsis, and ocular alignment with alternate prism cover test by a certified orthoptist. After pupil dilation with 2.5% phenylephrine and 1% tropicamide, ocular alignment was remeasured in primary gaze at 6 meters, at 1/3 meter, and at 1/3 meter with a +3.00 by a second certified orthoptist, masked to the previous measurements. The primary outcome was the mean difference in the angle of horizontal and vertical deviations after dilation in prism diopters., Results: A total of 55 patients were enrolled with a variety of diagnoses. For horizontal measurements the mean change was 0.54 prism diopters at 6 meters (95% confidence interval [CI] -0.36 to 1.43, P = .24), 1.67 prism diopters at 1/3 meter (95% CI -0.19 to 3.54, P = .08), and -0.05 prism diopters at 1/3 meter with a +3.00 add (95% CI -1.65 to 1.56, P = .95). The mean change in vertical deviation was 0.18 prism diopters at 6 meters (95% CI -0.19 to 0.56, P = .34), 0.57 prism diopters at 1/3 meter (95% CI 0-1.15, P = .05), and 0.47 prism diopters at 1/3 meter with a +3.00 add (95% CI -0.23 to 1.17, P = .18)., Conclusions: Pupil dilation does not meaningfully affect vertical or horizontal strabismus measurements in adults. Mild variability at near in younger patients is eliminated with the use of a +3.00 add., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To investigate variables associated with myopic progression despite treatment in the Atropine in the Treatment of Myopia Study., Design: Retrospective cohort study., Methods: Two hundred of 400 children were randomized to receive atropine 1% in 1 eye only in this institutional study. Children were followed up with cycloplegic autorefraction every 4 months over 2 years. Children whose myopia progressed by more than 0.5 diopter (D) in the atropine-treated eye at 1 year were classified as being progressors., Results: Among the 182 children still in the study at 1 year, 22 (12.1%) were classified as progressors. Univariate analysis suggested these children tended to be younger (8.5 ± 1.4 years vs 9.3 ± 1.5 years; P = .023), to have higher myopic spherical equivalent (SE) at baseline (-3.6 ± 1.3 D vs -2.8 ± 1.4 D; P = .015), and to have 2 myopic parents (77.3% vs 48.1%; P = .012). In nonprogressors, the myopia progression at 1 year was less in the atropine-treated eyes compared with the untreated fellow eye (+0.16 ± 0.37 D vs -0.73 ± 0.48 D; P < .001), but in progressors, progression was more similar between eyes (-0.92 ± 0.31 D vs -1.06 ± 0.44 D; P = .363). Regression analysis showed that the risk of being a progressor was 40% lower with each year of increased age, 43% lower for every 1.0 D less in myopia at baseline, and 59% lower for every 1.0 D less in myopic change in the untreated eyes over the first year., Conclusions: Doctors and parents need to be aware that there is a small group of children (younger, with higher myopia, and greater tendency of myopic progression) who may still progress while receiving atropine treatment., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effect of pupil dilation on biometric measurements and intraocular lens power calculation using the IOLMaster (Carl Zeiss Meditec)., Design: Prospective, observational case series., Methods: In this prospective study, 2 consecutive optical biometry measurements, before and after pupil dilation, were obtained using the IOLMaster on 318 eyes of 214 patients at the cataract presurgery clinic. The parameters compared were axial length, corneal power, cylinder, and the corresponding intraocular lens power, which was calculated using the Sanders-Retzlaff-Kraff/Theoretical formula., Results: This study found no statistically significant difference before and after dilation in axial length (0.005 mm; P = .476), corneal power (0.001 diopters [D]; P = .933), or calculated intraocular lens power (0.011 D; P = .609). A statistically significant difference was shown in cylinder measurements before and after dilation (0.102 D; P < .001)., Conclusions: This study demonstrated there is no clinically significant effect of pupil dilation on the IOLMaster measurements of axial length, corneal power, and corresponding theoretical intraocular lens power calculated using the Sanders-Retzlaff-Kraff/Theoretical formula., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To assess the accuracy and reliability of smartphone ophthalmoscopy, we compared the ability of a smartphone ophthalmoscope with that of a slit-lamp biomicroscope to grade diabetic retinopathy (DR) in patients with diabetes mellitus (DM)., Design: Clinical-based, prospective, comparative instrument study., Methods: This comparative clinical study was performed in 120 outpatients (240 eyes) with type 1 or type 2 DM. After pupil dilation, the patients underwent smartphone ophthalmoscopy with the D-Eye device, followed by dilated retinal slit-lamp examination, to grade DR according to a 5-step scale., Results: Overall exact agreement between the 2 methods was observed in 204 of 240 eyes (85%) (simple κ = 0.78; CI 0.71-0.84) and agreement within 1 step was observed in 232 eyes (96.7%). Compared to biomicroscopy, the sensitivity and specificity of smartphone ophthalmoscopy for the detection of clinically significant macular edema were 81% and 98%, respectively. Smartphone ophthalmoscopy and biomicroscopy could not be used to examine the fundus and grade DR in 9 eyes (3.75%) and 4 eyes (1.7%), respectively, because of cataract and/or small pupil diameter., Conclusion: Smartphone ophthalmoscopy showed considerable agreement with dilated retinal biomicroscopy for the grading of DR. The portability, affordability, and connectivity of a smartphone ophthalmoscope make smartphone ophthalmoscopy a promising technique for community screening programs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the usefulness of ultrasound biomicroscopy in confirming intraocular lens haptic-induced ocular irritation and in the management of these patients., Design: A retrospective review of patient data., Methods: Twenty pseudophakic patients who underwent ultrasound biomicroscopy examination between May 2009 and February 2011 to confirm the clinical suspicion of misplacement of intraocular lens haptics were reviewed. Ophthalmic findings at the time of presentation and at each follow-up visit, and management of each patient, were recorded., Results: Intraocular lens haptic misplacement was confirmed by ultrasound biomicroscopy in all suspected cases. In 75% of the eyes 1 haptic was embedded in the iris; it extended into the ciliary body process in 35% and into the pars plana in 10%. Focal iris thinning/atrophy was detected by ultrasound biomicroscopy in 15% of cases and focal angle closure in 25%. Intraocular lens exchange was performed in 40% of patients. The remaining 60% were kept under observation, with the addition of topical steroids and/or cycloplegics in eyes that demonstrated anterior chamber inflammation and intraocular pressure-lowering medications in eyes with persistent elevated intraocular pressure or glaucoma., Conclusions: Ultrasound biomicroscopy appears to be a valuable tool in confirming the presence of haptic-induced ocular irritation and in assisting the management of these patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: To study the change in spherical equivalent and other ocular parameters 1 year after stopping the administration of atropine., Design: Prospective randomized double-masked clinical trial., Methods: We assigned 400 myopic children, 6 to 12 years of age, to receive atropine 0.5%, 0.1% or 0.01% for 24 months, after which medication was stopped. Parents and children gave informed consent to participate in the research. Children were reviewed at 26, 32 and 36 months, and changes in cycloplegic spherical equivalent (SE), axial length (AL), visual acuity, pupil size, and accommodation were assessed., Results: Of the children, 356 (89%) entered into the washout phase. At entry, there was no significant difference in age, gender, SE, or AL among the children in the various atropine groups. Over the following 12 months, myopic progression was greater in the 0.5% eyes (-0.87 ± 0.52 D), compared to the 0.1% (-0.68 ± 0.45 D) and 0.01% eyes (-0.28 ± 0.33 D, P < 0.001). AL growth was also greater in the 0.5% (0.35 ± 0.20 mm) and 0.1% (0.33 ± 0.18 mm) eyes, compared to the 0.01% eyes (0.19 ± 0.13 mm, P < 0.001). Pupil size and near visual acuity returned to pre-atropine levels in all groups, but accommodation at 36 months was less in the 0.5% eyes (13.24 ± 2.72 D) compared to the 0.1% (14.45 ± 2.61 D) and 0.01% eyes (14.04 ± 2.90 D, P < 0.001). The overall increase in SE over the entire 36 months in the 0.5%, 0.1% and 0.01% groups was -1.15 ± 0.81 D, -1.04 ± 0.83 D and -0.72 ± 0.72 D, respectively (P < 0.001)., Conclusion: There was a myopic rebound after atropine was stopped, and it was greater in eyes that had received 0.5% and 0.1% atropine. The 0.01% atropine effect, however, was more modulated and sustained., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: To determine the effect of general anesthesia on the accommodative tone in children., Design: Cohort study in an academic practice., Methods: In children under 12 years of age who were undergoing general anesthesia, cycloplegic refraction was measured using streak retinoscopy during an office visit. Within 6 months, streak retinoscopy without cycloplegia was performed under general anesthesia. The main outcome measure was the difference between retinoscopy under anesthesia and cycloplegic retinoscopy in children., Results: In 41 children with an average age of 3.7 years (range, 0.8 to 11 years) retinoscopy under anesthesia yielded significantly more myopic measurements than cycloplegic retinoscopy for the sphere and spherical equivalent (P < 0.0001 for both) but was in good agreement with cycloplegic retinoscopy for cylinder power and axis. The average difference between retinoscopy under anesthesia and cycloplegic retinoscopy was -0.98 diopters (D) (95% limit of agreement, -3.08 D to +1.10 D) for the sphere, 0.08 D (95% limit of agreement, -0.67 D to +0.82 D) for the cylinder, and -0.94 D (95% limit of agreement, -3.01 D to +1.13 D) for the spherical equivalent. Retinoscopy under anesthesia was within 1 D of cycloplegic retinoscopy in 25 subjects (61%) for the sphere, in all subjects for the cylinder, and in 28 subjects (68.3%) for the spherical equivalent., Conclusions: Although general anesthesia reduced the accommodative tone in most children, it was still significant in some as compared to the tone found in cycloplegic retinoscopy. If an accurate measurement is essential, cycloplegia is recommended when measuring refraction in children under general anesthesia., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To compare nonmydriatic stereoscopic Optomap ultrawide field images with dilated stereoscopic Early Treatment Diabetic Retinopathy Study 7-standard field 35-mm color 30-degree fundus photographs (ETDRS photography) and clinical examination for determining diabetic retinopathy (DR) and diabetic macular edema (DME) severity., Design: Single-site, prospective, comparative, instrument validation study., Methods: One hundred three diabetic patients (206 eyes) representing the full spectrum of DR severity underwent nonmydriatic ultrawide field 100-degree and 200-degree imaging, dilated ETDRS photography, and dilated fundus examination by a retina specialist. Two independent readers graded images to determine DR and DME severity. A third masked retina specialist adjudicated discrepancies., Results: Based on ETDRS photography (n = 200), the results were as follows: no DR (n = 25 eyes [12.5%]), mild nonproliferative DR (NPDR; 47 [23.5%]), moderate NPDR (61 [30.5%]), severe NPDR (11 [5.5%]), very severe NPDR (3 [1.5%]), and proliferative DR (52 [2.5%]). One (0.5%) eye was ungradable and 6 eyes did not complete ETDRS photography. No DME was found in 114 eyes (57.0%), DME was found in 28 eyes (14.0%), and clinically significant DME was found in 47 eyes (23.5%), and 11 (5.5%) eyes were ungradable. Exact DR severity agreement between ultrawide field 100-degree imaging and ETDRS photography occurred in 84%, with agreement within 1 level in 91% (K(W) = 0.85; K = 0.79). Nonmydriatic ultrawide field images exactly matched clinical examination results for DR in 70% and were within 1 level in 93% (K(W) = 0.71; K = 0.61). Nonmydriatic ultrawide field imaging acquisition time was less than half that of dilated ETDRS photography (P < .0001)., Conclusions: Nonmydriatic ultrawide field images compare favorably with dilated ETDRS photography and dilated fundus examination in determining DR and DME severity; however, they are acquired more rapidly. If confirmed in broader diabetic populations, nonmydriatic ultrawide field imaging may prove to be beneficial in DR evaluation in research and clinical settings., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To determine whether change in refractive error is associated with ocular alignment in 105 children 3 to <7 years of age who previously participated in a randomized trial comparing atropine and patching for moderate amblyopia., Design: Prospective cohort study., Methods: One hundred five children 3 to <7 years of age previously participated in a randomized trial comparing atropine with patching for moderate amblyopia. Cycloplegic refraction was measured at baseline and 10 years of age. Ocular alignment at baseline was categorized as orthotropic, microtropic (1-8 Δ horizontal tropia), or heterotropic (>8 Δ horizontal tropia). Multivariate regression models evaluated whether change in spherical equivalent refractive error was associated with alignment category, after adjusting for age, baseline spherical equivalent refractive error, and type of amblyopia treatment., Results: Between enrollment and the age 10-year examination, there was a decrease in spherical equivalent refractive error from hyperopia to less hyperopia (amblyopic eye: -0.65 diopter, 95% CI -0.85, -0.46; fellow eye: -0.39 diopter, 95% CI -0.58, -0.20). A greater decrease in amblyopic eye refractive error was associated with better ocular alignment category (P = .004), with the greatest decrease occurring in orthotropic patients. There was no relationship between ocular alignment category and change in fellow-eye refractive error., Conclusions: Among children treated for anisometropic, strabismic, or combined mechanism amblyopia, there is a decrease in amblyopic eye spherical equivalent refractive error to less hyperopia after controlling for baseline refractive error. This negative shift toward emmetropia is associated with ocular alignment, which supports the suggestion that better motor and sensory fusion promote emmetropization., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the accuracy of 3 spectral-domain (SD) optical coherence tomography (OCT) devices (Topcon 3D-1000 [Topcon]; Cirrus HD [Carl Zeiss Meditec, Inc], and Spectralis OCT [Heidelberg Engineering]) before and after mydriasis for the diagnosis of diabetic macular edema., Design: Cross-sectional study., Methods: Sixty-two eyes of 62 consecutive patients with diabetes without recent loss of vision referred for retinal control were assessed. Two scans were performed for each SD OCT instrument. Central retinal thickness was measured before and after pupil dilation. Pupil dynamic was studied using pMetrics pupillometer (iVIS Technologies), and lens opacity was measured by Pentacam densitometry (Oculus). The diagnostic accuracy of SD OCT devices was assessed by sensitivity, specificity, and area under the receiver operating characteristic curve. Logistic regression analysis was used to assess the effect of pupil size and lens opacity on the reliability of SD OCT in the acquisition of adequate images., Results: The area under the receiver operating characteristic curve for the Topcon 3D OCT device was 0.84, that for the Cirrus HD OCT device was 0.93, and that for the Spectralis OCT device was 0.91. Significant differences in area under the receiver operating characteristic curve before and after pupillary dilatation were not found. Sensitivity and specificity associated with the cutoff value for the best performance were 82% and 74% for the Topcon 3D OCT device, 90% and 87% for the Cirrus HD OCT device, and 90% and 84% for the Spectralis OCT device, respectively. The Topcon 3D OCT device had an 11.3% segmentation algorithm failure rate for the central millimeter of the fovea, and the nuclear lens density was significantly greater in these eyes than in those without failure (17.1 ± 1.1 mm vs 10.4 ± 0.2 mm; P < .05)., Conclusions: SD OCT is a useful tool to detect and to measure diabetic macular edema without the need for pupil dilatation., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To investigate the effect of 'training' the patients' near vision and motivating them towards a spectacle-independent outcome on near vision performance in pseudophakic patients with standard intraocular lens (IOL)., Design: Prospective randomized, controlled, examiner-masked clinical trial., Methods: Eighty eyes of 40 patients with standard cataract surgery were randomly assigned to a "motivated" or "control" group. In the motivated group, subjects were told that they are taking part in a special protocol to improve their near-reading ability after cataract surgery and were instructed not to use reading glasses for at least three months and received cycloplegic eye drops for 10 days after surgery. Follow-up examinations at three months included best-corrected distance visual acuity (VA), distance-corrected near VA, best-corrected near VA, assessment of the defocus curve, and reading speed, as well as pilocarpine-, cyclopentolate- and nearpoint-induced IOL shift assessed with partial coherence interferometry. Additionally, a questionnaire evaluating patients' postoperative satisfaction, independency of reading glasses, and daily-life performance without glasses was carried out three months and one year postoperatively., Results: No difference in reading ability and IOL shift between "motivated" and "control" patients could be detected. However, the motivated patients were less dependent on reading glasses and their ability to be able to perform activities of daily life without glasses was significantly better., Conclusion: There was no improvement of ciliary body function in pseudophakic patients with a special training protocol. However, near vision training made patients more independent of reading glasses.

Purpose: To evaluate the monocular oral reading rate, accuracy, fluency, and comprehension in 10-year-old children previously treated for amblyopia., Design: Prospective, observational case series., Methods: Seventy-nine children (mean age, 10.3 years) previously treated in a multicenter randomized trial comparing patching and atropine were tested at seven sites using a modification of the Gray Oral Reading Test, Fourth Edition (GORT-4)., Results: The mean visual acuities (VA) in the amblyopic and fellow eyes at the time of the reading assessment were 0.17 logarithm of the minimum angle of resolution (logMAR) units (approximately 20/32) and -0.03 logMAR units (approximately 20/20), respectively. Compared with the sound eye, amblyopic eye performance was worse when reading orally with respect to rate (P < .001), accuracy (P = .03), and fluency (P < .001). Reading comprehension scores were similar with the amblyopic and fellow eyes (P = .45). Similar results were found with respect to original treatment group assignment (atropine or patching). There was a modest correlation between interocular difference (IOD) of VA at age 10 years and IOD in reading rate (r = 0.37; 95% confidence interval [CI], 0.18 to 0.56) and fluency (r = 0.28; 95% CI, 0.08 to 0.49). There was no correlation between the IOD in VA and IOD in accuracy (r = 0.08; 95% CI, -0.14 to 0.30) or comprehension (r = 0.16; 95% CI, -0.05 to 0.37)., Conclusions: The monocular oral reading ability when measured with the GORT-4 was slightly worse when reading with previously treated amblyopic eyes compared with fellow eyes in terms of rate, accuracy, and fluency, but reading comprehension testing was similar.

Purpose: To compare the efficacy and sensory outcome of pharmacologic and optical penalization in the treatment of moderate to mild amblyopia., Design: Randomized clinical trial., Methods: In an institutional setting, two- to 10-year-old children with strabismic or anisometropic amblyopia (visual acuity in the amblyopic eye at least 20/60) who were cooperative to measure visual acuity using the logarithm of the minimum angle of resolution (logMAR) crowded Glasgow acuity cards were randomized into two groups of therapy (n=35 in each group), 1% atropine, and optical penalization with positive lenses, after stratification by cause of amblyopia. Visual acuity was tested by the logMAR crowded Glasgow acuity cards, after retinoscopic refraction, and deviation angle were measured by the simultaneous prism and cover or Krimsky test. Stereoacuity was determined using the Titmus fly test and Randot preschool or Randot circles stereoacuity test. Change in visual acuity of the amblyopic eye and in interocular difference of visual acuity after six months of amblyopia therapy was the main outcome measure; stereoacuity at six months of therapy was a secondary outcome measure., Results: Thirty-one and 32 children completed the outcome examination in the atropine and optical penalization group, respectively. Average improvement in visual acuity of the amblyopic eye was larger in the atropine than in the optical penalization group (3.4 and 1.8 logMAR lines, respectively), as well as average improvement in interocular difference of visual acuity (2.8 and 1.3 logMAR lines, respectively). Better stereoacuity, but nonsignificantly different, was detected in the atropine group., Conclusions: Atropine penalization may be considered more effective than optical penalization with positive lenses.

Purpose: To compare the mydriatic efficacies of mist and drop delivery of tropicamide 1.0%., Design: Randomized, masked, active, controlled clinical trial., Methods: One hundred subjects were randomized to receive small-volume (6 microl) mist administration of tropicamide 1.0% in one eye and either nothing or a conventional drop (30 microl) of the same solution in the fellow eye., Results: Comparing misted eyes with untreated eyes in the same subjects, the mean maximal increase in pupil diameter in the misted eyes was 2.02 mm and was 0.25 mm in the fellow eyes. The difference is statistically significant (P

Purpose: To document the prevalence of correctable and non-correctable visual impairment in a representative sample of Australian children, predominantly age 12 years., Design: Population-based cross-sectional study., Methods: Logarithm of the minimum angle of resolution (logMAR) visual acuity was measured in both eyes unaided, with spectacles if worn, and after subjective refraction if required, in 2353 children, examined during 2004 to 2005. Cycloplegic autorefraction (using cyclopentolate) and dilated fundus examination were performed. Using a cut-off of 0.3 logMAR units (<20/40), presenting visual impairment was defined using unaided visual acuity if spectacles were not worn or with usual correction if spectacles were worn. Impairment not eliminated by refraction was considered non-correctable; any difference between this and presenting impairment was defined as correctable impairment. Myopia was defined as spherical equivalent refraction (SER) < or =-0.50 diopters (D), hyperopia as SER > or =+2.0 diopters, anisometropia as SER difference > or =1.00 diopters, and astigmatism as cylinder > or =1.0 diopters. Amblyopia was defined as corrected visual acuity <0.3 logMAR not attributable to an underlying structural eye or visual pathway abnormality., Results: Visual impairment was found in the worse eye of 117 children (5.0%) and comprised correctable (82%) and non-correctable impairment (18%). Correctable impairment was due to myopia in 67 (69.8%), hyperopia in 11 (11.5%) and astigmatism in 32 subjects (33.3%). Causes of non-correctable impairment were: amblyopia 66.7%, congenital glaucoma 9.5%, optic nerve hypoplasia 9.5%, congenital nystagmus 4.8%, and cortical blindness 4.8%., Conclusions: Visual impairment had a relatively low prevalence in this older childhood population, a large proportion of which was correctable by refraction alone.

Purpose: To evaluate the accuracy of autorefraction using three autorefractors comparing to subjective refraction in diagnosing refractive error in children., Design: A cross-sectional study., Methods: setting: Community based study. study population: 117 children sampled from primary schools. procedures: All subjects underwent autorefraction using three auto refractors and subjective refraction with and without cycloplegia. main outcome measures: Spherical power, cylindrical power, and spherical equivalence (SE)., Results: Without cycloplegia, the mean SE were significantly different for Retinomax K plus 2 (-1.55 diopters, SD 2.37 diopters; 95% CI -1.98 to -1.12; P < .0001) and Canon RF10 (-1.11 diopters; SD 2.61 diopters; 95% CI -1.59 to -0.64; P = .0023) compared with monocular subjective refraction (-0.80 diopters; SD 2.25 diopters; 95% CI -1.21 to -0.35). Mean SE was significantly different for Grand Seiko WR5100K (-0.79 diopters; SD 2.40 diopters; 95% CI -1.23 to -0.35; P = .0002) compared with binocular subjective refraction (-0.62 diopters; SD 2.51 diopters; 95% CI -1.07 to -0.16). With cycloplegia, there was no significant difference in mean SE between refraction methods. Sensitivity and specificity results for the diagnosis of myopia: Without cycloplegia: Retinomax K plus 2 (sensitivity 1.0, specificity 0.51); Canon RF10 (sensitivity 0.92, specificity 0.81); and Grand Seiko WR5100K (sensitivity 0.91, specificity 0.98). With cycloplegia: Retinomax K plus 2 (sensitivity 0.97, specificity 0.99); Canon RF10 (sensitivity 0.97, specificity 0.96); and Grand Seiko WR5100K (sensitivity 1.0, specificity 0.97)., Conclusions: Under noncycloplegic conditions, all three autorefractors have a tendency towards minus over correction in children resulting in over diagnosis of myopia. However autorefractors were accurate under cycloplegic conditions.

Purpose: To compare gradings of optic disk and cup diameters from stereoscopic film and nonstereoscopic digital images., Design: Comparison of techniques., Methods: setting: CLINIC-BASED., Patient Population: Right eyes of 62 adults. observation procedures: Images of the disk were taken through pharmacologically dilated pupils with a 45-degree digital camera (6.3 megapixels) and with a stereoscopic 30-degree film camera. Measurements were taken for vertical diameters of optic disks and cups., Main Outcome Measures: Agreement of disk and cup measurements and cup to disk ratios., Results: Optic disks and cups were slightly smaller when graded from the stereoscopic film images. Cup-to-disk ratios were similar. Correlations between film and digital images measurements were high., Conclusions: Measurements taken from nonstereoscopic digital images through a dilated pupil were similar to those taken from stereoscopic film images. Lack of stereoscopic effect may lead to small differences in measuring the optic disk and cup diameters. Nonstereoscopic digital imaging may be useful in epidemiologic studies when measures of optic cups and disks are needed.

Purpose: To quantify and characterize higher order aberrations in children and to investigate the influence of refractive error and cycloplegia., Design: Observational cross-sectional study., Methods: setting: Clinical practice. patients: One hundred sixty-two eyes of 82 children were examined. The mean age of the children was 6.7 years (range, 4 to 14 years), and the mean manifest refractive spherical equivalent was 2.39 +/- 3.35 diopters (range, -8.98 to +8.45 diopters). Aberrometry was performed with a wavefront analyzer (after cycloplegia and mydriasis with cyclopentolate 1%). Aberrometry was also conducted on a subgroup of 52 eyes of 27 children, both before and 30 minutes after the instillation of cyclopentolate 1% to investigate the effect of paralysis of accommodation., Results: Mean root mean square values of total-, third-, fourth-, and fifth-order aberrations were 0.37 +/- 0.13 microm, 0.23 +/- 0.12 microm, 0.16 +/- 0.11 microm, and 0.08 +/- 0.12 microm, respectively. Mean root mean square values of total coma (Z(3)(-1), Z(3)(1), Z(5)(-1), Z(5)(1)) and total trefoil (Z(3)(-3), Z(3)(3), Z(5)(-3), Z(5)(3)) were 0.27 +/- 0.31 microm and 0.21 +/- 0.29 microm, respectively. Myopes had statistically significant greater levels of total (P = .005) and fourth order (P = .002) aberrations and Zernicke terms (Z(3)(-3), Z(3)(-1), Z(3)(3), Z(4)(-4), and Z(4)(2)) compared with hyperopes. Cycloplegia had minimal influence on higher-order aberrations., Conclusion: Significant levels of higher-order aberrations were found in these children. They were influenced by refractive error, because myopes had significantly greater levels compared with hyperopes. Paralysis of accommodation with cyclopentolate appeared to have little effect on higher-order aberrations.

Purpose: To assess the effects of pupillary dilation on image quality and certitude of screening diabetic retinopathy by trained endocrinologists using a digital nonmydriatic camera., Design: Prospective, comparative, observational case series., Methods: One hundred fifty patients with diabetes attending a hospital-based photographic screening clinic had five-field (45 degree) digital retinal imaging and mosaic construction, first through dark-adapted pupils, then after a single application of tropicamide 1%. The 600 sets of images (150 patients, 300 eyes, before and after dilation) were graded independently and in a blinded manner by two endocrinologists and two ophthalmologists, with the consensual opinion on dilated images of the latter serving as the gold standard. The criteria of evaluation were assessment of image quality and certitude of detecting and grading retinopathy., Results: Of 300 eyes, pharmacological mydriasis improved image quality, with an increase in the number of eyes with five good images from seven to 160 and good-quality mosaics from 99 to 233. Dilation allowed better identification of maculopathy in the second eye because there was a decrease in ungradeable central images from 127 to 15 eyes. Dilation increased the number of eyes having retinopathy detected with certainty from 153 to 252 and graded with certainty from 173 to 277. No adverse effects were recorded., Conclusions: Single application of tropicamide 1% significantly improves image quality and certitude of screening diabetic retinopathy with nonmydriatic camera by endocrinologists.

Purpose: To determine the effect of off-axis retinoscopy on objective refractive measurement., Design: Prospective experimental study., Methods: Eight volunteers underwent cycloplegic retinoscopy of their right eye on-the-visual-axis, and 5, 10, 15, and 20 degrees off-the-visual-axis in adduction. A single masked examiner performed all retinoscopy with random order of the patient and axis refracted., Results: The average spherical retinoscopic value at 0, 5,10,15, and 20 degrees of off-axis alignment was -0.40, -0.90, -1.00, -1.38, and -1.80 diopters, respectively. The average spherical equivalent retinoscopic value obtained for each of the above positions of eye alignment was -0.02, -0.59, -0.45, -0.64, and -0.98 diopters, respectively. The induced cylinder power increased by an average of 3% for each degree of off-axis retinoscopy, though the axis of the cylinder was not predictable., Conclusion: Objective refractive measurement by retinoscopy is significantly altered by off-the visual-axis retinoscopy. The induced error may be clinically important even with small degrees of eccentricity.

Purpose: To compare the measurement of refractive errors (sphere, cylinder, and axis) between the hand-held Retinomax and on-table Topcon autorefractors in cyclopleged and noncyclopleged young children. The average bias and measurement agreement were assessed., Design: Observational cross-sectional study., Methods: The study included 114 cyclopleged and 156 noncyclopleged young children. The mean difference between the two methods and the 95% limits of agreement were calculated to evaluate the average bias. Two types of analyses were conducted to assess the degree of agreement. First, the proportion of the absolute mean differences was presented in different ranges (1.0 diopters for sphere and cylinder; 0-10, 11-20 and >20 degrees for axis). Second, the paired t test was conducted to evaluate the consistency of two types of measurements., Results: The data by the Retinomax had mild bias (0.59 diopters) toward a lower sphere data under noncycloplegia but no bias under cycloplegia. For cylinder and axis, there was either no bias or clinically acceptable bias (0.02-0.13 diopters for cylinder and 2-7 degrees for axis) regardless of cycloplegia. Besides the sphere data under noncycloplegia, in general 90% of the mean differences of sphere and cylinder were within 0.5 diopters. More than 97% of the difference in axis under cycloplegia and 68% under noncycloplegia were within 20 degrees. After adjusting for mild bias, the paired t test showed very consistent results., Conclusions: The data by the Retinomax were consistent with those by the Topcon. The Retinomax is a useful instrument to screen refractive errors in young children.

Purpose: To investigate changes of spherical aberration in eyes with accommodative spasm., Design: Case reports., Methods: Four eyes of two patients with accommodative spasm were studied. Ocular spherical aberration was measured with a Hartmann-Shack wavefront aberrometer for the central 4-mm zone., Results: The root mean square values of spherical aberration were negative (-0.086 +/- 0.026 microm root mean square). However, when the spasm of accommodation was cured or treated with a cycloplegic agent, the value shifted toward positivity (0.025 +/- 0.004 microm root mean square)., Conclusions: Excessive accommodative tone is manifested objectively by negative spherical aberration in eyes with accommodative spasm.

Purpose: To evaluate single-field digital monochromatic nonmydriatic fundus photography as an adjunct in the screening of diabetic retinopathy., Design: Prospective, comparative, observational case series., Methods: Patients with type I and type II diabetes mellitus (n = 197) were sequentially evaluated by three different techniques: single-field digital monochromatic nonmydriatic photography; dilated ophthalmoscopy by an ophthalmologist; and seven Early Treatment Diabetic Retinopathy Study (ETDRS) standardized 35-mm color stereoscopic mydriatic images. The seven stereoscopic color photographs served as the reference standard and were compared with either ophthalmoscopy or a single digital photograph transmitted electronically to a reading site. Levels of agreement were determined by kappa analyses. The sensitivity and specificity of the three methods were compared based on a threshold for referral to further ophthalmologic evaluation (ETDRS level > or =35)., Results: There was highly significant agreement (kappa = 0.97, P =.0001) between the degree of retinopathy detected by a single nonmydriatic monochromatic digital photograph and that seen in seven standard 35-mm color stereoscopic mydriatic fields. The sensitivity of digital photography compared with color photography was 78%, with a specificity of 86%. Agreement was poor (kappa = 0.40, P =.0001) between mydriatic ophthalmoscopy and the seven-field standard 35-mm color photographs. Sensitivity of ophthalmoscopy compared with color photography was 34%, with a specificity of 100%., Conclusion: A single nonmydriatic monochromatic wide-field digital photograph of the disk and macula was more sensitive for diabetic retinopathy screening than mydriatic ophthalmoscopy, the currently accepted screening method. When adjudicated by standard seven-field color photographs, the higher sensitivity of digital photography primarily reflected the reduced sensitivity of ophthalmoscopy in detecting early retinopathy.

Purpose: We investigated the reliability, accuracy, and repeatability of an autorefractor with the capability of over-refracting and measuring visual acuity for use in children in a prospective study., Methods: Before and after cycloplegia, 68 children (mean +/- SD age, 10 +/- 3 years, range 5-16 years) underwent autorefraction twice with the HARK 599 Autorefractor (Humphrey Instruments Inc., San Leandro, CA), subjective over-refraction through the HARK autorefractor, and subjective refraction using a phoro-optometer. After cycloplegia, retinoscopy was performed. Results are reported for one eye (left) of each child., Results: For 68 eyes of 68 children, before and after cycloplegia, correlation coefficients (R) for autorefraction reproducibility exceeded 0.95 for all comparisons of sphere and cylinder. R for spherical values for autorefraction vs. over-refraction was 0.93 and vs. subjective refraction 0.83 before cycloplegia and 0.94 and 0.97 after cycloplegia. Comparing values before and after cycloplegia, autorefraction, over-refraction, and subjective refraction, the data correlated > 0.81 for sphere and 0.75 to 0.87 for cylinder. Cycloplegic retinoscopy compared with autorefraction, over-refraction, and subjective refraction had R > 0.86 for sphere and cylinder for all comparisons except one. Cycloplegia increased the proportion of spherical equivalent values within 0.625 D of the subjective refraction from 41 of 68 eyes (61%) for auto- and over-refraction to 64 (94%) and 51 (75%) of the 68 eyes, respectively. A visual acuity of 20/30 or better was produced in 50 of 68 (73%) eyes with automated refraction before and after cycloplegia and in 62 (92%) with subjective refraction before cycloplegia and subjective refraction and retinoscopy after cycloplegia. Subjective over-refraction did not significantly improve the visual acuity., Conclusions: In children, HARK autorefraction improved in accuracy, when compared to subjective refraction, and the level of visual acuity improved after cycloplegia. Over-refraction through the instrument did not improve the results before or after cycloplegia.

Purpose: To compare the increased speed and accuracy of the Nidek ARK-900 objective refractor with standard retinoscopy., Methods: In a prospective study, 100 children aged 3 to 18 years were refracted after cycloplegia. Visual acuity measurements were determined in randomized fashion with the Nidek objective refractor, by retinoscopy, and by subjective refraction. One eye from each patient was included in the study., Results: Ninety-six percent of the children read the 20/30 line perfectly with the result from the objective refractor compared to 88% with retinoscopy. The mean +/- SD visual acuity value obtained with the objective refractor was 20/24 +/- 4.75 and with retinoscopy was 20/27 +/- 6.8, a significant difference (paired t value = 4.81, P < .001)., Conclusion: The Nidek ARK-900, representing the third generation of objective refractors, is comparable or superior to retinoscopy in accuracy in children, can be easily run by an ophthalmic technician, and therefore eliminates the physician's examination time required for retinoscopy.

Purpose: To describe a patient with manifestations of ocular leech infestation., Method: Case report., Results: The ocular foreign body was identified as a leech, Limnatis nilotica, by parasitologic examination. The leech was extracted, and the patient began using topical antibiotic and cycloplegic agents. By the third day after extraction, the patient had no obvious symptoms or signs, except for a limited subconjunctival hemorrhage, and no epithelial defect on the cornea was observed., Conclusions: Ocular leech infestation should be considered in patients with a history of swimming in streams and lakes. Attention should also be given to ocular leech infestation in the differential diagnosis of ocular trauma with iris prolapse.

Clinic patients and students were given several regular drops of commercial 10% phenylephrine HCl, and 1.0% cyclopentolate HCl or 1.0% tropicamide HCl. The drops were given three times at five-minute intervals. Mydriasis and cycloplegia were determined and compared with the results obtained by using one of the following: microdrops (0.005 or 0.01 ml) of a mixture of 5% phenylephrine HCl and 0.5% tropicamide HCl, or regular drops of mixtures of 1% phenylephrine HCl, or 0.4% hydroxyamphetamine hydrobromide with 0.1% cyclopentolate HCl, or 0.1% tropicamide in a vehicle of 1.6% or 1.0% methylcellulose 400, or artificial tears or lubricants (Absorbobase, Contique, Isopto Tears, Liquifilm, Lyteers, Ultra Tears). Except for an initial lag in the production of mydriasis with the diluted mixtures, the results were similar for all preparations. The diluted solutions produced little ocular irritation or tearing.

Microgram amounts of finely powdered phenylephrine HCl were administered to the conjunctiva of volunteers. A dose-response curve for white subjects showed a threshold mydriasis of less than 5 micrograms and a clinically useful mydriasis was obtained with one application of 50 micrograms. The time-response curve for the one time use of 50 micrograms of the powder was equivalent to giving three applications of 10% phenylephrine HCl drops. Twenty-five micrograms of pilocarpine HCl powder produced marked miosis. We investigated methods to deliver nonirritating microgram amounts of powdered phenylephrine HCl, pilocarpine HCl, and fluorescein.