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      Comparison of noncycloplegic and cycloplegic autorefraction in categorizing refractive error data in children

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          Abstract

          Purpose

          To systematically analyse the differences between cycloplegic and noncycloplegic refractive errors ( RE) in children and to determine if the predictive value of noncycloplegic RE in categorizing RE can be improved.

          Methods

          Random cluster sampling was used to select 6825 children aged 4–15 years. Autorefraction was performed under both noncycloplegic and cycloplegic (induced with 1% cyclopentolate drops) conditions. Paired differences between noncycloplegic and cycloplegic spherical equivalent ( SE) RE were determined. A general linear model was developed to determine whether cycloplegic SE can be predicted using noncycloplegic SE, age and uncorrected visual acuity ( UCVA).

          Results

          Compared to cycloplegia, noncycloplegia resulted in a more myopic SE (paired difference: −0.63 ± 0.65D, 95% CI: −0.612 to −0.65D, 6017 eligible right eyes) with greater differences observed in younger participants and in eyes with more hyperopic RE and smaller AL. Using raw noncycloplegic data resulted in only 61% of the eyes being correctly classified as myopic, emmetropic or hyperopic. Using age and uncorrected VA in the model, the association improved and 77% of the eyes were classified correctly. However, predicted cycloplegic SE continued to show large residual errors for low myopic to hyperopic RE. Applying the model to only those eyes with uncorrected VA <6/6 resulted in an improvement ( R 2 = 0. 93), with 80% of the eyes correctly classified. A higher VA cut‐off (i.e., ≤6/18) resulted in 97.5% of eyes classified correctly.

          Conclusion

          Noncycloplegic assessment of RE in children overestimates myopia and results in a high error rate for emmetropic and hyperopic RE. Adjusting for age and applying uncorrected VA cut‐offs to noncycloplegic assessments improves detection of myopic RE and may help in identifying myopic RE in situations where cycloplegia is not available but does not help in identifying the magnitude of refractive error and therefore is of limited value.

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          Increased prevalence of myopia in the United States between 1971-1972 and 1999-2004.

          Susan Vitale (2009)
          To compare US population prevalence estimates for myopia in 1971-1972 and 1999-2004. The 1971-1972 National Health and Nutrition Examination Survey provided the earliest nationally representative estimates for US myopia prevalence; myopia was diagnosed by an algorithm using either lensometry, pinhole visual acuity, and presenting visual acuity (for presenting visual acuity > or =20/40) or retinoscopy (for presenting visual acuity -2.0 diopters [D]: 17.5% vs 13.4%, respectively [P -7.9 D: 22.4% vs 11.4%, respectively [P < .001]; < or =-7.9 D: 1.6% vs 0.2%, respectively [P < .001]). When using similar methods for each period, the prevalence of myopia in the United States appears to be substantially higher in 1999-2004 than 30 years earlier. Identifying modifiable risk factors for myopia could lead to the development of cost-effective interventional strategies.
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            Increasing Prevalence of Myopia in Europe and the Impact of Education

            Katie Williams, Geir Bertelsen, Phillippa Cumberland … (2015)
            Purpose To investigate whether myopia is becoming more common across Europe and explore whether increasing education levels, an important environmental risk factor for myopia, might explain any temporal trend. Design Meta-analysis of population-based, cross-sectional studies from the European Eye Epidemiology (E3) Consortium. Participants The E3 Consortium is a collaborative network of epidemiological studies of common eye diseases in adults across Europe. Refractive data were available for 61 946 participants from 15 population-based studies performed between 1990 and 2013; participants had a range of median ages from 44 to 78 years. Methods Noncycloplegic refraction, year of birth, and highest educational level achieved were obtained for all participants. Myopia was defined as a mean spherical equivalent ≤−0.75 diopters. A random-effects meta-analysis of age-specific myopia prevalence was performed, with sequential analyses stratified by year of birth and highest level of educational attainment. Main Outcome Measures Variation in age-specific myopia prevalence for differing years of birth and educational level. Results There was a significant cohort effect for increasing myopia prevalence across more recent birth decades; age-standardized myopia prevalence increased from 17.8% (95% confidence interval [CI], 17.6–18.1) to 23.5% (95% CI, 23.2–23.7) in those born between 1910 and 1939 compared with 1940 and 1979 (P = 0.03). Education was significantly associated with myopia; for those completing primary, secondary, and higher education, the age-standardized prevalences were 25.4% (CI, 25.0–25.8), 29.1% (CI, 28.8–29.5), and 36.6% (CI, 36.1–37.2), respectively. Although more recent birth cohorts were more educated, this did not fully explain the cohort effect. Compared with the reference risk of participants born in the 1920s with only primary education, higher education or being born in the 1960s doubled the myopia prevalence ratio–2.43 (CI, 1.26–4.17) and 2.62 (CI, 1.31–5.00), respectively—whereas individuals born in the 1960s and completing higher education had approximately 4 times the reference risk: a prevalence ratio of 3.76 (CI, 2.21–6.57). Conclusions Myopia is becoming more common in Europe; although education levels have increased and are associated with myopia, higher education seems to be an additive rather than explanatory factor. Increasing levels of myopia carry significant clinical and economic implications, with more people at risk of the sight-threatening complications associated with high myopia.
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              Refractive Error, Visual Acuity and Causes of Vision Loss in Children in Shandong, China. The Shandong Children Eye Study

              Jian-Feng Wu, Hong-Sheng Bi, Shu-mei Wang … (2013)
              Purpose To examine the prevalence of refractive errors and prevalence and causes of vision loss among preschool and school children in East China. Methods Using a random cluster sampling in a cross-sectional school-based study design, children with an age of 4–18 years were selected from kindergartens, primary schools, and junior and senior high schools in the rural Guanxian County and the city of Weihai. All children underwent a complete ocular examination including measurement of uncorrected (UCVA) and best corrected visual acuity (BCVA) and auto-refractometry under cycloplegia. Myopia was defined as refractive error of ≤−0.5 diopters (D), high myopia as ≤−6.0D, and amblyopia as BCVA ≤20/32 without any obvious reason for vision reduction and with strabismus or refractive errors as potential reasons. Results Out of 6364 eligible children, 6026 (94.7%) children participated. Prevalence of myopia (overall: 36.9±0.6%;95% confidence interval (CI):36.0,38.0) increased (P<0.001) from 1.7±1.2% (95%CI:0.0,4.0) in the 4-years olds to 84.6±3.2% (95%CI:78.0,91.0) in 17-years olds. Myopia was associated with older age (OR:1.56;95%CI:1.52,1.60;P<0.001), female gender (OR:1.22;95%CI:1.08,1.39;P = 0.002) and urban region (OR:2.88;95%CI:2.53,3.29;P<0.001). Prevalence of high myopia (2.0±0.2%) increased from 0.7±0.3% (95%CI:0.1,1.3) in 10-years olds to 13.9±3.0 (95%CI:7.8,19.9) in 17-years olds. It was associated with older age (OR:1.50;95%CI:1.41,1.60;P<0.001) and urban region (OR:3.11;95%CI:2.08,4.66);P<0.001). Astigmatism (≥0.75D) (36.3±0.6%;95%CI:35.0,38.0) was associated with older age (P<0.001;OR:1.06;95%CI:1.04,1.09), more myopic refractive error (P<0.001;OR:0.94;95%CI:0.91,0.97) and urban region (P<0.001;OR:1.47;95%CI:1.31,1.64). BCVA was ≤20/40 in the better eye in 19 (0.32%) children. UCVA ≤20/40 in at least one eye was found in 2046 (34.05%) children, with undercorrected refractive error as cause in 1975 (32.9%) children. Amblyopia (BCVA ≤20/32) was detected in 44 (0.7%) children (11 children with bilateral amblyopia). Conclusions In coastal East China, about 14% of the 17-years olds were highly myopic, and 80% were myopic. Prevalence of myopia increased with older age, female gender and urban region. About 0.7% of pre-school children and school children were amblyopic.
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                Author and article information

                Contributors
                Xiangui He:
                ORCID: http://orcid.org/0000-0002-8938-1879
                xianhezi@163.com
                Jianfeng Zhu: jfzhu1974@hotmail.com
                Journal
                Journal ID (nlm-ta): Acta Ophthalmol
                Journal ID (iso-abbrev): Acta Ophthalmol
                Journal ID (doi): 10.1111/(ISSN)1755-3768
                Journal ID (publisher-id): AOS
                Title: Acta Ophthalmologica
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 1755-375X
                ISSN (Electronic): 1755-3768
                Publication date (Electronic): 07 November 2017
                Publication date (Print): November 2017
                Volume: 95
                Issue: 7 ( doiID: 10.1111/aos.2017.95.issue-7 )
                Pages: e633-e640
                Affiliations
                [ 1 ] Brien Holden Vision Institute Sydney New South Wales Australia
                [ 2 ] School of Optometry and Vision Science University of New South Wales Sydney New South Wales Australia
                [ 3 ] Department of Preventative Ophthalmology Shanghai Eye Disease Prevention and Treatment Center Shanghai Eye Hospital Shanghai China
                [ 4 ] School of Public Health Fudan University Shanghai China
                [ 5 ] College of Optometry University of Houston Houston Texas USA
                [ 6 ] Department of Ophthalmology Shanghai General Hospital Shanghai Jiao Tong University Shanghai China
                Author notes
                [*] [* ] Correspondence:

                Xiangui He and Jianfeng Zhu

                Department of Preventative Ophthalmology

                Shanghai Eye Disease Prevention and Treatment Center

                Shanghai Eye Hospital

                No. 380 Kangding Road

                Shanghai 200040

                China

                Emails: xianhezi@ 123456163.com (XH); jfzhu1974@ 123456hotmail.com (JZ)

                Author information
                http://orcid.org/0000-0002-8938-1879
                http://orcid.org/0000-0002-4246-4343
                Article
                Publisher ID: AOS13569
                DOI: 10.1111/aos.13569
                PMC ID: 5698763
                PubMed ID: 29110438
                SO-VID: 91ddf44b-e2ff-44af-bc8c-1a718b5f6517
                Copyright © © 2017 The Authors. Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.
                License:

                This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

                History
                Date received : 30 March 2017
                Date accepted : 30 July 2017
                Page count
                Figures: 5, Tables: 3, Pages: 8, Words: 5918
                Funding
                Funded by: Three‐year Action Program of Shanghai Municipality for Strengthening the Construction of the Public Health System (2015–2017)
                Award ID: GWIV‐13.2
                Funded by: Key Discipline of Public Health–Eye Health in Shanghai
                Award ID: 15GWZK0601
                Funded by: Overseas High‐end Research Team–Eye Health in Shanghai
                Award ID: GWTD2015S08
                Funded by: National Natural Science Foundation of China for Young Staff
                Award ID: 81402695
                Funded by: Shanghai Natural Science Foundation
                Award ID: 15ZR1438400
                Funded by: Brien Holden Vision Institute, Sydney, Australia
                Categories
                Subject: Original Article
                Subject: Original Articles
                Custom metadata
                source-schema-version-number 2.0
                component-id aos13569
                cover-date November 2017
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.2.6 mode:remove_FC converted:22.11.2017

                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: children,cycloplegic refraction,myopia,non cycloplegic refraction,refractive errors
                Data availability:
                ScienceOpen disciplines: Ophthalmology & Optometry
                Keywords: children, cycloplegic refraction, myopia, non cycloplegic refraction, refractive errors

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