Estimation Dynamic Distance Direct Ophthalmoscopy (eDDDO): A novel, objective method for the quantitative assessment of accommodation in young children

Purpose: To describe estimation dynamic distance direct ophthalmoscopy (eDDDO) and compare it with the monocular estimation method of dynamic retinoscopy (eDR) for the assessment of accommodation in children. Methods: In this prospective observational cohort study, an ophthalmologist performed eDDDO followed by eDR in children with normal eyes, and then under the partial effects of cyclopentolate and tropicamide to assess performance of eDDDO with eDR under the condition of pharmacologically induced accommodation failure. Only one eye of each child was recruited in the study. To study the inter-observer variation, two masked pediatric ophthalmology fellows performed eDDDO in the similar manner. Results: For the comparison of eDDDO with eDR, 60 eyes of 60 patients were recruited. The mean age of the patients was 10.4 years. The mean accommodation on eDDDO was 3.0D, 5.1D, 9.8D, and 11.3D at 40 cm, 25 cm, 10 cm, and 8 cm, respectively and 3.0D, 5.0D, 9.5D, and 11.0D on eDR. The eDDDO overestimated accommodation by a mean 0.17D (95% CL 0-0.48D, P = 0.5). The correlation of eDDDO with eDR was excellent (Pearson r 0.98, T value 76.0). The inter-observer difference with eDDDO was not significant (mean 1D, 95% CL 0-2.6D, P = 0.9) and the correlation between two observers was excellent (Pearson r 0.9, T value 12.7). The eDDDO and eDR were also performed on 12 eyes of 6 children with a mean age of 8.5 years (range 8-12 years) under the partial effect of cyclopentolate and tropicamide, where eDDDO overestimated the accommodation by a mean 0.3D (95% CL 0- 1.2D, P = 0.7) and the correlation was excellent (Pearson r 1.0, T value 45). Conclusion: eDDDO is a simple, reliable, quantitative, and objective technique of accommodation assessment for children. Further studies with larger sample are required to assess its performance in disorders of accommodation affecting younger children and in children with ocular comorbidities.

Dynamic distance direct ophthalmoscopy, a novel technique to assess accommodation in children.

Aim: To describe and compare dynamic distance direct ophthalmoscopy (DDDO) with dynamic retinoscopy (DR) in assessment of accommodation in children. Materials and Methods: This prospective observational study had four components. Component 1: to understand the characteristic digital images of DDDO. Component 2: to compare DDDO with DR for detection of accommodative defects in children (1–16 years). Component 3: to compare DDDO with DR for the detection of completeness of pharmacologically induced cycloplegia in children (5–16 years) and Component 4: to assess which one of the two techniques was more sensitive to detect onset of cycloplegia after instillation of 1% cyclopentolate eye drops. Results: Component 1: image analysis of DDDO on two subjects (7 years and 35 years) demonstrated superior pupillary crescent that progressively disappeared with increasing accommodation. Concurrently an inferior crescent appeared that became bigger in size with increasing accommodation. Component 2: the prevalence of defects in accommodation was 3.3% (33/1000 children). Three had unilateral accommodation failure. Sensitivity of DDDO was 94%, specificity 100%, positive predictive value 100%, negative predictive value 99%, and clinical agreement (kappa) 0.97. Component 3: in the detection of completeness of pharmacologically induced cycloplegia (n=30), the sensitivity of DDDO was 94%, specificity 96%, positive predictive value 97%, negative predictive value 93% and kappa 0.9. DR had two false positives. DDDO had one false negative. Component 4: DDDO detected onset of pharmacologically induced cycloplegia 5 min earlier than DR (n=5). Conclusion: DDDO is a novel, simple, clinical and reliable method to assess accommodation in young children. This test can assess the accommodative response of both eyes simultaneously.

Evaluación de la reproducibilidad de la retinoscopia dinámica monocular de Merchán / Evaluation of the reproducibility of the Merchán monocular dynamic retinoscopy

Objetivo: Evaluar la reproducibilidad de la retinoscopia dinámica monocular y su nivel de acuerdo con la retinoscopia estática binocular y monocular, retinoscopia de Nott y Método Estimado Monocular (MEM). Métodos: Se determinó la reproducibilidad entre los evaluadores y entre los métodos por medio del coeficiente de correlación intraclase (CCI) y se establecieron los límites de acuerdo de Bland y Altman.Resultados: Se evaluaron 126 personas entre 5 y 39 años y se encontró una baja reproducibilidad interexaminador de la retinoscopia dinámica monocular en ambos ojos CCI ojo derecho: 0.49 (IC95% 0.36; 0.51); ojo izquierdo 0.51 (IC95% 0.38; 0.59). El límite de acuerdo entre evaluadores fue ±1.25 D. Al evaluar la reproducibilidad entre la retinoscopia dinámica monocular y la estática se observó que la mayor reproducibilidad se obtuvo con la estática binocular y monocular y, en visión próxima, entre el método estimado monocular y la retinoscopia de Nott. Conclusiones: La retinoscopia dinámica monocular no es una prueba reproducible y presenta diferencias clínicas significativas para determinar el estado refractivo, en cuanto a poder dióptrico y tipo de ametropía, por tanto, no se puede considerar dentro de la batería de exámenes aplicados para determinar diagnósticos y correcciones refractivas tanto en la visión lejana como en la visión próxima.

Objective: To assess the reproducibility of monocular dynamic retinoscopy and its level of agreement with binocular static retinoscopy, the Nott retinoscopy, and the Monocular Estimated Method (MEM). Materials and methods: The reproducibility was determined among evaluators and among the methods through the intraclass coefficient of correlation (ICC) and set the limits of agreement of Bland and Altman. Results: A total of 126 subjects between 5 and 39 years of age were evaluated and low inter-rater reproducibility of the monocular dynamic retinoscopy was found in both eyes: ICC right eye: 0.49 (IC 95% 0.36; 0.61) left eye 0.51 (IC 95% 0.38; 0.59). The limit of agreement between evaluators was ±1.25D. In assessing reproducibility between the monocular dynamic retinoscopy and the static retinoscopy, it was observed that the greatest reproducibility was obtained with the binocular and monocular static retinoscopy and in near vision between the estimated method monocular and Nott retinoscopy. Conclusions: Monocular dynamic retinoscopy is not a reproducible test and presents clinical differences meaningful to determine the refractive state, regarding power dial and type of ametropy; therefore, it could not be considered within the battery of tests used to determine diagnoses and refractive corrections both in distant vision and in near vision.