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.

Use of atropine to predict the accommodative component in esotropia with hypermetropia.

This cohort study included children with esotropia and hypermetropia of ≥ +2.0 diopters (D). The deviation was measured at presentation, under atropine cycloplegia and 3 months after full refractive correction. Of 44 children with a mean age of 5.2 ± 2.4 years, 25 were males. Eighteen (41%) had fully refractive accommodative esotropia (RAE), 10 (23%) had partial accommodative esotropia (PAE), and 5 (11%) had nonaccommodative esotropia (NAE). Eleven (25%) had convergence excess (CE). Under cycloplegia, all with RAE and RAE with CE had orthotropia. There was no significant change in the deviation in the patients with NAE. The deviation under cycloplegia and that with full refractive correction in PAE and PAE with CE (with +3.0 D addition) were not different. The intraclass correlation coefficient for deviation under cycloplegia and after full refractive correction (+3.0 D addition for CE) was 0.89. It was concluded that ocular deviation under cycloplegia can help to predict the accommodative component in esotropia with hypermetropia.