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Cycloplegics are very safe and useful medications. To avoid the unpleasant side effects of these medications, six precautions are considered. They are: 1. dosage, 2. cycloplegic selection, 3. toxic reaction, 4. biologic variations, 5. topical anesthesia, 6. environmental temperature and humidity.
Complications from mydriatic and cycloplegic drugs are rare compared with their extensive use. Adverse effects are often related to dosage or other factors. The ocular complications include increased intraocular pressure, pigmentation of the conjunctiva and cornea, pigment in the anterior chamber, lacrimal duct blockage, macular edema, corneal endothelium damage, hyperemia, allergy, discomfort, and blurred vision. The systemic complications are those common to sympathomimetic and parasympatholytic drugs and include tachycardia, hypertension, headache, faintness. pallor, trembling, excessive sweating, palpitations, arrhythmias, confusion, hallucinations, drowsiness, ataxia, flushed skin, high fever, dysarthria, thirst, dry mouth, convulsions, disorientation, nervousness, coma, and death. An understanding of all possible side effects is of paramount importance to those using these drugs in the treatment of anticholinesterase poisoning. This review is intended as a ready reference to the adverse effects of mydriatic and cycloplegic drugs.
OBJECTIVES: To provide a description of refractive errors in healthy, term-born children, aged 1 through 48 months, and to test the hypotheses that spherical equivalent becomes significantly less hyperopic and less variable with increasing age. METHODS: Following a prospective, cross-sectional design, cycloplegic retinoscopy was used to measure the refractive error in both eyes of 514 healthy, term-born children in 12 age groups. Three hundred were aged 12 months or younger. Spherical equivalent and cylindrical power and axis were analyzed as a function of age. Prediction limits for spherical equivalent were calculated. RESULTS: Spherical equivalents of right and left eyes did not differ at any age. Hyperopia declined significantly with increasing age. The variability in spherical equivalent also decreased significantly with age. Cylindrical error of 1 diopter or more was found in 25% of the children; the proportion with astigmatism was highest in infancy and then waned. Myopia and anisometropia were rare, occurring in 3% and 1% of the sample, respectively. CONCLUSIONS: Significant declines in hyperopia and variability of spherical equivalent appear to be features of emmetropization. The normal prediction limits provide guidelines against which data from individual patients can be compared.
A new scheme for refractive measurements under atropine cycloplegia was tested in 90 strabismic children aged two to several years. Refraction was determined by an autorefractor (CANON R 10) 90 minutes after application of two drops of atropine (0.5% atropine children < 2 1/2 years; 1.0% atropine children > 2 1/2 years) and compared with the results after 3 days of receiving 1 atropine eyedrop 3 times daily. In 86.5% the spherical equivalents differ not more than 1.0 diopter (p = 0.05); the correlation was 0.99. Astigmatic corrections were in agreement in 95.5%, the axis of cylinders in 93.0% (p = 0.05); the correlations were 0.95 and 0.97. The residual accommodation 90 minutes after 2 drops of atropine was not more than 1 diopter in all children. The additional cycloplegic effect of the three-day-atropinization was only 0.5 diopters. This new type of application allows a more rapid and less toxic assessment of refraction than the usual three-day-atropinization.
Changes of cycloplegic retinoscopy refraction from 8.5 to 38.5 months of age were compared in two infant groups in the Cambridge population: "infant myopes", having at least one myopic axis (0 to -3.5 D inclusive), and a second, "control" group with low hyperopia (< or = +3.5 D). Cycloplegia eliminated the variable accommodation of infants. The myopic group showed a significant emmetropization of the mean spherical equivalent towards low hyperopia by 3 yr. There was no significant change in the control group's mean spherical equivalent power. Both groups showed a significant reduction in astigmatism with age. Analysis of the vertical and horizontal powers showed significant "emmetropization" of these meridians, in both groups, towards low hyperopia from 8.5 to 38.5 months. These meridional emmetropization changes were significant for both With-the-Rule and Against-the-Rule astigmatism.
The intereye difference of cycloplegic refraction was determined in a cohort of 350 rural Japanese schoolchildren aged 6 to 11 years. The intereye spherical difference remained statistically unchanged throughout 5 years, with mean value ranging from 0.21 to 0.28 D, median from 0.15 to 0.20 D, and the 95th percentile from 0.58 to 0.85 D. The prevalence of 1.0 D or greater spherical anisometropia was up to 3.1%. Linear regression analyses of the longitudinal data from individual children revealed that 295 (84.3%) children and remained unchanged while 55 (15.7%) showed significant increase or decrease in the amount of anisometropia with increasing age. The intereye astigmatic difference was also statistically unchangeable, with mean value ranging from 0.28 to 0.36 D, median from 0.20 to 0.39 D, and the 95th percentile from 0.70 to 0.90 D. The prevalence of 1.0 D or greater astigmatic anisometropia was up to 4.3%. There was a significant correlation between the spherical and astigmatic anisometropia. The results show the current state of intereye refractive difference in Japanese schoolchildren, demonstrating that it remains unchanged and significant anisometropia is rare during school age.
BACKGROUND: Because of its advantages, topical cyclopentolate is often preferred over the gold standard, atropine. The purpose of the study was to obtain an overview over current cycloplegia protocols and to estimate the likelihood of severe complications due to the use of cycloplegics. METHODS: A questionnaire was sent to 107 German-speaking centres with a supposed high cycloplegia frequency. RESULTS: 57 centres answered, whereby 1,112 cumulated years of experience with cycloplegia were available for analysis. The frequency of cycloplegias varied between 2 and 180/week/centre, median 25/week/centre. A cumulated amount of 1.7 million cycloplegias was computed. The average extrapolated experience with cycloplegia was 49,000 cycloplegias/30 years. Severe complications which would cause a medical follow up of several hours or which led to a follow up in a ward were named 47 times and 2 times, respectively. CONCLUSIONS: During 30 years of a cycloplegia career with an average of 34 cycloplegias/week, one may expect 2-10 severe complications. In current practice, the patient risk of severe complications is very small. Health care professionals and parents should be informed about the frequent occurrence of light side effects in order to reach a good compliance with cycloplegia.
A minimum clinical history and examination preceding drug instillation is described. Clinically effective doses of topically applied cycloplegic agents are summarized. A presentation of the causes and incidence of adverse drug reactions, both systemic and ocular, is followed by a discussion of general guidelines for their prevention or management.
This study was designed to provide information regarding two aspects of contrast sensitivity testing of aviator candidates: first to determine whether contrast sensitivity functions (CSF's) obtained with the Vistech Visual Contrast Test System (VCTS) are affected by cycloplegia and second to determine whether the VCTS provides useful CSF's under clinical screening conditions in a timely and simple manner. Contrast sensitivity thresholds were obtained at 5 spatial frequencies from 106 aviator candidates before and after administering a cycloplegic. CSF's obtained under cycloplegia were reduced by about 20%. The VCTS provided useful CSF's under military screening conditions, and added about 6 min to the time required for the standard flight physical.
We measured distance refractive error (Dist R), dark refractive error (Dark R), and cycloplegic refractive error (Cyclo R) in 196 subjects whose ages ranged from 4 to 17 years, using the Canon Autoref R-1. We defined the values of (Dark R--Dist R) as DFcus (Dist R) and those of (Dark R--Cyclo R) as DFcus (Cyclo R) in this study. Although DFcus (Dist R) was larger in less myopic and more hyperopic eyes similar to DFcus (Cyclo R), it was zero or plus in high hyperopic eyes, unlike DFcus (Cyclo R). We found Dist R was more strongly influenced by Cyclo R than was Dark R. It is not adequate to use Dist R as the far point for precise evaluation of the dark focus. We should use the difference between Dark R vs. Cyclo R as the true value of the dark focus of accommodation.
Twenty-seven Hong Kong Chinese children, aged 3 to 5 1/2 years, were recruited in this study to evaluate the relation between refractive error as measured retinoscopically before and after cycloplegia using cyclopentolate 1%. The noncycloplegic spherical refractive error of these children ranged from -0.75 to +2.50 D and approximately 98% of the Hong Kong pre-school children have a manifest spherical error within this range. The cycloplegic refractive error can be approximated by multiplying the spherical component of the manifest error by 1.45 and adding +0.39 D to the product, while keeping the astigmatic power and axis unchanged. Cyclopentolate 1% requires more time to produce mydriasis and cycloplegia in eyes with heavily pigmented irides; however, its final effect on refractive error is apparently independent of iris pigmentation and depends on the amount of spherical refractive error present.
Thirty-two children who had been refracted in early infancy were re-refracted at the age of 7 to 8 years. Refraction comprised cycloplegic retinoscopy at the mean age of 11 weeks and noncycloplegic retinoscopy and subjective examination at the mean age of 94 months. The change in spherical equivalent refraction (SER) was highly negatively correlated with the initial refraction (-0.863), demonstrating emmetropization; however, the correlation between the refractive error at age 7 to 8 years and the refractive error in infancy was much weaker (+0.225). The SER was significantly less and the astigmatism was greater in infancy in children who were myopic at age 7 to 8 years. There was, however, extensive overlap in range between the SER for the two groups and the initial SER was not a good predictor of myopia at 7 to 8 years, although it may help to identify children who are unlikely to become myopic. One hyperopic child with bilateral ptosis failed to emmetropize.
Static refraction in children after the topical instillation of atropine twice a day during 3.5 days was compared with the refraction after a single instillation of one drop of 0.85% cyclopentolate + 1.5% phenylephrine in a randomized cross-over study. Atropine eye drops were applied by the parents at home, while the combination drop was applied by personnel at the eye clinic. Refraction was determined by retinoscopy in 40 children (3-6 years) in a single blind manner. No statistically significant difference in cycloplegic effect was found between the 2 methods. The results imply that in clinical practice a single instillation of a combination of 0.85% cyclopentolate and 1.5% phenylephrine can be substituted for conventional "full" atropinization during 3.5 days.
AIMS: High hyperopia constitutes the majority of refractive errors in large scale visual screening at preschool ages. The authors aimed to assess the validity of the Retinomax hand held refractor to detect high hyperopia in a refractive screening performed without cycloplegia and carried out on children aged 9-36 months. They considered +1.5 D of manifest hyperopia to be the threshold value and abnormal absolute hyperopia to be above +3.5 D. METHODS: Of the 897 children screened without cycloplegia, 220 were refracted with cycloplegia. The validity of several thresholds of manifest hyperopia was estimated by receiver operating characteristic (ROC) curves using cycloplegic measures as a reference. The reproducibility of Retinomax measurements was assessed. Normal and quick mode measurements were compared using the Wilcoxon test. RESULTS: The manifest threshold of +1.5 D offered the best combination of sensitivity (70.2%), specificity (94.6%), positive predictive value (78.6%), and negative predictive value (91.9%) to disclose abnormal absolute hyperopia. A good agreement was obtained between the various measurements using Retinomax on the same subject. In the results of this survey, there is no evidence that accommodation is minimised in the normal mode of measurement compared with the quick mode. CONCLUSION: The Retinomax hand held infrared autorefractor is a suitable instrument to diagnose abnormal hyperopia (manifest hyperopia > +1.5 D) in noncycloplegic refractive screening at preschool ages. It is suggested as the quick mode of measurement as it is more feasible in children (success rate 98.5%).
We examined refractions of 102 eyes in 51 Japanese children after the topical instillation of cycloplegics. Cyclopentolate 1% was instilled 3 times after 5-min intervals, and refractions were evaluated 45 min after the last instillation. Atropine, 0.5% or 1%, was instilled twice daily for 7 days. Refractions were measured by an autorefractometer. The mean refraction in 102 eyes measured after atropine instillation was +3.07 dpt, and the mean after cyclopentolate instillation was +2.35 dpt. The mean difference in the direction of meridians of maximal refractions measured after atropine and cyclopentolate was 22 degrees. Our finding showed that atropine instillation may be adequate to determine exact refractions in Japanese children.
A case of toxic psychosis due to cycloplegic eyedrops is reported. The characteristic mental symptoms of atropine intoxication include confusion with vivid visual hallucinations, restlessness, muscular incoordination, and later emotional lability. These symptoms and a short period of retrograde amnesia occurred in our patient. The adverse drug reaction was confirmed following rechallenge. The possible preventive measures against intoxication caused by atropine eyedrops are described. All healthcare professionals should be aware of the possible temporal relationship between the appearance of pathology and the administration of a drug.
Retinoscopy under cycloplegia using cyclopentolate (Cyclogyl) hydrochloride was performed on 18 patients (36 eyes) with partial or complete accommodative esodeviation, during and after treatment with echothiophate (Phospholine) iodide. Measurements were clinically comparable on both occasions, regardless of concentration of echothiophate, duration of administration, or interval from discontinuance until refraction. It appears to be unnecessary to discontinue echothiophate iodide in order to obtain reliable cycloplegic retinoscopic measurements.
We have compared the performance of an off-axis (knife-edge) photorefractor with that of an on-axis (isotropic) system. Normal infants and children between the ages of 8 and 208 weeks were photographed with each camera both with and without cycloplegia. Refractive errors were estimated for each technique based on equations derived from ray-tracing. These refractions were compared to the results of retinoscopy under cycloplegia. Sensitivity and specificity of the two photorefraction systems were evaluated as a function of the magnitude of meridional hyperopia defined by retinoscopy. We also examined the effect of varying the photorefraction screening criterion. Thirteen percent of the infants in the screening sample presented with +3.50 diopters or more of meridional hyperopia. Using this level of ametropia as a referral criterion, the sensitivity and specificity of the off-axis system for infants without cycloplegia were 83% and 72%, respectively. For the on-axis system, sensitivity and specificity values were 85% and 53%. The use of cycloplegics did not significantly improve the performance of either system, but rather their use degraded the specificity of the on-axis system in the presence of moderate refractive errors. The results of the present study indicate that both on- and off-axis systems are effective in identifying highly ametropic infants, but that the off-axis system results in significantly fewer false positives. Moreover, the off-axis system has the advantages of an inherently greater dynamic range for a fixed camera design, and also more easily interpreted photographs.