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Copy of Cycloplegic refraction in infant and children

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sharath shetty

on 22 March 2013

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Transcript of Copy of Cycloplegic refraction in infant and children

Cycloplegic refraction
in infant and children What is cycloplegic refraction? Why child need cycloplegic refraction? A cycloplegic refraction is a procedure whereby a refractive error is determined while the ciliary
muscles that control accommodation are
temporarily paralysed with cycloplegic eyedrops.
This procedure is commonly used in children especially those below 10 years of age, who have immense accommodative powers. Because ofthe high level of accommodative activity found in many children, the cylinder power measured during retinoscopy without cycloplegia is frequently inaccurate. The amount of cylinder found using cycloplegic drugs is likely to be more accurate
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ahad 2- ATROPINE SULPHATE 3- Atropine- AtroPen 1-(tropicamide)-(Mydriacyl) 4- Homatropine Cycloplegic agents Control of accommodation in children of pre-school age is more commonly achieved by pharmacological means, using cycloplegic agents such as cyclopentolate and tropicamide .All of these drugs are muscarinic receptor blockers, thus they work by blocking the muscarinic receptors in the ciliary body, which in turn prevents accommodation. A mydriatic effect is concurrentlyachieved by inhibiting muscarinic stimulation of the iris sphincter muscle.

Types of Cycloplegic Drugs:1-Cyclopentolate Cyclopentolate 0.5% or 1.0% is
commonly used by practitioners as
the cycloplegic agent of choice for
paediatric examinations. The
cycloplegia achieved is not too deep,
as compared with atropine, but it is
quicker in Onset .

For children under the age of three months, it is advised that two drops of cyclopentolate 0.5% are used as opposed to 1%.This is becasue drug absorption through the conjunctival epithelium and skin is more rapid in infants compared to adults, due to immature metabolic enzyme systems in neonates and young children, which may prolong the effects of the drug.
Tropicamide This is an anti-muscarinic drug with short-lasting effect on the pupil (mydriasis) and on accommodation (cycloplegia) at the 1% .
-Tropicamide has been described as unsuitable for cycloplegic refraction in children and as clinically useless in all but those patients with very light irises and in cases of hypersensitivity to cholinergic agents, eg patients with Down’s syndrome.

Atropine Its administration is justified in children of pre-verbal age or when other cycloplegic agents fail to produce a satisfactory level of cycloplegia.
recommended in lightly pigmented irises while atropine 1% is indicated in the refraction of children with darkly pigmented irises, those with a constant strabismus with a suspected accommodative element or when cyclopentolate has proved to be ineffective

Indications for cycloplegic refraction: *Accommodative problems suggested in the case history (e.g difficulty changing focus, distance vision blur after a lot of near work).
*Patient with esotropia or convergence excess esophoria.

*A retinoscopy result much more positive than the subjective result.
*A subjective result more minus than
suggested by unaided visual acuity.
*A patient with myopia and esophoria.
*Patients with excessive lag or lead of accommodation
*Patients with accommodative infacility.

Side effects: All cycloplegic drugs have potentially serious systemic side effects, especially in infants and children. Both allergic and toxic reactions may occur with their use.
Systemic effects may include flushing, increased heart beat and confusion. You may experience rise in blood pressure, dizziness, paleness, headache, Thirst, dry mouth or skin, or unusual tiredness may also occur.

Side effects of Cyclopentolate: _ Temporary stinging in the eye.
_ Temporary sensitivity of the eyes to light due to the dilated pupil.
_ Blurred vision.
_ Raised pressure inside the eyeball.
_ If the drops are used for a prolonged time this can cause eye irritation, redness, swelling or conjunctivitis.

Cycloplegics can cause a serious rise in intra-ocular pressure in people with narrow angle glaucoma, and should not be given to people with this condition.
Atropine, Tropicamide, Scopolamine These three drops have the same side effects of Cyclopentolate

_ have the same side effects of Cyclopentolate but is characterized by
_ Irritation in area of use
_Inflammation of the lining of the eye, causing pain and redness (conjunctivitis)
_ Swelling of a small area (local oedema)
_ Watering eyes (lacrimation)
Advantages and disadvantages In general, the advantages of cycloplegic refraction are:
• accurate patient fixation is less crucial
• accurate retinoscopy can be achieved more easily
• latent hyperopia is revealed
• refractive error can be confirmed (Viner 2004)
• there is a better view of the fundus during
In general, the disadvantages of cycloplegic refraction are:
• distress to the patient on instillation of drops
• subsequent breakdown in child–clinician relationship
• photophobia caused by dilated pupils
• decreased ability in close-work tasks
• a risk of ocular and systemic side effects and adverse reactions
difficulty in assessing axes in the presence of aberrations resulting from a large pupil diameter.

Procedure: Before instilling, you should check the IOP(intraocular pressure) of the eyes. If the chamber angle is narrow, do gonioscopy exam. If there is adequate cycloplegia there should be less than two diopters of accommodation remaining using push-up method. After adequate cycloplegia, retinoscopy, subjective refraction could be performed.

About Records: Record the agent, concentration, number of drops, time , refraction technique, diopters and visual acuity.

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