Accuracy of Autorefraction in Children OTA

A report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Pediatric Ophthalmology/Strabismus Panel

Lorri B. Wilson, MD,¹ Michele Melia, ScM,² Raymond T. Kraker, MSPH,³ Deborah K. VanderVeen, MD,⁴ Amy K. Hutchinson, MD,⁵ Stacy L. Pineles, MD,⁶ Jennifer A. Galvin, MD,⁷ Scott R. Lambert, MD⁸

Ophthalmology, September 2020, Vol 127, 1259-1267 © 2020 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Purpose: The purpose of this assessment is to evaluate the accuracy of autorefraction compared with cycloplegic retinoscopy in children.

Methods: Literature searches were last conducted in October 2019 in the PubMed and the Cochrane Library databases for studies published in English. The combined searches yielded 118 citations, of which 53 were reviewed in full text. Of these, 31 articles were deemed appropriate for inclusion in this assessment and subsequently assigned a level of evidence rating by the panel methodologists. Four articles were rated level I, 11 were rated level II, and 16 were rated level III articles. The 16 level III articles were excluded from this review.

Results: Thirteen of the 15 studies comparing cycloplegic autorefraction with cycloplegic retinoscopy found a mean difference in spherical equivalent or sphere of less than 0.5 diopters (D); most were less than 0.25 D. Even lower mean differences were found when evaluating the cylindrical component of cycloplegic autorefraction versus cycloplegic retinoscopy. Despite low mean variability, there was significant individual measurement variability; the 95% limits of agreement were wide and included clinically relevant differences. Comparisons of noncycloplegic with cycloplegic autorefractions found that noncycloplegic refraction tends to over minus by 1 to 2 D. 

Conclusions: Cycloplegic autorefraction is appropriate to use in a pediatric population-based studies. Cycloplegic retinoscopy can be valuable in individual clinical cases to confirm the accuracy of cycloplegic autorefraction, particularly when corrected visual acuity is worse than expected or the autorefraction results are not consistent with expected findings. 

¹Casey Eye Institute, Oregon Health & Science University, Portland, Oregon

²Jaeb Center for Health Research, Tampa, Florida

³Jaeb Center for Health Research, Tampa, Florida

⁴Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts

⁵Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia

⁶Stein Eye Institute, University of California Los Angeles, Los Angeles, California

⁷Eye Physicians and Surgeons PC, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut

⁸Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California