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Ophthalmic Drugs Part 2 — the Pros and Cons of Cycloplegia

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Ophthalmic Drugs Part 2 — the Pros and Cons of Cycloplegia CET Continuing education Ophthalmic drugs Part 2 — The pros and cons of cycloplegia n active ciliary body In the second of our series looking at drugs and their use in controls the eye’s accommodation process, optometric practice, Catherine Viner discusses cycloplegics, how allowing near focusing they work, when they should be used and how to undertake to occur. The ciliary body is made up mainly cycloplegic refraction. Module C19478, one general CET point for Aof smooth muscle, known as the ciliary optometrists and dispensing opticians muscle. Accommodation occurs when the muscarinic receptors within the ciliary muscle are stimulated by the parasympathetic neurotransmitter, acetylcholine (see Part 1 Optician Poor acuity and/or stereopsis 29.06.12). The ciliary muscle then In paediatric patients, these can be contracts, pulling the ciliary body indicative of amblyopia, potentially forward. Tension in the suspensory caused by uncorrected hypermetropia, ligaments supporting the crystalline lens astigmatism, anisometropia or is reduced. As a result, the lens becomes strabismus. To fully investigate the more convex, and thereby increases its cause, a cycloplegic refraction is refractive power. Adequate focus for recommended. nearer targets is then achieved.1 To obtain the true distance correction, Family history of squint, it is imperative that refraction takes amblyopia or hypermetropia place when the patient has relaxed A child is predisposed to these his/her accommodation. For most conditions if a positive family history adults and some children, this can be exists. Should this be the case, due to the achieved by directing the patient to potential risk of amblyopia, it would view a non-accommodative distance seem sensible to fully investigate the target. However, in some individuals, child’s refractive status by performing particularly the young, this is not Figure 1 Cycloplegic agents are particularly useful when a cycloplegic refraction. sufficient and other methods must be examining young children employed to ensure an accurate result. Concentration difficulties Cycloplegia means ‘paralysis of Use of a cycloplegic agent reduces the ciliary body’. In this state, the eye cycloplegic agents, touches on their the need for a patient to concentrate cannot accommodate and the latent therapeutic applications and considers on a distance target to allow static prescription can be determined. alternatives to their use. retinoscopy to take place. This may To obtain cycloplegia, practitioners be beneficial in hyperactive children use drugs known as cycloplegic agents. Indications for cycloplegia or patients with physical or mental These are muscarinic antagonists disabilities. which block the muscarinic receptors Latent hypermetropia within the ciliary muscle (muscarine In young individuals, hypermetropia is Poor accommodation is a chemical that early neurology often masked by the use of highly active Decreased levels of accommodation researchers found to effectively block accommodation. The eye achieves may be found in individuals the acetylcholine receptors at the reasonably clear vision by using its with uncorrected hypermetropia, post ganglionic neurone action site accommodative system to overcome its amblyopia, or oculomotor nerve of the parasympathetic system). If ametropia. When a hypermetropic eye problems. Additionally, there is clear acetylcholine can no longer reach the accommodates, it brings the far point of evidence that in children with Down’s ciliary muscle, accommodation cannot focus closer to the retina, thus obtaining syndrome2,3 and cerebral palsy4,5 occur. a less blurred image. under-accommodation is considerable. Cycloplegic agents are particularly Unfortunately this can induce If an unexplained reduction in valuable within paediatric optometry increased convergence, which may accommodation levels is discovered, a (Figure 1). They are also beneficial result in an unstable esophoria, or fuller investigation of the problem may beyond this age group when examining an esotropia, leading to strabismic be made through use of a cycloplegic patients with particular refractive amblyopia. A cycloplegic refraction agent. needs. Furthermore, cycloplegia is is therefore essential in all infants occasionally desirable for patients and children who have a manifest Pseudomyopia receiving ophthalmological care. This deviation, a high or unstable esophoria Pseudomyopia occurs when a spasm of article explores the diagnostic uses of or a positive history of an eye turn. accommodation causes the muscle tone 14 | Optician | 13.07.12 opticianonline.net Continuing education CET within the ciliary body to be greater than adaptation to the new prescription closure glaucoma and patients who is necessary for the viewing distance. The by reducing the accommodation and drive should be advised to refrain from ciliary muscle is not relaxed, even for thereby improving acuity. doing so until the effects of the drops distance targets, giving the impression have worn off. of myopia. The accommodative spasm Amblyopia therapy A sensible choice of cycloplegic can be induced by prolonged close Cycloplegia can also be useful as a form agent should be made. Typically, this work and is also associated with stress. of penalisation as part of amblyopia will be cyclopentolate hydrochloride, Dispensing a myopic prescription may therapy.9 This method of treatment available in 0.5 per cent and 1.0 per cent encourage more spasm. Pseudomyopia has been found to be as effective as solutions. 0.5 per cent should always be should be considered when the conventional occlusion10 and can be used with infants under the age of six patient’s amplitude of accommodation particularly useful for patients who months. It may also prove useful with is unexpectedly low, and if a are intolerant to patching.11 Use of fair skinned individuals (who have noticeable esophoria exists (due to the atropine ointment (1 per cent) in the less iris melanin) over 12 years of age. relationship between accommodation good eye reduces its usefulness for For all other patients, the 1.0 per cent and convergence). Releasing the near focusing. The amblyopic eye solution should be used. spasm of accommodation by use of (with appropriate spectacle correction) Use of 1.0 per cent tropicamide can a cycloplegic agent allows a more is therefore encouraged to concentrate provide limited cycloplegia if two accurate prescription to be determined. at this distance instead. Care should be drops are instilled, five minutes apart. If this prescription demonstrates a taken to avoid occlusion amblyopia12 However, if retinoscopy does not take reduction in myopia, a diagnosis of and this technique is not recommended place immediately, a further drop pseudomyopia is fairly clear. In some in infants less than 18 months old. should be instilled after 35 minutes. cases an appropriate prescription will This method can provide sufficient be given. However, this may not be In ophthalmology cycloplegia in patients in their late teens tolerated as, in its post cycloplegic state, Cycloplegic agents are prescribed in or above. Manny, Hussein et al15 have the eye reverts to pseudomyopia. If this anterior uveitis.13 They allow relaxation also demonstrated that tropicamide 1.0 occurs, instillation of a cycloplegic agent of the inflamed ciliary body and per cent is an effective cycloplegic agent to relax the accommodation while the produce mydriasis which can reduce in myopic children, while Twelker patient adapts to the new prescription, the formation of posterior synechiae and Mutti16 presented tropicamide can be useful. and relieve pain of spasm. 1.0 per cent as a viable alternative to cyclopentolate in most nonstrabismic Malingering/visual conversion Correct procedure infants. A combination of tropicamide reaction (VCR) 0.5 per cent and phenylephrine 0.5 Malingering has been defined as the Prior to instillation per cent was found to be effective for ‘wilful, deliberate and fraudulent A thorough history and symptoms cycloplegic refractions in nonstrabismic feigning or exaggeration of symptoms of should be taken to ensure that the patient children and those aged older than five illness or injury done for the purpose of a has no known allergy to the cycloplegic years by Fan, Rao et al.17 consciously desired end’.6 VCR describes agent. Caution should be exercised Atropine sulphate 1.0 per cent is an unconscious process whereby a in administering cyclopentolate to usually only chosen if cyclopentolate psychosomatic response results in visual individuals known to have experienced has not produced adequate cycloplegia symptoms, sometimes referred to as CNS disturbances, especially following or prolonged penalisation is required. It ‘hysteria’.7 In either case, a cycloplegic closed head trauma. Some practitioners must not be used on infants under three refraction may reassure the practitioner hold a view that sensitivity to months of age as its prolonged action that the subjective findings are not cycloplegics is increased in patients with renders the infant at risk of stimulus caused by a significant refractive error. Down’s syndrome and cerebral palsy.14 deprivation amblyopia. Should a Interestingly, Nandakumar and Leat practitioner be of the opinion that the Refractive surgery reported no adverse reactions to 1 per cent use of atropine would be beneficial in Cycloplegic refractions in adult patients and 0.5 per cent cyclopentolate in their a particular case, he or she may refer have become more widespread in recent examination
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