• suspected latent hyperopia
• suspected pseudomyopia
• esotropia
• children under 3
• variable or inconsistent responses
• amblyopia
• suspected malingering

• angles too narrow
• history of angle closure
• concurrent use of contraindicated medications
• allergy
• non-consent by patient or parent

• makes latent refractive errors manifest
• eases determination of refractive error in amblyopia where the non-cycloplegic endpoints are difficult to determine
• allows determination of the full hyperopic refractive error of accommodative esotropes
• keeps hyper-active accommodation stable

• retinoscopy is difficult due to peripheral aberrations (only pay attention to retinal reflex in central 4mm area)
  • NOTE: if they have seizures, make sure they have taken your medications before doing ret on them
• potential adverse reaction to, and side effects of, the DPAs:
  • photophobia
  • blurred vision
  • dry eye/mouth
  • red eyes
  • CNS reaction
  • time consuming
• patient will be dilated for 24 hours so be sure to warn them of this and make sure they don't need to do near work during this time

1. Tropicamide
2. Cyclopentolate
3. Homatropine
4. Scopolamine
5. Atropine

Parasympatholytic:

Tropicamide

• Percentage:
• Cycloplegia Peak:
• Cycloplegia Recovery:
• Mydriasis Peak:
• Mydriasis Recovery:

• Percentage: 0.5-1%
• Cycloplegia Peak: 20-30 minutes
• Cycloplegia Recovery: 4-6 hours
• Mydriasis Peak: 20-40 minutes
• Mydriasis Recovery: 4-6 hours

Parasympatholytic:

Cyclopentolate

• Percentage:
• Cycloplegia Peak:
• Cycloplegia Recovery:
• Mydriasis Peak:
• Mydriasis Recovery:

• Percentage: 0.5-2%
• Cycloplegia Peak: 25-60 minutes
• Cycloplegia Recovery: 8 hours
• Mydriasis Peak: 30-60 minutes
• Mydriasis Recovery: 1 day

Parasympatholytic:

Homatropine

• Percentage:
• Cycloplegia Peak:
• Cycloplegia Recovery:
• Mydriasis Peak:
• Mydriasis Recovery:

• Percentage: 2-5%
• Cycloplegia Peak: 30-60 minutes
• Cycloplegia Recovery: 1-3 days
• Mydriasis Peak: 40-60 minutes
• Mydriasis Recovery: 1-3 days

Parasympatholytic:

Scopolamine

• Percentage:
• Cycloplegia Peak:
• Cycloplegia Recovery:
• Mydriasis Peak:
• Mydriasis Recovery:

• Percentage: 0.25%
• Cycloplegia Peak: 30-60 minutes
• Cycloplegia Recovery: 3-7 days
• Mydriasis Peak: 20-30 minutes
• Mydriasis Recovery: 3-7 days

NOTE: cycloplegic effect lasts longer than mydriatic effect

Parasympatholytic:

Atropine

• Percentage:
• Cycloplegia Peak:
• Cycloplegia Recovery:
• Mydriasis Peak:
• Mydriasis Recovery:

• Percentage: 0.5-3%
• Cycloplegia Peak: 1-3 hours
• Cycloplegia Recovery: 6-12 days
• Mydriasis Peak: 30-40 minutes
• Mydriasis Recovery: 7-12 days

NOTE: cycloplegic effect lasts longer than mydriatic effect

• selet a medication that provides adequate cycloplegia with minimal side effects
• infants to one year: use 0.5% cyclopentolate (also used on Down's patients)
• older children and adolescents: use 1% cyclopentolate
• people with darker eyes may require a stronger dose of medication in order to achieve the desired effect (melanin binds to medication, requiring more to be effective)
• use a smaller dose in children with Down syndrome or other central nervous system disorders

1. obtain a manifest refraction
2. completion of accommodative and vergence testing
3. explain to patient and parent what you will be doing and why (explain they are stronger than normal dilating drops and will yield a better prescription)
4. obtain patient and parental consent
5. follow protocols for using DPA's
6. pupils, angles, pressures, acuities

(I LOVE IT WHEN YOU CALL ME BIG PAPA)

NOTE: wait 30-60 minutes for full effect; must assess level of cycloplegia prior to testing

• comparing NRA and PRA recovery values:
  • performed monocularly
  • place +2.50 over best correction so they can see near card
  • measure the NRA
  • measure the PRA
  • the dioptric difference between the recovery values for these two tests is the residual accommodation
    
    • usually won't be 0 even when fully cyclopleged due to DOF
  • adequate cycloplegia = < 1.00D of residual accommodation

NOTE: looking at the amount of mydriasis is NOT an effective method for this

NO!

possible exception: accommodative esotropia

NOTE: JCC is often not accurate when cyclopleged because it will affect the axis, so don't even need to do JCC on wet refraction (get axis from dry refraction)

Variables to take into account when prescribing:

Ciliary Tonicity

cut 1.00D from the wet refraction

(no matter how good the cycloplege is, there will usually be at least 1.00D of accommodation left)

Variables to take into account when prescribing:

Age

cut more plus for younger patients

(puts final prescription closer to manifest refraction)

Variables to take into account when prescribing:

Prescription History

cut plus for adaptive reasons

(if never has had glasses, cut more plus to make adaptation easier)

Variables to take into account when prescribing:

Residual Accommodation

Variables to take into account when prescribing:

Dry Refraction

Variables to take into account when prescribing:

Phoric Posture

SIDE NOTE:

what does "cut less plus" means?

• patient's needs
• what they will be able to adapt to
• what will give them the best acuity and alignment

Usually the cylinder found with the dry refraction

(recall the inaccuracy of JCC when cyclopleged)

• likely necessary to have patient back to reassess their vision, posture and functioning with the proposed prescription
• keep in mind that they will likely accept more plus after they've been eased in