The Examination

Abstract

I am aware that many colleagues do cycloplegic refractions on all children, but in adults they only perform dry (manifest) refractions. There are several reasons for this. In patients with early nuclear sclerosis, dilation may compromise visual acuity testing. Also, in hyperopic patients it can be hard to predict how much latent hyperopia is present, and how much of the plus they will tolerate. But I find that many adult patients with strabismus (usually esotropes but not exclusively so) do “funny” things with respect to accommodation; they may not relax it during a dry refraction in the same way as non-strabismic patients do. I recall one patient who was referred to me for strabismus surgery in her late 40s. She had a history of accommodative esotropia (ET) that had been controlled for many years, but over the prior 10 years her eye began to increasingly cross. She had undergone five refractions over the prior 10 years, having seen five different comprehensive ophthalmologists, all of whom performed dry refractions; they did dilate her for fundoscopy. Although my dry refraction was close to what she was currently wearing in her spectacles, my cycloplegic refraction revealed three additional diopters of hyperopia. She was incrementally given more hyperopic correction which eliminated her ET and brought great relief from the asthenopia she was experiencing with visual tasks.

The power of accurate observation is commonly called cynicism by those who have not got it.

—George Bernard Shaw