In patients older than 40, it works well, but for younger patients especially younger than 30, its a little risky: sometimes you overcorrect for myopia. Also if you are planning to do refractive surgery, definitely you need to the post mydriasis refraction.

I think age is the most important factor to be considered while doing wet (mydriatic cycloplegia) retinoscopy. As a rule

      Aropine1 % ointment for 3 days in child less than 6 years and PMT after 15 days,

      Cyclopentolate 1% between 6-13 years and PMT after 2-3 days

       Tropicamide 13-30 years and PMT after 1 day

       Mydriatic or without after 30 years

This schedule can be relaxed

Thank you so much for your opinion.

I have come across a method which is followed by many. They do dilated (tropicamide) refraction for majority of their patients. (Age group 15 years onwards)

And then whatever is their refraction is, they will prescribe that with addition of "-0.25D" for tropicamide correction.

Good and practical alternative

Tropicamide 1% is much preferred by patients because of its short-acting cycloplegia and mydriasis (Hofmeister, 2005) and produces sufficient cycloplegia for accurate refractive determination in Caucasian non-strabismic young adults and older adults (Egashira, 1993; Hofmeister, 2005). I have never heard of adding -0.25DS for "Tropicamide Correction" and I cannot think of a rationale (Tropicamide is not a strong cycloplegic) unless the refraction was a subjective refraction performed at 4m. 

If using Cyclopentolate and Tropicamide, cycloplegic refractions can be performed on the day that the cycloplegic is given (~30 minutes after the last drop with multiple drops given 5 minutes apart if needed; e.g., Egashira, 1993; Kleinstein, 1999; Hofmeister, 2005; Ebri, 2007).

In younger patients with very dark irides, a combination of Cyclopentolate 1% and Tropicamide 1% may be preferred over Atropine (Kleinstein, 1999; Ebri, 2007). 

Hofmeister EM et al. Comparison of tropicamide and cyclopentolate for cycloplegic refractions in myopic adult refractive surgery patients. J Cataract Refract Surg. 2005 Apr;31(4):694-700

Egashira SM et al.  Comparison of cyclopentolate versus tropicamide cycloplegia in children. Optom Vis Sci. 1993 Dec;70(12):1019-26.

Ebro A et al. Cost-effectiveness of cycloplegic agents: results of a randomized controlled trial in Nigerian children. Invest Ophthalmol Vis Sci. 2007 Mar;48(3):1025-31.

Kleinstein RN et al.  Cycloplegia in African-American children. Optom Vis Sci. 1999 Feb;76(2):102-7.

It is actually favorable for younger patients who hyperopic. Over refraction tends to happen with myopes. In my experience cycloplegic refraction works better in those 10 age and less. Many a times a cycloplegic refracted patient comes in saying they can't see well with their current prescription. Sometimes I do a pre and post dilated refraction and that gives me a better idea

Personally, I feel if you are a careful refractionist with good retinoscopy skills, checking refractive error after dilation is not necessary in most cases.   I personally check refractive error after dilation less than 5% of the time.   

Hi Mark,

I think the rest of us were assuming that Dhaval meant post cycloplegia as he talks about it being the gold standard for refraction. I agree that the acronym PMT (Post-Mydriatic Test) isn't appropriate as it is the cyclopegic action of the drugs and not their mydriatic action that is important to refraction.

I agree with Mark. First, I observe the quality, intensity, and thickness of the reflex. With over 9 years of performing refraction in children and adults, I have a sound understanding whether a case requires cycloplegia or not. Generally, I do cycloplegia for all cases below 5 years but above that age, I look at the retinoscopic reflex quality, accommodative status, and visual acuity before making a decision for cycloplegic refraction. 

Sorry, I knew he meant a post cycloplegic refraction.   My answer is unchanged.   I agree with Nabin that in some younger patients it can be helpful.   But, for the greatest majority of my patients, I do not feel it is needed.   

@David Elliot Sir, Thank you for pointing out that I meant Post Cycloplegia only. PMT is controversial term used for post-cycloplegic refraction. (Still used commonly). Thank you for your detailed reply.

@Mark Wilkinson Sir, Thank you for your opinion regarding Dry Retinoscopy in majority of patients can be performed by experienced persons.

I think that the choice depends upon two variables and a half: the age of the patient, the refractive error that we suspect or we are going to test, and the half part is related to the knowledge of a previous visit ( we often have the cycloplegic previous refraction that allow us to prescribe more plus with the aging especially in hyperopia )

Age : as a rule of thumb it is important to have a full cycloplegia ( Atropine of Cyclopentolate ) if the patient is at risk of strabismus or amblyopia especially if hyperopia is ruled out.  As stated above the full cycloplegia is less important in myopic patients. I usually use a QUEST strategy to determine the visual threshold  of the patient and then I refract adding or subtracting minus lenses until the vision reaches that treshold. I.e. if I find that the threshold is 14 / 10 or 30/20 with -3 OU I test the patient for that limit until he says that the image is starting to blur ( for example with -2.5 ) and then I add -0.25 OU asking if the perceived image is clear. If no differences are perceived I prescribe -2.75 to avoid the REAL undercorrection of myopia and also the overcorrection. This is possible also with collaborative children if they're told and instructed about the procedure. Last but not least I always check for accomodation, vergences and phorias to balance the binocular vision.  

Refractive error : as stated above we must take care with hyperopia which is preferably best corrected after cycloplegia and careful examination of the whole components of the visual function. 

This is an important question in practice not only for private clinics but also for screening programs in preschool or school children for studying the prevalence of refractive error .  As we know repeated unstable refractive readings by the autorefractive tool especially the myopic readings means that the accomodation process is active and needs cycloplegia. All these tests are subjective however the objective devices were the photorefractor devices. These tools are Noninvasive, infrared video recorder linked to a laptop computer with proprietary software for evaluation. These devices measure the refractive data. During normal use, the examiner holds an infrared projector/recorder approximately 1 meter from the patient. The device produces noises to confirm fixation of the patient's gaze and needs no cycloplegia.

I used one of them in the screening program in school children, with a reasonable accuracy, especially in astigmatism.

Good question.

It depends on the patient and how much plus they can tolerate as well as your goal; if they have an accommodative strabismus you would probably prescribe more plus to control the strabismus. However as a "general rule" in our office we find that by subtracting -0.50 from the cycloplegic refractive values works fine. It seems therefore that the tonus of the lens generally is around 0.50 dioptres in normal individuals with cyclopentolate. We very rarely use atropine and the literature recommends 1.00D ciliary muscle tonus allowance for atropine. Other studies show that atropine uncover 0.3 - 0.40D more hyperopia than cyclopentolate. So depending on what you use anything between 0.50 to 1.00D tonic allowance should be fine.

Davies P H O’Connor (1981) The action and Uses of Ophthalmic Drugs. 2nd

ed, p 86, 121, 128. Butterworths, London

Robb RM, Petersen RA (1968) Cycloplegic refractions in children. J Pediatr

Ophthalmol 5: 110–114.

Psychological and gender factors, often influenced by proud parents in the case of juveniles, affect outcomes in hyperopes. especially high hyperopes. There is no guideline  significantly different from what is already written here. Contact lenses will often encourage acceptance of cycloplegic findings where spectacles or a "full strength" Rx are rejected until much later in life. I always diluted cyclopentolate and achieved adequate performance during 55 years of practice. . 

Except in children with accommodative estrabismus, I use Tropicamide 1% in most patients. I support the refraction result with an optical biometry. Then, I use a database that includes more than 14,000 eyes examined with the IOL MASTER. There must be a correlation between the refraction and the parameters of the biometry (axial length, keratometry and depth of anterior chamber).