Systematic review and meta‐analysis on the agreement of non‐cycloplegic and cycloplegic refraction in children

OBJECTIVE: To determine the diagnostic agreement of non‐cycloplegic and cycloplegic refraction in children. METHOD: The study methodology followed Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Electronic databases were searched for comparative studies exploring refraction performed on children under non‐cycloplegic and cycloplegic conditions. There was no restriction on the year of publication; however, only publications in the English language were eligible. Inclusion criteria consisted of children aged ≤12 years, any degree or type of refractive error, either sex and no ocular or binocular co‐morbidities. The QUADAS‐2 tool was used to evaluate the risk of bias. Meta‐analysis was conducted to synthesise data from all included studies. Subgroup and sensitivity analyses were undertaken for those studies with a risk of bias. RESULTS: Ten studies consisting of 2724 participants were eligible and included in the meta‐analysis. The test for overall effect was not significant when comparing non‐cycloplegic Plusoptix and cycloplegic autorefractors (Z = 0.34, p = 0.74). The pooled mean difference (MD) was −0.08 D (95% CI −0.54 D, +0.38 D) with a prediction interval of −1.72 D to +1.56 D. At less than 0.25 D, this indicates marginal overestimation of myopia and underestimation of hyperopia under non‐cycloplegic conditions. When comparing non‐cycloplegic autorefraction with a Retinomax and Canon autorefractor to cycloplegic refraction, a significant difference was found (Z = 9.79, p < 0.001) and (Z = 4.61, p < 0.001), respectively. DISCUSSION: Non‐cycloplegic Plusoptix is the most useful autorefractor for estimating refractive error in young children with low to moderate levels of hyperopia. Results also suggest that cycloplegic refraction must remain the test of choice when measuring refractive error ≤12 years of age. There were insufficient data to explore possible reasons for heterogeneity. Further research is needed to investigate the agreement between non‐cycloplegic and cycloplegic refraction in relation to the type and level of refractive error at different ages.