Acta Ophthalmologica 2016
carteolol, topical 0.1% betamethasone
twice daily and 7 mg oral prednisolone.
No cyclodialysis was evident by gonio-
scopy and ultrasound biomicroscopy;
cleft of trabecular meshwork was
observed at the trabeculotomy sites
OU by anterior segment optical coher-
ence tomography (Fig. 1G, arrow).
After a trabeculotomy greater than
180 degrees, marked IOP reduction was
achieved OU in the current case. As
reported regarding ab externo trabecu-
lotomy (Iwao et al. 2011), patients with
steroid-induced glaucoma also may be
good candidates for microhook ab
interno trabeculotomy. Several tech-
niques of ab interno trabeculotomy or
gonio-bypass surgeries using the
Trabectome (Neo-Medix, Tustin, CA,
USA) (Minckler et al. 2005), iStent
(Glaukos, Laguna Hills, CA, USA)
(Malvankar-Mehta et al. 2015) and
gonioscopy-assisted transluminal tra-
beculotomy (Grover et al. 2014) have
been reported. These techniques also
were indicated for the current case;
however, the absence of the need for
expensive or special devices is an advan-
tage of our procedure. To minimize the
damage of outer wall of Schlemm’s
canal, we recommend the surgeon to
make an initial goniotomy by scratching
the trabecular meshwork surface using
the tip of MVR knife rather than
cutting. The tip of the Sinskey hook
can be observed thorough the trabecular
meshwork under the visualization using
a Swan–Jacob gonioprism lens with
enough high magnification. To avoid
unintended tissue damage around the
trabecular meshwork, after the insertion
of a microhook into the Schlemm’s
canal, correct insertion, direction and
depth of the tip of hook should be
carefully monitored during the proce-
dure. The microhook ab interno tra-
beculotomy, a minimally invasive
glaucoma surgery that targets the out-
flow pathway while sparing the conjunc-
tiva without scleral dissection, can be a
surgical option in cases of open-angle
glaucoma with scleral thinning.
References
Grover DS, Godfrey DG, Smith O, Feuer WJ,
Montes DE OCA I & Fellman RL (2014):
Gonioscopy-assisted transluminal trabecu-
lotomy, ab interno trabeculotomy: tech-
nique report and preliminary results.
Ophthalmology 121: 855–861.
e372
Iwao K, Inatani M & Tanihara H (2011):
Success rates of trabeculotomy for steroid-
induced glaucoma: a comparative, multicenter,
retrospective cohort study. Am J Ophthalmol
151: 1047–1056.
Malvankar-Mehta MS, Chen YN, Iordanous
Y, Wang WW, Costella J & Hutnik CM
(2015): iStent as a solo procedure for glau-
coma patients: a systematic review and
meta-analysis. PLoS One 10: e0128146.
Minckler DS, Baerveldt G, Alfaro MR &
Francis BA (2005): Clinical results with
the Trabectome for treatment of open-
angle glaucoma. Ophthalmology 112: 962–
967.
Correspondence:
Masaki Tanito, MD, PhD
Division of Ophthalmology
Matsue Red Cross Hospital
200 Horo-machi, Matsue
Shimane 690-8506
Japan
Tel: +81-852-24-2111
Fax: +81-852-31-9783
Email: tanito-oph@umin.ac.jp
Supporting Information
Additional Supporting Information
may be found in the online version of
this article:
Video S1. Ab interno trabeculotomy
using a microhook in the right eye.
Cycloplegia in refraction:
age and cycloplegics
Virgilio Galvis,1,2 Alejandro Tello,1,2
Oscar Blanco2,3 and M. Margarita
Parra1,2
1
Centro Oftalmol

ogico Virgilio Galvis,
Floridablanca, Colombia; 2Universidad
Aut

onoma de Bucaramanga,
Bucaramanga, Colombia; 3Fundaci
on
Oftalmol

ogica de Santander (FOSCAL),
Floridablanca, Colombia
doi: 10.1111/aos.13064
Editor,
W e read your informative article
on corneal total astigmatism
measurement in the September 2014
issue (Sanfilippo et al. 2014). In
‘Methods’ although the intention of
making a comparison between different
age groups is very interesting, different
types of drugs were used and this could
lead to incorrect conclusions. The pur-
pose of the article was to investigate the
appropriate age cut-off for cycloplegia
in refraction, but the comparison
should have been made with drugs that
offer the same cycloplegic potential.
Several studies have shown that
cyclopentolate has more cycloplegic
effect than tropicamide and it reduces
the accommodative amplitude in adults
(Mutti et al. 1994; Owens et al. 1998;
Hofmeister et al. 2005). The authors
concluded that cycloplegia is not
required to provide an estimation of
refractive error for adults; we believe
that one cannot come to this conclu-
sion being as tropicamide was used in
the adult group. As discussed above,
this is a drug that produces less
cycloplegia than cyclopentolate.
Therefore, the amplitude of accommo-
dation will not remove efficiently and
autorefraction may show erroneous
data given the remaining reserve
accommodation. Although some
authors consider that this is not nec-
essary, based on the concept that the
amplitude of accommodation is lost
with age, the findings in their studies
have shown no significant differences
between perform it. It is also well
known based on many studies that
cycloplegic refraction is very impor-
tant in adults. Many authors conclude
that the lack of cyclopegia can show
an overestimation of myopia or an
underestimation of hyperopia or
emmetropia. This can lead to a wrong
spherical equivalent, even in patients
between the ages of 20 and 50. There-
fore, cycloplegia should be considered
the gold standard for epidemiological
studies of refraction in both children
and adults (Morgan et al. 2015). In
other studies, sensitivity and specificity
of non-cycloplegic autorefraction were
determined using cyclopentolate and
tropicamide. They found that the
absence of cyclopegia leads to signif-
icant errors in the measurement of
refraction which ceases to be impor-
tant in adults over the age of 50
(Fotouhi et al. 2012).
References
Fotouhi A, Morgan IG, Iribarren R, Khabaz-
khoob M & Hashemi H (2012): Validity of

noncycloplegic refraction in the assessment
of refractive errors: the Tehran Eye Study.
Acta Ophthalmol 90: 380–386.
Hofmeister EM, Kaupp SE & Schallhorn SC
(2005): Comparison of tropicamide
and cyclopentolate for cycloplegic refrac-
tions in myopic adult refractive surgery
patients. J Cataract Refract Surg 31: 694–
700.
Morgan IG, Iribarren R, Fotouhi A & Grzy-
bowski A (2015): Cycloplegic refraction is
the gold standard for epidemiological stud-
ies. Acta Ophthalmol 93: 581–585.
Mutti DO, Zadnik K, Egashira S, Kish L,
Twelker JD & Adams AJ (1994): The effect
of cycloplegia on measurement of the ocular
components. Invest Ophthalmol Vis Sci 35:
515–527.
Owens H, Garner LF, Yap MK, Frith MJ &
Kinnear RF (1998): Age dependence of
ocular biometric measurements under cyclo-
plegia with tropicamide and cyclopentolate.
Clin Exp Optom 81: 159–162.
Sanfilippo PG, Chu BS, Bigault O et al.
(2014): What is the appropriate age cut-off
for cycloplegia in refraction? Acta Ophthal-
mol 92: 458–462.
Correspondence:
Maria Margarita Parra
Centro Oftalmol
ogico Virgilio Galvis
Centro M
edico Ardila Lulle Floor 3rd
Floridablanca, Santander
Tel: 7 6392929
Fax: 7 6392626
Email: mariamargaritaparrac@gmail.com
Response: Cycloplegia in
refraction: age and
cycloplegics
Paul G. Sanfilippo,1 Byoung-Sun Chu,2
Olivia Bigault,1 Lisa S. Kearns,1
Mei-Ying Boon,2 Terri L. Young,3
Christopher J. Hammond,4
Alex W. Hewitt1,5 and
David A. Mackey5,6
1
Department of Ophthalmology, Centre
for Eye Research Australia, Royal
Victorian Eye and Ear Hospital,
University of Melbourne, Melbourne,
Victoria, Australia; 2School of
Optometry and Vision Science,
University of New South Wales, Sydney,
New South Wales, Australia; 3Duke
Center for Human Genetics, Durham,
North Carolina, USA; 4Twin Research
and Genetic Epidemiology Unit, St.
Thomas’ Hospital, London, UK; 5Centre
for Ophthalmology and Visual Science,
Lions Eye Institute, University of
Western Australia, Perth, Western
Australia, Australia; 6Discipline of
Medicine, University of Tasmania,
Hobart, Tasmania, Australia
doi: 10.1111/aos.13082
Editor,
W e appreciate the letter by Galvis
et al. (2016) regarding our
recent publication investigating age
cut-offs for cycloplegic refraction in
teenagers and young adults. Indeed, we
recognize that the use of two different
cycloplegic agents introduces an incon-
sistency into our methodology in mea-
suring cycloplegic effect. However, the
decision to use tropicamide in older
individuals was made after considering
both the available evidence and prag-
matic factors affecting our study pop-
ulation.
Many of our older subjects gra-
ciously gave off their time to partici-
pate in the study during work periods,
and in these cases, we felt the period of
cycloplegic recovery (up to 24 hours)
was inordinate. In the authors’ previ-
ous experience in similar studies, this
slow recovery has resulted in high rates
of loss to follow-up. The more desir-
able pharmacokinetic properties (and
safer profile) of tropicamide make this
an easier agent to use with the working
individual.
A review of the literature regarding
the cycloplegic potential of cyclopento-
late vs tropicamide will yield data find-
ing statistical favour with the
effectiveness of the former agent. How-
ever, what is much less clear is whether
these differences translate to meaningful
clinical effects – a reflection of the
importance of interpreting effect size in
statistical analysis. Accordingly, there
are several studies that would suggest
tropicamide is a useful cycloplegic agent
in many circumstances (Egashira et al.
1993; Mutti et al. 1994; Owens
et al. 1998; Manny et al. 2001; Nawrot
et al. 2012). It is interesting to note that
the largest genomewide association
study of myopia utilized a participant
reported rather than clinically based
Acta Ophthalmologica 2016
phenotype (Kiefer et al. 2013). Numer-
ous novel (and replicated) genetic asso-
ciations were identified using refractive
data from customers of 23 and Me
obtained without the assistance of
tropicamide or cyclopentolate. It would
appear that there is still some work to be
carried out in determining the relative
utility of both agents.
References
Egashira SM, Kish LL, Twelker JD, Mutti
DO, Zadnik K & Adams AJ (1993): Com-
parison of cyclopentolate versus tropicamide
cycloplegia in children. Optom Vis Sci 70:
1019–1026.
Galvis V, Tello A, Blanco O & Margarita
Parra M (2016): Cycloplegia in refraction:
age and cycloplegics. Acta Ophthalmol. 94:
e372–373.
Kiefer AK, Tung JY, Do CB, Hinds DA,
Mountain JL, Francke U & Eriksson N
(2013): Genome–wide analysis points to
roles for extracellular matrix remodeling,
the visual cycle, and neuronal development
in myopia. PLoS Genet 9: e1003299.
Manny RE, Hussein M, Scheiman M, Kurtz
D, Niemann K & Zinzer K (2001): Tropi-
camide (1%): an effective cycloplegic agent
for myopic children. Invest Ophthalmol Vis
Sci 42: 1728–1735.
Mutti DO, Zadnik K, Egashira S, Kish L,
Twelker JD & Adams AJ (1994): The effect
of cycloplegia on measurement of the ocular
components. Invest Ophthalmol Vis Sci 35:
515–527.
Nawrot P, Przekoracka-Krawczyk A, Perz K,
Rusiak P & Naskrecki R (2012): Change in
ocular refraction after tropicamide cyclople-
gia in preschool children. Klin Oczna 114:
278–281.
Owens H, Garner LF, Yap MK, Frith MJ &
Kinnear RF (1998): Age dependence of
ocular biometric measurements under cyclo-
plegia with tropicamide and cyclopentolate.
Clin Exp Optom 81: 159–162.
Correspondence:
Paul G. Sanfilippo, PhD
Department of Ophthalmology
Centre for Eye Research Australia
Royal Victorian Eye and Ear Hospital
University of Melbourne
32 Gisborne St East Melbourne
Melbourne 3002
Victoria
Australia
Tel: +61 3 9929 8360
Fax: +61 3 9929 8794
Email: prseye@gmail.com
e373