Objective Refraction Status before and after Cycloplegia: From Childhood to Young Adulthood
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe manuscript requires revision. Specific remarks:
1. Please explain in detail exclusion criteria.
2. Usually full cyckloplegia is achieved after administration of Cyclopentholate 1% drops twice. Please explain your protocol.
3. Lines 65-66 – please rephrase. It is hard to understand.
4. Please supply full ethical statement .
5. Please explain D for Table 1 subscript.
6. Line 147 – 150 , please specify what the p refers to. The variance or pairwise comparisons ? Or jest a difference between pre and post-cycloplegic values.
7. Discussion : how authors explain such a small decrease in % of myopia ? It is not consistent with other studies and with the hyperopic increase in the study group. Line 185-187: results of the present study are not really consistent with others.
8. Lines 206-208 – please provide references.
9. How authors think that administration of only one drop of Cyclopentolate could bias the results in younger children .
10. Discussion: please provide interpretation for % of astigmatism change after cycloplegia.
11. Lines 242-252 – it is an interesting information, but irrelevant for the study results. I would suggest to remove it.
Comments on the Quality of English LanguageModerate editing required.
Author Response
Please see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsThis is a well written manuscript on the effect of cycloplegic refraction with age but a few changes will be necessary. According to the abstract, this present study investigates how age and non-cycloplegic refractive status influences the classification of refractive errors. This, however, differs from the objective stated in the introduction section. The author has categorized the children into six age groups but it is not clear why the author chose not to analyze the findings with age as a continuous variable. Since state-funded eye exams mandates ophthalmologists to conduct cycloplegic refraction at ages 13-24 months, 3, and 6-7 years, but not older age groups, it will then be interesting for the author to discuss about how the findings from this present study will be relevant to the use of cycloplegia in the state-funded eye examinations. The research question should be clearly stated in the introduction to avoid reader’s speculation as the “local context” only appeared as a supplementary information in the discussion section. As correctly mentioned in the manuscript, the findings from this study cannot be generalised to the population. While the author describes that a proportion of the children in this study are myopic or hyperopic, the term “prevalence” may not be appropriate in a biased sample. In the result section, the author reported no statistical difference in astigmatism but contradicted that with clinically significant findings. The author did not acknowledge the ophthalmology clinic in the manuscript. The conclusion section is also missing from the manuscript. There is only one author mentioned in the manuscript, but there are two authors mentioned in the peer review system.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
Comments and Suggestions for AuthorsThis observational study describes the effect of 1 drop of 1% cyclopentolate by comparing pre-cyloplegic and post- cycloplegic refraction of 472 healthy participants (55% female) seen in an ophthalmology practice stratified by ages (3-5, 6-8, 9-11, 12-14,15-17, and above 18). Findings show that the post-cycloplegic spherical equivalent refraction of 34%, 6% and 23% became more hyperopic, myopic and emmetropic*, respectively. When examining the age stratification, the two youngest age groups were on average approximately 1.00 Diopter more hyperopic following cycloplegia. The 12-14 and above 18 were on average 0.30 and 0.20 Diopters more hyperopic, and those in the 9-11 and 15-17 age groups were on average 0.50 diopter more hyperopic after cycloplegia. Children seen in the Latvian ophthalmology practice aged 3-5 and 6-8 were more hyperopic whereas those above age 12 were more myopic indicating a myopic shift.
Overall the paper is well written and the statistics is robust. It can be improved by modifying the abstract to better describe the main goal and conclusion. The authors write that the study highlights the importance of cycloplegia use in children and young adults. However, it did not examine the importance of cycloplegia and this is not a conclusion that can be drawn based on the findings.
The introduction can be improved by providing some more background about how cycloplegia differentially affects populations of varying ethnicities to emphasize the contribution of the study to existing literature, and why it is worthwhile to report findings for a population from Latvia. In this sense, the ethnicity of the participants in the study is missing.
The results will be easier to follow with a Table of demographic outcomes. The long description in the text may be confusing (how many in each sub-group, their mean ages, their refractive outcomes, etc.).
The authors should include the clinical implications of their findings in the discussion. Are the pre- vs. Post-cylcoplegic refractive outcomes clinically significant? If a child from a particular sub-group is seen by a Latvian optometrist rather than an ophthalmologist- what is the risk of over-minusing? Is it clinically significant? And if so, what are the ramifications ? Will it cause a progression of myopia? Will it induce headaches?
The authors should elaborate on the refractive error changes of Latvian children. Is it similar to previously reported outcomes for Latvia? Similar to other places in the world? Is the myopic shift concerning like in Asian populations?
The authors did not discuss the mean and median change in refractive error for the sub-groups. Specifically there was a larger change in the 15-17 aged group compared to the above 18 and 12- 14 aged group. Do the authors have a hunch why this discrepancy? This is an interesting finding to discuss.
Local context: please elaborate what the findings mean in the context of the scope of practice of Latvian optometrists. For example, do the authors know the relationship between ophthalmologists to optometrists in Latvia? The discussion should compare this to other reports (see for example: Lee, K. E., Sussberg, J. A., Nelson, L. B., & Thuma, T. (2023). The economic downturn of pediatric ophthalmology and its impact on access to eye care. Journal of Pediatric Ophthalmology & Strabismus, 60(1), 18-24. And Siegler NE, Walsh HL, Cavuoto KM. Access to Pediatric Eye Care by Practitioner Type, Geographic Distribution, and US Population Demographics. JAMA Ophthalmol. 2024;142(5):454–461. Etc.)
Minor comments are listed below. Several instances of references are missing, medians and interquartile ranges should also be included as the data were abnormally distributed.
Lines 25-26 missing a reference
Line 27: how much fogging? Is there a reference for the amount?
How were inclusion criteria determined? Strabismus based on cover test? Please describe..
Lines 73-74: The adoption of the criteria for the refractive error classification should be referenced
For data that is not normally distributed, medians and interquartile ranges should be provided
Line 109: became
Line146: was
Would have liked to see Bland-Altman plots of the differences between non-cyclo vs cyclo- to see the bias
Line 201- describe the differences in ages between the studies
Lines 215-221: please elaborate regarding the importance of cycloplegia and risks of not using it in younger populations, especially given the results of the present study
Line 223: attended instead of were attending
Comments on the Quality of English LanguageThe manuscript is well written and easy to follow. Some minor changes have been suggested above.
Author Response
Please see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe revision is sufficient. Congrats.
Author Response
We truly appreciate your contribution as a reviewer in Round 1, which significantly improved the quality of our manuscript. Thank you for accepting the revised version in Round 2. Some additional changes were made in Round 2 (highlighted in revised manuscript): we substituted “distribution” with frequency, “administered” with “instilled”, updated reference [1], and added references [18] and [19]. We considered the concept of clinically significant changes in SE (≥ 0.50 D) and revised the presentation of our results accordingly: 'Clinically significant (≥ 0.50 D) hyperopic shift in SE for 60.2% of participants, a myopic shift in 1%, a clinically minor shift (< 0.50 D) in 27.1%, and no shift in 11.7%,' which required changes in Lines 13-14, 151-153, and 364-365. Additionally, we further addressed the interpretation of clinically significant SE changes in the Discussion (Lines 263-274). We added Table 2 to detail changes in refractive error type distribution (Δ) across age groups induced by cycloplegia, along with the frequency of clinically significant SE changes (≥ 0.50 D), as the median difference in refractive error from age 12, which was only 0.25 D, raised questions for Reviewer 3. We realized that median data alone did not fully convey the complete picture, as the clinically significant (≥ 0.50 D) change in SE was observed in 40.7% of participants aged ≥ 12 years, which is now reflected in Table 2. In Table 1, we added the mean ages and included a sentence confirming that the age between genders did not differ (Lines 67-68).
Reviewer 2 Report
Comments and Suggestions for AuthorsThe authors has carefully and adequately addressed the reviewer comments. Looking forward to seeing this published.
Author Response
We truly appreciate your contribution as a reviewer in Round 1, which significantly improved the quality of our manuscript. Thank you for accepting the revised version in Round 2. Some additional changes were made in Round 2 (highlighted in revised manuscript): we substituted “distribution” with frequency, “administered” with “instilled”, updated reference [1], and added references [18] and [19]. We considered the concept of clinically significant changes in SE (≥ 0.50 D) and revised the presentation of our results accordingly: 'Clinically significant (≥ 0.50 D) hyperopic shift in SE for 60.2% of participants, a myopic shift in 1%, a clinically minor shift (< 0.50 D) in 27.1%, and no shift in 11.7%,' which required changes in Lines 13-14, 151-153, and 364-365. Additionally, we further addressed the interpretation of clinically significant SE changes in the Discussion (Lines 263-274). We added Table 2 to detail changes in refractive error type distribution (Δ) across age groups induced by cycloplegia, along with the frequency of clinically significant SE changes (≥ 0.50 D), as the median difference in refractive error from age 12, which was only 0.25 D, raised questions for Reviewer 3. We realized that median data alone did not fully convey the complete picture, as the clinically significant (≥ 0.50 D) change in SE was observed in 40.7% of participants aged ≥ 12 years, which is now reflected in Table 2. In Table 1, we added the mean ages and included a sentence confirming that the age between genders did not differ (Lines 67-68).
Reviewer 3 Report
Comments and Suggestions for AuthorsI commend the authors for addressing the reviewers’ comments.
I am not sure that “distribution” is the correct replacement for the word “prevalence”. Perhaps “frequency” is a better word?
In the introduction, the fogging technique requires a reference
In line 58 there is a number typo in the word “equivalent”
In Table 1 I would add the mean of the ages in case there is a skewed sub-group
In the discussion, I am still missing a paragraph discussing what is a clinically meaningful change in refractive error. Specifically, the median difference in refractive error from age 12 was 0.25DS. However, in the younger age groups, the median difference ranged between 0.50-0.90 DS. I think this warrants attention and is interesting and significant for the clinician.
Author Response
We truly appreciate your contribution as a reviewer, which significantly improves the quality of our manuscript! Thank you!
Comments 1: I am not sure that “distribution” is the correct replacement for the word “prevalence.” Perhaps “frequency” is a better word?
Response 1: We have made the change from “distribution” to “frequency.” We appreciate your suggestion and agree with your recommendation.
Comments 2: In the introduction, the fogging technique requires a reference.
Response 2: We have added reference [1] for the fogging technique. After careful consideration of all scenarios (including situations where participants with myopia have sufficiently reduced uncorrected visual acuity and a fogging lens won’t be used), we decided to substitute the +2.50 D lens with a reference to the reduction in visual acuity until 0.2 (in decimal units) is reached, to avoid an overly long explanation of all situations.
[1] Benjamin, W.J. Borish's Clinical Refraction, 2nd ed.; Butterworth-Heinemann: St. Louis, USA, 2006; pp. 795. https://doi.org/10.1016/B978-0-7506-7524-6.X5001-7.
Comments 3: In line 58, there is a number typo in the word “equivalent.”
Response 3: Thank you for pointing out the typo in “equ74ivalent”; we have corrected it to “equivalent.”
Comments 4: In Table 1, I would add the mean of the ages in case there is a skewed sub-group.
Response 4: Thank you for this valuable suggestion. We have added the mean ages in Table 1 and included a sentence confirming that the age between genders did not differ: “There was no significant difference in mean age between genders (Z = -1.39, p = 0.16).”
Comments 5: In the discussion, I am still missing a paragraph discussing what is a clinically meaningful change in refractive error. Specifically, the median difference in refractive error from age 12 was 0.25 DS. However, in the younger age groups, the median difference ranged between 0.50-0.90 DS. I think this warrants attention and is interesting and significant for the clinician.
Response 5: We have considered your point and decided to supplement the Results section with Table 2, which provides a comprehensive understanding of frequency changes stratified by age groups (with participants aged 12 or older merged together) and refractive error type. Additionally, we have included separate frequencies of clinically significant changes (≥0.50 D) in the table, as the median data alone did not fully convey this information. Although the median difference in refractive error from age 12 was 0.25 D, a clinically significant (≥0.50 D) change in SE was observed in 40.7% of participants aged ≥12 years. We have also added a paragraph in the Discussion (Lines 263-274) to further address the interpretation of clinically significant SE changes.
