Definition of Cycloplegic Refraction

The Dilated Pupil

A completely dilated pupil.
A completely dilated pupil. | Source

About the Author

Melissa Flagg is an ophthalmic technician and has been examining patients on a daily basis for over 20 years.

She has had rigorous training under the supervision of an ophthalmologist and specialized in the cornea, cataracts, and retina as well as how systemic disease affects the eye. She is certified by JCAHPO as an OSC (ophthalmic scribe certified).

A cycloplegic refraction simply means the patient’s eyes are dilated prior to performing the test used to determine the patient’s glasses prescription called refraction.

The refraction is normally performed before the patient is given dilating drops. However, there are times when it is necessary to dilate before performing a refraction in order to get more accurate results. Reasons to do this can include:

  • Prior to LASIK or other refractive surgery
  • Patients who are extremely nearsighted
  • Prior to cataract surgery in some cases
  • Patients under the age of 18

Definition of the Term Cycloplegia

The term cycloplegia is derived from the Greek kyklo meaning circle or ring, and -plegia meaning paralysis. It is the paralysis of both the iris (specifically the sphincter muscle) and the ciliary body of the eye.

Cyclopentolate dilating eye drops.
Cyclopentolate dilating eye drops. | Source

Cyclopentolate, also known as Cyclogyl, is the most common dilating drop used to induce cycloplegia prior to refraction, although Mydriacyl (tropicamide) can also be used.

Cyclogyl is used because of its rapid onset (about 30 minutes) and effect on accommodation. Cyclogyl is most commonly used for:

  • Dilating patients prior to surgery (LASIK, cataract removal or other ocular surgeries)
  • Cycloplegic refractions
  • Preventing posterior synechiae in the treatment of iritis or uveitis
  • Dilating patients with very dark irises

What is a Refraction?

This is one of the most common questions I’m asked by patients during an exam and most of the time it’s because there is an extra charge for the test. The easy answer is: the refraction is the test used to determine your glasses prescription.

The Normal Undilated Pupil


However, a refraction can tell the technician and the doctor much more than just what your prescription is. It can also show whether or not the vision can be improved simply by changing the prescription.

If it cannot be improved with a prescription change, this tells the tech and the doctor that there is an underlying pathology causing the blurry vision or other symptoms. Conditions that can cause this could include:

  • Cataracts
  • Macular degeneration
  • Corneal dystrophy
  • Dry eye syndrome
  • Diabetes
  • High blood pressure

Refractions can be difficult to perform. One of the main concerns for the technician performing the test is accommodation, especially in those who are myopic (nearsighted).

The Anatomy of Accommodation

Accommodation is the ability of the eye to focus at different distances. Our ability to see clearly at various distances is the result of a symphony of actions involving several ocular structures including the:

  • Iris
  • Lens
  • Ciliary body
  • Zonular fibers (part of the cilliary body)

Structures of the Anterior Portion of the Eye

This drawing shows the anatomy of the iris as well as the structures involved in accommodation and dilation.
This drawing shows the anatomy of the iris as well as the structures involved in accommodation and dilation. | Source

The iris is the pigmented part of the eye that is actually a combination of two muscles: the sphincter and dilator. These muscles are responsible for the constriction and dilation of the pupil, the opening in the center of the iris.

The iris has its roots in the cilliary body which is found directly behind it. Also behind the iris is the lens which is responsible for about 30 percent of our focusing power and can actually be seen through the pupil. It is wrapped in a capsule and suspended by tiny strands called zonular fibers which originate from the cilliary body.

The ciliary body is the muscle that directly controls our ability to accommodate. For example, when we read, the eyes converge together, the pupil constricts and the size and shape of the lens changes due to contraction of the ciliary body. This releases the tension on the zonular fibers and causes the lens to bow forward which increases its thickness and power.

When we are looking at a distance (such as when driving), the opposite occurs. The eyes diverge, the pupil dilates and the ciliary body relaxes. Tension on the zonular fibers increases and the lens becomes thin and flat, decreasing its power.

How Accommodation Affects Refraction

When testing a patient for glasses, this ability to accommodate can lead to an inaccurate prescription, and the patient doesn’t even realize they are accommodating. This is most common in myopic patients because their lens is capable of accommodating at extremely close range.

This means they are capable of accommodating more power at distance. In other words, it’s very easy to give a myopic (nearsighted) patient too much prescription because their eyes can easily adapt to see clearly through the extra power. This is called "over-minused,” and it is the main reason for cycloplegic refractions.

The Phoropter

The phoropter is the equipment used to perform the refraction.
The phoropter is the equipment used to perform the refraction. | Source

Cycloplegia temporarily neutralizes the patient’s ability to accommodate and allows the technician to get a completely accurate reading of how much prescription the eye actually needs.

This is imperative prior to surgical procedures such as LASIK or cataract surgery. In the case of LASIK, it helps determine the amount of tissue that needs to be ablated (removed). Prior to cataract surgery, cycloplegic refraction will help determine the power of the IOL (intraocular lens).

Cycloplegia is also beneficial when refracting children due to their uncanny ability to accommodate. Often times an underlying refractive error such as hyperopia (farsightedness) will be found during the cycloplegic refraction of a child.

Many children have slight refractive errors that they can easily accommodate, and dilation is the only way to reveal the underlying refractive error.

What to Expect During a Cycloplegic Refraction of the Eye

Cycloplegic refraction is a very simple procedure. In fact, the eye exam is identical to the standard eye exam with one exception: a second refraction will be performed after dilation. The second refraction may be a bit more difficult for you due to glare, so the technician should turn down the lights in the exam room. If they don't, ask them to do so.

Dilation also makes the vision somewhat blurry, so you may not have perfectly clear vision at the end of the second refraction. The eye can’t accommodate at all after cycloplegia which means it can’t focus in anything whether it’s up close or far away (although distance vision is usually considerably better than near vision after the eyes have been dilated). So don’t expect your vision to be crystal clear.

Dilation of the eyes using Cyclogyl 1%
Dilation of the eyes using Cyclogyl 1% | Source

After the Cycloplegic Refraction

After your exam, you will be dilated for at least 24 hours, sometimes longer. Unless you have a pair of reading glasses or are very nearsighted, you won’t to be able to read anything up close. Computer screens will also be a problem. If you can’t miss work, you should schedule your appointment for a Friday afternoon (or the day before your weekend, whatever day that may be).

You will also be light sensitive for about 24 hours. Driving shouldn’t be too much of a problem during the day as long as you have a pair of very dark sunglasses. It’s wise to take a pair of the cheap paper sunglasses at the doctor’s office if they are offered - if they aren’t, ask for them. They won’t make a fashion statement, but they are designed for dilated eyes and are much darker than anything you can buy in a store. Post - surgical sunglasses also work well for this purpose.

Driving at night may not be difficult if you’re in a rural area. However, driving in a brightly lit city or town will be difficult because the vision will be blurred. The dilation will also cause excessive glare from street lights as well as from the headlights of oncoming traffic.

Some people are allergic to Cyclogyl, or the preservative in it (benzalkonium chloride). Itching and/or tearing can indicate an allergy especially when associated with redness that lasts longer than a few hours. This mild allergic reaction can be treated with an over-the-counter antihistamine such as Zaditor. Very rarely will a patient have a severe allergic reaction to Cyclogyl such as anaphylactic shock. If you suspect you’re having an allergic reaction, call your doctor right away.

© Copyright 2012 - 2016 by Melissa "Daughter of Maat" Flagg ALL RIGHTS RESERVED

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Comments 6 comments

TToombs08 profile image

TToombs08 3 years ago from Somewhere between Heaven and Hell without a road map.

So that's what that is! :) I thought the person saw their first earnings on HP and freaked. :) Have a great day, DOM! :)

phoenix2327 profile image

phoenix2327 3 years ago from United Kingdom

Thanks, DOM, for this hub. I had always wondered about the reason for dilating the pupils. Now I know why I had troubling reading afterwards.

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Daughter Of Maat 3 years ago from Rural Central Florida Author

@TToombs08 lmao!! Hubby thought I was cursing in that medical lingo stuff when I was telling him about it! lol

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Daughter Of Maat 3 years ago from Rural Central Florida Author

@phoenix, indeed, I'm really nearsighted, so after an exam I'm usually okay because I can take my glasses off to read. I do feel bad for those who are unable to read after they are dilated. Many of my patients would just go home and sleep because they couldn't do anything else!!

kittythedreamer profile image

kittythedreamer 3 years ago from the Ether

This is off-topic from this wonderfully informative hub, but I just wanted to say Happy Yule, my dear! Haven't talked to ya in awhile...just wanted to check in and wish you a very happy winter solstice. Blessings.

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Daughter Of Maat 3 years ago from Rural Central Florida Author

@Kitty, thank you! And a very happy and blessed Yule to you as well!!

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    Melissa Flagg (Daughter Of Maat)627 Followers
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    Melissa Flagg is an ophthalmic technician with over 20 years of experience working with patients in the eye care field.

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