I value nearpoint retinoscopy and all data sets of plus lens acceptance. However, valuable insights into latent hyperopia or pseudomyopia can also be obtained through intelligent use of autorefraction and the comparison of manifest to cycloplegic findings. For this purpose we’ve traditionally used 1% cycloplentolate. However, there has been a worldwide shortage of 1% cyclopentolate, and for that reason we’ve been temporarily substituting 1% tropicamide to do the job. There is ample evidence through journal articles as well as in the classic Bartlett & Jaanus text (5th ed., p. 134) to support this, particularly in the absence of strabismus or high hyperopia.
Here is a case in point, a 9 year-old female referred to me by a reading specialist. She noted that it was difficult for her to continue reading, experiencing visual discomfort after a short period of time. Leah had previously been evaluated by an optometrist two years ago who prescribed +0.25 OU with 1^ BI OU. She did not find the Rx to be helpful. On your right is the manifest autorefraction, showing fluctuating minus with more of a tendency toward spasm through the right eye. On your left are the findings with one drop of 1% tropicamide in each eye.
Hyperopia was revealed in both eyes after just 15 minutes. One can extrapolate that with a second drop, or by waiting an additional 15 minutes, an even higher degree of hyperopia would be revealed. In cases of this nature, my experience has been that 1% tropicamide yields results very similar to 1% cyclopentolate, though I will welcome when the latter is back in stock.
It is reasonable in these cases to try a low single vision plus Rx primarily for near. However, visually sensitive children with pseudomyopia or accommodative spasm oft times find it annoying to look up even briefly through a low plus single vision Rx. They not only find it uncomfortable due to blur, but anecdotally can experience a sense of nausea or disorientation. That is why a bifocal lens with plano in the distance and +1.00 at near is often ideal for these patients. Alternatively, an Eyezen lens providing a lower add of 0.40, 0.60, or 0.85 diopter can be effective. In Leah’s case, there was no compelling evidence to prescribe prism based on her binocular vision profile.