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Indian J Ophthalmol. 2019 Oct;67(10):1564-1569. doi: 10.4103/ijo.IJO_1935_18.

Estimation Dynamic Distance Direct Ophthalmoscopy (eDDDO): A novel, objective method for the quantitative assessment of accommodation in young children.

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Department of Pediatric Ophthalmology, Jyotirmay Eye Clinic, Thane, Maharashtra; Department of Pediatric Ophthalmology, Mahatme Eye Bank and Eye Hospital, Nagpur, India.
Johns Hopkins University School of Undergraduates, Baltimore, Maryland, USA.
Department of Pediatric Ophthalmology, Mahatme Eye Bank and Eye Hospital, Nagpur, India.
Department of Pediatric Ophthalmology, Jyotirmay Eye Clinic, Thane, Maharashtra, India.



To describe estimation dynamic distance direct ophthalmoscopy (eDDDO) and compare it with the monocular estimation method of dynamic retinoscopy (eDR) for the assessment of accommodation in children.


In this prospective observational cohort study, an ophthalmologist performed eDDDO followed by eDR in children with normal eyes, and then under the partial effects of cyclopentolate and tropicamide to assess performance of eDDDO with eDR under the condition of pharmacologically induced accommodation failure. Only one eye of each child was recruited in the study. To study the inter-observer variation, two masked pediatric ophthalmology fellows performed eDDDO in the similar manner.


For the comparison of eDDDO with eDR, 60 eyes of 60 patients were recruited. The mean age of the patients was 10.4 years. The mean accommodation on eDDDO was 3.0D, 5.1D, 9.8D, and 11.3D at 40 cm, 25 cm, 10 cm, and 8 cm, respectively and 3.0D, 5.0D, 9.5D, and 11.0D on eDR. The eDDDO overestimated accommodation by a mean 0.17D (95% CL 0-0.48D, P = 0.5). The correlation of eDDDO with eDR was excellent (Pearson r 0.98, T value 76.0). The inter-observer difference with eDDDO was not significant (mean 1D, 95% CL 0-2.6D, P = 0.9) and the correlation between two observers was excellent (Pearson r 0.9, T value 12.7). The eDDDO and eDR were also performed on 12 eyes of 6 children with a mean age of 8.5 years (range 8-12 years) under the partial effect of cyclopentolate and tropicamide, where eDDDO overestimated the accommodation by a mean 0.3D (95% CL 0- 1.2D, P = 0.7) and the correlation was excellent (Pearson r 1.0, T value 45).


eDDDO is a simple, reliable, quantitative, and objective technique of accommodation assessment for children. Further studies with larger sample are required to assess its performance in disorders of accommodation affecting younger children and in children with ocular comorbidities.


Accommodation; aniso-accommodation; dynamic distance direct ophthalmoscopy; dynamic retinoscopy; monocular estimation method; ophthalmoscopy; photorefraction; retinoscopy

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