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Introduction
Uncorrected refractive error has been recognized as the leading cause of moderate to severe visual impairment in the world and the second leading cause of treatable blindness.1,2 It has the potential for large-scale social and economic implications if left untreated due to limiting educational and employment opportunities.3 Aside from its impact on education, detection and treatment are especially important in children because it can lead to refractive amblyopia, which can produce lifelong uncorrectable visual impairment if not treated before 9 to 10 years of age.4 All of these potential consequences have significant public health implications, highlighting the need to increase detection and subsequent management.
Due to limitations in the ability to communicate and cooperate, children are too young to undergo subjective refraction, so cycloplegic retinoscopy is the gold standard for detection of refractive error in the pediatric population. Retinoscopy can be performed by pediatric ophthalmologists, orthoptists, and some comprehensive ophthalmologists. However, retinoscopy requires experience and skill and may not be routinely used by all comprehensive ophthalmologists, and thus many may be hesitant to treat refractive error in pediatric patients. There is a remarkable difference between the supply and demand of pediatric ophthalmologists in the United States, limiting the access of millions of patients throughout the country.5 Additionally, as more pediatric ophthalmologists retire, the number of new graduates is not expected to keep up with the unmet demand, further increasing this disconnect between supply and demand.5 Therefore, detection and management of refractive error in children remains a challenge now and will continue in the future due to limited access to pediatric subspecialists who are skilled in retinoscopy.
To address this problem, we must evaluate simpler means of assessing refractive error in children. There is a particular need for modalities that can be performed accurately and efficiently by comprehensive ophthalmologists, who are much more accessible than pediatric subspecialists. Prior research has shown that autorefraction is an accurate means of detecting refractive error in children when performed under cycloplegic conditions. In primary school-aged patients, cycloplegic autorefraction showed no significant differences in sphere, spherical equivalent, or cylinder compared to cycloplegic subjective refraction.6 When evaluating studies performed in United States populations, most were done using hand-held autorefractors.7,8 However, it is recommended...