title: Dynamic distance direct ophthalmoscopy, a novel technique to assess accommodation in children.
abstract: OBJECTIVE
  To describe and compare dynamic distance direct ophthalmoscopy (DDDO) with dynamic retinoscopy (DR) in assessment of accommodation in children.
  
  
  METHODS
  This prospective observational study had four components. Component 1: to understand the characteristic digital images of DDDO. Component 2: to compare DDDO with DR for detection of accommodative defects in children (1-16 years). Component 3: to compare DDDO with DR for the detection of completeness of pharmacologically induced cycloplegia in children (5-16 years) and Component 4: to assess which one of the two techniques was more sensitive to detect onset of cycloplegia after instillation of 1% cyclopentolate eye drops.
  
  
  RESULTS
  Component 1: image analysis of DDDO on two subjects (7 years and 35 years) demonstrated superior pupillary crescent that progressively disappeared with increasing accommodation. Concurrently an inferior crescent appeared that became bigger in size with increasing accommodation. Component 2: the prevalence of defects in accommodation was 3.3% (33/1000 children). Three had unilateral accommodation failure. Sensitivity of DDDO was 94%, specificity 100%, positive predictive value 100%, negative predictive value 99%, and clinical agreement (kappa) 0.97. Component 3: in the detection of completeness of pharmacologically induced cycloplegia (n=30), the sensitivity of DDDO was 94%, specificity 96%, positive predictive value 97%, negative predictive value 93% and kappa 0.9. DR had two false positives. DDDO had one false negative. Component 4: DDDO detected onset of pharmacologically induced cycloplegia 5 min earlier than DR (n=5).
  
  
  CONCLUSIONS
  DDDO is a novel, simple, clinical and reliable method to assess accommodation in young children. This test can assess the accommodative response of both eyes simultaneously.
authors.affiliation: Department of Pediatric Ophthalmology, Pediatric Neuroophthalmology and Adult Strabismus of Jyotirmay Eye Clinic, Thane, Maharashtra, India. drmihirkothari@jyotirmay.com
authors.forename: Mihir
authors.initials: M
authors.lastname: Kothari
authors.forename: Suvarna
authors.initials: S
authors.lastname: Balankhe
authors.forename: Shalaka
authors.initials: S
authors.lastname: Paralkar
authors.forename: Deepali
authors.initials: D
authors.lastname: Nar
authors.forename: Shreya
authors.initials: S
authors.lastname: Bhagat
authors.forename: Shashank
authors.initials: S
authors.lastname: Ranade
mesh_terms: D000065:Accommodation, Ocular; D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D008297:Male; D015835:Ocular Motility Disorders / Q000175:diagnosis* / Q000453:epidemiology; D009887:Ophthalmoscopy / Q000379:methods* / Q000592:standards*; D015995:Prevalence; D011446:Prospective Studies; D042262:Retinoscopy / Q000379:methods* / Q000592:standards*; D012680:Sensitivity and Specificity