Refractive Accuracy and Visual Outcome by Self-Refraction Using Adjustable-Focus Spectacles in Young Children: A Randomized Clinical Trial.



Uncorrected refractive error is the most common cause of vision impairment in children. Most children 12 years or older can achieve visual acuity (VA) of 20/25 or better by self-refraction using adjustable-focus spectacles, but data on younger children are lacking.


To assess refractive accuracy, corrected VA, and factors associated with not achieving VA of 20/25 or better among children aged 5 to 11 years performing self-refraction with Adspecs adjustable-focus spectacles (Adaptive Eyecare), compared with noncycloplegic autorefraction and cycloplegic refraction.

Design, setting, and participants

This was a cross-sectional noninferiority trial conducted from September 2, 2015, to December 14, 2017. The study setting was an academic pediatric eye clinic. Children aged 5 to 11 years with uncorrected VA of 20/40 or worse in 1 or both eyes and without systemic or ocular conditions preventing best-corrected VA of 20/25 or better were enrolled. Children who had best-corrected VA worse than 20/25 were excluded. Study data were analyzed from September 2017 to June 2023.


Children were taught to self-refract with adjustable-focus spectacles.

Main outcomes and measures

Spherical equivalent refractive error (using self-refraction, noncycloplegic autorefraction, and cycloplegic refraction) and VA (uncorrected and using self-refraction, noncycloplegic autorefraction, and cycloplegic refraction) for study eyes were evaluated. Potential predictors of failure to achieve VA of 20/25 or better with self-refraction were assessed using logistic regression.


A total of 127 consecutive children were enrolled. After exclusions, 112 children (median [IQR] age, 9.0 [8.0-10.3] years; 52 boys [46.4%]) were included in the study. Mean (SD) spherical equivalent refractive power was -2.00 (1.52) diopters (D) for self-refraction, -2.32 (1.43) D for noncycloplegic autorefraction, and -1.67 (1.49) D for cycloplegic refraction. Mean (SD) difference in refractive power between self-refraction and noncycloplegic autorefraction was 0.32 (1.11) D (97.5% 1-sided CI, 0.11 to ∞ D; P < .001) and between self-refraction and cycloplegic refraction was -0.33 (1.15) D (97.5% 1-sided CI, -0.54 to ∞ D; P = .77). The proportion of children with corrected VA of 20/25 or better was 79.5% (89 of 112) with self-refraction, 85.7% (96 of 112) with noncycloplegic autorefraction, and 79.5% (89 of 112) with cycloplegic refraction (self-refraction vs noncycloplegic autorefraction: McNemar P value = .27; self-refraction vs cycloplegic refraction: McNemar P value > .99). Those failing to achieve best-corrected VA of 20/25 or better with self-refraction had higher astigmatism (odds ratio [OR], 10.6; 95% CI, 3.1-36.4; P < .001) and younger age (OR, 1.5; 95% CI, 1.1-2.2; P = .02).

Conclusions and relevance

Self-refraction among children aged 5 to 11 years may result in more myopic power than cycloplegic refraction but not necessarily to a clinically relevant degree. Although the proportion of children achieving VA of 20/25 or better with self-refraction using adjustable-focus spectacles did not differ from cycloplegic refraction, it was less likely among younger children and those with higher astigmatism.






Published Version (Please cite this version)


Publication Info

Zhao, Lloyd, Qing Wen, David Nasrazadani, Nathan L Cheung, Marguerite C Weinert, Sharon F Freedman, Joshua Silver, Yos M Priestley, et al. (2023). Refractive Accuracy and Visual Outcome by Self-Refraction Using Adjustable-Focus Spectacles in Young Children: A Randomized Clinical Trial. JAMA ophthalmology. 10.1001/jamaophthalmol.2023.3508 Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.



Nathan Cheung

Assistant Professor of Ophthalmology

Dr. Cheung specializes in pediatric optometry and infant aphakia contact lens fittings.

As a new faculty member at Duke, Dr. Cheung plans to investigate further into various methods of myopia control and its validity. He is also very interested in establishing a pediatric optometry residency at Duke to train future optometry residents and equip them with the skills needed to work in a medical center.

He hopes to make every child’s visit at Duke Eye Center an unforgettable experience. He enjoys to educating and talking to patients and parents concerning their child’s eye condition.

Dr. Cheung came to Duke for the opportunity to reach his maximum potential and to work with the best and brightest minds in the field.


Yos M Priestley

Assistant Consulting Professor of Ophthalmology

Grace Prakalapakorn

Associate Professor of Ophthalmology

S. Grace Prakalapakorn, MD, MPH is a pediatric ophthalmology fellowship-trained clinician scientist with expertise in the diagnosis and treatment of retinopathy of prematurity. She initially joined the faculty at Duke University as a Clinician Scientist in 2011 and was awarded a K12 Mentored Clinical Scientist Development Program Award by the department of ophthalmology (2011-2014). She later applied for and was awarded a K23 Career Development Award by the National Institutes of Health (NIH) (2014-2018).

Her research focus is on improving access to care and outcomes in underserved communities by adapting innovative strategies to address clinically relevant problems. The majority of her research has focused on retinopathy of prematurity (ROP), a leading cause of preventable blindness in children worldwide. While appropriate screening and treatment can decrease the risk of blindness due to ROP, there is a lack of ophthalmologists trained to screen for ROP and there are difficulties with access to care. Because the number of trained ophthalmologists able and willing to screen for ROP is limited and is unlikely to meet the continuing need worldwide, innovative strategies to screen for ROP and expand our workforce in ROP screening are needed. Her program involves looking at alternative screening devices that could be used in store-and-forward telemedicine applications for ROP teaching and screening.

She has shown that videos acquired by an indirect ophthalmoscopy system can demonstrate important features of ROP and that images captured by an indirect ophthalmoscopy system are of high enough quality to be graded for ROP screening. She has also shown that a FDA-approved narrow-field, handheld non-contact digital retinal camera can capture retinal images of prematurely-born infants of sufficient quality to be accurately graded for the presence of posterior pole vascular changes by both human graders and semi-automated computer programs (i.e. ROPtool). These publications describe alternative strategies that could be used in an ROP telemedicine screening scenario which could change the way ROP is screened for in the future, especially in areas without access to a trained ROP specialist.

 In addition to her role as a clinician-scientist, Dr. Prakalapakorn is a recognized expert in infantile Pompe disease. Pompe disease is an inherited lysosomal storage disorder. Prior to the advent of enzyme replacement therapy (ERT), most patients with infantile-onset Pompe disease did not survive past 1 year of age. In her role as an academic physician, she has developed a knowledge base and niche in ocular findings in this population. In collaboration with the pediatric genetics department at Duke, she has published on ophthalmic findings in a series of children with infantile Pompe disease treated with ERT. Her group established the current recommendations for annual comprehensive eye examinations in this population.

 Dr. Prakalapakorn attended Duke University where she earned a B.S.E in Biomedical and Electrical Engineering with a minor in Chemistry. She was then awarded a Fulbright scholarship to study the role of directly-observed therapy short course in tuberculosis control in Bangkok, Thailand. Next she pursued a M.D./M.P.H. at Emory University as a Woodruff Scholar (full tuition, merit-based scholarship). She earned her M.P.H. with a focus on epidemiology. She then completed a transitional year internship at Scripps Mercy Hospital in San Diego, California and then returned to Emory University to complete her residency in ophthalmology. She then spent a year working as a staff ophthalmologist for ORBIS international aboard their Flying Eye Hospital. She then returned to Duke University to complete a fellowship in pediatric ophthalmology before accepting a faculty position at the Duke Eye Center.

 Dr. Prakalapakorn has also established a national and international presence in the field of public health and international health. Because of her expertise in pediatric ophthalmology and public health, she was invited to work with the Centers for Disease Control and Prevention (CDC) as a consultant and collaborator on Zika Virus and pediatric ophthalmology. She has been involved in guiding future CDC recommendations on screening for Zika. In addition, Dr. Prakalapakorn works with the NIH on the Partnership for Research on Ebola Vaccine in Liberia (PREVAIL) III study based in Monrovia, Liberia. Since her time at Duke University, she has also been invited to speak internationally on the topics of both ROP and global blindness.

 Dr. Prakalapakorn has also been selected and served as a member of various committees for both the American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). She was recognized for “special contributions to the Academy and ophthalmology outside the scope of the current Achievement Awards program” by the AAO with a Secretariat Award in 2017.

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