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Abstract

Purpose: Pseudomyopia is an accommodative disorder that can be identified by the difference between pre- and post-cycloplegic refractive error. The current study aimed to evaluate whether the axial length to corneal curvature (AL/CR) ratio, in conjunction with non-cycloplegic refractive error, can reliably identify pseudomyopia in children, thus avoiding the need for cycloplegia. Methods: Refractive error and biometry data from longitudinal studies based in Denmark (n = 645; age 7–17 years) and China (Anyang Childhood Eye Study; n = 2487; age 6–13 years) were used to train separate linear mixed models for children of European or East Asian ancestry, respectively, with AL/CR ratio as outcome and cycloplegic spherical equivalent refractive error (SER), age and sex as predictors. The models could be used to calculate the AL/CR 95% prediction interval in a child of known age, sex and non-cycloplegic SER; if the child’s AL/CR fell below the lower limit of the AL/CR 95% prediction interval, then the child was classified as pseudomyopic. The European and East Asian models were externally validated using data from participants of the Ireland Eye Study (IES; n = 92) and Sydney Myopia Study (SMS; n = 686) cohorts, and the Hong Kong Children Eye Study (HKCES; n = 9519) and Vietnam (n = 1165) cohorts, respectively. Results: The European model demonstrated moderate detection accuracy for pseudomyopia: sensitivity = 0.82 (IES) and 0.81 (SMS); specificity = 0.75 in both cohorts. By contrast, the East Asian model performed poorly: sensitivity = 0.22 (HKCES) and 0.13 (Vietnam); specificity = 0.99 in both cohorts. Conclusions: Despite moderate diagnostic performance in European samples, the current AL/CR-based models lacked sufficient accuracy for screening and performed poorly in East Asian children, suggesting that AL/CR is not a reliable non-cycloplegic marker of pseudomyopia. Further studies incorporating additional ocular biometric parameters and employing a more rigorous definition of pseudomyopia may build on these initial findings.

Keywords

Axial length, Corneal curvature, Myopia, Non-cycloplegic screening, Pseudomyopia, Refractive error

Publication Date

2026-01-01

Publication Title

Ophthalmic and Physiological Optics

ISSN

0275-5408

Acceptance Date

2026-01-01

Deposit Date

2026-10-06

Funding

Vietnamese Government Scholarship [Project 89, Decision No. 2671/QĐ-BGĐT dated 27/09/2024], with financial guarantee issued by the Department of International Cooperation (ICD), Ministry of Education and Training [Grant number: 60/ICD-FG;Date of award: 15/10/2024]. UK College of Optometrists PhD studentship award (Improving the genetic prediction of myopia). Vietnamese Government Scholarship, Ministry of Education and Training [Grant number: 75/ICD-FG; Date of award: 31/10/ 2023]. European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (ERC Advanced grant 101098324). National Natural Science Foundation of China (82471113, 82071000), The Excellent Youth Talents Program of Capital Medical University (A2307) and the Beijing Natural Science Foundation (L248023), Capital Health Research and Development of Special Grant (2024-2G-1081), the Beijing New-Star Plan of Science and Technology CrossCooperation Project (20250484983) and Beijing High-Tech Innovation Program Peak Project (G202512030). Institutional funding from TU Dublin (formerly DIT), alongside professional and regulatory body support from the Opticians Board and the Association of Optometrists Ireland. Australian National Health & Medical Research Council (grant 253732). National Natural Science Foundation of China (82425017) and CUHK Jockey Club Myopia Prevention Programme. Eye Foundation Finland, Tampere Region Support Foundation for the Visually Impaired.

Creative Commons License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.

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