Repeatability and reproducibility of manifest refraction

J Cataract Refract Surg. 2020 Dec;46(12):1659-1666. doi: 10.1097/j.jcrs.0000000000000343.


Purpose: To evaluate the intraexaminer repeatability and the interobserver reproducibility of manifest refraction.

Setting: Tertiary referral center.

Design: Retrospective study.

Methods: Patients attending at least 2 preoperative refractions before undergoing subsequent refractive surgery were included. All manifest refractions were performed by 1 of 4 experienced optometrists using an automated phoropter according to a standard protocol. The first manifest refraction was performed after obtaining automated refraction and measuring the spectacles of the patient. The second refraction was typically refined from the first also considering wavefront refraction and tomography/topography.

Results: The latest 2 manifest refractions of 1000 eyes obtained at 2 separate visits showed a mean pairwise absolute difference of 0.16 ± 0.19 diopter (D) (range 0 to 1.38 D) in spherical equivalent (SE). This SD was better than 0.25 D (the minimum measurement increment of refraction itself). The 95% limit of agreement (LoA) was within 0.50 D for sphere, cylinder, and SE. The SD of the astigmatism axis was approximately 10 degrees, and the 95% LoA was within 22 degrees (the difference in axis decreasing significantly with the measured cylinder magnitude). The SD for corrected distance visual acuity (CDVA) was half a Snellen line and the 95% LoA was within 1.5 lines (with increasing deviation with worse vision). There were no clinically meaningful differences in reproducibility (2 optometrists) compared with repeatability (same optometrist) in sphere, axis, and CDVA.

Conclusions: Reproducibility was 0.16 D irrespective whether refractions were performed by 1 or 2 different optometrists. Obtaining multiple refractions preoperatively might increase the predictability of surgery and decrease the enhancement rate.

MeSH terms

  • Astigmatism* / diagnosis
  • Humans
  • Refraction, Ocular
  • Reproducibility of Results
  • Retrospective Studies
  • Vision Tests*
  • Visual Acuity