Eyeglass prescribing in children, pretest/posttest given during lecture for Prescribing Eyeglasses in Children, The Medical City, March 16, 2016

1. E X E R C I S E S E T T M C , M A R C H 1 6 , 2 0 1 6
EYEGLASS PRESCRIBING IN
CHILDREN
PRESENTED BY:
AP SANTIAGO, MD

2. PRESCRIBING EYEGLASSES IN
CHILDREN EXERCISES
A P S A N T I A G O , M D
TMC, 16 March 2016

3. CASE 1A
Ø Orthotropic
Ø Age 2 years
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.5 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
What will you do?
1. Prescribe manifest refracTon?
2. Prescribe cycloplegic
refracTon?
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refracTon
as contact lenses?
5. Give atropine to halt
progression of myopia?

4. CASE 1B
Ø IntermiZent exotropia
Ø Age 2
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.50 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
Ø What will you do?
1. Prescribe manifest refracTon?
2. Prescribe cycloplegic
refracTon?
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refracTon
as contact lenses?
5. Give atropine to halt
progression of myopia?

5. CASE 1C
Ø Esotropic, intermiZent
Ø Age 2 yr
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.50 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
Ø What will you do?
1. Prescribe manifest refracTon?
2. Prescribe cycloplegic
refracTon?
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refracTon
as contact lenses?
5. Give atropine to halt
progression of myopia?

6. CASE 2A
Ø 3/F failed a preschool vision screening
Ø VA: OD 20/50 linear Allen,
20/30 single figures
OS 20/30 linear and single figures
Ø Orthotropic
Ø Manifest refracTon
Ø OD: -3.00D
Ø OS: -1.00D
Ø Cycloplegic refracTon
Ø OD: -2.50D
Ø OS: -1.00D
Ø What will you do?
1. Observe for now, child’s world
at near.
2. Prescribe manifest refracTon,
child is starTng school.
3. Prescribe cycloplegic refracTon
4. Prescribe cycloplegic refracTon
and start amblyopia therapy.
5. Repeat refracTon in 3 months.

7. CASE 2B
Ø 3yrs old, recent onset 30PD E(T)’
Ø Neurologically, systemically normal
Ø VA: OU, fixes, follows, can CSM
Ø Only lea eye always turns in
intermiZently
Ø Manifest: +0.50 -1.00 x 90 OU
Ø Cycloplegic refracTon:
(cyclopentolate 1%)
Ø +3.00 -1.00 x 90 OU
Ø What will you do?
1. Prescribe manifest refracTon
2. Cut plus by 1.0 D from
cycloplegic refracTon: +2.00
-1.00 x 090 OU
3. Give cyclopentolate cycloplegic
refracTon
4. Do atropine refracTon and
prescribe this
5. Prescribe cycloplegic refracTon
with bifocals.
6. PaTent’s case requires surgery.

8. CASE 2C
Ø 3/F with 25PD of X(T)
Ø VA OU: 20/20 either eye
occluded, unaided
Ø Either eye deviates outward with
no obvious eye preference
Ø Dry Manifest RefracTon: +2.00
-1.00 x 180
Ø Unable to cooperate for
subjecTve refracTon
Ø Cycloplegic refracTon +3.00 -1.00
x 180
Ø What will you do?
1. No prescripTon if paTent
does not want surgery.
2. Prescribe Rx even if paTent
does not want surgery.
3. Do surgery for 25PD XT and
prescribe Rx aaer surgery
for under- or overcorrecTon
4. Do atropine refracTon and
prescribe this if paTent
wants surgery.

9. END OF PRETEST

11. PRESCRIBING EYEGLASSES
FOR CHILDREN
A N S W E R S T O P R E T E S T

12. CASE 1A
Ø Orthotropic
Ø Age 2 years
Ø VA: OU fixes, follows, can CSM, no preference
Ø Manifest difficult: about -3.0 OD, -3.5 OS
Ø Cycloplegic refracTon
Ø OD -1.50D OS -2.00D

13. 1A: WHAT WILL YOU DO?
Ø Age 2: potenTal for amblyopia
Ø Myopia < -2.0D less potenTal for amblyopia although may sTll be
“amblyogenic”
Ø Child’s world is at near
Ø No misalignment

14. 1A: LOGICAL MANAGEMENT
Ø Observe
Ø Child’s world at near
Ø Low potenTal for amblyopia
Ø But need to monitor closely
Ø Will not interfere with “emmetropizaTon”
Ø Give cycloplegic refracTon
Ø PotenTal for amblyopia and symptoms to develop later

15. CASE 1A, 1A:
2Y,ORTHO, MYOPIA < -2.0D
Ø Orthotropic
Ø Age 2 years
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.5 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
What will you do?
1. Prescribe manifest refracTon?
2. Prescribe cycloplegic refracRon
3. Observe for now because a
child’s world is at near
4. Prescribe cycloplegic refracTon
as contact lenses?
5. Give atropine to halt
progression of myopia?

16. CASE 1B
Ø IntermiZent exotropia
Ø Age 2
Ø VA: OU fixes, follows, can CSM, no preference
Ø Manifest difficult: about -3.0 OD, -3.5 OS
Ø Cycloplegic refracTon
Ø OD -1.50D OS -2.00D

17. 1B: WHAT WILL YOU DO?
Ø Child has X(T)
Ø Age 2: potenTal for amblyopia
Ø Strabismic
Ø Ametropic: Myopic
Ø Myopia < -2.0D may be a sensory destabilizing factor

18. LOGICAL MANAGEMENT: 1B
Ø Give myopic (full) cycloplegic refracTon
Ø Start with lowest minus
Ø Improved VA may be enough to control X(T)
Ø Give manifest refracTon because of role of over minus lenses in X(T)
Ø May even give higher minus (up to -3.0D) if deviaTon small (<20D) –
Jampolsky et al
Ø Children tolerate “overminus” well

19. CASE 1B
Ø IntermiZent exotropia
Ø Age 2
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.50 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
Ø What will you do?
1. Prescribe manifest refracTon
2. Prescribe cycloplegic refracRon
3. Observe for now because a
child’s world is at near
4. Prescribe cycloplegic refracTon
as contact lenses
5. Give atropine to halt
progression of myopia
C

20. CASE 1C
Ø Esotropic, intermiZent
Ø Age 2 yr
Ø VA: OU fixes, follows, can CSM, no preference
Ø Manifest difficult: about -3.0 OD, -3.5 OS
Ø Cycloplegic refracTon
Ø OD -1.50D OS -2.00D

21. 1C: WHAT WILL YOU DO?
Ø Child has E(T)
Ø Age 2: potenTal for amblyopia
Ø Strabismic
Ø Ametropic: Myopic
Ø Myopia < -2.0D may be sTmulaTng excess accommodaTon &
convergence

22. LOGICAL MANAGEMENT: 1C
Ø Give myopic (full) cycloplegic refracTon
Ø No role for giving manifest refracTon or over minus lenses
Ø Monitor effect of Rx on alignment
Ø Monitor for development of amblyopia

23. CASE 1C
Ø Esotropic, intermiZent
Ø Age 2 yr
Ø VA: OU fixes, follows, can CSM,
no preference
Ø Manifest difficult: -3.00 OD,
-3.50 OS
Ø Cycloplegic refracTon
OD -1.50D OS -2.00D
Ø What will you do?
1. Prescribe manifest refracTon
2. Prescribe cycloplegic refracRon
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refracTon
as contact lenses?
5. Give atropine to halt
progression of myopia?
C

24. CASE 2A
Ø 3/F failed a preschool vision screening
Ø VA: OD 20/50 linear Allen, 20/30 singly
OS 20/30 linear and singly
Ø Orthotropic
Ø Manifest refracTon
Ø OD: -3.00D OS: -1.00D
Ø Cycloplegic refracTon
Ø OD: -2.50D OS: -1.00D

25. CASE 2A: WHAT WILL YOU DO?
Ø 3y: visual system immature
Ø Already amblyopic
Ø Linear acuity shows at least 2 line difference

26. 2A: LOGICAL MANAGEMENT
Ø Give cycloplegic refracTon (lowest minus)
Ø Monitor VA improvement (usually a month)
Ø Start amblyopia treatment if necessary

27. CASE 2A
Ø 3/F failed a preschool vision screening
Ø VA: OD 20/50 linear Allen,
20/30 single figures
OS 20/30 linear and single figures
Ø Orthotropic
Ø Manifest refracTon
Ø OD: -3.00D
Ø OS: -1.00D
Ø Cycloplegic refracTon
Ø OD: -2.50D
Ø OS: -1.00D
Ø What will you do?
1. Observe for now, child’s world
at near.
2. Prescribe manifest refracTon,
child is starTng school.
3. Prescribe cycloplegic refracTon
4. Prescribe cycloplegic refracRon
and start amblyopia therapy.
5. Repeat refracTon in 3 months.
C

28. CASE 2B
Ø 3yrs old, recent onset 30PD E(T)’
Ø Neurologically, systemically normal
Ø VA: OU, fixes, follows, can CSM
Ø Only lea eye always turns in intermiZently
Ø Manifest: +0.50 -1.00 x 90 OU
Ø Cycloplegic refracTon: (cyclopentolate 1%)
Ø +3.00 -1.00 x 90 OU

29. 2B: WHAT WILL YOU DO?
1. Cyclopentolate refracTon already > +2.00, higher likelihood that
atropine refracTon will uncover more plus
2. Likely to be a refracTve accommodaTve intermiZent ET
3. Right eye preference (only lea eye intermiZently turns in)
suggesTve of amblyopia though mild

30. 2B: LOGICAL MANAGEMENT
Ø Atropine cycloplegia
Ø Give full cycloplegic refracTon
Ø Determine effect on alignment and control of intermiZent
esodeviaTon
Ø Bifocals iff:
Ø Repeat atropine same refracTon as previous
Ø ET controlled at distance, residual ET’ at near

31. CASE 2B
Ø 3yrs old, recent onset 30PD E(T)’
Ø Neurologically, systemically normal
Ø VA: OU, fixes, follows, can CSM
Ø Only lea eye always turns in
intermiZently
Ø Manifest: +0.50 -1.00 x 90 OU
Ø Cycloplegic refracTon:
(cyclopentolate 1%)
Ø +3.00 -1.00 x 90 OU
Ø What will you do?
1. Prescribe manifest refracTon
2. Cut plus by 1.0 D from
cycloplegic refracTon: +2.00
-1.00 x 090 OU
3. Give cyclopentolate cycloplegic
refracTon
4. Do atropine refracRon and
prescribe this
5. Prescribe cycloplegic refracTon
with bifocals.
6. PaTent’s case requires surgery.
C

32. CASE 2C
Ø 3/F with 25PD of X(T)
Ø VA OU: 20/20 either eye occluded, unaided
Ø Either eye deviates outward with no obvious eye preference
Ø Dry Manifest RefracTon: +2.00 -1.00 x 180
Ø Unable to cooperate for subjecTve refracTon
Ø Cycloplegic refracTon +3.00 -1.00 x 180

33. CASE 2C: LOGICAL MANAGEMENT
1. Try to improve control:
Ø Determine if the EOR a destabilizing factor?
Ø withholding glasses similar to giving “over minus”?
Ø Trial with EOR, may need to Ttrate hyperopic component
Ø Role of orthopTcs, convergence and anTsuppression exercises

34. CASE 2C: LOGICAL MANAGEMENT
2. If for surgery:
Ø Need to uncover full plus (atropine) refracTon, give maximum plus
to as close to cycloplegic as possible
Ø Remeasure with Rx for target angle for surgery

35. CASE 2C
Ø 3/F with 25PD of X(T)
Ø VA OU: 20/20 either eye
occluded, unaided
Ø Either eye deviates outward with
no obvious eye preference
Ø Dry Manifest RefracTon: +2.00
-1.00 x 180
Ø Unable to cooperate for
subjecTve refracTon
Ø Cycloplegic refracTon +3.00 -1.00
x 180
Ø What will you do?
1. No prescripTon if paTent
does not want surgery.
2. Prescribe Rx even if paTent
does not want surgery.
3. Do surgery for 25PD XT and
prescribe Rx aaer surgery
for under- or overcorrecTon
4. Do atropine refracRon and
prescribe this if paRent
wants surgery.
C

36. 2C: 3Y, HYPEROPIC X(T)
1. No prescripTon if paTent does not want surgery.
Ø (significant EOR)
2. Prescribe Rx even if paTent does not want surgery
Ø (does not tell you if dry or wet)
3. Do surgery for 25PD of exotropia and prescribe Rx
aaer surgery for under- or overcorrecTon
Ø (Target angle sTll uncertain without trying max plus)
4. Do atropine refracRon and prescribe this if
paRent wants surgery.

37. END OF DISCUSSION OF
ANSWERS