Lecture given at the First Basic Course in Clinical Diagnosis and Instrumentation, Sentro Oftalmologico Jose Rizal, May 21, 2016

1. May 21-22, 2016
First Basic Course in Clinical Diagnosis & Instrumentation
Sentro Oftalmologico Jose Rizal

2. AMBLYOGENIC REFRACTIVE ERRORS
(PRESCHOOL)
Anisometropia (sph or cyl) > 1.5D
Hyperopia >3.5 in any meridian
Myopia >3.0 in any meridian
Astigmatism >1.5D at 90/180 deg
Astigmatism >1.0D >10 deg any meridian

3. AMBLYOGENIC REFRACTIVE ERRORS
Myopia > -1.00 D
Hyperopia
§ 0-1 y: >+4.00 D
§ 1-2 y: >+3.50 D
§ 2-6 y: >+2.00 D
Astigmatism >1.50 D
Anisometropia >1.50 D
Freedman, Preston, Ophthalmology 1992

4. Reduced amplitudes of
accommodation
§ 8 yrs old: up to 14D
§ 20 yrs old: up to 11D
§ 30 yrs: up to 9D
§ 40 yrs : up to 4 D
§ 50 yrs : less than 2 D
PRESBYOPIA & ACCOMMODATION
http://iovs.arvojournals.org/data/Journals/IOVS/932949/
z7g0060889470008.jpeg

5. SA cycloplegia
§ Tropic 0.5% (1%) q 15
min x 3, after 30 min
§ Tropic 0.5% -
phenylephrine (San-myd)
q3-5 min x 2-3 doses,
refract after 30 min
§ AAO: Tropic 0.5% q 5 min
x 2, after 30 min
• Recovery in 2-6h
• Considered inadequate
for most children’s
cycloplegia
CYCLOPLEGIA
Bin Aziz, Cycloplegic Agents and Refraction.
http://www.slideshare.net/
schizophrenicSabbir/cycloplegic-agents-
cyclorefraction

6. CYCLOPLEGIA
Intermediate cycloplegia
§ Cyclopentolate 1% (2%) q 5 min x 2, after 40 min
§ Tropic-phe-cyclopent (0.5/2.5/0.5%: Caputo drops) q
5min x 2, after 30 min
§ AAO: C1% q 5min x 2, after 30 min
Recovery in 24-48h

7. CYCLOPLEGIA
Long acting cycloplegia
§ Atropine 1% gold standard
§ Forewarn patients about atropine flush & skin
warmth, and product insert problems.
§ Dilute if necessary
§ TID x 3 days and morning of visit
§ BID x 2 days may be adequate (Rosenbaum, personal
communication)
§ Caution in infants, albinos, trisomy 21 (Down)

8. ERRORS OF INADEQUATE CYCLOPLEGIA
• Less hyperopia
• More myopia
• Higher with-the-rule astigmatism
• Same errors as computer autorefraction!

9. EMMETROPIZATION
• Children with EOR at birth usually become more
emmetropic with age
• Argument against giving glasses early
• Disturbance in emmetropization causes persistent
myopia and hyperopia
Jensen 1997

10. FACTORS AFFECTING DECISION TO PRESCRIBE
— Age and tolerable glasses
— Visual Needs
— Cycloplegic refraction
— Alignment
— Development of amblyopia
— Developmental milestones
— Associated abnormalities or delays
— Parents – attitude, finances

11. CHILDREN < 5 yrs
— Give refraction on axis as
refracted
— Full hyperopic cycloplegic
refraction tolerated well if
less than age 5 y
— Subjective manifest
refraction less important
ADULTS
— Give cyl closer to 90 or 180
degrees
— Maximum tolerated plus even
in refractive accommodative
esotropia
— Subjective manifest refraction
important.
SOME COMMON DIFFERENCES
BETWEEN ADULTS AND CHILDREN

12. CHILDREN < 5 yrs
• Tolerates anisometropia;
give full regardless of age,
strabismus, amblyopia
• < 12y: non wearing or
wearing wrong prescription
will affect eye health
§ Amblyopia, deviation, loss binocularity
ADULTS
• Tolerates anisometropia
poorly
• Non wearing or wearing
wrong prescription have
only minor temporary
consequences
§ Asthenopia, red eye, dry eye
SOME COMMON DIFFERENCES
BETWEEN ADULTS AND CHILDREN

13. CHILDREN < 5 yrs
— Tolerates aneisokonia better
but also considered an
impediment to fusion and
has amblyopia potential
— Anisometropic Rx,
Aneisokonic spectacle Rx
has a role especially in
patients requiring occlusion
ADULTS
— Tolerates aneisokonia poorly
— Will not wear Rx that has a large
difference in refraction between
the 2 eyes (threshold? Different
from patient to patient)
SOME COMMON DIFFERENCES
BETWEEN ADULTS AND CHILDREN

15. AMBLYOGENIC REFRACTIVE ERRORS
(PRESCHOOL)
Anisometropia (sph or cyl) > 1.5D
Hyperopia >3.5 in any meridian
Myopia >3.0 in any meridian
Astigmatism >1.5D at 90/180 deg
Astigmatism >1.0D >10 deg any meridian

16. AMBLYOGENIC REFRACTIVE ERRORS
Myopia > -1.00 D
Hyperopia
§ 0-1 y: >+4.00 D
§ 1-2 y: >+3.50 D
§ 2-6 y: >+2.00 D
Astigmatism >1.50 D
Anisometropia >1.50 D
Freedman, Preston, Ophthalmology 1992

17. HYPEROPIA >3.5D
• Prescribe plus that gives best VA
• Usually lower than actual cycloplegic refraction
• May not reach 20/20 right away
• Manifest refraction should be considered

18. ORTHOTROPIA & HYPEROPIA
— High hyperopia >+3.5D Cycloplegic
◦ Amblyogenic
◦ Asthenopic symptoms common
◦ Risk for developing refractive accommodative ET
◦ Cut plus from cycloplegic refraction by +1.0 to +1.5D in
younger child,
◦ May cut plus even higher in the cooperative child if good
manifest refraction can be obtained;
◦ some start by giving half plus

19. ORTHOTROPIA & HYPEROPIA
Hyperopia: Moderate > +2.50 to +3.50D Cycloplegic
§ Monitor closely: potential for amblyopia & refractive
accommodative esotropia
§ Cut by +1.0 to +1.5D
§ some start by giving half
§ If cooperative, get dry manifest and subjective
§ If cooperative with symptoms, give lowest plus with good VA

20. ORTHOTROPIA & HYPEROPIA
— Hyperopia: Low up to +2.50D cycloplegic
◦ Asymptomatic OBSERVE only for ET and amblyopia
◦ If cooperative, get dry manifest and subjective
◦ If cooperative with symptoms, give lowest plus with
good enough VA (20/40) so as not to interfere with
emmetropization
◦ If symptomatic uncooperative,
– Consider observe
– Consider giving plus but cut by +1.0 to +1.50D

21. MYOPIA >3.0
• Start with cycloplegic refraction
• Reevaluate with manifest refraction
• Give lowest minus that will yield VA of at least 20/40

22. ORTHOTROPIA & MYOPIA
Myopia
§ High myopia: > -3.0D
§ Amblyogenic
§ Double check with stronger cycloplegia, usually
atropine
§ More than age 6 mos: give cycloplegic refraction
§ Check refraction q 3 months
§ Regardless of symptoms (with or without symptoms)

23. MYOPIA </=3.0
• Start with cycloplegic refraction
• Reevaluate with manifest refraction
• Give lowest minus that will yield VA of at least 20/40
• Consider child’s visual needs, may not need to
prescribe right away

24. ORTHOTROPIA & MYOPIA
Moderate myopia: -1.0 to -3.0D
§ Potential for amblyopia
§ depends on visual tasks
§ Up to age 1, OBSERVE if -1.0 to -1.5D
§ Above age 6 mos, if >-2.0D, give cycloplegic
refraction
§ School age, give cycloplegic Rx
§ Depends on symptoms: AHP, squinting, spasm of
accommodation, etc.
§ Give cycloplegic refraction

25. ORTHOTROPIA & MYOPIA
Low myopia (<-1.0D):
§ depends on visual tasks
§ Preschool child, even up to grade 3, OBSERVE
§ Intermediate (Gr 4 or higher), give cycloplegic Rx
§ Rare for a child to complain about blurred vision
§ Depends on symptoms:
§ Anomalous head posture
§ Cannot see board
§ Squinting (pinhole behavior)
§ Spasm of accommodation, etc.

26. ORTHOTROPIA & ASTIGMATISM
Astigmatism
◦ With-the-rule
– Up to -1.50D cyl at 180 tolerated without Rx
– Consider potential for amblyopia and associated
symptoms
– Give full cylinder from cycloplegic refraction
◦ Against-the-rule
– Probably not tolerated as well even if low
– Tend to give cycloplegic refraction earlier

27. ORTHOTROPIA & ASTIGMATISM
Astigmatism
§ Oblique axis (exceeds 10-deg from 90 or 180)
§ Threshold lower: >1.0D, give Rx early
§ Consider potential for amblyopia and associated
symptoms
§ Give full cylinder from cycloplegic refraction on-axis
§ If cooperative and reliable with manifest, check if
90/180 degrees preferred

29. ESOTROPIA AND REFRACTIVE ERROR
FULL cycloplegic refraction
§ Myope: give full cycloplegic refraction
§ Hyperope: More common, > +2.00D
§ < 5 y: give full cycloplegic refraction
§ >5 y: maximum tolerated plus, push plus
§ Astigmat:
§ Give the full cylinder from cycloplegic refraction

30. ESOTROPIA AND REFRACTIVE ERROR
When to give bifocals:
§ High AC/A
§ Fusion at distance present (<10PD)
§ Full cycloplegic refraction / maximum tolerated plus
pushed
§ Repeat full cycloplegic refraction first
§ Careful with “V” pattern confused with high AC/A

31. ET HIGH AC/A AND ADDS
— Either give full +3.00D adds then taper, or give minimum
adds +1.00D then go higher to where ET’ controlled
— Objective: minimum plus to control ET’
— Monitor X(T) at near, excess adds
— Must bisect pupil
— Executive, flat top, D-segment

32. • Amblyopia
• Refraction
• Fusion at distance
• Residual near deviation
• Repeat refraction
• Amblyopia management
• Remeasure with glasses always
WHAT TO DO ON FOLLOW-UP:
ACCOMMODATIVE ET

33. ACCOMMODATIVE ET: FOLLOW-UP
Remeasure deviation with glasses ALWAYS both at distance
and near
If ET at distance
§ Consider undercorrected hyperopia first before surgery
If no ET at distance, ET’ at near only
§ Recheck refraction, repeat cycloplegia, increase plus if
necessary
§ Consider high AC/A requiring bifocals

34. ACCOMMODATIVE ET: FOLLOW-UP
If XT at distance
§ Reduce plus correction
If XT at distance, ET at near
§ reduce distance plus
§ Minimum Bifocals that will control near deviation
If ortho at distance but XT at near
§ Reduce adds

35. 0-8PD ET
Monofixation syndrome
ACCOMMODATIVE ET:
TREATMENT GOAL

36. Single vision lens
§ Cycloplegic refraction
§ Maximum tolerated plus
§ Push plus
ACCOMMODATIVE ET:
NONSURGICAL MANAGEMENT

37. ACCOMMODATIVE ET: BIFOCALS
• If and only if distance fusion present (<10PD)
• Reached maximum tolerated plus
• Executive or D segment bisecting pupil

38. ACCOMMODATIVE ET: PEARLS
• Refraction not always hyperopia
• Give full cycloplegic refractions whenever possible
• Push maximum tolerated plus
• Bifocals if and only if there is fusion at distance
• Goal: minimum bifocals to control near deviation;
eventually get patient out of bifocals

39. ACCOMMODATIVE ET: PEARLS
• Always check/repeat refraction for latent hyperopia
• Role of atropine in uncovering hyperopia
• Measure deviation wearing the correction
• Perform simultaneous prism cover test first before
alternate prism cover test
• Latent esotropia not for surgery

41. X(T) AND REFRACTIVE ERROR
• Any sensory destabilizing factor affects control,
including small EOR
• Improvement in VA usually helps control deviation

42. X(T) AND REFRACTIVE ERROR
• Hyperopia:
• If fully corrected, relaxes accommodative-
convergence, control worse
• Give minimum plus with best VA, usually better for
control of deviation
• Over minus lenses / Withholding hyperopia / giving
less plus has a role in management

43. X(T) AND REFRACTIVE ERROR
Hyperope*: If not for surgery
§ <5y: Cut plus by 1-1.5D
§ Minimum plus to control X(T) and give clear vision
§ Older children, consider manifest refraction
§ Excess plus can worsen X(T)
Hyperope*: For surgery
§ Give the full cycloplegic refraction or maximum tolerated
plus prescription to uncover all latent exodeviation.
§ Target angle for surgery
*Significant hyperopia ~ >+3.50 on cycloplegic refraction

44. X(T) AND REFRACTIVE ERROR
Myope
§ Give full cycloplegic refraction (lowest minus)
§ Consider over minus if not for surgery
§ Or, give minus lens that will give best VA
Astigmat
§ Give the full cylinder from cycloplegic refraction

46. ANISOMETROPIA & REFRACTIVE ERROR
Monocular XT
§ Anisometropic amblyopia
§ Cut plus by 1-1.5D
§ If >5 y, may need to manage like a little adult, decrease
anisometropia in glasses
§ Consider contact lenses to optimize vision
§ Prescribe glasses with patching
§ Role of laser refractive surgery?

47. ANISOMETROPIA & REFRACTIVE ERROR
Monocular ET
§ Anisometropic amblyopia
§ Usually with refractive accommodative component
§ Full cycloplegic refraction or maximum tolerated plus
§ If >5 y, may need to manage like a little adult:
decrease anisometropia in glasses
§ Prescribe glasses with patching
§ Consider strongly: contact lenses
§ Role of laser refractive surgery?

49. — Significant cylinder &/or
significant myopia
— Dry manifest refraction
highest and exceeds
cycloplegic refraction
— May need stronger
cycloplegia to determine true
target refraction
— Pharmacologic cycloplegia
CILIARY MUSCLE SPASM

50. CILIARY MUSCLE SPASM
Give lowest minus, lowest cylinder
Resist urge to give in to subjective refraction
§ usually higher minus
§ more with-the-rule astigmatism (minus cyl x 180)
Compromise needed for school age:
§ at least 20/40 (6/12 or 0.5) OU

51. REFERENCES
1. Chia A, Chua WH, Cheung YB etal. Atropine for the treatment of childhood myopia: safety and
efficacy of 0.5%, 0.1%, 0.01% (Atropine for Myopia 2) Ophthalmology 2012; 119.347-54.
2. Chia A, Chua WH, Wen L, et al. Atropine for the treatment of childhood myopia: changes after
stopping atropine 0.01%, 0.1%, and 0.05%. Am J Ophthalmol 2014; 157: 451-7.
3. Chia A, Lu QS, Tan D. 5-year clinical trial on atropine for the treatment of myopia 1: myopia
control with atropine 0.01% Eyedrops. Ophthalmology 2015; epub ahead of print.
4. Donahue SP, Arnold RW, Ruben JB, AAPOS Vision Screening Committee. Preschool vision
screening: what should we be detecting and how should we report it? Uniform guidelines
reporting results of preschool vision screening studies. J AAPOS 2003; 7: 314-5.
5. Bin Aziz, MA. Cycloplegic agents and cyclorefraction.
http://www.slideshare.net/schizophrenicSabbir/cycloplegic-agents-cyclorefraction.
Accessed March 15, 2016.
6. Apt L, Gaffney M. Cycloplegic Refraction.
http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/
v1c041.html. Accessed March 15, 2016.