Exercise Set for prescribing eyeglasses in children. Given at the Clinical and Surgical Course Lecture Series featuring Pediatric Ophthalmology, given at Sentro Oftalmologico Jose Rizal, Philippine General Hospital, May 7, 2017

1. E X E R C I S E S E T
EYEGLASS PRESCRIBING IN
CHILDREN
PRESENTED BY:
ALVINA PAULINE SANTIAGO, MD
MAY 7, 2017

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

3. CASE 1A
ØOrthotropic
ØAge 2 years
ØVA: OU fixes, follows, can CSM, no preference
ØManifest difficult: about -3.0 OD, -3.5 OS
ØCycloplegic refraction
ØOD -1.50D OS -2.00D

4. 1A: WHAT WILL YOU DO?
ØAge 2: potential for amblyopia
ØMyopia < -2.0D less potential for amblyopia although may still be
“amblyogenic”
ØChild’s world is at near
ØNo misalignment

5. 1A: LOGICAL MANAGEMENT
ØObserve
ØChild’s world at near
ØLow potential for amblyopia
ØBut need to monitor closely
ØWill not interfere with “emmetropization”
ØGive cycloplegic refraction
ØPotential for amblyopia and symptoms to develop later

6. CASE 1A, 1A:
2Y,ORTHO, MYOPIA < -2.0D
ØOrthotropic
ØAge 2 years
ØVA: OU fixes, follows, can CSM,
no preference
ØManifest difficult: -3.00 OD, -
3.5 OS
ØCycloplegic refraction
OD -1.50D OS -2.00D
What will you do?
1. Prescribe manifest refraction?
2. Prescribe cycloplegic
refraction
3. Observe for now because a
child’s world is at near
4. Prescribe cycloplegic refraction
as contact lenses?
5. Give atropine to halt
progression of myopia?

7. CASE 1B
ØIntermittent exotropia
ØAge 2
ØVA: OU fixes, follows, can CSM,
no preference
ØManifest difficult: -3.00 OD, -
3.50 OS
ØCycloplegic refraction
OD -1.50D OS -2.00D
ØWhat will you do?
1. Prescribe manifest refraction?
2. Prescribe cycloplegic
refraction?
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refraction
as contact lenses?
5. Give atropine to halt
progression of myopia?

8. CASE 1B
ØIntermittent exotropia
ØAge 2
ØVA: OU fixes, follows, can CSM, no preference
ØManifest difficult: about -3.0 OD, -3.5 OS
ØCycloplegic refraction
ØOD -1.50D OS -2.00D

9. 1B: WHAT WILL YOU DO?
ØChild has X(T)
ØAge 2: potential for amblyopia
ØStrabismic
ØAmetropic: Myopic
ØMyopia < -2.0D may be a sensory destabilizing factor

10. LOGICAL MANAGEMENT: 1B
ØGive myopic (full) cycloplegic refraction
ØStart with lowest minus
ØImproved VA may be enough to control X(T)
ØGive manifest refraction because of role of over minus lenses in X(T)
ØMay even give higher minus (up to -3.0D) if deviation small (<20D) –
Jampolsky et al
ØChildren tolerate “overminus” well

11. CASE 1B
ØIntermittent exotropia
ØAge 2
ØVA: OU fixes, follows, can CSM,
no preference
ØManifest difficult: -3.00 OD, -
3.50 OS
ØCycloplegic refraction
OD -1.50D OS -2.00D
ØWhat will you do?
1. Prescribe manifest refraction
2. Prescribe cycloplegic
refraction
3. Observe for now because a
child’s world is at near
4. Prescribe cycloplegic refraction
as contact lenses
5. Give atropine to halt
progression of myopia
C

12. CASE 1C
ØEsotropic, intermittent
ØAge 2 yr
ØVA: OU fixes, follows, can CSM,
no preference
ØManifest difficult: -3.00 OD, -
3.50 OS
ØCycloplegic refraction
OD -1.50D OS -2.00D
ØWhat will you do?
1. Prescribe manifest refraction?
2. Prescribe cycloplegic
refraction?
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refraction
as contact lenses?
5. Give atropine to halt
progression of myopia?

13. CASE 1C
ØEsotropic, intermittent
ØAge 2 yr
ØVA: OU fixes, follows, can CSM, no preference
ØManifest difficult: about -3.0 OD, -3.5 OS
ØCycloplegic refraction
ØOD -1.50D OS -2.00D

14. 1C: WHAT WILL YOU DO?
ØChild has E(T)
ØAge 2: potential for amblyopia
ØStrabismic
ØAmetropic: Myopic
ØMyopia < -2.0D may be stimulating excess accommodation &
convergence

15. LOGICAL MANAGEMENT: 1C
ØGive myopic (full) cycloplegic refraction
ØNo role for giving manifest refraction or over minus lenses
ØMonitor effect of Rx on alignment
ØMonitor for development of amblyopia

16. CASE 1C
ØEsotropic, intermittent
ØAge 2 yr
ØVA: OU fixes, follows, can CSM,
no preference
ØManifest difficult: -3.00 OD, -
3.50 OS
ØCycloplegic refraction
OD -1.50D OS -2.00D
ØWhat will you do?
1. Prescribe manifest refraction
2. Prescribe cycloplegic
refraction
3. Observe for now because a
child’s world is at near?
4. Prescribe cycloplegic refraction
as contact lenses?
5. Give atropine to halt
progression of myopia?
C

17. 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 refraction
Ø OD: -3.00D
Ø OS: -1.00D
Ø Cycloplegic refraction
Ø OD: -2.50D
Ø OS: -1.00D
ØWhat will you do?
1. Observe for now, child’s world
at near.
2. Prescribe manifest refraction,
child is starting school.
3. Prescribe cycloplegic refraction
4. Prescribe cycloplegic refraction
and start amblyopia therapy.
5. Repeat refraction in 3 months.

18. CASE 2A
Ø3/F failed a preschool vision screening
ØVA: OD 20/50 linear Allen, 20/30 singly
OS 20/30 linear and singly
ØOrthotropic
ØManifest refraction
ØOD: -3.00D OS: -1.00D
ØCycloplegic refraction
ØOD: -2.50D OS: -1.00D

19. CASE 2A: WHAT WILL YOU DO?
Ø3y: visual system immature
ØAlready amblyopic
ØLinear acuity shows at least 2 line difference

20. 2A: LOGICAL MANAGEMENT
ØGive cycloplegic refraction (lowest minus)
ØMonitor VA improvement (usually a month)
ØStart amblyopia treatment if necessary

21. 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 refraction
Ø OD: -3.00D
Ø OS: -1.00D
Ø Cycloplegic refraction
Ø OD: -2.50D
Ø OS: -1.00D
ØWhat will you do?
1. Observe for now, child’s world
at near.
2. Prescribe manifest refraction,
child is starting school.
3. Prescribe cycloplegic refraction
4. Prescribe cycloplegic
refraction and start amblyopia
therapy.
5. Repeat refraction in 3 months.
C

22. CASE 2B
Ø3yrs old, recent onset 30PD E(T)’
ØNeurologically, systemically normal
ØVA: OU, fixes, follows, can CSM
ØOnly left eye always turns in
intermittently
ØManifest: +0.50 -1.00 x 90 OU
ØCycloplegic refraction:
(cyclopentolate 1%)
Ø +3.00 -1.00 x 90 OU
ØWhat will you do?
1. Prescribe manifest refraction
2. Cut plus by 1.0 D from
cycloplegic refraction: +2.00 -
1.00 x 090 OU
3. Give cyclopentolate cycloplegic
refraction
4. Do atropine refraction and
prescribe this
5. Prescribe cycloplegic refraction
with bifocals.
6. Patient’s case requires surgery.

23. CASE 2B
Ø3yrs old, recent onset 30PD E(T)’
ØNeurologically, systemically normal
ØVA: OU, fixes, follows, can CSM
ØOnly left eye always turns in intermittently
ØManifest: +0.50 -1.00 x 90 OU
ØCycloplegic refraction: (cyclopentolate 1%)
Ø+3.00 -1.00 x 90 OU

24. 2B: WHAT WILL YOU DO?
1. Cyclopentolate refraction already > +2.00, higher likelihood that
atropine refraction will uncover more plus
2. Likely to be a refractive accommodative intermittent ET
3. Right eye preference (only left eye intermittently turns in)
suggestive of amblyopia though mild

25. 2B: LOGICAL MANAGEMENT
ØAtropine cycloplegia
ØGive full cycloplegic refraction
ØDetermine effect on alignment and control of intermittent
esodeviation
ØBifocals iff:
ØRepeat atropine same refraction as previous
ØET controlled at distance, residual ET’ at near

26. CASE 2B
Ø3yrs old, recent onset 30PD E(T)’
ØNeurologically, systemically normal
ØVA: OU, fixes, follows, can CSM
ØOnly left eye always turns in
intermittently
ØManifest: +0.50 -1.00 x 90 OU
ØCycloplegic refraction:
(cyclopentolate 1%)
Ø +3.00 -1.00 x 90 OU
ØWhat will you do?
1. Prescribe manifest refraction
2. Cut plus by 1.0 D from
cycloplegic refraction: +2.00 -
1.00 x 090 OU
3. Give cyclopentolate cycloplegic
refraction
4. Do atropine refraction and
prescribe this
5. Prescribe cycloplegic refraction
with bifocals.
6. Patient’s case requires surgery.
C

27. CASE 2C
Ø3/F with 25PD of X(T)
ØVA OU: 20/20 either eye
occluded, unaided
ØEither eye deviates outward with
no obvious eye preference
ØDry Manifest Refraction: +2.00 -
1.00 x 180
ØUnable to cooperate for
subjective refraction
ØCycloplegic refraction +3.00 -1.00
x 180
ØWhat will you do?
1. No prescription if patient
does not want surgery.
2. Prescribe Rx even if patient
does not want surgery.
3. Do surgery for 25PD XT and
prescribe Rx after surgery
for under- or overcorrection
4. Do atropine refraction and
prescribe this if patient
wants surgery.

28. CASE 2C
Ø3/F with 25PD of X(T)
ØVA OU: 20/20 either eye occluded, unaided
ØEither eye deviates outward with no obvious eye preference
ØDry Manifest Refraction: +2.00 -1.00 x 180
ØUnable to cooperate for subjective refraction
ØCycloplegic refraction +3.00 -1.00 x 180

29. 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 titrate hyperopic component
Ø Role of orthoptics, convergence and antisuppression exercises

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

31. CASE 2C
Ø3/F with 25PD of X(T)
ØVA OU: 20/20 either eye
occluded, unaided
ØEither eye deviates outward with
no obvious eye preference
ØDry Manifest Refraction: +2.00 -
1.00 x 180
ØUnable to cooperate for
subjective refraction
ØCycloplegic refraction +3.00 -1.00
x 180
ØWhat will you do?
1. No prescription if patient
does not want surgery.
2. Prescribe Rx even if patient
does not want surgery.
3. Do surgery for 25PD XT and
prescribe Rx after surgery
for under- or overcorrection
4. Do atropine refraction and
prescribe this if patient
wants surgery.
C

32. 2C: 3Y, HYPEROPIC X(T)
1. No prescription if patient does not want surgery.
Ø (significant EOR)
2. Prescribe Rx even if patient does not want surgery
Ø (does not tell you if dry or wet)
3. Do surgery for 25PD of exotropia and prescribe Rx
after surgery for under- or overcorrection
Ø (Target angle still uncertain without trying max plus)
4. Do atropine refraction and prescribe this if
patient wants surgery.