3. Introduction
The human eye undergoes dramatic anatomical and
physiological development throughout infancy and early
childhood.
Most of the growth takes place in first year of life.
So, on dealing with pediatric age group one should have
great expertise in determining refractive state.
4. Should have knowledge of:
Normal values of refractive error with age
Emmetropization
Relationship b/w vision , refraction ,state of BSV ,
and age of child
5. Background
AAO recommends the routine eye examination of a child
begins from 6 months of age because an average child will
reach a number of developmental milestones at this age.
Refractive error is among commonest visual problem in
children
Early detection & appropriate management of refractive error
helps to achieve optimal acuity , binocularity & overall
development.
6. Background
Clinicians who encounter pediatric age group must be
fully aware of impact of treatment on pediatric ocular
disorder.
Inappropriate refractive correction will hamper child’s
optical & neural development as a result of which child
will suffer life long.
Hence clinician must be aware about the development
of optical components of eye before appropriate
refraction and correction.
7. Age groups in pediatric population:
This subdivision of the pediatric population is based on the
developmental changes that occur from birth through childhood.
Age group Age
Neonate Birth-1month
Infant 1 months-1 yrs
Toddlers 1-3 yrs
Preschool age 3-6 yrs
School age 6-12 yrs
Adolescent 12-18yrs
8. Emmetropization
A process operating to obtain greater frequency of
emmetropia is called as emmetropization.
Achieved by negative feed back mechanism.
Biometric components in eyes influencing
emmetropization:
1. Corneal power
2. Crystalline lens power
3. Axial length
4. AC depth
9. Contd…
Rate is proportional to the initial error
Fails when refractive errors are outside normal range for
age
Risk for amblyopia and strabismus
Largely completed by the age of 2 years
May persist till 6-8 years.
Marsh-Tootle WL. Infants, Toddlers and Children. In: Borish Clinical Refraction. Benjamin
WJ(ed).Philadelphia: WB Saunders 1998.
10. Estimation
Variations in refractive
error
Components of eye
½ of variance Axial length
¼ of variance Corneal curvature
1/20 of variance Anterior chamber
1/5 of variance Due to measurement error
and variation in lens and
refractive indices
11. Changes in refractive error with age
Premature infants :- Mostly presented with high myopia
a/w ROP
Full term newborn :- Mostly presented with hyperopia
of (+1-2 D)but refractive error might range b/w from
+11 to -11 D
Preschool child :- Shift towards emmetropia / small
myopia / less hyperopia
School children :- Emmetropia / school myopia
Adolescent :- Mostly myopia
12. Children’s eye examination
•Familiar about the emmetropization
• AAO recommendation - Begin from age of 6 months
• Usual eye testing time - 18 to 24 months
• Monitor significant refractive error- Every 3
months during the first year of life.
*Scheiman MM,AMOs CS,Ciner EB,Marsh-Tooler WM,Moore BM,Rouse MW.Pediatric eye and
vision examination. Optometric Clinical Practice Guideline.St.Louis: American Optometric
Association; 2002.
13. Contd..
For children with disabilities , the story of refractive development
can be quite different ( i.e. Down’s syndrome ,children with
cerebal palsy )
The distribution of refractive error in the first months of life
mirrors that of typical children
Emmetropization fails in children with these conditions
So, one should be alert to the possibility of similar failure in
children with other disabilities.
15. Objectives Of pediatric refraction
To determine the refractive status in infants and
preverbal children’s
Must be appropriate for non-verbals ,uncooperative,
noncommunicative children’s
Must provide important information in refractive state
of eye
Must be understandable ,easily assessable and
accessible
Practitioner must be competent enough to deliver a
perfect judgement
16. Challenges
Child have a great ability to maintain a wide range of
accommodation
Un-cooperative
Greater range of accommodation
Difficulty in quantifying visual status
Risk of visual deprivation
Difficulty in making a child understand wear glasses
17. Normal value of refractive error
Infants Hyperopia Astigmatism Anisometropia
Toddlers(0-2
years)
+2.00 2.00 1-3
Preschoolers (3-5
years)
+1.00 1.25 <3
School age emmetropia emmetropia emmetropia
21. Introduction :
After detection & measurement of refractive error its proper
management is next most important part in pediatric
refraction.
Clinician must be aware about normal and abnormal
refractive findings & also the normal development of various
optical components
Along with Refraction & prescription other optometric test
procedures must go hand in hand (eg. Orthoptic examination
, fundus evaluations ) so that proper management of an
condition can be done.
22. Background :
A number of researches had been carried out regarding
power prescription in pediatric age groups.
But there is no any strict protocol for the power
prescription.
AAO , AOA and other well renowned associations have
given their own opinion regarding power prescription.
Beside this clinical experience of a clinician & his
personal decision also plays major role in power
prescription.
23. Questions that must be considered
before prescribing for children’s b/w
(0- 6 ) yrs. age??
Is the refractive error in normal range with child’s age?
Will this refractive error of the child emmetropize ?
Will this level of refractive error disturb normal level of
functional vision?
Will glass prescribing glass be beneficial for the child?
Will prescribing glass interfere with emmetropization ?
*Farbrother JE. Spectacle prescribing in childhood’s survey of hospital optometrists. Br J
Oph.thamol 2008; 92: 392-395.
25. Infants (0-1) yrs.
Isometropic
Hyperopia
Deviation
+ve (eso)
Deviation
-ve
Full cycloplegic
correction given when
error is (≥ 2 D) and
regular F/U for error
below this
Prescribe only when
error is (≥ 5 D ) i.e.
partial or 2/3rd
prescription is advised
27. Toddlers 1-3 yrs
Isometropic
Hyperopia
Deviation
+ve (eso)
Deviation
-ve
Full cycloplegic
correction given when
error is (> or = 2 D) and
regular F/U for error
below this
Prescribe only
when error is (> or =
3.5 D ) i.e. partial or
2/3rd prescription is
advised
28. Toddlers 1-3 yrs
Hyperopic
Anisometropia
< 2.00
D
> Or =
2.00 D
No prescription
needed ( follow
up 3-6 monthly)
partial
prescription
(No devation )
Full
prescription
(esodeviation
+ve
29. Preschoolers ( 3-6 ) yrs
Isometropic
Hyperopia
Deviation
+ve (eso)
Deviation
-ve
Full cycloplegic
correction given when
error is (≥ 1.5 D) and
regular F/U for error
below this
Prescribe only when
error is (≥ 2.50 D ) i.e.
partial or 2/3rd
prescription is advised
30. Preschoolers ( 3-6 ) yrs
Hyperopic
Anisometropia
< 1.50 D ≥1.50 D
No prescription
needed ( follow
up 3-6 monthly)
partial
prescription
(No devation)
Full prescription
(esodeviation
+ve )
31. School age (above 6 yrs)
Cycloplegic refraction is always recommended when
hyperopia is present in initial retinoscopy.
Since school children need good vision for both
distance and near proper correction is always needed
for better academic performance.
At school age a child is expected to be nearly
emmetropic.
Prevention of a child from amblyopia is major concern
if high hyperopia , deviation & anisometropia is
present.
32. Contd…
Isometropic error (> or = 1.50 D) in the school years
(without symptoms) is indicated for correction.
A full or near full correction may be given at this age, as
emmetropization has essentially ended.
Hyperopic anisometropia (> or = 1.00 D ) needs full
correction.
*American Optometric Association. American
Optometric Association: Care of the patient with
hyperopia
34. Infants (0-1yrs.)
Infants with low-to-moderate myopia may not need prescription.
Because they don’t need to view things in fine details.
But AAO gives prescription guidelines in such condition as :
Isometropic
myopia
< 5D
> or -5D
No need to prescribe (constant
monitoring)
Needs prescription (Reduce by 1-2 D)
35. Infants ( 0-1 yrs )
AAO suggests prescription of glasses when Myopic
anisometropia is ( > or = 2.50 D) in infants to reduce
possible chance of amblyopia.
High amount of myopia at birth is likely to produce
esotropia because far point is very close to eye .
36. Toddlers (1-3 yrs.)
No prescription is given for low myopia in toddlers but given for
moderate and high myopia.
Prescription indicated as per guidelines of AAO.
Isometropic
myopia
< or -4 D
≥ -4 D
No need to prescribe (constant monitoring)
Needs prescription (Reduce by 1 to2 D)
(for no deviation
37. AAO suggests Anisometropic myopia > or = 2.50 D needs prescription
in toddlers to prevent probable chance of amblyopia & deviation .
For muscle imbalances
For eso deviation : minimum minus for clear vision
For exo deviation : maximum minus for clear vision
38. Preschool age ( 3-6 yrs )
Isometropic
myopia
< -3 D
> or = -3
D
No need to prescribe (constant
monitoring)
Needs prescription (Reduce by 1-2 D)
(for no deviation)
39. School Age ( above 6yrs.)
Need proper vision for both near & distance at school
age so proper Rx for both near & distance is needed.
Although emmetropization almost completed at 6 yrs.
of age but still risk of deviation & amblyopia is present
40. Contd
Guidelines
Full prescription must be given to abolish amblyopia ,
deviation & avoid symptoms like squinting eyes.
Over correction must be avoided because overcorrecting
myopia can be detrimental and may cause accommodative
spasm leading to severe asthenopia and esotropia
41. Contd..
Only one circumstance where over minus glasses may be
prescribed is the presence of intermittent divergent
strabismus.
Minus glasses are used to induce accommodation and thus
accommodative convergence to control exotropia.
Slight under correction is done if a/w esophoria child more
than 6 yrs.
In very high myopia (> or = 10 D ) full correction can be
barely tolerated so under correction is recommended.
*American Optometric Association. American Optometric Association : Care of the patient with
Myopia
43. Infants (0-1 yrs.)
Isometropic
astigmatism
< 3.00D
> or =
3D
No need to prescribe (constant
monitoring)
Needs prescription i.e 3/4th can be
given (*we usually prefer to monitor
in consecutive follow up)
Anisometropi
c
astigmatism
< 2.50D
> or =
2.50D
No need to prescribe (constant
monitoring)
Needs prescription ( AAO).
Prescribing only after monitoring and
without hampering emmetropization
44. Toddlers (1-3)yrs. & preschooler(3-6)yrs
Isometropic
astigmatism
<2.50D
≥2.5D
No need to prescribe (constant
monitoring)
Needs prescription i.e 3/4th can be
given.
Anisometropic
astigmatism
<2.00D
≥2.0D
No need to prescribe (constant
monitoring)
Needs prescription ( AAO).
Prescribing full if amblyopia is +ve
Partial (3/4th) if amblyopia is -ve
45. Schooler age (above 6) yrs
Isometropic
astigmatism
<0.7D
≥0.7D
No need to prescribe (constant
monitoring)
Needs full prescription(even if
asymptomatic)
Anisometropic
Astigmatism
(*above 4yrs)
<1.5D
≥1.5D
No need to prescribe (constant
monitoring & F/U)
Needs full prescription ( AAO) if
amblyopia (+ve) & if no amblyopia is
seen initial partial can be given later
shifting to full Rx
46. Oblique astigmatism as antagonist in
normal visual development
Mayer and colleagues explained that oblique astigmatism of
(> or =1.00 D) is rare after 12 months
Oblique astigmatism at any age has greater chance of
developing amblyopia than regular astigmatism.
Oblique astigmatism of 1.00 D and greater must be corrected
from 1 year onwards.
Approximately ¾ correction up to the age of 2 yrs.& then
correct the full amount after then.
47. Prescribing in strabismus
Prescribing for Exotropia
I) Hyperopia with exotropia
Plus power correcting ametropia typically increases size of
deviation at near and also at far.
The most frequently prescribed correction for distance
exodeviations < 15pd and for the non-presbyopes and
presbyopes is the least plus to achieve best VA.
In high hyperopia or high AC/A ratio, correction results in
larger angle deviation significantly hence treatment option
other than correcting lens is considered.
48. II) Moderately large exodeviations with normal
accommodative skills
Responds well to minus over-correction. Hence under
correction of hyperopia and overcorrection of myopia is
considered. Minus over-correction helps in stimulating
accommodation and if proper accommodative response
is made then exotropia is controlled.
Minus over-correction of the lens should be considered
with good accepted visual acuity for distance (upto -
2.00Dsph)
49. III) Exotropia with Accommodation Insufficiency
Minus over-correction is contra-indicated and a plus add may
be needed to eliminate severe symptoms occurring at near.
Later on, Active Vision Therapy should be considered and
near add is removed.
50. IV) If plus addition changes the exodeviation frequency from
intermittent to constant (more often at near)
Bifocal should be avoided.
Active Vision Therapy should be initiated to improve
accommodative and motor skills.
51. Prescribing for Esotropia
I) Fully accommodative esotropia
Full cyclo prescription in case of hyperopic refractive error
(less than +3.00Dsph and <+1.00 cyl)
If the error Treatment for patients with spectacle correction
patients with a spectacle correction of >+3.00D and +1.00 cyl,
prescribe some additional hyperopic correction particularly
for close work, depending on near visual acuity
52. II) Refractive accommodative esotropia
From birth to 6 months: If hyperopia is greater
than +2.00D, Prescribe the glasses. The
prescription should include full retinoscope
findings plus an additional +1.50D. The additional
plus will provide clear vision up to 66 cm which is
the usual limit of the young infant’s world.
From 6 months to 6 years: Prescribe
Hypermetropia of more than +1.50D full
retinoscope finding. No any added lens required
53. From 6 months to 6 years: Prescribe Hypermetropia of
more than +1.50D full retinoscope finding. No any
added lens required.
Above 6 years of age : Optional prescription should
include the minimum power lens that should provide
both binocular single vision with esophoria and
maximum visual acuity.
54. III) Non-Refractive Accommodative esotropia
Can occur in emmetropia, hypermetropia or even myopes.
A bifocal add of about +3.0D over the full cycloplegic
refraction is useful for the treatment.
Below 6 months: Esotropia (intermittent or constant)
should be prescribed the full retinoscope findings plus an
additional of +1.50D as a single vision glass. Bifocals are not
required below 6 months because VA is limited to 66cm.
Above 6 months of age: A focal add of +3.0D should be
given along with full retinoscope findings
55. IV) Hypo accommodative esotropia
NPA is definitely remote so, near add of plus lenses are
required to compensate for the weak accommodation.
Full cycloplegic correction is prescribed for the distance
segment.
56. v)Partially accommodative esotropia
Full hyperopic correction should be prescribed.
High AC/A ratio can be treated by the help of bifocals.
VI) Infantile accommodative esotropia
Occurs at 3 to 4 months of age usually have hyperopia
greater than 2D
Full hypermetropic correction after cycloplegic refraction.
57. Prescribing in the case of NSBV
disorders
1.Convergence insufficiency
For error up to -0.50D= do not prescribe lens but vision therapy
should be done (Accommodation therapy followed by Fusional
Therapy)
If myopia persists even after therapy, prescribe for that error
For Minus prescriptions greater than 0.50Dsph, make optimum
prescription
Low amount of plus help for patient with consistent near work,
Plus will help in overcoming greater accommodative effort for
near
For greater plus error=partial prescription
58. 2.Basic Exophoria
Low myopes, don’t prescribe vision therapy helpful
Myopes greater than -0.50Dsph, make optimum correction
With low and moderate hyperopia to about +1.50D, wait
until patient progresses in vision therapy
If hyperopia is greater than +1.50D, partial correction should
be done
59. 3. Divergence Insufficiency
Full correction of hyperopia, astigmatism and
anisometropia
Minimum myopic prescription with acceptable vision
Prism must be incorporated in the glasses along with
distance correction
60. 4. Convergence Excess
Full cycloplegic correction if hyperopia is present
For myopic eyes, minimum minus that gives best corrected
VA
Added lens that eliminates patient’s symptoms can be given
For moderate to high esophoria at distance, BO prism
maybe useful
61. 5. Basic esophoria
Least minus with acceptable vision
Full Prescription of plus refractive error
6. Divergence Excess
Myopia and Isometropia should be fully corrected.
Low hyperopia: Don’t prescribe
Moderate to high Hyperopia: Only partial correction
63. Precscription in Aphakic and
Pseudophakic patients
Overcorrect by +2 to +3 DS in first few months for near
At about 1 year of life, overcorrection reduced to +1 to
+1.50 DS
After 1 year and preschool - Bifocal Rx can be given.
*Bobier WR. Evidence-based spectacle prescribing for infants and children.J Modern Optics
2007;54:1367-1377
64. Summary
The human eye undergoes dramatic anatomical and
physiological
Development through out infancy and early childhood
Inappropriate refractive correction will hamper child’s
optical & neural development as a result of which child
will suffer life long.
65. Contd..
Clinical experience of a clinician & his personal decision
also plays
major role in power prescription.
Hence making pediatric refraction & spectacle
prescription a major
part of routine pediatric examination.
American academy of ophthalmology
In 2010 it was estimated that 123 million people had significant refractive error due to uncorrected refractive error.(Brien Hlden Vision intitute
Cornea generally reaches its adult dioptric power around 4 yrs of age.
Lens: from 10 yrs onward the anterior curvature steepens. From 3-15 yrs lens Thi declines from 20.8 to 20.00 D. From 10 yrs onward lens thickness increases.
AXL: Birth 14-17mm….at 3 yrs 5mm increases 23mm……after 1mm bet 3 and 13 yrs.
AC depthupto approx. 13 yrs of age the ac-depth appears toi ncrease…20 to70 yra it decreases from 4mm to 3.5mm(0.1 mm=0.13D )
Hirsch and weymoth(1947)
Borish
American academy of ophthalmology
Canadian Journal Of Optometry <5yrs old
CET article
Journal of pediatric ophthalmology and strabismus
We begin with refraction
Now
So, cycloplegic refraction must be carried out in every patient with or without strabismus
Investigative Ophthalmology and Visual Science 18-19D
Carmen Barnhardt, Taming the Beast: Examining and Managing Young Children. COPE#25467, Southern California College of Optometry
American Association for Pediatric Ophthalmology and strabismus guidelines for prescription of glasses for children
AOA- American Optometric Association
Now I will be talking about guidelines to be followed before prescribing in each refractive errors…….
CET article
During prescription in anisometropia we must know that childrens can well tolerate spectacles difference upto4D ie well tolerate anisokonia than adults beyond this diplopia will occur.
In pre school the general rule is that while emmetripization is active,the refractive error is undercorrected, unless oyher factors such as the need to treat amblyopia or strabismus or to optimize ocular alignment outweigh the need to leave a stimulus for emmetropization
Note:- If exodeviation is associated plus correction must be reduced
Example : Highly myopic children appear to do well without correction and cannot always tolerate their full prescription. A two-year-old myope needing - 20.00DS may cope better with -10.00DS for a few months before gradually increasing the prescription.
In the school years, myopia should be corrected for function with full correction.
There is no evidence that a partial correction reduces the progression of myopia.
In fact, under correction may lead to further progression of myopia
Flowchart is according to AAO guidelines
Flowchart is according to AAO guidelines
The flow chart is according to AAO guideline.
Partial means ¾ th or reducing1-2 D upto 45 yrs they will wear partial correction later on when period of emmetropization completes shift to full can be done.
(Determination of bifocal add is by hit and trial method. Begin with +1.00D above the distance correction in the trial frame and then increase the power in steps of +0.50D up to a maximum of +3.00D till all the near esotropia is corrected)
Bifocals should be prescribed in one of two ways either as +3.00D add for all patients or the smallest amount of odd which controls the near deviation up to power of 3.50D.
