2017 PGH Prescribing Rx in kids

© AP Santiago 2017.
All rights reserved.
#RxinKids
YES
NO
Amblyopia
Attitude
Age
Finances
Vision
Strabismus
Symptoms
http://i.huffpost.com/gen/1760949/images/o-BALANCE-
SCALE-facebook.jpg
https://maneshnagar.files.wordpress.com/2014/07/ques
tionmark.png
Culture
Emmetropization
Visual Needs

#RxinKids
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

“Amblyogenic” Refractive Errors
http://www.jaapos.org/article/S1091-8531(03)00182-4/pdf
#RxinKids

“Amblyogenic” Refractive Errors
http://www.jaapos.org/article/S1091-8531(03)00182-4/pdf
All rights reserved. #RxinKids

Preschool Refractive Errors
Requiring Glasses
Anisometropia
> 1.5D
Myopia
> 3.0D
Hyperopia
> 3.5D
Astigmatism
> 1.5 @ 90/180
> 1.0 >10deg
#RxinKids

Amblyogenic: Age Dependent
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
#RxinKids

Amplitude of Accommodation
http://iovs.arvojournals.org/data/Journals/IOVS
/932949/z7g0060889470008.jpeg
#RxinKids
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

Cycloplegic Refraction
http://www.cybersight.org/data/1/rec_imgs/11176_toddler%20refraction_sm.JPG
#RxinKids

Cycloplegic Refraction
§ Atropine 1%
TID x 3-4 days, refract on day 4
§ Cyclopentolate 1%
2x q 5min, refract after 30-40 min
§ Tropicamide (0.5%)-
phenylephrine (2.5%)
q 3-5min x 2-3x, refract after 30 min
§ Tropicamide 0.5%
q 15min x 3, refract after 30 min
https://images.yaoota.com
#RxinKids

Apt & Gaffney. Cycloplegic Refraction.
http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html
Note: No tropicamide in this table.

Errors of
Inadequate Cycloplegia
§ Less hyperopia
§ More myopia
§ More with-the-rule
astigmatism
§ Same errors as
computerized
autorefraction
https://howardjbennett.files.wordpress.com/201
2/05/eyedrops.jpeg
#RxinKids

Child vs. Adult
http://www.wallpaperup.com/uploads/wallpapers/2014/08/04/
415502/big_thumb_0d0f0898e1deb1ffce7ad53db8ba4e99.jpg
http://guideimg.alibaba.com/images/shop/87/11/13
/8/nerd-bookworm-glasses-adult-halloween-
accessory_382378.jpg
#RxinKids

Child vs. Adult
üOn-axis
üFull plus tolerated
üLess important
üTolerated well
üAmblyopia, strabismus,
loss of binocularity
ü@ 90 / 180
üMaximum tolerated plus
üImportant
üPoor tolerance
üAsthenopia, Red eye,
Dry Eye
• Cylinder
• Hyperopia
Less than 5
years
• Manifest Refraction
• Anisometropia
& Aneisokonia
• Effect of Wrong
Prescription
#RxinKids

Orthotropia
Would you prescribe?
People
(Happiness)
http://carabineyecare.com/wp-
content/uploads/2016/01/Baby-
Wearing-Glasses-HD-Wallpaper.jpeg
#RxinKids

Preschool Refractive Errors
Requiring Glasses 2003
Anisometropia
> 1.5D
Myopia
> 3.0D
Hyperopia
> 3.5D
Astigmatism
> 1.5 @ 90/180
> 1.0 >10deg
#RxinKids

Amblyogenic refractive errors
EOR Freedom &
Preston 1992
Cibis-
Tongue &
Grin
Atkinson et
al
Hyperopia > +3.50D >+4.00D >+3.50D
Myopia >-1.00D >-2.00D >-2.00D
Aniso-
metropia
>1.50D >1.00D >1.00D
Cylinder >1.50D >1.00D >1.50D
#RxinKids

Miller JM, Harvey EM. Spectacle prescribing recommendations of AAPOS members. J Pediatr Ophthalmol Strabismus 1998;35:51-2.
1998
Replaced by
2003
Guidelines
#RxinKids

http://assets-
s3.usmagazine.com/uploads/assets/articles/82136
-new-gerber-baby-is-7-month-old-girl-named-
grace/1421876680_grace-gerber-baby-zoom.jpg
Hyperopia ≤3.5D
Ø Monitor
ØLowest plus
Ø Best vision
Ø Not always 20/20
Ø Manifest refraction
Ø Cut plus
All rights reserved. Rx in Kids

Orthotropia & Hyperopia </= +2.50D
• Asymptomatic OBSERVE only for ET and
amblyopia
• If cooperative, get dry manifest and subjective
refraction
• 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
#RxinKids

Orthotropia & Hyperopia > +2.50D to +3.50D
§ 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
refraction
§ If cooperative with symptoms, give lowest plus
with good VA
#RxinKids

Hyperopia >3.5D
o 2017.
erved. #RxinKids
Ø Plus that gives best VA
ØLowest plus
Ø Best vision
Ø Not always 20/20
Ø Cut plus
Ø1-1.5 in younger child
ØMore in older, manifest
refraction
ØHalf plus http://i1303.photobucket.com/albums/ag153/jenmal37/baby-
reading-with-glasses_zps90e33e7d.jpg
§ Amblyogenic
§ Asthenopic symptoms
common
§ Risk for developing
refractive
accommodative ET

Myopia
≤-3.0D
Ø Cycloplegic refraction
Ø Lowest minus
Ø VA at least 20/40
ØReevaluate subjective
refraction and visual needs
Ø Visual needs
e.g. Myopia -1.00D (1 vs 11 yrs)
Ø Symptoms
https://www.goggles4u.co.uk/media/wysiwyg/Arti
cles/Kids-Eyeglasses-1.jpg
© AP Santiago 2016 .
Rx in Kids

Orthotropia & MYOPIA
Moderate myopia: -1.0 to -3.0D
0Potential for amblyopia
0depends on visual tasks
0Up to age 1, OBSERVE if -1.0 to -1.5D
0Above age 6 mos, if >-2.0D, give cycloplegic
refraction
0School age, give cycloplegic Rx
0Depends on symptoms: AHP, squinting, spasm of
accommodation, etc.
0Give cycloplegic refraction

Orthotropia & MYOPIA
Low myopia (<-1.0D):
0depends on visual tasks
0Preschool child, even up to grade 3, OBSERVE
0Intermediate (Gr 4 or higher), give cycloplegic
Rx
0Rare for a child to complain about blurred vision
0Depends on symptoms:
0Anomalous head posture
0Cannot see board
0Squinting (pinhole behavior)
0Spasm of accommodation, etc.

Myopia
>-3.0D
http://www.tipskey.com/article/concave_lenses_w
orsen_myopia/myope.jpg
#Rxinkids
ØAmblyogenic
ØDouble check with stronger
cycloplegia, usually atropine
ØMore than age 6 mos: give
cycloplegic refraction
ØManifest refraction
ØLowest minus
ØVA at least 20/40
ØCheck refraction q 3
months
ØRegardless of symptoms
(with or without symptoms)

Astigmatism
Ø With-the-rule
Up to -1.50D tolerated well
without glasses
Ø Against-the-rule
Less tolerated without Rx
Ø Oblique
Lower threshold: > 1.0D
On-axis
Ø Cycloplegic refraction
Ø Lowest cylinder
http://townsend.offixonline.com/wp-
content/uploads/astigmatism_sim1.jpg
#RxinKids

Orthotropia & Astigmatism
0Astigmatism
◦ 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

Orthotropia & ASTIGMATISM
0 Astigmatism
0 Oblique axis (exceeds 10-deg from 90 or 180)
0Threshold lower: >1.0D, give Rx early
0Consider potential for amblyopia and associated
symptoms
0Give full cylinder from cycloplegic refraction on-axis
0If cooperative and reliable with manifest, check if
90/180 degrees preferred

Esotropia
People
(Happiness)
#RxinKids

ESOTROPIA
§ Full cycloplegic refraction
§ Maximum tolerated plus
§ Push plus
§ Lowest minus correction
§ Full cylinder from cycloplegic
refraction
http://www.pedseye.com/img/eso_ex_01.jpg
© AP Santiago. 2017
All rights reserved. #RxinKids

Bifocals:
When to give them
http://www.aapos.org/client_data/files/2011/_376
_bifocal.jpg
ü High AC/A
üFusion at distance: </= 10PD
ü Full cycloplegic refraction
ü Repeat full cycloplegic
refraction
ü Maximum tolerated plus
ü Push plus
ü Wary of V-pattern
#RxinKids

Bifocals:
How to give them
Objective: minimum plus to
control ET’
http://www.aapos.org/client_data/files/2011/_376
_bifocal.jpg
Rx in Kids
ü Executive, flat top or D-segment
ü Just enough to control ET’
ü Minimum adds
ü X(T)’: taper
üProgressive lenses?

• Amblyopia & Management
• Refraction
• Fusion at distance
• Alignment both distance & near
• Remeasure with glasses always
Follow-up: Accommodative ET
Rosenbaum & Santiago, 1999
#RxinKids

• If XT at distance
Reduce plus correction
• If XT at distance, ET’
reduce distance plus
minimum Bifocals that will control near
If ortho at distance but XT at near
Reduce adds
#RxinKids

• 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
#RxinKids

Goal of
Treatment
§ Monofixation syndrome
§ 0-8 PD from orthotropia
#RxinKids

0 Single vision lens
0 Cycloplegic refraction
0 Maximum tolerated plus
0 Push plus
Accommodative ET:
Nonsurgical Management
#RxinKids

Accommodative ET: Pearls
• Always check/repeat refraction for latent hyperopia
• Refraction not always 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
#RxinKids

Exotropia
People
(Happiness)
https://s-media-cache-
ak0.pinimg.com/originals/f3/6e/17/f36e173ec1a27ae18193ba1c
7b404ba7.jpg
#RxinKids

X(T) and
Refractive
Error
• Any sensory destabilizing
factor affects control,
including small EOR
• Improvement in VA
usually helps control
deviation
Rx in Kids

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
• Improvement in VA helps
control the deviation
Rx in Kids

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
§ Cut more plus 2-2.5 D
§ Start with half plus
§ Excess plus can worsen X(T)
Rx in Kids
*Significant hyperopia ~ >+3.50 on cycloplegic refraction

X(T) and
Refractive
Error § Hyperope*: For surgery
§ Give the full cycloplegic
refraction or maximum
tolerated plus prescription to
uncover all latent
exodeviation.
§ Target angle for surgery
Rx in Kids
*Significant hyperopia ~ >+3.50 on cycloplegic refraction

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
Rx in Kids

Anisometropia
How would you prescribe?
Rx in Kids
People
(Happiness)

Anisometropia
& Refractive
Error
(Orthotropia
& Exotropia)
§ Manifest refraction important
§ Cut plus by 1-1.5D
§ If >5 y, may need to manage
like a little adult, decrease
anisometropia in glasses
§ Compromise vision
§ Consider contact lenses to
optimize vision
§ Prescribe glasses with
patching
§ Role of laser refractive
surgery?
http://shawlens.com/wp-
content/uploads/2012/03/portfolio-default.jpg
#RxinKids

Anisometropia
& Refractive
Error
(Esotropia)
• 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?
http://shawlens.com/wp-
content/uploads/2012/03/portfolio-default.jpg
#RxinKids

Ciliary Muscle
Spasm
How much to prescribe?
#RxinKids
People
(Happiness)

Ciliary Muscle
Spasm
— Significant cylinder
&/or significant myopia
— Dry manifest refraction
highest and exceeds
— May need stronger
cycloplegia to
determine true target
refraction
— Pharmacologic
cycloplegia
© AP Santiago 2017
#RxinKids

Ciliary Muscle
Spasm
§ Give lowest minus, lowest
cylinder
§ Resist urge to give in to
subjective refraction
§ Compromise needed for school
age:
§ at least 20/40 (6/12 or 0.5)
OU
#RxinKids

Special Problem: Pediatric Aphakia
§ Monocular
§ Soft “scleral” contact lens
§ Consider other eye: avoid anisometropia
§ Need adds eventually
§ Pseudoaccommodation
§ Binocular
§ Contact lenses and glasses
§ Reading adds

Pediatric Aphakia
0 Repeat refraction q 1-3 mos
0 Bifocals at about age 1 year or later (e.g. school age)
affects ambulation in early stages of motor
development
0 Executive / flat top / D-segment
0 Aspheric / high index lenses
0 Not readily available if > +18.0D

Decision to Prescribe
Which will be your
primary focus?
alignment
age
amblyopia
vision
emmetropization
Rx in Kids

http://www.markshep.com/peace/books/Narayan_art.jpg
#RxinKids

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/v
1c041.html. Accessed March 15, 2016.
#RxinKids

2017 PGH Prescribing Rx in kids

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