5. Pretest
Case 1,
1, orthotropic
⢠SA Cycloplegic refraction: +4.50 OU
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50
6. Pretest
Case 2,
1, Esotropic
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
7. Pretest
Case 3,
10, esotropic
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
8. Pretest
Case 4,
10, exotropic
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
9. Pretest
Case 5
10
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-8.00 20/20 -8.00 20/20
SA Cyclo +1.00 +1.00
A.Remove glasses
B. Give -8.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Full cycloplegic refraction
10. Pretest
Case 6
40
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-2.00 20/20 -2.00 20/20
SA Cyclo +1.00 +1.00
A.Remove glasses
B. Give -2.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Full cycloplegic refraction
F. Give Bifocals
11. Pretest
Case 7
1, esotropic
OD OS
SA Cyclo +1.50 +2.50
Full Cyclo +3.50 +3.50
A.Prescribe +1.50, +2.50
B. Prescribe +1.75 OU
C. Prescribe +2.50 OU
D.Prescribe +3.50 OU
12. Pretest
Case 8
10, esotropic
OD OS
VA sc 20/20 20/20
Dry objective +1.50 20/20 +2.50. 20/30
Subjective +1.00. 20/20. +1.00. 20/20
SA Cyclo +2.50 +2.50
Full Cyclo +3.50 +3.50
A.Prescribe +1.00 OU
B. Prescribe +1.50, +2.50
C. Prescribe +1.75 OU
D.Prescribe +2.50 OU
E. Prescribe +3.50 OU
13. Pretest
Case 9
10, exotropic
OD OS
VA sc 20/20 20/20
Dry objective +1.50 20/20 +2.50. 20/30
Subjective +1.00. 20/20 +1.00. 20/20
SA Cyclo +2.50 +2.50
Full Cycl +3.50 +3.50
A.No glasses
B. Prescribe +1.00 OU
C. Prescribe +1.50, +2.50
D.Prescribe +1.75 OU
E. Prescribe +2.50 OU
F. Prescribe +3.50 OU
15. âAmblyogenicâ Refractive Errors
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
Donahue et al, Preschool vision screening: what should we be detecting and how should we report it? Uniform
guidelines for reporting results of preschool vision screening studies. J AAPOS. 2003 Oct;7(5):314-6
16. Preschool Refractive Errors Requiring Glasses
Anisometropia
> 1.5D
Myopia
> 3.0D
Hyperopia
> 3.5D
Astigmatism
> 1.5 @ 90/180
> 1.0 >10deg
Donahue et al, Preschool vision screening: what should we be detecting and how should we report it? Uniform guidelines for
reporting results of preschool vision screening studies. J AAPOS. 2003 Oct;7(5):314-6
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
17. AAPOS Amblyopia Risk Detected by Automated Preschool Screening
Refractive Risk Factor Targets
Age, Months Astigmatism Hyperopia Anisometropia Myopia
12-30 > 2.0 D > 4.5 D >2.5 D >- 3.5 D
31-48 > 2.0 D > 4.0 D > 2.0 D > -3.0 D
>48 >1.5 D > 3.5 D > 1.5 D > -1.5 D
Non Refractive Risk Factors
All ages manifest strabismus > 8PD in primary position
Media opacity > 1 mm
Donahue SP, et al. AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-year,
evidence-based update. J AAPOS. 2013; 17:4â8. [PubMed: 23360915]
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
18. Christiansen et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017
20. Emmetropization
Process by which eye moves
from state of ametropia
towards emmetropia
Mayer DL et al 2007, Cycloplegic refractions in healthy children age 1-48
mos, Arch Ophthalmol, 119: 1625-1628
22. General rules
Small errors do not need correction: do
not disrupt emmetropization
Myopia is less amblyogenic. Higher
threshold before starting glasses
Large hyperopic errors do not need to be
fully corrected if ortho
No emmetropization after age 3
Hyperopia fully corrected in the
esotropic less than 5 yo
23. 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
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
Freedman HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology
1992; 99: 1785-95
24. Christiansen et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017
29. Ciliary Muscle Spasm
Give lowest minus, lowest cylinder
Give
Resist urge to give in to subjective
refraction
Resist
Compromise needed for school age:
⢠at least 20/40 (6/12 or 0.5) OU
Compromise
31. 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
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
Freedman HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology
1992; 99: 1785-95
32. Christiansen et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017
33. Hyperopia >3.5D
Ă Lowest plus
Ă Best vision
Ă Not always 20/20
Ă Manifest refraction
Ă Cut plus
http://i1303.photobucket.com/albums/ag153/jenmal37/baby-
reading-with-glasses_zps90e33e7d.jpg
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
34. Hyperopia â¤3.5D
Ă Monitor
ĂLowest plus
Ă Best vision
Ă Not always 20/20
Ă Manifest refraction
Ă Cut plus
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
Š AP Santiago 2016.
All rights reserved.
Rx in Kids
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
35. Myopia
>-2.5D
Ă Cycloplegic refractions
Ă Manifest refraction
Ă Lowest minus
Ă VA at least 20/40
http://www.tipskey.com/article/concave_lenses_wors
en_myopia/myope.jpg
Š AP Santiago 2016.
All rights reserved.
Rx in Kids
36. Myopia <-2.5D
Ă Cycloplegic refractions
Ă Manifest refraction
Ă Lowest minus
Ă VA at least 20/40
Ă Visual needs
e.g. Myopia -1.00D (1 vs 11 yrs)
Ă Symptoms
https://www.goggles4u.co.uk/media/wysiwyg/Articles
/Kids-Eyeglasses-1.jpg
Š AP Santiago 2016 .
All rights reserved.
Rx in Kids
37. Astigmatism
Ă With-the-rule
up to -1.50D tolerated well
Ă Against-the-rule
Less tolerated without Rx
Ă Oblique
Lower threshold: > 1.0D on-axis
Ă Cycloplegic refraction
Ă Lowest cylinder
http://townsend.offixonline.com/wp-content/uploads/astigmatism_sim1.jpg
38. Posttest Case 1,
1, ortho
⢠SA Cycloplegic refraction: +4.50 OU
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50
39. Christiansen et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017
40. Posttest Case 1,
1, ortho
⢠SA Cycloplegic refraction: +4.50 OU
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50
41. Hyperopia >3.5D
Ă Lowest plus
Ă Best vision
Ă Not always 20/20
Ă Manifest refraction
Ă Cut plus
http://i1303.photobucket.com/albums/ag153/jenmal37/baby-
reading-with-glasses_zps90e33e7d.jpg
Š AP Santiago 2018. All rights reserved. #eyeglasses4kids
42. Posttest Case 1,
1, ortho
⢠SA Cycloplegic refraction: +4.50 OU
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50
43. Posttest Case 5,
10, ortho
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-8.00 20/20 -8.00 20/20
SA Cyclo +1.00 +1.00
A.Remove glasses
B. Give -8.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Give full cycloplegic refraction
45. Posttest Case 5,
10, ortho
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-8.00 20/20 -8.00 20/20
SA Cyclo +1.00 +1.00
A.Remove glasses
B. Give -8.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Give full cycloplegic refraction
46. Posttest Case 6,
40, ortho
A.Remove glasses
B. Give -2.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Give full cycloplegic refraction
F. Give bifocals
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-2.00 20/20 -2.00 20/20
SA Cyclo +1.00 +1.00
47. Posttest Case 6,
40, ortho
A.Remove glasses
B. Give -2.00 OU
C. Tropicamide 1-3x OU
D.Gadget Holiday
E. Give full cycloplegic refraction
F. Give bifocals
OD OS
Vision sc 20/40 20/40
Objective
(Dry)
+0.50 +0.50
Manifest/Sub
jective (Dry)
-2.00 20/20 -2.00 20/20
SA Cyclo +1.00 +1.00
49. ESOTROPIA
§ Full cycloplegic refraction
§ Maximum tolerated plus (not to exceed
full cycloplegic refraction)
§ Push plus
§ Lowest minus correction
§ Full cylinder from cycloplegic refraction
http://www.pedseye.com/img/eso_ex_01.jpg
50. Bifocals:
When to give them Ăź Fusion at distance
Ăź Full cycloplegic refraction
Ăź Repeat full cycloplegic
refraction
Ăź Maximum tolerated plus
Ăź Push plus
Ăź Wary of V-pattern
http://www.aapos.org/client_data/files/2011/_376_bi
focal.jpg
51. Bifocals:
How to give them
Ăź Executive, flat top or
D-segment
Ăź Just enough to control
ETâ
Ăź Minimum adds
Ăź X(T)â: taper
http://www.aapos.org/client_data/files/2011/_376_bi
focal.jpg
53. What to do on follow-up:
Accommodative ET
Amblyopia Refraction Fusion at
distance
Alignment
both distance
& near
Remeasure
with glasses
always
Rosenbaum & Santiago, 1999
54. What to do on follow-up:
Accommodative ET
⢠If XT at distance
Reduce plus correction
⢠If XT at distance, ETâ
reduce distance plus
minimum Bifocals that will control
near
⢠If ortho at distance but XT at near
Reduce adds
Rosenbaum & Santiago, 1999
56. 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?
57. Posttest Case 2: 1, ET
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
58. Posttest Case 2: 1, ET
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
59. Pretest Case 3: 10, ET
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
60. Pretest Case 3: 10, ET
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
61. Posttest Case 7: 1, ET
A. Prescribe +1.50, +2.50
B. Prescribe +1.75 OU
C. Prescribe +2.50 OU
D. Prescribe +3.50 OU
OD OS
SA
Cyclo
+1.50 +2.50
Full
Cyclo
+3.50 +3.50
62. Posttest Case 7: 1, ET
A. Prescribe +1.50, +2.50
B. Prescribe +1.75 OU
C. Prescribe +2.50 OU
D. Prescribe +3.50 OU
OD OS
SA
Cyclo
+1.50 +2.50
Full
Cyclo
+3.50 +3.50
63. Posttest Case 8:10, ET
A. Prescribe +1.00 OU
B. Prescribe +1.50, +2.50
C. Prescribe +1.75 OU
D. Prescribe +2.50 OU
E. Prescribe +3.50 OU
OD OS
VA sc 20/20 20/20
Dry
objective
+1.50 20/20 +2.50.
20/30
Subjective +1.00. 20/20. +1.00.
20/20
SA Cyclo +2.50 +2.50
Full Cycl +3.50 +3.50
64. Posttest Case 8:10, ET
A. Prescribe +1.00 OU
B. Prescribe +1.50, +2.50
C. Prescribe +1.75 OU
D. Prescribe +2.50 OU
E. Prescribe +3.50 OU
OD OS
VA sc 20/20 20/20
Dry
objective
+1.50 20/20 +2.50.
20/30
Subjective +1.00. 20/20. +1.00.
20/20
SA Cyclo +2.50 +2.50
Full Cycl +3.50 +3.50
66. X(T) and Refractive Error
⢠Any sensory destabilizing
factor affects control,
including small EOR
⢠Improvement in vision
usually helps control
deviation
67. X(T) and 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
⢠Risk for myopia progression?
*Significant hyperopia ~ >+3.50
on cycloplegic refraction
68. §If not for surgery
§<5y: Cut plus by 1-1.5D
§May start w half the plus
§Minimum plus to control
X(T) and give clear vision
§Older children, consider
manifest refraction
§Excess plus can worsen X(T)
*Significant hyperopia ~ >+3.50
on cycloplegic refraction
X(T) and Hyperopia
69. §For surgery
§Give the full cycloplegic
refraction or maximum
tolerated plus prescription to
uncover all latent
exodeviation.
§Target angle for surgery
X(T) and Hyperopia
*Significant hyperopia ~ >+3.50
on cycloplegic refraction
70. Myopia
§ 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
X(T) and Refractive Error
71. 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?
http://shawlens.com/wp-content/uploads/2012/03/portfolio-default.jpg
72. Posttest
Case 3,
10, XT
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
73. Posttest
Case 3,
10, XT
⢠SA Cycloplegic refraction: +4.50 OU
⢠Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50
74. Posttest
Case 9
10, XT
A.No glasses
B.Prescribe +1.00 OU
C.Prescribe +1.50, +2.50
D.Prescribe +1.75 OU
E.Prescribe +2.50 OU
F.Prescribe +3.50 OU
OD OS
VA sc 20/20 20/20
Dry objective +1.50 20/20 +2.50. 20/30
Subjective +1.00. 20/20 +1.00. 20/20
SA Cyclo +2.50 +2.50
Full Cycl +3.50 +3.50
75. Posttest
Case 9
10, XT
A.No glasses
B.Prescribe +1.00 OU
C.Prescribe +1.50, +2.50
D.Prescribe +1.75 OU
E.Prescribe +2.50 OU
F.Prescribe +3.50 OU
OD OS
VA sc 20/20 20/20
Dry objective +1.50 20/20 +2.50. 20/30
Subjective +1.00. 20/20 +1.00. 20/20
SA Cyclo +2.50 +2.50
Full Cycl +3.50 +3.50
78. References
1. Santiago AP, Lee JA, Valbuena MN. Prescribing eyeglasses in children. College of Medicine, University of the Philippines Manila, Philippine General Hospital, Department of
Ophthalmology & Visual Sciences, 2021.
2. 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.
3. 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.
4. 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.
5. 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.
6. Donahue SP, et al. AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013; 17:4â8.
[PubMed: 23360915]
7. Freedman HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology 1992; 99: 1785-95
8. Glasser A, Campbell MC, Presbyopia and the optical changes in the human crystalline lens with age. Vision Research 1998; 38: 209-29.
9. Caputo AR, Lingua RW. The problem of cycloplegia in the pediatric age group. A combination formula for refraction. J Pedaitr Ophthalmol Strabismus 1980; 17: 119-128.
10. Caputo AR, Schnitzer RE, Lindquist TD, Sun S. Dilation in neonates: a protocol. Pediatrics 1982; 69: 77-80.
11. Bin Aziz, MA. Cycloplegic agents and cyclorefraction. http://www.slideshare.net/schizophrenicSabbir/cycloplegic-agents-cyclorefraction. Accessed March 15, 2016.
12. Apt L, Gaffney M. Cycloplegic Refraction. http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html. Accessed March 15, 2016.
13. Wallace et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017 https://www.aao.org/preferred-practice-
pattern/pediatric-eye-evaluations-ppp-2017. Accessed March 4, 2021
14. Mayer DL et al 2007, Cycloplegic refractions in healthy children age 1-48 mos, Arch Ophthalmol, 119: 1625-1628