Prescribing Eyeglasses in Children

DOVS Department
Conference
Alvina Pauline D. Santiago, MD
March 25, 2021

Outline
Pretest
• Problems
• Orthotropic Children
• Esotropic Children
• Exotropic Children
Discussion
Post Test
Summary

Outcomes
Enumerate and
discuss problems
encountered in
pediatric prescribing
01
Discuss
emmetropization
02
Provide rationale for
prescribing glasses in
children
03

Pretest
Case 1,
1, ortho
• SA Cycloplegic refraction: +4.50 OU
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50

Pretest
Case 2,
1, ET
• Full Cycloplegic Refraction: +5.50 OU
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

Pretest
Case 3,
10, ET
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

Pretest
Case 4,
10, XT
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

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

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
D.Gadget Holiday
E. Full cycloplegic refraction
F. Give Bifocals

Pretest
Case 7
1, ET
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

Pretest
Case 8
10, ET
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
E. Prescribe +3.50 OU

Pretest
Case 9
10, XT
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
C. Prescribe +1.50, +2.50
F. Prescribe +3.50 OU

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/question
mark.png
Culture
Emmetropization
© AP Santiago 2018. All rights reserved. #eyeglasses4kids
NO CLEAR RULES!
(+) Family Hx

“Amblyogenic” Refractive Errors
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

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

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; 17:4–8. [PubMed: 23360915]

Christiansen et al, 2017. AAO Preferred Practice Pattern Pediatric Ophthalmology/Strabismus Panel, Pediatric Eye Evaluations PPP -2017

Threshold Amblyogenic Refractive Error,
Preschool (3-4y)
Astigmatism
• >1-1.5D
• >2D
• >1.5D
Hyperopia
• >3.5D
• >4D
• >3.5D
Myopia
• >3D
• >3D
• >2.5D
Anisometropia
• >1.5D
• >2D
• >1.5-2.5D
1. Donahue 2003
2. Donahue 2013
3. AAO 2017 PPP

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

Emmetropization
Fails with refractive
error, strabismus,
and amblyopia
Disrupted by giving
glasses early
• Glasses reduce risk

General rules
Small errors do not need correction:
do not disrupt emmetropization
Large errors do not need to be fully
corrected
No emmetropization after age 3
Hyperopia not fully corrected

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 HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology
1992; 99: 1785-95

Accommodative Spasm
Ciliary muscle
spasm
Ciliary muscle
fatigue

Ciliary Muscle Spasm Significant cylinder &/or
significant myopia
Dry manifest refraction
highest and exceeds
cycloplegic refraction
May need stronger
cycloplegia to determine
true target refraction
Pharmacologic cycloplegia

Amplitude of Accommodation
http://iovs.arvojournals.org/data/Journals/IOVS/93
2949/z7g0060889470008.jpeg
Glasser A, Campbell MC, Presbyopia and the optical changes in the human crystalline lens with
age. Vision Research 1998; 38: 209-29.

Ciliary Muscle
Spasm
How much to prescribe?
http://carabineyecare.com

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

Orthotropia
Would you prescribe?
http://carabineyecare.com

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 HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology
1992; 99: 1785-95

Hyperopia >3.5D
Ø Lowest plus
Ø Best vision
Ø Not always 20/20
Ø Manifest refraction
Ø Cut plus
http://i1303.photobucket.com/albums/ag153/jenmal37/baby-
reading-with-glasses_zps90e33e7d.jpg

Hyperopia ≤3.5D
Ø Monitor
ØLowest plus
Ø Best vision
Ø Not always 20/20
Ø 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
© AP Santiago 2016.
All rights reserved.
Rx in Kids

Myopia
>-2.5D
Ø Cycloplegic refractions
Ø Lowest minus
Ø VA at least 20/40
http://www.tipskey.com/article/concave_lenses_wors
en_myopia/myope.jpg
© AP Santiago 2016.
Rx in Kids

Myopia <-2.5D
Ø Cycloplegic refractions
Ø Lowest minus
Ø VA at least 20/40
Ø Visual needs
e.g. Myopia -1.00D (1 vs 11 yrs)
Ø Symptoms
https://www.goggles4u.co.uk/media/wysiwyg/Articles
/Kids-Eyeglasses-1.jpg
© AP Santiago 2016 .
Rx in Kids

Astigmatism
Ø With-the-rule
up to -1.50D tolerated well
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

Posttest Case 1,
1, ortho
A. Observe
B. Prescribe +2.25
C. Prescribe +3.50
D. Prescribe +4.50

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
D.Gadget Holiday
E. Give full cycloplegic refraction

Posttest Case 6,
40, ortho
A.Remove glasses
B. Give -2.00 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

Esotropia
What would you prescribe?

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

Bifocals:
When to give them ü Fusion at distance
ü Full cycloplegic refraction
ü Repeat full cycloplegic
refraction
ü Maximum tolerated plus
ü Push plus
ü Wary of V-pattern
http://www.aapos.org/client_data/files/2011/_376_bi
focal.jpg

Bifocals:
How to give them
ü Executive, flat top or
D-segment
ü Just enough to control
ET’
ü Minimum adds
ü X(T)’: taper
http://www.aapos.org/client_data/files/2011/_376_bi
focal.jpg

Bifocals: Guidelines
< 6 years
Mid pupil
< 6-8 years
Pupil Edge
> 9 years
Lower limbus

What to do on follow-up:
Accommodative ET
Amblyopia Refraction Fusion at
distance
Alignment
both distance
& near
Remeasure
with glasses
always
Rosenbaum & Santiago, 1999

What to do on follow-up:
Accommodative ET
• 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
Rosenbaum & Santiago, 1999

Goal of Treatment
•Monofixation syndrome
•0-8 PD from orthotropia

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?

Posttest Case 2: 1, ET
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

Pretest Case 3: 10, ET
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

Posttest Case 7: 1, ET
A. Prescribe +1.50, +2.50
D. Prescribe +3.50 OU
OD OS
SA
Cyclo
+1.50 +2.50
Full
Cyclo
+3.50 +3.50

Posttest Case 8:10, ET
A. Prescribe +1.00 OU
B. Prescribe +1.50, +2.50
D. Prescribe +2.50 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

Exotropia
What would you prescribe?

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

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
*Significant hyperopia ~ >+3.50
on cycloplegic refraction

§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)
X(T) and Hyperopia

§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

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

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

Posttest
Case 3,
10, XT
A. Prescribe +2.75
B. Prescribe +4.50
C. Prescribe +5.50

Posttest
Case 9
10, XT
A.No glasses
B.Prescribe +1.00 OU
C.Prescribe +1.50, +2.50
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

Deciding to
prescribe:
Primary Focus?

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

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. Donahue SP, et al. AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS. 2013; 17:4–8.
[PubMed: 23360915]
6. Freedman HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology 1992; 99: 1785-95
7. Glasser A, Campbell MC, Presbyopia and the optical changes in the human crystalline lens with age. Vision Research 1998; 38: 209-29.
8. 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.
9. Caputo AR, Schnitzer RE, Lindquist TD, Sun S. Dilation in neonates: a protocol. Pediatrics 1982; 69: 77-80.
10. Bin Aziz, MA. Cycloplegic agents and cyclorefraction. http://www.slideshare.net/schizophrenicSabbir/cycloplegic-agents-cyclorefraction. Accessed March 15, 2016.
11. Apt L, Gaffney M. Cycloplegic Refraction. http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html. Accessed March 15, 2016.
12. 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
13. Mayer DL et al 2007, Cycloplegic refractions in healthy children age 1-48 mos, Arch Ophthalmol, 119: 1625-1628

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