crash course: prescribing eyeglasses in children
TRANSCRIPT
May 21-22, 2016
First Basic Course in Clinical Diagnosis & Instrumentation Sentro Oftalmologico Jose Rizal
AMBLYOGENIC REFRACTIVE ERRORS (PRESCHOOL)
Anisometropia (sph or cyl) > 1.5D Hyperopia >3.5 in any meridian Myopia >3.0 in any meridian Astigmatism >1.5D at 90/180 deg Astigmatism >1.0D >10 deg any meridian
AMBLYOGENIC REFRACTIVE ERRORS 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
Reduced 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
PRESBYOPIA & ACCOMMODATION
http://iovs.arvojournals.org/data/Journals/IOVS/932949/z7g0060889470008.jpeg
SA cycloplegia § Tropic 0.5% (1%) q 15
min x 3, after 30 min § Tropic 0.5% -
phenylephrine (San-myd) q3-5 min x 2-3 doses, refract after 30 min
§ AAO: Tropic 0.5% q 5 min x 2, after 30 min
• Recovery in 2-6h • Considered inadequate
for most children’s cycloplegia
CYCLOPLEGIA
Bin Aziz, Cycloplegic Agents and Refraction. http://www.slideshare.net/
schizophrenicSabbir/cycloplegic-agents-cyclorefraction
CYCLOPLEGIA Intermediate cycloplegia § Cyclopentolate 1% (2%) q 5 min x 2, after 40 min § Tropic-phe-cyclopent (0.5/2.5/0.5%: Caputo drops) q
5min x 2, after 30 min § AAO: C1% q 5min x 2, after 30 min Recovery in 24-48h
CYCLOPLEGIA Long acting cycloplegia § Atropine 1% gold standard § Forewarn patients about atropine flush & skin
warmth, and product insert problems. § Dilute if necessary § TID x 3 days and morning of visit § BID x 2 days may be adequate (Rosenbaum, personal
communication) § Caution in infants, albinos, trisomy 21 (Down)
ERRORS OF INADEQUATE CYCLOPLEGIA • Less hyperopia • More myopia • Higher with-the-rule astigmatism
• Same errors as computer autorefraction!
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
FACTORS AFFECTING DECISION TO PRESCRIBE � Age and tolerable glasses � Visual Needs � Cycloplegic refraction � Alignment � Development of amblyopia � Developmental milestones � Associated abnormalities or delays � Parents – attitude, finances
CHILDREN < 5 yrs � Give refraction on axis as
refracted � Full hyperopic cycloplegic
refraction tolerated well if less than age 5 y
� Subjective manifest refraction less important
ADULTS � Give cyl closer to 90 or 180
degrees � Maximum tolerated plus even
in refractive accommodative esotropia
� Subjective manifest refraction important.
SOME COMMON DIFFERENCES BETWEEN ADULTS AND CHILDREN
CHILDREN < 5 yrs • Tolerates anisometropia;
give full regardless of age, strabismus, amblyopia
• < 12y: non wearing or wearing wrong prescription will affect eye health
§ Amblyopia, deviation, loss binocularity
ADULTS • Tolerates anisometropia
poorly • Non wearing or wearing
wrong prescription have only minor temporary consequences
§ Asthenopia, red eye, dry eye
SOME COMMON DIFFERENCES BETWEEN ADULTS AND CHILDREN
CHILDREN < 5 yrs � Tolerates aneisokonia better
but also considered an impediment to fusion and has amblyopia potential
� Anisometropic Rx, Aneisokonic spectacle Rx has a role especially in patients requiring occlusion
ADULTS � Tolerates aneisokonia poorly � Will not wear Rx that has a large
difference in refraction between the 2 eyes (threshold? Different from patient to patient)
SOME COMMON DIFFERENCES BETWEEN ADULTS AND CHILDREN
AMBLYOGENIC REFRACTIVE ERRORS (PRESCHOOL)
Anisometropia (sph or cyl) > 1.5D Hyperopia >3.5 in any meridian Myopia >3.0 in any meridian Astigmatism >1.5D at 90/180 deg Astigmatism >1.0D >10 deg any meridian
AMBLYOGENIC REFRACTIVE ERRORS 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
HYPEROPIA >3.5D • Prescribe plus that gives best VA • Usually lower than actual cycloplegic refraction • May not reach 20/20 right away • Manifest refraction should be considered
ORTHOTROPIA & HYPEROPIA � High hyperopia >+3.5D Cycloplegic ◦ Amblyogenic ◦ Asthenopic symptoms common ◦ Risk for developing refractive accommodative ET ◦ Cut plus from cycloplegic refraction by +1.0 to +1.5D in
younger child, ◦ May cut plus even higher in the cooperative child if good
manifest refraction can be obtained; ◦ some start by giving half plus
ORTHOTROPIA & HYPEROPIA
Hyperopia: Moderate > +2.50 to +3.50D Cycloplegic § 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 § If cooperative with symptoms, give lowest plus with good VA
ORTHOTROPIA & HYPEROPIA
� Hyperopia: Low up to +2.50D cycloplegic ◦ Asymptomatic OBSERVE only for ET and amblyopia ◦ If cooperative, get dry manifest and subjective ◦ 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
MYOPIA >3.0 • Start with cycloplegic refraction • Reevaluate with manifest refraction • Give lowest minus that will yield VA of at least 20/40
ORTHOTROPIA & MYOPIA Myopia § High myopia: > -3.0D § Amblyogenic § Double check with stronger cycloplegia, usually
atropine § More than age 6 mos: give cycloplegic refraction § Check refraction q 3 months § Regardless of symptoms (with or without symptoms)
MYOPIA </=3.0 • Start with cycloplegic refraction • Reevaluate with manifest refraction • Give lowest minus that will yield VA of at least 20/40 • Consider child’s visual needs, may not need to
prescribe right away
ORTHOTROPIA & MYOPIA Moderate myopia: -1.0 to -3.0D § Potential for amblyopia § depends on visual tasks § Up to age 1, OBSERVE if -1.0 to -1.5D § Above age 6 mos, if >-2.0D, give cycloplegic
refraction § School age, give cycloplegic Rx
§ Depends on symptoms: AHP, squinting, spasm of accommodation, etc.
§ Give cycloplegic refraction
ORTHOTROPIA & MYOPIA Low myopia (<-1.0D): § depends on visual tasks § Preschool child, even up to grade 3, OBSERVE § Intermediate (Gr 4 or higher), give cycloplegic Rx
§ Rare for a child to complain about blurred vision § Depends on symptoms: § Anomalous head posture § Cannot see board § Squinting (pinhole behavior) § Spasm of accommodation, etc.
ORTHOTROPIA & ASTIGMATISM Astigmatism ◦ 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
Astigmatism § Oblique axis (exceeds 10-deg from 90 or 180) § Threshold lower: >1.0D, give Rx early § Consider potential for amblyopia and associated
symptoms § Give full cylinder from cycloplegic refraction on-axis § If cooperative and reliable with manifest, check if
90/180 degrees preferred
ESOTROPIA AND REFRACTIVE ERROR FULL cycloplegic refraction § Myope: give full cycloplegic refraction § Hyperope: More common, > +2.00D § < 5 y: give full cycloplegic refraction § >5 y: maximum tolerated plus, push plus
§ Astigmat: § Give the full cylinder from cycloplegic refraction
ESOTROPIA AND REFRACTIVE ERROR When to give bifocals: § High AC/A § Fusion at distance present (<10PD) § Full cycloplegic refraction / maximum tolerated plus
pushed § Repeat full cycloplegic refraction first § Careful with “V” pattern confused with high AC/A
ET HIGH AC/A AND ADDS � Either give full +3.00D adds then taper, or give minimum
adds +1.00D then go higher to where ET’ controlled � Objective: minimum plus to control ET’ � Monitor X(T) at near, excess adds � Must bisect pupil � Executive, flat top, D-segment
• Amblyopia • Refraction • Fusion at distance • Residual near deviation • Repeat refraction • Amblyopia management • Remeasure with glasses always
WHAT TO DO ON FOLLOW-UP: ACCOMMODATIVE ET
ACCOMMODATIVE ET: FOLLOW-UP Remeasure deviation with glasses ALWAYS both at distance
and near 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
ACCOMMODATIVE ET: FOLLOW-UP If XT at distance § Reduce plus correction If XT at distance, ET at near § reduce distance plus § Minimum Bifocals that will control near deviation If ortho at distance but XT at near § Reduce adds
0-8PD ET Monofixation syndrome
ACCOMMODATIVE ET: TREATMENT GOAL
Single vision lens § Cycloplegic refraction § Maximum tolerated plus § Push plus
ACCOMMODATIVE ET: NONSURGICAL MANAGEMENT
ACCOMMODATIVE ET: BIFOCALS
• If and only if distance fusion present (<10PD) • Reached maximum tolerated plus • Executive or D segment bisecting pupil
ACCOMMODATIVE ET: PEARLS • Refraction not always hyperopia • Give full cycloplegic refractions whenever possible • Push maximum tolerated plus • Bifocals if and only if there is fusion at distance • Goal: minimum bifocals to control near deviation;
eventually get patient out of bifocals
ACCOMMODATIVE ET: PEARLS • Always check/repeat refraction for latent 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
X(T) AND REFRACTIVE ERROR
• Any sensory destabilizing factor affects control, including small EOR
• Improvement in VA usually helps control deviation
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
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 § Excess plus can worsen X(T) Hyperope*: For surgery § Give the full cycloplegic refraction or maximum tolerated
plus prescription to uncover all latent exodeviation. § Target angle for surgery
*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 cycloplegic refraction
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?
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?
� Significant cylinder &/or significant myopia
� Dry manifest refraction highest and exceeds cycloplegic refraction
� May need stronger cycloplegia to determine true target refraction
� Pharmacologic cycloplegia
CILIARY MUSCLE SPASM
CILIARY MUSCLE SPASM Give lowest minus, lowest cylinder Resist urge to give in to subjective refraction § usually higher minus § more with-the-rule astigmatism (minus cyl x 180) Compromise needed for school age: § at least 20/40 (6/12 or 0.5) OU
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/v1c041.html. Accessed March 15, 2016.