2019 Prescribing Eyeglasses in Children

Prescribing
Eyeglasses in
Children
by
Alvina Pauline D. Santiago, MD
Pediatric Ophthalmology
© AP Santiago 2019. All rights reserved.
#eyeglasses4kids

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/qu
estionmark.png
Culture
Emmetropization
© AP Santiago 2019. All rights reserved. #eyeglasses4kids

“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
off 90/180
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]

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

Spectacle prescribing
recommendations/opinions AAPOS 1998
MYOPIA
Age Mean SD Proportion of respondents who
will prescribe
25% 50% 75%
<2y 3.78 1.51 3.0 4.0 4.5
2-4y 2.67 1.07 2.0 2.5 3.0
4-7 1.67 0.83 1.0 1.5 2.5
Modified from Miller J, Harvey M. Spectacle prescribing recommendations
of AAPOS Members, JPOS 1998 35(2): 51-52.
#eyeglasses4kids

HYPEROPIA
Age Mean SD Proportion of respondents who
will prescribe
25% 50% 75%
<2y 4.82 1.20 4.0 5.0 5.5
2-4y 4.35 1.02 4.0 4.0 5.0
4-7 3.99 0.98 3.0 4.0 4.5
#eyeglasses4kids

ASTIGMATISM
Age Mean SD Proportion of respondents
who will prescribe
25% 50% 75%
<2y 2.6 0.83 2.0 2.5 3.0
2-4y 2.19 0.71 1.75 2.0 2.5
4-7 1.72 0.61 1.5 1.5 2.0
#eyeglasses4kids

ANISOMETROPIA
Age Mean SD Proportion of respondents
who will prescribe
25% 50% 75%
Any 1.64 0.56 1.25 1.5 2.0
#eyeglasses4kids

Amplitude of Accommodation http://iovs.arvojournals.org/data/Journals/IO
VS/932949/z7g0060889470008.jpeg
Glasser A, Campbell MC, Presbyopia and the optical changes in the human crystalline
lens with age. Vision Research 1998; 38: 209-29.
© AP Santiago 2019. All rights reserved.#eyeglasses4kids

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

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

Caputo Drops
u 1.3% cyclopentolate
u 0.167% mydriacyl
u 1.6% phenylephrine
u 3.75 ml cyclopentolate 2%
u 7.5 ml mydriacyl 1%
u 3.75 ml phenylephrine 10%
Yield:
u Cyclopentolate 0.5%
u Mydriacyl 0.5%
u Neosynephrine 2.5%
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.
Caputo AR, Schnitzer RE, Lindquist TD, Sun S. Dilation in neonates: a protocol. Pediatrics 1982; 69: 77-80.

Errors of
Inadequate Cycloplegia
§ Less hyperopia
§ More myopia
§ More with-the-rule
astigmatism
§ Same errors as
computer
autorefraction
https://howardjbennett.files.wordpress.com/2
012/05/eyedrops.jpeg

http://www.wallpaperup.com/uploads/wallpapers/2014/08/0
4/415502/big_thumb_0d0f0898e1deb1ffce7ad53db8ba4e99.jpg
http://guideimg.alibaba.com/images/shop/87/11/13/8/nerd-
bookworm-glasses-adult-halloween-accessory_382378.jpg

Child vs. Adult
ü On-axis
ü Full plus tolerated
ü Tolerated well
ü Amblyopia,
strabismus, loss of
binocularity
ü @ 90 / 180
ü Maximum tolerated
plus
ü Poor tolerance
ü Asthenopia,Red eye,
Dry Eye
• Cylinder
• Hyperopia
Less than 5
years
• Anisometropia &
Aneisokonia
• Wrong Rx
#eyeglasses4kids

Child vs. Adult
ü Focused retinal image
ü Balance between
accommodation &
convergence
ü Sometimes impossible
or inappropriate
ü Best corrected VA
ü Important
• Endpoint
Less than 5
years
• Subjective
Refraction

Additional pearls
u Habitual accommodative tone
u Relax accommodation
u Need for cycloplegia
u Variability in vertex distance and
pantoscopic tilt: phoropter vs trial lens
u Over-refraction on current eyeglasses

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

Preschool Refractive Errors
Requiring Glasses
Anisometropia
> 1.5D
Myopia
> 3.0D
Hyperopia
> 3.5D
Astigmatism
> 1.5 @ 90/180
> 1.0 >10deg
off 90/180
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 Anisometropi
a
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-

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/
y-reading-with-glasses_zps90e33e7d.jpg

Hyperopia ≤3.5D
Ø Monitor
Ø Lowest plus
Ø Best vision
Ø Not always 20/20
Ø Cut plus
http://assets-
s3.usmagazine.com/uploads/assets/articles/821
36-new-gerber-baby-is-7-month-old-girl-named-
grace/1421876680_grace-gerber-baby-zoom.jpg
#eyeglasses4kids

Myopia
>-3.0D
Ø Cycloplegic
refractions
Ø Lowest minus
Ø VA at least 20/40
http://www.tipskey.com/article/concave_lense
s_worsen_myopia/myope.jpg
Rx in Kids

Myopia ≤-3.0D
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/A
rticles/Kids-Eyeglasses-1.jpg
© AP
Santiago
2016 .
All rights
reserved.
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

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-patternhttp://www.aapos.org/client_data/files/2011/_
376_bifocal.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_bifocal.jpg

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

Exotropia
What would you prescribe?

X(T) & 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

§ 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)
*Significant hyperopia ~ >+3.50 on cycloplegic refraction
X(T) and Hyperopia

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

Anisometropia
How would you prescribe?

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

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?

Ciliary Muscle
Spasm
How much to prescribe?

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

Amplitude of Accommodation http://iovs.arvojournals.org/data/Journals/IO
VS/932949/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
§ 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

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

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

References
1. Apt L, Gaffney M. Cycloplegic Refraction.
http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html. Accessed March
15, 2016.
2. Bin Aziz, MA. Cycloplegic agents and cyclorefraction. http://www.slideshare.net/schizophrenicSabbir/cycloplegic-
agents-cyclorefraction. Accessed March 15, 2016.
3. 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.
4. Caputo AR, Schnitzer RE, Lindquist TD, Sun S. Dilation in neonates: a protocol. Pediatrics 1982; 69: 77-80.
5. 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.
6. 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.
7. 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.
8. 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.
9. Donahue SP, et al. AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: a 10-
10. Freedman HL, Preston KL, Polaroid photoscreening for amblyogenic factors. Ophthalmology 1992; 99: 1785-95
11. Glasser A, Campbell MC, Presbyopia and the optical changes in the human crystalline lens with age. Vision Research
1998; 38: 209-29.
12. Miller J, Harvey M. Spectacle prescribing recommendations of AAPOS Members, JPOS 1998 35(2): 51-52.

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