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PrescribingEyeglassesinChildren
byAlvinaPaulineD.Santiago,MDPediatricOphthalmology© AP Santiago 2016.
All rights reserved.
Rx in Kids
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© AP Santiago 2016. All rights reserved. Rx in kids
YES
NOAmblyopia
AttitudeAge
Finances
Vision
Strabismus
Symptoms
http://i.huffpost.com/gen/1760949/images/o-BALANCE-SCALE-facebook.jpg
https://maneshnagar.Niles.wordpress.com/2014/07/questionmark.png
Culture
Emmetropization
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“Amblyogenic”RefractiveErrorsJAAPOS2003
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PreschoolRefractiveErrorsRequiringGlasses
Anisometropia>1.5D
Myopia>3.0D
Hyperopia>3.5D
Astigmatism>1.5@90/180>1.0>10deg
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Amblyogenic:AgeDependent
© AP Santiago 2016. All rights reserved. Rx in Kids
Myopia >-1.00DHyperopia
0-1y: >+4.00D1-2y: >+3.50D2-6y: >+2.00D
Astigmatism >1.50DAnisometropia >1.50D
Freedman,Preston,Ophthalmology1992
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AmplitudeofAccommodation© AP Santiago 2016. All rights reserved. Rx in Kids
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CycloplegicRefractionhttp://www.cybersight.org/data/1/rec_imgs/11176_toddler%20refraction_sm.JPG
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CycloplegicRefraction
© AP Santiago 2016. All rights reserved. Rx in Kids
§ Atropine1%TIDx3-4days,refractonday4
§ Cyclopentolate1%2xq5min,refractafter30-40min
§ Tropicamide(0.5%)-phenylephrine(2.5%)q3-5minx2-3x,refractafter30min
§ Tropicamide0.5%q15minx3,refractafter30min
https://images.yaoota.com
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ErrorsofInadequateCycloplegia
© AP Santiago 2016. All rights reserved. Rx in Kids
§ Lesshyperopia§ Moremyopia§ Morewith-the-ruleastigmatism
§ Sameerrorsascomputerautorefraction
https://howardjbennett.Niles.wordpress.com/2012/05/eyedrops.jpeg
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Childvs.Adult
© AP Santiago 2016. All rights reserved. Rx in Kids
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Childvs.Adult
© AP Santiago 2016. All rights reserved. Rx in Kids
ü On-axisü Fullplustolerated
ü Lessimportant
ü Toleratedwell
ü Amblyopia,strabismus,lossofbinocularity
ü @90/180
ü Maximumtoleratedplus
ü Important
ü Poortolerance
ü Asthenopia,Redeye,DryEye
• Cylinder
• Hyperopia
Lessthan5years
• ManifestRefraction
• Anisometropia&Aneisokonia
• WrongRx
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OrthotropiaWouldyouprescribe?
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People(Happiness)
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PreschoolRefractiveErrorsRequiringGlasses
Anisometropia>1.5D
Myopia>3.0D
Hyperopia>3.5D
Astigmatism>1.5@90/180>1.0>10deg
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Amblyogenic:AgeDependent
© AP Santiago 2016. All rights reserved. Rx in Kids
Myopia >-1.00DHyperopia
0-1y: >+4.00D1-2y: >+3.50D2-6y: >+2.00D
Astigmatism >1.50DAnisometropia >1.50D
Freedman,Preston,Ophthalmology1992
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Hyperopia>3.5D
Ø LowestplusØ BestvisionØ Notalways20/20Ø ManifestrefractionØ Cutplus
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reading-with-glasses_zps90e33e7d.jpg
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Hyperopia≤3.5D
Ø MonitorØ LowestplusØ BestvisionØ Notalways20/20Ø ManifestrefractionØ Cutplus
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Myopia>-3.0D
Ø CycloplegicrefractionsØ ManifestrefractionØ LowestminusØ VAatleast20/40
http://www.tipskey.com/article/concave_lenses_worsen_myopia/myope.jpg
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Myopia≤-3.0D
Ø CycloplegicrefractionsØ ManifestrefractionØ LowestminusØ VAatleast20/40Ø Visualneedse.g.Myopia-1.00D(1vs11yrs)
Ø Symptoms
https://www.goggles4u.co.uk/media/wysiwyg/Articles/Kids-Eyeglasses-1.jpg
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Astigmatism
Ø With-the-ruleUpto-1.50Dtoleratedwell
Ø Against-the-ruleLesstoleratedwithoutRx
Ø ObliqueLowerthreshold:>1.0DOn-axis
Ø CycloplegicrefractionØ Lowestcylinder
http://townsend.ofNixonline.com/wp-content/uploads/astigmatism_sim1.jpg
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ESOTROPIA
§ Fullcycloplegicrefraction§ Maximumtoleratedplus§ Pushplus§ Lowestminuscorrection§ Fullcylinderfromcycloplegicrefraction
http://www.pedseye.com/img/eso_ex_01.jpg
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Bifocals:Whentogivethemhttp://www.aapos.org/client_data/Niles/2011/_376_bifocal.jpg
© AP Santiago 2016. All rights reserved. Rx in Kids
ü Fusionatdistanceü Fullcycloplegicrefractionü Repeatfullcycloplegicrefraction
ü Maximumtoleratedplusü Pushplusü WaryofV-pattern
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Bifocals:Howtogivethemhttp://www.aapos.org/client_data/Niles/2011/_376_bifocal.jpg
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ü Executive,NlattoporD-segmentü JustenoughtocontrolET’ü Minimumaddsü X(T)’:taper
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• Amblyopia• Refraction• Fusionatdistance• Alignmentbothdistance&near• Remeasurewithglassesalways
Whattodoonfollow-up:AccommodativeET
Rosenbaum&Santiago,1999
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Whattodoonfollow-up:AccommodativeET
Rosenbaum&Santiago,1999
© AP Santiago 2016. All rights reserved. Rx in Kids
• IfXTatdistanceReducepluscorrection
• IfXTatdistance,ET’reducedistanceplusminimumBifocalsthatwillcontrolnear
IforthoatdistancebutXTatnearReduceadds
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GoalofTreatment
§ MonoNixationsyndrome§ 0-8PDfromorthotropia
© your company name. All rights reserved. Title of your presentation
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X(T)andRefractiveError
• Anysensorydestabilizingfactoraffectscontrol,includingsmallEOR
• ImprovementinVAusuallyhelpscontroldeviation
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X(T)andRefractiveError
• Hyperopia:• Iffullycorrected,relaxesaccommodative-convergence,controlworse
• GiveminimumpluswithbestVA,usuallybetterforcontrolofdeviation
• Overminuslenses/Withholdinghyperopia/givinglessplushasaroleinmanagement
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X(T)andRefractiveError § Hyperope*:Ifnotforsurgery
§ <5y:Cutplusby1-1.5D§ MinimumplustocontrolX(T)andgiveclearvision
§ Olderchildren,considermanifestrefraction
§ ExcesspluscanworsenX(T)
© AP Santiago 2016. All rights reserved. Rx in Kids
*Significant hyperopia ~ >+3.50 on cycloplegic refraction
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X(T)andRefractiveError § Hyperope*:Forsurgery
§ Givethefullcycloplegicrefractionormaximumtoleratedplusprescriptiontouncoveralllatentexodeviation.
§ Targetangleforsurgery
© AP Santiago 2016. All rights reserved. Rx in Kids
*Significant hyperopia ~ >+3.50 on cycloplegic refraction
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X(T)andRefractiveError
§ Myope§ Givefullcycloplegicrefraction(lowestminus)
§ Consideroverminusifnotforsurgery
§ Or,giveminuslensthatwillgivebestVA
§ Astigmat§ Givethefullcylinderfromcycloplegicrefraction
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AnisometropiaHowwouldyouprescribe?
© AP Santiago 2016. All rights reserved. Rx in Kids
People(Happiness)
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Anisometropia&RefractiveError
§ MonocularXT§ Anisometropicamblyopia§ Cutplusby1-1.5D§ If>5y,mayneedtomanagelikealittleadult,decreaseanisometropiainglasses
§ Considercontactlensestooptimizevision
§ Prescribeglasseswithpatching
§ Roleoflaserrefractivesurgery?
http://shawlens.com/wp-content/uploads/2012/03/portfolio-default.jpg
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Anisometropia&RefractiveError
http://shawlens.com/wp-content/uploads/2012/03/portfolio-default.jpg
© AP Santiago 2016. All rights reserved. Rx in Kids
§ MonocularET§ Anisometropicamblyopia§ Usuallywithrefractiveaccommodativecomponent
§ Fullcycloplegicrefractionormaximumtoleratedplus
§ If>5y,mayneedtomanagelikealittleadult:decreaseanisometropiainglasses
§ Prescribeglasseswithpatching§ Considerstrongly:contactlenses
§ Roleoflaserrefractivesurgery?
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CiliaryMuscleSpasmHowmuchtoprescribe?
© AP Santiago 2016. All rights reserved. Rx in Kids
People(Happiness)
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CiliaryMuscleSpasm
� SigniNicantcylinder&/orsigniNicantmyopia
� Drymanifestrefractionhighestandexceedscycloplegicrefraction
� Mayneedstrongercycloplegiatodeterminetruetargetrefraction
� Pharmacologiccycloplegia
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CiliaryMuscleSpasm
§ Givelowestminus,lowestcylinder
§ Resisturgetogiveintosubjectiverefraction
§ Compromiseneededforschoolage:§ atleast20/40(6/12or0.5)OU
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DecisiontoPrescribeWhichwillbeyourprimaryfocus?
alignment
age
amblyopiavision
emmetropization
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References1. ChiaA,ChuaWH,CheungYBetal.Atropineforthetreatmentofchildhoodmyopia:safety
[email protected]%,0.1%,0.01%(AtropineforMyopia2)Ophthalmology2012;119.347-54.
2. ChiaA,ChuaWH,WenL,etal.Atropineforthetreatmentofchildhoodmyopia:changesafterstoppingatropine0.01%,0.1%,and0.05%.AmJOphthalmol2014;157:451-7.
3. ChiaA,LuQS,TanD.5-yearclinicaltrialonatropineforthetreatmentofmyopia1:myopiacontrolwithatropine0.01%Eyedrops.Ophthalmology2015;epubaheadofprint.
4. DonahueSP,ArnoldRW,RubenJB,AAPOSVisionScreeningCommittee.Preschoolvisionscreening:whatshouldwebedetectingandhowshouldwereportit?Uniformguidelinesreportingresultsofpreschoolvisionscreeningstudies.JAAPOS2003;7:314-5.
5. BinAziz,MA.Cycloplegicagentsandcyclorefraction.http://www.slideshare.net/schizophrenicSabbir/cycloplegic-agents-cyclorefraction.AccessedMarch15,2016.
6. AptL,GaffneyM.CycloplegicRefraction.http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html.AccessedMarch15,2016.
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