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Home , Exophoria, Myopia

Prescribing for Preverbal Children

Valerie M. Kattouf O.D. FAAO, FCOVD Illinois of Associate Professor Prescribing for Preverbal Children

 Issues to consider:  Age  Visual Function  Norms  Amblyogenic Risk Factors  Birth History  Family History  Developmental History Emmetropization

 A process presumed to be operative in producing a greater frequency of occurrence of than would be expected in terms of chance distribution, as may be explained by postulating that a mechanism coordinates the formation and the development of the various components of the human which contribute to the total refractive power Emmetropization

 Passive process = nature and genetics  60% chance of if 2 parents myopic (Ciuffrieda)

 Active process = mediated by blur and compensates for blur Refractive Error Norms

 Highest rate of emmetropization – 1st 12-17 months

Hyperopia

 Average refractive error in infants = +2 D

 > 1.50 diopters hyperopia at 5 years old – often remain hyperopic

Refractive Error Norms

Myopia

25% of infants are myopic

Myopic Newborns (Scharf)

@ 7 years 54% still myopic @ 7 years 46% emmetropic @ 7 years no hyperopia Refractive Error Norms

Astigmatism

 Against the rule more prevalent switches to with-the-rule with development

 At 3 1/2 years old astigmatism is at adult levels

INFANT NORMS

AGE SPHERE CYL 0-1mo -0.90+/-3.17 -2.02+/-1.43 2-3mo -0.47+/-2.28 -2.02+/-1.17 4-6mo -0.00+/-1.31 -2.20+/-1.15 6-9mo +0.50+/-0.99 -2.20+/-1.15 9-12mo +0.60+/-1.30 -1.64+/-0.62 12-15mo +0.60+/-1.30 -1.25+/-0.62 15-18mo +0.60+/-1.30 -1.44+/-0.77 18-24mo +0.60+/-1.30 -1.44+/-0.77 24-36mo +1.96+/-0.40 -1.00 POTENTIALLY AMBLYOGENIC REFRACTIVE ERRORS

ISOMETROPIA DIOPTERS  Astigmatism > 2.50 D  Hyperopia > +5.00 D  Myopia > -8.00 D

ANISOMETROPIA  Astigmatism > 1.50 D  Hyperopia > +1.50 D  Myopia > -3.00 D

9 MYOPIA Question # 1

 What is the threshold amount of myopia for which you would prescribe eyeglasses in a 1 year old? a) –1.00 to –1.75 D b) –2.00 to – 2.75 D c) –3.00 to –3.75 D d) –4.00 D or higher

Myopia – Case Example

 Age = 3 month old twins, 8 week premature

 Birth weight = 2 lbs, 4 oz and 3 lbs, 2 oz

– fixate and follow OD, OS

 EOM – FROM OD, OS Myopia – Case Example

 Kappa / Hirschberg – ortho

 Bruckner = (+) Bifixation

 Cycloplegic ~  - 6.50 -1.00 x 180 OD, OS

 Ocular Health evaluation = normal, no retinal signs of ROP

Myopia – Case Example

 Age = 6 month old twins, 3 month follow-up

 Kappa / Hirschberg – ortho

 Cycloplegic Retinoscopy ~  - 3.00 -1.00 x 180 OD, OS

Myopia – Case Example

3 months -6.50 D  6 months -3.00 D  9 months -0.50

Myopia and Prematurity

 Prematurity = strong predictor of myopia  Greater than then low birth weight

of Prematurity  strong predictor for myopia (> BW =  myopia)

 Etiology   axial length   lenticular power   corneal curvature Question # 2

 What is the threshold amount of myopia for which you would prescribe eyeglasses in a 2-3 year old?

a) –1.00 to –1.75 D b) –2.00 to –2.75 D c) –3.00 to –3.75 D d) –4.00 D or higher

2 year old Hispanic Female

 FT birth / (-) developmental delay  c/o getting close to TV and books

 Visit #1  DVA :UTT (poor cooperation noted)  F&F OD, OS

(distance & near): orthophoria

 EOM: FROM OD, OS

 Stereopsis: UTT (poor cooperation noted)

2 year old Hispanic Female

 Cyclyplegic Retinoscopy  - 5.00 -2.50 x 180 OD, OS

 Assessment / Plan  High Myopia/Astigmatism  Rx given = -5.00 -1.50 x 180  RTC 1 month after Rx wear 2 year old Hispanic Female

 Visit #2  Tremendous compliance with Rx, Mom notes behavioral changes  No longer gets close to things  More attentive  More active  More emotionally connected

 DVA: 20/32 OD, OS (Lea Symbols)

 Stereopsis: (+) Fly

Bilateral Spherical Refractive Myopia

 Prescribing Guidelines   -5 D - Rx at any age  -3-5 D - Rx at 1-3 years of age  -1-3 D - Rx if > 3 years of age (Ciner)

Risks  Isometropic Amblyopia risk @ > - 8 D

HYPEROPIA Question # 3

 What is the threshold amount of hyperopia for which you would prescribe eyeglasses in an orthophoric 1 year old?

a) +2.50 D or lower b) +2.75 to +4.75 D c) +5.00 to +7.00 D d) +7.25 D or higher

POTENTIALLY AMBLYOGENIC REFRACTIVE ERRORS

ISOMETROPIA DIOPTERS  Astigmatism > 2.50 D  Hyperopia > +5.00 D  Myopia > -8.00 D

24 Question # 4

 Which is the threshold amount of hyperopia for which you would prescribe eyeglasses in an orthophoric 2-3 year old?

a) +2.50 D or lower b) +2.75 to +4.75 D c) +5.00 to +7.00 D d) +7.25 D or higher

3 Visits/ First at 14 months

 Spina bifida w/ hydrocephalus  Significant Developmental Delay  (+) OT/PT/Speech/Developmental Therapy  Asthma  No visual complaints  VA: F&F OD, OS  NCT: Orthophoria 22 month old Hispanic Male

 Cycloplegic Retinoscopy :

 14 months old  +5.00 – 3.50 x 180 OU

 18 months old  +4.00 – 2.00 x 180 OU

 22 months old  +4.00 -2.00 x 180 OU

22 month old Hispanic Male

 Assessment/Plan

 Hyperopic Astigmatism OU

 Above age appropriate  Significant developmental delays  Rx given = +3.00 -1.50 x 180 OU  Follow-up 3-4 months

Question # 5

 In an orthophoric preverbal child with a +7.00 cycloplegic retinoscopy OU, what would you normally prescribe?

a) +7.00 D OU b) +6.25 D OU c) +3.00 to +4.00 D d) Observe, no spectacles at this time e) None of the above

Bilateral Spherical Refractive Hyperopia 2 year old female

• C/o and squinting • No significant family ocular history • No significant ocular or medical history

• Visual Acuity

Distance Near

OD 20/200 OD 20/60 OS 20/200 OS 20/60 Bilateral Spherical Refractive Hyperopia 2 year old female

• Cover Test (sc) : 4  X’

• Dry Retinoscopy Bilateral Spherical Refractive Hyperopia OD +7.00D 20/603 year old female OS +7.00D 20/60 •Cover Test with +7.00 D OU : 14 X(T)’

•Trial Frame OD +5.00D 20/25+ OS +5.00D 20/25+ •Cover Test with +5.00 D OU : 8 X’ Bilateral Spherical Refractive Hyperopia 2 year old female

 Cycloplegic Retinoscopy  OD +7.50D  OS +7.50D

Bilateral Spherical Refractive Hyperopia 2 year old female

 Dry Ret : +7.00  Cyclo Ret : + 7.50  20/25 VA : +5.00

 Rx Given  OD + 4.50 D  OS + 4.50 D

Bilateral Spherical Refractive Hyperopia

 Prescribing Guidelines  < +2 D - do not Rx until 5 years of age  Excluding   Amblyopia

  +2 D - consider Rx with attention to :  excessive accommodative effort  risk of amblyopia or  Monitor at risk patients every 3 months  Monitor lower amounts at 6 months of age, 1 y.o., 2-3 y.o. years, and 5 years (Ciner)  Amblyopia Risks  Isometropic Amblyopia risk @ > +5 D

Bilateral Spherical Refractive Hyperopia

 8 month old male  Myotonic Dystrophy  Cover Test – orthophoria

 Cycloplegic Retinoscopy  OD +10.00  OS +10.00

 Rx given  OD +6.00  OS +6.00 Bilateral Spherical Refractive Hyperopia

 7 year old male (brother)  First Rx at 6 y.o.  Myotonic Dystrophy

 Cover Test – AE(T)’

 Current Rx  OD +6.50 20/50  OS +6.00 20/50 ASTIGMATISM

Question # 6

 What is the threshold amount of symmetrical astigmatism in which you would prescribe eyeglasses in a 1 year old?

a) 1 diopter or less b) 1.25 to 2.00 D c) 2.25 to 3.00 D d) 3.25 D or higher

Question # 7

 What is the threshold amount of symmetrical astigmatism in which you would prescribe eyeglasses in a 2-3 year old?

a) 1 diopter or less b) 1.25 to 2.00 D c) 2.25 to 3.00 D d) 3.25 D or higher

Pediatric Outreach Exams 4/19/11

AGE REFRACTIVE ERROR FINDINGS

 4.6 HF +3.00 -3.00 x 180  4.9 HF +3.00 -3.00 x 180  4.1 HF pl -3.00 x 180

 5.7 HM +2.50 -4.50 x180 (twin)  5.7 HM +2.50 -3.50 x180 (twin)  4.11 HF +3.00 -4.00 x180 +3.00 -5.00 x 180  4.5 HF pl -5.00 x 180 pl -4.00 x 180 Bilateral Spherical Refractive Astigmatism 3 year old male

• Case History • Close working distance, Mom notes squinting, no strab reported

• Visual Acuity (sc) •Distance 20/100 OD, OS •Near 20/100 OD, OS

• Cover Test : 6 at Near

• Retinoscopy • -1.50 -2.75 x 010 20/40- • -1.00 -2.75 x 170 20/40-

Bilateral Spherical Refractive Astigmatism 3 year old male

 Rx Given  -1.50 -2.75 x 010 20/40-  -1.00 -2.75 x 170 20/40-

 3 month Follow-up  -1.50 -2.75 x 010 20/25-  -1.00 -2.75 x 170 20/25-  20/20- OU

Bilateral Spherical Refractive Astigmatism

 Prescribing Guidelines  Research  Large amounts common < 3 years of age  born with > 2D  1D by 3 years of age  Management  Do not correct before 1 year, but monitor frequently < 3 years  Prescribe when  Child  3 years of age  Magnitude > 1.25 D  Stable over 3 visits (Ciner)

 Amblyopia Risks  Isometropic Amblyopia risk @ > 2.50 D

Summary : Isometropic Amblyopia

 Potentially Amblyogenic Refractive Errors

 Myopia > -8.00 D  Hyperopia > +5.00 D  Astigmatism > 2.50 D

ANISOMETROPIA Question # 8

 Assuming no strabismus is present, what difference in refraction would you consider significant enough to prescribe eyeglasses in a preverbal child with hyperopic anisometropia?

a) +0.25 to +0.75 D b) +1.00 to +1.50 D c) +1.75 to +2.25 D d) +2.50 D or higher

Hyperopic Anisometropia

 3 year old male

 Hearing impaired, cochlear implant after diagnosis

 Visual Acuity  OD UTT, could not track a light, toy, etc.  OS 20/20

 Cover Test  Orthophoria

 Cycloplegic Retinoscopy  +7.50 UTT (deep amblyopia)  +1.50 20/20

 Rx given ?

Hyperopic Anisometropia

 Currently:

 OD +6.00 sph 20/25

 OS plano 20/20

Question # 9

 Assuming no strabismus is present, what difference in refraction would you consider significant enough to prescribe eyeglasses in a preverbal child with myopic anisometropia? (Assume one eye is plano)

a) –0.75 to –1.50 D b) –1.75 to –2.50 D c) –2.75 to –3.50 D d) –3.75 to –4.50 D e) –4.75 D or higher

Question # 10

 What would you prescribe for a child with –11.50D of myopia in one eye?

(Assume the other eye is plano) a) spectacles (plano & -11.50D) b) spectacles (plano polycarb. OU) c) spectacles (plano & -4.00 polycarb) d) –10.25 D contact e) None of the above

Myopic Anisometropia

 2 year old female  Normal birth and developmental history  Rubs/tugs left eye as per Mom  (-) Family ocular history for strabismus and/or high refractive error Myopic Anisometropia

 Visual Acuity  OD 20/80  OS F&F

 K/H= orthophoria  EOM – FROM OD,OS

 Cycloplegic Refraction  OD -1.50 D  OS -10.00 D Myopic Anisometropia

 Assessment / Plan  Anisometropic Amblyopia OS  Myopia OD

 SCL Fit OS (disposable/ EW)  Spectacles over CLS Question # 11

 Assuming no strabismus is present, what difference in refraction would you consider significant enough to prescribe eyeglasses in a preverbal child with astigmatic anisometropia? (Assume one eye is plano)

a) 1 diopter or less b) 1.25 to 2.00 D c) 2.25 to 3.00 D d) 3.25 D or higher

Summary : Anisometropic Amblyopia

Anisometropic Amblyogenic Risk Factors

 Myopia > -3.00 D  Hyperopia > +1.50 D  Astigmatism > 1.50 D

Anisometropia

 Research  Instability - fluctuations common until 4 years of age  Significant relationship to amblyopia and strabismus

 Management  < 3 years of age - monitor (especially hyperopic, antimetropia, cylindrical)  Monitor all types for problems (Ciner)

Prescribing Guidelines for Anisometropia

 Prescribe when:

 Magnitude > 1 D  Stable over 3 visits, 3 months apart  child > 3 years of age  VA or binocularity is below normal  Rx full correction (it equalizes the accommodative response) (Ciner)

POTENTIALLY AMBLYOGENIC REFRACTIVE ERRORS

ISOMETROPIA DIOPTERS  Astigmatism > 2.50 D  Hyperopia > +5.00 D  Myopia > -8.00 D

ANISOMETROPIA  Astigmatism > 1.50 D  Hyperopia > +1.50 D  Myopia > -3.00 D

58 Case Example – A little bit of everything…..

 4 year old male, first exam

 c/o blinking, Mom suspects blur, close working distance

 VA  OD 20/60  OS 20/400??

 Cover Test – orthophoria??/ Poor Case Example – A little bit of everything…..

 EOMS – FROM OD, OS

 Bruckner – OS whiter , brighter

 Cycloplegic Retinoscopy / Rx given  OD +9.00 -4.00 x 170 20/50  OS +10.00 -3.00 x 040 20/200 PHNI

 Diagnosis? Rx given?

Case Example – A little bit of everything…..

 Assessment/Plan

 Strabismic vs. Anisometropic Amblyopia OS

 OD +7.00 -3.00 x 170 20/30  OS +8.00 -2.00 x 040 20/200

 RTC 1 month after Rx dispense begin occlusion tx 4-6 hrs daily OD with Rx

Case Example – A little bit of everything…..

 4 year old male, 2 month follow-up, treated with occlusion therapy OD 4-6 hours daily

 Rx given  OD +7.00 -3.00 x 170 20/30  OS +8.00 -2.00 x 040 20/80

 Cover Test  Distance – 6 Δ Left Esotropia  Near – 6 Δ Left Esotropia

 Visuoscopy - 3 Δ nasal eccentric fixation OS

 Fusion  Central suppression  No random dot stereopsis  (+) Stereo Fly

Case Example – A little bit of everything…..

 6 months Follow-up

 After and 4 months of occlusion treatment:

 OD +7.50 -4.00 x 170 20/20  OS +8.50 -3.00 x 040 20/40 Bringing in Binocular Vision Problems…. Question # 12

 What is the least amount of hyperopia for which you would prescribe eyeglasses in a child one year of age or younger, if the child has 30 prism diopters of esotropia?

a) +1.00 to +2.00 D b) +2.25 to +3.00 D c) +3.25 to +4.00 D d) +4.25 D or higher 20 month old Hispanic Female

 Normal birth and development hx  Unremarkable medical hx  c/o eye turn in since shortly after birth

 VA: F&F OD, OS

 EOM: 1+ OAIO OD, OS

 NCT: 35  AET’  NCT w/ +2.00 D: 35 AET’ 2 year old Hispanic Female

 Cyclo:  OD : +1.00 -1.00 x 160  OS : +1.50 sph

 A/P  Infantile Esotropia  Constant  No amblyogenic risk  Surgical referral

Hyperopia with Esotropia

 Infantile / Congenital Esotropia

 Clinical Characteristics

 Onset 6-12 months  Constant, large angle (30-60)  Refractive error = normal range

Hyperopia with Esotropia

 Amblyopia Risk Factors involving Strabismus

 Strabismic Amblyopia  Unilateral Strabismus  Constant Strabismus  Present at Distance and Near Fixation  Present in All Fields of Gaze

 Must be present BEFORE 6 years of age…

Question # 13

 What is the least amount of hyperopia for which you would prescribe eyeglasses in a child 2-3 years of age, if the child has 30 prism diopters of esotropia?

a) +1.00 to +2.00 D b) +2.25 to +3.00 D c) +3.25 to +4.00 D d) +4.25 or higher

4 year old African American Female

 FT birth / (-) developmental delay  c/o eyeturn in since birth

 DVA: 20/30 OD, OS  EOM: 3+ OAIO OD, OS

 Krimsky: 40  AET’  NCT: 40-60  AET’ (variable)  NCT w/ +2.00 D = 60  AET’

 Stereopsis (-) Fly, (-) RDS

4 year old African American Female

 Cyclyplegic Retinoscopy  + 2.50 sph OD, OS

 Assessment / Plan  Infantile Esotropia  Constant, large magnitude, (-) stereopsis  Attempted Rx wear x 1 month, minimal compliance, no change in magnitude of ET with Rx  Surgical consult Hyperopia with Esotropia

 Accommodative Esotropia

 Clinical Characteristics  Onset  6 months – 7 years (mean = 2.5 years)  Gradual, intermittent  Magnitude of strabismus at near > distance  Amblyopia rare at onset

 Mechanisms  Uncorrected hyperopia (+2.00 - +7.00)  High AC/A ratio (with low hyperopia)  Combination

Hyperopia with Esotropia/ 3 year old female

 Case History  Mom c/o eye crossing when child concentrates on something x 2-3 months  No significant family ocular history

 VA (sc) 20/25 OD, OS

 Cover Test (sc) 10  E’ (initially)

 Stereopsis (+) Lang forms

Hyperopia with Esotropia/ 3 year old female

 Repeat Cover Test (later in exam)  AE(T)’  20

 Dry Retinoscopy = +2.50 D sphere OU 20/20 OD, OS  Trial Frame = +3.50 D sphere OU 20/25 OD, OS

 Repeat Cover Test with +3.50 OU  Orthophoic

 Cycloplegic Retinoscopy  +5.00 D sphere OU

 What would you Diagnose ? Rx?

Hyperopia with Esotropia: 3 year old female

 Assessment  Accommodative Esotropia

 Plan  Rx given +4.00 OU  RTC 1 month after Rx wear for re- evaluation Question # 14

 How often do you prescribe minus lenses in emmetropic, or slightly hyperopic children with intermittent ?

a) always b) frequently c) sometimes d) never

3 year old Caucasian female

 cc: LE drifting out x 1.5 years

 VA (cc)– 20/20 OD, 20/20 OS

 DCT (sc) 60  AX(T) = variable angle   distance vs near  NCT (sc) 20  AX(T)  RE fixation preferred 90%

 Stereo  (+) fly  3/3 animals 3 year old female

 Treatment options?  TF= -2.00 D, no  in frequency of XT  MOA: stimulation of accommodative convergence

 TF= 8 BI OD, no  in frequency of XT

 Assessment/Plan  Exotropia / Intermittent – well controlled, good fusion  Begin alternate patching 2 hrs daily  Discussed spec, orthoptic and sugical txs  Follow-up x 3 months or sooner if frequency of XT increases

Prescribing for Exotropia / 2 year old female

 Case History  developmental delays  intermittent eye turn outward noticed x 1 year

 Visual Acuity  20/30 OD, OS

 Cover Test  25-30 RX(T) 75%  25-30 RX(T)’ 50%

Prescribing for Exotropia :2 year old female

 Dry Retinoscopy  OD plano  OS plano

 Cyclo Retinoscopy  OD +0.75 sph  OS +0.50 sph

Prescribing for Exotropia / 2 year old female

 Cover test with -2.00 sphere OU  10 X’  12  RX(T) 30%

 Cover Test without Rx  25-30 RX(T) 75%  25-30 RX(T)’ 50%

 Use of Rx to overminus  high AC/A = 10/1   frequency of XT

Studies evaluating IXT Treatment Options

 Treatment options in intermittent exotropia: a critical appraisal (Optom Vis Sci 1992 may;69 (5):386-404)

 Review of clinical literature

 Over minus Therapy: 28%  Prism Therapy: 28%  Occlusion therapy: 37%  EOM : 46%  Orthoptic : 59%

Studies evaluating Overminus Lens Tx for IXT

 Overcorrecting minus lens therapy for treatment of intermittent exotropia ( 1983 Oct;90 (10):1160-5)

 Goal of tx: secure ↑ in quality of fusion  35 children -2D - - 4D x 18 mo.

 46% improved quality of fusion during therapy  26% improved quality of fusion and quantitative decrease in angle of deviation  28% inadequate improvement in quality of fusion or decrease in angle size

Studies evaluating Overminus Lens Tx for IXT

 Refractive Error Changes in children with intermittent exotropia under overminus lens therapy (Arq Bras Oftalmol. 2009 Nov-Dec;72(6):751-4)

 Goal of study: Does ↑ (used with ↑ accommodative convergence) increase myopia?  Record review  Conclusion:  Treatment of IXT did not induce refractive error changes, even considering age, treatment period, initial spherical equivalent and overcorrection magnitude used

Question # 15

 How much astigmatism would you feel necessitates prescribing eyeglasses in a 2-year-old child with intermittent exotropia?

a) 50 to 1.00 D b) 1.25 to 1.75 c) 2.00 to 2.50 d) 2.75 or higher

Prescribing for Exotropia

 EXOTROPIA CHARACTERISTICS

 Early onset / often intermittent

 Sensitive to unequal retinal image clarity  Small refractive error critical to sensory fusion  Sensitive to small amounts of astigmatism  Monitor amount of hyperopia prescribed

Prescribing for Exotropia : 3 year old male

 Case History  intermittent alternating exotropia x 1 year  > in AM, when tired, in sunlight

 Visual Acuity (sc) Allen Pictures  20/30 OD, OS distance & near

 Cover Test (sc)  Distance 45 AX(T) (95 %)  Near 35 AX(T)’ (75%)

 Stereopsis (sc)  (+) Forms Lang

Prescribing for Exotropia : 3 year old male

 Auto Keratometry  40.75/43.12 x 176  41.00/ 43.87 x 019

 Retinoscopy  +1.50 - 2.00 x180  +1.50 -3.50 x 180  CT : 40 AXT’

Prescribing for Exotropia : 3 year old male

 Trial Frame

 pl -2.00 x 180 20/20  pl -3.50 x 180 20/20

 CT : 25  X’  CT: 40  AX(T) (60%)

Prescribing for Exotropia : 3 year old male

 Final Rx

 pl -2.00 x 180 20/20 4∆BI  pl -3.50 x 180 20/20 4∆BI

 CT : 15 X’  CT: 30 AX(T) (30%)

Bifocals in Children…. Question # 16

 How often would you prescribe in orthophoric children with myopia?

a) always b) frequently c) sometimes d) never

Using Bifocals in Prescribing 10 y.o HF

 Chief complaint = Distance blur w/o Rx  Wears spectacles  1st Rx 3 years ago  Lost Rx several months ago

 Also c/o difficulty with near work when wearing Rx  w/Rx = (+) significant asthenopia and dull after a few minutes, (-)

 (-) med, NKMA Using Bifocals in Prescribing 10 y.o HF

 DVA  sc 20/300 OD, OS  NVA  sc 20/20 OD, OS  NCT  sc 12 X’

 Retinosocopy = Subjective  -4.25 -0.75 x 090 20/20  -4.50 sphere 20/20

Using Bifocals in Prescribing 10 y.o HF

 Rx given  -4.25 -0.75 x 090 20/20  -4.50 sphere 20/20

 DCT (cc):ortho

 NCT (cc):18 ∆ AE(T)’ – intermittent alternating esotropia

 Prism Bar (cc)

 NBI x/10/4  NBO x/25/20

Using Bifocals in Prescribing 10 y.o HF

 Repeat Cover Test (with +2.00 D OU over Rx)  NCT = 4 ∆ esophoria (was 18 ∆ AE(T)’ )

 Repeat Prism Bar Vergences (with +2.00 D OU)  NBI x/12/10 (was x/10/4)  NBO x/20/16 (was x/25/20)

Using Bifocals in Prescribing 10 y.o HF

 Assessment  Myopia OU  Convergence Excess

 Plan  Rx given  OD -4.00 -0.75 x 090  OS -4.50 sphere  +2.00 Add Question # 17

 How often would you prescribe bifocals in children with high AC/A ratios not corrected at near by their hyperopic eyeglasses?

a) always b) frequently c) sometimes d) never

Question # 18

 In a young child with an accommodative esotropia not controlled at near with full hyperopic correction, how much esotropia at near would necessitate the use of bifocals in your patient?

a) 8 or less b) 9 – 15 or less c) 16 – 24 or less d) 25 or higher e) None of the above

Using Bifocals in Prescribing / 5 year old female

 Case History

 S/P Strabismus Surgery @ 13 months old  No Rx given pre/post-op  1st Rx at 2 y.o. after consecutive CRET  Suspicion of amblyopia, tx with occlusion therapy  Mom reports NO COSMESIS of ET with Rx

 Current Rx : +5.50 sphere OD, OS

Using Bifocals in Prescribing:5 year old female

 Visual Acuity (Lea)

 Distance : OD 20/40- OS 20/30  Near : OD 20/32 OS 20/20

Using Bifocals in Prescribing / 5 year old female

 Strabismus Evaluation

 Cover Testing

 Distance : 6  RET (cc)

 Near : 12  RET’ (cc) 25  RET (sc) 2  E’ (+2.00 ADD)

 EOM : FROM OU OAIO OD

Using Bifocals in Prescribing / 5 year old female

 Refractive Evaluation

 Retinoscopy Over +5.50 Rx  OD +1.00 sph  OS +1.00 sph

 Cycloplegic Retinoscopy  OD +6.50 sphere  OS +6.50 sphere

Using Bifocals in Prescribing 5 year old female

 Assessment  Accommodative Esotropia OD  residual ET at near with current specs  Resolved amblyopia OD

 Plan  New Rx : +6.00 sphere OU, +1.50 Add  RTC 3 months

Bilateral Spherical Refractive Hyperopia 6 month male (brother)

 Case History  (+) Family History Accom ET 6 y.o. sister  Mom notes no ET  Birth/developmental hx wnl

 Visual Acuity  Fixates& Follows  10  BD = (+) alternation

 Ocular Alignment/ Kappa-Hirshberg  ortho

Bilateral Spherical Refractive Hyperopia 6 month male (brother)

•Retinoscopy

Near/Dry +3.50 OU

Cycloplegic +5.00 OU

• Would you prescribe? • If yes, what Rx? • Follow up?

Question # 19

 How often do you prescribe polycarbonate lenses for monocular children (one eye with vision of 20/200 or less)?

a) always b) frequently c) sometimes d) never Prescribing Review  Isometropia Risks  Anisometropia Risks  Strabismus Risks  Visual Function / Visual Acuity  Soft Binocular Vision Disorders  Prescribing Guidelines

 Each patient is an individual!!!!  Each practitioner has individual preferences!! Statistics  25% of school age children have vision problems

 11.5% of teenagers have undetected or untreated vision problems

 Early detection of child’s vision problem  negative effect on child development QUESTIONS? Contact :

Valerie M. Kattouf O.D.

[email protected]