Prescribing Lenses in Children

8/4/2019 Prescribing Lenses in Children

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Prescribing Lenses in Children

Andrea Monzon MD, DPBOPediatric Ophthalmology and Strabismus

Dagupan Eye Specialists



Introduction

� Pediatric patients are unique«

± Cannot offer feedback

± Lack of cooperation ± Visual requirements are different from that of

adults

± Amblyopia

± MD will have to rely on behavioral clues (the

child does not express symptoms)



Introduction

� Examples

± Children who hold objects/ books too close to

the face or sit too close to the television ~

significant myopia

± squinting



Developmental Aspects

� 19% of normal infants have astigmatism ±

decreases with age

� Fovea reaches maturity at ~ 4 years of age

� Fusion develops between 4.5 to 6 months

of age

� Stereopsis develops at approximately 3

months of age



Developmental Aspects

� Visual system of a normal infant is capable of 20/20 vision by age 18 months (by VEP)

� Visual Acuity:

± By VEP:� birth = 20/200 ± 20/100

� by 1 year: 20/20

- By Preferential looking tests:- Birth: 20/400

- By 30 months: adult level

- By Linear acuity- By 3 years old: 20/40

- By 4-5 years old: 20/30

- By 6 years old: 20/20



Important Points«

� Pediatric Vision Screening

± All infants by age 1 should have been

screened for ocular health, and another

screening should be done by age 3

± Formal visual acuity testing should be done

by age 5



Important Points«

� Comprehensive Eye Evaluation

± High risk infants

± Abnormalities found on screening



Comprehensive Eye Evaluation

� History

� Ophthalmologic Examinations ± Visual Acuity

± Pupillary Exam ± Ocular Alignment and Motility

± External Exam

± Anterior Segment Evaluation

± Cycloplegic refraction ± Fundus Examination

� Additional Tests



Indications for Spectacle Correction

� Prevent amblyopia

� Correct strabismus

� Preserve binocularity� Improve visual acuity

± Enhance visual efficiency

± Restore comfortable vision



Contraindications for Spectacles

� Low visual demands

� Interruption of emmetropization



When to Prescribe Spectacles

� Amblyogenic Refractive Error

± Threshold amounts of refractive error warranting spectacle correction vary among

MD¶s/ authors ± No set values

± Individualized according to patient¶s needs

� Strabismic patients with refractive errors

� Special cases



Amblyogenic Refractive Errors

� Myopia 1 yr old and below: >/= -4.00D

2-3 yr old: >/= -2.00 D

older children: >/= -1.00 D is potentially amblyogenic

� Hyperopia

0-1 yr old: > +4.00 D 1-2 yrs old: > +3.50D

2-6 yrs old: > +2.00D



Amblyogenic Refractive Errors

� Astigmatism

> 1.50 D to 2.00 D

� Anisometropia

> 1.50 D difference (especially if hyperopic or

astigmatic)

Consider contact lenses



Strabismus and Refractive Errors

� Strabismic patients often require cycloplegic

refraction

± SAC

� Tropicamide 0.5%, q15 x 3, after 30 mins

� Tropicamide-phenylephrine, q10-15 x 3, after 30 mins

± Intermediate

� Cyclopentolate 1%, q5 x 2, after 40mins

� Tropicamide-phenylephrine-cyclopentolate q5 x 2, after 30mins

± Long-acting/ FCR

� Atropine 1% TID x 3 days




� Esotropia

± Rationale: Give the highest plus to relax

accommodation and control ET, but consider

patient¶s tolerance

± Hyperope

� < 5y.o: give FCR (full plus)

� > 5y.o: maximum tolerated plus ± Myope

� Give FCR (least minus)




± Astigmat

� Give full cylinder from FCR

± High AC/A

� Try FCR first

� May need bifocals if <10PD ET at distance but with

larger ET at near

± Anisometropia with ET

� Give max plus but if >5y.o, may have to adjust to

decrease anisometropia

� Consider contact lenses




� Exotropia

± Rationale: You want the patient to

accommodate ± give the least plus (most

minus) that improves vision and control

± Hyperope

� Cut plus by 1-1.5D or cut by half

� Try manifest and subjective refraction in older children ± get least plus with best VA

� If for surgery, may try giving max plus to bring out

largest XT ± target for surgery




± Myope

� Give full minus

� May even try over-minus

± Astigmat

� Give full cylinder from FCR

± Anisometropia with XT

� Cut plus (more minus) but if > 5 y.o., may have toadjust to decrease anisometropia

� Consider contact lenses



Special Cases

� Pediatric aphakia

� One-eyed child

± Polycarbonate lenses for protection



In summary«

� Weigh the indications versus the

contraindications to giving spectacles� Give spectacles only when absolutely

necessary

�Individualized according to needs of each patient



THANK YOU

Prescribing Lenses in Children

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