Prescribing_Spectacles_in_Children__A_Pediatric.9.pdf

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PERSPECTIVE

Prescribing Spectacles in Children: A PediatricOphthalmologist’s Approach

SEAN P. DONAHUE, MD, PhD

Departments of Ophthalmology, Pediatrics, and Neurology, Vanderbilt University School of Medicine, Nashville, Tennessee

ABSTRACTThe prescribing of spectacles for preschool children is very different from that for adults. Reasons for these differences

include the inability to determine accurately a child’s uncorrected and corrected visual acuity; as well as their lesservisual demands; their more proximal working distance; and their more plastic visual cortex, which places them at risk foramblyopia and strabismus. Most guidelines for spectacle treatment in such children are based upon clinical experiencerather than randomized, masked clinical trials. Fortunately, the prescribing thresholds suggested by optometrists are quitesimilar to those suggested by pediatric ophthalmologists.(Optom Vis Sci 2007;84:110–114)

Key Words: hypermetropia, anisometropia, refractive error, spectacles, glasses, children

C

hildren are not simply little adults. They have unique needs

based upon their visual demands and their developing visual

system. One cannot simply extrapolate the spectacle needsof adults onto young children. Doing so creates cognitive disso-

nance for parents, who feel their child’s visual system will be dam-

aged by not wearing glasses, but who hear their child insisting that

he doesn’t see any better while wearing the glasses. As a general rule

(anisometropia excepted) if a child appreciates the improvement

obtained with spectacles, he or she will wear them. The opposite is

also true: The child who doesn’t want to wear spectacles (or who

forgets them repeatedly) likely obtains no significant benefit from

them, and should not be forced to wear them.

Most practice patterns with respect to spectacle prescribing for

young children are based on experience, rather than evidence. Ob-

taining evidence of the usefulness of spectacles for children withmild and moderate myopia, hyperopia, or astigmatism, and an

otherwise healthy visual system would be difficult, if not impossi-

ble. Therefore, most guidelines are obtained by surveys of practi-

tioners, and are based upon experience acquired over many years.

Fortunately, it appears as though optometrists and ophthalmolo-

gists whose practices are dedicated to children usually have rela-

tively similar practice patterns. The biggest variable appears to be

the practitioner’s degree of expertise with examining and treating

preschool children. Continuing education of ophthalmologists

and optometrists, and additional research regarding the natural

history of refractive development are needed to further improve

quality of care.

Unique Visual Needs of Young Children

Children have unique characteristics that influence their use of

spectacles, In adults, one typically makes a decision to prescribebased upon the difference between uncorrected and corrected vi-sual acuity. This is not useful for most preschool children. Most

children younger than 4 years of age cannot provide a reasonable,reliable, and repeatable objective visual acuity in a busy office withstandard techniques of measurement. Although such measure-

ments can be done, their high variability limits their clinical use-fulness in making a decision about prescribing. Even after a childbecomes verbal, the measured acuity often underestimates the true

acuity, because the child may tire, or simply have no interest inreading small letters on an eye chart. One must therefore alsoconsider the level of refractive error, as determined with cyclople-

gia. Therefore, cycloplegic refraction is mandatory in determining the spectacle needs of children.

Most pediatric ophthalmologists use cyclopentolate 1% to ob-tain cycloplegia for the examination. When the detection of latenthypermetropia is crucial (a child with new onset esotropia, or re-

sidual strabismus in a previously well-controlled accommodativeesotrope), 2 drops of cyclopentolate are administered 5 min apart.Refraction should be carried out 30 min following the seconddrop. Although this method provides adequate cycloplegia in

nearly all children, it may not provide sufficient mydriasis in those with darkly pigmented irides; 1% tropicamide and 2.5% phenyl-ephrine are therefore used in addition to 2% cyclopentolate in

black and Hispanic children. Most hospital pharmcotherapeutic

1040-5488/07/8402-0110/0 VOL. 84, NO. 2, PP. 110–114

OPTOMETRY AND VISION SCIENCE

Copyright © 2007 American Academy of Optometry

Optometry and Vision Science , Vol. 84, No. 2, February 2007



committees prohibit mixing of medication, so a noncommercialmix of agents (or a spray) is not used in most academic practices.Some pediatric ophthalmologists will instill one drop of topicalproparacaine before cyclopentolate to decrease the stinging (andpossibly enhance absorption). I do not, as proparacaine also stings,and the combination means that the child needs 4 drops ratherthan 2. Similar hospital policy issues exist with a combination of topical anesthesia and cycloplegic as described above. Tropicamide

alone can produce cycloplegia, but its half-life is so short as to makeit not useful in a busy pediatric office. Atropine can be used fordifficult refraction but in my experience is almost never necessary.

In addition to being more difficult to examine, children alsohave different visual demands than adults. The working distance of most preverbal children is very different from that of adults. Gen-erally, children have minimal or no need for sharply focused dis-tance acuity (although we invariably describe visual function onthe basis of distance acuity). This is especially true for children of the age of 3. The preschoolchild typically has a working distance of 1 to 2 m. Thus, in contrast to older children and adults, preschoolchildren have minimal need for mild symmetric myopia correction.

Children also have different accommodative abilities thanadults. There is vast literature, dating back to the early 1900s, thatdescribes the extremely high levels of accommodation that young children possess.1,2 Healthy children in their first decade of lifetypically possess 12 D or more of accommodative function.3 Ac-cordingly, even moderate uncorrected hypermetropia does not de-grade acuity in young children.4 As a result, there is minimal needto correct moderate hyperopia, except when it is associated withstrabismus.

The final unique characteristic of a child’s visual system is itsincreased risk of amblyopia, from anisometropic, strabismic, orhigh spherical or cylindrical refractive errors. In contrast to aniso-

metropia or strabismic adults who do not jeopardize their visualsystems by failing to correct the nondominant eye, the young childis at risk of permanent vision loss unless the eyes are straight andhave symmetrical and adequately focused retinal images. However,the level of refractive error that produces amblyopia for each par-ticular child is different, and depends on other factors, such as thefamily history.5 Thus, no firm evidence-based recommendations canbe made regarding the threshold levels of refractive error that need tobe corrected to protect against the development of amblyopia.

The above characteristics of children mean that spectacle pre-scribing for children is an art, requiring interpretation of the child’srefractive error and visual acuity within the global evaluation of thechild. This is especially true for children who are not yet able toprovide an accurate objective visual acuity measurement, and for whom the only information available is the cycloplegic refractiveerror, and the visual behavior of the child. The remainder of thismanuscript will detail the thought processes many pediatric oph-thalmologists use to determine when to prescribe spectacles.

Prescribing for Myopia

Because of the minimal risk of amblyopia with symmetricalmyopia, prescribing for symmetric myopia should solely be basedupon anticipated visual acuity needs. Two fundamental observa-tions underscore the minimal need to prescribe spectacles for sym-

metric low levels of myopia in young children. First the visual

acuity demands of very young children are unlikely to exceed20/40 before the late elementary school years. Although the fovea is adequately developed and capable of 20/20 acuity by 6 years of age, most of the items a child views are not small enough to requiresuch fine resolution. The second factor impacting prescribing formyopia in children is their proximity to the visual target. Unlikeadolescents and adults, who are required to view distant targets with high resolution, most children have a working distance that is

close to them. Infants, for example, have a very proximate working distance; a newborn infant typically only needs to see her mother’sface, which often is only 25 cm away. The ocular structures of infant eyes are also not capable of high spatial resolution. Hence,only extreme myopia (approximately minus 4 D or more) is prob-ably necessary to treat in this age group. Late in the first year of life,the eyes become anatomically capable of better spatial resolution,but until a child begins to walk, he is rarely interested in objectsmore than 2 to 3 feet away. Therefore, Ϫ3.00 D of myopia is a threshold one may consider correcting in the very young child.5

Guidelines from the American Academy of Ophthalmology’s Pre-ferred Practice Pattern6 and the Pediatric Eye Disease Investigator

Group5

both set 3.00 D of myopia as a threshold for correction. A similar magnitude was established as a criterion to detect using pre-school vision screening by the Vision Screening Committee of the American Association of Pediatric Ophthalmology and Strabismus.7

Children in kindergarten or first grade typically do not use a chalkboard at school, but do most things at school at a desk, andare beginning to read. Thus, arguably even up to 1.5 D of myopia may not be important to correct for children in this age group.However, older children, beginning in the mid elementary schoolyears, when acuity can be tested accurately, warrant full correctionof myopia. The optometry community probably has less tolerancefor undercorrection of myopia in preschool children than does the

pediatric ophthalmology community. Reasons for this are unclear.However, there is no well-documented evidence that either under-or overcorrection of myopia stimulates or retards its progression.In fact, a recent well-controlled study failed to find any effect, even when myopia was overcorrected.8

Most pediatric ophthalmologists do not prescribe bifocals inyoung myopic children to retard myopia progression despite theCOMET conclusions. This is because most feel that a small differencein myopia as an adult is of little clinical relevance compared with theadded cost and cosmetic issues associated with bifocal wear. Similarthought processes limit the use of atropine and pirenzipine.

Correction of AstigmatismMild to moderate meridional astigmatism of Ͻ1.5 D produces

minimal degradation of visual acuity in the young child and is notfelt to be amblyogenic when symmetric.5 Oblique astigmatismdegrades visual acuity more, and may be amblyogenic with slightly less magnitude. High levels of astigmatism are typically found inthe American Indian population and therefore should be screenedfor.9 If astigmatism is balanced by spherical refractive error (com-pound myopic astigmatism or compound hyperopic astigmatism),the spherical equivalent places the Conoid of Sturm nicely on theretina. Also, depending upon the degree of accommodation used,the necessary portion of the visual environment may be sufficiently

focused to prevent amblyopia or significantly decreased acuity.

Spectacles for Children: A Pediatric Ophthalmologist’s Approach—Donahue 111




This may explain why some patients tolerate moderate levels of astigmatism without spectacles.

Preverbal children with symmetric astigmatism Ͻ1.5 D typi-cally do not need correction unless the astigmatism is associated with high myopia or high hyperopia. The AAPOS vision screening committee has set a threshold of 1.5 D of meridional cylinder as a target condition to detect with preschool vision screening.7 TheVision in Preschoolers (VIP) study group had a similar threshold10

as does the Pediatric Eye Disease Investigator Group.5

The Pedi-atric Preferred Practice Pattern for Children aged 2 to 3 yearssuggests prescribing at a slightly higher magnitude (2.0 D).6 Early elementary school-age children with 1.0 to 1.5 D of astigmatismmay benefit from correction, and a trial of spectacles is probably warranted for such children. However, the parents should be in-formed that not wearing spectacles will not harm a child’s vision,and if children choose not to wear the glasses, they should not forcethem to do so. For children in the late elementary school years, a postcycloplegic manifest refraction to compare best corrected vi-sual acuity with uncorrected acuity can help guide the decision of whether or not to prescribe spectacles for lower levels of astigma-

tism. In all such situations, one would prescribe the full cylinderthat can be tolerated.

Correction of Anisometropia

Anisometropia can be a very powerful amblyogenic factor, andanisometropic amblyopia is extremely difficult to detect with tra-ditional screening of preliterate children. However, the treatmentof what appears to be asymptomatic anisometropia detected eitheron a routine eye examination or following referral from a photore-fractive screening causes a dilemma for the ophthalmologist andoptometrist, because severe levels of anisometropia often cause

amblyopia but mild and moderate levels often do not.

11,12

In ad-dition, some children, especially those having a family history of amblyopia may develop amblyopia even with relatively small levelsof cylindrical or spherical ametropia. Finally, the natural history of anisometropic refractive error over time is not well established. Forexample, a child with moderate anisometropia may have theametropia completely resolve before school entry. Whether or notsuch anisometropia needs to be treated is unclear. Anisometropia usually produces amblyopia by the age of 3 years12; thus, if theuncorrected acuity is normal at that age, treatment is likely unnec-essary. In addition, recent evidence from the amblyopia treatmentstudy series has demonstrated that many preschoolers with mild tomoderate anisometropic amblyopia can have restoration of goodvisual acuity and stereopsis simply with spectacle correction alone,even at late ages.13,14 Hence, the importance of detecting andtreating very small levels of anisometropia in very young children,even when amblyopia is already present, is now open to question.

The threshold for treating anisometropia is also controversial.The vision screening committee of AAPOS recommends that pre-school screening detect children having Ͼ1.5 D anisometropia.7 A similar threshold was chosen by the VIP study group.10 Thresholds within 0.5 D of this value are suggested by the PEDIG5 and the American Academy of Ophthalmology Preferred Practice Pattern.6

Evidenced-based data support these thresholds. Weakley 11 eval-uated acuity results from several hundred anisometropic children

seen in his practice and concluded thatϾ1.0 D of spherical aniso-

metropic hyperopia andϾ1.5 D of cylindrical hypermetropia pro-duced an increased risk of amblyopia development. A retrospectivereview by Kutschke et al.15 found that anisometropic amblyopia wasnever associated with Ͻ1.5 D of anisometropia unless a coexisting strabismus was present, and that 1.0 D appeared to be a threshold at which anisometropia began to be associated with amblyopia.

An additional difficulty with treating anisometropic amblyopia is that the dominant fellow eye typically has minimal refractive

error, and therefore, many children do not appreciate any improve-ment and do not wish to wear the glasses. This is the primary instance in pediatric ophthalmology in which spectacle compli-ance is often difficult and needs to be forced; in most other situa-tions, compliance with spectacles wear is not difficult, even foryoung children, providing the above guidelines are adhered to (andthe prescription is correct!).

Treatment of anisometropia should consist of symmetric reduc-tion of hypermetropia of up to 2.0 D, prescribing the full amountof cylinder unless the child has an associated accommodative es-otropia. In this situation, all hypermetropia should be correctedalong with the full cylindrical correction. This practice has been

well established by clinical care, and is used in the PEDIG study protocols.5

Prescribing for Hypermetropia

Prescribing spectacles for hypermetropia also presents uniquechallenges. Uncorrected hypermetropia can produce accommoda-tive esotropia, strabismic amblyopia, and isoametropic (refractive)amblyopia. Fortunately, the practitioner is aided by evidence-based guidelines from population studies, as well as surveys.

Most young children are mildly hypermetropic; hence, moder-ate hypermetropia does not need to be corrected.6 The threshold

for treatment of hypermetropia, however, is controversial. Someevidence is available to help guide this decision. The prevalence of hypermetropia has been estimated in several studies.16,4,17 It isdifficult to compare the studies, as the definition of hypermetropia varies based upon whether the hypermetropia is thought to bepotentially pathologic4 or if it is simply being distinguished fromametropia.4,16,18 Nevertheless, these studies generally show thatfewer than 1% of healthy children have Ͼ4 D of hyper-metropia 4,15; other studies not referenced here have reached simi-lar conclusions.

A recent study examined the relationship of increasing hyper-metropia with degradation of visual acuity, and failed to dem-onstrate any significant reduction in acuity until hypermetropia exceeds 4 D.4 This threshold represents only a very small por-tion of the population.4,16

Prescribing spectacles for hypermetropia has also been postu-lated to improve reading ability. An excellent study by Helvestondemonstrated that in the absence of acuity degradation there is norelationship between reading ability, school performance, and levelof hypermetropia.19 Thus, children with moderate levels of hyper-metropia do not need spectacles simply to improve their near vi-sion or reading ability.

The treatment of moderate to high hypermetropia has beendemonstrated to decrease the risk of strabismus and amblyopia inprospective randomized studies. Atkinson et al. compared treat-

ment vs. no treatment of otherwise healthy hypermetropes.20 Chil-

112 Spectacles for Children: A Pediatric Ophthalmologist’s Approach—Donahue




dren with hypermetropia Ͼϩ3.50 D had a 13 times greater risk of developing strabismus or amblyopia than did children who had no

significant hypermetropia. Prescribing spectacles for the hyper-metropia decreased the risk substantially, but these children re-mained at a four times greater risk than the general population.These results suggest that levels of hypermetropia Ͼ4.00 D should warrant consideration of correction, especially if there is a family

history of strabismus or amblyopia, or if there is a poorly controlled

phoria without correction.Guidelines for treatment of hypermetropia have also been de-

termined from practice patterns and surveys. Most surveys havedemonstrated that optometrists have a lower threshold for prescrib-ing spectacles for children than do ophthalmologists. Reasons for this

are unclear. Lyons et al. performed a survey of 212 optometrists and102 ophthalmologists (both comprehensive and pediatric).21 They were asked whether they would prescribe spectacles for a 6-year-oldchild having between ϩ3.00 and ϩ4.00 D hypermetropia. Op-tometrists prescribed spectacles in 33% of instances, whereas only

5% of ophthalmologists did. For 2-year-old children, most oph-thalmologists and optometrists began to prescribe spectacles at a

level of ϩ5.00 D of hyperopia. A separate but similar survey of Pediatric Ophthalmologists

demonstrated that threshold levels for prescribing hypermetropia vary by child age and by the level of hyperopia.22 Fifty percent of

Pediatric Ophthalmologists would prescribe spectacles for childrenyounger than the age of 2 years when hyperopia reachedϩ5.00 D.For children older than age 2 years, 50% prescribed at 4.00 D of hyperopia.

The American Academy of Ophthalmology has guidelines forprescribing spectacles in their Preferred Practices Patterns (PPP).6

The PPP “Childhood Eye Examinations” indicates that “cyclople-gia is mandatory” in determining the refractive needs of children.

For children aged 3 years and younger, they suggest prescribing atϩ4.50 D of hypermetropia. For children aged 4 years or older,they indicate that spectacles should be prescribed if necessary to

improve acuity, or alleviate esotropia. No numerical thresholdguidelines are given in this situation.

A final set of guidelines are provided from papers regarding pre-school vision screening techniques. The American Academy of Pedi-atric Ophthalmology and Strabismus (AAPOS) Vision Screening Committee has published standards on what should be detected with

preschool vision screening. They suggest that vision screening instru-ments and tests should detect hypermetropia Ͼϩ3.50 D in any meridian.7 Likewise, the Vision in Preschoolers study, which is pri-

marily optometry based, defines hypermetropia Ͼϩ3.50 D as a con-dition that is important to detect.10

Concern abounds about the effect of spectacle correction of

hypermetropia on the eventual emmetropization of the eye. Stud-ies both support and oppose this notion. The issues regarding thiscomplicated topic are deferred to Dr. Mutti’s paper, which is partof this transcript.

When a decision is made to correct hypermetropia, how muchshould be corrected? Full correction in the nonstrabismic childshould be avoided as the accompanying blur at distance can be a factor that hinders compliance. The Pediatric Eye Disease Investi-gator Group has mandated symmetric reduction of up to 1.5 D of

spherical hypermetropia when treating anisometropic amblyopia

in the amblyopia treatment studies, with full correction of all hy-permetropia for the strabismic child.23–25

An exception to these threshold levels for prescribing for hyper-metropia is for children with developmental delay or Down Syn-drome. Some children, especially those with severe developmentdelay, are minimally interactive, and have very little need for spec-tacle correction. Children with significant cortical visual impair-ment, severe structural ocular abnormalities, and marked mental

retardation are examples. Many such children will not appreciatethe improvement provided by the spectacles and will not toleratethem on their face. In my experience, well-minded parents oftenbecome exhausted in futile attempts to keep such glasses on thesechildren, fearing that notwearing them will damage the child’s vision.In contrast, childrenwithDown syndrome are often hypo-accommo-dators, andhavelowaccommodativeamplitudes.Therefore,they may benefit from spectacle correction at lower thresholds.

In summary, a consensus appears to exist to prescribe spectaclesfor hypermetropia in children when hypermetropia exceeds 3.5 Dand acuity cannot be adequately determined. As accurate determi-nation of uncorrected visual acuity is often quite difficult until

approximately age 4 years, a better method considers a child’svisual demands, based upon the child’s age, his or her baseline levelof cycloplegic refractive error, and whether there is a family history of amblyopia or strabismus. A discussion with the parents thatreassures them that the lack of wearing spectacles will not harm thechild in the absence of anisometropia is also important. Finally,parents should be warned that children who develop eye crossing should be seen immediately, as such an observation mandates spec-tacle correction of full hypermetropia.

ACKNOWLEDGMENTS

This work was supported by Research to Prevent Blindness, New York, New York.

Received October 7, 2006; accepted December 6, 2006.

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Sean P. Donahue

Department of Ophthalmology Vanderbilt University

1211 21st Avenue S 104 Medical Arts Building

Nashville, TN 37212-1348 e-mail: [email protected]

114 Spectacles for Children: A Pediatric Ophthalmologist’s Approach—Donahue


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