Guidelines for Prescribing Eyeglasses in Young Children

by Patrick A. DeRespinis, MD

Introduction

Prescribing eyeglasses in young children is a particular dilemma for eye care professionals.
No guidelines exist and practitioners frequently rely on their own experience and
preconceived information, which are not always based on science. Usually, children younger
than 3 years cannot offer any feedback in the decision making process of physicians
prescribing spectacles. There is also a frequent lack of cooperation in children of this age
group.

A child's visual requirements differ greatly from those of an adult. The development of
amblyopia as it pertains to myopia, astigmatism, hyperopia, anisometropia, and strabismus,
does not occur in the adult population, yet it is the most important consideration in young
children. Parental and child noncompliance in treatment also impedes the practitioner from
obtaining a favorable visual outcome.

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A firm understanding of examination techniques is important, but knowledge of the

development of the human eye and changes in refraction is essential. This tutorial reviews
these areas and supplements the information with survey results gathered from the nation's
pediatric ophthalmologists. Interesting trends, therapies, and controversies in prescribing
eyeglasses will also be discussed.

History and Examination

The proper and comprehensive ophthalmic evaluation of a young child should include the
following:

History
o Family history
o Birth history and general health
o Behavior
Assessment of visual acuity
Detection of any physical disorders, which could affect acuity
Motility exam
Cycloplegic retinoscopy

A careful history of the child's behavior at home may often reveal a potential visual
deficiency. Significantly myopic children often tend to hold objects or books close to their
face. They may squint and also sit close to the television, yet occasionally myopic toddlers
give their parents no indication they have any visual deficiency. They tend to adapt to their
visual state due to their relative lack of appreciation of normal vision.

Small to moderate amounts of hyperopia appear to be the norm in preverbal children and are
accommodated well as long as esotropia does not occur. Higher amounts of bilateral
hyperopia and astigmatism can cause ametropic amblyopia due to blurring of perceived
images at both near and far. Anisometropic amblyopia can be particularly insidious because a
relatively small amount of refractive imbalance can cause a significant unilateral visual loss
that is not always detected by the parents or the pediatrician.

Children born premature, particularly those with retinopathy of prematurity, are more likely
to develop myopia and/or astigmatism.1,2 The child's general health is also important because
congenital and hereditary disorders can be associated with refractive errors (e.g., Down
syndrome,3 Marfan syndrome,4 and Sticker disease5). Myopia can be inherited as either an
autosomal dominant or autosomal recessive trait, with recessive often mistaken as a sporadic
event. A good family history is essential.

Quantitating the visual acuity in a preverbal child, although not impossible, is time
consuming, not always accurate, and impractical for most busy practices.6 Preferential
looking techniques such as Teller7 and Cardiff8, and Vernier cards9 may provide results
skewed by false positives due to observer bias and false negatives due to lack of child
cooperation. Fixation responses are also obscured by the presence of underlying disorders
such as nystagmus or strabismus. Children suspected of being visually impaired may also
undergo electrophysiological testing such as visual evoked potentials (VEP). The results of
VEPs correlate well with behavioral acuity estimates. However, unfortunately, the use of a
VEP is impractical due to time restraints and cost. It is still a useful diagnostic tool in difficult
cases.10,11

In the majority of practices, the detection of visual asymmetry in preverbal children is usually
obtained by using small test objects of interest to the child. Using such acronyms as F&F (fix
and follow) or CSM (central, steady, and maintained fixation), the visual acuity of young
children is qualitatively noted on charts. The term "resistance to cover" is also an effective
way to describe a dominant versus amblyopic eye. A child with strabismus who "cross
fixates" usually has relatively equal vision due to the obvious lack of preference in fixation.
These observations must be correlated with the entire history and the pertinent clinical
findings obtained during the examination.

Possible organic disorders must be eliminated as a cause of visual impairment before

eyeglasses are prescribed. Even relatively inconspicuous corneal and lenticular opacities can
be the cause of visual loss in the amblyogenic period. A small retinal lesion can also cause
visual loss and strabismus in young children. Therefore, a funduscopic exam is essential to
rule out entities such as retinoblastoma and toxoplasmosis.

The motility evaluation is important in differentiating among forms of strabismus. Measuring

the deviation at near and far and correlating the results with a good cycloplegic refraction
distinguish between accommodative and nonaccommodative esotropia, and also high AC/A
ratio deviations. Intermittent exotropias of the divergence excess type also vary at near and
far fixation. Incomitancy of horizontal gaze can identify Duane's retraction syndrome and
third and sixth nerve palsies, among other entities. Vertical imbalances can identify A and V
patterns and fourth nerve palsies. Occasionally, V pattern esotropias are confused with high
AC/A ratio deviations due to improper measuring technique.

Developmental Aspects and Refractive Findings

The mean axial length of a full-term infant's eye is approximately 16.5 mm with an average
axial length increase of 3.75 mm in the next 18 months.12 By the age of 13 years, the mean
value is 23 mm, which is near the adult mean of 24.5 mm.13 This explains why 75% of
newborns have some form of hyperopia opposed to 25% having myopia.14 The mean
refractive error of a full-tem infant has been found to be approximately 2 D with +/-2 D of
standard deviation.15 Myopia appears to be much more common in premature infants, along
with astigmatism and/or anisometropia.1,2 Anisometropia is relatively common at birth, but
decreases fairly rapidly thereafter. In a normal child, hyperopia can increase to the end of the
seventh year and myopia increases from age 8 to 13 years, on the average.16 Approximately
19% of normal infants have astigmatism of 1 D or more, which is at least twice the amount of
adults. The trend is toward decreasing incidence of astigmatism with increasing age.17

The accommodative range has been determined to be a function of advancing age. The
amplitude is approximately 14 D (+/-2 D) at 8 years of age. It decreases by 1 D every 4 years
until the age of 40.18 Therefore, it is likely that a newborn has an accommodative reserve in
excess of 14 D, and corrections for infants other than those with high hyperopia are unlikely.

Newborns preferentially view face-like stimuli and by 1 month of age can discriminate
between a circle and a triangle. 19,20 Contrary to popular belief, a normal infant's visual system
is capable of resolving a 20/20 target by at least 18 months of age.21 Fusion develops between
4.5 and 6 months of age and stereopsis has been demonstrated at approximately 3 months of
age.22,23

Indications for Spectacle Correction

The following factors are indications for eyeglasses in young children. The overall visual
effect of correcting the refractive error can provide multiple benefits, which may be
reciprocally related:

Prevent amblyopia (e.g., anisometropic, strabismic, and ametropic)

Correct strabismus
Preserve binocularity
Improve acuity
Other
o Restore comfortable vision
o Enhance visual efficiency
o Prevent progression of visual impairment
o Protect a nonamblyopic eye
o Prism therapy

Refractive Situations
The diagnosis of ametropic (bilateral) amblyopia can usually occur with a hyperopic
correction of 5 D or higher. Amblyopia in bilateral myopia does not generally occur because
of the preservation of near point vision. Unilateral high myopia can cause a significant
amblyopia but may be treated with spectacles, unlike the unilateral hyperopia found in
aphakia. This can be explained by Knapp's rule, which states, "If the ametropia is axial in
origin, a correcting lens placed on the anterior focal plane of the eye produces an image equal
in size with that of the emmetropic eye." 24 The following are refractive situations for which
spectacles are prescribed:

Bilateral myopia
Bilateral hyperopia
Bilateral astigmatism
 Types of anisometropia
o Hyperopic
o Myopic
o Astigmatic
o Compound
o Unilateral high myopia

Strabismic Situations
Generally, patients with strabismus caused by accommodative esotropia, high AC/A ratio
esotropia, or forms of exotropia require eyeglasses.

Slide 1. Flat Top 35-type bifocals.

Slide 2. The improper bifocal height adjustment for a young

child's eyeglasses.

When bifocals (BF) are indicated, the proper segment must be chosen:

Flat Top 35 BF (Slide 1). Fused BF segment (glass) or molded (plastic), with a thin segment
line. There is a minimal blur area and the 35-mm segment covers the majority of the near
visual field for a child. There is uniform power of add throughout the segment. The flat top
35 BF is the most inexpensive type of BF and is easy to fit. The optician should bisect the
pupils with the segment tops (Slide 2 and Slide 3).
 Slide 3. The correct bifocal height adjustment for a young child's
eyeglasses.

Slide 4. Executive-type bifocals.

Executive BF (Slide 4). Molded BF segment with a front segment ridge. There is a larger blur
area and the segment covers the entire near visual field. There is a uniform add power
throughout the segment and they are inexpensive and easy to fit. The executive BF is not
available in polycarbonate. The pupils should be bisected.

Progressive Lens (Slide 5). Multifocal, molded lens with no segment line. Cosmetically
favorable with no blur area but visual distortion as you go further from the visual axis. The
power of the add increases as you go downward. They are expensive and difficult to fit. In
infants

Slide 5. A multifocal-type (Progressive) lens.

and toddlers, the frames are too small to accommodate the progressive lens and still allow for
distance vision. The progressive near power must be set 4 mm higher.25 They are generally
recommended in the nonamblyogenic period (older than 8 years) and in smaller deviations
(ages 6 to 8 years).

Contraindications for Spectacles

The practitioner must decide whether the indications for eyeglasses outweigh the reasons for
not prescribing them. These reasons include:

Low visual demands

Likely noncompliance
Cost
Interruption of "emmetropization"

Emmetropization is the combination of active (visual feedback) and passive (eye growth)
factors, which during development of the visual system, guide the refractive error towards
emmetropia and then maintain it at an approximately emmetropic level.26
Trends in Spectacle Prescribing

Slide 6. The threshold amount of myopia for which

ophthalmologists would prescribe eyeglasses in 1-year-old child
and 2- to 3-year-old children, based upon a survey of AAPOS
members.

Slide 7. The threshold amount of hyperopia in which

ophthalmologists would prescribe eyeglasses in orthophoric
children 1 year old and 2 to 3-years old, based upon a survey of
AAPOS members.

Threshold Amounts of Refractive Error

U.S. pediatric ophthalmologists were asked an array of questions pertaining to spectacles in
preverbal children. The prescribed threshold amounts of myopia, hyperopia, and symmetrical
astigmatism in 1-year-old and 2- to 3-year-old children were the initial questions. Because of
low visual demands, 1-year-old children are not prescribed myopic corrections until acuity is
-4 D, whereas the majority of 2- to 3-year olds are given spectacles at -2 D to -3.75 D (Slide
6). In symmetrical hyperopia, 1-year-old children can usually tolerate larger amounts without
correction because of their larger accommodative reserves. Prescribing hyperopic corrections
too early may also interfere with emmetropization (Slide 7). Corrections for symmetrical
astigmatism are generally given at 2.25 D to 3 D in both age groups to prevent ametropic
amblyopia (Slide 8). Practitioners wait longer to prescribe astigmatic glasses in 1-year-old
children due to decreased visual demands and to allow for the normal reductions in
astigmatism, which occur with age.

Slide 8. The threshold amount of symmetrical astigmatism in

which ophthalmologists would prescribe eyeglasses in 1-year-old
and 2- to 3-year-old children, based upon a survey of AAPOS
members.

Most ophthalmologists who responded would prescribe between 3 D and 6.25 D of correction
in an orthophoric preverbal child with a 7 cycloplegic retinoscopy in both eyes. The
prevention of ametropic amblyopia is the chief concern in this case because of the larger
amount of hyperopia. The total amount of correction is often reduced for visual comfort since
the child is orthophoric, yet it still enhances the child's ability to focus.

Anisometropia
Anisometropia is fairly common at birth but decreases rapidly over the first year. The
majority of pediatric ophthalmologists are concerned with the development of amblyopia and
the loss of binocular vision with hyperopic anisometropia. Fifty percent prescribe spectacles
when the amount is more than 1.50 D. The responses were similar with regard to myopic
anisometropia of more than -1.50 D (41%) and astigmatic anisometropia of greater than 1.50
D (60%). In unilateral high myopia (assuming one eye is -11.50 D and the other is plano),
59% prescribe the same amount in spectacle correction, while 33% utilize a contact lens. In
an orthophoric child with 1.50 D in one eye and -3 D in the other, the majority of respondents
maintain the difference in prescriptions with 38% giving 0.50 D and -4 D, and 23 % giving
1.50 D and -3 D, respectively.
Accommodative Esotropia
When queried on the least amount of hypermetropia for which eyeglasses would be
prescribed in children at 1 year of age and 2 to 3 years of age, if a child had a 30 pd esotropia,
the respondents chose the following: In the 1-year-old group, 49% prescribed at 2.25 D to 3
D. In the 2- to 3-year-old age group, 61% prescribed at 1 D to 2 D. Cholinesterase inhibitors
were prescribed infrequently. In 1-year-old children, it is unlikely that 30 pd of esotropia will
be corrected by small amounts of hyperopia, especially when hyperopia is the norm and
congenital esotropia is a common entity. As the child matures, accommodative esotropia will
become a more likely diagnosis and this is why we see smaller amounts of hyperopic
correction prescribed (Slide 9).

High AC/A Ratio

In young children with accommodative esotropia not controlled at near with their full
hyperopic correction, 62% of pediatric ophthalmologists believed the use of bifocals was
necessary when 9 pd to 15 pd of esotropia was present at near fixation. Twenty-one percent
prescribed BFs at 8 pd or less of esotropia. The attempt to preserve binocular vision in this
age group is the reason for this trend.

Slide 10. The frequency bifocals are prescribed in children with

high AC/A ratios not corrected at near by their hyperopic
eyeglasses, based upon a survey of AAPOS members.

Slide 11. The frequency bifocals are prescribed in orthophoric

children with myopia, based upon a survey of AAPOS members.
Bifocals
When asked how often bifocals were prescribed in children with high AC/A ratios not
corrected at near by their hyperopic eyeglasses, the respondents chose to always or frequently
prescribe them a total of 87% of the time (Slide 10). In contrast, bifocals in orthophoric
myopes were never prescribed 87% of the time and only occasionally given in 12% of the
cases (Slide 11). Obviously, bifocals in myopia are a controversial issue because properly
corrected myopia is unlikely to cause asthenopia, near blurring, or myopic progression.

Exotropia
Most practitioners opt to correct vision in an attempt to control an intermittent exotropia.
Sixty-three percent of respondents would treat young people with between 1.25 D and 1.75 D
of astigmatic correction when exotropia is present. Few would attempt to treat this form of

Slide 12. The frequency minus lenses are prescribed in

emmetropic or slightly hyperopic children with intermittent
exotropia, based upon a survey of AAPOS members.

strabismus with "overminusing" (46% utilize it on occasion but 42% never use it). This is
only a temporary therapy and leads to asthenopia and noncompliance (Slide 12).

Protection
The prescribing of polycarbonate lenses in a monocular sighted child should be standard
procedure. Unfortunately, when asked, only 61% of pediatric ophthalmologists routinely
prescribe them (Slide 13). Protection of the nonamblyopic eye is imperative. It is a policy
statement of the American Academy of Ophthalmology, American Academy of Pediatrics,
and American Association for Pediatric Ophthalmology and Strabismus, which also makes it
a litigation issue if an unfortunate injury befalls an unprotected child.
 Slide 13. The frequency polycarbonate lenses are prescribed for
monocular children (one eye with vision of 20/200 or less), based
upon a survey of AAPOS members.

Conclusion

In making intelligent decisions on prescribing eyeglasses in a preverbal child a clinician

must:

Obtain a good history and perform a thorough examination

Be aware of the developmental and refractive changes in children
Know the refractive and strabismic situations that necessitate spectacles
Decide whether the indications for eyeglasses outweigh the reasons influencing the
practitioner not to prescribe them.

Table 1 and Table 2 are based on a survey of the nation's pediatric ophthalmologists and the
information found in this text. These tables can be used when prescribing eyeglasses in young
children.

Table 1. Recommendations for Prescribing Eyeglasses in Preverbal Children*

Age
0 mo to 1 yr 1 to 2 yrs 2 to 3 yrs
-4 D or -3 D or
Myopia (symmetrical) -2 D or greater
greater greater
Hyperopia
6 D or 5 D or
(symmetrical 5 D or greater
greater greater
and orthophoric)
Hyperopia (e.g.,
Greater than 2 Greater than 2 Greater than
accommodative ET of
D D 1.5 D
approx 30 pd)
Astigmatism 2.50 D or 2.50 D or
2 D or greater
(symmetrical) greater greater
Anisometropia
-2.50 D or -2.50 D or
Myopic -2 D or greater
greater greater
1.50 D or 1.50 D or
Hyperopic 2 D or greater
greater greater
1.50 D or 1.50 D or
Astigmatic 2 D or greater
greater greater

*Based on a survey of AAPOS members.

Reduce prescription by 1 D to 2 D. If the cycloplegic refraction is greater than 7 D, the
prescription may be reduced approximately 3 D.
Give full cycloplegic refraction. If greater than 3 D, approximately 0.5 D may be cut
from the final prescription.

Table 2. Other Indications for Spectacle Correction in Preverbal Children

Bifocals in high AC/A ratios where the near deviation is

greater than 10 pd to 15 pd.

Polycarbonate lenses for monocular children (one eye

with 20/200 acuity or less).

Lesser amounts of astigmatism or myopia in children

with X(T).

Unilateral, high axial myopia. A contact lens may also

be prescribed.

Prescribing Spectacles in Children: A Pediatric

Ophthalmologist's Approach
DONAHUE, SEAN P. MD, PhD

Author Information

Departments of Ophthalmology, Pediatrics, and Neurology, Vanderbilt University School of

Medicine, Nashville, Tennessee

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

Abstract

The 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 lesser visual demands; their more
proximal working distance; and their more plastic visual cortex, which places them at risk for
amblyopia and strabismus. Most guidelines for spectacle treatment in such children are based
upon clinical experience rather than randomized, masked clinical trials. Fortunately, the
prescribing thresholds suggested by optometrists are quite similar to those suggested by
pediatric ophthalmologists.

Children 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
needs of adults onto young children. Doing so creates cognitive dissonance for parents, who
feel their child's visual system will be damaged 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. Obtaining evidence of the usefulness of spectacles for
children with mild and moderate myopia, hyperopia, or astigmatism, and an otherwise
healthy visual system would be difficult, if not impossible. Therefore, most guidelines are
obtained by surveys of practitioners, and are based upon experience acquired over many
years. Fortunately, it appears as though optometrists and ophthalmologists whose practices
are dedicated to children usually have relatively 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 prescribe based upon the difference between uncorrected and
corrected visual 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 with standard techniques of measurement. Although such
measurements can be done, their high variability limits their clinical usefulness in making a
decision about prescribing. Even after a child becomes verbal, the measured acuity often
underestimates the true acuity, because the child may tire, or simply have no interest in
reading small letters on an eye chart. One must therefore also consider the level of refractive
error, as determined with cycloplegia. Therefore, cycloplegic refraction is mandatory in
determining the spectacle needs of children.

Most pediatric ophthalmologists use cyclopentolate 1% to obtain cycloplegia for the

examination. When the detection of latent hypermetropia is crucial (a child with new onset
esotropia, or residual strabismus in a previously well-controlled accommodative esotrope), 2
drops of cyclopentolate are administered 5 min apart. Refraction should be carried out 30 min
following the second drop. 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% phenylephrine are therefore used in addition to 2% cyclopentolate in
black and Hispanic children. Most hospital pharmcotherapeutic committees prohibit mixing
of medication, so a noncommercial mix of agents (or a spray) is not used in most academic
practices. Some pediatric ophthalmologists will instill one drop of topical proparacaine before
cyclopentolate to decrease the stinging (and possibly enhance absorption). I do not, as
proparacaine also stings, and the combination means that the child needs 4 drops rather than
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 make it not useful in a busy pediatric office. Atropine can be used for difficult
refraction but in my experience is almost never necessary.

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

Children also have different accommodative abilities than adults. There is vast literature,
dating back to the early 1900s, that describes the extremely high levels of accommodation
that young children possess.1,2 Healthy children in their first decade of life typically possess
12 D or more of accommodative function.3 Accordingly, even moderate uncorrected
hypermetropia does not degrade acuity in young children.4 As a result, there is minimal need
to correct moderate hyperopia, except when it is associated with strabismus.

The final unique characteristic of a child's visual system is its increased risk of amblyopia,
from anisometropic, strabismic, or high spherical or cylindrical refractive errors. In contrast
to anisometropia or strabismic adults who do not jeopardize their visual systems by failing to
correct the nondominant eye, the young child is at risk of permanent vision loss unless the
eyes are straight and have symmetrical and adequately focused retinal images. However, the
level of refractive error that produces amblyopia for each particular child is different, and
depends on other factors, such as the family history.5 Thus, no firm evidence-based
recommendations can be made regarding the threshold levels of refractive error that need to
be corrected to protect against the development of amblyopia.

The above characteristics of children mean that spectacle prescribing for children is an art,
requiring interpretation of the child's refractive error and visual acuity within the global
evaluation of the child. This is especially true for children who are not yet able to provide an
accurate objective visual acuity measurement, and for whom the only information available is
the cycloplegic refractive error, and the visual behavior of the child. The remainder of this
manuscript will detail the thought processes many pediatric ophthalmologists use to
determine when to prescribe spectacles.

Prescribing for Myopia

Because of the minimal risk of amblyopia with symmetrical myopia, prescribing for
symmetric myopia should solely be based upon anticipated visual acuity needs. Two
fundamental observations underscore the minimal need to prescribe spectacles for symmetric
low levels of myopia in young children. First the visual acuity demands of very young
children are unlikely to exceed 20/40 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 require such fine resolution. The second factor
impacting prescribing for myopia in children is their proximity to the visual target. Unlike
adolescents 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's face,
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
probably 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 objects more than 2 to 3 feet away. Therefore, -3.00 D of myopia is a threshold
one may consider correcting in the very young child.5 Guidelines from the American
Academy of Ophthalmology's Preferred 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 preschool 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, and are 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 school years, when acuity can be tested accurately,
warrant full correction of myopia. The optometry community probably has less tolerance for
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 in young myopic children to retard
myopia progression despite the COMET conclusions. This is because most feel that a small
difference in myopia as an adult is of little clinical relevance compared with the added cost
and cosmetic issues associated with bifocal wear. Similar thought processes limit the use of
atropine and pirenzipine.

Correction of Astigmatism

Mild to moderate meridional astigmatism of <1.5 D produces minimal degradation of visual

acuity in the young child and is not felt to be amblyogenic when symmetric. 5 Oblique
astigmatism degrades visual acuity more, and may be amblyogenic with slightly less
magnitude. High levels of astigmatism are typically found in the American Indian population
and therefore should be screened for.9 If astigmatism is balanced by spherical refractive error
(compound myopic astigmatism or compound hyperopic astigmatism), the spherical
equivalent places the Conoid of Sturm nicely on the retina. 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. This may explain why some
patients tolerate moderate levels of astigmatism without spectacles.

Preverbal children with symmetric astigmatism <1.5 D typically 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 The Vision in Preschoolers (VIP) study group had
a similar threshold10 as does the Pediatric Eye Disease Investigator Group.5 The Pediatric
Preferred Practice Pattern for Children aged 2 to 3 years suggests prescribing at a slightly
higher magnitude (2.0 D).6 Early elementary school-age children with 1.0 to 1.5 D of
astigmatism may benefit from correction, and a trial of spectacles is probably warranted for
such children. However, the parents should be informed that not wearing spectacles will not
harm a child's vision, and if children choose not to wear the glasses, they should not force
them to do so. For children in the late elementary school years, a postcycloplegic manifest
refraction to compare best corrected visual acuity with uncorrected acuity can help guide the
decision of whether or not to prescribe spectacles for lower levels of astigmatism. In all such
situations, one would prescribe the full cylinder that can be tolerated.
Correction of Anisometropia

Anisometropia can be a very powerful amblyogenic factor, and anisometropic amblyopia is

extremely difficult to detect with traditional screening of preliterate children. However, the
treatment of what appears to be asymptomatic anisometropia detected either on a routine eye
examination or following referral from a photorefractive screening causes a dilemma for the
ophthalmologist and optometrist, because severe levels of anisometropia often cause
amblyopia but mild and moderate levels often do not.11,12 In addition, some children,
especially those having a family history of amblyopia may develop amblyopia even with
relatively small levels of cylindrical or spherical ametropia. Finally, the natural history of
anisometropic refractive error over time is not well established. For example, a child with
moderate anisometropia may have the ametropia completely resolve before school entry.
Whether or not such anisometropia needs to be treated is unclear. Anisometropia usually
produces amblyopia by the age of 3 years12; thus, if the uncorrected acuity is normal at that
age, treatment is likely unnecessary. In addition, recent evidence from the amblyopia
treatment study series has demonstrated that many preschoolers with mild to moderate
anisometropic amblyopia can have restoration of good visual acuity and stereopsis simply
with spectacle correction alone, even at late ages.13,14 Hence, the importance of detecting and
treating 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 preschool screening detect children having >1.5 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. Weakley11 evaluated acuity results from
several hundred anisometropic children seen in his practice and concluded that >1.0 D of
spherical anisometropic hyperopia and >1.5 D of cylindrical hypermetropia produced an
increased risk of amblyopia development. A retrospective review by Kutschke et al.15 found
that anisometropic amblyopia was never associated with <1.5 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
improvement and do not wish to wear the glasses. This is the primary instance in pediatric
ophthalmology in which spectacle compliance is often difficult and needs to be forced; in
most other situations, compliance with spectacles wear is not difficult, even for young
children, providing the above guidelines are adhered to (and the prescription is correct!).

Treatment of anisometropia should consist of symmetric reduction of hypermetropia of up to

2.0 D, prescribing the full amount of cylinder unless the child has an associated
accommodative esotropia. In this situation, all hypermetropia should be corrected along 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 unique challenges. Uncorrected

hypermetropia can produce accommodative 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, moderate hypermetropia does not
need to be corrected.6 The threshold for treatment of hypermetropia, however, is
controversial. Some evidence is available to help guide this decision. The prevalence of
hypermetropia has been estimated in several studies.16,4,17 It is difficult to compare the studies,
as the definition of hypermetropia varies based upon whether the hypermetropia is thought to
be potentially pathologic4 or if it is simply being distinguished from ametropia.4,16,18
Nevertheless, these studies generally show that fewer than 1% of healthy children have >4 D
of hypermetropia4,15; other studies not referenced here have reached similar conclusions.

A recent study examined the relationship of increasing hypermetropia with degradation of

visual acuity, and failed to demonstrate any significant reduction in acuity until
hypermetropia exceeds 4 D.4 This threshold represents only a very small portion of the
population.4,16

Prescribing spectacles for hypermetropia has also been postulated to improve reading ability.
An excellent study by Helveston demonstrated that in the absence of acuity degradation there
is no relationship between reading ability, school performance, and level of hypermetropia.19
Thus, children with moderate levels of hypermetropia do not need spectacles simply to
improve their near vision or reading ability.

The treatment of moderate to high hypermetropia has been demonstrated to decrease the risk
of strabismus and amblyopia in prospective randomized studies. Atkinson et al. compared
treatment vs. no treatment of otherwise healthy hypermetropes.20 Children with
hypermetropia >+3.50 D had a 13 times greater risk of developing strabismus or amblyopia
than did children who had no significant hypermetropia. Prescribing spectacles for the
hypermetropia decreased the risk substantially, but these children remained at a four times
greater risk than the general population. These results suggest that levels of hypermetropia
>4.00 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 determined from practice patterns
and surveys. Most surveys have demonstrated that optometrists have a lower threshold for
prescribing spectacles for children than do ophthalmologists. Reasons for this are unclear.
Lyons et al. performed a survey of 212 optometrists and 102 ophthalmologists (both
comprehensive and pediatric).21 They were asked whether they would prescribe spectacles for
a 6-year-old child having between +3.00 and +4.00 D hypermetropia. Optometrists prescribed
spectacles in 33% of instances, whereas only 5% of ophthalmologists did. For 2-year-old
children, most ophthalmologists and optometrists began to prescribe spectacles at a level of
+5.00 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 children younger than
the age of 2 years when hyperopia reached +5.00 D. For children older than age 2 years, 50%
prescribed at 4.00 D of hyperopia.

The American Academy of Ophthalmology has guidelines for prescribing spectacles in their
Preferred Practices Patterns (PPP).6 The PPP Childhood Eye Examinations indicates that
cycloplegia is mandatory in determining the refractive needs of children. For children aged 3
years and younger, they suggest prescribing at +4.50 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 threshold guidelines are given in this situation.

A final set of guidelines are provided from papers regarding preschool vision screening
techniques. The American Academy of Pediatric Ophthalmology and Strabismus (AAPOS)
Vision Screening Committee has published standards on what should be detected with
preschool vision screening. They suggest that vision screening instruments and tests should
detect hypermetropia >+3.50 D in any meridian.7 Likewise, the Vision in Preschoolers study,
which is primarily optometry based, defines hypermetropia >+3.50 D as a condition that is
important to detect.10

Concern abounds about the effect of spectacle correction of hypermetropia on the eventual
emmetropization of the eye. Studies both support and oppose this notion. The issues
regarding this complicated topic are deferred to Dr. Mutti's paper, which is part of this
transcript.

When a decision is made to correct hypermetropia, how much should be corrected? Full
correction in the nonstrabismic child should be avoided as the accompanying blur at distance
can be a factor that hinders compliance. The Pediatric Eye Disease Investigator 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
hypermetropia for the strabismic child.23-25

An exception to these threshold levels for prescribing for hypermetropia is for children with
developmental delay or Down Syndrome. Some children, especially those with severe
development delay, are minimally interactive, and have very little need for spectacle
correction. Children with significant cortical visual impairment, severe structural ocular
abnormalities, and marked mental retardation are examples. Many such children will not
appreciate the improvement provided by the spectacles and will not tolerate them on their
face. In my experience, well-minded parents often become exhausted in futile attempts to
keep such glasses on these children, fearing that not wearing them will damage the child's
vision. In contrast, children with Down syndrome are often hypo-accommodators, and have
low accommodative amplitudes. Therefore, they may benefit from spectacle correction at
lower thresholds.

In summary, a consensus appears to exist to prescribe spectacles for hypermetropia in

children when hypermetropia exceeds 3.5 D and acuity cannot be adequately determined. As
accurate determination of uncorrected visual acuity is often quite difficult until approximately
age 4 years, a better method considers a child's visual demands, based upon the child's age,
his or her baseline level of cycloplegic refractive error, and whether there is a family history
of amblyopia or strabismus. A discussion with the parents that reassures them that the lack of
wearing spectacles will not harm the child 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 spectacle correction of full hypermetropia.