Journal of Optometry (2016) 9, 22---31

www.journalofoptometry.org

ORIGINAL ARTICLE

A survey of the criteria for prescribing in cases

of borderline refractive errors
Einat Shneor a,∗ , Bruce John William Evans b,c , Yael Fine a , Yehudit Shapira a ,
Liat Gantz a , Ariela Gordon-Shaag a

a
Department of Optometry, Hadassah Academic College, Jerusalem, Israel
b
Institute of Optometry, London, United Kingdom
c
City University London, London, United Kingdom

Received 25 June 2015; accepted 12 September 2015

KEYWORDS Abstract
Refractive errors; Purpose: This research investigated the reported optometric prescribing criteria of Israeli
Optometric optometrists.
prescribing; Methods: An online questionnaire based on previous studies was distributed via email and social
Optical prescription; networking sites to optometrists in Israel. The questionnaire surveyed the level of refractive
Prescribing criteria; error at which respondents would prescribe for different types of refractive error at various
Symptoms ages with and without symptoms.
Results: 124 responses were obtained, yielding a response rate of approximately 12---22%, 92%
of whom had trained in Israel. For all refractive errors, the presence of symptoms strongly
influenced prescribing criteria. For example, for 10---20 year old patients the degree of hyperopia
for which 50% of practitioners would prescribe is +0.75 D in the presence of symptoms but twice
this value (+1.50 D) in the absence of symptoms. As might be expected, optometrists prescribed
at lower degrees of hyperopia for older compared with younger patients. There was a trend
for more experienced practitioners to be less likely to prescribe for lower degrees of myopia
and presbyopia. Practitioner gender, country of training, the type of practice environment, and
financial incentives were not strongly related to prescribing criteria.
Conclusions: The prescribing criteria found in this study are broadly comparable with those
in previous studies and with published prescribing guidelines. Subtle indications suggest that
optometrists may become more conservative in their prescribing criteria with experience.
© 2015 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

∗ Corresponding author at: Research and Senior Lecturer, Hadassah Academic College, Optometry and Vision Science, 37 hanevi’im St.,

P.O.Box 1114, Jerusalem, 91010, Israel.

E-mail addresses: [email protected], [email protected] (E. Shneor).

http://dx.doi.org/10.1016/j.optom.2015.09.002
1888-4296/© 2015 Spanish General Council of Optometry. Published by Elsevier España, S.L.U. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Criteria for prescribing borderline refractive errors 23

PALABRAS CLAVE Encuesta sobre criterios de prescripción en casos de errores refractivos límite
Errores refractivos;
Resumen
Prescripción
Objetivo: Este estudio investigó los criterios de prescripción optométrica reportados por los
optométrica;
optometristas israelíes.
Prescripción óptica;
Métodos: Se distribuyó un cuestionario online basado en estudios previos, utilizando el correo
Criterio de
electrónico y las redes sociales, a los optometristas de Israel. Dicho cuestionario sondeaba
prescripción;
el nivel de error refractivo para el cual los encuestados realizarían prescripciones, para los
Síntomas
diferentes tipos de error refractivo, a diversas edades y con variedad de síntomas.
Resultados: Respondieron 124 personas, obteniéndose un índice de respuesta de aproximada-
mente el 12---22%. El 92% de los participantes se había formado en Israel. En hipermetropía, la
presencia de síntomas influyó considerablemente en los criterios de prescripción. Por ejemplo,
para pacientes de 10-20 años de edad, el grado de hipermetropía para el cual el 50% de los facul-
tativos realizaría una prescripción sería de +0,75 D en presencia de síntomas, pero se duplicaría
este valor (+1,50 D) en ausencia de ellos. Como cabría esperar, los optometristas prescribirían a
personas mayores grados más bajos de hipermetropía, en comparación a las personas jóvenes.
Los facultativos más experimentados reflejaron una tendencia de menor probabilidad de pres-
cripción cuanto menor fuera el grado de miopía y presbicia. El sexo del facultativo, el país
de formación, el tipo de entorno de práctica, y los incentivos financieros no guardaron una
relación sólida con los criterios de prescripción. Los criterios de prescripción hallados en
este estudio son ampliamente comparables a los de los estudios previos y a los de las guías
publicadas.
Conclusiones: Los criterios de prescripción optométrica en Israel pueden compararse a las
recomendaciones de las guías publicadas por país de formación de los facultativos, profe-
sional, género, o entorno laboral. Existen débiles indicadores que sugieren que los optometristas
pueden volverse más conservadores, en cuanto a criterios de prescripción, con la experiencia.
© 2015 Spanish General Council of Optometry. Publicado por Elsevier España, S.L.U. Este
es un artículo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction conditions and the topic was reviewed by O’Leary and

Evans.8
One of the most frequent decisions that optometrists make In Israel, following the 1991 Optometry Law9 two aca-
is whether to prescribe a correction for refractive errors, demic programs in optometry were established in 1995, with
whether it be with spectacles or contact lenses. This deci- the first intake graduating in 1999. Most of the optometrists
sion is generally straightforward if a large uncorrected in Israel are graduates of those two schools, which provide
anomaly is present, but becomes much more difficult in bor- a four-year undergraduate degree in optometry based on
derline cases. Considering the fact that most optometrists the European Diploma Syllabus. The schools, Hadassah Aca-
make this decision several times every day, it is surprising demic College10 and Bar Ilan University, share several clinical
that little research has been undertaken to help determine faculty. In Israel, prescribing is carried out primarily by
at what point optometrists typically intervene. optometrists and not by ophthalmologists; therefore we
There are several guidelines that have been published limited this survey to optometrists.
to help optometrists and ophthalmologists when prescrib- This study aimed to assess prescribing decisions for bor-
ing for refractive errors with either specific or general derline refractive prescriptions by Israeli optometrists and
guidelines. The American Optometric Association provides whether prescribing is influenced by working environment,
guidelines for correction of hyperopia, myopia and pres- gender and years of experience.
byopia based on consensus among expert optometrists.1---3
The American Academy of Ophthalmology has general guide-
lines for adults with refractive errors4 and specific guidelines Methods
for children age three and younger.5 The Royal College of
Ophthalmologists has specific guidelines for strabismus, but An online questionnaire based on one used by O’Leary and
not for healthy adults or children with refractive errors. Evans8 was distributed to Israeli optometrists via email and
The American Association for Pediatric Ophthalmology and social media: emails were sent to approximately 500 gra-
Strabismus warns about and defines high refractive errors duates of the two Israeli optometry schools. In addition,
in children that might lead to amblyopia, but does not the questionnaire was posted on three Israeli optometry
have specific prescribing guidelines.6 Leat7 provides guide- Facebook pages (with a total of 1600 members). It should
lines for prescribing in childhood for various refractive be noted that there is considerable overlap between the
24 E. Shneor et al.

email list and the members of the Facebook page, and that Experience of optometirsts
some members of the Facebook page are not optometrists 50
(opticians, suppliers, distributers, etc.). The questionnaire
40

Prevalence, %
invited optometrists only and required all questions to be
answered to submit the questionnaire (see Appendix 1). 30
Google Docs was used to design the questionnaire and
20
responses were automatically exported to Excel 2010 hence
avoiding transcribing errors. 10

0
Questionnaire design <1 >1 <3 3-5 6-10 11-15 16-20 >20
Years
The questionnaire included demographic questions per- Figure 1 Distribution of years of experience in study cohort.
taining to the practitioner’s age and gender, alongside Each bin describes ranges of years of experience.
professional questions, which included years of experience,
work environment, scope of practice and financial incentives order to evaluate correlations between years of experience
(Appendix 1). and the answer for each question.
There were 12 questions regarding prescribing philoso- For each question, the average, standard deviation and
phies for different refractive errors (simple myopia, simple range were calculated. The 50th percentile and 75th per-
hyperopia, astigmatism without a spherical component and centile were calculated using the Excel Percentile function,
presbyopia with cylinder less than 0.75 D) in the presence which calculates the kth percentile of a supplied range of
and absence of symptoms and for varying age group ranges. values for a given value of k. The frequency of each bin was
Symptoms were not defined and the clinicians were left to counted for every question and the cumulative percentage
interpret this as they thought best. It was anticipated at the was calculated.
outset that it would be challenging to persuade busy prac- In addition, Igor pro (Wavemetrics, Lake Oswego, OR)
titioners to complete the questionnaire. Therefore, brevity was used to fit a univariate distributions using least squares
was an import design consideration. It was felt that a ques- estimates of the cumulative distribution functions with the
tionnaire that sampled all prescribing decisions for every equation: y = y0 + A * e(invTau * x). The constant y0 was set to
age group would be too lengthy, so the decision was made 100%, since a cumulative percentile distribution will plateau
to target the age groups that would be most instructive for at that value.
each type of refractive error. In Israel children under the age
of 6 years rarely consult community optometrists. Further-
more, myopia and astigmatism are infrequently corrected Results
in this age-group.11 Thus, for myopia and astigmatism the
questionnaire started at age 6 years. The few children who Respondents
are seen under the age of 6 years are mostly aged 4---6 years
Most of the optometrists in Israel are graduates of Hadas-
and hyperopic11 ; therefore, this category was included for
sah Academic College and Bar Ilan University. At the time of
hyperopia. Once patients reach the age of 40 years, prescrib-
the study, there were approximately 900 graduates of both
ing decisions are likely to be confounded by presbyopia and
Institutions. Personal emails were sent to 500 graduates for
the possibility of multifocal lenses. Therefore, over the age
whom current information was available and Facebook was
of 40 years the questionnaire concentrated on presbyopia.
used in an attempt to reach other optometrists. A total of
The exact questions can be seen in Appendix 1. The par-
112 Israeli graduates participated in the survey with an aver-
ticipant was forced to select from a scale of refractive errors
age (±SD) of 5.42 ± 4.3 years of work experience (range
in 0.25 D increments (bins).
0.4---17 years). The response rate varies from 12 to 22%
depending on the audience reached. If only the graduates
Statistical analysis contacted via email are considered, then the response rate
is (112/900) ∼22%. On the other hand, if all 900 graduates
Analyses were performed with SPSS, version 22 (SPSS, are members of the Facebook page and actually saw the
Inc., Chicago, IL) and with Microsoft Excel 2010. Normality post, then the response rate is 12% of optometrists trained
was tested using the Anderson---Darling test and statisti- in Israel (112/900).
cal significance was assessed with the Mann---Whitney test. An additional 12 participants responded who studied
Armstrong12 criticized the blanket use of Bonferroni correc- optometry abroad. An initial analysis demonstrated that the
tions for multiple corrections as being so conservative that it results for the Israeli educated cohort (N = 112) were not sig-
would lead many ‘‘real’’ effects to go undetected. However, nificantly different from the total cohort, therefore, all the
he recommended a Bonferroni correction should be consid- data were pooled.
ered to be appropriate in some circumstances. In the present In total, 124 subjects participated in the survey with
work, we have included a Bonferroni correction where one an average of 7.18 ± 8.0 years of work experience (range
hypothesis is tested several times in similar datasets (e.g., 0.4---48 years, see Fig. 1).
in testing whether the prescribing behavior of men differs Years of work experience was not normally distributed
from that of women using the same statistical tests on data (Anderson---Darling, p < 0.0005) with the majority of respon-
for myopia, hyperopia, astigmatism, and presbyopia). Non- dents having five or fewer years of work experience (see
parametric correlations (Spearman test) were calculated in Fig. 1). 66.1% of the respondents were women.
Criteria for prescribing borderline refractive errors 25

In addition, the exact 50th and 75th percentiles were

Table 1 Work environment of the cohort.
calculated from the data plotted in Fig. 2. Curves were fit
Work environment N % with a univariate cumulative distribution function with sim-
Work place
ilar results to that shown in Table 2, with no statistically
Optical chain 34 27.4
significant difference (paired t-test, p = 0.91).
Private optical practice 73 58.9
Clinic 16 12.9 Hyperopia
Both clinic and store 1 0.8
The data in Table 2 highlight the importance of symptoms in
Self-employed or salaried
prescribing for hyperopia. For example, for 10---20 year old
Salaried position 106 85.5
patients the degree of hyperopia for which 50% of practition-
Self employed 18 14.5
ers would prescribe is +0.75 D in the presence of symptoms
Job description but twice this value (+1.50 D) in the absence of symptoms.
Work solely as optometrist 38 30.7 As can be seen in Table 3, there is a shift to prescribing at
Optometrist + dispenser 55 44.4 lower powers from younger to older age groups (aged 4---6 to
Optometrist + store manager 24 19.4 6---10, 6---10 to 10---20 with and without symptoms and 10---20
Optometrist + dispenser + store manager 3 2.4 to 20---40 with symptoms only; p value Mann---Whitney <0.05).
Work solely as dispenser 2 1.6 The exception is that there is no difference, in the absence
Research 2 1.6 of symptoms, between prescribing criteria for hyperopia in
Earn % of sales (commission) 10---20 and 20---40 year olds.
Yes 46 37.1
No 78 62.9 Myopia

Table 2 demonstrate that the degree of myopia for which

Table 1 describes the working environment of the cohort. 50% of practitioners would prescribe is the same for all age
Most respondents work in a private optical store (58.9%), groups: −0.50 in the presence of symptoms and −0.75 in
are in salaried positions (85.5%), and work as optometrists the absence of symptoms. However, there is a shift to pre-
and sell products (44.4%) without sales incentives (62.9%). scribing lower powers in older patients when contrasting the
Thirty-two subjects (25.8%) reported that they work in an 6---10 year and 10---20 year age groups (Tables 2 and 3). These
optical chain with at least 10 branches. Two subjects manu- trends most likely reflect the similar visual needs of high
ally commented that they work in a chain of four branches, school students and young adults.
and were included in the category of ‘‘optical chain.’’
Astigmatism
General trends There is a shift to prescribing lower powers from younger to
older age groups at ages 6---10 to 10---20 with symptoms only
Fig. 2 shows the cumulative frequency plotted as a function (p value Mann---Whitney <0.05, see Fig. 2C and Table 3).
of refractive error bin for each question. Fig. 2A---D sum-
marizes data from all the questions regarding hyperopia,
Presbyopia
myopia, astigmatism and presbyopia, respectively. Each age
group is represented by a single color, and shown for asymp-
tomatic (square) and symptomatic (triangle) questions. For There is a shift to prescribing lower powers from younger
all types of refractive errors, in the presence of symptoms, to older age groups at age 40---50 to 50---70 with and with-
optometrists prescribe at lower refractive errors than in the out symptoms (p value and Mann---Whitney U statistic <0.05,
absence of symptoms (p < 0.0001 in all cases, Mann---Whitney, Fig. 2D and Table 3), which reflects loss of accommodation
Table 2). Even when using the Bonferroni correction, these with age.
results remain highly significant (p < 0.0025). The age of the
patients determines prescribing philosophy in many cases Work environment and prescribing philosophies
(Table 3), but not all, as will be described below.
We reasoned that the 50th percentile represents the cut- The optometrist’s work environment may influence pre-
off criteria at which a prescription is no longer considered scribing philosophy. For example, if an optometrist earns
borderline. The 75th percentile is interpreted as indicative a commission (a percentage of spectacle sales) it might
of commonplace prescribing practice. These data are shown provide an impetus (if so, hopefully only subconsciously) to
in Table 2 and will be addressed in the next section for dif- prescribe at lower powers. Based on the assumption that
ferent refractive conditions. The Excel Percentile function the prescribing philosophy may be influenced by the work
was used the function to calculate these variables, which environment, the cohort was divided into two groups: those
uses interpolation where required. For example, the 50th who receive commission and those who do not. In the former
percentile for prescribing for a hyperope with symptoms group we included both salaried employees who receive a
aged 20---40 is +0.625, indicating that fewer than 50% of the bonus based on sales and optometrists who own the optical
respondents would prescribe for refractive errors of 0.625 D business at which they work. The Mann---Whitney test was
or less. used to compare these groups, as the data were not normally
26 E. Shneor et al.

(A) Hyperopia (B) Myopia

100% 100%

75% 75%

4-6 with symptoms

6-10 with symptoms
%

%
50% 4-6 without symptoms 50%
6-10 with symptoms 6-10 without symptoms
6-10 without symptoms 10-20 with symptoms
10-20 with symptoms
25% 25% 10-20 without symptoms
10-20 without symptoms
20-40 with symptoms 20-40 with symptoms
20-40 without symptoms 20-40 without symptoms
0% 0%
0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

2.50

2.75

3.00

3.25

3.50

–0.25

–0.50

–0.75

–1.00

–1.25

–1.50

–1.75

–2.00
Refraction (D) Refraction (D)

(C) Astigmatism (D) Presbyopia

100% 100%

75% 75%
%

%
50% 6-10 with symptoms 50%
6-10 without symptoms
40-50 with symptoms
10-20 with symptoms
40-50 without symptoms
25% 10-20 without symptoms 25%
20-40 with symptoms 50-70 with symptoms
20-40 without symptoms 50-70 without symptoms
0% 0%
–0.25

–0.50

–0.75

–1.00

–1.25

–1.50

–2.00

–2.25

–2.50

–2.75

–3.00
–1.75

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

2.50

2.75

3.00
Refraction (D) Refraction (D)

Figure 2 Cumulative frequency plotted as a function of refractive error bin for each question [(A) hyperopia, (B) myopia, (C)
astigmatism and (D) presbyopia]. Age groups represented by a single color (ages 4---6 years: blue, ages 6---10 years: red, ages 10---20
years: yellow, ages 20---40 years: green, ages 50---70 years: brown). Both asymptomatic (square) and symptomatic (triangle) questions
are shown. Dash red and black lines represent the 75th and 50th percentile respectively. The lines connecting the data points are
not fitted curves and are for illustrative purposes only. They cannot be used to extrapolate. (For interpretation of the references
to color in this figure legend, the reader is referred to the web version of this article.)

distributed (Anderson---Darling). A statistically significant was only a statistically significant difference between men
difference was observed only in two areas (from a total of (1.21 ± 0.6 D) and women (1.03 ± 0.4 D) in prescribing for
24 comparisons): for myopic patients ages 6---10 and 10---20 50---70 year old patients without symptoms, but this did not
with symptoms, the optometrists who earn commission were reach statistical significance when using the Bonferroni cor-
more likely to prescribe at lower powers (Mann---Whitney, rection.
p < 0.04 and p < 0.02, respectively). However, when applying
the Bonferroni correction, this lost statistical significance.
Similarly, it could be hypothesized that optometrists who Experience and prescribing behavior
work for chains would be more likely to prescribe at lower
powers. We defined a chain as at least 4 stores. In this To test whether years of work experience in optometry
case a statistically significant difference was observed in influenced prescribing behavior, a Spearman correlation was
only three comparisons (from a total of 24): symptomatic calculated between years of experience and the prescription
hyperopic patients ages 4---6 and 6---10 and symptomatic at which the optometrist would prescribe spectacles, for
myopic patients ages 10---20. In these cases, optometrists every question (Table 4). Two interesting trends emerged,
who worked at chains were more likely to prescribe at lower although only with a weak correlation. For myopic patients
powers (Mann---Whitney, p < 0.05 in all cases). Again, when of all ages with symptoms and for all presbyopic patients
applying the Bonferroni correction, these values no longer in the absence of symptoms, there was a positive correla-
reached statistical significance. tion between years of experience and the level of refractive
power at which practitioners prescribed. In other words,
Gender more experienced practitioners were less likely to prescribe
for low degrees of myopia and presbyopia. In addition, for
The gender of the optometrist did not emerge as a fac- young (6---10 year old) astigmatic patients there is also a pos-
tor affecting prescribing behavior in almost all cases. There itive correlation between experience and refractive power.
Criteria for prescribing borderline refractive errors 27

Table 2 Columns 2---7 give the refractive error at which the proportion of respondents indicated in column 1 would prescribe
for the scenario outlined in column 1.
With/without symptoms and percentile Aged 4---6 Aged Aged Aged Aged Aged
(D) 6---10 (D) 10---20 (D) 20---40 (D) 40---50 (D) 50---70 (D)
Hyperopia
With symptoms 50th percentile +1.00 +1.00 +0.75 +0.63 --- ---
With symptoms 75th percentile +1.50 +1.25 +1.00 +0.75 --- ---
Without symptoms 50th percentile +2.00 +1.50 +1.50 +1.25 --- ---
Without symptoms 75th percentile +2.50 +2.00 +1.75 +1.50 --- ---
Myopia
With symptoms 50th percentile --- −0.50 −0.50 −0.50 --- ---
With symptoms 75th percentile --- −0.75 −0.50 −0.50 --- ---
Without symptoms 50th percentile --- −0.75 −0.75 −0.75 --- ---
Without symptoms 75th percentile --- −1.00 −0.75 −0.75 --- ---
Astigmatism
With symptoms 50th percentile --- −0.75 −0.50 −0.50 --- ---
With symptoms 75th percentile --- −0.75 −0.75 −0.75 --- ---
Without symptoms 50th percentile --- −1.00 −1.00 −1.00 --- ---
Without symptoms 75th percentile --- −1.25 −1.00 −1.19 --- ---
Presbyopia
With symptoms 50th percentile --- --- --- --- +0.75 +0.75
With symptoms 75th percentile --- --- --- --- +1.00 +1.50
Without symptoms 50th percentile --- --- --- --- +1.00 +1.25
Without symptoms 75th percentile --- --- --- --- +1.25 +1.50
All Mann---Whitney tests between with symptoms vs. without symptoms were significant (at least p < 0.0001).

Table 3 Prescribing behavior as a function of patient age group. Mann---Whitney U statistic and p values between the adjacent
age groups are given in the table. (p values are in brackets, * demonstrates significant value.).

Age category (years) 4---6 vs. 6---10 6---10 vs. 10---20 10---20 vs. 20---40 40---50 vs. 50---70
U (p) U (p) U (p) U (p)
Hyperopia
With symptoms 6083.5 5632.5 6536.5 ---
(0.004*) (0.00*) (0.03*)
Without symptoms 5780.5 6263.0 7020.5 ---
(0.001*) (0.01*) (0.23)
Myopia
With symptoms --- 5899.0 7028.0 ---
(0.001*) (0.21)
Without symptoms --- 6412.0 7604.5 ---
(0.02*) (0.87)
Astigmatism
With symptoms --- 6604.5 7121.0 ---
(0.05*) (0.29)
Without symptoms --- 6894.5 7494.5 ---
(0.14) (0.72)
Presbyopia
With symptoms --- --- --- 4541.5
(0.00*)
Without symptoms --- --- --- 5689.0
(0.00*)
28 E. Shneor et al.

Table 4 Spearman correlation between years of experience and prescribing behavior in each age group. (p values are in
brackets, * demonstrates significant value.).

4---6 6---10 10---20 20---40 40---50 50---70

Hyperopia
With symptoms 0.16 0.16 0.11 0.15 --- ---
(0.07) (0.08) (0.23) (0.10)
Without symptoms 0.09 0.02 −0.05 0.03 --- ---
(0.34) (0.84) (0.62) (0.75)
Myopia
With symptoms --- 0.29 0.25 0.23 --- ---
(0.01*) (0.01*) (0.01*)
Without symptoms --- 0.04 −0.01 −0.03 --- ---
(0.64) (0.97) (0.74)
Astigmatism
With symptoms --- 0.23 0.16 0.17 --- ---
(0.01*) (0.08) (0.07)
Without symptoms --- 0.15 0.04 0.11 --- ---
(0.11) (0.68) (0.21)
Presbyopia
With symptoms --- --- --- --- 0.15 0.13
(0.10) (0.14)
Without symptoms --- --- --- --- 0.23 0.22
(0.01*) (0.02*)

Discussion Association for Pediatric Ophthalmology and Strabismus

(AAPOS),15 The Royal College of Ophthalmologists16 and
As expected from previous research,8 this study shows that the American Optometric Association17 all have prescrib-
symptoms are an important factor that influences pre- ing guidelines. Leat7 reviewed these guidelines, updated
scribing criteria. It is reassuring that in this cohort, the them and provided more detail. Therefore, the results of
prescribing behavior between different modes of optomet- the present study were compared with Leat’s recommenda-
ric practice was insignificant using Bonferroni correction, tions, where our questions related to similar age groups to
i.e. we did not find financial incentive to be an influential those covered by Leat.
factor in prescribing decisions. Patients’ age was a signif- In general, the 50th percentile for prescribing for this
icant factor when comparing prescribing criteria for young cohort is very similar to the recommendations of Leat7
children to older children and teenagers, for both hyperopia for all refractive errors assessed except for pre-school age
and myopia. In most cases patients’ age was not a factor for hyperopic children. For this age group, Leat recommends
prescribing in astigmatism but was a factor for prescribing prescribing only above +2.50 D in the absence of signs or
in presbyopia, which increases with age.13 symptoms. This is based on studies of visual function and
A weak correlation emerged between the optometrists’ functional vision18---20 and the upper 95th percentile of the
years of experience and prescribing criteria in the following range for refractive error in this age group, which was
scenarios: all myopic patients in the presence of symptoms, +2.60 at 3 years and +2.90 at 4 years.21 In the current study,
young astigmatic patients in the presence of symptoms and Israeli optometrists prescribed at +2.00 D in the absence of
all presbyopic patients in the absence of symptoms. This may symptoms and +1.00 D in the presence of symptoms. The
suggest that the more years of experience the optometrist findings in the absence of symptoms are similar to Leat’s
has, the less likely they are to prescribe glasses at borderline recommendations. We think that the symptom most likely to
refractive errors. However, since the correlation was weak, be reported in pre-school hyperopes is a parental report of
this conclusion should be regarded with caution. strabismus and Leat indicates that in this scenario prescrib-
This is the first survey of prescribing philosophy carried ing is required. We therefore speculate that our finding of a
out in Israel. Since optometry in Israel is a young profession lower threshold for prescribing in the presence of symptoms
with only 15 years of local graduates, it is important to eval- is consistent with Leat’s recommendations.
uate the optometrists’ prescribing behavior and compare to For school age hyperopic children, Leat’s recommenda-
that of more established counties. In our study, most partic- tions were identical to the 50th percentile in this study:
ipants have graduated recently thus having a few years of >1.50 and >1.00 D in the absence and presence of symptoms,
experience, and this may influence results. respectively.
Various prescribing guidelines exist for pediatric patients The results of this study for myopia and astigmatism are
based on evidence and expert opinion. For example, similar to the recommendations of Leat.7 Concerning pre-
the American Academy of Ophthalmology,14 American scribing recommendations for myopia, Leat recommends full
Criteria for prescribing borderline refractive errors 29

correction although does not specify from what refractive Myopia and astigmatism
error one should do so. The cohort in this study would pre-
scribe for >−0.75 and >−0.50 in the absence and presence A survey of the AAOPS members (N = 334),15 assessed
of symptoms, respectively. Since −0.25 D is in the range of prescribing for myopic and astigmatic children age 4---7
error of emmetropia, our cohort is effectively prescribing in years. For myopic children, the 50th percentile was higher
the presence of any refractive error. For astigmatic school (−1.50 D) than that found in this study, −0.75 and −0.50
age children, Leat recommends correction of >0.75 D, which in the absence and presence of symptoms, respectively.
is within 0.25 D of that recommended in all cases in this This may reflect the difference in prescribing philosophy
study. between optometrists and ophthalmologists.
Prescribing guidelines do not necessarily reflect pre- The results for astigmatic children were within 0.50 D of
scribing behavior in clinical practice. Surveys of prescribing that found in the current study (−1.00 D). To the best of
behavior attempt to describe what actually happens in clin- our knowledge, there are no previous surveys of prescrib-
ical practice (see ‘‘Limitations’’ section below). We will ing for myopia for other age groups and only one study of
attempt to compare the results of this study to previous prescribing behavior for astigmatism. The survey of O’Leary
ones, although many did not specify the presence of symp- and Evans8 referred to astigmatic patients ‘‘of any age’’ and
toms or age group. In general, the results of this study were their results are similar to the current study in the presence
similar to other surveys of optometrists. However, when of symptoms (−0.75). However, in the absence of symp-
there are differences, the trend is that Israeli optometrists toms the 50th percentile for prescribing was higher than
prescribe at lower refractive errors. Further research will be the current study (−1.50 D vs. −1.0 D), again reflecting the
required to validate this finding and, if replicated, explore trend of Israeli optometrist to prescribe at lower refractive
the reason(s). errors.

Hyperopia Presbyopia

Prescribing for hyperopia in young children was surveyed in The results for prescribing in presbyopia were similar to a
several studies showing a wide range for behavior. Surveys previous study in the presence of symptoms (0.75),8 how-
of American optometrists22 and German ophthalmologists ever, in the absence of symptoms, Israeli optometrists would
(OMD)23 found that 67% and 84%, respectively, of practi- prescribe at lower additions (1.00 D as opposed to 1.50 D).
tioners would prescribe spectacles for four-year-old children
with +3.00 D of hyperopia. While this is similar to the 50th Limitations
percentile in the current study (+2.00 D), it is hard to com-
pare since the choices in those surveys were either +1.00 D Surveys of prescribing behavior attempt to describe what
or +3.00 D as opposed to the 0.25 D bins in this study. actually happens in clinical practice. However, it is impor-
Farbrother24 surveyed 93 hospital based optometrists and tant to note that people may tend to optimize their
found the 50th percentile for non-symptomatic children to responses toward what they think they should do, rather
be slightly higher than the results in the present study than what they actually do.
(+2.50 D). Leat et al.25 , in an audit of pediatric patient cases One of the limitations of this study is the low response
(including both those with and without symptoms) found the rate (12---22%). However, the results are within what can be
50th percentile to be +2.70 D. Two studies of OMDs, found expected from other electronic surveys.26 While electronic
that these practitioners prescribed only for higher refrac- surveys are increasingly used because of their accessibil-
tive errors. Lyons22 found that OMDs prescribed only above ity, rapidity, reduced cost, less need for human resources
+5.00 D (54%) in the absence of symptoms for patients aged and elimination of human errors, paper-based surveys still
4---6 years, while in a survey of 334 AAOPS members15 the possess higher response rates.27
50th percentile was +4.00 D. Shah et al.28 reviewed methods of measuring clinical
The only publication that we have found addressing pre- practice and noted that the gold standard methodology is
scribing behavior for older hyperopic children and teenagers ‘‘standardized patients’’ who present unannounced to clin-
is Leat et al.25 The differences between their results and this ics. However, such research (e.g., Shah et al.29 ) is expensive
study were between 0.15 and 0.58 D, which may be due to and can only sample a relatively small proportion of a pro-
the fact that their age groups were slightly different. fession. Another approach would be record abstraction,30
Only one study surveyed prescribing behavior for hyper- but this is also time-consuming and practitioners might be
opic adults.8 That study found that for patients under age less willing to consent to having their records examined
40, in the presence of symptoms, the 50th percentile for than to answering a survey. The advantage of surveys, such
prescribing is +0.75 D. However, in the absence of symptoms as that used in the present research, is that a larger pro-
optometrists would not prescribe at any of the powers in portion of the profession can be sampled, but it has to
the questionnaire (+1.75 D) more than 50% of the time that be acknowledged that such approaches are likely to over-
they are encountered. For the current study, in the pres- estimate clinical competence.31 Although the sample size
ence of symptoms, the 50th percentile for 20---40 year olds in the present research of 124 is more than could have
is +1.25 D, which is within 0.50 D of the cited study.8 How- been investigated with standardized patient methodology,
ever, in the absence of symptoms, the 50th percentile for this is only 7% of the Israeli optometric population and this
the Israeli cohort was +0.625 D, which is much lower than is another limitation of the present research. It is reassuring
the previous (UK) study. that we sampled practitioners working in a range of practice
30 E. Shneor et al.

environments and we are not aware of any systematic biases 4. American Academy of Ophthalmology. Refractive Errors &
in those who responded to this survey. Refractive Surgery PPP --- 2013; 2013.
Another limitation of the study is the wide age bracket 5. American Academy of Ophthalmology. Pediatric Eye Evalua-
used in the older presbyope question (aged 50---70). Also, for tions PPP --- 2012; 2012.
the myopia and hyperopia questions the optometrists were 6. The American Association for Pediatric Ophthalmology and
not instructed as to whether they should respond, for astig- Strabismus. AAPOS Policy Statement Medical Need for Glasses;
2012.
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7. Leat SJ. To prescribe or not to prescribe? Guidelines for spec-
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In addition, in this study most participants have gradu- 2011;94:514---527.
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may influence results. interventions: literature review and practitioner survey. Oph-
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Future research LegislationLibrary/Mikzoha 04.pdf; 1991 [accessed 7.08.14].
10. Paritzky D, Gordon-Shaag A, Eichler R. The Hadassah Aca-
This study and the comparison with other research have demic College Department of Optometry. Optom Vis Dev.
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There are only a few studies that have investigated the 11. Peckham CS. Vision in childhood. Br Med Bull. 1986;42:
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12. Armstrong RA. When to use the Bonferroni correction. Oph-
real patients32,33 rather than the artificial situation of sim-
thalmic Physiol Opt. 2014;34:502---508.
ulating refractive errors, typically in university students.
13. Charman WN. The eye in focus: accommodation and presby-
More research, preferably randomized controlled trials, opia. Clin Exp Optom. 2008;91:207---225.
would be valuable to investigate the benefit from borderline 14. American Academy of Ophthalmology. Amblyopia Preferred
optometric prescriptions. Practice Patterns; 2012. Available from: http://one.aao.org/
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tions of AAPOS members. J Pediatr Ophthalmol Strabismus.
Authors report no conflicts of interest and have no pro- 1998;35:51---52.
prietary interest in any of the materials mentioned in this 16. Royal College of Ophthalmologists. Guidelines for the Manage-
article. ment of Amblyopia. Available from: http://rcophth-website.
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17. Moore BD, Augsburger AR, Ciner EB, Cockrell DA, Fern KD, Harb
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about the department and Prof. Sharona Gordon for help
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with statistical analyses. The authors would like to thank
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Ms. Dinah Paritzky for critical reading of the manuscript. (Copenh). 1990;68:428---434.
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Appendix 1. Supplementary data
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