Round table: Physicians discuss the art of prescribing glasses

Members of the OSN Pediatrics/Strabismus Section discuss the challenges they face when prescribing glasses for children and their thresholds for refractive correction in this first excerpt from a round table held during the AAPOS meeting.

Robert S. Gold

Robert S. Gold, MD: A topic that has been going around the pediatric listserv recently has to do with the art of prescribing glasses. I would like each of you to comment on your criteria for prescribing glasses.

First, in children younger than 2 years old, please comment on hyperopia, myopia and astigmatism. I am being very general so that you can comment however you would like. Regarding strabismus problems, be creative, as we always are, and add what you would like.

Scott E. Olitsky

Scott E. Olitsky, MD: I divide these patients into groups. In one group, wearing glasses is vital. These children may have accommodative esotropia, or they may have amblyopia or be at high risk for developing amblyopia. Or, I might worry about protection; for example, the patient may have only one good eye. In another group are patients who I would like to wear the glasses, but I am not sure that they will benefit from the glasses at that early age. So that directs how hard I might push the parents to get their child to wear the glasses if the child does not want to wear them.

In borderline cases when I am not concerned about amblyopia or strabismus, or a case of accommodative esotropia, I tend to tell the parent to get the glasses and offer them to the child. If he does not wear them, then I would not force him to wear them.

Dr. Gold: What age child are you talking about?

Dr. Olitsky: Generally this might be a 2- to 3-year-old.

Dr. Gold: Let’s talk about a specific situation. You see a 2-year-old child in your office for a family history of strabismus. There is no history of crossing, and the cycloplegic refraction is +6 D. What would you do?

Rudolph S. Wagner

Rudolph S. Wagner, MD: That is a typical case because you have an asymptomatic child. What makes this case easier is the family history of strabismus.

Dr. Gold: Correct.

Dr. Wagner: The family history gets the parents thinking along the lines of the child needing glasses. It might be easier for them to accept glasses. More difficult is the same case without a family history of strabismus. The child appears relatively asymptomatic to the parents and has not displayed signs of poor vision, but you find +6 D of hyperopia on cycloplegic retinoscopy. Those cases are difficult. I always say that you get more second opinions generated when you give a young child, 2 years of age or younger, a pair of glasses than you will if you tell the parents their child needs surgery. People really don’t want to hear that their child needs glasses, especially when there is not an obvious complaint or sign such as strabismus.

In this specific case, you have +6 D, which is a significant amount of hyperopia. This is a child who you would be concerned about, and I would give glasses. I would reduce the total amount that I would prescribe. There are a lot of kids walking around who have 3 D of hyperopia on cycloplegic retinoscopy who are asymptomatic, so if I can get that +6 D to +3 D, I think I am going to improve this situation.

Dr. Gold: So let’s go the other way. No family history of strabismus and you get this +6 D cycloplegic refraction in each eye.

Dr. Wagner: That +6 D is still a number that I am concerned about. That is significant. If you had picked +4 D, that would be easier. I am going to follow them for now and not prescribe lenses. However, +6 D in a 2-year-old? I would prescribe glasses.

Roberto Warman

Roberto Warman, MD: The +6 D is easy because most of us at +5 D and higher will prescribe something. But if there is no family history of anything and there is nothing wrong, I do not go with the +4 D. For +4 D, I wait, particularly in that first 2 years. The only thing that I might do differently is ask the parents, “Why don’t you come back in a year instead of 2 or 3 years because this is a high hyperopia?” It really is a problem to put glasses on the very young ones. We can discuss exactly the same thing with mild anisometropia. For a patient with 3.5 D in one eye and 2.5 D in the other eye, only plus, and no astigmatism in the first 2 years, it is said that you should go ahead and prescribe, but I am not sure it makes a big deal of a difference.

There is a big difference when the child is 3 or 4 years old, but in the first 2 years, my threshold is higher, even for known good screening referrals.

Anthony P. Johnson

Anthony P. Johnson, MD: The +6 D does make it easy. One of the things that I did not really appreciate for a long time was the need to follow someone along for bilateral amblyopia. So you see this child who is 2 years old, +6 D, not symptomatic, and may or may not have a family history. Knowing family history makes it easier as well, but to know that the child is at risk for bilateral amblyopia really pushes me into implementing the correction, whether you reduce the cycloplegia by 1 D or 2 D or whatever you decide. It is very reasonable.

A corollary to that is the 8-month-old who comes in with just the classic nasolacrimal duct obstruction. You do a complete exam and the child has +7 D in one eye, +8 D in the other, or +7 D in both eyes. The mother is very frustrated with the tearing and the discharge, no family history of anything, and now the 8-month-old needs glasses because he is at risk for accommodative esotropia and bilateral amblyopia. Those situations always generate additional opinions. The first question the parents ask after they leave and talk to other people is, “Well, how did anybody measure my baby’s prescription because my baby can’t talk?”

We have all experienced that. That speaks to the necessity for doing a complete exam, even when time is restricted, because you never know when a child may have something other than what they initially appear to have. But for me, in a 2-year-old, I would probably even prescribe for a +5 D, maybe even a +4 D. It depends on the situation, and that is consistent with the American Academy of Ophthalmology’s Preferred Practice Pattern as well for children between age 1 and 2 years; their threshold is generated by a number of pediatric ophthalmologists and their opinions. But I think that is consistent with what our colleagues feel, that +5 D and higher is significant.

Kenneth P. Cheng

Kenneth P. Cheng, MD: I agree with everything that has been said. One thing that is really important, though, especially in a child who has a family history of accommodative esotropia and whose eyes are currently straight, is to give significantly less than the full cycloplegic refraction. Otherwise, you are much more likely to develop crossing of the eyes when the patient takes off their glasses and when they are not wearing the glasses. I warn parents about the possibility of developing crossing of the eyes whenever there is high hyperopia. I explain to the parents that he needs the glasses because we want to make sure that he does not get into a situation of amblyopia and that his brain is stimulated to get good vision. Secondly, we want him in the glasses to hopefully prevent a problem with development of crossing of the eyes. However, with this family history, because of the eyes and the refraction, he is at risk for crossing. If the parents start seeing crossing, they should let us know about it. I explain to them that I am not worried about crossing with the glasses off. I am concerned, though, about crossing when they are on. It is much easier to explain this to the parents before than after, when they have brought in a child with perfectly straight eyes and you give them glasses, and now when they take off the glasses, the eyes are crossing.

I also tell them that there is evidence to suggest that working to accommodate and focus and not giving them the full strength in the glasses may have some effect in emmetropization or decreasing the level of hyperopia, so that is important. For example, I would give +4 D to the patient with +6 D to keep the eyes working, if possible.

Thresholds for refractive correction

Dr. Gold: Let’s shift and try to do the other forms of refractive errors. In a preschool-aged patient, what is your threshold for myopia? I am not talking about anisometropia now. I am talking about just myopia, and I know there are patterns. Obviously we can only use our own patterns.

Dr. Johnson: My threshold for correcting symmetrical myopia varies a little based upon whether or not the parents feel the child cannot see. That is often influenced by a parent who is very nearsighted and whatever their experience has been. They feel like they did not start wearing glasses until they missed 2 or 3 years of development because nobody knew that they needed glasses. Parents will probably lean toward having the child in glasses sooner rather than later. But I explain to the family that even if the child is –3 D or –4 D, as long as they seem to be doing the things that the parent would expect and they are a preschooler, even up until age 4 years, as long as it does not appear that they are not able to do their hobbies or tasks or anything they are trying to do, I would not push that child into correction until they start school.

However, if the parent is concerned and they are really asking for glasses, I do not have any problems at all, knowing that the child is going to now be able to see everything with glasses.

Dr. Wagner: I agree with Dr. Johnson’s threshold amount of –4 D. I will correct lesser amounts the older they are. I certainly would not correct –4 D in a baby, but I would certainly correct that in a 5-year-old or a kindergartener. A lot of times, the decision depends on what the parents are noticing regarding the child’s visual behavior.

Some parents really do not want you to give the glasses because they believe that their own vision was made worse once they started wearing glasses as a child. This is where the art of pediatric ophthalmology comes in. You have to carefully explain what you expect them to observe and how you expect the child to respond. As children get older, the decision to initially give glasses becomes much easier and is more readily accepted by the parents or caregiver.

Dr. Gold: I specifically go through myopic progression in detail with the parents to let them know that just because we are putting them in glasses now, it does not mean their child will outgrow them next year. It is going to get worse until a certain point until the child really stops growing. So I agree that you have to go into that in detail.

Dr. Olitsky: We all see those kinds of borderline cases, and I tell parents, “I don’t know if your child is going to want to wear these glasses.” But I will often explain to them that they will spend more money and more time getting a second opinion than getting a pair of glasses for their child. Now, if their child wears them, they made the right decision. If not, try again in 6 months and see if anything has changed.

Dr. Gold: Let’s also just touch on astigmatism a bit because this also generates a lot of discussion. What is your threshold, and when do you prescribe and when do you not?

Dr. Warman: Again, obviously, we have very high astigmatisms, let’s say 3.5 D, 4.5 D. My threshold is much shorter and our goal is a younger age. For those patients and probably those numbers in anybody older than 3 years old, I would definitely put glasses on them. I think the tricky ones are the 1.5 D, sometimes 2 D, on the very young kids. That is where I have a problem with the preferred patterns and the standards because it does not matter that much in the focusing in the first 24 months of life and sometimes at 36 months. There is just no real data. Suppose we really see a little amblyopia at age 3 years. We have very good data that you treat for the first time a patient with 1.5 D or 2 D of astigmatism at age 3 and that you correct them. So before 3 years of age, I am not very strict with up to, let’s say, 2 D of astigmatism even though it is not what the preferred pattern exactly says.

Dr. Olitsky: I completely agree. If I see a 9-month-old who comes in for a tear duct obstruction, I ask, “How worried would I be if this child came in having failed the vision screening at kindergarten and he’s not going to get better?” And that tempers some of the excitement to correct that child.

The other thing I look at is how much myopia coexists, because a patient with moderate to severe myopia and astigmatism sees better than the child with just astigmatism.

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; e-mail: kpc123@verizon.net.
• Robert S. Gold, MD, can be reached at 225 W. State Road 434, Suite 111, Longwood, FL 32750; 407-767-6411; fax: 407- 767-8160; e-mail: rsgeye@aol.com.
• Anthony P. Johnson, MD, FACS, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-8390; e-mail: apj@jervey.com.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; e-mail: seolitsky@cmh.edu.
• Rudolph S. Wagner, MD, can be reached at Children’s Eye Care Center, 1 Clara Maass Drive, Belleville, NJ 07109; 973-751-1702; fax: 908-665-8482; e-mail: wagdoc@comcast.net.
• Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155-4072; 305-662-8390; fax: 305-661-7862; e-mail: rwarman@eyes4kids.com.