OPT 218 Refractive Error II (Hyperopia/ Astigmatism)

What is the purpose of retinoscopy?

gives starting point for a prescription;

we want to also take into account symptoms, the child's age, binocularity, VA sc, VA cc, prior Rx

What are some pediatric eyeglass pearls?

-let the child pick the frames, even if parent's don't like them
-make sure frames are "kid friendly"
-make sure child uses them properly

What is the prevalence of hyperopia?

3-34%

What is hyperopia associated with?

-decreased near visual skills
-poor reading
-poor educational achievement
-poor attention
-juvenile delinquency

For cases between 6-72 months, what race/ethnicity has the greatest prevalence of hyperopia greater than 2.00D?

hispanic and white

For cases between 6-72 months, what race/ethnicity has the greatest prevalence of hyperopia greater than 3.00D?

white and african american

What is the full term average for hyperopia in infants/toddlers?

+2.00 (significant decrease between 3-9 months)

When is the emmetropization complete?

18 months; so hyperopia will be less than or equal to 2.00D

What hyperopia in children is a red flag (according to the Ingram study)?

>4.00D at 6 months should be monitored for vision problems

-20% risk of vision defects
-amblyopia
-strabismus
-glasses v no glasses

What hyperopia in children is a red flag (according to the Atkinson & Braddick study?

-infants with >+3.50 D
-13x more prone to strabismus by age 4
-6x more prone to amblyopia

note that only 5-6% aged 6-8 mos and 3.6% aged 12+ months are greater than +3.25)

T or F: infants/toddlers experience very little change in refractive error between 12 and 36 months?

True

With hyperopia, what kind of strabismus is more common?

esotropia

What value of hyperopia results in a risk of bilateral amblyopia?

+5.00D

With the VIP study, what percent of preschoolers aged 3-5 have hyperopia greater than 3.25D?

11.7%; of that percentage, only 4% have greater than or equal to 5.00D and 8% have between 3.25D and 5D

34% had amblyopia and 17% had strabismus

For the PEDIG study, what patients were included?

-ages 1-2 years
-glasses v. observation
-cycloplegic greater than or equal to 3.00D and less than or equal to 6.00 SE
-no strabismus

What was considered a fail in the PEDIG study of immediate vs delayed glasses for moderate hyperopia?

-decreased stereo
-decreased VA
-manifest strabismus

For the VIP study, what patients were included (uncorrected hyperopia and preschool early literacy)?

-retinoscopy greater than or equal to 4.00D
-retinoscopy greater than or equal to three but less than or equal to six with decreased near acuity and stereo 240'' or worse in 4-5 y/o

What is the TOPEL test? What does it look at?

-print knowledge
-definitional vocabulary
-phonological awareness

What were the results of the Rosner and Rosner 1997 study?

significantly lower achievement test scores among children with refractive error >+1.25D (dry)

What were the results of the vanRijn 2014 study?

65 hyperopes aged 9-10 at least +0.75D in least hyperopic eye; full correction improved 1 minute reading score by 13%

What group did the correction of hyperopia in children study look at?

6-12
-rx +1.00-+4.00 cyclo
-glasses x 6 months

What was the primary outcome of the CHICS study?

change in reading comprehension

What was the secondary outcome of the CHICS study?

change in attention, visual function

What were the results of the CHICS study?

-change in reading comprehension
-improved attention

What can overminusing by 2.00D cause?

ADHD symptoms

When is prescribing for hyperopia indicated according to the AAO?

-3 years old or less= +4.50 hyperopia
-4 years or greater= as necessary to improve acuity or alleviate esotropia

When is prescribing for hyperopia indicated according to the AOA?

-infants +3.50
-young child +2.50
-adolescence +1.50

How do we usually treat esotropia?

plus lenses

What did the Marsh Tootle, Mayer studies say about rxing for hyperopia?

greater than or equal to +2.50D

may rx for lower amounts to increase stereo, increase near VA, and to alleviate symptoms

we want to cut the cyclo 1-2D

What are symptoms of hyperopia for children?

-blurry vision
-headaches when reading
-gets blurry as reading
-below grade level for reading
-tired when reading
-avoids reading

In terms of binocularity, what is the goal for school age children?

slight XP in distance and ortho at near

if there is reduced stereopsis, the goal is improvement (pseudo Cl)

What issues with accommodation is seen with hyperopia?

-insufficiency
-high lag
-variable reflex

What phoria classifies as convergence insufficiency?

XP' at least 4 greater than the distance

What PFV values are considered a fail for convergence insufficiency?

fail sheard of greater than or equal to 15 blur/break

What NPC is considered convergence insufficiency?

greater than or equal to 6 cm break

What kind of problem is pseudo-CI?

accommodative; patient presents with NPC and reduced PFV, XP' is present

-also low amplitude of accommodation and high lag

When should plus be considered?

-hyperopia
-eso at near (low exo at near)
-high MEM/FCC (normal MEM/FCC)
-low amp of accommodation (normalized)
-low PRA/high NRA (equal NRA/PRA)
-reduced stereo at near (improved stereo)
-reduced NPC (improved NPC)

Who has the greatest amount of astigmatism (age group)?

infants; decreases over 4-5 years (often axis 090)

When is astigmatism at adult levels?

by 4-5 yoa; with the rule becomes more common

What is the rarest form of astigmatism?

oblique; we rx 1 DC at 1+ yoa because there is a large risk of amblyopia

What population generally has the highest prevalence of astigmatism?

Native populations and Hispanic populations (population least commonly affected by astigmatism= white and asian)

According to the NICER study, what was concluded about changes in astigmatism?

Prevalence is unchanged between 6-7 yoa and 15-16 yoa but there is still individual patient change possible

T or F: It is difficult to predict from their refractive data who will demonstrate changes in astigmatism.

True; this is why it is important for all children to have regular eye exams

What are ways in which astigmatism can be diagnosed?

-cycloplegia (ATR may go away after cyclo and may not be evident with k readings)
-keratometry (cornea, axis, magnitude, changes)
-topography (more for irregularities)

What may small amounts of ATR astigmatism indicate?

accommodative dysfunction or myopia progression (especially if amount is <1.00 DC)

When should we Rx for astigmatism for patients at 15 months+?

> 2.50 D; partial correction is okay and astigmatism may decrease over time

When should we Rx for astigmatism for patients at 2 years+?

≥ +2.00 D; partial correction is ok and astigmatism may decrease overtime

When should we Rx for astigmatism for preschoolers?

1.50 DC @4 yoa+

usually give full Rx and not as much adaptation is required (because of visual demands)

When should we consider Rx-ing for school aged children?

≥ 0.75 DC

-VA levels, text size, and symptoms are things to keep in mind

What did the Orlansky study say about the relationship between uncorrected astigmatism and academic readiness?

they experience lower scores in
-personal and social development
-language and literacy
-physical development
-personal/social communication
-fine motor

What did the Harvey study say about reading fluency in children with bilateral astigmatism?

oral reading fluency was significantly reduced with ≥ 1.00 D of uncorrected astigmatism; this stressed importance of wearing correction