Myopia and Anisometropia - Diagnosis and Management of Common Ocular Conditions Spring 2026

Why may PRA be reduced in an uncorrected myope?

They have been lazy recently and not accommodating fully. When full RX is placed in front of them, they will not like to fully accommodate.

Can accommodation be reduced because of disease?

Yes

After correction, accommodation will usually return to normal within ____ wks

1-2

In a myopic patient, the phoria will be less (eso/exo) when corrected vs uncorrected

Less exo when corrected with (-) lenses

Do we want an uncorrected myope to be ORTHO at near?

No -- we may drive them into ESO posture once corrected at near

An ORTHO posture in an uncorrected myope will be highly suggestive of what?

convergence excess

Does correcting myopia alter accommodation at distance?

No

Does correcting myopia alter accommodation at near? Increase or decrease?

yes -- it will INCREASE the accommodative demand at near

Do we want to overminus our myopic patients? Why?

No - this will increase accommodative demand at distance and near

What is a situation in which we MAY consider overminusing a patient?

to treat significant BV issue -- exotropia in the presence of a high AC/A (divergence excess)

Should myopes wear their RX full time once they get it? Why is this important?

Yes -- wear full time in order to get used to accommodating fully again

Should myopes remove their glasses for near during the initial adaptation period?

No

What is a possible plan for myopes that is not offered for hyperopes?

myopia management

You can consider a _______ for near vision in a myope if BV conditions are present (ESO)

near add/remove the RX for near

Over Minus Patients Key Features

Will a patient who is over-minused have blurry vision?

No -- distance and near vision will be clear

Over Minus Patients Key Features

What are the key complaints of a patient who is over-minused?

HA & asthenopia d/t fatigue of accommodation, esophoria, or no symptoms at all

Over Minus Patients Key Features

Blur on (BI/BO) vergences at distances

BI

**There is accommodation to drop at distance when there is usually not any accommodation present. Increase divergence ability

Over Minus Patients Key Features

NRA ??

> +2.75

**they have more accommodation to drop

Over Minus Patients Exam Findings

Common findings of hyperbole myopes during exam?

Ret, monocular subjective, and final RX may be variable (like a hyperope)

Over Minus Patients Exam

What are some useful tools during the examination of a patient who you suspect is over-minused?

-red/green & then going to the 1st green response

-push plus by bluring 20/20 to unreadable and then wait to see if the letters will clear

Only give the LEAST MINUS RX to an over-minused patient if there are ______

symptoms

Do patients like increase of contrast with more minus?

Yes -- you should discuss this loss of contrast with patients

Should you trial frame a patient who you are prescribing LESS minus to?

Yes -- for acceptance

Should you consider SLOWLY DECREASING MINUS over time in a patient who has been over-minused?

yes

Should you ever criticize other clinicians if a patient comes in who is over-minused?

No -- there may be a reason for this

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

How much does this patient accommodate at 40 cm without correction?

-1.00D underminused

-+1.50 accommodative demand at near

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

How much does this patient accommodate at 40 cm with MR correction?

-emmetrope

-+2.50 accommodative demand at near

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

What is the predicted near phoria through the MR?

-Near: 8EP

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

This patient likely has ________

convergence excess

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

Is the built in add d/t being undercorrected actually helping the patient from having near symptoms?

Yes

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: 2EP; N CT sRx: Ortho

MR: -1.00 OU

AC/A: 8 pd/D

What would you prescribe for this patient?

--1.00 OU w/ +1.00 ADD OR

-1.00 for distance only & then take off the glasses for near work

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: ORTHO; N CT sRx: 8XP

MR: -1.00 OU

AC/A: 4 pd/D

What is the predicted phobia through the RX?

4XP

26 YO patient comes in for 1st eye exam. Notes distance blur

DVA: 20/60 OD/OS

NVA: 20/20 OU

D CT sRx: ORTHO; N CT sRx: 8XP

MR: -1.00 OU

AC/A: 4 pd/D

What would you prescribe for this patient?

-1.00 OU for full time wear

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

How much is the patient accommodating at near in the current RX?

-Patient is overminused by -0.75

-Patient is accommodating +3.25D at near

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

How much is the patient accommodating at near in the MR?

+2.50 (emmetrope)

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

How much is the patient accommodating at distance in the current RX?

Currently accommodating +0.75 at distance

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

How much is the patient accommodating at distance in the MR?

0

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

What will happen to the phoria in this patient when we RX the MR?

Less Eso, more EXO posture at both distance and near

26 YO patient. No complaints

DVA: 20/20 OD/OS

NVA: 20/20 OU

D CT sRx: 2 ESO; N CT sRx: 2 ESO

MR: -4.75 OU

Lensometry: -5.50

What would you prescribe for this patient?

-5.00 or -5.25 OU for full time wear

What is anisometropia?

different amounts of refractive error between the eyes

What is clinically significant anisometropia?

1.00D of SE difference

Is anisometropia of >1.00D an amblyogenic risk factor in hyperopic kids/adults?

yes

If there is uncorrected anisometropia present, can a patient be asymptomatic?

Yes

What are the possible symptoms of uncorrected anisometropia?

HA, strain, blur, poor depth perception

What are the effects of corrected anisometropia, esp in glasses?

issues with prismatic effects when looking away from the optical center

What is refractive aniseikonia?

-equal axial lengths

-image sizes are different

What is Prentice's Rule?

Prismatic Effect = d*P

d = distance from the optical center in cm

P = power of the lens

What is the predicted phoria through 5PD of BO prism in an ORTHO patient?

5PD exophoria

**the eye will follow the image IN and swing IN. Seeing an eye move in looks like an EXO deviation

OD: -2.00

OS: +5.00

A patient is viewing 20mm to the right of optical center. What is the induced phoria of each eye?

-Prentice Rule: Prismatic Effect = dP

-OD: 2*2 = 4 BO

-OS: 2*5 = 10 BO

-OU Prismatic Effect= 14BO

-Induced Phoria = 14 exo

OD: -2.00

OS: +5.00

A patient is viewing 20mm to the left of optical center. What is the induced phoria of each eye?

-Prentice Rule: Prismatic Effect = dP

-OD: 2*2 = 4 BI

-OS: 2*5 = 10 BI

-OU Prismatic Effect= 14BI

-Induced Phoria = 14 eso

OD: -2.00

OS: +5.00

A patient is viewing 20mm from the right to the left of optical center. What is the change in phoria ?

Δ28 of change

Correcting refractive anisometropia with glasses will cause _____ difference between the eyes

image size

More (plus/minus) eye will have a larger image size

plus

Will anisometropia cause symptoms in some patients who experience different image sizes?

yes

What is the BEST correction option for patients with anisometropia?

CLs

WHY are CLs the best treatment option for patient's with anisometropia?

-no induced prism

-may eliminate aniseikonia

Are backup glasses still needed for patients with anisometropia?

Yes

Will all patients with anisometropia be interested in Cls?

No

If the patient insists on having glasses for full time wear with anisometropia, what should our treatment plan be?

-Demo the RX

-Counsel patient on how to use glasses & be a head pointer... NOT an eye mover

-Avoid the periphery of the glasses to eliminate unwanted prismatic effects

If the patient STILL does not accept their RX with anisometropia & have anisokonia... what can we do?

-Eikonic lens design

-Cut amount of anisometropia corrected

Can we cut the amount of anisometropia in a child RX?

No -- we want they to develop good VA in each eye

How to cut amount of anisometropia in an adult RX?

decrease plus or minus in the higher powered eye & then DEMO to determine how much needs cut off

For a bifocal design in a patient with anisometropia, what may we consider?

Slab off to get more BU in front of the more minus eye to get around the prismatic effects that happens when the patient needs to go into downgaze to get into their bifocals

ADULT PATIENT

MR OD: +6.00; OS: +1.00

You determine that you want to cut the aniso that is prescribed by 2.00D. What should you RX?

You should prescribe +4.00 OD; +1.00 OS

ADULT PATIENT

MR OD: -6.00; OS: -1.00

You determine that you want to cut the aniso that is prescribed by 2.00D. What should you RX?

You should prescribe -4.00 OD; -1.00 OS