Lecture 6 - Management of Pediatric Refractive Errors

What is assessed at all comprehensive pediatric eye exams?

Refractive error

How is refractive error objectively evaluated in children?

Retinoscopy

What are the two types of retinoscopy used in pediatric patients?

Dry retinoscopy and wet retinoscopy

How is refractive error subjectively evaluated in children?

Refraction

Is subjective refraction age dependent in pediatric patients?

Yes

What is the most common method used to determine a pediatric prescription?

Retinoscopy

What information does dry retinoscopy provide?

The refractive error under normal viewing conditions

What information does wet retinoscopy provide?

The refractive error without accommodation

What is the purpose of refraction in pediatric patients?

To help refine the prescription

What factors should be considered when performing refraction on a child?

Age and cognitive abilities

Why may subjective refraction be less reliable in children?

They may always say something is better, choose the first option, or be afraid to get it wrong

What should be trusted when subjective findings are questionable in children?

Objective findings

What should be done if a child cannot comprehend a refraction?

Check visual acuity through the retinoscopy

When is checking visual acuity through retinoscopy especially important?

When considering a prescription, when refractive error is abnormal for age, or when entering visual acuity is reduced

What is the first question to consider before prescribing glasses to a child?

Does the patient have reduced visual acuity based on age?

What should be considered regarding age norms before prescribing glasses?

Whether the refractive error is outside the expected range for age

Why should the expected rate of refractive change be considered before prescribing?

Some refractive errors occur during periods of rapid change

Why should amblyopia risk be considered before prescribing glasses?

Refractive errors may cause amblyopia

How can binocular vision influence prescribing decisions?

Glasses may correct ocular alignment or binocular vision problems

What lifestyle factor should be considered when prescribing pediatric glasses?

The patient's visual needs

What should be done if you are unsure about prescribing a child?

Bring the patient back for another appointment

Why might a child return before a prescription is prescribed?

To confirm the refractive error

When can a follow-up be scheduled after prescribing glasses?

4-6 weeks later

Is it acceptable to change a pediatric prescription after prescribing?

Yes

What is the primary goal of pediatric prescribing?

Meet the patient's visual needs based on age

What visual goal should always be prioritized when prescribing for children?

Maximize visual acuity

What visual systems should be considered during pediatric prescribing?

Binocularity, accommodation, and ocular motility

How long may young children be monitored before prescribing?

3 months

Why do younger children often require greater refractive errors before prescribing?

They tolerate larger refractive errors

How should partial anisometropic prescriptions be adjusted?

Cut symmetrically

What is the prescription threshold for infants with myopia?

Greater than -4.00 D

What is the prescription threshold for toddlers with myopia?

Greater than -2.00 D

What is the prescription threshold for preschoolers with myopia?

Greater than -1.00 D

How should myopia be prescribed in school-age children?

Full amount of myopic refractive error

Are pediatric myopia guidelines absolute rules?

No, they should be tailored to the child based on signs and symptoms

How should pediatric myopia generally be prescribed?

Correct the full distance refractive error

Should pediatric myopes be underminused?

No

Why was myopic undercorrection historically used?

It was thought to slow myopia progression

What effect does undercorrection actually have on myopia progression?

It encourages progression

Should pediatric myopes be overminused?

No

Why should dry and wet retinoscopy findings be compared in myopia?

To avoid overcorrecting myopia

Why may bifocals be considered during myopia progression?

More esophoria is often present at near

How do bifocals affect accommodative demand?

They reduce accommodative demand

How do bifocals affect accommodative convergence?

They reduce accommodative convergence

How do bifocals affect ocular posture at near?

Less esophoria or more exophoria

What effect do bifocals have on myopia progression?

They reduce progression

Are bifocals the most effective myopia control option?

No

When should bifocals be considered in pediatric myopia?

If 20/20 near vision cannot be achieved through the distance prescription

When should bifocals be considered based on binocular vision findings?

When significant near esophoria is present through the distance prescription

What are the goals of myopia control?

Slow refractive error change and slow axial elongation

What are the major myopia control treatment options?

Low-dose atropine, soft multifocal contact lenses, orthokeratology, and myopia control spectacle lenses

What type of drug is atropine?

A nonselective antimuscarinic antagonist

What ocular effects does atropine produce?

Potent, long-acting mydriasis and cycloplegia

What atropine concentrations are used for myopia control?

Low-dose concentrations

What are the clinical uses of atropine besides myopia control?

Cycloplegic refractions, amblyopia penalization, and treatment of uveal inflammation

What are the common ocular side effects of atropine?

Mydriasis and cycloplegia

What symptoms may occur from atropine-induced mydriasis and cycloplegia?

Glare and near blur

How can glare from atropine be managed?

Photochromic lenses

How can near blur from atropine be managed?

Near add lenses

What allergic reactions may occur with atropine?

Itchy eyes, follicular reaction, and lid erythema

What rare systemic side effects can occur with atropine?

Dry skin, dry mouth, dry throat, drowsiness, restlessness, irritability, delirium, tachycardia, and facial flushing

How might atropine slow myopia progression according to current theory?

Through biochemical effects on the retina or sclera

What receptors does atropine block?

Muscarinic receptors

How does atropine affect neurotransmitters?

It alters neurotransmitter release

What neurotransmitter release is thought to increase with atropine?

Dopamine

How does dopamine affect axial elongation?

Acts as a stop signal

How does dopamine affect scleral fibroblasts?

Reduces proliferation

Why is accommodation inhibition considered a less likely explanation for atropine's myopia control effects?

Low doses minimally affect accommodation and atropine slows myopia in animals lacking accommodation

Why is pupil dilation considered a less likely explanation for atropine's myopia control effects?

Tropicamide causes mydriasis but does not slow myopia progression

What prescription requirement exists before starting atropine therapy?

Full distance correction

Should atropine patients be underminused?

No

Can atropine be used in patients with astigmatism?

Yes

What are the advantages of atropine treatment?

Cost, ease of use, and minimal age or maturity requirements

What are the disadvantages of atropine treatment?

Effects on pupil size and accommodation

How does atropine affect accommodation?

Reduces accommodative amplitude

How can atropine affect near vision?

May cause blurry near vision

How does atropine affect binocular posture?

May increase esophoric posture

What atropine concentration was historically used for myopia control?

0.5-1%

Why are high atropine concentrations no longer commonly used?

Excessive cycloplegia and mydriasis

What low-dose atropine concentrations are commonly used today?

0.01%, 0.025%, and 0.05%

How do higher low-dose atropine concentrations affect accommodation?

Produce greater reductions in accommodative amplitude

What factors influence the optimal atropine concentration?

Age, ethnicity, and rate of myopia progression

What optical principle do multifocal contact lenses use for myopia control?

Peripheral myopic defocus

What type of multifocal design is needed for myopia control?

Distance-center multifocal lenses

How do multifocal contact lenses influence peripheral retinal focus?

Create myopic defocus in the peripheral retina

Which non-FDA-approved multifocal lens options were listed?

Biofinity, Proclear, and NaturalVue

Which multifocal lens option has a toric version?

Biofinity

Which multifocal lens option was discontinued in late 2026?

Proclear

Which multifocal lens option is available as a daily disposable?

NaturalVue

Why must a distance-center multifocal be selected for myopia control?

Most multifocal lenses are near-centered

What are the advantages of multifocal contact lenses for myopia control?

Daily disposable options, less chair time, and faster comfort adaptation

What are the disadvantages of multifocal contact lenses for myopia control?

Higher cost and image degradation

Which contact lens is currently FDA approved for myopia control?

MiSight

What age range is MiSight approved for?

8-12 years

What refractive range is MiSight approved for?

-0.75 D to -4.00 D with less than 0.75 D cylinder

Up to what myopia is MiSight available?

-7.00 D

What is considered off-label use of MiSight?

Use outside its FDA-approved parameters

How do multifocal contact lenses affect accommodative demand?

They reduce accommodative demand

How do multifocal contact lenses affect accommodative response?

They reduce accommodative response

How do multifocal contact lenses affect convergence?

They alter accommodative convergence