008 Prescribing for Children Part 2

Why is prescribing for pediatric hyperopia less straightforward than for myopia, and what factors determine whether to prescribe?

Prescribing hyperopic correction is less obvious because children may accommodate through some hyperopia.

Key factors to consider:

• Age

• Amount/magnitude of hyperopia

• Anisometropia

• Eye alignment

• Accommodative ability

• School/achievement symptoms

What are the general isoametropic hyperopia prescribing cutoffs in infants and young children?

Isoametropic hyperopia (no manifest deviation):

• <1 year: prescribe at +6.00 D or more

• 1–2 years: prescribe at +5.00 D or more

• 2–3 years: prescribe at +4.50 D or more

If hyperopia is associated with esotropia:

• <1 year: +2.50 D or more

• 1–2 years: +2.00 D or more

• 2–3 years: +1.50 D or more

What are the general anisometropic hyperopia prescribing cutoffs in young children?

Anisometropic hyperopia (without strabismus):

• <1 year: +2.50 D or more

• 1–2 years: +2.00 D or more

• 2–3 years: +1.50 D or more

Does giving spectacles to infants with hyperopia prevent normal emmetropization?

Prescribing hyperopia does not necessarily stop the normal reduction in hyperopia over time, so decisions should be based on:

• amount of hyperopia,

• alignment,

• symptoms,

• and functional needs.

If all other findings are normal (no large esophoria or esotropia), what are the age-based rules of thumb for prescribing hyperopia?

If everything else is normal, consider prescribing when hyperopia is greater than:

• <1 year: +5.00 D

• 1–2 years: +4.00 D

• 3–5 years: +3.00 D

• 5+ years: +2.50 D

When is anisometropia hyperopic enough to consider prescribing glasses?

Consider prescribing if anisometropia is amblyogenic, around >1.00 D.

What does it mean to prescribe full balance in hyperopic anisometropia?

Whatever amount of plus is subtracted from the cycloplegic refraction in one eye, the same amount must be subtracted in the other eye. This ensures both eyes have equal accommodative demand in glasses.

What is the purpose of balancing hyperopic anisometropia, and how is it applied clinically?

The eyes accommodate the same amount, even if the refractive errors are unequal.
So, the Rx must be balanced so that one eye is not forced to do more of the seeing.

Does “prescribe full balance” in anisometropic hyperopia mean you must prescribe the full amount of hyperopia in each eye?

No. It means you subtract the same amount of plus power from the cycloplegic refraction in each eye.

Why is ocular alignment especially important when deciding whether to prescribe hyperopia in a child?

Because hyperopia is the strongest predictor of developing esotropia (ET).
Key points:

• Esotropia occurs in ~1–3% of children <6 years

• The possibility of ET changes what you prescribe for hyperopic children

What should you prescribe for a hyperopic child with esotropia?

Full cycloplegic Rx

What should you do if esotropia persists at near even with the full cycloplegic Rx?

Give full cycloplegic Rx with an ADD (bifocal).

How do basic esophoria and high AC/A (convergence excess) differ?

Basic esophoria

• Same or similar magnitude at distance and near

• Usually has a normal AC/A ratio

High AC/A / convergence excess

• Larger eso deviation at near than at distance

• Can be phoria or tropia

• Indicates excess convergence per unit of accommodation

What is the clinical significance of high AC/A ratio in a hyperopic child with eso deviation?

A high AC/A ratio means the child generates too much convergence when accommodating, so near eso is worse than distance eso.

Clinical implication:
These children often need:

• Full cycloplegic hyperopic correction

• Plus add/bifocal for near if needed

How can you recognize a basic esophoria pattern from cover testing?

Think basic EP when:

• Distance eso and near eso are similar in magnitude

• AC/A ratio is not elevated

Example:

• Distance cover test: 6 EP

• Near cover test: 5 EP

• Cycloplegic refraction: +2.00 DS OU

How is hyperopia often prescribed in a child with basic esophoria and normal AC/A?

If the child has basic esophoria (not high AC/A), you may leave some hyperopia uncorrected rather than giving full cycloplegic plus.

How can you recognize convergence excess / high AC/A from cover testing?

Think high AC/A / convergence excess when:

• Distance deviation is small or ortho

• Near deviation is significantly more eso

Example from slide:

• Distance cover test: ortho

• Near cover test: 10 EP

• Cycloplegic refraction: +0.50 DS OU

This pattern suggests high AC/A, because near eso is much larger than distance eso.

What is the key prescribing distinction between basic esophoria and high AC/A convergence excess?

• Basic esophoria / normal AC:A: may leave some hyperopia uncorrected

• High AC/A / convergence excess: prescribe full cycloplegic Rx + near add

How do you determine whether a child’s amplitude of accommodation (AA) is normal?

Use the formula: Expected AA = 18.5 − 0.3(age)

What MEM finding is considered normal, and what additional MEM feature should you observe?

Normal MEM is about: +0.50 to +0.75 D

What accommodative findings suggest a child may benefit from spectacle correction?

Consider prescribing when there is:

• Reduced AA

• High lag on MEM

• Increasing lag over time during MEM

If accommodation findings indicate treatment is needed, what should you prescribe?

Consider prescribing the amount of plus needed to normalize MEM.

What school/achievement history should you ask about when deciding whether to prescribe refractive correction in a child?

Always ask about school function:

• Is the child on an IEP or 504 plan?

• Are they getting extra help or tutoring?

• Do they dislike reading, struggle with reading, or avoid reading?

How should school difficulties influence the eye exam and prescribing decision in a child?

If a child has school/reading concerns, scrutinize the exam data closely.
This means paying closer attention to:

• Hyperopia

• Accommodation findings

• Binocular alignment

• Other subtle visual factors that may affect sustained near work