Nelson: Today's topic is management of refractive errors in young children. A 1-year-old child presents with a nasolacrimal duct obstruction of the right eye. Refraction was −2.00 diopters (D) in the right eye and −0.50 D in the left eye. How would you manage the refraction in this child?
Medow: I'd like to know the history of the family. Is there any amblyopia in the family? I'd look at his rotations and his fixing and following. I probably would not give him glasses if he showed no signs of being unhappy having the left eye covered. It's close. I think he's going to see well, and I would see him in 3 or 4 months just as a follow up.
Nelson: Would you repeat the refraction at that time?
Bacal: Because he has epiphora on that side, I would make sure there was no sign of glaucoma. Assuming we've ruled out any sign of glaucoma, if a child that age is −2.00 D in one eye and −0.50 D in the other eye, he is not going to have any visual difficulty because a 1 year old's visual world and visual tasks are at near fixation. I would tell the family that this is not a typical refraction for a child that age and I would recheck him in 6 months, but I would not prescribe glasses at this point.
Nelson: The next patient is a 16-month-old boy who was referred by the pediatrician for an abnormal spot test. This is the test that the pediatricians are doing and it's fairly reliable. The patient fixates well in both eyes. He has a refraction of +1.00 +1.75 @ 90 in the right eye and +0.50 +1.25 @ 90 in the left eye.
Bacal: I would not consider this a significant degree of anisometropia. The difference in astigmatism in each eye is 0.50 D and the difference in hyperopia is 0.50 D, so that's going to be a spherical equivalent difference of 0.75. My threshold for concern is typically 1.00 D, although I have seen a mild case of amblyopia with anisometropia below this level. I would tell the family that there is a slight difference between the two eyes, but typically this difference in refractive error does not cause amblyopia. However, if the difference were to increase, we would need to address it. I would recheck the child with cycloplegic refraction in 6 months.
Medow: I would do the same, but my threshold level is different. I prescribe glasses when I find something, not because of a number. I'd like to hear a history of amblyopia in the family. I'd like to see that he doesn't fix and follow as well in one eye as the other. Other than that, 1.00 D doesn't prompt me to give him glasses. If he came back with a 1.00 or 1.25 D difference and showed no preferential issues, I probably wouldn't give him glasses.
Bacal: You could have a child with 20/60 in one eye and 20/30 in the other eye. He is too young to check that, but if you use the fix and follow test, both eyes are going to fix and follow. Although fixing and following is important, I don't know if it's necessarily going to be able to detect a two- or three-line difference in acuity.
Medow: It may not. I'd also want to know from the parent whether the child has strabismus.
Nelson: Let's assume that this patient fixed and followed well but there's a family history of amblyopia. Would that change how you would treat this child or would you just continue to follow him?
Medow: At this point, even with a history of amblyopia, I wouldn't give him glasses. If it changed in 6 months, my other rule is follow the patient. When you're not sure whether you're going to prescribe glasses, you see them again in 6 months. At this age, children can have large refractive error changes in a rather narrow period of time. So I'd watch him carefully for 6 months.
Bacal: I wouldn't change anything with my management, but I would explain to the parents that because there is a family history of this, it does increase the chance in other family members so we're going to be extra cautious with their child. But I still wouldn't prescribe glasses at this point.
Nelson: Would you see him again in 6 months?
Nelson: A 7-month-old female infant came for an examination because the parents noticed that she seemed to have esotropia. On your examination, her eyes were absolutely straight, but she had a refraction of +3.75 +0.50 @ 90 in both eyes. How would you manage this patient at this time in terms of the refraction?
Deutsch: If I saw that there was absolutely no turn at all, I would still continue to observe, but bring her back relatively soon for another examination. I wouldn't be shocked if this patient goes on to develop accommodative esotropia, but I think I would not intervene at that age. I would bring her back in 3 or 4 months.
Bacal: I would express to the family that based on the refractive error the child is at risk for having a crossed eye. However, if it cannot be demonstrated on the examination, despite repeated alternate cover testing, even if it is occurring, it's occurring so infrequently that it's not going to affect her visual development. But as soon as it could be documented in the office she would need glasses.
Nelson: Let's assume her eyes are straight. How would you treat this child at 7 months?
Bacal: I thought the family said that they were noticing the eye turn.
Nelson: Yes, but you did not.
Bacal: I would not give glasses at this point in time.
Medow: She's in the first year of life where refractive errors vary widely and can change rather rapidly. Symmetry is good news. I would tell the parents that I don't see any strabismus. She has a flat nasal bridge and a refractive error that's equal in both eyes, but not enough that I think she needs glasses. I'd like to watch her and I'd see her in 4 to 6 months.
Deutsch: I'm not going to be surprised if this progresses to accommodative esotropia. Studies show that a certain percentage of children younger than 1 year are completely straight and the refraction is ascribed to pseudoesotropia, but they then go on to have accommodative esotropia at a higher incidence than the general population. That's probably because these children are on their best behavior and not showing off their intermittent turn early on. I wouldn't be shocked to see this happen and I think it's good to alert the parents. I also ask them to take photographs when they see the eye turn. I find this helpful because sometimes it is a pseudostrabismus and sometimes there is evidence of real turns.
Nelson: Are you saying that because the child has an apparent esotropia now she is at greater risk for developing it? Or are you more concerned about the refraction at this age, which predisposes to developing accommodative esotropia?
Deutsch: I think it's both. Just seeing the false appearance of crossed eyes in my observation did not make that child more likely to develop it, but some of these children who are intermittent have good control. Having that amount of farsightedness, a certain percentage of them will go on to lose their control.
Nelson: The next patient is a 4-month-old male infant who was referred for conjunctivitis. The conjunctivitis was treated. On follow-up examination 3 weeks later at almost 5 months of age, the conjunctivitis was cleared and he had a refraction of −4.00 D in each eye. How would you manage this child's refraction?
Medow: I might think about giving him glasses, but I might not because the whole world of a 5 to 7 month old is up close. He's not going to become amblyopic if he's symmetrical. I might observe. I would ask the parents whether they want their 5-month-old child to be wearing glasses.
Nelson: The parents decide that they're willing to hold off at this time. They come back 3 or 4 months later, you repeat the refraction, and he is still −4.00 D. He is now 8 or 9 months of age. Would that change how you would manage his refraction at that point?
Medow: Probably not. If the child starts to ambulate and you presented this as a 14- or 15-month-old child running around with −4.00 D in both eyes, I would consider giving him glasses. I'm very conservative about giving glasses. I would talk to the parents about it if they're both myopic and they've both been wearing glasses since they were 4 or 5 years old. I will tell them that the myopia is not going to disappear and he is going to be wearing glasses at some time in the future. If you told me that the child went from −4.00 to −8.00 D in 3 or 4 months, I would prescribe the glasses then.
Bacal: I agree. The key is ambulation. If the child is not ambulating yet and can see one-quarter of a meter clearly and then it becomes slightly blurry after that, I think the child is fine. But as soon as the child is starting to ambulate, this could potentially affect the progress of development. So, if he is ambulating, I would be inclined to give glasses.
Nelson: Let's say the child is now 13 months of age, but he's not ambulating yet and he's still −4.00 D. Would the fact that he's a little older change how you would treat this child at this point?
Bacal: The myopia could potentially be the cause of him not walking. But I meant ambulating such as crawling around and wanting to see the world and explore. After 1 year of age, I would be inclined to give the glasses.
Deutsch: I agree that I would not give glasses at 4 months of age. I have seen some incidental findings of mild myopia in the −1.00 to −1.50 D range at 4 months but the child comes back at 1 year old and it's not there at all. I think it is rare, but I haven't seen −4.00 D go away. I would not give glasses until after the child is walking.
Nelson: The next patient is a 16 month old referred again for the spot test. The refraction was +1.00 +2.00 @ 90 again in each eye. It's a symmetrical refraction. How would you manage this particular child's refraction?
Bacal: For that degree of astigmatism, I would certainly discuss it with the parents, but I would not give a 16 month old glasses for 2.00 D of astigmatism. For 3.00 D or higher, regardless of the age, I'm worried about bilateral refractive amblyopia so I typically give glasses. But in this range, I would not give glasses. I try to take into account where the child is in life and what the visual tasks are.
Deutsch: I'd be tempted to give the glasses. At +2.00 D, I would think about giving glasses. I might not give all of the sphere, but I think I would give the cylinder at this point. I certainly start thinking of giving the child glasses even at that young an age.
Nelson: So for you +2.00 D and greater at this age would be enough to give the glasses.
Deutsch: For an older child I would give them with less astigmatism, but at this age, yes. I would have a discussion with the parents if they were set on giving their child glasses. As someone who's worn glasses from an early age, I enjoy my clear vision and I would let that influence me.
Medow: I would not give the glasses at all. It's symmetrical astigmatism of +2.00 D. I would observe him.
Nelson: Is your cut-off the same at +3.00 D or greater?
Medow: Yes. When it comes to +3.00 D, I'm more apt to prescribe it. It depends on my observation and discussion with the parents. We've all seen parents who have had glasses at a young age and they no longer wear them. For this child, I would wait until it was +3.00 D and then I'd be concerned.
Bacal: Obviously if the results of cycloplegic refraction are values I would consider amblyogenic, then I'm going to prescribe glasses. Below that, my general philosophy is talking about that specific child and what the child is doing in life. In other words, for the same refraction for a 1 year old, a 5 year old, and a 15 year old, I'm not going to give the family the same answer.
Medow: We all get referrals for a failed vision test in school and my first question is how does the child do at home? Do the parents think he needs glasses? The parent often says no, I think he sees fine. I generally rely on how the child functions in my office during the examination.
Deutsch: I work at a large public hospital and sometimes I worry that if I do not give glasses at a certain point, I may not see that child again in the clinic for 3 or 4 years. That sometimes influences whether I give the glasses or not.
Medow: How many times have you given glasses and they come back 3 or 4 years later saying they lost the glasses 2 months after you gave them to them and they've never worn the glasses for 3 years now? I don't give them glasses based on whether they're going to return for follow up. I don't think I'm always 100% correct.
Deutsch: We try to do our best.
Nelson: The next case is a 20-month-old boy who was noted to be squinting a lot. He's fixing and following well. The refraction was −4.00 +2.25 @ 90 in both eyes. How would you manage this child's refraction?
Deutsch: I would give the child the refraction.
Medow: How is his function?
Nelson: He seems to function well except the parents brought him in because he does squint the minute he has to look at something at any kind of reasonable distance.
Medow: So he's showing me some functional response to his being myopic. I would think about potentially giving him glasses. If the parents are telling me that there's something that I could attribute to his need for glasses, I'm going to give him the glasses. Squinting is something that myopes always do.
Deutsch: You are evaluating his vision based on his visual behavior. He is telling you that he wants to see better and, therefore, you give the glasses.
Bacal: I agree. If we are only provided with the refraction, and no history of behavior, I might defer prescribing glasses at this point. But the fact that the child is displaying symptoms that point toward some difficulty would push me to give the glasses at this point.
Nelson: The final case is a 19-month-old girl who was examined only because the parents had a strong history of amblyopia. The child seems to fixate well. The refraction is +2.75 D in the right eye and +2.00 D in the left eye. How would you manage this particular child?
Bacal: This is similar to one of the other patients you presented earlier. The refractive discrepancy of 0.75 D would be just under the threshold where I would typically be worried about amblyopia, although I have seen patients who did have mild amblyopia with this scenario. I would tell the family that there is a concern for the right eye. We need to watch this child closely, especially considering the family history, but I would not give a glasses prescription yet. I would re-cycloplege her in 6 months.
Deutsch: I would not give glasses at this point, but it would be on my radar and I would see the child relatively frequently.
Nelson: When would you see her again?
Deutsch: Between 4 and 6 months.
Medow: I would see the child in 4 months and explain to the parents that because amblyopia is prevalent in the family we have to consider it as a possibility, so I'd like to see her in 4 months to re-check her prescription. Or sooner if they notice her eyes turning.
Nelson: Thank you for your insights on this topic.
This Eye to Eye session was conducted on April 30, 2019.