Anne Cees
Houtman
UZ-VUB
REFRACTION IN
CHILDREN
M 7 days old 3640
Hyperextensibility joints
Mild retrognathia
Request eye assessment
What are you going to do
11-2-2014 refraction in children 2
WARD REFERRAL
Schisiservaringennl
Externally normal
Clear media
Normal fundi
11-2-2014 refraction in children 3
WARD REFERRAL
Schisiservaringennl
A little history
What determines refraction
What is normal
The 5Wrsquos of refraction
Refractive error
A treatable condition Guidelines for prescribing
Refractive surgery in children
A bonus refraction as a differential diagnostic sign
Refract ion in
chi ldren
11-2-2014 refraction in children 4
OUTLINE
11-2-2014 refraction in children 5
A LITTLE
HISTORY
Tommaso da Modena Treviso
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
M 7 days old 3640
Hyperextensibility joints
Mild retrognathia
Request eye assessment
What are you going to do
11-2-2014 refraction in children 2
WARD REFERRAL
Schisiservaringennl
Externally normal
Clear media
Normal fundi
11-2-2014 refraction in children 3
WARD REFERRAL
Schisiservaringennl
A little history
What determines refraction
What is normal
The 5Wrsquos of refraction
Refractive error
A treatable condition Guidelines for prescribing
Refractive surgery in children
A bonus refraction as a differential diagnostic sign
Refract ion in
chi ldren
11-2-2014 refraction in children 4
OUTLINE
11-2-2014 refraction in children 5
A LITTLE
HISTORY
Tommaso da Modena Treviso
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Externally normal
Clear media
Normal fundi
11-2-2014 refraction in children 3
WARD REFERRAL
Schisiservaringennl
A little history
What determines refraction
What is normal
The 5Wrsquos of refraction
Refractive error
A treatable condition Guidelines for prescribing
Refractive surgery in children
A bonus refraction as a differential diagnostic sign
Refract ion in
chi ldren
11-2-2014 refraction in children 4
OUTLINE
11-2-2014 refraction in children 5
A LITTLE
HISTORY
Tommaso da Modena Treviso
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
A little history
What determines refraction
What is normal
The 5Wrsquos of refraction
Refractive error
A treatable condition Guidelines for prescribing
Refractive surgery in children
A bonus refraction as a differential diagnostic sign
Refract ion in
chi ldren
11-2-2014 refraction in children 4
OUTLINE
11-2-2014 refraction in children 5
A LITTLE
HISTORY
Tommaso da Modena Treviso
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 refraction in children 5
A LITTLE
HISTORY
Tommaso da Modena Treviso
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
2112014 Refraction in children 6
KEPLER EN DESCARTES
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
2112014 Refraction in children 7
SETTLED OPINIONS AND IGNORANCE
ldquothe mad fashion of wearing glassesrdquo against which we
ldquocannot warn too insistentlyrdquo
(Jaeger 1855)
Young persons wearing glasses were
ldquolooked on as dudesrdquo
(Hoyer 1836)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
2112014 Refraction in children 8
SCIENTIA TENEBRAS VINCERE
ldquoPhysiological opticsrdquo
(Helmholtz 1856)
ldquoAccommodation and refraction of the eyerdquo
(Donders 1864)
ldquoSkiascopy and its practical applications to the Study of
Refractionrdquo
(Jackson 1895)
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 Refraction in children 9
WHAT
DETERMINES
REFRACTION
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 10
ORGANOGENESIS
FOXC1
PITX2 neural crest
LMX1B
FOXE3 lens
MAF
CYP1B1 gt P450 enzyme
PAX6
Refraction in children
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 11
Cornea
Lens
Axial length
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 12
Cornea
Lens
Axial length
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Genetics Environment
11-2-2014 Refraction in children
Twin studies
Parental refraction
Ethnicity
E-Asia S-Asia Eur Afr
Hereditary conditions
Visual input
Peripheral retinal defocus
Accommodation
Daylight hours
Education
Geography
Social-economic status
Outdoor activity
LBWIUGR
Maternal ageheight
Cigarettes
Height at adult age
13
DEVELOPMENT OF REFRACTION
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 Refraction in children 14
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 Refraction in children 15
ABNORMAL DEVELOPMENT WILL AFFECT REFRACTION
Matta NS Silbert DI High prevalence of amblyopia risk factors in
preverbal children with nasolacrimal duct obstruction JAAPOS 2011
Aug15(4)350-2
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHATrsquoS NORMAL
11-2-2014 Refraction in children 16
Text book of ophthalmology Vol IV Errors of refraction p4247 W Stewart Duke-Elder Henry Kimpton London
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHATrsquoS NORMAL
11-2-2014 Refraction in children 17
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHATrsquoS NORMAL
11-2-2014 Refraction in children 18
The prevalence of refractive errors among children adolescents and adults in Germany Jobke s et al Clin Ophthalmol 2008 (2) 3 601-7
N=536
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Who
What
Where
When
Why
11-2-2014 19 refraction in children
THE 5 WrsquoS OF
REFRACTION
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHO IS GOING TO DO
IT
11-2-2014 refraction in children 20
THE 5 WrsquoS
OF
REFRACTION
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 21
THE 5 WrsquoS
OF
REFRACTION
ldquoEVERY CHILD HAS THE RIGHT OF A
CYCLOPLEGIC REFRACTIONrdquo
wwwcommunityniorg
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHO IS GOING TO
HAVE IT DONE
11-2-2014 refraction in children 22
THE 5 WrsquoS
OF
REFRACTION
And remember
ldquoCycloplegic drops ought to be used as if they
were freerdquo
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 23
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 24
THE 5 WrsquoS
OF
REFRACTION ldquoIt is however an art which cannot be learned
from books for efficiency can only be attained
by long assiduous and painstaking practicerdquo
Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4377
Bowman 1859 CuignetMenginLandolt 1878 Parent 1880
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 25
THE 5 WrsquoS
OF
REFRACTION
Retinoscopy simulators
wwweyeontechscom
wwwmrcophthcom ndash test yourself
wwwmedroundorg - $$
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 26
THE 5 WrsquoS
OF
REFRACTION
Autorefractors
Retinomax
Plusoptix
Edinburghoptometryca
wwwcalcoastophthalmiccom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 27
THE 5 WrsquoS
OF
REFRACTION
Retinomax
Comparison of the Retinomax autorefractor with hand-held retinoscopy in 1-year old infants
Gole GA et al Clinical and Experimental Ophthalmology 2003 31 341-347
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 28
THE 5 WrsquoS
OF
REFRACTION
Plusoptix
N=118 mean age 5
Plusoptix S08 -005 plusmn 161
Cycloplegic retinoscopy -015 plusmn 131
Cycloplegic AR -012 plusmn 141
Int Ophthalmol 2013 Oct 10 [Epub ahead of print]- abstract
Comparison of photorefraction autorefractometry and retinoscopy in children
Demirci G Arslan B Ozsuumltccediluuml M Eliaccedilık M Gulkilik G
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
UZ-VUB
2013
N=58 ( p r e l i m i n a r y r e s u l t s )
11-2-2014 refraction in children 29
PLUSOPTIX
RETINOMAX
AR amp
RETINOSCOPY
Average non-cyclo ARRM seq RE -005
Average non-cyclo Plusoptix +013
Average cyclo ARRM
+054
And then we found the autorefractors and
retinoscopy may disagree by 275 D (spherical power) in some cases
And 175D for cylindershellip
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 30
THE 5 WrsquoS
OF
REFRACTION
ldquoRetinoscopy is the most generally satisfactory and accurate
method for the objective determination of the refractionrdquo Textbook of ophthalmology Duke-Elder S Vol IV London Henry Kimpton 1950 p4386
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 31
THE 5 WrsquoS
OF
REFRACTION
ldquoYour best friendrdquo (D Taylor) Snellen and Landolt 1874
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHAT ARE YOU GOING
TO DO
11-2-2014 refraction in children 32
THE 5 WrsquoS
OF
REFRACTION
Cycloplegia
atropine 1h 2w
cyclopentolate 30-60rsquo 48h
tropicamide 20-30rsquo 6h
Residual accommodation (6-12 yrs) tropicamide +047 D than cyclopentolate
(Mutti ea The effect of cycloplegia on measurement of the ocular components IOVS 1994)
Residual accommodation may be as much as 2D more than atropine according
to several authors
side effects hypersensitivity reactions fever dry mouth rapid pulse nausea vomiting
flushing and rarely behavioral changes
(several dozen case reports over a century ndash so probably safe)
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHERE ARE YOU GOING
TO DO IT
11-2-2014 refraction in children 33
THE 5 WrsquoS
OF
REFRACTION
Well anywhere reallyhellip
hellipas long as you do it
httptelemedicineorbisorg
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHEN
11-2-2014 refraction in children 34
THE 5 WrsquoS
OF
REFRACTION
First visit
Check yearly
Frequently pseudophakiaaphakia glaucoma
eyelid lesions
Decrease in VA
Intolerance to glasses
Change in squint angle
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHY
11-2-2014 refraction in children 35
THE 5 WrsquoS
OF
REFRACTION
Importance of vision for general development
Poor growthdevelopment may be associated
with visual problems
And think of refractive error as
a treatable condition (glasses have very few side effects)
a differential diagnostic sign
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Guidelines
for
prescribing
11-2-2014 refraction in children 36
A
TREATABLE
CONDITION
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Cont roversy
abounds
11-2-2014 refraction in children 37
PRESCRIBING
WHAT
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
RCOphth
Not found
recent ly on
website
11-2-2014 refraction in children 38
PRESCRIBING
WHAT
Anisometropia hypermetropia 150
astigmatism 200
myopia 200
Isometropia hypermetropia 450
myopia 300
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
AAO
A gain hard to
f ind the
guidel ines
11-2-2014 refraction in children 39
PRESCRIBING
WHAT
hyperopia (no tropia) gt +450D
hyperopia with esotropia gt +150D
astigmatism gt 200D
anisohyperopia gt 150D
myopia gt 200D
astigmatism gt 200D
myopia gt -300D
wwwaaoorgeducationlibrarypppindexcfm
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
MYOPIA
11-2-2014 myopie op de kinderleeftijd 40
Undercorrect or fully correct
The Cochrane Col laborat ion
Interventions to slow progression of myopia in children W a l l i n e J J L i n d s l e y K V e d u l a S S C o t t e r S A M u t t i D O T w e l k e r J D
ldquoLimited evidence favoring ful l correct ionrdquo
Undercorrection of myopia enhances rather than inhibits myopia progression Chung
K V is ion Res 2002422555 -9
The possible effect of undercorrection on myopic progression in children Adler D et
a l C l in Exp Optom 2006 Sep89(5) 315 -21
ldquoConsistent evidence of meaningful benefit with ant i -muscarinic drugs rdquo
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
HYPERMETROPIA
11-2-2014 myopie op de kinderleeftijd 41
Accommodation convergence strabismus asthenopia
Well-known since the mid-19 th century but neglected often
Strongly consider partial or full correction in non-strabismic
hypermetropia eg gt +45 D (risk of ametropic amblyopia)
Full correction in strabismus
Hypermetropic correction does not influence emmetropization
I n f a n t H y p e r o p i a D e t e c t i o n D i s t r i b u t i o n C h a n g e s a n d C o r r e l a t e s mdash O u t c o m e s F r o m t h e C a m b r i d g e I n f a n t S c r e e n i n g P r o g r a m s
A t k i n s o n J e t a l O p t o m e t r y a n d V i s i o n S c i e n c e 2 0 0 7 8 4 8 4 ndash 9 6
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
Ver y
cont roversial
11-2-2014 refraction in children 42
REFRACTIVE
SURGERY IN
CHILDREN
Refractive surgery may be
considered in
High anisometropia and isoametropia
associated with amblyopia when standard
treatment fails
Neurobehavioural disorders
Techniques corneal refractive surgery
intraocular surgery
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
11-2-2014 refraction in children 43
eg
Phakic intraocular lens correction of high ametropia in children with neurobehavioural
disorders Tychsen L Hoekel J Ghasia F Yoon-Huang G Journal of AAPOS 200812282-289
Preop -2275 to -100 D (-149 D N=11 18 eyes)
Directly postop -03 D(+-11)
Regression +06 D (+-15D)
Postop +02 D (+- 08)
Preop UCVA 203400 (logMAR 223 +-057)
Postop UCVA 2057 (logMAR 046 +- 028)
60 x
T-test p=000
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHY
11-2-2014 refraction in children 44
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High hypermetropia
Leber congenital amaurosis
Achromatopsia
Nanophthalmus
Cornea plana
Microphthalmia
XLRS
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHY
11-2-2014 refraction in children 45
THE 5 WrsquoS
OF
REFRACTION
A differential diagnostic sign
High myopia
CSNB
Congenital glaucoma
Megalocornea
FAS
Stickler
Stargardt
Gyrate Atrophy
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
2112014 Refraction in children 46
What about that ward referral
Brother RE -12 LE -10
vitreous lacunae
high arched palate gtgt Stickler
Baby +3 +3
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
2112014 Refraction in children 47
SOhellip
Think refraction
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom
WHYhellip
BECAUSE WE HAVE TO
2112014 Refraction in children 48
REFRACTION IN CHILDREN
littlefoureyescom