wk11: CL/M - Non surgical mx of Hyperopia

Question 1

When does the major post-natal growth of the eye occur?

Answer 1

during the first 3 years of life

Question 2

How long is the axial length for the neonatal eye, infant eye (3 yrs), and adult eye (16 yrs)

Answer 2

Neonatal: 16.5mm
Infant: 22.5mm
Adult: 23.5mm

Question 3

According to research by Mayer et al. 2001 on refractive error distribution in children over the first 48 months of life: during what time period was a wider spread of refractive errors noticed?

Answer 3

In first year of life

Question 4

According to research from Mayer et al. 2001, what was the average spherical equivalent mean refraction for 1 month old and 48 month old?

Answer 4

1 month: +2.20 diopters
48 months: +1.13 diopters

Question 5

According to Ip et al., 2008: What level of hyperopia (in diopters) do most children up to 6 years old have?

Answer 5

Below +2.00DS

Question 6

According to Ip et al. 2008: What is the prevalence of moderate hyperopia (+2.00D or more) in 6 year olds? What about 12 year olds?

Answer 6

6 year olds: 13%
12 year olds: 5%

Question 7

How good of an indication is refractive state measured soon after birth for the final refractive error of the child? Explain

Answer 7

Good. With those myopic early in infancy eventually regressing back to myopia despite emmetropising in early childhood

Question 8

How can we measure refractive error? (3))

Answer 8

Auto-refractor
Non-cycloplegic ret
Cycloplegic ret

Question 9

Which method of measuring refractive error in children is the gold standard?

Answer 9

cycloplegic retinoscopy (using cyclopentolate obviously)

Question 10

What should we aim for when doing cylcoplegic retinoscopy?

Answer 10

Maximum plus

Question 11

Is subjective refraction reliable in a child younger than 7-8 years of age?

Answer 11

No.

Question 12

What did The Vision in Preschoolers Study group conclude when comparing 11 preschool vision screening tests by licensed eye care professionals?

Answer 12

1. Screening tests vary widely in performance
2. With 90% specificity, the best tests detected only 2/3rds of chilren having >/= 1 targeted condition, but nearly 90% of children with the most important conditions
3. The 2 tests that use static photorefractive technology were less accurate than 3 tests that assess refractive errors in other ways

Question 13

In the study of screening tests by The Vision in Preschoolers Study, how did the sensitivity and specificity of non-cycloplegic retinoscopy compare to auto-refractors?

Answer 13

had a higher overall sensitivity and specificity for detecting refractive error than any of the measured auto-refractors

Question 14

What is the gold standard for refractive assessment in children under 4 and children with esotropia?

Answer 14

Cycloplegic ret (with cyclopentolate)

Question 15

Will you be able to determine the final hyperopia measure by the end of the first visit with a child under 4 or with esotropia?

Answer 15

No you won’t be able to determine this

Question 16

For what level of hyperopia in children should clinicians prescribe optical correction for? (3)

Answer 16

moderate to high hyperopia. For 2-3 year olds, many practitioners use a threshold of +3.00D bilateral aysmptomatic hyperopia, while others use a threshold of +5.00D

Question 17

What does the American Academy of Ophthalmology state as the prescribing standards for:
- Hyperopia in 0-1 year old px
- Hyperopia in 1-2 year old px
- Hyperopia in 2-3 year old px

Answer 17

0-1: >+6.00D
1-2: >+5.00D
2-3: >+4.50D

Question 18

What does the American Academy of Ophthalmology state as the prescribing standards for:
- Hyperopia with esotropia in 0-1 year old px
- Hyperopia with esotropia in 1-2 year old px
- Hyperopia with esotropia in 2-3 year old px

Answer 18

0-1: >+3.00D
1-2: >+2.00D
2-3: >+1.50D

Question 19

What considerations are there when considering prescribing a child an optical correction for their hyperopia? (4)

Answer 19

1. Will you interrupt the normal emmetropisation process by prescribing for hyperopia?
2. Will you improve, or disturb the binocular function of the infant or child?
3. What is the risk of convergent strabismus (esotropia) if you don’t prescribe?
4. What is the risk of amblyopia if the hypermetropia is different in the two eyes and you don’t prescribe?

Question 20

What is the most common origin for esotropia? What percentage?

Answer 20

Refractive. Over 50% of all esotropes are refractive

Question 21

What percentage of 48 children aged 9 months with over +4.00D with a prescription became strabismic by age 4? How does this compare to 76 children who did not wear a prescription?

Answer 21

6% vs 21%

Question 22

Does prescribing harm emmetropisation?

Answer 22

No. In children with uncorrected and corrected hyperopia, the rate of reduction of hyperopia with age was a function of the initial level of hyperopia, not whether they were corrected.

Question 23

If uncorrected hyperopia results in the accommodative demand being greater, what can this result in? (5)

Answer 23

Blur
Abnormal phorias and possible strabismus
Asthenopic symptoms
Reduced reading efficiency, fluency, accuracy
Avoiding of reading

Question 24

What are the considerations you should make for management of hyperopia in children? (8)

Answer 24

Magnitude of hyperopia (relative to age)
Px ability to accommodate
Acceptance of plus at distance vs near
Binocular alignment and function
Visual needs and demands
Visual acuity
Risk of amblyopia
Symptoms

Question 25

What tests should you undertake in a child with hyperopia? (6)

Answer 25

Dry retinoscopy
Subjective refraction (if appropriate)
Blur function
Binocular vision and stereopsis
Accommodative function
Cycloplegic retinoscopy

Question 26

What does dynamic retinoscopy allow?

Answer 26

rapid assessment of accommodative ability

Question 27

Why should you quickly neutralise the reflex in MEM ret?

Answer 27

otherwise the lens alters the accommoative response

Question 28

What does MEM ret provide a measure of? What should you observe when doing this? (3)

Answer 28

accommodative response (posture). Observe: magnitude, stability, equality

Question 29

What is the aim when prescribing from MEM ret? (3)

Answer 29

Aim to prescribe the minimum plus that provides:
- equal lag of accommodation
- stable lag of accommodation
- low lag of accommodation

Question 30

What tests and procedures should you do when assessing hyperopia in young adults? (6)

Answer 30

Dry ret
Binocular refraction
Push Plus! (that’s not really a test though, more like advice)
Oculomotor balance (for phorias at both distance and near)
Dynamic ret (to achieve accommodative posture at habitual reading distance)
Amplitude of accommodation (is amplitude low for age?)

Question 31

What is the earliest age that research has found a narrowing of the refractive distribution and a shift nearer to emmetropia?

Answer 31

3 months