Transcript BV MEETING September 2007

BV MEETING
September 2007
LIONEL KOWAL
To Emmetropize or Not to Emmetropize? The Question
for Hyperopic Development
MUTTI, DONALD Ohio
American Academy of Optometry Volume 84(2),February 2007pp 97-102
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Emmetropization is usually rapid, occurring in
the first year of life. Failure to emmetropize
leaves 2-8% of children with potentially clinically
significant hyperopia after infancy.
Uncorrected hyperopia in childhood has a
negative impact on distance acuity and the
accuracy of the accommodative response for an
unknown number of children.
The clinical gray zone for these problems as
judged by distance refractive error alone begins
around +2 to +3 D.
To Emmetropize or Not to Emmetropize? The Question
for Hyperopic Development
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Refractive correction seems to improve distance
acuity and the accuracy of accommodation.
Reluctance to prescribe hyperopic corrections to
children to improve visual performance might be
unwarranted.
If emmetropization is largely complete, if defocus has
only a minor effect on the development of refractive
error in infancy or childhood, and if the hyperopic eye is
already growing longer but not moving toward
emmetropia, then there may be little reason to either
wait or be concerned about interfering with
emmetropization that may never happen. The
immediate visual benefit may outweigh these concerns.
To Emmetropize or Not to Emmetropize?
The Question for Hyperopic Development
LK comment:
 Normal population, not a strabismus population.
 Does a strabismus population consistently
emmetropise <12 mo of age?
 Abrahamsson : non- emmetropization 
strabismus
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
ATKINSON, J; BRADDICK, O; et alii. London & Oxford
American Academy of Optometry Volume 84(2),February 2007,pp 84-96
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2 screening programs to detect significant
refractive errors in >8000 8-9 mo infants,
examine the sequelae of infant hyperopia, and
test whether early partial spectacle correction
improved visual outcome (strabismus and
acuity).
2nd program: also examined whether infant
hyperopia was associated with developmental
differences across various domains such as
language, cognition, attention, and visuomotor
competences up to age 7y.
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
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#1: orthoptic examination and isotropic
photorefraction, with cycloplegia.
#2: no cycloplegia.
Hyperopic infants (≥+4D) were followed up
alongside an emmetropic control group, with
visual and developmental measures up to age
7y, and entered a controlled trial of partial
spectacle correction.
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
RESULTS
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#2 : accommodative lag with a target at 75 cm (focus
≥+1.5 D) was a marker for significant hyperopia.
In each program, prevalence of significant hyperopia at
9 to 11 mo was around 5%
Infant hyperopia : increased strabismus at 4y.
Manifest strabismus was 0.3% at 9 mo and 2% by school age.
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Infant hyperopia : poor acuity at 4y.
The hyperopic group showed poorer overall
performance than controls between 1 - 7 y on
visuoperceptual, cognitive, motor, and attention tests
…… no consistent differences in early language or
phonological awareness.
Infant Hyperopia: Detection, Distribution, Changes and Correlates.
Outcomes From the Cambridge Infant Screening Programs
RESULTS….continued
Spectacle wear by infant hyperopes :
 better visual outcome than in uncorrected infants. Improvement in
strabismus with spectacle wear was found in the first program only.
.. did not affect emmetropization to 3.5y.
 Both corrected and uncorrected groups remained more hyperopic
than controls in the preschool years.
Conclusions.
 Photo/videorefraction can successfully screen infants for refractive
errors
 Visual outcomes may be improved by early refractive correction.
 Infant hyperopia is associated with mild delays across many
aspects of visuocognitive and visuomotor development.
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Eye advance online publication 2 February 2007
Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
J M Ip1, …. P Mitchell
Sydney
2353 students (75% response) from a
random cluster-sample of 21 secondary
schools across Sydney.
 Examinations included cycloplegic
autorefraction, and measures of Ks,
anterior chamber depth, and axial length.
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Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
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Participants mean age was 12.7 y (range 1114); 49% female.
60% European Caucasian ethnicity, 15% East
Asian, 7% Middle Eastern, and 5% South Asian.
The most frequent refractive error was mild
hyperopia (59%), [SE +0.50 - +1.99D].
Myopia (≤-0.5D) was found in 12%,
Moderate hyperopia (+2D) in 3.5%.
Ethnic differences in refraction and ocular biometry in a
population-based sample of 11–15-year-old Australian children
Myopia prevalence was lower among European
Caucasian children (5%) and Middle Eastern children
(6%) than among East Asian (40%) and South Asian
(32%) children.
 European Caucasian children had the most hyperopic
mean SE (+0.8D) and shortest mean axial length
(23.2mm). East Asian children had the most myopic
mean SE (-0.7D) and greatest mean axial length
(23.9mm).
Conclusion The overall myopia prevalence in this
sample was lower than in recent similar-aged European
Caucasian population samples. East Asian children in
our sample had both a higher prevalence of myopia and
longer mean axial length.
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Prevalence of Hyperopia and Associations
with Eye Findings in 6- and 12-Year-Olds
Jenny M. Ip, MBBS,1 … Paul Mitchell, MD, PhD1
Ophthalmology 2007;xx:xxx © 2007 by the American Academy of Ophthalmology.
Purpose: To describe the prevalence of hyperopia and associated factors in a
representative sample of Australian schoolchildren 6 and 12 years old.
Participants: Schoolchildren ages 6 (n 1765) and 12 (n 2353) from 55 randomly
selected schools across Sydney.
Methods: Detailed eye examinations included cycloplegic autorefraction, ocular
biometry, cover testing, and dilated fundus examination. Information on birth and
medical history were obtained from a parent questionnaire.
Main Outcome Measures: Moderate hyperopia defined as spherical equivalent
refraction of 2D), and eye conditions including amblyopia, strabismus, astigmatism,
and anisometropia.
Results: Prevalences of moderate hyperopia among children ages 6 and 12 were
13.2% and 5.0% respectively
It was more frequent in children of Caucasian ethnicity (15.7% and 6.8%, respectively)
than in children of other ethnic groups.
Prevalence of Hyperopia and Associations
with Eye Findings in 6- and 12-Year-Olds…2
Compared with children without significant ametropia, the prevalence of eye conditions
including amblyopia, strabismus, abnormal convergence, and reduced stereoacuity
was significantly greater in children with moderate hyperopia (all Ps 0.01).
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Maternal smoking was significantly associated with moderate hyperopia among 6year-olds (P 0.03), but this association was borderline among 12-year-olds (P
0.055).
 Early gestational age ( 37 weeks) and low birth weight ( 2500 g) were not
statistically significant predictors of moderate hyperopia in childhood.
Conclusions: Moderate hyperopia was strongly associated with many common eye
conditions, particularly amblyopia and strabismus, in older children. Birth
parameters did not predict moderate hyperopia.
Management of hyperopia in children
Jeddi Blouza A, ….. Tunis, Tunisia.
J Fr Ophtalmol. 2007 Mar;30(3):255-9.
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To study the prevalence of hyperopia in schoolaged children and to analyze the factors that
increase the risk of squint or amblyopia in a
retrospective study.
300 eyes of 150 children with hyperopia who
did not have anisometropia ≥ 1.5 D.
Hyperopia : spherical equivalent ≥ +0.5 D.
Amblyopia was screened and treated by
patching therapy and then penalisation.
Complete spectacle correction for children
≥+3.5D or in presence of squint or amblyopia.
Hyperopia in Tunisian children
RESULTS 1
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Mean age 9.5+/-2.7 y.
Mean overall refraction +2 D (+/-1.65).
Hyperopia ≥ +3.5D: 19% of children; latent in 35%.
Strabismus in 7%, accommodative in 25%.
ET most prevalent deviation (73%).
Prevalence of amblyopia 12%. Mean sphere in
amblyopic children was 5.7 D (+/-1.64 D).
Initial depth of amblyopia was mild to moderate and
98% of the children achieved iso-acuity after patching
therapy.
Hyperopia in Tunisian children
RESULTS 2
Correlation between high +, amblyopia, and squint
statistically significant.
 ≥ + 3.5D: Risk ratios of squint 5.2, amblyopia 3.7.
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CONCLUSION: Children ≥ +3.5 D have an increased risk
of amblyopia and squint that threatens their visual
function.
Hyperopic correction should be prescribed even if no
strabismus or amblyopia is detected in order to prevent
this risk.
Hyperopia in Tunisian children
COMMENT
Tunis: Hyperopia ≥ +3.5D:
19% of children; latent in 35%.
Sydney Middle Eastern children ≥+2D:
8% of 6y, 7% of 12y
Longitudinal changes in the spherical equivalent refractive error
of children with accommodative esotropia
S R Lambert…. Atlanta, GA, USA
British Journal of Ophthalmology 2006;90:357-361
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Longitudinal changes in spherical equivalent
(SE) refractive errors of children with
accommodative esotropia as a function of the
age when glasses were prescribed.
126 children with accommodative ET followed
longitudinally for 4.4 (SD 2.5) years.
Cycloplegic refractions were performed using
autorefractor for older children and retinoscopy
for younger children.
The refractive data were analysed for three
groups of children based on their age at the
time spectacles were prescribed.
Longitudinal changes in the spherical equivalent refractive error
of children with accommodative esotropia
RESULTS…..
The initial SE refractive error was age dependent
 <2y +5.1 (1.9) D
 2- <4y
+4.2 (1.9) D
 4-8y,
+3.8 (1.7) D.
 All ages : initial increase in refractive error, followed by
later decrease. Greatest decrease in oldest age group.
 Refractive error peaked 1y after glasses prescribed for
children 4-8y vs...... 6y after glasses prescribed for
children < 2y.
Conclusion: Longitudinal changes in refraction for
children with accommodative ET vary as a function of
age when glasses wear is initiated.
Management of Childhood Hyperopia: A
Pediatric Optometrist's Perspective
COTTER, SUSAN A. California
American Academy of Optometry Volume 84(2),February 2007, pp 103-109
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Variations in prescribing patterns for childhood + occur
within optometry & within ophthalmology.
Differences : due to a greater level of concern among
optometrists about associated vision functions such as
accommodation, vergence, & stereopsis, & potential
impact of uncorrected + on reading & school
performance.
Conclusions. If indications for prescribing spectacles for
children with hyperopia are to be validated, randomized
controlled trials need to be performed.
Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective
Survey 1: Prescribing for bilateral
asymptomatic + in young children
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65% of pediatric optometrists use +3 D of
bilateral hyperopia as their prescribing
threshold for 2yo.
28% used a higher threshold with 25% using +5
D as their threshold.
Pediatric ophthalmologists: 66% use +5D as
their threshold. 25% use a +3D threshold.
Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective
Survey 2: What magnitude of + in asymptomatic children should be
referred in a vision screening because it is worrisome
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College of Optometrists in Vision Development
(COVD) & American Association of Pediatric
Ophthalmology and Strabismus (AAPOS)
AAPOS: worrisome level of hyperopia was +5D
from 0 - 6 mo; +4D for 6- 48mo.
COVD : +3.50 D at 0- 6 mo; +3 D from 6 - 24
mo, +2.50 D from 24 -30 mo, and +2D 30- 48
mo.
Management of Childhood Hyperopia: A Pediatric Optometrist's Perspective
Hyperopic children who have
strabismus and/or amblyopia
Views of Donders (1864) and Worth (1903)
used similarly within both professions  maximum + to produce alignment in ET,
 full amounts of correction for anisometropia
and astigmatism to provide equal retinal
image clarity between the eyes,
 symmetrically reduced + prescriptions when
needed to ensure or promote acceptance of
spectacles.
 Greatest prescribing variability: children
≤12 y who have approximately equal + in the
2 eyes with neither strabismus nor amblyopia.
Ocular Dominance Diagnosis and
Its Influence in Monovision
Olga Seijasa … Pilar Gomez de Liano, Rosario Gomez de Liano, …
American Journal of Ophthalmology Volume 144, Issue 2, August 2007, Pages 209-216
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9 different tests were carried out in a group of
51 emmetropic subjects to determine both
motor and sensory ocular dominance.
For analysis, patients were divided into 2
groups according to age.
Normal ophthalmologic examination results
were the inclusion requirement, with normal
binocular vision and good stereoacuity.
Ocular Dominance Diagnosis and Its
Influence in Monovision
RESULTS
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A significant % of uncertain or ambiguous results in
all tests performed was found, except in the hole-incard and kaleidoscope tests.
When the tests were compared, two by two, the
correlation or equivalence found was low and was
much lower if tests were compared three by three.
No clear ocular dominance was found in most studied
subjects; instead, there must be a constant
alternating balance between both eyes in most
emmetropic persons, but not in those with pathologic
features. This fact would explain the great variability
both between and within different kinds of tests.
Ocular Dominance Diagnosis and Its
Influence in Monovision
RESULTS
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Also, it would explain why monovision
technique is well tolerated in most patients,
with unsuccessful results only in those
patients with strong or clear dominance.
…. it seems appropriate to evaluate patient’s
dominance before monovision surgery to
exclude those individuals with clear
dominance.
Association between fixation preference
testing and strabismic pseudoamblyopia Hakim
OM Saudi Arabia
J Pediatr Ophthalmol Strabismus. 2007 May-Jun;44(3):174-7
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.. to evaluate the strength of the association
between fixation preference and strabismic
amblyopia.
80 pts (3 to 8y) with manifest strabismus and
ability to do a Snellen E test ….
Fixation preference was graded from 0 (free
alternation) to 3 (strong uniocular fixation).
We compared acuity and the grade of fixation
preference.
Association between fixation preference
testing and strabismic pseudoamblyopia
RESULTS
60 pts had strong uniocular fixation (grade 3). Of
these patients, 50 had no amblyopia and only 10 had
deep amblyopia.
 10 pts had moderate fixation (grades 1 and 2). Of these
patients, 5 had no amblyopia and 5 had moderate
amblyopia.
 10 patients had free alternation (grade 0). These
patients had equal vision.
CONCLUSION: Treatment of strabismic amblyopia on the
basis that the sound eye will show strong fixation
preference can be hazardous. Fixation preference could
be a severe form of eye dominance, and better methods
for testing visual acuity in preverbal children are
required.
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Ocular findings in individuals
with intellectual disability.
Karadag R, ….
Can J Ophthalmol. 2007 Oct 4;42(5)
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Random sample of 180 intellectually disabled
children and adults aged 9 - 50
Refractive error in 56 of 166 patients.
Strabismus 2nd most frequent abnormality.
Eyelid abnormalities in 30 patients.
Cataract inc. congenital lens opacity was 4th
most frequent pathology
Posterior segment findings were detected in 23
of 166 patients.
Age at strabismus diagnosis in an
incidence cohort of children.
Mohney BG, …. Mayo Clinic Rochester, Minnesota
Am J Ophthalmol. 2007 Sep;144(3):467-9
Medical records of all Olmsted County,
Minnesota, residents < 19 y diagnosed with ET,
XT or hypertropia from January 1985 to
December 1994 reviewed.
The median age at diagnosis of
 esotropia (n = 380) : 3.1y
 exotropia (n = 205): 7.2y
 hypertropia (n = 42) : 6.1y
(P = .001).
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Age at strabismus diagnosis in an
incidence cohort of children.
Mohney BG, …. Mayo Clinic Rochester, Minnesota
Am J Ophthalmol. 2007 Sep;144(3):467-9
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6 y, ET had highest
incidence
 XT predominated age 7-12.
 Each form similarly likely to
occur 13 -18 y P = .001
incidence cohort.
Mohney BG. Mayo Clinic
Am J Ophthalmol. 2007 Sep;144(3):465-7.
Medical records of all Olmsted County,
Minnesota, residents < 19 y with ET, XT or
hypertropia 1985 - 94. 627 new cases of
childhood strabismus identified
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ET 380 (60%)
accomm 28%, nonaccomm 10%, neurological
7%,
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XT 205 (33%)
I-mitt 17%, convergence insufficiency 6%
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Hypertropia 42 (7%).