Lecture: Prescribing for Children: The Pitfalls and Tricks to Keep Kids in Glasses

DR WASSNIG: Hi, everyone. Thanks so much for joining us today. I’m just going to switch to the PowerPoint over here.

So… My name is Sarah. And we’re gonna discuss today prescribing for kids. I got…

After reading all of your questions, there seems to be a really big interest in what tests and what normals I’m looking for, for each age group.

So we’re gonna start with that first, before moving on to some case studies, and sort of how I adjust prescriptions.

To suit each kid individually. So the hardest thing in working with kids I think is losing their attention. So the first thing I advise when testing kids is to be prepared to perform all of your tests as soon as the patient sits down.

So I try to avoid lengthy conversations with the caregiver, fussing about with equipment. I try to have everything ready to go. I have the child sitting on the parent’s lap or by themselves. You’ve got to start testing straight away.

I get a team at the front to send a questionnaire to the caregiver beforehand or to ask a few probing questions while making the appointment. Why have you come in today? Is there something you have worried about or want to speak to the doctor about? Have they had an eye test before?

If they have, has it been very successful or not? Are there any special considerations we should know about? And this is when kids with special needs might come out.

Or things might come out like dyslexia or we’re concerned about school or something like that.

As I walk in, I just say to the patient… I’m just gonna start with some tests. Whilst I have little Johnny’s attention.

And then I’ll be asking some questions about why you’re here and any concerns that you have, if that’s okay.

So just let the parent know what to expect, so they’re on board. But it is a lot easier just to start talking to the patient straight away.

The questionnaire beforehand also covers all of the factors that may increase the risk of visual impairment. These may include but are not limited to prematurity, any birth complication, any systemic or developmental conditions that the child has.

Also a family history of eye conditions. Which includes refractive errors. Remember, a child with one or two myopic parents is at higher risk of developing myopia.

This is also the case with strabismus. It’s not actually, interestingly enough, always the case with hyperopia. Which is very interesting.

I address all my questions to the little one, and I get down on their level. My seat is quite low and I get down on their level, and I look at them when I’m speaking to them and when they’re speaking to me, rather than fussing around with my equipment or writing or typing anything.

My first question is always: What’s your name or how old are you? Even though I know the answer to this. This allows me to gauge their level of communication and to start a relationship with them.

If they’re older, I’ll ask what grade are you in? What subjects do you like? Just to start that relationship. I’m from Richmond in the UK, so here we ask about football. Particularly now with the World Cup. We ask about what football team you go for. That kind of stuff.

If the kids are preschoolers or younger, I always say: We’re gonna test how strong your eyes are today. Are you pretty strong? Show me how strong you are. I do this and I squeeze their little arms and get them giggling and excited and relaxed.

The best way to relax them is just to engage with them. Before they leave our care, we want to be sure that they have healthy eyes.

And we want to make sure that they’re seeing equally and that they’re coordinating well together. So when they’re really little, I’m looking for the big stuff. Is the refraction within normal limits for their age? Is it equal between the eyes? Are there any major concerns with ocular anatomy?

Are they straight? Are they interacting with their environment, as we’d expect? And then as the child gets older, then my testing becomes more and more specific to include accommodations, stereopsis, and all of those sorts of binocular vision tests.

We’re gonna go through the test to perform for each age group. But the most important thing is: You want to plan. And you want to plan before the kid enters the room.

So you know your testing flow, and you know exactly what’s coming next. So you don’t really have to think too much or stop the test, to think about where you’re going next.

Also with kids, you want to be really, really flexible. If something isn’t working, move on. Even if it’s really important, if it’s retinoscopy, anything, just say… I really want this answer. Move on to something else. Do something fun. And come back to it and keep in mind that most likely you’re allowed to bring them back.

So just keep that in the back of your mind. It’s not make or break if you don’t get the answer immediately.

So… We’re gonna start with the little ones. We’ll keep coming back to this slide. There’s a lot of information on this slide. So we’ll keep coming back to this slide.

I always start by lighting up a toy. I have a couple of rubber finger puppets here. And I place them over my transilluminator or my light, and it lights up their little face.

This is fun. Which is good. It builds a rapport with the kid. Also, because of the lights, it gives me a Hirschberg, which is really invaluable.

I start with ocular motility. Showing them the toy, moving it side to side, up and down. If you move their focus halfway, just pause for a second, and then redirect them and keep going. So you don’t have to sort of keep starting from the middle.

And then sometimes even if they’re a little bit older, I’ll go woo and get them to look all the way around, just for a little bit of fun, because it always makes them smile.

I always do NPC at the end, because I figure — why not? I’ve already got the equipment in my hand and ready. And it’s quite funny to sort of… As it’s coming closer and closer, say… He’s gonna give you a kiss, he’s gonna give you a kiss, and tap them on the end of the nose.

I do it a couple of times. It relaxes them and also gives me a bit of information. So I think that’s a good sort of way to start a test. I have a few different things here. As you can see from the slide, this little one here has lots of different very detailed pictures, which is quite handy.

And I have little toys on sticks and things like that. So I’ve always got them handy, and I can just keep switching over.

Then I move straight to cover test. Because I’ve already got the stimulus in my hand. So whatever I’ve been doing motility with, I do cover tests with.

I might, if I feel like they weren’t interested, or I’ve lost their attention, I might quickly switch over to something else, but I want to, again, have it right on hand, and not take too much time looking for it.

By this stage, the toddler — especially if they’re a little older… This lady is funny! What’s she gonna do with this now? Which is good, because I really need to get a good result on cover tests. I really need them to be focusing.

So at this point, they’re thinking… All right. What’s she going to do? What’s she gonna do? And they’re watching the target really carefully, which is great.

I use my thumb in younger kids. As you can see here. This isn’t me, but this is a picture of someone doing cover tests using their thumb. I think it’s a lot less intrusive and I’m less likely to be pushed aside. I place my hand on their head, and they concentrate so much looking at the target, they often don’t notice.

But I pop my hand on their head so they know I’m there and that my thumb is coming, at least, and I block their visual access with my thumb.

Once I’ve done the cover test, I quickly cover one eye fully and then the other and go back to the other one, to see if I get a really big reaction. It may be that they just don’t want their — my hand in front of their eye.

And that is fine. That’s fair enough. But it could indicate if they really react to one eye — it could indicate that that’s because there’s amblyopia, and so you’re covering the good eye, and they’re thinking… Oh, no. What’s she doing?

And so that’s sort of something that will give you a few clues.

So… I put down my transilluminator and grab my direct ophthalmoscope already assembled and ready to go.

You want to be about sort of half a meter to a meter away. And I usually say to the kids: Do you know how to have your photo taken? And of course kids nowadays all say yes.

We’re constantly taking photos of them. I know I am with my kids. And they give a big wide smile. And when they do, most importantly, they give big wide open eyes.

You want to dial in about +1 or keep it at plano at your direct ophthalmoscope, and look through the hole, just like the picture here.

And observe the red reflex coming back from the pupil. This gives you some really big general sort of information. So worst case scenario, if everything stops here, they have to go away and come back, you’ve got some information to go on.

You can identify refractive errors in a general way. Gives you an indication if there’s a large asymmetry between the eyes. And it’s also a really easy way to pick up any media opacities or any strabismus that you hadn’t noticed, if it’s a microstrabismus.

So in number one and two here, you can see one bright, whitish reflex coming back at you, and one red one. The little one has straight eyes, but a media podcast in the left eye. And in number two, the kid has a right esotropia. This is about 30 prism diopters. So you’re gonna notice this one.

But if it’s a little less noticeable, then it’s really sort of handy for the microtropias or anything you haven’t noticed yet.

In number three, four, and five, we’re just showing you the different types of refractive errors. So hyperopia has a superior crescent, myopia gives an inferior crescent, and on number five, you can see there’s an asymmetry, quite apparent, between the two eyes.

In number four, this kid has -11 and -13 refractive error. So you can see the higher the refractive error, the harder it is to pick up the reflex. So I’m thinking at the back of my mind… The reflex looks a little bit flimsy. Maybe this is quite a high refractive error.

So at this point, I’m pretty happy. I know if I have strabismus, nystagmus, tracking issues, media opacities, possibly amblyopia, if they really reacted to me covering one eye.

And I have a ballpark refractive error and asymmetry. I have an idea of what I’m looking at. If this is all I can get, regarding refractive error, then no worries. I’ll take a quick look through the pupil, to rule out any major referral stuff.

And then I’ll bring them back, if I feel like I need to. If they’re pretty happy in the test so far, they’re relaxed, and they’re still communicating, and I’ve got their attention, then we’ll move on to measuring retinoscopy.

So the kid is usually on mom or dad’s lap, unless they’re really mature for their age. I get the parent to cover one of the eyes. Another thing I do is when I’m holding my lens… That’s not a lens at all. It’s not gonna help you…

When I’m holding my lens, I can use these fingers to block off the other eye.

You want to be in near total darkness when you do Mohindra retinoscopy. And I give everyone a heads up — even if they’re not verbal yet, they do understand you.

So just let them know — I’m gonna turn the lights down. Is that okay? Also give mom and dad a heads up. Realistically, I don’t have total darkness, so I can see what I’m doing.

But don’t forget to turn off your vision chart and your computer screen, because they give off quite a lot of light. I also turn those off before I start the test, because I don’t really need them with kids anyway.

And the darkness is really just to encourage the baby or the infant or toddler to look at your retinoscope’s light. So about 50 centimeters from the patient, you can use loose lenses or ret rack.

I think loose lenses are a little less intrusive. If they push the lens away, then I show them with the lens on me. And then them. And then me. And then them.

So they’re a little bit more comfortable. And they can see that I’m happy to do it as well.

As with all retinoscopy, you just change the lens until you get a neutral reflex. If there’s a with reflex, you’re adding plus. If there’s an against reflex, you’re adding minus.

If there’s astigmatism, use spherical lenses to neutralize each meridian. Not cylindrical lenses. Because remember, you’re in the dark. So it’s hard to align the lenses correctly.

This technique also needs you to have a super organized trial lens set. So you know that you’re grabbing the correct lens. So you need to be quite prepared. There’s no time for cleaning lenses, all that kind of stuff.

Once you have your neutral point, to get to your final refractive error, you go into subtracting about +.75 for kids less than 2 years. 1, for kids who are 3 or 4, and 1.25 for kids who are older.

So you’re at 50 centimeters, you neutralize the reflex at +5. If the kid is 18 months old, you’re thinking that’s about a +4.25. If the kid is 4 years old, you’re thinking that’s about a +4.

So with that said… I start with the lens I expect to be neutral for their age. Thinking, first off… Is there a large with or against movement that’s abnormal?

So if they’re 6 months, I’m gonna just pop up a +4. And I’m expecting something close to neutral. Maybe some against. I’m not expecting a really large with.

At 1, I might pop up a +3. And I should be kind of close to neutral. A little bit against. By the time they’re 4, they should be really close to neutral with my working distance lens of 1.25. So I pop up a 1.25.

If I get a really big with, I’m thinking… Okay. This is not normal. If I get a really big against, I’m thinking… Okay. This is not normal.

If it seems pretty okay, or even if it doesn’t, I scan 180, then, all the way around, and I’m just looking for significant astigmatism. So big changes from what I’m getting at 180, as I move across. Do I see a huge amount of astigmatism?

Then I compare the other eye with the same lens to see if there’s a big difference between the two eyes.

If the reflex is close to neutral in both eyes, and there’s no significant astigmatism, I stop. Because who really cares if they’re +2 or +1.75? I just want to know if the refractive error is healthy, and if it’s gonna cause any issues.

If in doubt, cycloplege every time. Not an issue. Better to be safe than sorry. I had an attendee question ask if we could use tropicamide. If you have to, do what you have to do. But keep in mind it doesn’t demobilize accommodation in the same way.

I had someone ask how old do I stop cyclopleging? I think if the kid can sit reliably, looking at the distance, at target, then I don’t cycloplege.

If I don’t see any issues, if there’s no symptoms, if they’re just coming in for something routine, I don’t see anything, Mohindra comes back pretty acceptable and I’m confident in my result, I’m happy not to cycloplege, even if they’re an infant.

But I will cycloplege a teenager, if I think there’s some hyperopia that’s significant. I’ll cycloplege if a parent is concerned about strabismus.

If visual acuity doesn’t match retinoscopy. If I’m trying 1 and they get 0.75, it doesn’t match up. If there’s stereopsis, accommodation seems to be fluctuating, there’s a large lead, which we’ll talk about in a second, if refraction or visual acuity is unstable, I’ll raise 0.65 and they come back to that line, and say I can’t see that anymore.

If the patient seems to be raising one eye or winking when they’re reading, something like that. Keep in mind when you’re doing retinoscopy, you want to be looking at the central 3 to 4 millimeters, because there’s a lot of peripheral aberrations. And you want to ask the child to be looking at your light. Just to be sure that you’re right on the visual axis.

If they’ve got strabismus, when you’re doing the strabismic eye, you can get the parent to cover the non-strabismic eye to make sure that the strabismic eye is fixating and focusing on your retinoscope.

So as you can see… Children should be born with a small amount of hyperopia. Which decreases over time to about 1.50, by the time they’re 4. Here I’ve just got the mean refractive error.

So there’s a little bit of leeway to either side. In kids about 0 to 2 years, the majority of emmetropization is occurring. After two years, the amount of emmetropization is not as clinically significant. So keep that in mind.

When you’re prescribing. And you’re thinking… I want to leave a little bit to the kids to emmetropize. They will a little bit. But not to the same degree as between 0 and 2.

In the early months, children are more likely to have astigmatism, and tend to emmetropize over the first two years. Don’t be too concerned. The greater the astigmatism means the greater rate of reduction. So don’t be too concerned. Just keep monitoring and making sure it’s decreasing.

Anisometropia may also be transient, so monitor if it’s less than a delta. Higher levels of anisometropia, greater than 3, less likely to be transient. If you want to monitor it, you’re probably going to be thinking I’m gonna be treating this soon.

Prescribing for pseudoaphakia — I’m not gonna cover this in great detail. You want to overcorrect by 2 or 3 diopters, because a kid’s world is really at near. And you’re gonna reduce to a single vision intermediate add.

1 or 1.50 by the age of 1. And after 2, you’re prescribing a distance correction with a bifocal near to correct their — to accommodate for their lack of accommodation.

Contact lens is often the correction of choice here.

If everything is going well, before I cycloplege, I will do visual acuity. But if it’s getting to be a really long test now… For a little person, this is a long time.

So it may not be accurate. So keep that in mind. Also, keep in mind that you can always bring them back to do visual acuity, and just before you cycloplege at your next appointment, so just gauge how the patient and the parent are feeling.

Are they getting tired? Are they distracted? I think it’s a good idea to tell caregivers that a kid’s test usually takes two to three visits. I like to set low expectations.

Because if they get it done in one or two, then great. I’m amazing. I’ve beat all expectations. But if I have to bring them back two or three times, then the parents want to know — they already knew that that was gonna happen.

The preferential looking is a great way to assess the preverbal or multidisabled individuals.

It can overestimate visual acuity a little. So keep that in mind. The child is shown two stimuli. A grating on one side and a gray side opposite.

And there’s various sizes of grating, which go from very wide to very fine. You start with the widest grating. That’s gonna be your highest visual acuity. I spin, flip the cards around, flip them up, make a noise to get them looking in my direction, and I note where the child is looking.

To the left or to the right. And then I check the card myself. Keep randomly changing it from side to side. You don’t always want to have it on the right or on the left. When a child stops showing a preference for the grating, about 75% or 3/4 of the time you know that they can’t tell the difference.

So you’ve reached their limit of visual resolution, and you go up to the grating before. To be their measurement of visual acuity. When you say preferential looking, I always think Teller Acuity. But realistically, unless you’re in a hospital setting, the odds of you having these cards is incredibly low.

This is me down at the bottom here. You don’t want to be doing this with an audience. I was teaching. Generally you don’t want to be doing this with an audience. You don’t want to distract the child.

Also, try not to make any noise or movements that will help the child pick the correct side. And you often have to keep reminding mom or dad also not to give them any clues.

If you can’t afford Teller Acuity, which… You can’t afford that kind of investment or you don’t want to…

Cardiff’s test is cheaper. They have a familiar picture like a duck, and the other one has a gray side and it gets less and less clear to the child.

There’s also an app that you can use on your iPad. You can have a bit of a play with that. The child touches the screen. Peekaboo Vision. There’s a grating side and a clear side and the child touches the screen.

Also Lea Grating Paddles. They’re gonna set you back a bit, but they’re recognized for visual acuity. Keep in mind I don’t do this in practice, because I don’t care for such a little one what the vision is. If I’m happy with the refractive error, I’m gonna leave it at that.

If I’m not happy with the refractive error, I’m going to correct it. But these are options. And this is how we would — if we had to — check the visual acuity of such a little kid.

Don’t forget to check ocular health before they leave. And pupils. Quickly. You don’t want to miss any big red flags that require an emergency referral.

For the sake of time, we’re not gonna go over those emergency referrals. All those red flags. They’re the same in adults, pretty much.

I check anterior health by holding up my 20 diopter lens from my BIO to provide some magnification, and I use my ophthalmoscope, which I’ve already got in my hand, just to look at the anterior eye.

Also, don’t forget to just observe. There are milestone behaviors to look for in infants. And as a primary care professional, sometimes you’re the first person to notice that they’re not achieving something.

And you’re in a really good position in the community to refer on to the correct specialist, or give a patient or the patient’s parents some resources. Or even just to send them off to the kid’s GP and say… Look, something doesn’t seem like they’re achieving a particular milestone.

This is my general summary of what I’m looking for in each age group.

It includes vision, and the tests that I do, but also hearing, language, motor skills, things like that.

These slides will be on… I’ll send Lawrence an updated version. But they’ll be on Cybersight, on the lecture. So 3 to 6 years. We’re gonna do the same tests, basically. But if the kid is mature enough, we’ll move closer to an adult method for each test.

Double H/X for excursions, I might use an occluder for cover tests, I switch to static retinoscopy, so they look at a distance target when I think they’re ready for that. And with older kids, I’m more likely to use my retinoscopy racks. As they’re a lot quicker.

Here… These are my… These are your retinoscopy racks. Very good for all the little lenses along here. So it’s a lot easier than taking out a lens from your trial lens set.

I also add in MEM. And I switch up to Lea Symbols. Just a quick note on Hirschberg. I’m not gonna go over this. But people’s red reflexes give you invaluable information. Take note of these with the first test using the pen torch. The lit up toy.

Visual acuity for children — I use a Lea Symbol Chart. It’s well researched, formatted in LogMAR progression, so I can move it. I prefer a wall mounted one to a computer screen. So I can get up and point to the type that I want them to name. You want to test this in great lighting.

No dim rooms. Start by showing them the symbols on a handheld chart. Something like this. And look… They can call them whatever they like. Kids will probably call it a house if you prompt them and say… What do you live in? What has a roof? Oh, a house.

Often, as you get further down the test, they’ll start calling it a triangle. That’s fine.

For me, that is the correct answer. That’s just a naming error. So don’t be too concerned, as long as they’re consistent. Try and encourage mom or dad not to correct them.

I leave this with them to hold as a reference. Or if they get shy, a little bit further down the chart, or they’re preverbal, they can point to the shape that I’m pointing to.

I start with big symbols. I move down the chart. Just one line at a time.

When they start getting things wrong, I go up a couple. And I do the whole line.

Whether or not they get the answer correct, I’m ridiculously encouraging. I’m bouncing around. Awesome! Beautiful! That’s great! Woo!

A colleague of mine says he can hear me from the room next door. I’m so loud.

So encourage the kids, even if they’ve got it wrong, and try to encourage mom and dad to do the same.

Look at the patient, not the chart. Notice if the patient is needing to squint and if they’re shifting forward to do that. I use occluder glasses. These are the ones I use. They come in different shapes and sizes. Sometimes I’ll wear a pair to make them feel a little bit more comfortable.

If they’re shy, I might start binocularly and then test one eye and the next. But I’ve learned over time that this game quickly becomes really boring for kids.

So I don’t want to get the visual acuity of just one eye. Nowadays, I usually jump straight into the occluder glasses. If they’re wearing glasses, you just pop these over the top.

If you’re moving the chart or it’s not stuck to the wall, pop some masking tape on your floor so you know where you need to be standing.

So when you’re going to refer on visual acuity, this is taken from the American Academy of Pediatrics. There are various versions. They all have about the same values, give or take. This is down at the bottom — the normal visual acuities I’m thinking about at each stage, both in LogMAR and in meters.

Accommodation should be like an adult by 6 months. So I do MEM, or monocular estimation method.

Some do naught retinoscopy, which I won’t go through, but the theory behind it is very similar to MEM. Compared to doing amplitude accommodation, naught and MEM allows me to adjust the accommodation and measure the patient’s lag and lead. So it gives me a lot of information.

Against or any lead is abnormal — I’m thinking latent hyperopia, pseudomyopia, accommodative spasm. A lag of greater than +1, I’m thinking I’ve undercorrected the hyperopia. Or not corrected it.

Lack of accommodation amplitude… Reduced accommodative facility, things like that.

Just on NPC, and just quickly — two things that I like to think about, when doing NPC is I like to do it with a non-accommodative target. So I start with my pen torch first. And then if it’s low, I’ll move to an accommodative target, and if that’s within normal, I’m thinking… Okay. Accommodation is really dragging this… Really driving this patient’s convergence.

So it gives me an idea of sort of what I want to test next. When it comes to binocular vision. Definitely don’t rush the last 10 centimeters. Go really slow. Because you want to test the patient’s ability to converge. But also, if they can sustain that convergence.

By 6 years old, sometimes younger if the kid’s mature, and adding stereopsis, and color vision, and also adding more binocular testing, like Ac/A ratios, if I think there’s an issue, suppression tests, like the four dot, I might use a modified Thorington or Prentice card. Here in the UK, some might reach for their Mallet units. I’m not so confident in this, as I wasn’t trained on it.

But that’s probably something that you’ll grab for. There are a couple of great lectures on Cybersight that cover binocular vision testing. So go on after this and check those out. Stereopsis. Here are some guidelines for age normals for stereopsis. Most of us have stereopters that require a filter for the kids to wear. For those who have Lang and Frisby, they can be performed a lot earlier. They’re not always as reliable on younger kids.

So keep that in mind. In children with low vision, you want to investigate visual field. Which Lea does as well and contrasts for the tests like Hiding Heidi. There are some great lectures on Cybersight covering low vision testing and working with kids with special needs and low vision.

So go on to Cybersight and check that out.

Lastly, checking — testing children with special needs — they can be approached in the same way. If you’re able to meet with the caregiver beforehand, or send out a questionnaire, it’s great to know more about your patient’s conditions before they come in.

Ask extra history questions. Know what the child’s routine is. So you understand what the visual goals are from the parent’s point of view, and from the child’s point of view. Also other things in the environment that they won’t react to. Like noise or bright lights or flashing lights.

How does the patient communicate? Do they already have glasses? Or have they had a previous eye exam? And how stressful was that? Because that might give you an idea if the child is gonna be really nervous.

There’s a lot of information out there on how to interact and communicate successfully with people with special needs.

So I recommend if you’re seeing a lot of kids with a particular special need, like autism, ADHD, cerebral palsy, Down syndrome, know what it’s like for that child with that condition. And how they communicate, and things that are common.

Look for people like Dr. Paul Constable, who was really interested in making eye tests accessible for people on the autism spectrum. People like Dr. Constable are doing — put out a lot of resources to help clinicians treat patients on that spectrum.

So I had two questions from a lot of you. Gonna have a drink, sorry.

What tips and tricks do you have for testing uncooperative children? And how do you get the kids to wear their glasses?

For putting drops in successfully, I have a couple of stuffed toys, friendly toys. They’re small. So they’re just for little hands. And I squeeze them. And I tell them my friend Leslie… She’s around here somewhere… She has… She is very good at absorbing any nervous energy.

So we squeeze her really hard. On that note… Loads of toys, within reach. You want to be able to just grab them whenever you need them.

You want to minimize the amount of waiting in the waiting room. And you want to minimize the amount of parental chatting at the beginning. Which is why I mentioned at the start. Always explain what you’re about to do. For example: This is the light. And shine it on the palm of their hands. Then they’re not too worried about it.

Don’t use words like scary or hurt or bright. Even if it’s in the context of: This won’t be scary. Or this won’t hurt. Or won’t be bright.

The kid doesn’t hear the “won’t”. They only hear the negative adjective. They only hear the “bright”. So you’ll get them immediately shutting down.

For wearing glasses, parents need to understand the consequences of not wearing the glasses. A lot of parents come in and say… Oh, well, you know, when he’s a little bit more mature, we can pop him in some glasses.

Which in some cases is the opposite of what I want. I want to get them early. And then after their critical period, they can stop wearing their glasses.

So you want to make sure the parent understands exactly why they’re wearing the glasses.

Also, think about how much you need to prescribe the glasses. Does the kid need to wear them all the time? Because if not, telling them they need to wear them all the time could be quite daunting.

And could make it a little bit trickier to discipline as well.

I think it’s a lot easier for the kid if they don’t have to wear them all the time. If the kid and the parent understand what specific tasks they do need them for. Like reading or whenever you’re at school.

It’s a lot easier to discipline if they have a specific task that they’re supposed to have them on.

Obviously there are some kids who have to wear them 24/7. You tell them: You get up, you pop them on, you go to bed, you take them off.

I think also make sure they’re fitting comfortably. There’s lots of ways to strap these things on to kids’ heads. And make sure the kid chooses and glasses and not the parent. Because they’re unlikely to want to wear it, then.

Just briefly on compliance with patching. I think the patches that go over the glasses are more successful than the patches that stick to the face if they’re older.

The patches that stick to the face are good for young kids who don’t understand what’s going on and will try to pull the glasses off.

But no one really actually wants anything stuck to their face. Let the child pick the patch. Give really clear instructions. A big R or a big L on the back of the patch.

So it’s as easy as possible. Again, be realistic on the amount of time you need the child to be wearing it. If you only need to wear them for… You only need them to wear it for two hours, then don’t prescribe four.

I can barely find two hours in my day to do something with my toddler. So… You prescribing four hours is really daunting. And I’m more likely to say… You know what? Let’s just forget it for today.

I give the kids a calendar. It’s a big poster, about 7a3 size. It has 31 squares for all the days in the month like a calendar. The kids pick which color they want.

And each day, the kid colors in a square or draws a picture at the end of having their patch on, or whilst they’ve got their patch on. And then at their review, they bring it in for me to look at.

When they do, I spend a good five minutes really exploring it with them. Making them feel special, as they show me all the pictures that they drew.

And this turns the power struggle into something they have control over. And something they might even be saying… Oh, mum, our patch story! We’ve got to do that! When mum’s forgotten. So it really shifts the power to the kids.

I’m not gonna cover patching any further. I don’t know if we have a lecture on amblyopia. If we don’t, on Cybersight, we’ll address that. But if we do, then please check it out. It will, I’m sure, give a lot of helpful information.

These are my general rules for prescribing, based on Leat’s publication from 2011. Not everyone fits into these, but they guide me on where I need to go. In addition to refractive error, Leat also asks us to consider emmetropization. So remember, it’s finished about school age. So if you’re gonna leave them a little undercorrected at school…

Do so with the thought of: Will they be able to cope? Most kids that age can. Rather than the thought of emmetropization. It’s less of a concern by the time they’re in school.

Also keep in mind that if a kid is struggling at school, that outweighs any sort of myopia control or any emmetropization. If they’re not doing well, you want to correct them.

To ensure that they can see clearly and do everything that they need to do.

So… I am, as per usual, I’m gonna end up running a little bit over time. But what I want to do is…

So I’m gonna send these slides to Lawrence. So he’ll have them underneath my lecture on Cybersight.

And so there’s some sort of tips or things that I’m thinking about, when it comes to optical correction in amblyopia.

Strabismus — keep in mind that this is never normal.

And you want to be thinking about what is causing this.

If it’s an exotropia, you want to be thinking: Is the child gonna grow out of this? Or is surgery required? Do I need to refer this kid? And how longstanding is it? Has it been here for a while, or is it something that just happened, where it’s started to break down?

If it’s an esotropia, is it accommodative? And if so, you want to check if the tropia can be eliminated by the full plus, and that will tell you if it’s accommodative. If the tropia isn’t eliminated by the full plus, you know it’s a little more than just accommodative esotropia.

If it is eliminated, then you can try to reduce the prescription binocularly. So the same amount in each eye. Making sure that you’re still not detecting any movement, and then you would stop. If you started detecting movement, you would go back up a step.

Or when you got to the child’s age normal.

Hyperopia — if there’s strabismus, I get my kids to wear all their plus. If there’s no strabismus, no amblyopia, I’m inclined to prescribe a partial prescription up to their age. What I want to make sure, though, is if I am going to undercorrect hyperopia, then I undercorrect it by the same amount in each eye.

Also I’m thinking… Like I said before, it can have some huge impacts on learning. And so at a time when they’re meant to be developing a love for reading and writing, lifelong learning…

If they’re having issues with the hyperopia, you’re better off to correct that straight away, without too much concern for correcting the prescription fully.

So I have this little fellow, four years old. No glasses, no parental concerns. Cycloplegia shows hyperopic emmetropia. So 1.75 in the right eye, 3.50 in the left eye, but the visual acuities are equal and they’re not far off what I expect for his age. You’re thinking… Oh, 6/9.5? But remember for a 4-year-old, that’s pretty good.

I prescribe for each eyes to keep them equal and I hope that he’ll emmetropize just a touch more. Maybe not a whole lot, but a touch for. If the anisometropia is less than 4 diopters, I’m not gonna reduce the anisometropia. I’m just gonna correct it.

I corrected this little one for two reasons. Mainly because they were having a lot of issues with school.

When kids are at school, I ask them a lot of questions about reading. Even if they say… Oh yeah, it’s clear up close. I say… Do you like reading? Are you a fast or slow reader? Because I’m a super slow reader. Do you read with your finger or your ruler? Do you lose your place sometimes or reread the same lines sometimes?

Are the letters clear all the time? Do the words ever move or jump around a little bit? So I want lots and lots of information about sort of what it’s like for this kid to read.

Here I have a kiddo who’s a little older. And he’s gonna be less happy if I give them all that plus. I did a suggested which was a lot lower than the prescribed glasses, but at least I could improve the visual acuities and get quite good visual acuities. The child also has been recently diagnosed with dyslexia. And when I did my test, I saw 4 esophoria at near. Accommodation is high.

They reported blurring in the distance after reading. Accommodation is really high and it’s taking that accommodation time to relax.

And you’ve also got a lead of accommodation on MEM. So on cycloplegia, we see a lot more hyperopia. For the age, for her age, than we expect. She isn’t gonna want to wear the full plus. It’s gonna be uncomfortable.

In fact, she reports that she doesn’t wear her current glasses all that much, because she doesn’t like the vision when she puts them on.

So what I’ve done is I’ve given her a prescription that’s a little bit closer to what we’ve got in her subjective refraction. So I know she’s quite comfortable with that.

And then to assist with her vision at near, I’ve given her a +1.50 reading add. I prescribed a varifocal because she was not gonna wear a bifocal for cosmetic reasons. Even though she’s 10, these kids know what they want.

And I left a little bit of residual, 0.75, because at this point her accommodation on MEM was a plus 0.25 lag. And that’s normal. I don’t need to correct it fully. This was a great success, because after 6 months, she was no longer classified as having dyslexia.

Dyslexia is a very real concern, and a very real diagnosis. But I find in a lot of cases, there has either been a misdiagnosis, or maybe there’s a binocular vision defect going alongside the dyslexia.

So you just want to make sure that these kids are refractively managed well at first. So if they are going into dyslexia management, learning tasks, and things like that, then they can be really successful in them.

These kids I saw recently… So I have no follow-up yet. But I thought they were really interesting cases. The first little boy, similar to our 10-year-old… Except visual acuities were not great. Or even.

Hyperopias reveal to be much higher than cycloplegia. Sort of got a +8. This kid was also advised to wear it full-time. And thinking about improving — that was a bit of amblyopia.

He is 7. So you’re sort of close to the critical period. But they did… In the PD group do a study showing you can still get a lot of success with older kids. So don’t give up on an eye.

Hopefully as we’re reviewing, he’ll accept more of these hyperopic prescription in the distance and I can drop his reading add.

He could read 6/9.5 and then 6/12. So that was sort of the thing. He came in… Moderate hyperopia. And that was really all I was getting on my ret.

But he was saying he would read the 6/9.5 line and then say… Oh, no. I can’t see that. So I knew as we were testing him, something was wrong. So that’s why I cyclopleged him. Lucky I did.

I cyclopleged his sister, who was a 14-year-old, on the right there. She reported vision as pretty good. And loving to read. No issues. But my retinoscopy was a little higher.

And so we cycloed her. I picked her add based on a varifocal. So I left her a little undercorrected. But she sees all the four dots on West Four Dots, so I know she’s not suppressing with the add, and she doesn’t have amblyopia, so I can afford to undercorrect her a little bit.

And with time, as they use the bifocal, the varifocal more and more, they’ll relax a little bit more and more, and hopefully accept more and more plus into their distance prescription. Maybe even to the point where we can put them in a single vision lens.

Anisometropia here… We had a couple of questions about how to treat anisometropia. It can be treated in a number of ways. Corrective lenses are commonly used.

But if it’s greater than 4 diopters, then we’ve got a little… A few issues and concerns about anisoconia. So the table here is taken from Leat’s recommendations in 2011. And I think that it’s a really good start, when you’re thinking about: How am I gonna adjust this prescription for a kid with anisometropia?

If there’s no amblyopia and the anisometropia is greater than 3 diopters and they’re 1 to 3.5, you want to prescribe the astigmatism and myopia and hyperopia according to their age, but consider reducing the higher eye by about a diopter.

These are just a few things I’m thinking about, when requesting lenses to be dispensed. And these things that you guys — I know you’re dealing with on a daily basis.

So this brings us to myopia, and our last slide. I had two questions. From attendees. One was an 8-year-old boy with a plano right eye and a -4 left. And the other one was a little kid with a -9 in the right eye and a -OTC in the left.

I think myopia is trickier in one sense to deal with, because we’re so concerned, as we should be, about myopia progression, but we also have to think about correcting it in such a way that we’re eliminating any of the amblyogenic risk factors that high anisometropia will pose.

And that takes priority. I think one thing, though, one great things that myopic anisometropia has going for it, is that you can correct the myopic eye with orthokeratology, and this eliminates any issues with anisoconia and prism effects, magnification with lenses.

So in both of these cases, I put an ortho-k lens on the myopic eye. And leave the other eye.

Uncorrected. And I think the kids would really like that. I won’t discuss myopia control. There’s an entire lecture on this. In fact, an entire conference in and of itself. But there’s an entire lecture on Cybersight on this.

Also I think myopia profiles from fellow Australian Dr. Paul and Kate Gifford is an amazing resource. And the Myopia Institute Calculator is a great resource for showing parents how myopia control can have an effect on their kid’s refraction.

I’m just gonna finish with — someone asked how early you would put a kid in contact lenses.

And can they sleep in them? Obviously orthokeratology lenses they can sleep in.

I think if they’re silicone hydrogel, I think they don’t need to.

If they’re capable of taking them in and out. I’m happy if a kid can pop it… Take it out, but they can’t quite put it in, if they need mom or dad’s help, I’m fine with that. All I’m concerned about is if something happens and they need to take it out, they have the ability to do that.

But if they need someone’s help to pop it in, I think that’s absolutely fine. Night and Day is great, because it has a smaller diameter of 13.8. But to be honest, as long as they sit properly, then I don’t really care.

I go for a silicone hydrogel, and they’re fitting properly — that’s sort of what I’m really concerned about.

I’m happy to fit kids who are really young with ortho-k lenses. And with soft lenses. But I think you’ve just got to let your patient’s readiness and the parents’ readiness dictate where you want to go.

I start talking about contact lenses really early. So they’re already thinking… Okay. This might be something that we’re thinking about.

In the near future.

So that is it from me.

We should have some questions. I know that we’re running super, super late. So I’m sorry.

We’re about ten minutes late. Not too bad. Not too bad. So let’s see if I can…

Stop sharing here. So I can see… Our questions. Okay.

So we’ve got a couple of things. How to measure accommodation vergence in young kids who can’t respond to subjective tests?

I think MEM is really great. Or naught retinoscopy is really great to measure accommodation. Vergence… I think NPC is absolutely fine.

You might want to do it a few times, over and over again. Just to make sure that you’ve got what you need.

Also know what the distance is between the tips of your small finger or your thumb. That’s really helpful to hold it up to the kid so you don’t have to whip out a ruler or anything like that.

As they sort of duck away, you’re gonna get a pretty good idea is Mohindra retinoscopy the same as streak retinoscopy? That is a good question.

So streak retinoscopy — I’m always thinking about the light of the retinoscope.

As opposed to retinoscopes that have a circular light. So that’s a really good question. Mohindra retinoscopy you want to be doing in the dark.

And the child looking at your retinoscope. But as far as I always understood… Streak retinoscopy just referred to the type of retinoscope that you had. But I am happy to be… Happy to stand corrected there.

Do you do Van Herick? I don’t do Van Herick, because I don’t put them on the slit lamp all that often if they’re really little.

What I do — and I took this out of my lecture, because it just kept getting longer and longer — but I use the light just to check the angle. So even if you Google checking anterior chamber depth with a pen torch…

You’ll find a few examples of this. If the iris lights up, it gives you… Or if there’s a shadow, it gives you an idea of if it’s closed or not. It is something that I do. Because I have that light, that ophthalmoscope light in my hand. Checking with the 20 diopter lens, and the light — and I’ll quickly check from the side, because I have it in my hand.

But I don’t generally put them on the slit lamp unless I’m looking for something anterior, specifically, coming from an allergy or an anterior concern.

If you notice a small slight turn in an XR eso when you’re doing cover/uncover, at what diopter measurement would you refer or monitor and recall if there’s not a family history with strabismus?

So… I would… If it’s small, I think…

I might even get the parent to monitor as well. If they notice it, at any stage…

Sometimes you might get a parent coming in, saying they notice it, but in your room, you’re not seeing anything.

So keep that in mind. Parents are a really great resource. So you want them to keep an eye on these things, if you think that this is happening.

I would monitor… If it’s intermittent and small enough… Actually, now that I’m sort of thinking about it… I would also see if I can… See if there’s anything else causing it. So I’m gonna do all my other tests and cycloplege and all of that.

They might turn out to be a +8. And then in that case, I’m thinking… Okay. I’m gonna fix that. And that’s gonna fix the little eso that’s coming up.

So do all the other tests first. I think strabismus… Often comes hand in hand with something else that’s going on. So you just want to make sure that there’s nothing sort of encouraging it.

If it’s an exotropia, then kids can grow out of that. So I’ll keep an eye on it. But I certainly don’t want them getting double vision or suppressing or anything like that.

That’s the point you want to send a kid off to get checked out.

I want to ask about reducing the amount of correction. What happens if you reduce the sphere or cylinder and visual acuity is decreased. Yeah. Don’t decrease visual acuity. Definitely don’t decrease visual acuity.

The only reason I would reduce their prescription is either they’re so young and there’s no strabismus or amblyopia, so I don’t have to worry about that, and they’re so young that I could maybe get quite a bit of emmetropization out of it, if I left them a little uncorrected.

Or even if they’re above 2 to 4, I might still get enough. It’s still at the back of my mind. I’m thinking that’s something that could be happening.

But in that case also, my visual acuities aren’t that accurate. So I’m not gonna really base my decisions on visual acuity. I’m gonna base it on my refractive knowledge.

If you’ve got a kid who is 10, and by reducing the prescription you’re reducing visual acuity, then absolutely don’t reduce it.

If you’ve got a kid that has really large astigmatism, and you’re worried by reducing the astigmatism, you might lower visual acuity, but you’re also gonna lower that discomfort…

So I had a patient the other day who had fairly high astigmatism and myopia, and has never worn glasses before.

So I did… She was 12. So I gave her a partial correction for her astigmatism. And with the thought… Here in NHS, if there’s a change in prescription, they’ll cover it… So with the thought of…

When she comes back, and she’s able to accept more of that astigmatism, she’s adapted to wearing her new glasses, we can bump that up a little bit.

But the main thing is: When I’m reducing the amount of correction, I always — unless I’m thinking about anisometropia, specifically, and reducing the difference between the two eyes, I want to make sure that I reduce it by the same amount in both eyes.

So if I’m gonna decrease this by +1, I want to decrease this one by +1. So accommodative effort is the same.

How do you deal with a patient with exotropia having very high hyperopia? That’s always really tricky, isn’t it?

I think… What I’m gonna do is I’m thinking about how old this kid is. Yeah? I’m thinking about… Is there any amblyopia or anything like that.

I want to make sure they can see clearly. I want to make sure that…

They’re using their eyes or developing their eyes binocularly as best as we can. But if they’ve got a really large exotropia, then you’re also sending him off to an ophthalmologist to get that checked out, to see if they can straighten that.

And then you can correct the hyperopia. So work with your local ophthalmology team and ask them what they think you should be doing.

And tell them what your thoughts are as well. And you sort of might compromise somewhere in the middle and co-manage with them.

Yes. I think it’s better to do MEM in a room with normal illumination. Yes, I agree. Did it say something different? Did it say dim lighting? If it does, I apologize.

With monocular estimation method, yes, absolutely, you want full lighting. Because they’re reading the little card that’s on your MEM — that’s on your retinoscope.

If you don’t have one of those little cards, I also… Just hold up my… A little… What do you call them? A little chart or something. Or a little stick for them to read off.

Just sort of up right underneath my retinoscope.

Is there a role of spectacles in hypertropia or hypotropia? I think hyper and hypotropia… Is a tricky one.

You want to co-manage with your specialist there.

I think that you want to make sure that the kids are corrected. A hypertropia and a hypotropia is gonna indicate that something else is going on. That’s outside of that refraction.

What is the best way to examine an albino kid? This is what someone has written… I think it’s really… If kids have albinism…

Definitely check Nicole Ross’s lecture on Cybersight. She works with a lot of albinism. And I think you’ll get a lot of good tips and tricks from that lecture.

You want to make sure those kids are wearing a hat. Things are very, very bright. But also you want to make sure you’ve got all the low vision devices that they need. Yeah.

I’m just having a look here. In terms of cycloplegic assessment, how can you get the best or closest access to the patients with astigmatism? Are there any tips?

So I think that you should be correcting… It’s too tricky to hold up the lens. Investing in pediatric trial frames — this is in Amazon in the UK, and it costs less than 20 pounds. It just means that you know that it’s fitting properly and not falling down their nose or anything like that.

I think definitely investing in a small trial frame. And use spherical lenses to correct. I think that’s a lot easier and it’s a lot easier to get the axis correct as well.

Also looking in that central 3 to 4 millimeters of the pupil. So you don’t get too many aberrations.

We have a lot of questions here, and I’m gonna have a patient that’s coming in soon. So I just wanted to wrap things up.

I am on Cybersight. And as one of the mentors… So any of the questions — any questions that you have, that I haven’t answered, please feel free to connect with the Cybersight team, and they’ll sign you up for that service.

And we can discuss kids — at any stage. Always happy to discuss cases with people.

Also, I’ve got a very long list of questions here.

Which Lawrence will pass over to me. And so we can answer those in time as well.

Is there anything urgent, or are we okay to wrap up, Lawrence?

>> That’s great. Yep! You’re free to go. And thank you for your time.

DR WASSNIG: No, thank you. And thanks for having me. Sorry, everyone, that we had such a mishap a couple of weeks ago. But I’m really, really glad that we could do this.

Even at a delayed time. And I’m glad that you all came to join me for a second time. So thank you so much!