2016 mdh prescribing rx in kids

PrescribingEyeglassesinChildren

byAlvinaPaulineD.Santiago,MDPediatricOphthalmology© AP Santiago 2016.

All rights reserved.

Rx in Kids

© AP Santiago 2016. All rights reserved. Rx in kids

YES

NOAmblyopia

AttitudeAge

Finances

Vision

Strabismus

Symptoms

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Culture

Emmetropization

“Amblyogenic”RefractiveErrorsJAAPOS2003

© AP Santiago 2016. All rights reserved. Rx in Kids

PreschoolRefractiveErrorsRequiringGlasses

Anisometropia>1.5D

Myopia>3.0D

Hyperopia>3.5D

Astigmatism>1.5@90/180>1.0>10deg


Amblyogenic:AgeDependent


Myopia >-1.00DHyperopia

0-1y: >+4.00D1-2y: >+3.50D2-6y: >+2.00D

Astigmatism >1.50DAnisometropia >1.50D

Freedman,Preston,Ophthalmology1992

AmplitudeofAccommodation© AP Santiago 2016. All rights reserved. Rx in Kids

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CycloplegicRefractionhttp://www.cybersight.org/data/1/rec_imgs/11176_toddler%20refraction_sm.JPG


CycloplegicRefraction


§  Atropine1%TIDx3-4days,refractonday4

§  Cyclopentolate1%2xq5min,refractafter30-40min

§  Tropicamide(0.5%)-phenylephrine(2.5%)q3-5minx2-3x,refractafter30min

§  Tropicamide0.5%q15minx3,refractafter30min

https://images.yaoota.com

ErrorsofInadequateCycloplegia


§  Lesshyperopia§ Moremyopia§ Morewith-the-ruleastigmatism

§  Sameerrorsascomputerautorefraction

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Childvs.Adult


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Childvs.Adult


ü On-axisü Fullplustolerated

ü Lessimportant

ü Toleratedwell

ü Amblyopia,strabismus,lossofbinocularity

ü @90/180

ü Maximumtoleratedplus

ü Important

ü Poortolerance

ü Asthenopia,Redeye,DryEye

•  Cylinder

•  Hyperopia

Lessthan5years

•  ManifestRefraction

•  Anisometropia&Aneisokonia

•  WrongRx

OrthotropiaWouldyouprescribe?


People(Happiness)

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PreschoolRefractiveErrorsRequiringGlasses

Anisometropia>1.5D

Myopia>3.0D

Hyperopia>3.5D

Astigmatism>1.5@90/180>1.0>10deg


Amblyogenic:AgeDependent


Myopia >-1.00DHyperopia

0-1y: >+4.00D1-2y: >+3.50D2-6y: >+2.00D

Astigmatism >1.50DAnisometropia >1.50D

Freedman,Preston,Ophthalmology1992

Hyperopia>3.5D

Ø LowestplusØ BestvisionØ Notalways20/20Ø ManifestrefractionØ Cutplus

© AP Santiago 2016. All rights reserved. Rx in Kids http://i1303.photobucket.com/albums/ag153/jenmal37/baby-

reading-with-glasses_zps90e33e7d.jpg

http://assets-s3.usmagazine.com/uploads/assets/articles/82136-new-gerber-baby-is-7-month-old-girl-named-grace/1421876680_grace-gerber-baby-zoom.jpg

Hyperopia≤3.5D

Ø MonitorØ LowestplusØ BestvisionØ Notalways20/20Ø ManifestrefractionØ Cutplus


Myopia>-3.0D

Ø CycloplegicrefractionsØ ManifestrefractionØ LowestminusØ VAatleast20/40

http://www.tipskey.com/article/concave_lenses_worsen_myopia/myope.jpg


Myopia≤-3.0D

Ø CycloplegicrefractionsØ ManifestrefractionØ LowestminusØ VAatleast20/40Ø Visualneedse.g.Myopia-1.00D(1vs11yrs)

Ø Symptoms

https://www.goggles4u.co.uk/media/wysiwyg/Articles/Kids-Eyeglasses-1.jpg

© AP Santiago 2016 . All rights reserved. Rx in Kids

Astigmatism

Ø With-the-ruleUpto-1.50Dtoleratedwell

Ø Against-the-ruleLesstoleratedwithoutRx

Ø ObliqueLowerthreshold:>1.0DOn-axis

Ø CycloplegicrefractionØ Lowestcylinder

http://townsend.ofNixonline.com/wp-content/uploads/astigmatism_sim1.jpg


ESOTROPIA

§  Fullcycloplegicrefraction§ Maximumtoleratedplus§  Pushplus§  Lowestminuscorrection§  Fullcylinderfromcycloplegicrefraction

http://www.pedseye.com/img/eso_ex_01.jpg

© AP Santiago. 2016 All rights reserved. Rx in Kids

Bifocals:Whentogivethemhttp://www.aapos.org/client_data/Niles/2011/_376_bifocal.jpg


ü Fusionatdistanceü Fullcycloplegicrefractionü Repeatfullcycloplegicrefraction

ü Maximumtoleratedplusü Pushplusü WaryofV-pattern

Bifocals:Howtogivethemhttp://www.aapos.org/client_data/Niles/2011/_376_bifocal.jpg


ü Executive,NlattoporD-segmentü JustenoughtocontrolET’ü Minimumaddsü X(T)’:taper

•  Amblyopia•  Refraction•  Fusionatdistance•  Alignmentbothdistance&near•  Remeasurewithglassesalways

Whattodoonfollow-up:AccommodativeET

Rosenbaum&Santiago,1999


Whattodoonfollow-up:AccommodativeET

Rosenbaum&Santiago,1999


•  IfXTatdistanceReducepluscorrection

•  IfXTatdistance,ET’reducedistanceplusminimumBifocalsthatwillcontrolnear

IforthoatdistancebutXTatnearReduceadds

GoalofTreatment

§ MonoNixationsyndrome§  0-8PDfromorthotropia

© your company name. All rights reserved. Title of your presentation

X(T)andRefractiveError

•  Anysensorydestabilizingfactoraffectscontrol,includingsmallEOR

•  ImprovementinVAusuallyhelpscontroldeviation



•  Hyperopia:•  Iffullycorrected,relaxesaccommodative-convergence,controlworse

• GiveminimumpluswithbestVA,usuallybetterforcontrolofdeviation

• Overminuslenses/Withholdinghyperopia/givinglessplushasaroleinmanagement


X(T)andRefractiveError § Hyperope*:Ifnotforsurgery

§  <5y:Cutplusby1-1.5D§ MinimumplustocontrolX(T)andgiveclearvision

§ Olderchildren,considermanifestrefraction

§  ExcesspluscanworsenX(T)


*Significant hyperopia ~ >+3.50 on cycloplegic refraction

X(T)andRefractiveError § Hyperope*:Forsurgery

§  Givethefullcycloplegicrefractionormaximumtoleratedplusprescriptiontouncoveralllatentexodeviation.

§  Targetangleforsurgery


*Significant hyperopia ~ >+3.50 on cycloplegic refraction


§ Myope§  Givefullcycloplegicrefraction(lowestminus)

§  Consideroverminusifnotforsurgery

§ Or,giveminuslensthatwillgivebestVA

§ Astigmat§  Givethefullcylinderfromcycloplegicrefraction


AnisometropiaHowwouldyouprescribe?


People(Happiness)


Anisometropia&RefractiveError

§ MonocularXT§ Anisometropicamblyopia§  Cutplusby1-1.5D§  If>5y,mayneedtomanagelikealittleadult,decreaseanisometropiainglasses

§  Considercontactlensestooptimizevision

§  Prescribeglasseswithpatching

§ Roleoflaserrefractivesurgery?

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Anisometropia&RefractiveError

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§ MonocularET§ Anisometropicamblyopia§ Usuallywithrefractiveaccommodativecomponent

§  Fullcycloplegicrefractionormaximumtoleratedplus

§  If>5y,mayneedtomanagelikealittleadult:decreaseanisometropiainglasses

§  Prescribeglasseswithpatching§  Considerstrongly:contactlenses

§ Roleoflaserrefractivesurgery?

CiliaryMuscleSpasmHowmuchtoprescribe?


People(Happiness)


CiliaryMuscleSpasm

�  SigniNicantcylinder&/orsigniNicantmyopia

�  Drymanifestrefractionhighestandexceedscycloplegicrefraction

�  Mayneedstrongercycloplegiatodeterminetruetargetrefraction

�  Pharmacologiccycloplegia


CiliaryMuscleSpasm

§  Givelowestminus,lowestcylinder

§ Resisturgetogiveintosubjectiverefraction

§  Compromiseneededforschoolage:§  atleast20/40(6/12or0.5)OU


DecisiontoPrescribeWhichwillbeyourprimaryfocus?

alignment

age

amblyopiavision

emmetropization



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References1.  ChiaA,ChuaWH,CheungYBetal.Atropineforthetreatmentofchildhoodmyopia:safety

[email protected]%,0.1%,0.01%(AtropineforMyopia2)Ophthalmology2012;119.347-54.

2.  ChiaA,ChuaWH,WenL,etal.Atropineforthetreatmentofchildhoodmyopia:changesafterstoppingatropine0.01%,0.1%,and0.05%.AmJOphthalmol2014;157:451-7.

3.  ChiaA,LuQS,TanD.5-yearclinicaltrialonatropineforthetreatmentofmyopia1:myopiacontrolwithatropine0.01%Eyedrops.Ophthalmology2015;epubaheadofprint.

4.  DonahueSP,ArnoldRW,RubenJB,AAPOSVisionScreeningCommittee.Preschoolvisionscreening:whatshouldwebedetectingandhowshouldwereportit?Uniformguidelinesreportingresultsofpreschoolvisionscreeningstudies.JAAPOS2003;7:314-5.

5.  BinAziz,MA.Cycloplegicagentsandcyclorefraction.http://www.slideshare.net/schizophrenicSabbir/cycloplegic-agents-cyclorefraction.AccessedMarch15,2016.

6.  AptL,GaffneyM.CycloplegicRefraction.http://80.36.73.149/almacen/medicina/oftalmologia/enciclopedias/duane/pages/v1/v1c041.html.AccessedMarch15,2016.


2016 mdh prescribing rx in kids

Health & Medicine

Transcript of 2016 mdh prescribing rx in kids