Dr. Ann Morrison, Assistant Professor, The Ohio State University College of Optometry
In 1971, Dr. Ted Grosvenor published a paper called “The Neglected Hyperope”1, which brought attention to the underrepresentation of hyperopia in pediatric vision research compared to myopia. Last year, Dr. Mark Rosenfield’s paper, “And Still the Hyperope Remains Neglected” highlighted the persistent gap between pediatric myopia and hyperopia in vision science research that has remained for the last fifty years.2 While these editorials focused on the lack of research on pediatric hyperopia, the same discrepancies are seen in clinical care.
Unlike managing pediatric myopia, managing pediatric hyperopia is more nuanced. Last year, I had the privilege of publishing data about the prescribing patterns of pediatric hyperopia by pediatric optometrists and ophthalmologists. While the study looked at a several clinical scenarios and factors, one thing is certain: There are no clear prescribing patterns for pediatric hyperopia.3 We have to rely on our own clinical experience and the limited research to make decisions about when and how much to prescribe for our pediatric patients.
Colleagues often ask me advice about prescribing for pediatric patients, especially from infancy to age 5. Generally, pediatric optometrists like myself incorporate a lot of clinical factors when describing when to prescribe and how much I prescribe for my pediatric hyperopes. Here are some guidelines I generally follow:
1) Age and Amount of Hyperopia. Consider if the hyperopia is normal for their age. Prescribing is more likely if it deviates from the norm, but more caution is needed for infants who might still be undergoing emmetropization. Remember, most of the emmetropization process happens before the patient’s first birthday. If you find higher than normal plus in an infant exam and feel that prescribing is warranted, you should not be afraid to prescribe. Studies show that partial correction does not impede the emmetropization process.4 I would warn against prescribing full plus during emmetropization. If at one year, you find a refractive error of +3.00 D or more, you should start considering prescribing or at least following up with these patients more often. Patients with this much hyperopia are more likely to develop strabismus and amblyopia.5
2) Strabismus. Prescribe the full plus if strabismus is present, particularly esotropia. Add a near bifocal for accommodative esotropia, if necessary.
3) Anisometropia and Amblyogenic Risk Factors. If 1.0 D of anisometropia is detected, it should be prescribed. Bilateral high plus can also be amblyogenic. The AOA states that bilateral +5.00 is amblyogenic, but studies suggest that lower amounts of bilateral plus can be amblyogenic (starting at around +3.00 D).6 Remember, while you do not have to prescribe full plus, the full anisometropia needs to be maintained in the prescription, if present.
4) Near Visual Function. If a patient’s near visual function (visual acuity, stereopsis, and phoria) seem to be impeded or below normal, prescribing should be considered. Often these measures get forgotten about in this age range. If near visual acuity or stereopsis is reduced (global or local), or a significant esophoria is present, prescribing should occur.
5) Accommodation. If accommodation is not normal, prescribing should be considered. In this age group, monocular estimation method (MEM) is the best way to determine if patients are accommodating accurately. In children who are older, push-up accommodative amplitudes should be used with a grain of salt. Some studies have shown that push-up amplitudes overestimate accommodation7, and you have to rely on a patient’s subjective perception of blur. If I find an MEM ≥+1.25 in this age group, I am much more likely to prescribe plus. Near visual acuity will help guide you here too.
6) Visual Behavior. In older children, patient symptoms and school performance are factors I consider when prescribing. If a child is on an IEP or 504, is clearly struggling in certain aspects of school, or complains of asthenopic symptoms, I am more likely to prescribe, even with smaller amounts of hyperopia. For preschool aged children, you have to rely on parent observation. Does the child avoid tasks that require more visual input? Do they seem to have issues with mobility and getting around that could be impeded by decreased visual input? Does the child rub their eyes a lot? Is there an abnormal head posture when viewing things? Do you see signs of squinting? Are they avoiding visual tasks they used to do with no problems? These kinds of observations might persuade you to prescribe or not to prescribe.
By incorporating these factors, hopefully the decision of whether or not to prescribe for pediatric hyperopia should be a little easier.
References:
From Dr. Ann Morrison on Thursday 02/08/2024 at 02:26 PM
In response to Dr. Stalker's comment:
When a patient is hyperopic and amblyopia is present, or you suspect that amblyopia is present, there is sometimes a misconception that you must prescribe the full amount of plus. For example, If you have a patient who is +5.00 OD and +2.00 OS, you do not need to prescribe +5.00 OD and +2.00 OS. You can cut the plus to help with adaptation. I might prescribe +3.50 OD and +0.50 OS. I have maintained 3 D of anisometropia in the glasses prescription. Generally, I only prescribe full plus when a patient has strabismus, more specifically esotropia.
Kristi Stalker on Thursday 02/08/2024 at 12:00 PM
Thanks for this helpful info! One sentence confused me however. Can you please explain? Maybe I’m reading it wrong. “ Remember, while you do not have to prescribe full plus, the full anisometropia needs to be maintained in the prescription, if present. ”