Challenges in Pediatric Refraction
Challenges in Pediatric Refraction
Challenges in Pediatric Refraction
PEDIATRIC REFRACTION
Dyanamic
Static Retinoscopy
Retinoscopy
Manifest Cycloplegic
Mohindra retinoscopy
infii
Infants Retinoscopy with/without cycloplegic
Photorefraction
Keratometry
Retinoscopy with/without cycloplegic
Preschool
MEM retinoscopy
Subjective refraction
Book retinoscopy
Keratometry
Manifest / cycloplegic retinoscopy
School Aged
Dyanamic retinoscopy
Subjective refraction
Indication of Cycloplegic Refraction
Uncooperated patients (8 years or
younger)
With strabismus
Indications
Latent hyperopia
Pseudomyopia
History
Visual Acuity
Medical Hyperemia in
Allergic conjunctiva
(near /distance)
Emotional
Blurred Vision
Photophobia
Systematic side effect except
tropicamide
Adverse Effects
Caution
Cyclopentolate may produce
oedma, follicular conjunctivitis &
dermitis in some patients
Consistent BCVA
5 W’s of Refraction
Who
What
Where
When
Why
Difficulty in retinoscopy
Possible causes Solutions
Opaque / hezy ocular media In most cases, it is overcome by use of
mydriatics*
Small pupil size Use of mydriatics*
High degree of refractive errors Follow up case: check PGP to get a rough
estimation
First examination: if reflex is dull, try -7
first and then +7. if reflex is still dull
proceed to 15D or 20D , untill the reflex is
visible and proceed from there
*Perform all the indicated investigation and rule out contraindication before dilating
Possible causes Solutions
Wandering fixation Give a specific fixation target
Abnormally active accommodation Fogging technique
Cycloplegic refraction may be
required
Possible causes Solutions
High astigmatism Rotate the retinoscopic beam to find
angle where scissor reflex is minimum
Nebular corneal opacity Increase retinoscopic illumination to
decrease pupil diameter.
Spot retinoscopy may be helpfull
Possible causes Solutions
Irregular astigmatism Do keratometry and prescribe
minimum power that gives maximum
visual acuity. Subjective refraction
may also be done in school going
children.
Keratoconus Relate refraction to visual acuity
Perform corneal topography
Perform keratometry
Possible causes Solutions
Positive aberration (in normal Increase retinoscope illumination to
accommodating lens) decrease pupil diameter
Concentrate on the centrral bright glow
and ignore the peripheral glow
Negative aberration (more in lenticular Increase retinoscopic illumination
nuclear sclerosis Perform cycloplegic refraction
What is the greatest challenges to pediatric refraction
so, cycloplegic refraction must be carried out in every patient with or without strabismus
Additional challenges of pediatric refraction
• Nystagmus
• Strabismus
• Aphakia
• Small pupil
• Cataract
• Corneal opacity
• Faint retinoscopic reflex
• In case of nystagmus, retinoscopy should
performed in the null zone if such is present
• In case of strabismus, the child is asked to alter
gaze to another fixation (or close to eye) so that
the tested eye is better positioned
• And should perform retinoscopy slightly off axis
• In case of aphakia, the retinoscopy should
performed after dilatation
Redical retinoscopy
• This technique is applied in case of small pupils,
cataract, media opacity and faint retinoscopic reflex
• Instead of performing at usual working distance, the
examiner move closer to the patient. So, that
observable reflex can be obtained
• May involve working distance as close as 20 cm or 10
cm
• Finally, the dioptric poer of the WD is deducted from
the retinoscopic value
• Example – the retinoscopy value = +3.00DS/
-1.50X 90
Working distance = 20cm i.e. +5.00D
Net retinoscopy value = - 2.00DS/ -1.50X90
GUIDELINES FOR PRESCRIPTION IN HYPEROPIA
Infants (0 -1 yrs)
Isometropic Hyperopia
Deviation + ce
(eso) Deviation –ce
Isometropic Hyperopia
Deviation +ce
(eso) Deviation -ce
Full cycloplegic correction given Prescribe only when error is ( > or = 2.50
when error is D) i.e. partial or 2/3rd prescription is
(> or = 1.5 D) and regular F/U for advised
error below this
Cont…
• Preschol (3 – 6 yrs)
Hyperopia ( Anisometropic)
Full prescription
No prescription Partial (esodeviation
required ( F/U 3-6 prescription (no +ce)
monthly) deviation)
Infants (1 – 3yrs )
Infants with low to moderate myopia may not need prescription.
Because they don’t need to view things in fine details.
But AAO gives prescription guidelines in such condition as:-
Isometropic Myopia
> Or =
Required prescription
-5.00 D
( reduced by 1-2 D)
AAO suggests prescription of glasses when myopic anisometropia is (> or = 2.50 D) in infants to
reduce chances of amblyopia.
High amount of myopia at birth is likely to produce esotropia becoz far point is very close to eye.
Toddlers ( 1 – 3 yrs)
No prescription is given for low myopia in toddlers but given for moderate and high myopia.
Prescription guidelines as per AAO
No need to precribe
< - 4.00 D ( constant monitoring)
Isometropic myopia
Needs prescription ( reduced by 1- 2
> Or =-4.00
D)
D
( Fr no deviation)
Example : highly myopic children appear to do well without correction and cannot always
tolerate their full prescription. A 1.5 year myope requiring -10.00 D may cope better with
-7.00 D for a few months before, gradually increasing the prescription.
For muscle imbalances
For eso deviation : minimum minus for clear vision
For exo deviation : maximum minus for clear vision
No need to prescribe
< - 3.00 D
(costant Monitoring)
Isometropic
Myopia
Isometropic
Needs full prescription (reduced
Astigmatism
prescription can be given first to
> Or = 1.5 D
adapt)
• Accommodative Esotropia
• Constant Esotropia or IET
• Congenital Aphakia
• Down’s Syndrome
• Esophoria
• Pseudophakic child
Commonly Encountered conditions in pediatric
clinic with type of refractive errors seen in those
• Albinism – astigmatism in all subtypes (myopic or
hyperopic)
• ROP – high myopia
• Down’s Syndrome – hyperopia with or without
WTR astigmatism
• Nanophthalmos – high hyperopia upto +20D
• Sclerocornea & cornea plana – high hyperopia
• Congenital defects like Marfan’s syndrome,
homocystinuria – myopic error (most commonly).
References
Primary care optometry, Theodorer P. Grosvenor, 3 th edition
Borish’s clinical refraction, William J.Benjamin, 2 nd edition
Optometric Clinical Guidelines for pediatric eye and vision examination; American optometric Association
Clinical pediatric optometry, Leonard J. Press, Bruce D. Moore, 2 nd edition
Principles and practice of pediatric optometry, Alfred A. Rosenbloom, Meredith W. Morgan
Essential of pediatric optometry, Goutam Dutta
Comprehensive pediatric eye and vision examination, American optometric Association
Pediatric optometry, David Taylor
A Textbooks for optics and refractive Anomalies, AK Jain
Thank You