Follow-up: Eye Glasses - FULL or PARTIAL Prescription ?

Discussion in 'Glasses' started by Mary Daniele, Sep 1, 2004.

  1. Mary Daniele

    Mary Daniele Guest

    Thanks to all who provided input to our original posting. We do appreciate
    it. We had to take a few days to digest all the info and read the document
    provided by Neil (it did help understand Hyperopia much better - thanks!).

    This is all new to us since we have no history of vision problems in our
    families. We just want to have a good understanding to ensure we make an
    intelligent decision for our daughter. We were quite surprised to learn
    about our daughter's condition at a routine check-up. Our daughter spent
    most of the day doing close "work / play" such as looking at books, writing,
    coloring, and she never showed any signs of vision discomfort (rubbing eyes
    or blinking).

    It has been 6 months now that she's been wearing her +3 corrective lenses,
    and she does "look" for them when she forgets to put them on when she gets
    up. She does say she can't see well without them and seems to be dependant
    upon them now.

    We still have some points that we are trying to understand and still have
    some questions..perhaps some of you can help clarify...

    Re: Follow ups

    What does the Doctor look for in order to know when it is time to increase
    the prescription of the lenses?

    Re: Contact Lenses Option

    At what age can a child begin wearing contact lenses?

    Re: Child's brain development

    What would happen to a child's brain development with respect to vision if
    their condition is not corrected at all?

    We're trying to understand why the difference in opinions. The optometrist
    had explained that should we not correct our daughter's condition, she would
    never be able to achieve 20-20 vision even with corrective lenses once she
    is older than 10 years. In his opinion, a FULLl prescription is required to
    prevent this. The ophthalmologist on the other hand explained (as did Mike
    Tyner) that partial correction leaves stimulus for the eyes to grow and
    perhaps reduce hyperopia. But then again, what if the condition remains at
    +5 correction? Is the child's brain not developing properly without FULL

    I read this statement in an article and am curious to know if it has been

    "For most people, presbyopia comes on around the age of 45, but farsighted
    people can be affected as young as 25 or 30. This difference exists because
    farsighted eyes that are not corrected with glasses are already using up
    some of their accommodation to see at all distances. Because there is less
    accommodation remaining, it tends to "run out" sooner. It is the depleted
    accommodation that creates the presbyopia. However, if the farsightedness is
    corrected with glasses, presbyopia will be put off until 45 or so, the time
    it would normally occur."

    One last question for Larry:

    Can you just explain (so that we may understand) the reasoning behind the
    following two points you had made in your response to our original posting:

    (1) "I'd probably move it to +3.75 or 4 at the 6 month point if it is still
    +5, but not if the plus is less.) If by the time she is learning to
    read, even spending time with books (they like to pretend that they're
    reading-----and they sort of really are!), and that might be very soon.
    and she still measures +5, I'd start moving the power up to that level
    or close to it." - why would you increase it at this point?

    (2) "Meanwhile, encourage her to draw/color/read with the near objects as
    away from her face as practical " - why ?

    Thanks in advance.
    Mary Daniele, Sep 1, 2004
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  2. Mary Daniele

    LarryDoc Guest

    I'm only going to address a couple of your questions, some briefly. and
    leave the rest for the other docs. You will likely find some areas of
    agreement and disagreement.
    Increasing or decreasing correction, status of ocular motor (eye
    crossing or not) function and level of acuity (do both eyes maintain
    equal vision ability?)
    There is no appropriate age for using contacts. It is an issue of
    handling, inserting and removing the lenses, or whether or not to allow
    extended wear (overnight) use. Some kids as young as 5 can put in/take
    out their own lenses. Age 6 or 7 is often a more developmentally
    appropriate age. Or, a parent can do it. Optically, there is no
    question that is the desirable, if not preferred option. From a
    practical standpoint, it may be a different story. Last week I had a 5
    year old who absolutely refused to even try contacts. A few weeks
    earlier, a 6 year old who would choose nothing else.
    Under correcting the hyperopia by two diopters is reasonable in the
    short term, especially if doing so allows the eye to develop to a
    position of less hyperopia and there are no other issues. My thinking is
    that if there is any tendency for the eyes to cross or for the brain
    processing to surpress visual information due to the uncorrected
    hyperopia, I'd want to prescribe the power level that prevents that. The
    additional stimulation by the increasing near point vision tasks
    (learning to read, classroom desk activities) increases the risk of
    ocular-motor dysfunction (crossing) and surpression. I personally do not
    feel comfortable leaving 2 diopters uncorrected after age 5 or 6 if
    there is no proven trend to decreasing hyperopia, but a diopter or
    diopter and a half is certainly reasonable. If testing indicated no
    problems with leaving 2 diopters uncorrected, then that's probably fine,
    too, but I'm of the opinion to undercorrect less. It's not a factor
    that etched in stone and the decision requires more information.
    The further away the object of regard, the lower the accomodative
    (focusing) demand and the less convergance (turning in) effect. Leaving
    2 diopters uncorrected increases that demand anyway, oftentimes an
    acceptable condition (as discussed above) but not so if the accomodative
    demand exceeds the ability of the vision system to deal with it.
    Up-close work combined with the uncorrected hyperopia can do it. I
    discuss "proper" use of the eye with all children that I examine.
    Farsighted or not, for the same reasons.



    Dr. Larry Bickford, O.D.
    Family Practice Eye Health & Vision Care

    The Eyecare Connection
    larrydoc at eye-care-contacts dot com (remove -)
    LarryDoc, Sep 1, 2004
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  3. Mary Daniele

    Otis Brown Guest

    Dear Mary,

    While there is an majority-opinion that a lens of
    +5 diopters should be placed on your four year old
    child -- there is also a second-opnion, that says
    that is not a good idea.

    Here is the opnion of a professor of ophthalmology.

    The judgment is that the child is still in a growing
    phase, and that a strong plus will inhibit the
    natural "emmetropization" process.

    Something to consider.



    Subject: Does a very young child REQUIRE a plus lens?

    How to Eliminate Hyperopia
    (A positive refractive state of the eye.)

    by Merrill Allen, OD, PhD, FAAO, FCOVD


    Indiana University.

    Summary: The young eye should be given time to move towards zero
    diopters (emmetropiia). A strong plus lens will
    interfere with the "normalization" process (i.e,,
    interfere with "emmetropization". This statement is the
    "second-opinion" by a highly qualified experts.)

    Re: When I'm in the mall, I see thick glasses on small children
    and I have to control myself. I know that wearing those
    glasses blocks emmetropization. (i.e., blocks the
    process of normal vision growth. OSB) If Mom would put
    the glasses on the child only in the afternoon, the
    child would grow out of his/her hyperopia and require
    several spectacle power reductions. If the child's
    correction is less than the refractive error, he/she
    will grow out of the need for those glasses and soon
    weaker lenses will be needed. Dr. M. Allen


    Humans are adaptable. The refractive error distribution in
    the population of newborns is almost a normal curve. By the first
    grade the distribution has become leptokurtic with the great
    majority of the population falling within -0.5 and +2.00 diopters
    of error. The babies have grown out of their refractive errors!

    Graduate Students at Indiana University did a study of babies
    at 2 weeks of age who performed as well on focusing tests as
    college students. The one baby who did not was about 5 D
    hyperopic. After 6 weeks or so it was clearly withdrawn and
    abnormal in personality. The baby could not respond to the test.
    Application of +4 D glasses changed the baby's personality
    overnight! Regarding the overcoming of hyperopia by optometric
    intervention, the baby above was not followed, but if the baby
    continued to wear those glasses, now as an adult, he/she will
    still be +4 hyperopic.

    I worked with an 18 month old esotropic girl whose eyes were
    so crossed I thought she had convergence fixus. However when I
    held her at arms length and turned my body through 360 degrees her
    vestibulars took over and her eyes straightened and she showed
    nystagmus. At each of the three visits I increased the plus to
    take home. Her eyes straightened with +11D. Then at the age of
    three years while moving to another city she lost her glasses and
    went without them for 3 months. The new eye examination showed
    her Rx to be +4. She had lost 7 diopters in three months!

    I did not realize the significance and was not smart enough
    to say to Mom: "Let's leave the glasses off for another 3
    months," or "Let's wear plano glasses with binasal occluders for 3
    months." The last checkup of this patient was at age 18 years when
    she was wearing +4D contact lenses! We cured her of esotropia and
    reduced 7 diopters of hyperopia! She has of course continued to
    be straight eyed.

    Wild monkeys have low hyperopia or emmetropia and no myopia.
    Caged monkeys have less hyperopia and much more myopia. Because
    the evidence for emmetropization is so strong, I suggest a couple
    of approaches on how to emmetropize young hyperopes.

    Only prescribe as much plus as needed to keep the eyes
    straight. (In the case of our baby that couldn't focus and had
    personality problems, the plus probably wouldn't be needed for
    more than a week or two as the child figured out how to use his

    At most the Rx should only be about half of the retinoscopic
    Rx and then reduced in power as the eyes change. With esotropia,
    more plus power may be needed at first to establish normal
    binocular vision, after which treatment of hyperopia may proceed.
    Alternatively for esotropia, the no Rx, binasal approach, see
    below, is highly recommended. Use no lens power but provide
    binasal occluders such as frosty Scotch tape applied with the
    outer edges placed at the distance apart of the centers of the
    pupils, minus 4mm.

    A growing child will require frequent occluder adjustments as
    his/her pupillary distance increases. The binasals will
    straighten crossed or exotropic eyes as well as cause
    emmetropization. Within 6 months the occluders can be removed.
    Strabismus and refractive error should be cured in that time! if
    you or the parents forget, the child will grow out of the binasals
    [they will cover less and less of the visual field] and will be

    We know that older people grow into myopia, so I would not
    put an upper age on when a person can grow out of hyperopia. The
    important condition is that they be able to intensively pursue
    visual tasks requiring accommodation. If they are not visually
    involved, and if we eliminate the need to emmetropize, they will
    not emmetropize!

    When I'm in the mall, I see thick glasses on small children
    and I have to control myself. I know that wearing those glasses
    blocks emmetropization. If Mom would put the glasses on the child
    only in the afternoon, the child would grow out of his/her
    hyperopia and require several spectacle power reductions. If the
    child's correction is less than the refractive error, he/she will
    grow out of the need for those glasses and soon weaker lenses will
    be needed.
    Otis Brown, Sep 1, 2004
  4. Mary Daniele

    Otis Brown Guest

    Dear Mike,

    Thanks for the nit-pick correction. I did "mis-speak".

    Yes, Merrill Allen is a Ph.D. and a professor of
    ophthalmology. But I guess the fact that is is not
    an OPHTHALMOLOGIST disqualfies him. And so also
    the fact that YOU are an optometrist would do the
    same thing to you.

    Equally, this woman asked for a "second opinion", and
    I am certain, like all other issues, there
    are ophthalmologists who would say the same thing -- that
    if you put a 5.0 diopter on a child at +5 diopters
    then her vision will stay at +5.0 diopters,
    and she will be wearing +5.0 D (if not greater)
    coke bottles for the rest of her life.

    But I managed to omit making that statement
    to this woman about one of the "minuses" of
    putting her small child in such a strong plus lens.

    At least she now has a "balanced" opinion -- and
    it must be her choice.


    Otis Brown, Sep 2, 2004
  5. Mary Daniele

    Otis Brown Guest

    Dear Mike -- and other ODs,

    Assume a child had a refractive status of +2.0 diopters.

    Would you all put her is a +2.0 diopter lens?

    Or would you tell her that there is no requirement that
    she wear a +2.0 diopter lens all the time at age 4?

    If yes -- why?

    Ir no -- why?




    Otis Brown, Sep 2, 2004
  6. Mary Daniele

    Otis Brown Guest

    Subject: Since the use of a +2.0 D, on a child with
    a refractive status of +2.0 D, then the there are indeed
    two opinions on the subject.

    Thus the opinion of Dr. Merrill Allen OD (keep the
    plus off as much as possible) is a valid as
    putting a +5 D, on a child with a refractive status
    of +5 D.

    I would also point out that primates are born
    with refractive status that run from minus to
    plus 9 diopters -- at birth.

    Their refractive status (in a "zero" visual enviroment)
    moves towards that environment. If that enviroment
    is changed from zero to +5 D (in monkeys) the
    eye will "emmetropize" on the +5 diopter environment.

    That is one of the "objective" or experimental
    (in primates) reasons why Dr. Allen maintained
    as stated his reluctance to use a strong plus
    on a very young child.



    Otis Brown, Sep 3, 2004
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