Help 7 month old with anisometropia and possible amblyopia

Discussion in 'Optometry Archives' started by Rafael, Nov 7, 2003.

  1. Rafael

    Rafael Guest

    I have a 7 month old little girl. We took her in for a check-up with a
    pediatric oftalmologyst since her mother (and many in her family)
    suffer from 'lazy eye'.
    There had been no symptoms, she seems to see just fine, no strabismus,
    we were pretty confident nothing would be found.

    Well, we ended up visiting 4 specialists in 3 weeks and here are their

    1. Diagnozed lazy eye, +5 +7 (negative cylinder), treatment: glasses
    +2.5, +4.5 (not full prescription), come back in 2months

    2. No lazy eye, 3.5 4.5 (positive cylinder), treatment: glasses full
    prescription, come back in 3 months

    3. Diagnozed lazy eye, +4 +5.5 (positive cylinder) ,treatment glasses:
    +2 +3.5, patching to start in 3 months.

    4. NO lazy eye, +4.5 +5.5 (positive cylinder). No treatment needed,
    come back in 6 months.

    They all mentioned that amblyoptic behaviour was not existent or
    barely starting. They did all comfirm some level of anisometropy. But
    as you can see we have several treatment options.

    What should we do?. We understant that once we start with glasses
    there is no turning back. We want to offer our child the best
    opportunity to have good/correct vision, but we get conflicting
    opinions.... (She is kind of young to start her with glasses...)

    Can anyone shed some light????

    Rafael, Nov 7, 2003
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  2. I assume all 4 dilated the eyes to determine refraction? And, if so, WHY
    would you subject this poor child to all that in 3 weeks?

    You need to post the full Rx findings and prescription to make any sense of
    this information: ie: Right eye +3.00 +1.50 x120 / left eye +2.00 +1.25
    x135; glasses prescription: ... (in the same format as above).

    "Lazy eye" in a 7 month old is diagnosed by their visual behavior, and only
    really gross differences in the vision can be determined. If there is a
    difference there is significant amblyopia (try not to use the term "lazy
    eye" - it means lots of different things). If therre seems to be no
    difference in fixation behavior, there can still be amblyopia, just not
    enough to determine this way.

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and strabismus subspecialty
    Member of AAPOS
    (American Academy of Pediatric Ophthalmology and Strabismus)
    David Robins, MD, Nov 7, 2003
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  3. Rafael

    Rafael Guest

    Yeap... We did not know it was a big deal for the girl (were are new
    to this). She never cried or complained. She was always very cheerful
    through all examinations. If anything, we felt that given the 'big'
    decision we were about to make (glasses), we wanted to make sure on
    the best diagnosis.
    Oops, sorry, Here it is:

    1. Diagnozed lazy eye,
    +5 (negative cylinder)
    +7 (negative cylinder)
    This was verbally, also mentioned that she would prescribe just
    enough to match both eyes and to keep sight error within normal for
    Glasses presc:
    OD +2.50 -0.50 x 180
    OS +4.50 -1.25 x 15

    2. No lazy eye,
    This doctor told us that he was prescribing full correction, so we
    assume his findings were the same as the precription.
    glasses presc:
    +3.50 +1.25 x 90
    +4.50 +2.25 x 90

    3. Diagnozed lazy eye,patching to start in 3months.
    This doctor also said that he would prescribe enough to match both
    eyes and bring them down 2D only... Same idea as 1st doctor, that the
    child should be left with some error within normal ranges.
    Glasses presc:
    OD +2.00 1.25 x 90
    OS +3.50 1.50 x 90

    4. NO lazy eye, Found from looking at his notes on the medical record:
    +4.5 +1.50 x90
    +5.5 +1.50 x90
    No treatment recommended, come back in 6 months.

    Here is what we beleive and need to make sense of:

    1. Sabrina does not have amblyopia as of this moment?

    2. Sabrina is in danger to develop amblyopia because of the
    anisometropia and genetic pre-disposition...

    3. If amblyopia is to be developed from nerve de-generation, the eye
    glasses will not alone stop this and patching will be needed, but
    glasses would greatly help the process.

    4. We have read that anisometropia of only 1d to 1.5d should not be

    Concerns with the 4 opinions:

    1. They all vary in the prescription, we understand that with babies
    it is not an exact science... But:

    a. 3 out of 4 said to start glasses and come back within 3 months

    b. One said to not do anyting and come back in 6 months (this one
    happens to be the doctor with the most experience in the area and by
    far the longest in practice of the group, also seemed the most sure of
    his assesment). Of course we really don't want to put glasses on the
    baby unless it is needed, so this doctor is saying want we want to
    hear - everything is OK - .

    c. 1 out of 3 recommended full prescription.

    This is driving my wife and I a little crazy. She has amblyopia with
    very little use of her left eye (almost 0 stereo vision), and she does
    not want this for her baby...

    How can we pick on the right action?

    Thank youfor taking the time to answer...

    Rafael, Nov 7, 2003
  4. Rafael

    Dr. Leukoma Guest

    First of all, your child has two risk factors for amblyopia - hyperopia and
    heredity, and 2 out of four "specialists" in agreement. Furthermore, what
    exactly is the risk of treating this with spectacles? What is the risk of
    prescribing too strong vs. too weak? Myopic children rarely develop
    amblyopia. The risk of patching is the development of occlusion amblyopia
    in the good eye. This is minimal in the hands of an experienced doctor.

    Go with someone in whose reputation and experience you trust, and not with
    someone who tells you what you want to hear. If this were my child, I
    would risk treatment vs. nothing.


    (Rafael) wrote in
    Dr. Leukoma, Nov 7, 2003
  5. Rafael

    Otis Brown Guest

    (Rafael) wrote in message
    Dear Rafael,

    Please remember that, even in medicine, there are
    contradictory opinions.

    The majority opinion may be to "do something", like put
    glasses on a 6 month old child, but there are other
    ophthalmologist who would suggest "going slow" particularly
    with at child that young.

    Re:> Can anyone shed some light????

    If you put a +5 diopter lens on a child with a focal
    status of +5 diopters -- the eye tends to stay
    at 5 diopters. (i.e., emmetropizes on the +5 diopter

    Since you have published the various opinions, I think the
    wise one is number four:
    Young primate eyes are born with focal stats that run from
    zero to +8 or +9 diopters. The +5 in a primate eye
    is not unusual. (Reference Dr. Dave Guyton's publications
    on eye suture studies on young primate eyes.)

    Do not panic. Dr. David Robins probably is giving you
    the best advice here.


    Otis Brown
    Otis Brown, Nov 7, 2003
  6. Rafael

    Otis Brown Guest

    (Rafael) wrote in message
    Re: > What should we do?. We understant that once we start with
    there is no turning back. We want to offer our child the best
    opportunity to have good/correct vision, but we get conflicting
    opinions.... (She is kind of young to start her with glasses...)
    Can anyone shed some light???? Thanks!!! Rafael

    Re:> 4. NO lazy eye, +4.5 +5.5 (positive cylinder). No treatment
    needed, come back in 6 months.

    Dear Rafael,

    Subject: The "second opinion" -- basis for item #4

    Here are the remarks of a highly skilled OD, on placing
    a strong plus on a young child.

    The disagreement is very deep indeed -- and has never
    been resolve. It is always good to keep in mind
    the fact that Dr. Merrill Allen recognizes that the
    young eye "emmetropizes" on the applied positive lens.
    You should consider this the "second opinion".




    (From I-SEE library)

    How to Eliminate Hyperopia


    by Merrill Allen, OD, PhD, FAAO, FCOVD

    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.

    Otis Brown, Nov 7, 2003
  7. Rafael

    Dan Abel Guest

    I can't comment on what you say from a medical standpoint, but as a
    parent, how on earth do you keep glasses on a kid at 7 months of age? I
    remember the little girl across the street getting glasses very young,
    perhaps less than 3, and that worked pretty well.
    Dan Abel, Nov 7, 2003
  8. Rafael

    Dan Abel Guest

    I can't comment on the medical stuff, because last time I posted on this
    subject I found that I knew less than nothing.

    However, why do you say that there is no turning back once you start with
    glasses? It seems like if they aren't working, you just stop using them.
    It's not like LASIK, where if it doesn't work for you, there is no "magic
    wand" to get back to where you were before the surgery.
    Dan Abel, Nov 7, 2003
  9. Rafael

    Dr. Leukoma Guest

    (Dan Abel) wrote in
    Eyeglasses for infants have cable earpieces so they stay put.

    Dr. Leukoma, Nov 7, 2003
  10. Rafael

    Francine Guest

    Hi Rafael,

    I am in agreement with the docs on this one.

    I've seen the kind of confusion you are experiencing lots of times, on
    the group "Lazy Eye" and on the AAPOS forum.

    The point is this: If your daughter has no stereo vision, there is an
    imperative that she begin to develop it. One thing that all the POs
    who examined her found was a large difference in refraction between
    the two eyes. If she is not amblyopic...and some of them think she
    already is...she most probably will be, without some sort of
    therapeutic intervention.

    It is a very common practice to put glasses on the little kid so as to
    get BOTH eyes seeing well enough so that they want to work together.
    In amblyopia, the brain suppresses info from the "less able" eye and
    once this tendency is firmly established, it is not easy to get rid

    So why does it matter if she has stereo vision? Why does it matter if
    her two eyes work together? The answer is that without this capacity,
    which nature intended us to have, her learning and development will be
    disrupted. You don't want this to happen. Therefore the strategy is
    clear: Have her wear glasses, and get her frequent checkups. You have
    gotten a lot of professional opinions, which is usually wise, but in
    your case it has confused you. This, unfortunately, is sometimes the
    case. In the end, one has to make up his or her own mind.

    There is no "downside" to giving her glasses at this point. You don't
    want her learning to be stunted.

    Some children do grow less hyperopic over time. There is no way to
    determine that at this point. The trouble right now is that she is so
    young that a definitive diagnosis of amblyopia seems rather elusive.

    One thing you have to realize, though: Amblyopia, once established,
    never, never goes away all by itself.

    If your child grows older and she is still hyperopic, and definitely
    amblyopic, she can get patching or Vision Training or both. Amblyopia
    is a condition that needs treatment.

    You may want to join the newsgroup "Lazy Eye," as it is full of
    parents who have been through all this and can offer you support and
    information. I highly recommend it.

    Francine, Nov 7, 2003
  11. You still didn' say for sure if each exam was a dilated (cycloplegic )
    refraction. If not, the non-cycloplegic ones are suspect, because they can't
    compensate for accommodation during the test. If cyclopleged, the difference
    between refractions should be around 0.50 to 0.75 maximum, typically.

    IO am conecerned because the eye-to-eye difference in the prescriptions
    varies from 2.00 to 1.00. Around 1.50 and up is felt to be amblyogenic.
    However, you cannot determine amblyopia from the prescription alone.
    Amblyopia is determined clinically by the fixation pattern in young children
    (or the eyechart in older children). Fixation pattern may not show up mild
    amblyopias. Also, if they are rather far-sighted, based on the more
    farsighted eye, over about 5.00 or less, as some people believe), they
    should have glasses. (If thye are crossing, almost any amount of
    farsightedness over 1.00 may be contributory.) IF they are 1.50D
    anisometropic or more, glasses should be ordered. However, if they are
    verbal and can read an eyechart, you may find amblyopia with less than 1.50
    anisometropia, or you may find more than 1.50 and no amblyopia.

    HOWEVER: if the anisometropia is 1.00D as in #4, and borderline high
    hyperopia, and only age 7 months, then I would do the same - see back in 6
    months, as she may be significantly less hyperopic then. If not, then order
    glasses at that time, probably ordering 1.5 to 2 dipoters less than the full
    Rx, unless significant amblyopia is detected, in which case the full Rx
    probably is needed.

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and strabismus subspecialty
    Member of AAPOS
    (American Academy of Pediatric Ophthalmology and Strabismus)
    David Robins, MD, Nov 8, 2003
  12. I disagree only with the last statement, that this degree of hyperopia is
    not likely to go away.

    In a 7 month old, this degree of hyperopia can easily go away - I have seen
    it many times. It also can remain the same of even increase. Best way to
    find out, as this is not so hyperopic in this young age, is to wait 6 months
    and recheck to see if it is falling. If not, then probably give an Rx that
    leaves them about 2D hyperopic (about average at this age) so as not to
    enocurage Otis's emmetropization to the high plus lens, as most of us agree.

    This same power in a 6 year old would be totally a different case, and
    should be ordered on first exam, as stated below by the poster.

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and strabismus subspecialty
    Member of AAPOS
    (American Academy of Pediatric Ophthalmology and Strabismus)
    David Robins, MD, Nov 8, 2003
  13. Depending on the personality, kids at this age may wear glasses very well.

    And yes, I agree, to disagree with the statement about the huge disservice.

    David Robins, MD
    Board certified Ophthalmologist
    Pediatric and strabismus subspecialty
    Member of AAPOS
    (American Academy of Pediatric Ophthalmology and Strabismus)
    David Robins, MD, Nov 8, 2003
  14. Rafael

    Rafael Guest

    As I understant it, since the real problem we are compensating for is
    the anisometropia (difference in diffraction between eyes). Taking the
    glasses off in the near future would confuse the brain. It is not that
    both eyes are moving from a +7 to +3 and back to +7 (for example), but
    really we are moging a +1.5 difference to 0 back to 1.5. Once the
    brain is used to the fact that both eyes see as well, if we take the
    glasses off, it would be even more 'obvious to the brain' that
    something has gone wrong with the weaker eye....

    Make sense?
    Rafael, Nov 8, 2003
  15. Rafael

    Rafael Guest

    Yeap, we ordered fisher-price frames from the web. They fit very well.
    Now comes the desicion on the prescription....
    Rafael, Nov 8, 2003
  16. Rafael

    Rafael Guest

    Our main concern in the anisometropia. If she were +5 in both eyes, I
    would wait. But from what I have read, even though the diffraction
    errors can get better, it sees that difference in diffraction between
    eyes does not get 'fixed by itself'...

    We are leaning on a prescription that leave her at least 2d behing
    full, but keeps both eyes at the same level...
    Rafael, Nov 8, 2003
  17. Rafael

    Dr. Leukoma Guest

    This study was published in Investigative Ophthalmology and Visual Science,

    Normal Emmetropization in Infants with Spectacle Correction for Hyperopia
    Janette Atkinson1, Shirley Anker1, William Bobier2, Oliver Braddick1, Kim
    Durden1, Marko Nardini1 and Peter Watson3
    1 From the Visual Development Unit, London and Cambridge, Department of
    Psychology, University College London, United Kingdom; the 2 School of
    Optometry, University of Waterloo, Canada; and the 3 Department of
    Ophthalmology, Addenbrooke’s Hospital, Cambridge, United Kingdom.

    (I paraphrase here).

    The study followed 143 infants longitudinally for 2.5 years, starting at
    the ages of 8 to 9 months. The infants were divided into two hyperopic
    groups, and one control group. The hyperopic groups met the following
    criteria: a significant amount of hyperopia, with at least one meridian of
    +3.5 D or greater, which comprised 89% of all hyperopic infants detected at
    screening. This group was subdivided into two groups, one of which
    received corrective lenses. Infants with any meridian more than +6 D,
    anisometropia more than 1.5 D, or manifest strabismus were excluded and
    referred for appropriate ophthalmic treatment.

    In the treated group, spectacles were prescribed with sphere values 1 D
    less than the least hyperopic meridian, with no correction prescribed for
    less than 1.5 D. One-half of any astigmatic error if over 2.5 D for
    children up to age 2 years, half of any astigmatic error between 2 and 3.5
    years, and the full correction at greater than 3.5 years.

    Intermediate cycloplegic refractions were taken at 4- to 6-month intervals
    up to the age of 36 months. The results were that all groups showed an
    overall reduction in hyperopia. On average, the treated hyperopes
    initially emmetropized more slowly than the untreated group, with a mean of
    1 D greater at 18 months, but the difference narrowed by 36 months. At
    outset, the treated group had a mean refractive error of +4.6 D. At 36
    months is was +3.4 D. The untreated group was +4.3 D in the beginning, and
    +3.1 D at the end. The control group was +1.9 D at the outset, and was
    +1.6 D at the end.

    The conclusion was that the degree of emmetropization was related to the
    level of hyperopia at the beginning of the study, and that emmetropization
    was not impeded by spectacle correction. However, it must be emphasized
    that the spectacles corrections were partial, rather than complete. The
    authors also found that prescribing according to this protocol had the
    effect of reducing the incidences of strabismus and poor acuity ty two-
    thirds in compliant children.

    Therefore, the results of this study favor spectacle treatment over no
    treatment, especially in an infant with such high hyperopia. The study
    also shows that with a mean reduction in the untreated group of 1.2 to 1.6
    diopters over 2.5 years, it is unlikely that an infant will show any
    sustantial reduction in refraction between 7 months and 13 months, and that
    witholding treatment for 6 months, or approximately one-half of the
    infant's age at that point may not serve any useful purpose, and that the
    real risk would seem to be that of witholding treatment.

    Dr. Leukoma, Nov 8, 2003
  18. Rafael

    Dr. Leukoma Guest

    (Rafael) wrote in
    See my post above.

    Dr. Leukoma, Nov 8, 2003
  19. Rafael

    Dr. Leukoma Guest

    Hopefully nobody takes this nonsense seriously. Hopefully. Dr. Allen
    retired many, many years ago. To my knowledge, his area of expertise was
    in the design of highway markers and stop signs.


    (Otis Brown) wrote in
    Dr. Leukoma, Nov 8, 2003
  20. Rafael

    Otis Brown Guest

    (Rafael) wrote in message
    Dear Rafael,

    Re:> Can anyone shed some light???? Rafael

    Re: > ...and then there are completely useless comments from people who enjoy
    practicing medicine without the benefit of the education, the license and
    the responsibility that goes along with it. DrG

    I do not "practice medicine" and I have made that fact clear.
    Offering you a discussion of the "majority opinion" and
    the "second opinion" is not "practicing medicine" although
    Dr. G. seems to miss that point.

    I have spent a great deal of time reviewing this issue. It
    is true that I am an engineer, but the "opinion" I expressed
    was that you completely inform youself about the "second opinion"
    on this subject, and not plunge your daughter immediately
    into the use of a strong plus on a 7 month old infant.

    Let me make this clear. The opinion I expressed is
    IDENTICAL to Dr. Dave R.'s opinion, and further
    amplified by the true expert in the field.

    A man with both extensive clinincal experinece as
    well as a Ph.D.

    I would suggest reading his complete paper found on:

    Under: "How elliminate hyperopia",
    by Dr. Merrill Allen.

    The real question is how these men would treat
    their own child and grandchild. I am certain
    they would follow their own recommendations
    if it were their own child.

    However -- they disagree.

    The side of caution would be to at least delay
    the use of the plus -- until the child is
    one year old.

    This is the "second opinion" as discussed by
    Dr. Merrill Allen.


    Otis Brown, Nov 8, 2003
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