Help 7 month old with anisometropia and possible amblyopia

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
findings:

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????

Thanks!!!

 

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)

 

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
children.
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
treated...

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

 

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.

DrG

(Rafael) wrote in

 

(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
lens.

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.

Best,

Otis Brown
Engineer

 

(Rafael) wrote in message
Re: > 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???? 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".

Best,

Otis
Engineer

__________________

(From I-SEE library)


How to Eliminate Hyperopia

(Excerpt)

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.


___________________________

 

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.

 

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) wrote in 64en129.sonoma.edu:

Eyeglasses for infants have cable earpieces so they stay put.

DrG

 

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
of.

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.

http://health.groups.yahoo.com/group/LazyEye/

Cheers,
Francine

 

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)

 

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)

 

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)

 

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?

 

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

 

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...

 

This study was published in Investigative Ophthalmology and Visual Science,
2000;41:3726-3731.

==========================================================================
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.

DrG

 

(Rafael) wrote in

See my post above.

DrG

 

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.

DrG

(Otis Brown) wrote in

 

(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:

http://www.i-see.org/library.htm

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.

Best,

Otis