Should a strong plus be used on young children

Discussion in 'Optometry Archives' started by Otis Brown, Dec 7, 2003.

  1. Otis Brown

    Otis Brown Guest

    Dear Friends,

    Here is a paper that argues that
    a plus should be used on young children.

    I disagree -- but here is the paper for your interest.




    Zhonghua Yan Ke Za Zhi. 2001 Jan;37(1):24-7.

    [A research of infant refraction in Kunming Municipality]

    [Article in Chinese]

    Li L, Ma Y, Hu X.

    Department of Ophthalmology, Kunming Children's Hospital, Kunming
    650034, China.

    OBJECTIVE: To study the infant refraction, detect ametropia in mass
    screening refraction and correct the ametropia properly for the
    treatment and prevention of amblyopia and strabismus as early as

    METHODS: The refraction status of 1 146 children (2 291 eyes, aged 1
    month -3 years) were determined with retinoscopy after tropicamide

    RESULTS: The results of statistics showed that 89 eyes (3.88%) had
    emmetropia, 2 139 eyes (93.37%) hypermetropia, 38 eyes (1.66%) myopia,
    560 eyes (24.44%) astigmatism and 25 eyes (1.09%) mixed astigmatism.
    In cases with ametropia, most of them were mild, and 97 eyes (4.23%)
    were moderate and severe. Anisometropia occurred in 34 infants
    (2.97%), and 7 infants (11 eyes, 0.48%) had strabismus. The degree of
    hypermetropia decreased with the increase of age. The percentage of
    astigmatism decreased with the age increase (chi(2) = 7.46, P<0.01),
    and the degree of astigmatism also decreased with the age increase
    (chi(2) = 26.1l, P < 0.01). Myopia increased with the age increase
    (chi(2) = 4.06, P < 0.05).

    CONCLUSIONS: The prevention of amblyopia and strabismus in children
    should begin at the infant period, and the cases with moderate and
    severe ametropia should wear eye glasses as early as possible.
    Otis Brown, Dec 7, 2003
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  2. Otis Brown

    Dr Judy Guest

    snip method, refraction determined with cycloplegia
    Where is the argument that plus should be used?

    Less than 5% of children had moderate to severe refractive error (in the
    abstract, moderate to severe is not defined), and the authors conclude that
    this small subset should have glasses as soon a possible. Presumably some
    are hyperopic, some are myopic and some are astigmatic.
    So I don't think the authors are arguing for plus lenses, they are arguing
    for plus, minus or cylindric lenses to be used when moderate to severe
    refractive error exists.

    The conclusion is that prevention of amblyopia should begin as soon as
    possible. Why do you disagree? Do you think that the 3% of children with
    anisemetropia (which causes amblyopia) should not be corrected to prevent

    Dr Judy
    Dr Judy, Dec 8, 2003
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  3. Otis Brown

    Otis Brown Guest

    Dear Dr. Judy,

    Exact science depends on exact defintions.

    Emmetropia is generally defined as a focal state
    of exactly zero. Any focal state that is not
    zero is ametropia.

    What is not defined is EXACTLY what these
    people mean by "emmetropia". Maybe
    you could define EXACTLY what they mean
    by "emmetropia" -- as discussed below.

    Below are the possibilities.


    I have never seen a precise definition of "emmetropia". But I have
    heard the following suggestions.

    1. A focal state of exactly zero.

    2. Focal states from -1/2 diopter to +1/2 diopter.

    3. Only focal states that are positive -- i.e., zero to +3/4 diopter.

    Because there is no "accepted" definition, it is very difficult
    to talk about EXACTLY "89 eyes (3.88%) had emmetropia."

    If they specified the emmetropia-spread in the scientific article it
    would make more sense.

    Also, monkeys are born with focal states running from zero to +9
    diopters (at
    the moment of birth. If this article were consistent in its argument,
    all the highly "hyperopic" eyes should be wearing a strong plus lens!

    Because uncorrected farsighedness (hyperopia) might caluse

    This is another case of "logical inconsistency" in the
    Donders-Helmholtz concept
    that all focal states (other than zero) are "refractive errors", or
    defective ametropia.

    But I do agree that an MD who checks these eyes using
    atropine or some other drug will most likely not prescirbe
    a strong positive lens -- because he recognizes that
    for the "emmetropication" (feedback control) process
    to work correctly the natural eye must have
    a normal visual enviroment. And a lens (minus or plus)
    will change that visual enviroment.

    This was evaluated correctly by Dr. Merrill Allen. I hold
    his opinion (as the honest second opinion).

    But I know that each doctor will make up his own
    mind about these issues. But there is profound
    disagreement here.


    Otis Brown, Dec 8, 2003
  4. Otis Brown

    Dr Judy Guest

    The abstract you printed did not define it, I expect if you found the whole
    paper, you may find that is was defined. I cannot possibly define what
    someone else meant.
    Given that less than 4% of the infants has "emmetropia, this definition is
    quite likely.
    Since about 95% of the infants had "mild" ametropia, I would wager that this
    range of refractive error (-0.50 to +0.75, but excluding 0.0) was included
    in the mild definition, not as emmetropia.
    Uncorrected farsightedness is ametropia, not a cause. Or did you mean
    What inconsistency? You use the term "defective". The term refractive
    error means that the particular eye, when accommodation is at rest, does not
    focus parallel light rays on the retinal plane, this does not mean the eye
    is defective, it simply is a statement of fact and measurement. The compass
    on my sailboat also has deviation or error that is unique to my boat; the
    compass is not defective but the error exists and I must compensate for it
    when navigating.
    No disagreement here. The published paper, as stated in its purpose was
    about the prevention of amblyopia. Eye doctors everywhere would agree that
    small refractive errors in young children should not be corrected and the
    process of emmetropization allowed to run its course with one exception.
    And that exception is the one cited in the paper: when moderate to severe
    error exists and amblyopia may result from failing to correct the refractive
    error. I'm sure Merril Allen would not argue that amblyopia is an
    acceptable price to pay for not wearing glasses.

    Dr Judy
    Dr Judy, Dec 9, 2003
  5. Otis Brown

    Dr. Leukoma Guest

    (Otis Brown) wrote in


    You were posting the ABSTRACT. I am sure that the authors defined what
    they meant in the text of the article.
    Emmetropia is understood as meaning no refractive error. If one-quarter
    diopter is measured, that is considered refractive error. However, the
    term "significant refractive error," means something else. I believe that
    the authors were interested in that group.
    Yes, it might.

    The term "ametropia" has a meaning in and of itself. You inserted the word
    "defective" as a descriptor. I have never heard the term "defective
    ametropia" mentioned in professional circles.
    What is your authority to speak on behalf of all MD's? I submit that some
    would prescribe and others would not prescribe depending on their
    perception of the infant's risk for amblyopia.
    There is disagreement, but consensus is beginning to emerge as demonstrated
    by the aforementioned paper as well as others. Everyone should be
    interested in a paper published in Investigative Ophthalmology and Visual
    Science, 2000;41:3726-3731, titled "Normal Emmetropization in Infants with
    Spectacle Correction for Hyperopia." This longitudinal study of infants
    from 8 months to 36 months of age debunks the myth that prescribing for
    significant infant hyperopia impairs the normal regulation of refraction.

    At some point in the not too distant future, an MD who does not prescribe
    for significant infant refractive error might be judged to be committing

    Dr. Leukoma, Dec 9, 2003
  6. Otis Brown

    Otis Brown Guest

    Dear Dr. G,

    Again, the words "significant refractive error", and
    "committing malpractive", come into view.

    There are major disagreements here that can not be
    "papered over" by talking as though their
    is "one opinion".

    I would not use the word "malpractice". I would
    discuss reasonable alternatives and state that
    there is no universal agreement on the topic
    of placing a +5 diopter on an infant withkj
    a 5 diiopter positive focal status.

    Ultimately, if it a parent, who is also an
    optometrist, then the infant will get what
    the optometrist believes is best for the child.

    Perhaps that is real base-line ethics in medicine.
    What you are prepared to do for your own children -- even
    if it differs from the majority opinion.



    Dr. Steve Leung
    Donald Rehm
    Otis Brown, Dec 9, 2003
  7. Otis Brown

    Dr. Leukoma Guest

    (Otis Brown) wrote in
    Otis, I do not invent these terms. Parents get quite upset when they find
    out that their child has amblyopia. They get even more upset when they
    realize that it could have been prevented with early detection and
    treatment. As much as parents dislike eyeglasses for their children, they
    dislike unilateral blindness even more.

    There is a broad consensus on what constitutes an amblyopiagenic refractive
    error. However, the only impediment to prescribing is the real or imagined
    inhibition of interfering with the normalization process. As I pointed
    out, there is now a growing consensus on prescribing, rather than
    witholding. In addition, there is a growing movement, fueled in part by
    angry parents of amblyopic children, to mandate early childhood
    professional vision examinations at the state level, or at least informing
    parents that a screening is not a substitute for such an examination.

    Otherwise, your post makes no sense to me except as trivialization of a
    serious subject. With you there are only focal states, and as a non-
    professional dispensing advice, you cannot be sued for malpractice.

    Dr. Leukoma, Dec 10, 2003
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