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Management of refractive error


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J. Margaret Woodhouse

Refracting young children is not difficult, but may require specialised techniques. Determining the significance of findings is more complex than for adult patients, as the refraction that can be considered 'normal' in children varies with age. The impact of a refractive error on a young child's development will depend on many factors such as accommodation. This article discusses the issues for optometrists dealing with young children.

The measurement of refractive error


The standard procedures of static retinoscopy followed by subjective is not feasible for young children; instead, the two techniques of cycloplegic and Mohindra retinoscopy are used. Studies show that the two give equivalent findings in infants and children,1,2 so the practitioner can be confident in choosing either one. Lynne Speedwells article Optometric examination of children, (OT February 9 2007) dealt thoroughly with guidelines for choice of cycloplegic drug, activation time etc. Cycloplegic refraction has the obvious advantage of dilating the pupil, making subsequent ophthalmoscopy much easier. On the other hand, a widely dilated pupil gives rise to aberrations that can make retinoscopy more difficult. It is not always possible to ensure equality of cycloplegia in the two eyes, especially if the child has been reluctant to open his/her eyes during instillation, so the binocular balance of the final prescription may be suspect. Cycloplegia prevents postrefraction assessment of ocular

motility, accommodation and near functions. It is, of course, an invasive technique that is uncomfortable or even distressing for the child. The Mohindra technique is much more child-friendly and is also quick, since there is no waiting time for drops to take effect. Accommodation and near functions remain intact so a complete eye examination can take place on the same occasion. Since accommodation is equal in the two eyes, binocular balance is assured. The Mohindra technique relies on the observation that, in total darkness, the eyes adopt a stable small amount of accommodation (that can be predicted) and this is equal in the two eyes. As Mohindra takes place in total darkness, a few children might find it disturbing, but with appropriate preparation, this is rarely a problem. So, begin by explaining what is going to happen. Position the child on a parents lap, or ensure that the parent in close by and in physical contact with the child (to avoid the child jumping or sliding off the chair in the dark). Lower the lights gradually,

keeping the retinoscope light on the childs eyes all of the time (so that the child always has something to see). If the child is nervous, remember to keep talking all the time. The technique should be performed monocularly to prevent convergence clues to the distance of the light from stimulating accommodation. If you are not using a trial frame, then simply cover one eye with the hand holding the lenses. A dimmed retinoscope light will also minimise any stimulus to accommodate. When watching the reflex, wait for maximum pupil dilation if the pupils constrict, the eyes are accommodating. Neutralise the reflex in the usual way. For a 50cm (2.00D) working distance, Mohindra recommended subtracting 1.25D, thus allowing for 0.75D accommodation3. Saunders and Westall1 showed that this is not appropriate for children: they recommend subtracting 0.75D for infants under the age of two years (allowing for 1.25D accommodation), and 1.00D for children of two years and over (allowing for 1.00D

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accommodation). Using these working distance allowances, Saunders and Westall showed that Mohindra gives the same final refractive error as cycloplegia. If the optometrist works at a different distance, adjustments can be made accordingly.

The repeatability of measurement of refraction


The repeatability of an optometric technique is an important concept. It is a description of the precision of the measurement, and for clinical purposes, it allows the optometrist to determine whether a visual or ocular function has changed over time. For example, if a child has a refractive error of +2.25D on one occasion, and at a six-month re-check refraction reveals +2.75D, has the refractive error changed? The repeatability gives the confidence limits for recognising a real change in visual function. For refractive error, repeatability is arrived at by measuring the error twice (with a short time delay) in a group of subjects, and recording the difference between the two occasions. The repeatability co-efficient is 1.96 times the standard deviation of these differences. In young children (between six months and four years) the repeatability of both Mohindra and cycloplegic refraction (to the nearest 0.25D) is 0.50D1 i.e. 95% of all differences between refractions will fall within 0.50D. This means that, in the example given above, we can be confident that the childs refractive error has not changed, as the observed difference can be accounted for by variability in the technique. We would need to record an increase or decrease in refraction of 0.75D or more on the second occasion before we could be confident that refractive error has changed. It is worth noting that repeatability of refraction for adult subjects (retinoscopy followed by subjective) is generally held to be 0.50D4. Refraction of a child subject (by an experienced observer) is as precise as the refraction of an able adult.

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< Figure 1 Distribution of spherical refraction in young children (from Hirsch and Weymouth5)

average refractive error and range or spread of errors, and Lynne Speedwells article has already introduced the word emmetropisation to describe the expected change in refraction over time. In this article we will look in more detail at normal and abnormal progress in refraction, in order to develop evidence-based guidelines for the management of errors in practice. Classical data, represented by Figure 1 shows that, among newborns, refraction is widely distributed - in fact the distribution is statistically normal. Describing refraction in early

infancy simply by the mean value, +3.00D, is clearly insufficient, since higher amounts of hypermetropia and low amounts of myopia are not at all uncommon. By school-age the distribution is very different (the figure shows ages 6-8, but in fact the distribution is similar to this by age 45 years). Now the curve is far from statistically normal; there is a marked peak around +1.50D hypermetropia and the distribution is extremely narrow. Myopia is rare, and hypermetropia is confined to +3.00D or less. It is the process by which children grow out of refractive errors

The significance of refractive findings


Amongst young children, refractive error varies with age, in terms of both

< Figure 2 Individual data from 7 children showing a change in refractive error between first examination and 12-17 months of age (from Saunders et al8)

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Refractive error (D) Age 0-1 yr Age 1-2 yr Age 2-3 yr

Isometropia (similar refractive error in both eyes) Myopia Hypermetropia no strabismus * Hypermetropia with esotropia Astigmatism Anisometropia Myopia Hypermetropia Astigmatism >-2.50 >+2.50 >2.50 >-2.50 >+2.00 >2.00 >-2.00 >+1.50 >2.00 >-4.00 >+6.00 >+2.00 >3.00 >-4.00 >+5.00 >+2.00 >2.50 >-3.00 >+4.50 >+1.50 >2.00

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spectacles

< Table 1 Modified from the American Academy of Ophthalmology guidelines for prescribing
* may reduce the amount by up to +2.00D, or if the cycloplegic prescription is +7.00D may reduce by up to +3.00D

(of whatever sign) in infancy that is known as emmetropisation. (For the purposes of the following discussion, we need to consider emmetropia as including low hypermetropia, the peak of the 6-8 year curve in Figure 1. Research papers tend to define emmetropia as a refraction within the range 0.25 to +1.00D or thereabouts). Hypermetropic eyes, in general, are small eyes and the observation that hypermetropic eyes become less hypermetropic as children grow is perhaps not surprising. Newborn eyes have, on average, an axial length of 17mm6 while eyes of six year olds have an axial length of 22.6mm.7 It is the myopic eyes, which grow overall and yet become less myopic, which provide (part of) the evidence that emmetropisation is an active, rather than a passive, growth process. Further evidence comes from longitudinal studies, such as that illustrated in Figure 2, which show emmetropisation taking place in individual eyes. The higher the initial refractive error, the greater the rate of change towards emmetropia. There is

also considerable evidence that emmetropisation is a visually-driven process; in animal studies refractive errors can be readily manipulated by using spectacle or contact lenses to induce optical blur9. The story with regard to astigmatism in infancy is similar, although rather less dramatic. The incidence of astigmatism (of 1.00D or more) may be as high as 65% among young infants. This largely disappears, so that by school age only 4-8% of children will have astigmatism of this value.10 Anisometropia (usually defined as a difference of >0.75D or >1.00D between eyes) is uncommon in children, although some studies suggest that up to 25% of newborns are anisometropic, outgrowing it over the first few months as part of the emmetropisation process. By school age, only 3-4% of children will exhibit anisometropia.10 The association between anisometropia and amblyopia/strabismus is well known. So the refractive error that can be considered normal in a child will be very different at different ages, leaving

a dilemma for practitioners trying to determine when to prescribe spectacles. The American Academy of Ophthalmology publishes (as part of its Preferred Practice Patterns series) the guidelines (see table 1) for prescribing spectacles. However, the table carries the following important note: These values were generated by consensus and are based solely on professional experience and clinical impressions, because there are no scientifically rigorous published data for guidance. Individual practitioners will have very different opinions about what level of refractive error requires correction. My task here is to discuss the published studies that may allow us to inject a little evidence into our decision-making. Lets begin by thinking about what we expect to be the benefits of refractive correction. These are minimising the risk of defects such as strabismus and amblyopia, providing good visual function with a clear retinal image and improving binocular function (including straightening squint). The last point was dealt with in the article on binocular vision anomalies (OT, April 6). Practitioners would presumably agree on prescribing for a hypermetropic child who is already exhibiting strabismus and/or amblyopia. The relationship between refractive error and strabismus is well known: in typical children there is a strong association between hypermetropia and convergent strabismus, so some attention has been paid in research projects to the management of hypermetropia in early infancy, before such defects develop. In spite of expectations that correcting hypermetropia might be a useful preventative measure, the Cambridge longitudinal study produced inconclusive results in terms of prevalence of strabismus at age 3.5 years between hypermetropic children who had been corrected at a young age (9-12 months) and those left uncorrected.11 However, correction had a positive impact on visual acuity by the age of 3.5 years and therefore reduced the prevalence of amblyopia. Studies, of course, use statistical

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the initial refraction. For ease of analysis Saunders et al (1995) plotted only two points for each child in the graph, but the apparent linear reduction in hypermetropia is an illusion. Most studies show that refraction changes at a faster rate during the first year of life than during subsequent years. And, of course, as in all aspects of development, children differ amongst themselves in growth rate. So it is not possible to recommend a fixed re-test interval: practitioners need to consider the factors in each case: the age of child at first test and the refractive error, as well as other risk factors such as binocular status and family history, in determining the date of the next test. How much change in refraction to expect will also depend on age at first

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probabilities to describe results; as far as advising for an individual child is concerned, there are no certainties. So should we be prescribing for all hypermetropic infants in order to maximise acuity in childhood? Are there any dangers in such an approach? Animal studies would suggest that correcting refractive errors at a young age is likely to impede emmetropisation, (in effect fooling the eyes into thinking they are already emmetropic) and one study with children supports this12. On the other hand, the Cambridge longitudinal study showed that spectacle correction (in this case a partial correction more of this later) did not influence the final level of refractive error compared to an uncorrected control group, although the corrected group were slower in achieving emmetropisation.11 More usefully for the eyecare practitioner, several studies suggest that children who go on to develop strabismus and amblyopia have not shown the usual reduction in refractive error prior to the onset of the defect13,14. This means that monitoring a refractive error in a young child will be more predictive of risk for strabismus and amblyopia than a single measure of refractive error at one age. If refractive error reduces over time, risk is minimal, whereas if there is no such reduction, risk is heightened. Restricting correction of hypermetropia to those children whose refractive error does not reduce over time would appear to be the best strategy. Two questions now arise. When monitoring refraction in a young child, at what interval should retests take place, and how much change in refraction towards emmetropia should we expect? If refraction changed at a similar rate in all children in a linear fashion, we could develop precise guidelines for monitoring. But this is not the case. The longitudinal data in Figure 2 (p31) show that the rate of change of refraction depends on the initial level of ametropia. Since in clinical practice we do not see all children at the same very young starting age, we are unlikely to know

test. The 0.50D repeatability limits of the refraction procedure must also be borne in mind in interpreting findings. If refractive error is not proceeding in the emmetropic direction, or a child arrives at the age at which emmetropisation is considered complete (four years) what level of hypermetropia constitutes a risk or defect? When correcting, how much of the hypermetropia should be corrected? The American Academys table (table 1) carries another note: * when correcting hypermetropia with no strabismus, the consensus is that the prescription may be reduced by up to +2.00D, or when the refraction exceeds +7.00D, it may be reduced by up to +3.00D. Undercorrecting hypermetropia appears to be standard

practice, but do we consider why this should be? Figure 1 (p31) seems to explain this: the mean refractive error in children is hypermetropia - by school age the mean is around +1.50D. It may, therefore, seem intuitive that reducing a hypermetropic correction to leave a child in the usual state of affairs is appropriate, but we have no experimental evidence to show that. How do children cope with this refractive error? The answer, of course, is accommodation. Small amounts of hypermetropia are not detrimental if the accommodative system compensates for the error. We expect children to have ample accommodation to readily overcome low to moderate hypermetropia. The general finding of good visual acuity in children and young adults with low hypermetropia argues that the defect is habitually overcome by accommodation. But should we take this for granted? By far the most common refractive status in school age children, as Figure 1 shows, is low hypermetropia. Yet we would consider ourselves negligent if we didnt measure refractive error in every child patient, but simply assumed it. Why, then, do we often assume accommodation is ample? Few practitioners routinely measure accommodation, but I am going to argue for its inclusion in routine practice, in order to allow the optometrist to make informed decisions about refractive correction. There is evidence for the importance of accommodation measures; a largescale longitudinal study of refraction in childhood reports that accommodative deficits are common amongst hypermetropes15.

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Measurement of accommodation
Accommodation in adults is usually measured by the subjective push-up technique to give the amplitude. Since children may not understand the concept of blur, this is not a feasible way to test. A push-down technique may be a viable alternative: show a small picture target, letter or word within a centimetre or two of the childs eye. Gradually move the target further away, asking the child to name the target as soon as s/he can.

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< Figure 3 Dynamic retinoscopy


An objective technique, which does not rely on a childs verbal responses and which can be used with even the youngest patient is dynamic retinoscopy. It is a simple procedure that can readily be incorporated into a routine. The one described here (modified Nott retinoscopy) measures the accuracy of accommodation, not the amplitude arguably a more useful measure for determining the need for a refractive correction. It has been shown to be a valid and repeatable technique when compared with autorefraction measures of accommodation.16 Measure accommodation after refraction, so that the distance refractive error is corrected, if appropriate. Mount a detailed and interesting picture on a near-point rule. The most useful single distance to place the target is at the childs habitual working distance; the younger the child (and the shorter her/his arms), the closer this will be. In the illustration (Figure 3) we have a Perspex cube with a picture on each face. Children tire of the same picture quickly, so it is useful to have alternatives. A self-illuminated target means that the room lights can be turned down, making the retinoscopy reflex easy to see. With a nonilluminated target, you may need the room lights on, or try shining light from the test chart onto the target so that it is bright enough to grab the childs attention. We need to stimulate accommodation, so talk about the picture or ask the child questions about it, to maintain her/his attention. Place the retinoscope alongside the target. Since distance refractive error is corrected or negligible, we need only look at one meridian of one eye. If the child is accommodating accurately to the target, then the reflex seen alongside the target will be neutral - this is the optics of retinoscopy. If the child is overaccommodating, the reflex will be against. In order to measure the

discrepancy or lead of accommodation, move the retinoscope towards the child (keeping the target still) to find neutral. The dioptric distance between neutral and the target will be the lead. Overaccommodation may indicate a binocular vision problem, and will trigger further investigation of convergence etc. If the child is under-accommodating, the reflex seen from alongside the target will be with. Move the retinoscope further from the child to find neutral. The dioptric distance between neutral and target will be the lag of accommodation. Generally, we accept a lag of zero to 0.75D as within the normal range for children, using a viewing distance of 25cm17. A greater lag may indicate a binocular vision problem, or a difficulty in accommodating accurately. To use the above technique to estimate the need for a hypermetropic correction, simply assess accuracy of accommodation uncorrected. If the lag exceeds 0.75D, then use partial corrections of the hypermetropia until the lag is within the normal range. Rather than simple reliance on a standard under-correction of hypermetropia, as suggested by the note to Table 1, the use of dynamic retinoscopy allows us to determine the most suitable correction for an individual child.

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< Figure 4 Accommodation in children (adapted from McClelland et al19 and from Woodhouse et al 18)
A myopic correction may leave a child struggling to accommodate for near. This dynamic technique can be used to decide what advice to give a child on spectacle wear - full-time or for distance use only. correction should be considered. Children with Downs syndrome tolerate bifocals very well22 and one case report showed that even varifocals have been successful in cerebral palsy.23

Children with disabilities


Amongst children with disabilities, accommodation difficulties are common. Studies have shown that the majority of children with Downs syndrome (68%18) and children with cerebral palsy (58%19) show a large lag for near targets (Figure 4). These children are therefore hampered for close work in school by a blurred retinal image, even when they are wearing their distance correction for refractive error. Further, children with disabilities are much more likely to have refractive errors than are typical children (Figure 5), and so are in greater need of optometric eye care. Emmetropisation is much less likely in children with disabilities, for reason not yet understood, but poor accommodation may play a role in preventing the usual emmetropisation process21. It is appropriate to prescribe refractive correction earlier for children with disabilities, and to fully correct hypermetropia in all cases in which accommodation is compromised. If the accommodation deficit remains in spite of distance correction, a near

Correction for myopia


As we have seen, hypermetropia is the most common form of refractive error amongst young children. Myopia is unusual in typical young children. When myopia does exist, providing it

is equal in the two eyes, the risk of amblyopia is low; the child will have clear vision for near tasks. Since young children have most, if not all of their interests at near, this means that myopia can be left uncorrected in the early years. Once children get to school, distance vision becomes more important and myopia is best corrected. As children approach adolescence, myopia becomes more prevalent, and depending largely on ethnicity, can become quite common. There is a considerable research effort worldwide in the field of myopia, but full discussion of the theories of its aetiology is beyond the remit of this article, except to say that the accommodative response to blur may be inefficient in the myopic eye.24,25 Here we will concentrate on the correction of myopia and the attempt to slow its progression. Bifocals, progressives and contact lenses appear to have little clinical benefit in slowing myopic progression. Some authorities have advocated under-correcting myopia as a means of slowing progression, but a recent study has shown this approach to be counterproductive. Chung, Mohidon and OLeary26 compared myopia progression between two groups of 48 children (9-14 years of age). One

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< Figure 5 Distribution of refraction in children (adapted from McClelland20 and from data of the Cardiff Downs Syndrome Vision Research Unit)

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group wore an under-correction (acuity blurred to 6/12) while the other group wore a full myopic correction. Myopia progression over a two-year period was significantly greater in the undercorrected group. The recommendation is for full correction for myopia, at least for distance wear. A separate study showed that removing spectacles for near work had no influence on myopia progression27.

Dispensing for children


As for adult patients, spectacles can only be successful if they are comfortable and fit well, with the lenses situated appropriately. Children are, of course, also entitled to spectacles that look good. Generally, especially with todays fashion for small metal frames, dispensing creates very few problems. Many frames have sides that are too long; ensure that you carry stock frames in which sides are adjustable. Keep different pads available. Depending on the size and shape of a childs nose, button pads or strap bridges may be more suitable than the standard oval pads; be prepared to change pads to suit individual children. Remember to take note of a childs eyelashes - a frame that sits too close to a childs eyes may prevent him/her from blinking! Some children are reluctant at first to wear glasses. Some children dislike new situations, and this applies particularly to children with learning disabilities. Spectacle lenses provide a focused image; we interpret this as better but a child may interpret this as different and reject the glasses on those grounds. Even if your eventual aim is full-time wear, dont expect a reluctant child to keep the glasses on all the time from the start. Discuss an adaptation programme with the parent. The exact form will depend on the refractive error, the purpose of the spectacle correction and on the childs interests. Identify a favourite activity for which the spectacles are suitable and during which the child can have a parents (or other family members) full attention. Make this spec wearing time, and allow the child to remove the glasses at the end of the activity. This way the child

learns to associate glasses with an enjoyable activity, and begins to appreciate clearer vision for that activity. If the child is struggling to cope with the glasses, the activity should be very short. Gradually increase the length of the activity, and/or introduce a second activity. Reassure the parents that the process may take weeks or even months (and anything shorter becomes a bonus) and above all, dont make a parent feel guilty or inadequate if this is a slow process. Similarly, dont allow the parents and child to turn it into a battle the child will win! Contact lenses can be a viable alternative to spectacles for some children, but the topic is beyond the scope of this article.

References
1. Saunders KJ, Westall CA. Comparison between near retinoscopy and cycloplegic retinoscopy in the refraction of infants and children. Optometry and Vision Science. 1992;69:615-622. 2. Woodhouse JM, Pakeman VH, Cregg M, et al. Refractive errors in young children with Down syndrome. Optometry and Vision Science. 1997;74:844-851. 3. Mohindra I. A noncycloplegic refraction technique for infants and young children. Journal of the American Optometric Association. 1977;48:518-523. 4. Smith G. Refraction and visual acuity measurements: what are their measurement uncertainties? Clinical and Experimental Optometry. 2006;89:66-72. 5. Hirsch MJ, Weymouth FW. Prevalence of refractive anomalies. In: Grosvenor, T, Flom, MC, eds. Refractive anomalies. Stoneham: Butterworth-Heinemann; 1991:15-38. 6. Larson JS. The sagittal growth of the eye: IV Ultrasonic measurement of axial length from birth to puberty. Acta Ophthalmologica. 1971;49:873-886. 7. Huynh SC, Wang XY, Rochtchina E, Crowston JG, Mitchell P. Distribution of Optic Disc Parameters Measured by OCT: Findings from a Population-Based Study of 6-Year-Old Australian Children. Investigative Ophthalmology & Visual Science. 2006;47:3276-3285. 8. Saunders KJ, Woodhouse JM, Westall CA. Emmetropisation in human infancy: Rate of change is related to initial refractive error. Vision Research. 1995;35:1325-1328. 9. Wildsoet CF. Active emmetropisation - evidence for its existence and ramifications for clinical practice. Ophthalmic and Physiological Optics. 1997;17:279-290. 10. Saunders KJ. Early refractive development in humans. Survey of Ophthalmology. 1995;40:207-216. 11. Atkinson J, Braddick O, Nardini M, Anker S. Infant hyperopia: Detection, distribution, changes and correlates - outcomes from the Cambridge infant screening programs. Optometry and Vision Science. 2007;84:84-96.

Summary
Refraction in young children changes rapidly, in the usual case in the direction of emmetropisation. A single measure of refractive error, unless extreme or anisometropic, is not a useful indicator of the need for correction. Monitoring refractive error at regular intervals will allow the optometrist to distinguish between eyes that are emmetropising (low risk of defects) and eyes that are not (high risk of defects). If a child is in the high risk category, then correction for refractive error is probably beneficial. Hypermetropia in children may be compensated by active accommodation, but it is not sufficient to assume this. Practitioners should measure accommodation routinely and use this to determine the need for and the amount of a hypermetropic correction, rather than rely on consensus tables or usual practice. Myopia should be corrected by school age, (earlier if marked, or if the child has distance interests) and be fully corrected for distance. Accommodation can be measured to determine whether spectacles may be worn for near tasks. Finally, the refractive error cannot be considered in isolation. Binocular vision status and visual acuity without and with a refractive correction will, of course, contribute to our decisionmaking, as will family history, and the wishes of both parent and child.

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12. Ingram RM, Gill LE, Lambert TW. Effect of spectacles on changes of spherical hypermetropia in infants who did, and did not, have strabismus. British Journal of Ophthalmology. 2000;84:324-326. 13. Abrahamsson M, Fabian G, Andersson AK, Sjostrand J. A longitudinal study of a population based sample of astigmatic children I: Refraction and amblyopia. Acta Ophthalmologica. 1990;68:428-434. 14. Ingram RM, Gill LE, Goldacre MJ. Emmetropisation and accommodation in hypermetropic children before they show signs of squint - a preliminary analysis. Bulletin de la Socit belge d' ophtalmologie. 1994;253:41-56. 15. Mutti DO. To emmetropize or not to emmetropize? The question for hyperopic development. Optometry and Vision Science. 2007;84:97-102. 16. McClelland JF, Saunders KJ. The repeatability and validity of dynamic retinoscopy in assessing the accommodative response. Ophthalmic and Physiological Optics. 2003;23:243-250. 17. Rouse MW, Hutter RF. A normative study of the

accommodative lag in elementary school children. American Journal of Optometry and Physiological Optics. 1984;61:693-697. 18. Woodhouse JM, Cregg M, Gunter HL, et al. The effect of age, size of target and cognitive factors on accommodative responses of children with Down syndrome. Investigative Ophthalmology and Visual Science. 2000;41:2479-2485. 19. McClelland JF, Parkes J, Hill N, Jackson AJ, Saunders KJ. Accommodative dysfunction in children with cerebral palsy: a population-based study. Investigative Ophthalmology & Visual Science. 2006;47:1824-1830. 20. McClelland J: Accommodative dysfunction and refractive anomalies in children with cerebral plasy, Faculty of Life and Health Sciences. University of Ulster, Coleraine, 2004, pp. 309. 21. Stewart RE, Woodhouse JM, Cregg M, Pakeman VH. The association between accommodative accuracy, hypermetropia and strabismus in children with Down's syndrome. Optometry and Vision Sciences. 2007;84:149-155.

22. Stewart RE, Woodhouse JM, Trojanowska LD. In focus: the use of bifocals for children with Down's syndrome. Ophthalmic and Physiological Optics. 2005;25 514-522. 23. Ross RM, Heron G, Mackie R, McWilliam R, Dutton G. Reduced accommodative function in dyskinetic cerebral palsy: a novel management strategy. Developmental Medicine and Child Neurology. 2000;42:701-703. 24. Gwiazda J, Thorn F, Bauer J, Held R. Myopic children show insufficient accommodative response to blur. Investigative Ophthalmology and Visual Science. 1993;34:690-694. 25. O'Leary DJ, Allen PM. Facility of accommodation in myopia. Ophthalmic and Physiological Optics. 2001;21:52-55. 26. Chung K, Mohidin N, O'Leary DJ. Undercorrection of myopia enhances rather than inhibits myopia correction. Vision Research. 2002;42:2555-2559. 27. Ong E, Grice K, Held R, Thorn F, Gwiazda J. Effect of spectacle intervention on the progression of myopia in children. Optometry and Vision Science. 1999;76:363-369.

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Module questions
Please note, there is only one correct answer. Enter online or by form provided
1. Which one of the following is NOT an advantage of the Mohindra retinoscopy technique? a. Oculo-motor tests can be carried out on the same occasion b. Subsequent ophthalmoscopy is easier c. Binocular balance is more reliable d. There is no discomfort 7. a. b. c. d.

Course code: c-5203

An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-5203) OT, Ten Alps plc, 9 Savoy Street, London WC2E 7HR by May 30 2007.
Which statement is CORRECT regarding refractive errors in children? The higher the initial error, the faster the growth towards emmetropia Refraction is relatively static between birth and 12 months Emmetropisation is considered complete at two years old Myopic errors at birth remain myopic

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2. Which one of the following is INCORRECT regarding the Mohindra retinoscopy technique? a. It is performed in total darkness b. It should be performed monocularly c. Maximum pupil dilation should be achieved prior to neutralisation d. It should be performed binocularly 3. Which one of the following is INCORRECT regarding the repeatability of refractive error measurement? a. Repeatability is based on the standard error of the differences between successive measures b. Repeatability defines the confidence a practitioner may have in determining a change in refraction over time c. Repeatability of Mohindra retinoscopy is less than 0.75D d. Repeatability defines the likelihood that refractive error changes towards emmetropia 4. a. b. c. d. 5. a. b. c. d. Which statement is CORRECT? The process of emmetropisation: Means that childrens refraction becomes more hypermetropic with age Can be impeded by leaving errors uncorrected Is likely to be an active visually-driven process Results in most children having zero refraction by school age Which statement is CORRECT regarding school-age children? 3-4% are anisometropic Approximately 26% have astigmatism of 1.00D or more 10-15% are myopic Approximately 2% are hypermetropic

8. You carry out modified Nott dynamic retinoscopy with a child, setting the target at 25cm. You find neutral at 40cm.What is the accommodative lag? a. 4.00D b. 2.50D c. 1.50D d. 1.00D 9. Which statement is INCORRECT regarding modified Nott dynamic retinoscopy? a. A lead of more than 0.75D would indicate insufficient accommodation b. The technique informs decisions about a hypermetropic prescription c. The practitioner need only measure one meridian of one eye d. The target is best placed at the childs habitual working distance 10. a. b. c. Which statement is CORRECT regarding children with disabilities? The peak of the refractive error distribution in cerebral palsy is -4D Children with Downs syndrome tolerate bifocals very well By school-age, children with disabilities have refractive errors similar to typical children d. Accommodation difficulties are rare 11. In order to minimise the progression of myopia in children, the best strategy appears to be: a. Do not correct until school age b. Under-correct by around 1.00D c. Give full correction d. Provide bifocals 12. Which is the LEAST likely to encourage a child to wear glasses for the first time? a. Encouraging full-time wear to minimise the adaptation period b. Fitting appropriately so that the frame stays in place c. Adopting a programme of gradual increases in wearing time d. Associating spectacles with a favourite activity

6. Which statement is INCORRECT regarding strabismus and amblyopia? a. Children at risk will not have shown the usual reduction in refractive error prior to the onset of the defect b. Both are highly associated with hypermetropia c. Children at risk can be best identified by monitoring refraction over time d. If refractive error increases over time, risk of strabismus and amblyopia is minimal

Please complete on-line by midnight on May 30 2007 You will be unable to submit exams after this date answers to the module will be published in our June 1 issue

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CET answers
1. The correct answer is C. Neonatal misalignments should be becoming less frequent in the second month of life. 2. The correct answer is B. Nystagmus with an onset in adulthood is not a common feature of infantile esotropia syndrome. 3. The correct answer is C. Epicanthus can co-exist with intermittent esotropia. 4. The correct answer is A. Unlike the other options, a family history of primary open angle glaucoma is not a significant risk factor for strabismus in young children. 5. The correct answer is C. Crowded Lea pictures are the best visual acuity test of those listed for detecting strabismic amblyopia. 6. The correct answer is A. Of the options listed, a decompensated exophoria at near is the least significant reason for carrying out a cycloplegic refraction in an 8 year old.

Course code: c-5199

These are the correct answers to Module 10 Part 4, which appeared in our April 6, 2007 issue
7. The correct answer is D. There can be difficulties in detecting a microtropia with the cover test. 8. The correct answer is C. It is not appropriate for fully accommodative esotropia to be treated surgically. 9. The correct answer is A. Of the options given, the most accurate description of divergence excess intermittent exotropia is a deviation that is greatest for far distance vision and the patient is typically unaware because they suppress when the eye deviates. 10. The correct answer is D. The most accurate of the statements is that the treatment of strabismic amblyopia is associated with a high risk over the age of 7-8 years. 11. The correct answer is A. The most accurate of the statements is that where there is a significant refractive error, the first stage of amblyopia treatment is refractive correction. 12. The correct answer is B. It is not true to say that a lateral rectus palsy usually causes most symptoms during near vision. This type of palsy usually causes maximum diplopia in distance vision, when looking to the side of the affected muscle.

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